Choice in her hands: challenging provider bias to support reproductive self-care

By Raveena Chowdhury, Head of Integrated Service Delivery at MSI Reproductive Choices.

At MSI Reproductive Choices, for over 40 years, we have remained committed to de-medicalizing reproductive healthcare and putting choice in the hands of our clients. In this piece, we share our learnings on deconstructing provider hesitancies and bias around reproductive self-care methods, in order to scale up access to Sayana Press in Malawi, ensuring reproductive choice is in the hands of our clients.

A lot has changed since MSI first set out in our work to deliver reproductive choice to all – products and awareness have improved, but new challenges have arisen. In just the past year, national lockdowns have restricted movement, hesitancies have increased around accessing healthcare facilities, and public health systems have become overwhelmed, diverting resources to the COVID-19 response. As a result, access to sexual and reproductive healthcare has changed radically and access to reproductive healthcare outside of facilities has become all the more important.

Choice in her hands: contraceptive self-care with Sayana Press

For family planning under lockdown, self-injectable products such as DMPA-SC, broadly known as Sayana Press, have allowed women to safely self-administer an effective form of contraception, providing up to three months of protection against pregnancy. Via the easy-to-use injectable, Sayana Press has the potential to put reproductive choice directly in the hands of women, whether a client looking for a convenient method to take from home, or someone unable to travel to a facility for their normal method due to COVID-19.

Despite its convenience and efficacy, global usage of self-injectables such as Sayana Press remains relatively low. There is a lack of awareness of the products among clients and providers, who are often untrained on how to support women to self-administer. This is only worsened by provider biases around whether women have the required skills to self-inject. To challenge this, tailored training programmes that increase capacity amongst providers to support and empower women to self-administer, and challenge provider bias, are needed, combined with support at a national level.

Pictured (left): Client at outreach clinic, MSI Malawi programme, 2018

The challenge: prevailing provider bias around reproductive self-care

In Malawi, for example, the benefits of safe self-care options are clear. According to FP2020 and the Track20 Project, just under half of all women (48.3%) in Malawi are using a modern form of contraception. While the government has made enormous strides in increasing access to modern contraception over the past decade, with the percentage of women using modern contraception rising by 10% since 2012, barriers to access persist, particularly in rural, underserved regions. In these regions, access to self-care methods could make a huge difference in providing women and girls with reproductive autonomy via easy-to-use, effective products.

In Malawi, the injectable is by far the most popular form of contraception, with FP2020 reporting that 49.8% of women opt to use it, but self-injection has been slow to pick up. To support providers to empower clients to self-administer using products such as Sayana Press, and ensure access is protected regardless of location, Banja La Mtsogolo (BLM), MSI’s programme in Malawi, partnered with the Ministry of Health to deliver a national roll out of DMPA-SC (Sayana Press).

Starting in 2019, the team worked with the Ministry of Health to deliver training across 90 reproductive healthcare facilities, spanning BLM’s centres, their mobile outreach teams, serving rural regions, and 45 public sector sites. The training focused on how to counsel clients on the self-injection method, as well as train clients to self-administer the next dose themselves. It was then scaled up in response to COVID-19, training additional public healthcare providers and government Health Surveillance Assistants, who ordinarily provide short-term contraception within their local communities.

The impact: expanding access to rural, marginalised communities in Malawi
MSI Malawi vehicle

By working through provider bias and hesitancies in training and post-training support sessions, demonstrating how easy Sayana Press is to use and its benefits for clients seeking an effective, convenient form of contraception, the BLM teams were able to train up over 1,000 public sector providers, expanding access radically. Between June and November of 2020 alone, MSI’s teams in Malawi delivered over 31,500 Sayana Press products, with a large proportion delivered through our public sector sites and via our mobile outreach teams, ensuring that women in rural, marginalised communities have the knowledge, confidence and products to self-administer too.

With the prevailing global rates around self-injectable uptake, we are sure that providers in Malawi are not alone in their hesitancies around self-care methods. However, as seen in Malawi, through close collaboration between the public and private sector, and continued support for providers, a strong groundwork can be set for ensuring that providers and clients alike feel empowered to provide and access quality self-care products. With these learnings, we look forward to seeing access to self-care in Malawi and elsewhere go from strength to strength. After all, it is through putting reproductive choice in women’s hands that they will be able to determine their bodies, their choices and their futures.

Banner Image: Client and team member at outreach site, MSI Malawi programme, 2018