From Awareness to Autonomy: Exploring the Knowledge Gap and Acceptability of Self-Injectable DMPA-SC among Women in Central India

Abstract

Background:

Self-administered subcutaneous depot medroxyprogesterone acetate (DMPA-SC) provides a novel contraceptive modality that can expand access, autonomy, and continuation rates, especially among low-resource populations. While endorsed worldwide, the use and awareness of DMPA-SC in India remain undocumented.

Objectives:

To assess awareness, acceptability, and willingness toward self-administration of DMPA-SC among married women of reproductive age in central India.

Methods:

A cross-sectional survey was conducted among 320 women aged 18–49 years at a tertiary hospital in central India. Data were collected through pretested questionnaires assessing sociodemographic factors, contraceptive history, knowledge of intramuscular DMPA (DMPA-IM) and DMPA-SC, and willingness for self-injection.

Results:

While 90% had heard of DMPA-IM, no participant had heard of DMPA-SC before. Despite this, 78% showed interest in learning about DMPA-SC and were ready to self-administer after demonstration (62.5%). The most prominent motivators were saving time (37.5%) and decreasing travel expenses (18.8%). Barriers for using DMPA were fear of side effects and myths like infertility or chances of abortion.

Conclusion:

DMPA-SC awareness does not exist among women in central India, but acceptability for self-injection is high when accompanied by education. Inclusion within India’s family planning basket, combined with systematic training for community health workers and information, education, and communication interventions, can increase contraceptive accessibility and autonomy.

INTRODUCTION

Depot medroxyprogesterone acetate (DMPA) is a widely used injectable contraceptive that comes in two formulations: intramuscular (DMPA-IM) and subcutaneous (DMPA-SC). DMPA-IM is most typically administered by healthcare providers, while DMPA-SC has the potential for self-administration.[1] The latter is an attractive and liberating option, allowing women to take control of their contraception with minimal need for repeat attendance at the clinic. Despite these advantages and endorsements by organizations such as the World Health Organization and the Centers for Disease Control and Prevention, DMPA-SC use is low, especially in low-resource settings such as central India.[2,3]

The COVID-19 pandemic has put into focus the various scalable healthcare options, including those related to family planning and contraceptive care. Non-urgent care at most healthcare facilities during the pandemic was limited, with regular contraceptive services being deprioritized on various occasions.[4] The disruption had the effect of illuminating self-administered options like DMPA-SC, which offer sustained contraceptive protection without individual visits. Self-administration with DMPA-SC has, according to studies, greater continuation than DMPA-IM administered in the clinic, and is hence an important alternative for maintaining contraceptive protection and reducing unwanted pregnancies.[5,6,7]

Various international studies have addressed DMPA-SC acceptability and feasibility. For instance, one program in Benin began community-based provision of DMPA-SC with promising results, with wider use possible in similar settings.[8] In Nigeria, users accessed DMPA-SC from public and private sources, with satisfactory utilization being reported.[9] In a similar fashion, a pilot study in the rural province of Lualaba, Democratic Republic of the Congo (DRC), found that community health workers’ provision of DMPA-SC was well-accepted by acceptors.[10] These studies indicate that with appropriate support and education, DMPA-SC could be implemented efficiently in community-based health programs.

Self-administration of DMPA-SC has been shown by systematic review and meta-analysis to improve contraceptive outcomes, with greater continuation and satisfaction among users.[11,12] Another prospective cohort study from Senegal again showed self-injection to be practical and acceptable, reinforcing the potential benefits of self-administration.[13] The pandemic has underlined the role that DMPA-SC plays toward equitable access to contraceptive care, with rising interest and take-up during health emergencies.

DMPA-SC has significant advantages, including reduced progestin content than DMPA-IM, yet sharing similar efficacy. In Nigeria, self-injection with DMPA-SC has seen greater momentum, signifying a paradigm shift in contraceptive practice.[9] A randomized controlled Malawian study confirmed that self-administration with DMPA-SC led to greater continuation than provider-administered injections.[14] Observations from other nations like Burkina Faso, DRC, and Uganda similarly indicate rising acceptance and usage of DMPA-SC.[9,10] Adolescent women with unmet family planning needs have indicated a favorable attitude regarding DMPA-SC, signifying how it could meet the contraceptive gap among adolescent women. Additionally, DMPA-SC supplement preparations have emerged, ensuring greater family planning options, improving wider availability and utilization. Despite global support, evidence is limited regarding awareness and willingness toward self-administrating DMPA-SC among population groups from India. The study bridges this gap by studying such factors among central Indian women.

Urban central India remains sparingly represented in studies related to contraceptive research despite having high unmet need groups for modern methods of spacing. Most research studies related to the usage of injectable contraceptive have been conducted in the southern and northern regions of India.[15,16,17] Therefore, the present study assessed factors influencing acceptance and promotion among women regarding DMPA-SC by using the urban field practice site of a central Indian tertiary care hospital. The identification of such factors helps to formulate strategies that sustain the use of DMPA-SC, thereby expanding contraceptive access and autonomy for women in central India.

METHODS

A cross-sectional observational survey was conducted among reproductive-age married women (18–49 years) at a tertiary healthcare institution to assess the acceptability of DMPA-SC. Data were collected between June 2020 and December 2022. A questionnaire that was previously validated and pretested was administered by face-to-face interviews. The questionnaire took detailed data such as demographic information, obstetric history, knowledge about DMPA, preference/dispreference for injectable DMPA with their respective rationales, and awareness about DMPA-SC.

All married women aged 18–49 years who visited the outpatient department of Obstetrics and Gynecology took part. Women unable to provide informed consent were excluded. As this was an exploratory cross-sectional study evaluating awareness and acceptability of a relatively novel contraceptive modality, a formal sample size calculation was not performed. Consecutive eligible women attending the outpatient department during the study period were invited to participate using convenience sampling. A total of 320 complete responses were available for final analysis.

The questionnaire data were collected through face-to-face interviews conducted by trained investigators. As none of the participants had prior knowledge of DMPA-SC, a standardized counseling and demonstration session regarding self-injectable DMPA-SC was provided after completion of the questionnaire. The demonstration consisted of a 10–15 min counseling session conducted by a trained obstetrician or family planning counselor using the Uniject device model, covering the injection site, administration technique, storage requirements, disposal methods, timing of repeat injections, and management of missed doses. Participants were subsequently asked regarding their willingness to learn about and self-administer DMPA-SC. Interviews were conducted behind closed doors at the hospital to ensure confidentiality and openness. Operational definitions used in the study are stated below:

• Awareness: Participant had heard of DMPA-SC before the interview.

• Acceptability: Participant expressed interest in learning or considering DMPA-SC after counseling.

• Willingness to self-inject: Participant agreed to self-administer DMPA-SC after demonstration.

The questionnaire data were entered into SPSS version 22 software for analysis. Descriptive statistics condensed the demographic information, while Chi-square tests and analyses identified factors associated with preference for and awareness of DMPA-SC. Ethical clearance for conducting the study was provided by the institution’s ethics committee, and informed consent was provided by all participants before participation.

RESULTS

A total of 370 women attending the outpatient department were screened for eligibility during the study period. Of these, 28 declined participation and 12 did not meet the eligibility criteria. Consequently, 330 women provided informed consent to participate in the study. Ten questionnaires were excluded because of incomplete responses, resulting in a final analytical sample of 320 participants [Figure 1].

Figure 1.

STROBE participant flow diagram showing screening, exclusion, consent, and final inclusion of study participants. STROBE = Strengthening the Reporting of Observational Studies in Epidemiology

The mean age of the study participants was 29.4 ± 5.1 years. The majority of participants belonged to the 26-30 years age group (37.2%), followed by the 31–35 years age group (27.8%). Overall, 41.6% of participants were older than 30 years. All study participants were literate, with 53.4% (171/320) having completed graduation or higher education. Approximately 57.8% (185/320) of participants resided in rural areas, while 44.7% (143/320) were employed. The baseline characteristics of the study participants are presented in Table 1.

Table 1.

Demographic and fertility statistics profile of respondents (n=320)

Characteristic		Group		Number (n)		Percentage (%)
Age (in years)		<20 21–25 26–30 31–35 >35		8 60 119 89 44		2.5 18.8 37.2 27.8 13.8
Education		Illiterate Primary Middle Secondary Higher secondary Graduate and above		0 6 6 56 81 171		0 1.9 1.9 17.5 25.3 53.4
Residence		Urban Rural		135 185		42.2 57.8
Employment status		Unemployed Employed		177 143		55.3 44.7
Type of family		Joint Nuclear		106 214		33.1 66.9
Duration of marriage		<1 year 1–5 years 6–10 years >10 years		57 118 63 82		17.8 36.9 19.7 25.6
Age at marriage		21–30 years >30 years		243 77		76 24
Menstrual cycles		Regular Irregular		227 93		70.9 29.1
Number of living children		0 1 2 3 and more		34 126 92 68		10.6 39.4 28.7 21.3

A total of 270 women (84.3%) were multiparous, including 10 women (3.1%) who were grand multiparous. The majority of participants (68.8%) had two or three living children. Previous use of any contraceptive method was reported by 240 women (75.0%), with condoms being the most commonly used method (120/320, 37.5%), followed by oral contraceptive pills (60/320, 18.8%) [Table 2].

Table 2.

Obstetric history of study participants (n=320)

Variable		Frequency (n)		Percentage (%)
a. Number of pregnancies
0–1		50		15.6
2–3		200		62.5
4–5		60		18.8
>5		10		3.1
b. Previous contraceptive use
Yes		240		75
No		80		25
c. Current contraceptive method
Condoms		120		37.5
Oral contraceptive pills		60		18.8
Intrauterine device		40		12.5
DMPA-IM		80		25
None		20		6.3

DMPA-IM=intramuscular depot medroxyprogesterone acetate

The majority of participants were aware of DMPA-IM (90.0%, 288/320; range: 86.7%–93.3%); however, none had prior awareness of the subcutaneous formulation (DMPA-SC) [Figure 2]. A total of 80 (25.0%) participants reported current or previous use of DMPA-IM, whereas 240 (75.0%) participants had never used injectable contraception. Among women using injectable contraception, the commonly cited reasons for preference included convenience, ease of use, privacy, and long-acting contraceptive protection.

Figure 2.

Knowledge and awareness of DMPA-IM and DMPA-SC (N = 320). DMPA = depot medroxyprogesterone acetate, DMPA-IM = intramuscular DMPA, DMPA-SC = subcutaneous DMPA

During face-to-face interviews, participants’ knowledge regarding DMPA-IM was further explored. Overall, 71.2% (228/320) correctly identified that repeat injections were administered at 3-month intervals, while 46.6% (149/320) were aware that fertility returns following discontinuation of DMPA, although with a variable delay. Approximately 40.0% (128/320) correctly recognized that DMPA can be safely used during breastfeeding. However, misconceptions regarding injectable contraception were common: 75.9% (243/320) believed that DMPA could cause permanent infertility, and 30.6% (98/320) believed that its use could result in abortion in subsequent pregnancies [Table 3].

Table 3.

Knowledge of study participants regarding DMPA-IM (n=320)

Variable		Number (n)		Percentage (%)
Ideal interval between two doses
Gap of 3 months		228		71.2
More than 3 months		50		15.7
Do not know		42		13.1
How long does it take to become pregnant after discontinuing DMPA?
After 1–2 months		149		46.6
After 3–6 months		56		17.5
After 1 year		77		24.1
Do not know		38		11.9
Can a woman who is breastfeeding safely use DMPA?
Yes		128		40
No		115		35.9
Do not know		77		24.1
Does DMPA make a woman infertile?
Yes		243		75.9
No		57		17.8
Do not know		20		6.2
Does DMPA cause abortion?
Yes		98		30.6
No		183		57.2
Do not know		39		12.2
Source of information about injectable contraceptive method (DMPA)
Healthcare provider		78		24.4
Media (social and print)		164		51.2
Relatives and friends		78		24.4

DMPA=depot medroxyprogesterone acetate

Among women reporting previous or current use of injectable contraception, convenience (120/320, 37.5%) and ease of use (90/320, 28.1%) were the most frequently cited reasons for preference [Figure 3]. Conversely, concern regarding side effects (100/320, 31.3%) and fear of injections (80/320, 25.0%) were the most common reasons for not preferring injectable contraception [Figure 4].

Figure 3.

Reasons for preferring injectable DMPA-IM (N = 320). DMPA-IM = intramuscular depot medroxyprogesterone acetate

Figure 4.

Reasons for not preferring injectable DMPA (N = 320). DMPA = depot medroxyprogesterone acetate

Of the 320 participants, 250 (78.0%) expressed willingness to learn about DMPA-SC, while 200 (62.5%) were willing to self-administer the method. The most commonly reported reasons for choosing DMPA-SC were saving time (37.5%), followed by reducing travelling expenses (18.8%), and avoiding missed work (15.6%) and multiple hospital visits (15.6%) [Table 4].

Table 4.

Willingness to learn about and use DMPA-SC (n=320)

Variable		Frequency (n)		Percentage (%)
Willingness to learn about DMPA-SC
Yes		250		78
No		70		22
Willingness to self-administer DMPA-SC
Yes		200		62.5
No		120		37.5
Reason for selecting DMPA-SC
Save time		120		37.5
Decrease travel expenses		60		18.8
Avoid missing work		50		15.6
Avoid multiple hospital visits		50		15.6

DMPA-SC=subcutaneous depot medroxyprogesterone acetate

None of the participants had prior awareness of self-injectable DMPA-SC. Following a standardized counseling and demonstration session conducted by a trained healthcare provider using the Uniject device model, participants were introduced to the concept of self-administration, including injection technique, injection site, storage requirements, disposal procedures, timing of repeat injections, and management of missed doses. After this demonstration, many participants expressed interest in learning more about this contraceptive option and perceived self-administration as a potentially convenient approach because of reduced travel requirements, improved privacy, and greater flexibility in accessing contraception.

DISCUSSION

This study was conducted with the goal of understanding awareness, interest, and potential acceptability among married women of reproductive age residing in central India toward DMPA-SC. In India, DMPA-IM has been available free of cost through the Government of India’s Antara Programme since July 2017 as part of the National Family Planning Programme. The Antara Programme has expanded access to injectable contraception through public health facilities and frontline healthcare workers.[18] However, self-administered DMPA-SC has not yet been incorporated into routine public-sector family planning services, and evidence regarding women’s awareness and willingness to adopt self-injection remains limited, particularly from central India. The study revealed a stark gap between universal awareness about DMPA-IM and an absolute lack of awareness concerning DMPA-SC. Despite such lack of awareness, most women demonstrated widespread interest in learning more about DMPA-SC and self-administration of the injection provided appropriate training is given. These findings indicate an immediate need and future potential for introducing DMPA-SC as a self-administrated contraceptive method within the public health policy of India. This gap in awareness and the latent interest in DMPA-SC must also be understood within the broader context of contraceptive method preferences and usage patterns currently prevalent among the population. Condoms are most prevalent because they are widely available, non-intrusive, and instantly reversible, despite increased awareness of injectable contraceptive methods such as DMPA-IM. This pattern is consistent with national trends from national family health survey 5, where male condoms remain prevalent among modern contraceptive use in urban population groups.[19,20]

Interpreting these use patterns provides insights on the practical barriers with existing methods like DMPA-IM and sheds light on the potential advantages of adopting more user-friendly alternatives like DMPA-SC. One major barrier to continued DMPA-IM use is that it requires monthly in-person visits, often occasioning time, out-of-pocket transportation, and scheduling problems, particularly among rural or resource-scarce locations. These barriers were even greater during the COVID-19 pandemic, which suspended routine reproductive health services and underscored the need for more accessible, user-based contraceptive options. DMPA-SC, by virtue of simplified injection regimens and the potential for self-administration, directly addresses these barriers. It accesses avenues toward increased contraceptive autonomy, increased continuation, and broader availability, especially among hard-to-reach locations.[11,21] In the present study, although DMPA-IM was commonly known, no respondent reported prior awareness or exposure to DMPA-SC. This finding is in alignment with broader global trends, where awareness of DMPA-SC as a self-injectable contraceptive remains low despite its operational advantages. Although market research commissioned by the Ipas Development Foundation and several Indian studies have explored perceptions of DMPA-SC self-administration and experiences with injectable contraception under the Antara Programme, published evidence specifically evaluating awareness and willingness toward DMPA-SC self-injection among women attending public tertiary care facilities in central India remains limited.[22,23] For instance, Ontiri et al. (2023) highlighted substantial missed opportunities for promoting DMPA-SC awareness in Uganda and Nigeria, with over one-third of family planning clients in both countries receiving no information on the method despite its availability.[24] Similarly, Wood et al. (2022) reported that although injectable contraceptives were widely known (over 80% awareness), only a few women (13%–25%) across settings such as Burkina Faso, DRC, Kenya, and Nigeria had heard of the self-injection option for DMPA-SC.[25] These findings emphasize the critical need for robust, community-level awareness and provider-driven communication to support DMPA-SC adoption, a strategy highly relevant for potential rollout in India.

Global evidence confirms that lack of awareness is the principal barrier to DMPA-SC use, and not user reluctance. Osinowo K (2021) in Nigeria showed that awareness regarding DMPA-SC was low (<25%), but acceptability took off with counseling and demonstration examples, with over 80% expressing desire for self-administration.[26] Similarly, Ali et al. (2023) from Malawi showed high enthusiasm among adolescent girls and young women, particularly because of the convenience and privacy of the method.[27] These commonalities across varied settings reflect that with appropriate communication and provider support, DMPA-SC can gain ground even among those with no previous exposure.

Here, DMPA-SC acceptability fits with the rising international evidence supporting its practicality and effectiveness. Burke et al. (2022) and Ali et al. (2023) have indicated that users of DMPA-SC—particularly those trained in self-injection—demonstrate greater continuation rates and satisfaction compared with those dependent on provider-administered DMPA-IM.[26,27] In Malawi, 12-month continuation was at 73% among self-administrating DMPA-SC users compared with just 45% among DMPA-IM users administered at the clinic.[27] In Uganda and Senegal, comparable trends have emerged with pilot programs attaining greater contraceptive use, reduced travel-associated cost, and minimal administration blunders among self-administrators.[28,29]

Apart from user acceptability, the drug and logistics advantages of DMPA-SC compared with DMPA-IM are established. DMPA-SC is delivered with a prefilled device with a small gauge needle that results in minimal pain upon injection. It is also given with a low progestin dose (104 mg) compared with DMPA-IM (150 mg), but with comparable contraceptive efficacy and protection duration.[29] These features are especially ideal for self-administration and program distributions at the community level.

Another advantage realized by international literature is the potential for task-shifting. Liu et al. highlighted community health extension workers enhancing access to DMPA-SC, particularly among rural and hard-to-reach groups. Their model directly applies to the large accredited social health activist (ASHA) and auxiliary nurse midwife (ANM) network of India and could be enabled with the right training modules and supervision to educate, counsel, and support women with self-injection.[30] Correct supervision and right training modules could significantly improve outreach and reduce facility burden, particularly considering the overworked public health facilities of India.

Despite these obvious advantages, numerous concerns have been voiced by respondents during this research. Most prevalent among these concerns was fear of the injection, potential pain, and uncertainty regarding proper safe self-administration. These concerns are mirrored by those voiced by respondents during studies conducted in Ghana, Malawi, and Ethiopia, where such fears have rightly been dissipated during targeted structured sessions of instruction and follow-up support. Most respondents also revealed misconceptions, such as beliefs that DMPA would lead to infertility or abortion. These myths are important barriers among potential users of contraceptive methods and highlight the value of including targeted information, education, and communication efforts designed to eliminate such misconceptions.

Our analysis also reveals that provider-level and systemic barriers are at the same level of significance as user-level barriers. As with the analysis of Liu et al., quality of counseling and provider interaction significantly influenced user satisfaction and uptake.[30] Clients who accessed care through private channels reported significantly better counseling experiences than those who accessed care through public facilities.[31] Although we could not stratify by provider category, the message is simple: effective implementation of DMPA-SC in India will require more than user awareness, but provider training and systems should be established.

Despite high acceptability among women for the use of DMPA-SC after demonstration, there is significant justification for its addition to the primary healthcare contraceptive basket for India. Inclusion of DMPA-SC would expand options and improve reproductive autonomy, especially in low-utilization areas. ASHAs and ANMs should be provided with systematic training for educating, counseling, and demonstrating self-injection among eligible women. This task-sharing model, which has been successfully implemented in numerous African countries, could expand reach and sustainability. International evidence supports task-sharing models for DMPA-SC implementation. In Kinshasa, DRC, medical and nursing students successfully trained women in self-injection with high competency and acceptability, demonstrating that non-physician cadres can effectively support self-injection programs. Similar competency-based training could be adapted for India’s existing ASHA and ANM workforce, who already play a central role in contraceptive counseling under the National Family Planning Programme.[32] National guidelines should additionally address procurement, cold chain logistics, and surveillance to ensure proper scale-up through the public health system. Safe disposal of discarded injection devices must also be addressed with community-level interventions like provision of puncture-proof containers and ASHA training for facilitating removal or supervised disposal with reference to the biomedical waste guidelines.

This study makes a new contribution by sharing this awareness gap in central India, where even information regarding DMPA-SC is remarkably scarce. Moreover, it reveals the adoption potential among a population often exempted from self-care technologies—married rural women with low prior exposure to health technologies. Importantly, their openness to self-injection after brief education evidenced the potential of user-centered approaches.

The present study has certain limitations. Participant-level linkage between sociodemographic characteristics and willingness to self-administer DMPA-SC was not retained, precluding inferential analyses to identify predictors of self-injection willingness. The use of convenience sampling at a single tertiary care center may limit the generalizability of the findings. In addition, the cross-sectional design did not permit assessment of actual self-injection practices, continuation rates, or long-term behavioral outcomes. As willingness was assessed immediately following counseling and demonstration, the findings may not necessarily reflect actual uptake in routine practice. Furthermore, face-to-face interviews may have introduced social desirability bias, and the influence of male partners and family members on contraceptive decision-making was not evaluated. Future longitudinal community-based studies are required to assess real-world implementation and long-term acceptability of self-injectable DMPA-SC.

CONCLUSION

The present study highlights a substantial awareness gap regarding self-injectable DMPA-SC among women attending a tertiary care center in central India, despite high awareness of DMPA-IM available under the Antara Programme. The favorable response observed following counseling and demonstration suggests that DMPA-SC represents an acceptable and feasible extension of existing injectable contraceptive services for appropriately selected women. Integration of structured counseling, provider training, and community-based education initiatives may facilitate informed choice and improve access to self-injectable contraception. Further implementation studies are required to evaluate long-term acceptability, continuation, and programmatic feasibility in the Indian context.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.