Setbacks in the road to self-injection: a descriptive study of provider and mystery client reports on the DMPA-SC care-seeking experience in Nigeria

Madeline Griffith^1*Sneha Challa¹Ayobambo Jegede²Ivan Idiodi²Chioma Okoli²Aminat Tijani²Shakede Dimowo²Awawu Grace Nmadu²Elizabeth Omoluabi²Jenny Liu¹

• ¹University of California, San Francisco, San Francisco, United States
• ²AkenaPlus Health, Abuja, Nigeria

This mixed-methods study describes perspectives from health providers and simulated clients on initiation and continuation of DMPA-SC for self-injection in Nigeria. Through mystery (simulated) client interactions, we found that providers were similarly willing to dispense units of DMPA-SC for selfinjection to different client profiles, which varied in age, marital status, and parity. However, in-depth interviews with providers revealed nuance in their approaches to assessing clients' eligibility for unsupervised self-injection of DMPA-SC. Factors including client age, marital status, parity, and education influenced who they deemed able to self-inject, which may limit access to DMPA-SC for clients who wish to self-inject the method. Quantitative and qualitative data also indicated that clients faced setbacks in continuing unsupervised self-injection when seeking refills from an unfamiliar provider. Stockouts of DMPA-SC further complicated access; some providers resorted to purchasing DMPA-SC privately and passing the cost onto clients. These findings highlight the need for clearer refill protocols and more consistent supply to ensure equitable access to DMPA-SC for self-injection in Nigeria.Research has tracked the implementation and scale-up of DMPA-SC since the introduction of the method in Nigeria in 2015. Sieverding et al. first described the method initiation experience with a mystery client (MC) study in 2016 in South West Nigeria, which found provider bias in contraceptive provision to adolescents and young women (9). Despite the potential benefits of self-injection of DMPA-SC to empower self-care, persistent barriers hinder women's ability to initiate and continue using DMPA-SC, including the ability to reliably find and obtain refills. Structural barriers, including method availability, cost, and the multi-step dispensing guidelines, complicate method initiation and continuation for both providers and clients, as noted in Nigeria's National Guidelines for the