Safety and Acceptability of Community-Based Distribution of Injectable Contraceptives: A Pilot Project in Mozambique

Nearly one-third of married women in Mozambique have an unmet need for family planning, but the supply of family planning services is not meeting the demand. The preferred method for future contraceptive use is injectable contraceptives, with over 42% of women of reproductive age expressing a desire for this method. However, only 4.3% of all women were using injectable contraceptives in 2011, suggesting an unmet need. Access to contraception itself increases use, and in Mozambique, rural women find themselves cut off from access to family planning services due to a shortage of health facilities. The Mozambique Ministry of Health (MOH) approved the revitalization of the national CHW program in 2010, recognizing the critical importance of CHWs to expand access to basic primary health care services to communities. Some CHWs, called agentes polivalentes elementares (APEs), focus on improving the health of the community primarily through health promotion and prevention activities. Historically, APEs have not provided family planning services, although some APEs provided contraceptives informally. In 2016, APEs will offer a new package of services that includes provision of pills, condoms, and injectables. The MOH trained 2,270 APEs on this new family planning package in December 2013. Mozambique's Family Planning Strategy 2010-2014 was released at the same time the APE program restarted, recognizing the need for community involvement and participation to improve universal access to family planning services. The strategy also addressed the potential role of traditional birth attendants (TBAs) in the provision of family planning counseling and select methods. A pilot study conducted in Senegal successfully included matrones, or trained TBAs, to distribute injectables. Although policy makers are supportive of CBD in Mozambique, there is limited country-specific experience on best practices, so stakeholders have called for operations research in Mozambique. In response to the call for more research, a pilot study was conducted to determine whether APEs and TBAs could safely and effectively administer the injectable contraceptive depot-medroxyprogesterone acetate (DMPA), with high client acceptability, among women in 2 rural districts. The study was conducted in 2 districts in northern Mozambique, Chiure and Montepuez, from February 2014 to April 2015. The intervention was designed so that TBAs served clients in Montepuez and APEs served clients in Chiure. A total of 1,432 women enrolled in the study, with the majority (63% to 66%) of women starting to use contraception for the first time during the study period. Most women (over 66%) did not report side effects at the 3-month and 6-month follow-up visits, and very few (less than 0.5%) experienced morbidities at the injection site on the arm. Satisfaction with the performance of TBAs and APEs was high and improved over the study period.