Injectable contraceptive continuation and user experiences in Punjab, Pakistan: a non-randomized prospective cohort study protocol.

Background: Evidence from multiple pilots and post-introduction scale-up initiatives have demonstrated that self-administered subcutaneous depot-medroxyprogesterone acetate (DMPA-SC) has potential to improve contraceptive continuation rates and expand contraceptive access to populations with limited utilization of facility-based health services. Only a few of these studies have been conducted in South Asian countries, and none where most contraceptive use is of non-hormonal methods that require limited to no contact with the health system, leaving policymakers in countries like Pakistan with limited context-specific evidence to guide decisions on whether, how, and for whom to introduce DMPA-SC.

Methods: A prospective cohort study will be conducted in 41 health facilities and surrounding communities in Punjab, Pakistan. The primary objective of the study is to compare the 12-month contraceptive continuation rate for women who receive DMPA-SC with that for women who receive intramuscular depot-medroxyprogesterone acetate (DMPA-IM). The secondary objectives are to compare characteristics and experiences of participants who opt for DMPA-SC with those of women who opt for DMPA-IM, which must be administered by a health worker. Additionally, a sub-study is planned to assess how well women opting for self-injection of DMPA-SC adhere to standards for commodity storage, injection timing, injection technique and waste disposal.

Discussion: This research offers an opportunity to contribute to global efforts to reduce inequities in access to contraceptive method choices, while generating actionable evidence to inform health sector decision-making in Pakistan. Although study sites are limited to health facilities where a woman's first self-injection of DMPA-SC is supervised by a nurse, midwife, medical officer, Lady Health Visitor, Family Welfare Worker or Family Welfare Councilor, the research protocol and findings will provide a foundation for future studies testing alternative service provision and self-injection support models.

Trial Registration: Registered on clinicaltrials.gov as an observational study (NCT05774626).