Every journey from her house is long and laborious. Mercy Rono trudges uphill through a patchwork of mud, puddles and dewy shrubs every day to reach the agrovet shop she co-owns with her husband.
She lives in a one-room house in Police Lines estate near Kapsabet town. Until last year, Mercy struggled with a painful waist joint that made her daily journey to work even more treacherous.
She blames it on an injectable contraception she had used since her only child was born nine years ago.
She remembers her tiring trips to the Kapsabet Referral Hospital for an injection every three months since 2015. “I would queue for at least one hour. Afterwards I would go for many months without my menses, while enduring the joint pains,” she says.
On this day, we find Mercy anxiously waiting for us at her home. After some pleasantries, she washes her hands and produces a small plastic pack that fits in her palm. This is a self-injectable contraception she uses at home.
It is 99 per cent effective at preventing unintended pregnancy when used correctly and on time every three months. The 29-year-old Mercy is among the thousands of women in Kenya who are now injecting themselves with this contraception at home. They no longer visit health facilities every three months for a jab.
Injectables are the most popular contraception in Kenya, according to the 2022 Kenya Demographic and Health Survey. They are used by 20 per cent of married women.
The government began piloting the new self-injectable method early last year. It is known as Depot Medroxyprogesterone Acetate-subcutaneous (DMPA-SC), or simply by its brand name ‘Sayana Press’.
It comes in a prefilled pack with a small needle that you simply inject under the skin on the abdomen or thigh to prevent pregnancy for the next three months.
“There are no side-effects, and the waist pain is now gone. I also have monthly periods as usual,” says Mercy, who has been on DMPA-SC since late last year.
She plans to have her next shot today, in our presence.
FEWER SIDE-EFFECTS
DMPA-SC was approved in Kenya in 2016 and was added to the country’s Essential Medicines List. Studies by Jhpiego demonstrated that it was acceptable and feasible in the country.
After that, MoH developed a curriculum and trainings for health workers, who would then train users to self-inject.
Despite the quick regulatory approvals, the subsequent rollout in Kenya has involved more slow and sensitive discussions.
The current rollout of the self-injectable is guided by Kenya’s National Guideline on Selfcare in Reproductive Health, released in January last year.
Women take home two doses to last a total of six months, which means they only need to go for refills in hospital twice a year.
The World Health Organisation’s ‘Implementation Research on DMPA-SC Self-Injection’ indicates that this improves contraception continuation rates.
The percentage of married women using modern contraceptives in Kenya was 57 per cent in 2022, way below the 64 per cent target for 2030, according to the 2022 KDHS.
Discontinuation rates are also high, with some studies indicating that a third of all Kenyan women, 15-24 years, discontinue their contraception within 12 months after initiation. Most cite unwanted side effects.
The WHO says the new method may reduce that. It also expands accessibility among women and girls who may find it inconveniencing having to go to healthcare facilities to be injected by trained healthcare workers.
PAINLESS OPTION
Margaret Chepchirchir, a former tea picker, is one such beneficiary. We find the 32-year-old mother of two girls and one boy drying simsim seeds outside her rented room near Kapsabet town at midday.
“The economy is hard, so I do not want any more kids,” she says. Her firstborn is a 14-year-old girl, while the lastborn boy is eight.
Like Mercy, she was on Depo Provera, an intramuscular contraception that prevents pregnancy with a shot every three months. The shot must be given by healthcare workers.
Margaret was on that method for six years until December last year. At that time, she worked as a casual tea picker at Kiropket village in Emgwen constituency.
“I’d get worried whenever the time for my injection approached I knew I would lose a day’s work and still pay for the trip (Sh150 one way) to hospital,” she says.
“So one day, the nurse told me there was a stockout. She told me there was an alternative that did not require me to come to hospital every three months. That I could inject myself.”
The nurse trained her how to do it. DMPA-SC has a shorter needle, similar to the insulin pen used by people with diabetes. It is stored at room temperature (15°C to 30°C) and remains stable for three years.
Margaret was injected by the nurse the first time. She returned to hospital after three months, and injected herself in the presence of the nurse, who confirmed she did it well.
She was given two doses to last six months. “The third time I injected myself at home,” she says.
“It’s not painful. I inject in the right thigh because I can see it,” she says.
“The previous contraception I used had a lot of side-effects. For instance, I did not have monthly periods. I had many joint pains, especially at the waist. With this one now I have my monthly periods as usual and no joint pains.
“I have also added weight. I used to be 54 kilos and now I am 60kg.”
SELF-CARE
Anastasia Chepkoech is a nurse at Kapsabet Referral Hospital’s family planning department. She has been trained on DMPA-SC and has trained many women on self-injection, broadly known as ‘self-care’ in programme parlance.
“We provide all services. We give pills, we give implants, we give IUD, both hormonal and non-hormonal. Our clients are informed of all these choices. They then make their choice, we don’t choose for them. So it is always according to the client’s choice,” Anastacia told the Star.
The department attends to about 500 women every month. “For those who choose Sayana Press (DMPA-SC), the first time we injected them and teach them how to do it on the thighs or the abdomen, because that’s the easiest place for someone to inject herself,” she says.
“When they come for the second time, we supervise them injecting themselves. Then we give them maybe one or two more doses so that when their time comes, they can do it at home. So they don’t need to come back to the facility all the time.”
This is the second year the hospital is giving women the self-injectable contraception. Anastacia says the major challenge has been some clients fearing to inject themselves, and disposal of the needles. “Another challenge is storage, and timing.
The clients want a specific date because they might miscalculate.” The health workers are overcoming those challenges through the help of Community Health Promoters.
“So there has been a lot of sensitisation to our community health promoters. Our CHPs carry the same information to the clients and even remind them of the injection dates,” she says.
“They also collect needles from clients who are unable to dispose them and bring them here for safe disposal.”
According to the UNFPA, which supports the Kenyan programme, self-care interventions offer huge potential in increasing the accessibility of family planning.
UNFPA country representative Anders Thomsen says adding subcutaneous DMPA-SC to the available family planning method mix will provide women in Kenya with more choices and autonomy to fulfil their fertility goals.
“The self-administered method can also play a crucial role in addressing the unmet need for contraception among women from vulnerable and remote communities, who encounter numerous barriers to accessing family planning,” he says.
UNMET NEED
The unmet need for family planning in Kenya currently stands at 14 per cent, according to the KDHS.
Thomsen says with support from the UK Government, UNFPA procured and in May distributed 450,000 doses of DMPA-SC to the Ministry of Health for onward distribution to health facilities across the country.
“The contraceptives are expected to benefit over 400,000 women of reproductive age, which is estimated that will contribute to the prevention of 42,750 unintended pregnancies and 122 maternal deaths,” he said.
Thomsen noted that improving access to family planning and other sexual and reproductive health services can help prevent maternal deaths, maternal complications such as obstetric fistula and unsafe abortions, and reduce unintended pregnancies, especially among adolescent girls.
About one-third of maternal deaths could be prevented annually if women who did not wish to become pregnant had access to and used effective contraception, according to estimates.
The Reproductive Health Network, a local non-profit that monitors the DMPA-SC rollout, says about 55,000 women are now using the method in Kenya, up from 4,000 last year. Most of them (39,600) are aged 24 years and below, the data indicates.
Dr Edward Serem, head of the Division of Reproductive Maternal Child and Adolescent Health at the Ministry of Health, says the current uptake is just a pilot. A full rollout will come in 2025.
“We are now going to come up with [specific] guidelines to make sure the population is guided on how they can use those DMPA-SC products because we are cognisant of the fact that, first of all, they have to be trained,” he said.
After they have used the products comes the question of disposal, which he said is very key. “As a country, we are yet to standardise the rollout. So, that is going to happen in a few months. Early next year.” At her house in Police Lines, Mercy Rono is now ready to self-inject.
She tears the pack apart to reveal a small reservoir pre-filled with the fluid connected to a small needle. She shakes the content vigorously.
Mercy points the small needle upward while her left hand presses a port downwards. She then takes the cap off the needle. After that, she pulls back her skirt to expose a part of the thigh she had cleaned.
She presses the needle straight into the skin for about 10 seconds before pulling it out. After that, she returns the device in its pack and steps out to dispose it in a nearby latrine. On return, she crosses September 28, 2024 on the calendar.
She then marks the next date she will inject herself: December 28, 2024. Relief washes over her face. “I’m done,” Mercy says. No hospital trip, no missed work. This small act gives her control over her life and body. She smiles, knowing she can do this on her own.
