More and more women are asking for injectable contraceptives. This method can be more widely available when it is offered in the community as well as in clinics.

A WHO technical consultation in 2009 reviewed evidence and program experience and concluded that “community-based provision of progestin-only injectable contraceptives by appropriately trained community health workers is safe, effective, and acceptable” to clients.

Community-based providers of injectables should be able to screen clients for pregnancy and for medical eligibility. Also, they should be able to give injections safely and to inform women about delayed return of fertility and common side effects, including irregular bleeding, no monthly bleeding, and weight gain. They also should be able to counsel women about their choice of methods, including methods available at the clinic. All providers of injectables need specific performance-based training and supportive supervision to carry out these tasks.

It is desirable, if possible, to check blood pressure before a woman starts an injectable (see p. 65, question 3). However, in areas where the risks of pregnancy are high and few other methods are available, blood pressure measurement is not required.

For success, clinic-based providers and community-based providers must work closely together. Programs vary, but these are some ways that clinic-based providers can support community-based providers: treating side effects (see pp. 75–77), using clinical judgment concerning medical eligibility in special cases (see p. 67), ruling out pregnancy in women who were more than 4 weeks late for an injection of DMPA or 2 weeks late for NET-EN, and responding to any concerns of clients referred by the community-based providers.

The clinic also can serve as “home” for the community-based providers, where they go for resupply, for supervision, training, and advice, and to turn in their records.

A new type of prefilled, single-use syringe could be particularly useful to provide DMPA in the community. These syringes have a short needle meant for subcutaneous injection (that is, injection just below the skin). They contain a special formulation of DMPA, called DMPA-SC. It is meant only for subcutaneous injection and not for injection into muscle. This formulation of DMPA is available in conventional prefilled auto-disable syringes and in the Uniject system, in which squeezing a bulb pushes the fluid through the needle (see photo below). Like all single-use syringes, these syringes should be placed in a sharps box after use, and then the sharps box should be disposed of properly (see Infection Prevention in the Clinic, p. 312).