How This Self-Injectable Is Helping Ugandan Women Keep Their Birth Control Secret

Before the birth of her first child last year, Warom Molly had never used hormonal birth control. But at her daughter Bethel’s postnatal checkup in Gulu, Uganda, Warom knew exactly which method she wanted: Sayana Press, a three-month, progestin-only contraceptive shot that is self-injectable.

Following this hospital visit, Warom would receive some training on self-injection, and then get to take home a dose to administer to herself. This “do-it-yourself” option represents a radical and potentially life-saving level of control for women in places like Gulu, where contraception can be difficult to obtain. Many Ugandan women have to travel miles away from their villages, usually by foot, and wait hours in long lines to get medical care, including contraception, whether that’s Depo-Provera, the birth control shot that has to be administered in a clinic, or the far less popular option in Uganda, the pill.

But thanks to its novel injection system developed by the global health nonprofit PATH, Sayana Press, which is manufactured by Pfizer and costs just $1 per dose, is very easy (and safe) for health workers — and women themselves — to administer.

Sayana Press, which PATH is distributing in partnership with the Ugandan Ministry of Health, also helps to solve another vexing problem for the women of Uganda: the opposition of controlling partners, who may be against birth control altogether. A discreet shot injected every three months is far easier to hide. "Some of [the husbands] are very bitter,” explains Rosemary Lamwaka, one of the nurses in Gulu teaching women how to self-inject Sayana Press. “They don’t want their wives to use family planning. They heard some local myths that family planning makes women barren. [Women] want Sayana Press [so they can] keep their secret very well, and they end up injecting when the man is not around.”
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And by reclaiming reproductive agency, the women of Gulu are, quite literally, fighting threats to their survival. Uganda has the 14th highest maternal mortality rate in the world, according to the United Nations Population Fund, with close to 11% of women of reproductive age dying in childbirth. The average Ugandan woman gives birth to nearly two more children than she'd like to have (6.2 versus 4.5), and more than four out of every 10 pregnancies in the country are unplanned.

This lack of control over one’s reproduction isn’t just about having more kids than one would like or not being able to plan for one's future; it’s also about being pregnant against one's will in a country where that’s a huge risk to one's life, due to poor health infrastructure (like a lack of hospitals in which to safely give birth), and severe restrictions to abortion. In 2008, the Ugandan Ministry of Health estimated that abortion-related causes were responsible for 26% of the country's maternal mortality.

Birth control is the key to driving down all of these numbers — the Guttmacher Institute estimates that Uganda’s maternal mortality rate would drop by 40% if its needs for family planning were met — and Sayana Press seems particularly poised to help.

Some of [the husbands] are very bitter…They heard some local myths that family planning makes women barren. [Women] want Sayana Press…and they end up injecting when the man is not around.

Rosemary Lamwaka
The other birth control shot available in Uganda, Depo-Provera (Depo for short), accounts for some 40% of the contraceptives used in Uganda and other countries in East and South Africa. Like Sayana Press, Depo provides three months of protection and is relatively easy for clinic workers to administer. That is, if the community has a clinic.

Sayana Press takes the benefits of Depo further in that it can be made available in even the smallest, most rural, and most poverty-stricken villages in Uganda. In those villages, which are the least likely to have clinics, village health teams (VHTs) can step in and help with distribution.

VHTs, which have been around since the early 2000s, are part of a government project to train locals in rural villages to share knowledge and distribute basic health tools, such as condoms and malaria-fighting mosquito nets. These volunteers drive, bike, or walk to health centers to get these supplies for their communities, and the idea is that they will pick up Sayana Press when they do so, saving women the trouble.

It hasn’t been totally seamless. “When it rains, the roads are bad and cannot be accessed,” one VHT reports. “The distance is very long to the health center. At times, the bicycle gets mechanical problems.”

But the key here is that the new injection system is what makes distributing birth control in this way at all possible: Depo needs to be injected into the muscle, which requires skillful administration by another person. Sayana Press is injected just under the skin. What’s more, it’s tiny, doesn’t require assembly, and is easily disposable.

Plus, many women like Sayana Press better: Because it’s injected under the skin, it’s less painful than Depo. It also contains just two-thirds the progestin per dose of Depo, meaning its side effects may be less intense than those of Depo, which include irregular bleeding, weight gain, and headaches.

"I was using Depo before, but when Sayana came in, I changed," Lamwaka says. "The difference is that with Depo, it used to make me fat." She laughs. "When I came to Sayana, I don’t have any side effects."

To prove the method’s potential, PATH launched studies with around 380 participants in Uganda and 380 participants in neighboring Senegal — and the results so far are promising. While findings from Senegal are still forthcoming, most women in the studies in Uganda — around 95% of them — self-injected proficiently after just one training session, and even three months later when they reinjected on their own at home, says PATH’s Uganda program director Emmanuel Mugisha, PhD.

And now Sayana Press is on track to become the birth control method of choice in neighboring countries Niger and Burkina Faso, as well. Thanks to a unique partnership between PATH, Pfizer, and the health ministries of these countries, women like Warom and Lamwaka in certain communities across sub-Saharan Africa (a region home to 62% of the world’s maternal deaths in 2013) are currently using Sayana Press, as well, with use expanding to even more women soon.
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Funding from the Gates Foundation and the Children’s Investment Fund Foundation is making Sayana Press available for $1 a dose to qualified purchasers, and hopefully by 2020, that price option will be extended to a projected total of 69 of the world’s poorest countries.

As the global health world enthuses over this unique partnership and its possibilities, some warn that relying on any one method of contraception is limiting and dangerous. “Self-injectables, like other new technologies, hold a lot of promise,” says Beirne Roose-Snyder, director of public policy for the Center for Health and Gender Equity, an organization that works to protect sexual and reproductive rights globally. But her point is that if a woman uses Sayana Press not because she has decided it’s the best method for her, but because she has no other choices, it has failed to live up to its promise.

For example, nothing can replace condoms, which are key for stopping the spread of STIs. (Lamwaka instructs all her Sayana Press trainees to continue to use condoms for this reason.) But also, even with Sayana Press’ many pluses, it’s not as though Sayana Press will work for every woman — perhaps because they prefer seeing a professional for their contraception or they simply don’t like needles. For those women, it’s important to keep pushing for other options.

Still, more women are using birth control simply because this is now an option. Birth control use overall has indeed increased in the countries in which PATH has introduced Sayana Press. According to Claire Hudson, PATH’s spokesperson at the time of our interview, some 74% of the women who first opted for it in Niger after it was introduced there had never used birth control. (The maternal mortality rate in Niger is 630 deaths per 100,000 live births, making it even higher than Uganda’s rate.)

“In just these studies [in Niger, Senegal, and Uganda], 30 to 60% of the women who accepted Sayana Press were actually new to family planning,” adds Nomi Fuchs-Montgomery, deputy director of the Family Planning Program at the Bill and Melinda Gates Foundation. “If I could look into a crystal ball, I would say that there is just such incredible potential to drive towards more user-controlled methods, and injectables are a perfect way to do that.”

In Gulu, Warom is enjoying the autonomy Sayana Press has so far provided her as she plans for her future. She knows she would like to have more children eventually, but there is so much else she'd like to do, too. "I did a fashion design diploma," she says. "I want to open a boutique.” Now that she is in control of her fertility, her odds have never been better.
This reporting was made possible in part by press fellowships to the 2016 International Conference on Family Planning and Women Deliver 2016 granted to the author by the United Nations Foundation and Women Deliver via Global Health Strategies, respectively.
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