Lessons from Ghana to Inform DMPA-SC Safe Storage and Disposal

The Ghana Health Service (GHS) collaborated with The Evidence Project, led by the Population Council, to conduct a feasibility and acceptability study on home-based self-injection. The study aimed to understand storage and disposal practices in a context where at-home disposal in pit latrines and open spaces is explicitly not allowed. The study was conducted in rural, peri-urban, and urban areas within two regions of Ghana—Ashanti and Volta. A total of 150 family planning providers were trained on DMPA-SC counseling and administration, including how to teach clients to self-inject correctly. Clients who chose DMPA-SC as their contraceptive method were offered the option to be trained by the provider on self-injection. After self-injection instruction and assessment by the provider, the client was permitted to self-inject under provider supervision and given two doses of DMPA-SC to take home for future self-injections. Self-injection clients were also given information on DMPA-SC safe storage and disposal, which included instructions to store the Uniject devices in a cool, dry area at room temperature, dispose of them in a puncture-proof container, and return that container to a facility when it was full or when the woman needed a refill of DMPA-SC. Each client was provided a puncture-proof container that could hold up to 5 used Uniject devices. The study found that nearly all women reported storing the Uniject devices as instructed in a cool, dry area at room temperature (96% after third injection) and found this easy to do (94%). Women were able to keep DMPA-SC out of reach of children, and they were successful in keeping the devices away from family members for privacy, if desired. The study also found that almost all women reported correctly disposing the devices in a puncture-proof container (98% after 6 months) and found this easy to do (96%). However, some disposed of it in the toilet and reported that they were told by providers to do so if they were not given a container. Others who were not provided with a container mentioned being told by providers to keep the used syringes in a tin. The study demonstrated that with proper training, women are able to safely store and dispose DMPA-SC. The findings are relevant for other countries that seek to expand access to DMPA-SC through self-injection while addressing safety and ecological hazards associated with disposal of used sharps into pit latrines and open space disposals. The study led the GHS to include containers in nation-wide scale up plans for home self-injection of DMPA-SC. Emergent promising practices include the provision of DMPA-SC for home self-injection should include containers for safe disposal of used Uniject devices. Puncture-proof containers provided in this study were discreet and could hold up to five Uniject devices. If containers are not available, providers should discuss alternatives that do not involve throwing the used devices in a pit latrine or an open space. Providers can describe other household containers that women likely already have, such as petroleum jelly containers made of plastic with screw-top lids, that could be used as a safe alternative. Increasing options beyond returning filled containers to the health facility can also facilitate proper disposal. Alternatives such as pick up by community health workers who are already visiting the household for other reasons, or bringing filled containers to a convenient drop-off point such as a pharmacy or other nearby facility, may avert added transportation time and costs.