SUMMARY:

Subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is a progestin-only injectable contraception method that is FDA approved. Recommendations regarding eligibility and us of DMPA-SC are included in U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) and is the same as for IM route. DMPA is most commonly used by younger women (aged 15 to 24 years), non-Hispanic Black women, and women with lower income. The CDC reviewed the literature and available data to determine whether self-administered DMPA-SC should be be made available as per WHO 2019 guidance.

KEY POINTS:

WHO Guidance (2019)

• WHO recommends that self-administered injectable contraception should be made available as an additional approach to deliver injectable contraception to persons of reproductive age
• Evidence was considered to be of moderate-certainty and that the benefits of self-administration outweighed any potential harms, resulting in a ‘strong’ recommendation
• The WHO approach is in line with shared decision making models

CDC Evidence Review

• Literature review included RCTs and observational studies that
  • Compared self-administered DMPA-SC with provider-administered DMPA-SC or DMPA-IM
  • Provided outcomes that included: Pregnancy | Side effects or adverse events | Initial use of injectable contraception | Continuation rate of injectable contraception | Self-efficacy | Knowledge, and empowerment | Social harms
• Risk of bias was evaluated using The Cochrane Collaboration tool for RCTs and the Evidence Project tool for observational studies
• CDC also
  • Updated the search to identify additional articles published through January 15, 2021
  • Considered global information on values and preferences about self-administration of DMPA-SC and information on implementation of self-administered DMPA-SC in the United States
  • Invited 18 external experts to serve as ad hoc reviewers of the evidence and the WHO recommendation
• Findings
  • 2019 systematic review identified six studies: 3 RCTS and 3 prospective studies
  • Higher rates of continuation were observed with self-administered DMPA-SC
  • Pregnancy rates were low overall (≤1%) and did not differ between self-administered and provider-administered groups.
  • No other side effects or adverse events were increased with self-administration
  • In an additional secondary analysis of one study, 12-month continuation rates were similar for self-administered DMPA-SC among younger (aged 18 to 24 years) and older (aged ≥25 years) participants

CDC Recommendation

• Based on the above review, including a focus on the US data

CDC adopted the WHO recommendation for self-administered DMPA-SC, which was guided by evidence that the practice increases contraceptive continuation and has equivalent rates of pregnancy, side effects, and associated adverse events compared with provider-administration

The new U.S. SPR recommendation states that self-administered DMPA-SC should be made available as an additional approach to deliver injectable contraception 

Learn More – Primary Sources:

Update to U.S. Selected Practice Recommendations for Contraceptive Use: Self-Administration of Subcutaneous Depot Medroxyprogesterone Acetate (CDC MMWR)

No Restrictions: ACOG Supports Over-the-Counter Access to Hormonal Contraception

Related ObG Topics:

CDC Resources: Contraception in Women with Medical Conditions (US MEC)

ACOG & SMFM Guidance on the Use of IUDs and Contraceptive Implants

No Restrictions: ACOG Supports Over-the-Counter Access to Hormonal Contraception