This piece was originally published on the Delivering Innovation in Self-Care (DISC) blog.
By Alexandrina Nakanwagi, DISC Project Lead
“It starts with yourself.”—Mom, Kaduna
Women have self-managed their reproductive health needs for decades, including through the use of contraceptive pills. Contraception has been, and remains, key in women’s ability to pursue life goals, including the goal of becoming a mother if, and when, the time is right. Given the huge unmet need for modern contraceptives, it’s clear that women need options. Where access is constrained, the ability to take home affordable contraceptive coverage (up to a nine-month supply) has been referred to as a potential “game changer” for women who desire contraception.
As a self-care technological innovation, subcutaneous DMPA (DMPA-SC, or Sayana® Press) self-injectable offers undeniable benefits to women who want to take more control of their sexual and reproductive health (SRH). Yet, despite a rapidly growing evidence base demonstrating its safety, effectiveness and acceptability, women’s knowledge and use of this method—either self-injected or provider administered—has been slow to take off, and uptake remains low.
As a woman-centered program, a woman’s power to achieve and to decide for herself is at the core of DISC’s design work. DISC yearns to understand women’s own conceptions of power and agency, and how these relate to their contraceptive use journey. Do women desire full autonomy in their SRH decisions and actions? Is it important for women to enjoy shared decision making with a spouse or partner? Will male partners (and providers) be supportive?
The Demographic and Health Surveys (DHS) ask women about decisions in their healthcare as one metric to gauge women’s power and level of agency within their households. According to the most recent DHS data, the majority of married women in both Nigeria and Uganda made the decision to use contraception jointly with their husband, 66% and 62% respectively. Thirty-one percent of Ugandan women and 23% of Nigerian women made the decision on their own, with the balance indicating that it is mainly the husband’s decision in each country.
With this evidence in mind, DISC wanted to develop a clearer understanding of how urban youth and young mothers (Mums) in its catchment areas of Nigeria and Uganda felt. Insight gathering around these women’s preferences and needs revealed a nuanced picture about power and agency. Some felt full ownership over the decision to use contraception. Others felt they could comfortably share contraceptive decision making with a supportive spouse or partner, while still others focus on concealing their contraceptive use for other reasons, such as fear of stigma or marital conflict. Overall, women inherently recognized their power within (“a person or group identity’s sense of self-worth, self-awareness, self-knowledge and aspirations, which are also related to agency”) and power to (“the potential of a person or group to form, pursue and realize aspirations for their life and society…[t]his can include education, skills, capabilities and the confidence to exercise them”). In practice, however, women’s realization of their power is complex.
Where Mum segments largely report enjoying shared decision-making with their male partners, they also discussed their intention to act privately on SRH decisions, including termination of pregnancy. Young mothers in particular prioritized broader ambitions, noting that an unintended pregnancy would be a threat to these, and explicitly linking the power to achieve life aspirations with the power to make autonomous SRH decisions.
“I might not talk about it again. If he is not giving me an audience, I will do it and protect my life. It is my body anyways. I will inject when he’s not around.” —Mom, Kaduna
“Being a boss lady, I decided to go for family planning to be able to fulfill my goals…” —Mom, Oyo
Where women felt their family and community did not agree or affirm their decision-making, women may still exercise their power to decide, but conceal it out of a sense of fear of repercussions or disparagement. Urban youth in particular (and some Mums) were more likely to focus on concealing the entirety of the contraceptive user journey—from awareness through continuation and advocacy.
“I would love to be secretive whether married or single.” —Urban youth, Kaduna
DISC is paying attention, not only to the health system requirements of delivering self-injectable contraception among the basket of family planning options, but to women’s experiences, desires, preferences and needs as expressed through the insights related to self-injection. As women’s experiences of power over, within, and in relation to their use journey are varied, so DISC’s strategy to reach diffuse segments of women is varied as well. One aspect of DISC’s creative campaign messaging uses bold imagery and messaging that affirms some women’s proud and unabashed independence, power and agency in contraceptive decision-making.
This messaging is intended to resonate with those women who will act on their own intentions, planning a use journey that is theirs alone. DISC’s metrics have shown that the ‘I decide’ and ‘Yes’ messaging themes perform well on engagement levels (i.e. comments, likes), generating the highest number of reactions across the two countries, as well as amongst the most comments and shares. The ‘how to self-inject’/product specific messages perform well on click throughs.
The campaign additionally acknowledges those women who welcome a partner’s support and engagement in their use journey, as expressed by this Mum from Nigeria: “Emotional support from my husband will go a long way to help me [feel comfortable and informed to use SI]” —Mom, Oyo
DISC is tailoring its messaging and strategies, remaining attentive to the fact that women’s needs and user journeys are highly individualized, encompassing varied gender and power dynamics. This openness to learning and adaptive posture will be important to ensure the ongoing relevance of demand generation activities to all women, including those who openly use SI (perhaps with additional support from a husband/partner/provider), and those who want to adopt a method completely privately, and on their own. One way that the project is continuing to deepen its understanding of women’s power and agency is by conducting participatory workshops with its target populations in both Nigeria and Uganda. During the workshops, groups of women will use art and theater-based activities, as well as open-ended discussion, to contextualize power, powerlessness and the perceived relationship between reproductive health, contraceptive use and women’s decision-making power in these contexts. The approach will not predetermine what ‘power’ means but invites participants to determine how this is defined, and what metrics are thereby relevant in relation to contraceptive use and self-managed care. For example, one metric strives to assess whether a woman has as much decision-making power as she wants, rather than defaulting to the assumption that making a decision ‘on one’s own’ always equates with greater power. The selection of more contextually grounded indicators will inform tracking studies that will examine women’s perceptions of their power, voice and agency, explore how these perceptions change over time, as well as whether this translates into uptake of SI as DISC interventions are rolled out.
 Spieler J. 2014.Sayana® Press: Can it be a “game changer” for reducing unmet need for family planning? Contraception. 2014;89(5):335–338.