Injectables Toolkit
Essential Knowledge About
Injectable Contraceptives
Fonda Kingsley, MHS
Johns Hopkins Bloomberg School of Public Health
Center for Communication Programs
Knowledge for Health (K4Health) Project
Ruwaida M. Salem, MPH
Johns Hopkins Bloomberg School of Public Health
Center for Communication Programs
K4Health Project
October 2010
Suggested citation: Kingsley F and Salem RM. (2010) Essential Knowledge About Injectable Contraceptives. Injectables
Toolkit. Available: http://www.k4health.org/toolkits/injectables/essential-knowledge-about-injectables
www.k4health.org/toolkits/injectables
Contents
Method Characteristics ............................................................................................................................. 3
Composition ........................................................................................................................................... 3
Injection Schedules ................................................................................................................................ 4
Effectiveness .......................................................................................................................................... 4
Return to Fertility .................................................................................................................................... 4
Mechanism of Action .............................................................................................................................. 4
Side Effects ............................................................................................................................................ 4
Non-Contraceptive Health Benefits ........................................................................................................ 6
Health Risks ........................................................................................................................................... 7
STI-Related Health Risks ....................................................................................................................... 7
Client Knowledge and Attitudes ................................................................................................................ 8
Knowledge About and Use of Injectables ............................................................................................... 8
Satisfaction with Injectables ................................................................................................................... 8
Counseling and Informed Choice .............................................................................................................. 9
Training of Injectable Providers ................................................................................................................. 9
Service Delivery ...................................................................................................................................... 10
Who Can Provide Injectables ............................................................................................................... 10
Who Can Use Injectables ..................................................................................................................... 10
Availability and Access ......................................................................................................................... 11
Modality of Provision ............................................................................................................................ 11
Initiating Injectables.............................................................................................................................. 12
Follow-Up Visits ................................................................................................................................... 13
Medical Barriers ................................................................................................................................... 13
Provider Perspectives .......................................................................................................................... 13
Cost Considerations ............................................................................................................................. 14
Safe Injection and Waste Disposal....................................................................................................... 14
Logistics: Commodities, Supplies, and Instruments ................................................................................ 15
Marketing and Communication ............................................................................................................... 15
Key Guidance Documents ...................................................................................................................... 16
Bibliography ............................................................................................................................................ 17
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Essential Knowledge About Injectables
Injectable contraceptives are a safe, highly effective, long-lasting, reversible method of
contraception that can be used privately and does not require action at the time of sex. This
review presents the latest biomedical, social science, and programmatic knowledge about
injectable contraceptives as of July 2010. The information pertains to all types of progestin-only
and combined injectables currently available, unless otherwise specified.
Method Characteristics
Composition
Women interested in using injectable contraceptives can choose between progestin-only
injectables or combined injectables. (Combined injectables contain both progestin and estrogen.)
Both types of injectables come in several formulations (see Table 1, below). Most family planning
programs offer a progestin-only injectable, either DMPA (depot medrosxyprogesterone acetate)
or NET-EN (norethisterone enanthate). Many also offer a combined injectable, such as Cyclofem.
Most injectable formulations are given by injection into the muscle (intramuscular injection) either
into the woman’s hip, upper arm, or buttocks, but a new formulation of DMPA was developed to
be injected into the tissue just under the skin (subcutaneously). DMPA given subcutaneously is
just as effective and has similar side effects as DMPA injected intramuscularly.30, 32
Table 1. Injectable Contraceptives: Formulations and Injection Schedules30, 32
Common
Formulations
Injection Type
Trade Name
and Schedule
Progestin-Only Injectables
Depo-Provera®,
Depot
One intramuscular (IM)
®
®
Megestron , Contracep ,
medroxyprogesterone
injection every three months
Depo-Prodasone®
acetate (DMPA) 150 mg
depo-SubQ provera 104®
DMPA 104 mg
(DMPA-SC)
Noristerat®, Norigest®,
Norethisterone enanthate
®
Doryxas
(NET-EN) 200 mg
Combined Injectables (progestin + estrogen)
Cyclofem®, Ciclofeminina®, Medroxyprogesterone
Lunelle®
acetate 25 mg + Estradiol
cypionate 5 mg
(MAP/E2C)
Mesigyna®, Norigynon®
NET-EN 50 mg + Estradiol
valerate 5 mg (NETEN/E2V)
®
®
Deladroxate , Perlutal ,
Dihydroxyprogesterone
Topasel®, Patectro®,
acetophenide 150 mg +
®
®
Deproxone , Nomagest
Estradiol enanthate 10 mg
®
®
Anafertin , Yectames
Dihydroxyprogesterone
acetophenide 75 mg +
Estradiol enanthate 5 mg
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One subcutaneous injection
every three months
One IM injection every two
months
One IM injection every
month
One IM injection every
month
One IM injection every
month
One IM injection every
month
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Injection Schedules
Women using progestin-only injectables must have an injection every three months for DMPA or
every two months for NET-EN. Women using combined injectables must have an injection once a
month (see Table 1, above).
It is important for women to try to be on time for the next injection because effectiveness depends
on getting injections regularly. However, DMPA injections can be given as much as two weeks
early and up to four weeks late, and NET-EN injections as much as two weeks early or two weeks
late.72 Injections of combined injectables can be up to one week early or late.69, 72
This guidance from the World Health Organization (WHO) is based on an analysis of data from a
study that followed 2,290 DMPA users for 24 months. The findings showed that of those women
who returned two to four weeks late for their re-injection, only one pregnancy was recorded. Thus,
the researchers concluded a grace period of up to four weeks for late DMPA injections does not
increase risk of pregnancy.56
Effectiveness
Injectables are highly effective at protecting against pregnancy. When injectables are used
correctly (that is, women have injections on time), injectables are more effective than female
sterilization. In the first year of use, on average, 3 among every 1,000 women using progestinonly injectables will become pregnant, and 5 among every 10,000 women using combined
injectables.58
As used commonly, 3 in every 100 women using injectables will become pregnant, making the
method less effective as commonly used than IUDs, implants and sterilization, but more effective
than oral contraceptives.58
Return to Fertility
Injectables are a reversible method of contraception; fertility returns after a woman stops using
injectables. On average, women who discontinue use of injectables take several months longer to
conceive than women who have used other methods. Women who stop using DMPA become
pregnant on average 10 months after their last injection. For NET-EN, women become pregnant
on average six months after their last injection, and for combined injectables, five months after
their last injection. 2, 39, 41, 46, 51
Mechanism of Action
Injectables work by slowly releasing hormones into the blood. This prevents pregnancy primarily
by preventing ovulation. Injectables also prevent pregnancy by thickening the cervical mucus,
which blocks sperm from meeting the egg thereby preventing fertilization.36, 42, 43, 67
Side Effects
Bleeding
Like other hormonal contraceptive methods, users of injectable contraceptives are likely to
experience bleeding changes. These bleeding changes are not harmful. Most women who use
progestin-only injectables (DMPA or NET-EN) have frequent or irregular bleeding during the first
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three months of use and then little or no monthly bleeding at one year of use. Amenorrhea (no
monthly bleeding) becomes more common the longer a woman uses DMPA. About 12% of
women experience amenorrhea after three months of use, 25% after six months of use, 37% after
nine months of use, and 46% after one year of use.26 Many women using progestin-only
injectables experience amenorrhea because the lining of the uterus does not thicken, ovulation
usually does not occur, and so there is no (or less) menstrual bleeding. NET-EN causes similar
changes to a woman’s bleeding patterns, but to a lesser degree.14, 20, 32, 76
Combined injectables are likely to change bleeding patterns unpredictably during the first three
months of use. Typically women using combined injectables report lighter monthly bleeding,
fewer days of bleeding, or irregular or infrequent bleeding.19, 76 Compared with progestin-only
injectables, combined injectables disturb vaginal bleeding patterns less. 38, 67 Irregular, frequent or
prolonged bleeding usually occurs less after three months of use and most women have regular
patterns (around 28 days from the start of a monthly bleeding to the next) after one year of use. 67
Thorough counseling about bleeding changes is critical because changes in menstrual bleeding
patterns are the most commonly reported side effect among injectable users and a common
reason given for the discontinuation of injectables use.6, 23, 25, 34 (See Counseling and Informed
Choice, p. 9.)
Bone Density
Progestin-only injectables, particularly DMPA injectables, are associated with a decrease in bone
density that is generally temporary and reversible. The amount of bone loss is somewhere
between 5% to 7% in the hip and spine. However, when women of reproductive age stop using
DMPA, they regain their bone mineral density over a short time period. Among adults who stop
using DMPA, after two to three years their bone density appears to be similar to that of women
who have not used DMPA.70
Two groups of women who are using progestin-only injectables may need special attention:
teenagers and women who enter menopause while using injectables. Teenagers are still making
bone in a way that adult women do not. Therefore, it is not clear whether the loss of bone density
during use of progestin-only injectables among teenagers prevents them from reaching their
potential peak bone mass. If there is a negative effect, this may lead to weaker bones and an
increased risk of fracture later in life. A recent study reports that bone mineral density loss among
female adolescents who use DMPA is substantially or fully reversible.24 Therefore, the chance is
small that the loss of bone density during use of DMPA will increase the risk of fracture later in
life.8, 10, 35, 47, 70
For older women who reach menopause while still using DMPA, there is concern that they may
not have the opportunity to regain their bone mineral density before entering the period of bone
loss normally associated with the postmenopausal period. 71
In light of this issue, WHO reviewed the evidence and recommends:

For women aged 18 to 45, there should be no restriction on the use of DMPA (and other
progestin-only injectables), including no restrictions on duration of use if otherwise eligible to
use the method (Medical Eligibility Criteria category 1; use the method in any circumstance).
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
For women under the age of 18 or over 45, WHO concludes the advantages of using DMPA
(and other progestin-only injectables) generally outweigh the theoretical concerns about bone
fracture risk for these women (category 2; generally use the method). WHO advises that these
women and their health care providers should consider the overall risks and benefits for
continuing use of the method over time because data are still insufficient to determine fracture
risk with long-term use of the method among these age groups.71, 75
Weight Gain
Both progestin-only and combined injectables are associated with weight gain. Women gain an
average of 1-2 kg/year when using DMPA. Some of the increase in weight may be due to the
usual gain in weight as people age. Not all women who use injectables gain weight; some have
no significant change in weight and some report weight loss during use. Asian women in
particular do not tend to gain weight when using DMPA.3, 20, 22, 76
Evidence suggests that adolescents using injectables gain more weight than adolescents using
oral contraceptives and those not using hormonal contraception.4 Furthermore, adolescent DMPA
users who are obese may gain more weight than adolescent DMPA users of normal weight. This
observation was not seen in adult DMPA users.12
Other Side Effects
Some women using progestin-only injectables have reported mood changes, such as depression,
and less sex drive, but the majority do not. Other side effects reported among users of either
progestin-only or combined injectables include headaches and dizziness. Abdominal bloating
and discomfort have been reported by users of progestin-only injectables and breast tenderness
has been reported by users of combined injectables. 7, 14, 29, 31, 67 There is no sufficient evidence
that any of these side effects are method-related, and thus, they may be due to other factors.
There is no evidence supporting the notion that use of injectables changes a women’s sexual
behavior.32, 76
Non-Contraceptive Health Benefits
Progestin-Only Injectables
In addition to protecting against pregnancy, DMPA also helps protect against cancer of the lining
of the uterus (endometrial cancer) and uterine fibroids. DMPA use may also help protect against
pelvic inflammatory disease and iron-deficiency anemia.1, 29, 66 NET-EN also protects against irondeficiency anemia. Additionally, DMPA use is known to reduce sickle cell crises among women
with sickle cell anemia, lessen symptoms of endometriosis (pelvic pain and irregular bleeding),
and decrease the frequency of grand mal seizures.20, 29 NET-EN may offer many of the same
health benefits as DMPA.
Combined Injectables
Long-term research studies on combined injectables are limited, but researchers expect that their
health benefits will be similar to those of combined oral contraceptives (COCs). Thus, it is
expected that combined injectables will protect against endometrial cancer, ovarian cancer, and
pelvic inflammatory disease. It is also expected that combined injectables may protect against
ovarian cysts and iron-deficiency anemia and will reduce the following: menstrual cramps,
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menstrual bleeding problems, ovulation pain, excess hair on face or body, symptoms of polycystic
ovarian syndrome, and symptoms of endometriosis. 29, 76
Health Risks
There are no known health risks to using progestin-only injectables. Long-term research studies
on combined injectables are limited, but researchers expect that their health risks are similar to
those of COCs.
COC use is associated with a very rare risk of blood clot in deep veins of legs or lungs (deep vein
thrombosis or pulmonary embolism) and an extremely rare risk of stroke and heart attack. A key
difference between combined injectables and COCs is that combined injectables do not pass
through the liver first because they are not taken by mouth like COCs. Short-term studies have
shown that combined injectables have less effect than COCs on blood pressure, blood clotting,
the breakdown of fatty substances (lipid metabolism), and liver function. Long-term studies are
underway.9, 60, 76
STI-Related Health Risks
STIs and Injectables
Injectables do not protect against sexually transmitted infections (STIs), including HIV. Users of
injectables who are at risk of STIs should use condoms along with the injectables to prevent STI
transmission. Some research indicates a possible increased risk of Chlamydia infection among
users of DMPA. The reason for this increase in risk is not clear.20, 37, 76 Research does not
suggest DMPA use increases risk of gonorrhea.20, 37
HIV/AIDS and Injectables
Research indicates that hormonal methods of contraception, including injectables, do not
increase the risk of becoming infected with HIV for women in the general population. 37, 47
Progestin-only injectables are safe and effective for women who have HIV, including those who
have AIDS and those taking antiretroviral (ARV) medications.32, 47, 62, 75, 76
Women who are infected with HIV, have AIDS, or are on ARV therapy can safely use combined
injectables. However, some ARV medications may reduce the effectiveness of combinedhormonal contraceptives. It is known that some classes of ARVs, including ritonavir-boosted
protease inhibitors, speed up processing of hormonal contraceptives in the liver. 15 This could
potentially lower hormone levels in the blood making the contraceptive less effective. Thus, the
updated WHO guidance from the April 2008 Expert Working Group meeting advises that women
with AIDS who are treated with ritonavir-boosted protease inhibitors generally should not use
combined hormonal methods including combined injectables (Medical Eligibility Criteria category
3). These women can use progestin-only injectables, implants, and other methods safely and
effectively. Women taking only other classes of ARVs can use any hormonal method safely and
effectively.75
Additionally, it has been suggested that women using ARVs should be especially urged to return
on time for re-injections. However, women who use ARVs and return late but are within two
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weeks (if using NET-EN) or 4 weeks (if using DMPA) of their re-injection date should not be
denied an injection.72, 75
Research findings have been mixed on whether hormonal contraceptives, including injectables,
speed up HIV disease progression.47, 50, 57 Although more research is needed, at this point there
has been no change in the guidance that women with HIV can safely use hormonal methods.
Furthermore, preliminary results from a multicenter study in Kenya, Thailand, and Zimbabwe
indicate there is no reason to advise women with HIV infection to avoid use of hormonal
contraception. This study is evaluating the impact of different contraceptive methods on the
clinical course of HIV infection to determine disease progression, the incidence of opportunistic
infections, and changes in CD4+ cell count and viral load. Early results from the study do not
suggest that there are large differences in disease progression according to type of contraceptive
method used.57 Another recent analysis on a group of women in Uganda also concluded no
increase in progression of HIV among hormonal contraceptive users, including women using
injectables.44
It is also not known whether women are more likely to transmit HIV if they are using hormonal
contraception. Women with HIV should continue using condoms even if they are also using
injectable contraception.11, 47, 50, 57
Client Knowledge and Attitudes
Knowledge About and Use of Injectables
Injectables are currently the fourth most popular contraceptive method worldwide. In sub-Saharan
Africa, injectables are the most popular method; among women using modern methods, 38% use
injectables.32 Levels of use, however, vary widely within regions. In some countries within subSaharan Africa, Asia, and Latin America and the Caribbean, over 40% of married contraceptive
users rely on injectables, while less than 5% use injectables in other countries. 32 Variations within
regions can be attributed to a variety of factors, including access to injectables, norms related to
contraceptive use, government policies, women’s tolerance for side effects, and communication
about injectables.32 According to recent Demographic and Health Surveys, most women
throughout sub-Saharan Africa, the Middle East and North Africa, Asia, and Latin America and
the Caribbean have heard of injectable contraception.32
Satisfaction with Injectables
Injectables are a popular choice among women because they are highly effective, long-acting,
reversible, and private.32
However, many women do not choose injectables or discontinue use mainly due to side effects—
particularly bleeding changes and weight gain—or because they have trouble returning for
injections.32, 33, 61 In a large multinational WHO trial, on average half of the women stopped using
DMPA and NET-EN within 12 months.65 In the United States, more women discontinue use of
injectables within 12 months than do those using oral contraceptives and the copper IUD. 58
Discontinuation rates for combined injectables are lower than those for progestin-only injectables
primarily because irregular bleeding patterns are less common with combined injectable use, and
they tend to decrease with length of use.61
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Counseling and Informed Choice
All individuals and couples have the basic human right to decide freely and responsibly the
number and spacing of their children and to have the information, education, and means to do so.
Under the Cairo Programme of Action, 180 governments have committed to "…provide universal
access to a full range of safe and reliable family-planning methods…" (para 7.16) and to
"…conform to ethical and professional standards in the delivery of family planning and related
reproductive health services aimed at ensuring responsible, voluntary and informed consent…"
(para 7.17) (United Nations Department for Economic and Social Information and Policy Analysis,
1994).
Greater contraceptive choice has been shown to improve uptake and use of all methods.40, 55
Therefore, it is important that women have access to an array of methods, including injectable
contraceptives.
Good counseling, especially about changes in monthly bleeding and other side effects, helps
women decide whether injectable contraception will suit them and it helps women continue using
injectables.20, 32 Simply encouraging women to come in for a visit if they are having a problem
with injectables can also improve continuation rates.20
A 2006 systematic review on improving adherence to and acceptability of hormonal methods of
contraception suggests that intensive counseling interventions with multiple contacts may be
needed to improve contraceptive use.23
Training Providers of Injectables
As demand for injectables increases, programs need more health care workers who can provide
injectables to expand access to the method. With training, any health care worker can give
contraceptive injections safely. Such providers may include pharmacists, auxiliary nurses,
midwives, medical assistants, and community providers.53, 74
Comprehensive training to provide injectables may be needed if a program is adding injectables
as a new method or if a program already offers injectables but is training new health care workers
to provide them. Such training may include:

Characteristics of injectables and the importance of returning on time for the next injection

Giving safe injections

Counseling clients, with an emphasis on bleeding changes

Screening clients using the WHO Medical Eligibility Criteria

Correcting misperceptions

Conducting return visits

Managing side effects
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Focused training can be used to address a specific component of service delivery that needs
strengthening, such as counseling. Refresher training can help providers maintain safe injection
practices and maintain good-quality care.
Competency-based training—training that develops skills, knowledge, and attitudes—has proved
more effective than conventional training approaches. With this approach, training continues until
each trainee is competent to provide injectables, using techniques such as role playing,
discussion, use of job aids, and simulation.32
Service Delivery
Who Can Provide Injectables
In addition to physicians and nurses, many other types of health care providers can give
contraceptive injections if appropriately trained. These providers include pharmacists, auxiliary
nurses, midwives, medical assistants, community health workers, and others who have been
specifically trained to provide family planning, as well as those who have general medical
education.53, 74 In an effort to meet increased demand for injectable contraceptives and unmet
family planning needs in underserved populations, more countries and programs are allowing
community health workers to provide injectable contraceptives outside of clinic settings.17, 74 For
example, the Nakasongola project in Uganda, the Matlab project in Bangladesh, and the
APROFAM project in Guatemala have implemented initiatives to provide DMPA through
community-based distribution by training community health workers to safely provide DMPA
injections.17
Service delivery guidelines in some countries restrict who can give injections. Thus, in some
cases allowing certain groups of providers to give injectables may require changes in national
policy.32
Who Can Use Injectables
Almost all women generally can use injectable contraceptives safely and effectively, including, but
not limited to, women who:75

Are of any age (including adolescents and women over 40 years of age)

Are not married

Have or have not had children

Are postpartum (at least 21 days postpartum for combined injectables)

Are breastfeeding (progestin-only injectables can be used as soon as six weeks after
childbirth and combined injectables can be used starting six months after childbirth)

Have just had an abortion, miscarriage, or ectopic pregnancy

Are obese (body mass index of 30 kg/m2 or more)
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
Smoke cigarettes (combined injectable use is not recommended (category 3) if the woman is
35 years of age or older and smokes 15 cigarettes or more each day)

Are at risk of sexually transmitted infections, including HIV

Have HIV or AIDS

Have HIV or AIDS and are using ARVs (combined injectable use is not recommended if using
ritonavir-boosted protease inhibitors (category 3))
For more details about who can use injectables and who should not use them, please consult the
most up-to-date version of the WHO Medical Eligibility Criteria.
Availability and Access
The rapid growth in use of injectable contraceptives is largely explained by greater access to
injectables.33 A common reason for discontinuation of injectables, however, is a lack of access.
Many women are unable to return to the clinic or pharmacy as needed for another injection and
some clinics have drastic shortages and are unable to give women their injection when they
return.61
To improve access to contraceptive injectables, program managers can make sure women get
services easily (for example, services are within walking distance, women can get services
without a long wait), ensure that services are offered in rural areas through community programs,
make injectables available in a variety of clinical settings (e.g., hospitals, family planning clinics,
maternity clinics, pharmacies), and guarantee that the location of service outlets and their hours
are well known to women and their partners. See the Checklist for Improving Access to
Injectables for additional details on how program managers can remove barriers and improve
access to injectables.32 Additionally, community health workers can safely and effectively provide
injectable contraceptives and in doing so can greatly expand availability and access to injectable
contraceptives (see Modality of Provision below).17, 74
To keep injectables available, programs need to maintain adequate supplies. “Stockouts” of
injectables are a common problem, however. Better forecasting has enabled some programs to
anticipate increases in demand and place timely orders to manufacturers, donors, or procurement
agents. To respond quickly to unexpected demand, emergency shipments are available from the
United Nations Population Fund (UNFPA) and from USAID for USAID-funded programs.48
Modality of Provision
Injectable contraceptives can be provided safely and effectively both in the clinic and in the
community.32, 53, 74 Although injectable contraceptives are usually provided in clinics, communitybased distribution (CBD) of injectables can also be safe and effective. Community-based
distribution of contraception has the potential to increase family planning access and convenience,
particularly in countries with large rural populations, low contraceptive prevalence, high unmet
need for contraception, and critical shortages of trained clinic personnel.18
Community provision has significantly increased use of injectables. In the Navrongo Initiative, for
example, contraceptive prevalence rose from 3.4% to 8.2% between 1993 and 1999, when 92%
of contraceptive users were using injectables.13 In Bangladesh, adding injectables to the method
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mix in CBD programs resulted in more than doubling the contraceptive prevalence rate in some
districts; contraceptive use increased from 21% to 47% in the Abhoynagar subdistrict and from 11%
to 41% in the Sirajganj subdistrict. Furthermore, the use of injectables increased from 0.1% to 25%
over an eight-year period.16 Several projects involving community provision have found that many
women will choose injectables as their first modern method of contraception. 32
Community-based programs can serve both urban and rural areas, giving women the choice of
injectable contraceptives in parts of countries where clinics are hard to reach. Community
programs can offer injectables from mobile clinics, village clinics, periodic temporary outreach
clinics, or at the homes of clients or community health workers. Injectable services can also be
added to community provision of oral contraceptives and condoms, and offered along with
immunizations, other maternal and child health services, and some curative services.
Initiating Injectables
Many women can have their first injection immediately. A woman does not need to wait until she
is menstruating to initiate injectables. She can start using injectables any day of the menstrual
cycle. If she is starting within seven days after the start of her menstrual cycle or switching from
another hormonal method, she does not need to use a backup method. If it is more than seven
days after the start of her menstrual cycle, she can be given an injection as long as it is
reasonably certain she is not pregnant. (To be reasonably certain she is not pregnant, use the
Pregnancy Checklist.) In this case, she will need to abstain from sex or use a backup method for
the first seven days after the injection. If a woman is switching from another injectable, she should
have the new injectable given when the repeat injection would have been given; no additional
backup method is needed.69, 75 If pregnancy cannot be ruled out with the Pregnancy Checklist,
the client must use a pregnancy test or wait until her next menstrual period to start injectables. 33
Also, a woman can initiate injectables after an abortion or postpartum. A woman can have her
first injection immediately postabortion and no additional backup method is needed. If a woman is
postpartum and not breastfeeding, she can begin progestin-only injectables immediately and
does not need a backup method if the injection is given within three weeks after delivery. For
combined injectables, a woman can have her first injection anytime after she is 21 or more days
postpartum and it is reasonably certain she is not pregnant. In this case, she will need to abstain
from sex or use a backup method for the first seven days after the injection.
If the woman is fully or nearly fully breastfeeding and her monthly bleeding has not returned, she
can be given a progestin-only injection any time between six weeks and six months after giving
birth and does not need to use a backup method. For combined injectables, she can be given her
first injection any time after six months postpartum if it is reasonably certain she is not pregnant;
abstinence from sex or a backup method will be needed for the first seven days after the injection.
If the woman is fully or nearly fully breastfeeding, her monthly bleeding has returned, and she is
more than six weeks postpartum (or six months postpartum for combined injectables), pregnancy
should be ruled out prior to giving the first injection. Also, she will need to abstain from sex or use
a backup method for the first seven days after the injection if it has been more than seven days
since her last menstrual bleeding started.69, 75 (For more information on when to start injectables
and a checklist to help assess whether it is reasonably certain a woman is not pregnant, see
Family Planning: A Global Handbook for Providers.)
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Follow-Up Visits
Injectable users need to return for follow-up for their next scheduled injection: in three months for
DMPA, two months for NET-EN, or one month for combined injectables. Women should be
counseled that effectiveness of their method depends on having their injections on time and so
they should return on time. However, they can come up to two weeks early or four weeks late and
still have their injection if using DMPA, up to two weeks early or late if using NET-EN, and up to
one week early or late if using combined injectables. Women should return no matter how late
they are for their next injection, because they still may be able to receive their injection.69, 72
In addition to planning a follow-up visit for a client’s next injection, women should be encouraged
to come back any time they have problems or questions, experience a major change in health, or
think they might be pregnant.33, 76
Medical Barriers
Medical barriers are policies or practices derived at least partly from a medical rationale that
result in scientifically unjustifiable impediment to, or denial of, contraception. They are a
significant problem impeding wider access to modern contraception, including injectables.52
Contraceptive provision in many settings continues to be based on outdated medical information,
unproven theoretical concerns, and provider biases. Studies have found that in some developing
countries 25% to 50% of women seeking contraceptives are refused services until they are
menstruating.5 Additionally, many women who request a contraceptive method, such as
injectables, are denied their choice based on eligibility criteria that are neither scientifically
justified nor consistent with national guidelines. These medically unjustified criteria include
marriage and spousal consent requirements, minimum or maximum age and parity restrictions,
menstruation requirement, or norms that discourage uptake by requiring too many routine followup visits.52, 54, 63
Checklists are one important tool for health care workers at various levels to apply the latest
WHO medical eligibility criteria and guidelines for contraceptive use, including injectables. The
Pregnancy Checklist and DMPA/NET-EN Checklist from FHI can be used by providers at all
levels, including community agents and other para-professionals. Based on the WHO medical
eligibility criteria, the DMPA/NET-EN Checklist includes simple questions to help providers
identify health conditions that might preclude a woman from using progestin-only injectables.5
National polices can also be a barrier to injectables. Service delivery guidelines in some countries
restrict who can give injections, limiting provision to doctors and nurses. Thus, it is important that
countries modify their service delivery guidelines to allow a wide range of health care providers
and community-based distributors to provide injectables.32, 49
Provider Perspectives
Many misconceptions exist about injectable contraceptives, including misconceptions about their
mechanism of action, side effects and eligibility criteria (for example, incorrectly believing that
injectables cause abortion, infertility, cancer or change in sexual behavior and desire). 28, 76
Addressing providers’ fears, myths, and misconceptions requires multiple and repeated
interventions.47 Passive dissemination of scientific evidence and new guidelines often has little or
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no effect on providers’ practices. Effective approaches that facilitate the application of research
findings include educational outreach, interactive workshops, supportive supervision, on-the-job
reminders, the engagement of opinion leaders, and the involvement of local stakeholders. 21
Cost Considerations
To keep costs down programs can buy supplies in bulk, set up services in existing buildings, and
share facilities with other health services. Programs that buy their own commodities can get low
prices by asking for competitive bids from some of the more than two dozen manufacturers of
injectables. To ensure the quality of supplies, programs should ask for bids only from
manufacturers that have been assessed for quality. Programs can also work with UNFPA, which
helps countries procure injectables and other contraceptives at low prices. Also, a number of
procurement agents consolidate orders from several clients to qualify for volume discounts from
manufacturers, and they ensure the quality of the products that they order.32
Safe Injection and Waste Disposal
Giving injections safely and disposing of waste appropriately are crucial for safely providing
injectable contraceptives. Applying safe injection technique and the universal precautions,
including disposing of used syringes and needles properly, helps prevent the spread of infection
form clients to other clients, health care providers, and the community.32
Safety guidelines for contraceptive injections are the same guidelines that apply to all medical
injections. A safe injection is defined by the WHO as one that does not harm the recipient, does
not expose the provider to any unavoidable risk, and does not result in waste that is dangerous to
people. Disposable auto-disable (AD) syringes are preferred over sterilizing and reusing injection
equipment. AD syringes cannot be reused because they inactivate after a single use. 32
Universal precautions prevent infection transmission. Universal precautions for infection control
and best practices for injections are a simple set of practices designed to protect health care
workers and their clients from infection in health care settings. Under the universal precautions
principle, health care workers assume that all blood and body fluids are infectious, regardless of
actual infectiousness.32, 59, 73
Rules for injections include:

Prepare each injection in a clean designated area where contamination from blood or body
fluid is unlikely.

Wash hands with soap and water before and after giving an injection, if possible. Gloves are
not needed unless there is a chance of direct contact with blood and other body fluids.

Use a sterile syringe and needle for each injection. Use an AD syringe, if possible. If only
sterilizable equipment is available, sterilize according to WHO guidelines.

Discard used disposable needles and syringes in sharps containers immediately after use. Do
not recap used needles.

Safely dispose of sharps waste according to local or regional environmental regulations
27, 68,
73
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To ensure safe waste disposal, programs offering injectable contraceptives must have a
procedure in place for collecting, storing, transporting, and disposing of used needles and
syringes. Used disposable needles and syringes should be placed in a sharps container
immediately after use. Once full, sharps containers and their contents can be destroyed by burial,
burning or incineration.32
A Checklist for Giving Intramuscular Contraceptive Injections was developed to help providers
give injections and dispose of waste safely.33
Logistics: Commodities, Supplies, and Equipment
“Stockouts” of needed equipment and supplies are commonly reported in service programs.
Attention to logistics and supplies is critical because unavailability of either the injectable
contraceptive itself or of the other needed supplies means injectable contraceptive services are
also unavailable. Increasing demand for injectables challenges programs to maintain a steady
flow of supplies and respond quickly as more clients ask for injectables. Maintaining a continuous
supply of injectables means maintaining vials of the contraceptive, needles, syringes, and sharps
containers for disposal of used equipment. Thus, assessing and forecasting demand for
injectables is essential in planning and supplying to meet demand.32
Injectables should be stored between 20º and 25ºC (68º and 77ºF), away from direct sunlight,
and protected from freezing. Changes in temperature can affect the size and solubility of particles
in DMPA and the combined injectable Cyclofem. Heat can decrease the effectiveness of NET-EN
without changing its odor or appearance. The shelf life of progestin-only injectables is three to five
years, and of combined injectables, at least three years. Vials remaining beyond their shelf life
should be discarded.32
Marketing and Communication
Family planning programs and providers can play an important role in communication on
injectables; both to help women try and use injectables. When communicating about injectable
contraceptives, it may help to tailor messages to potential and current users of injectables, as well
as their husbands and partners. For example, many women have heard about injectables, but
hesitate to try them because they need more information. Some have fears based on
misinformation, and others need to talk with a trusted source of information. Seeing satisfied
users and receiving correct information can help women make informed choices about injectables.
Current users of injectables may have questions or concerns about side effects. Interacting with a
trusted source of information helps women cope with changes if they occur. Partners and
husbands can support use and help women use injectables effectively. A 1995 study in the
Philippines found that women whose husbands approved of injectables were more than twice as
likely to continue using the method.45
Formative research will help identify the benefits and negative aspects of injectables as perceived
by a particular target group. Findings can then help programs choose messages, sources, and
media that will be effective for the specific audiences they address. Furthermore, making reliable
and balanced information available to the public and providers has helped programs both avoid
and deal with controversy. Maintaining a good working relationship with the news media and
making sure reporters are well-informed is an important task for family planning programs.32
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Information in the mass media or on the Internet can be an effective way to reach many potential
or current users of injectables, delivering accurate information on the advantages, side effects,
and health concerns for injectable contraceptives. Interactive sources, however, may be more
helpful in informing people who are hesitant or skeptical of injectable contraceptives. Examples of
communication mediums that offer opportunity to interact include: (1) telephone hotlines, which
offer a private connection with a trained family planning counselor;( 2) discussions with providers,
which gives women a chance to interact directly with a trusted source; and (3) community
meetings, which are an interactive and public way to improve knowledge and answer questions
about injectables.32
Key Guidance Documents
The World Health Organization publishes and periodically updates its four “cornerstones of
effective contraceptive use” in a family planning guidance series. Together, these four
cornerstones, described below, support the safe and effective provision and use of family
planning methods; they are:

Medical Eligibility Criteria for Contraceptive Use (MEC) (4th edition, 2010) is one of the WHO's
two evidence-based guidelines on contraceptive use, intended for policymakers, program
managers, and the scientific community to support national programs in preparing service
delivery guidelines. The document reviews the medical eligibility criteria for use of
contraception, offering guidance on the safety of use of 19 different methods for women and
men with specific characteristics or known medical conditions. The recommendations are
determined by expert consensus and are based on systematic reviews of available clinical
and epidemiological research.75

Selected Practice Recommendations for Contraceptive Use (2nd edition, 2004 edition) along
with the 2008 Update, the companion guideline to Medical Eligibility Criteria for Contraceptive
Use, provides guidance on the safe and effective use of a wide range of contraceptive
methods. The recommendations, which answer 33 questions selected by the WHO, were
determined by expert consensus and are based on systematic reviews of available clinical
and epidemiological research. Five of the 33 questions address use of injectables and related
issues. 69, 72

Decision-Making Tool for Family Planning Clients and Providers incorporates the guidance of
the first two cornerstones and reflects evidence on how best to meet clients’ family planning
needs. It is intended for use during counseling.64

Family Planning: A Global Handbook for Providers is the fourth cornerstone and also
incorporates the guidance of the first two cornerstones. As a thorough reference guide, it
offers technical information to help health care providers deliver family planning methods
appropriately and effectively, providing specific guidance on 20 family planning methods
including injectables.76
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