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 Table of Contents  
EDITORIAL
Year : 2020  |  Volume : 11  |  Issue : 1  |  Page : 180

Injectable depot medroxy progesterone acetate: A safe contraceptive choice in public health system of India


1 Department of Community Medicine, Government Medical College, Shahdol, Madhya Pradesh, India
2 Department of Community Medicine, SHKM Govt. Medical College, Nalhar, Nuh, Haryana, India

Date of Submission06-May-2019
Date of Acceptance13-Aug-2019
Date of Web Publication26-Nov-2020

Correspondence Address:
Vikas Gupta
F3/6, GMC Campus, Shahdol, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpvm.IJPVM_163_19

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How to cite this article:
Gupta V, Chawla S, Goel PK. Injectable depot medroxy progesterone acetate: A safe contraceptive choice in public health system of India. Int J Prev Med 2020;11:180

How to cite this URL:
Gupta V, Chawla S, Goel PK. Injectable depot medroxy progesterone acetate: A safe contraceptive choice in public health system of India. Int J Prev Med [serial online] 2020 [cited 2021 Jan 17];11:180. Available from: https://www.ijpvmjournal.net/text.asp?2020/11/1/180/301688




  Background Top


India was the first country in the world to launch a family planning programme, as early as 1952, with the main aim of controlling its population. India's population has already reached 1.26 billion and considering the high decadal growth rate of 17.64, the country's population is slated to surpass that of China by 2028.[1] Over the years national family planning programme too has evolved with a shift in focus from merely population control to more critical issues of saving the lives and improving the health of mothers and children through use of reversible spacing methods leading to reduction in unwanted, closely spaced and mistimed pregnancies and thus avoiding pregnancies with higher risks and chances of unsafe abortions.[2] Presently the spacing options are limited to only condoms, Intra Uterine Contraceptive Devices (IUCDs) and oral pills contributing to 5.6%, 1.5% and 4.1% share of modern Couple Protection Rate (mCPR) respectively [Figure 1]. Evidence of contraceptive method mix clearly indicates that with the addition of a single method there is a linear increase in mCPR by 3%-4%. Development of a long-acting reversible contraceptive was a goal of family planning researchers for many years.[3]
Figure 1: What Contraceptive Methods do Women Use (Source: NHFS-4, 2015-2016)

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What is new

The injectable contraceptives contain synthetic hormones resembling the natural female hormones. When administered (intramuscular/subcutaneous) there is a slow release of hormone into the blood stream and it provides protection from pregnancy for a long duration of time to the client. Injectable Depot Medroxy Progesterone Acetate (DMPA) is an aqueous suspension of microcrystal for depo injection of pregnane 17 alfa – hydroxyprogesterone – derivative progestine medroxyprogesterone acetate. Depot Medroxy Progesterone Acetate can be given through intramuscular route (DMPA-IM) or subcutaneous route (DMPA-SC).[1],[4]

Injectable contraceptive (DMPA) mainly inhibits ovulation by suppressing mid cycle peaks of Luteinizing Hormone (LH) and Follicle Stimulating Hormone (FSH), it also does the thickening of cervical mucus due to depletion of estrogen and the thick mucus prevents sperm penetration into the upper reproductive tract. Apart from this it does thinning of endometrial lining due to high progesterone and depleted estrogen, making it unfavorable for implantation of fertilized ovum. DMPA may cause a delay in the return of fertility. Since one injection is effective for 3-4 months, the return of fertility takes 7-10 months from date of last injection (average 4-6 months after 3 months effectivity of last injection is over). A DMPA injection can be started any time if it is reasonably certain that the woman is not pregnant. In lactating breastfeeding women DMPA can be started after 6-week post- partum whereas in non-breastfeeding women it can be started anytime within 4 weeks after ruling out pregnancy. A physical examination is always an important part of good reproductive healthcare but recent scientific studies have shown it is not required for the provision of DMPA.[4]

Safety and effectiveness

DMPA is a safe contraceptive. Studies by World Health Organization (WHO) on over 3 million woman months of DMPA use give reassurance that DMPA presents no overall risks for cancer, congenital malformation or infertility. Also an extensive research has found that DMPA use exerts a strong protective effect against endometrial cancer, also has not been found to affect the risk of developing liver cancer in areas where hepatitis B is endemic, does not cause any significant changes in blood pressure or on the coagulation of the fibrinolytic system affecting thrombosis, keeps the fertility intact although it takes a woman few months (4-6 months) longer to become pregnant after discontinuing DMPA than Combined Oral Contraceptives (COCs), IUCDs or barrier methods. Studies have found no differences in the health, growth, sexual development, aggression, physical activity or sex role identity of teenage children exposed in utero to DMPA as compared with no in- utero exposure. DMPA is the fourth most prevalent contraceptive and is widely used as an effective, safe and acceptable method of contraception across the world. It is estimated that currently, an estimated 42 million women worldwide use injectables as a method of choice. It is a highly effective contraceptive method. With a standard regimen the first year effectiveness is 99.7% when the drug is used correctly. The perfect use failure rate of 0.3% is lower in comparison to 0.5% of female sterilization, 0.8% of IUCD and 3% of COCs.[5]


  Contraceptive Benefits Top


A private and confidential method, convenient and easy to use (does not require daily routine or additional supplies), acts for 3 months with a grace period of 4 weeks, completely reversible, does not interfere with sexual intercourse/pleasure, pelvic examination not required prior to use, suitable for women who are not eligible to use an estrogen containing contraceptive, suitable for breast feeding women (after 6 weeks postpartum) as it does not affect quantity, quality and composition of breast milk, provides immediate postpartum (in non-breastfeeding women) and post-abortion contraception, may be used by women at any age or parity if they are at risk of pregnancy.[6]

Non-contraceptive benefits

It decreases menstrual cramps and reduce pre-menstrual syndrome/tension, improves anemia by reducing menstrual blood loss due to menstrual changes such as amenorrhea, reduces the symptoms of endometriosis, decreases benign breast disease and ovarian cysts, helps to prevent uterine tumors, reduces the incidence of symptomatic pelvic inflammatory disease (PID), protect against endometrial cancer and possibly ovarian cancer, reduces sickle-cell crises in women with sickle-cell anemia, protects against ectopic pregnancy (since ovulation does not occur).[6]

Limitations

DMPA injectable contraceptive does not protect against Sexually Transmitted Infections (STI)/Reproductive Tract Infections (RTI) and Human Immunodeficiency Virus (HIV) infection, once taken its action cannot be stopped immediately, it causes changes in the menstrual cycle and bleeding due to its inevitable effect on a woman's body hormones, it has to be repeated every three months to achieve desired contraceptive effectiveness, longer duration for return of fertility (4-6 months). With consistent use of DMPA, bone mineral density decreases by 5%-6% in 5 years, with most loss happening in first 2 years.[7],[8]

Special issues on DMPA

There is evidence of a possible increased risk of acquiring HIV among progestin-only injectable users. Uncertainty exists about whether this is due to methodological issues with the evidence or to a real biological effect.[9],[10] On March 2, 2017, the WHO, in its Medical Eligibility Criteria for Contraceptive Use, changed use of DMPA injectable products among women at high risk of HIV acquisition from category 1 to Category 2. This means that for women at high risk of HIV, the advantages of using DMPA products generally outweigh the theoretical or proven risk. Women should not be denied progestin-only injectables because of concerns about the possible increased risk of HIV. Rather, women considering progestin-only injectables should be advised about these concerns, about the uncertainty over whether there is a causal relationship, and about how to minimize their risk of acquiring HIV, including correct and consistent use of condoms, antiretroviral therapy initiation for partners living with HIV where appropriate, and pre-exposure prophylaxis are available. The ongoing Evidence for Contraceptive Options and HIV Outcomes (ECHO) study is designed to fill this gap and provide robust evidence on the relative risks (HIV acquisition) and benefits (pregnancy prevention) between three effective contraceptive methods (DMPA-IM; levonorgestrel implant; copper intrauterine device).[11],[12]

DMPA subcutaneous versus DMPA intramuscular

DMPA-SC offers more women (especially those who face barriers when interacting with the health system) access to a new voluntary contraceptive method that could meet their needs and reproductive intentions.[13],[14] New acceptors which often include younger clients, and younger clients may prefer DMPA-SC if it is available closer to their homes and because the needle is smaller than the intramuscular needle, although proximity and needle size are traits that many users find attractive.[15],[16] One reason that clients are attracted to DMPA-SC is the cost and time savings that it offers. In community-based distribution settings, a woman would not need to travel to a clinic since it is offered in her community. In self-injection settings, clients are often given 2-3 doses, reducing the number of trips they would need for resupply. DMPA-SC may also ameliorate the high contraceptive discontinuation rates that are typical of intramuscular injection. The typical discontinuation rate at 12 months for DMPA-IM is 40%-50%, but studies have found that DMPA-SC self-injectors have a more than 50% increase in continuation through 12 months compared with a provider administered injection.[10]

Barriers

Misaligned government policies and priorities (e.g., favoring provision of contraceptives by medical personnel), opposition by medical professionals and social and cultural norms and dynamics. Lack of system capacity for DMPA distribution (e.g., delivery or administrative challenges, lack of equipment, supply chain stock-outs due to mismanagement, and staff burden), competing alternatives for political or consumer attention, data collection challenges and lack of knowledge/awareness.[17] Since when the DMPA is being offered free in the public health system the acceptance rate increased from 0.1% in 2006 to 0.2% in 2016 but is very low as compared with other contraceptive methods [Figure 1]. The overall lower acceptance rate is also due to inadequate level of knowledge or awareness (69%) about injectables among women. Also, discontinuation rates are high (51%) as compared with other contraceptive methods [Figure 2] and the most common reason is side effects or health concerns which can be overcome by in-depth counselling. In-depth counselling consists of detailed information of the drug along with emphasis on how to handle the side effects and this will be given at each reinjection visit every three months.[18]
Figure 2: Contraceptive Discontinuation Rates for Modern Spacing Methods (Source: NHFS-4, 2015-2016)

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  Conclusion Top


The ability for a woman to receive DMPA injections every 3 months without a daily or pericoital regimen, and usually in a private room without others being aware of her contraception use, were critical characteristics of the product that can enable scaling up in several low-income contexts. These features figure prominently in the marketing of DMPA and stand in contrast to other types of contraceptive products, such as oral pills or condoms, which are more likely to be observed by or require negotiation with other household members. Dialogue with community at early stages and throughout implementation effective education through social marketing, use of data to improve program performance and maintaining compatibility with religious norms are key for its scaling up and to eventually counter the challenge of unmet need of family planning methods. Providing adequate supports such as staff training and clinic space and using peer social networks and conducting stakeholder assessments from community can make DMPA a successful choice to combat the menace of population explosion in India.



Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Department of Health and Family Welfare. Reference Manual for Injectable Contraceptive (DMPA). New Delhi. Ministry of Health and Family Welfare; 2016.  Back to cited text no. 1
    
2.
Ahmed S, Li Q, Liu L, Tsui AM. Maternal deaths averted by contraceptive use: An analysis of 172 countries. Lancet 2012;380:111-25.  Back to cited text no. 2
    
3.
Population Foundation India. Evidences on Contraceptive Method Mix in developing countries: South/South-East Asia. New Delhi: PFI; 2016.  Back to cited text no. 3
    
4.
Srivastava RK, Tanwar H, Singh P, Patro BC. Injectable Contraceptives to Expand the Basket of Choice under Family Planning Programme: An Update. New Delhi. Ministry of Health and Family Welfare; 2012.  Back to cited text no. 4
    
5.
Jain J, Jakimiuk AJ, Bode FR, Ross D, Kaunitz AM. Contraceptive efficacy and safety of DMPASC. Contraception 2004;70:269-75.  Back to cited text no. 5
    
6.
Association of Reproductive Health Professionals. Choosing a birth control method: Injectables. Available from: https://www.arhp.org/Publications-and-Resources/Quick-Reference-Guide-for-Clinicians/choosing/Injectable. [Last accessed on 2019 Feb 20].  Back to cited text no. 6
    
7.
Arias RD, Jain JK, Brucker C, Ross D, Ray A. Changes in bleeding patterns with depot medroxyprogesterone acetate subcutaneous injection 104 mg. Contraception 2006;74:234-8.  Back to cited text no. 7
    
8.
Kaunitz AM, Arias R, McClung M. Bone density recovery after depot medroxyprogesterone acetate injectable contraception use. Contraception 2008;77:67-76.  Back to cited text no. 8
    
9.
Polis CB, Curtis KM, Hannaford PC, Phillips SJ, Chipato T, Kiarie JN, et al. An updated systematic review of epidemiological evidence on hormonal contraceptive methods and HIV acquisition in women. AIDS 2016;30:2665-83.  Back to cited text no. 9
    
10.
Cole K, Saad A. The coming-of-age of subcutaneous injectable contraception. Glob Health Sci Pract 2018;6:1-5.  Back to cited text no. 10
    
11.
Hofmeyr GJ, Morrison CS, Baeten JM, Chipato T, Donnell D, Gichangi P, et al. Rationale and design of a multi-center, open label, randomised clinical trial comparing HIV incidence and contraceptive benefits in women using three commonly-used contraceptive methods (the ECHO study). Gates Open Res 2017;1:17.  Back to cited text no. 11
    
12.
Jain AK. Hormonal contraception and HIV acquisition risk: Implications for individual users and public policies. Contraception 2012;86:645-52.  Back to cited text no. 12
    
13.
Jain AK, Obare F, RamaRao S, Akew I. Reducing unmet need by supporting women with met need. Int Perspect Sex Reprod Health 2013;39:133-41.  Back to cited text no. 13
    
14.
Jain A, Winfrey W. Contribution of contraceptive discontinuation to unintended births in 36 developing countries. Stud Fam Plann 2017;48:269-78.  Back to cited text no. 14
    
15.
Burke HM, Mueller MP, Perry B, Packer C, Bufumbo L, Mbengue D. Observational study of the acceptability of Sayana® Press among intramuscular DMPA users in Uganda and Senegal. Contraception 2014;89:361-7.  Back to cited text no. 15
    
16.
Polis C, Nakigozi GF, Nakawooya H, Mondo G, Makumbi F, Gray RH. Preference for Sayana® Press versus intramuscular Depo-Provera among HIV-positive women in Rakai, Uganda: A randomized crossover trial. Contraception 2013;89:385-95.  Back to cited text no. 16
    
17.
Curry L, Taylor L, Pallas SW, Cherlin E, Pérez-Escamilla R, Bradley EH. Scaling up depot medroxyprogesterone acetate (DMPA): A systematic literature review illustrating the AIDED model. Reprod Health 2013;10:39.  Back to cited text no. 17
    
18.
International Institute for Population Sciences. National Family Health Survey (NFHS-4), 2015–16: India: Volume I. Mumbai, India: IIPS; 2017. Available from: http://www.rchiips.org/nfhs/report.shtml. [Last accessed on 2019 Aug 11].  Back to cited text no. 18
    


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