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CDC Adopts WHO Recommendations for Self-Administration of Subcutaneous Depot Medroxyprogesterone Acetate

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the WHO recommendation for self-administration of DMPA-SC
2. Describe the review undertaken by CDC for self-administration of DMPA-SC and the final recommendation

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from through , participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.25 contact hours.

Designated for 0.25 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

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

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CDC Adopts WHO Recommendations for Self-Administration of Subcutaneous Depot Medroxyprogesterone Acetate