Self-managed Contraception in South Sudan

The right and ability to choose whether and when to have children is fundamental to the ability of women and girls to achieve their potential, yet contraception and abortion is often deprioritized and under-funded in crises. The cycle of unintended pregnancy and unsafe abortion is both a cause and result of gender inequality and becomes more severe during crises, leading to excess morbidity and mortality. Women, girls and their newborns have a right to receive the care they need, where they need it, at every stage of their reproductive journey, but humanitarian actors and governments too often fail to deliver.

IRC’s vision is to revolutionize access to sexual and reproductive health (SRH) services in humanitarian settings through self-care, so that every woman and adolescent girl has the agency, power, and resources to achieve her SRH rights. 

Self-Injectable Contraception Research in South Sudan

In South Sudan, maternal mortality currently stands at 789 deaths per 100,000 births and the unmet need for contraception among women and girls of reproductive age is 30%. Studies in West and East Africa have demonstrated that Sayana Press, a self-injectable contraceptive method, can be safely administered by community health workers and clients themselves. However, its acceptability and use among low-literacy women living in rural humanitarian settings has never been investigated. 

Studies in West and East Africa have demonstrated that Sayana Press (or DMPA-SC), a self-injectable contraceptive method, can be safely administered by community health workers and clients themselves. However, its feasibility among low-literacy women living in rural humanitarian settings has never before been investigated. The IRC partnered with the Ministry of Health to conduct operational research on the self-administration of DMPA-SC. This is the second-ever study to date that demonstrates the feasibility of self-injectable contraception in low-literacy and humanitarian or fragile settings. 

The IRC, in partnership with the Ministry of Health, conducted operational research on the self-administration of DMPA-SC. The goals of this research study were to: 

• Apply user-centered design processes with both trainers and the users to ensure that the service delivery package for self-injection, including training, packaging, messaging, and reminders are all conducive to intervention uptake in the community.
• Document the proportion of women and girls in the study who can self-inject competently immediately after training, based on an existing observational checklist developed by PATH, and then subsequently at the 3-, 6-, 9- and 12-month marks. 
• Evaluate the acceptability and feasibility of a DMPA-SC self-injection program from the perspective of clients, health providers, and other stakeholders.

Our findings show:

• Women’s ability to self-inject. In the rural area of Aweil, all enrolled women were able to self-inject accurately with three or fewer rounds of practice (66% of the participants were able to perform self-injection after one round of practice, 29% after two rounds, and 5% after three rounds). Similarly in the urban area, all enrolled women were able to self-injected accurately with three or fewer rounds of practice, but with more women needing two rounds of practice (19% of the participants were able to perform self-injection after one round of practice, 65% after two rounds, and 15% after three rounds).
• Acceptability of a self-injected contraception (DMPA-SC). Participants used self-injected contraception primarily to prevent unwanted pregnancies, to space their children, to continue their education or pursue career opportunities, and to improve their economic situation by providing better support for their current family. Self-injection was also preferred because it reduces the number of visits to a health facility, ease of use, convenience, privacy, and small needles compared to other injectables.
• Demand for self-injected contraception (DMPA-SC). In Aweil, 57% of women continued to self-inject beyond 12 months and 66% beyond 6 months. Some of this was due to loss to follow-up (this is a highly migratory population) and competing client priorities. In Juba, the probability of self-injection continuation beyond 6 months was 75%..
• Reminder systems. Women in both rural and urban areas used different methods of reinjection recall. In rural areas, common reminder systems included asking others such as CHVs, children, and fellow participants about the dates, tracking the dates on their own or their husband's phone, monitoring the dates in their minds, and listening to radio announcements or market day schedules. On the other hand, most women living in urban areas can recall their reinjection dates without using any reminder system. They also used other methods, such as writing the dates down on a piece of paper or notebook, using their phone's calendar, or seeking help from CHVs.

The IRC also validated the distribution and disposal of the self-injection cartridges by both community health workers and formal health facilities. We additionally designed two mechanisms to support on-time injection. 

These findings motivated policymakers to integrate self-care into a new and forthcoming National Family Planning Policy. The IRC is now working with local and national stakeholders to further share our findings and prioritize the next steps for research, program implementation and policy development. At the end of 2023, we presented our findings during a research validation workshop to national-level policymakers, program implementers, and other organizations and aimed to inform a future research and learning agenda for self-care in South Sudan with a research prioritization exercise.