Registered in over 25 countries and the European Union, DMPA-SC (depot medroxyprogesterone acetate administered subcutaneously; brand name Sayana Press) availability is expanding worldwide ¹ . DMPA-SC has an all-in-one injection system and studies have shown DMPA-SC to be safely and easily administered by lower-level health cadres such as community-based health workers ² , and even by women who self-inject ^{3, 4} . Studies examining the introduction of DMPA-SC in a variety of pilot settings show high acceptability among users, high desire to continue with the method, and increased contraceptive continuation ^{3, 5– 8} . DMPA-SC has a contraceptive efficacy and safety profile equivalent to that of DMPA-intramuscular ^{9– 11} . Because of the popularity of injectable contraceptives among women in many resource-poor settings, adding DMPA-SC to the contraceptive method mix holds promise for reducing unmet need for contraception, especially in high-fertility countries ^{12, 13} .

Results from pilot experiences lent critical evidence for the scale-up of DMPA-SC, for which many countries are in the processes of planning. However, no studies have explored users’ experiences with DMPA-SC within the context of national scale-up. While pilot settings offer program implementers more control for focused learning and experimentation, lessons from pilots may lack generalizability, particularly for programs that will ultimately operate in complex, mixed public-private health systems. Many operational and implementation challenges may only surface when programs are scaled and delivery systems interact with the full array of actors and environments within their communities.

For the DMPA-SC program in Nigeria, national scale-up through a total market approach was the objective from the outset. Although the program took a phased geographic and sectoral approach, the program was implemented to attain high population coverage at each step. A more rigorous and research-based monitoring and evaluation effort (M&E) was mounted alongside program implementation to maximize learnings for each phase of program scale-up. Lessons learned from the first phase of implementation, which focused only on introducing DMPA-SC through private sector social marketing, have been published elsewhere ^{14– 16} . Here, we report on the results of the second phase of implementation, which expanded private sector distribution and initiated public sector delivery. This paper aims to compare user experiences in acquiring DMPA-SC across public and private sector service providers, characterize their sociodemographic profile differences, analyze their reasons for choosing their provider, and assess the quality of care received. The results highlight important considerations for service delivery in future efforts to expand the use of DMPA-SC in Nigeria and beyond.

In Nigeria, where the modern contraceptive prevalence rate (mCPR) remains low (19% among all married women in 2018 ¹⁷ ), DMPA-SC was introduced as part of a larger public health initiative to reach 27% mCPR by 2020 ^{18, 19} . In 2015, DKT Nigeria introduced DMPA-SC in seven states in South West Nigeria through social marketing and private sector channels ¹⁴ . Key features of this program included supply-side innovations (e.g., targeting high-volume contraceptive service health facilities and drug shops and offering rewards for bulk purchases, distributing through existing wholesale distribution channels, and in-facility trainings for participating providers) and demand generation activities that leveraged online and social media platforms in addition to traditional media approaches. DKT Nigeria initiated a community-based distribution (CBD) model, one that sought to capitalize on a recent government task-shifting policy that empowered community health extension workers (CHEWs) to administer injections ²⁰ . The CBD model proved difficult to adapt for these workers, many of whom preferred to work inside public health facilities giving out free commodities, rather than work in the community on a performance-based remuneration scale; DKT Nigeria ultimately phased out the model after attempts to restructure the program.

In 2016, as part of continued scale-up efforts, private sector distribution of DMPA-SC was expanded to all states in Nigeria. DKT Nigeria focused its supply-side activities on training additional private providers and distributing to high-volume contraceptive service health facilities and drug shops, wholesale suppliers, and professional health worker associations. In early 2017, DKT Nigeria completed a series of demand-side activities begun during the final stages of the introductory phase (late 2016): (a) airing education and interactive audience call-in programs on traditional mass media (e.g., television, radio); (b) leveraging digital and online media with an independent brand and website (honeyandbanana.com) focused on SRH; and (c) using social media platforms for messaging and live chat fora (e.g., Facebook, Instagram, Twitter). Throughout the scale-up period, as they had during the introductory phase, DKT Nigeria continued to operate an automated, free text message service to remind DMPA-SC users of their next reinjection.

Public sector delivery launched in late 2016, coordinated by UNFPA Nigeria and implemented through three local non-governmental organizations (NGOs) to deliver free contraceptive services including DMPA-SC to targeted (primarily urban and per-urban) areas in 10 states. The program and its lessons learned are described in detail elsewhere ²¹ . UNFPA Nigeria based its service delivery model on a DMPA-SC pilot as part of a larger family planning project leveraging CBD previously conducted in two states (Kebbi, Ebonyi). To conduct CBD, UNFPA and its implementing partners recruited and trained volunteers, including individuals who operated businesses in local markets, members of youth organizations, previously-trained community oriented resource persons (CORPS), health volunteers, and other candidates who met minimum qualifications (e.g., completed primary school, proficient in spoken English), as lay health workers. Volunteers were trained to provide contraceptive information, offer counseling on contraceptive services, provide nonprescriptive methods (e.g., condoms and pills), and refer clients to trained CHEWs for DMPA-SC initiation and other prescriptive contraceptive services. Each NGO made adaptations of this basic model to fit their operational expertise and the needs of local contexts. For example, proactive door-to-door household canvassing was used as an outreach strategy for more conservative areas in Northern Nigeria. All services and products in the public sector program were given free of charge.

Due to a challenge in product procurement in early 2017, both private and public sector scale-up activities were delayed. Although some training for public sector providers and volunteers occurred during the months of procurement delay, service delivery did not commence until March 2017, when new stock was acquired. Similarly, private sector distribution of DMPA-SC was halted from November 2016 until April 2017. After the procurement delay ended, DKT Nigeria required an additional month to repackage DMPA-SC from high-quantity (200 units) boxes into single-unit packs that were more suited for retail sale to clients by private providers. By the end of 2017, over 120,000 units of DMPA-SC were administered to women through the public sector program. In the private sector, only distribution numbers for DMPA-SC sales to providers and wholesalers were able to be tracked, showing an increase of 420,000 units over the year (from 726,700 in January 2017 to 1,150,415 by December 2017).

Monitoring and evaluation conducted alongside program implementation during this scale-up phase (late 2016 through 2017) was standardized to enable comparisons in service delivery across sectors to the text feasible, and inform further program expansion efforts in Nigeria. A mixed-methods approach to data collection was designed to monitor and asses a set of key performance indicators (KPIs) for program activities, outputs, and outcomes. A large set of KPIs were focused around the quality of the user experience in care-seeking for contraceptive services and provision of DMPA-SC across health sectors.

Our assessment of the user experience in care-seeking for DMPA-SC during program scale-up in Nigeria suggests that the inclusion of DMPA-SC in the contraceptive method mix may be encouraging contraceptive uptake among women who have never used modern contraception before. While the extent of this expansion is unknown due to the limitations of our convenience sample of survey respondents (see limitations), the finding that many respondents were new users of modern contraception suggests that demand or need for contraception may be increasingly met where DMPA-SC has been made available as a method option. In fact, estimates of new users in the public sector obtained from our phone survey are conservative compared to all public sector program client records which indicate that, among all clients served, 78% were new users of modern contraception ²¹ .

In addition, by using different models of service delivery, public and private sector modalities for contraceptive service provision including DMPA-SC may complement each other. Consistent with larger trends in contraceptive care-seeking and the differential availability of health providers ²⁵ across Nigeria, older, more-educated, and wealthier women tend to seek care from private sector providers whereas younger and poorer women may opt for free public sector services ²⁶ . In our DMPA-SC respondent survey, younger (under age 25) and less-educated women were similarly more likely to be serviced through the public sector program, even after controlling for differences across regions. For these subpopulations, the CBD-centered public sector approach may be helping to overcome many persistent barriers of contraceptive access as evinced by the large portion of new users reached through this modality. Some of these reduced barriers may be related to structural factors, such as lowering the distance to, time for, and monetary costs of care-seeking, and addressing myths and misconceptions related to contraception. Others may be related to socio-behavioral factors, such as reducing the need to negotiate permission for seeking care or reducing associated stigma. CBD may be particularly important for overcoming the confluence of these barriers in Northern Nigeria where private health providers are less prevalent ^{25, 27} and sexual and gender norms more conservative ²⁸ . Past studies in Nigeria and beyond have also found that, compared to facility-based service provision, CBD yields higher contraceptive uptake by reaching more marginalized populations ^{29– 33} .

Indeed, the care-seeking experience across sectors reported by survey respondents support the notion that certain modalities of service provision may be more effective for reaching different subpopulations. For respondents of the public sector program, awareness of DMPA-SC (and by extension, contraception in general) mainly occurred through word-of-mouth—via friends/family or outreaches in communities—while factors for choosing a provider and DMPA-SC as a method were primarily related to the convenience of proactive CBD and ease of use of DMPA-SC. In contrast, care-seeking for private sector program was largely dominated by factors associated with their chosen provider, one who was often either conveniently located or was previously visited, and whose initiative was most often cited for becoming aware of and choosing DMPA-SC. Thus, it seems that DMPA-SC distribution through private sector channels continues to fulfill demand among consumers who more often seek care from providers at established facilities and drug shops ^{14, 27, 34– 36} , in contrast to public sector provision which may be more suited for individuals less likely to seek facility-based services. Our results also showed that the proportion of respondents who found out about DMPA-SC through media outlets was more prevalent among private sector respondents, an understandable finding given that they were the primary audience for the mass media campaign. However, respondents who became aware of DMPA-SC through mass media was low compared to other sources of information, which may reflect the longer time needed to influence care-seeking behavior through these approaches.

Our results also showed that there were areas in which the quality of care received by DMPA-SC users can be improved. Public sector providers were less likely to ask about general medical and contraceptive history or to describe anticipated side effects associated with DMPA-SC. In contrast, interactions with private sector providers were potentially more stigmatizing for younger or unmarried clients. Private providers may also have been more aggressive in specifying a method preference, but were more thorough in describing more than one method choice to clients. Training providers in these areas may help to improve women’s experiences when obtaining DMPA-SC, which may fuel word-of-mouth recommendations from friends, family members, and providers. While many previous studies have found poor quality of care for contraceptive services in Nigeria, particularly for younger or unmarried women ^{16, 37– 39} , to the best of our knowledge, no previous studies have assessed quality across sectors.

Limitations of our sample notwithstanding, our study provides some indication of the experiences of women obtaining DMPA-SC across a large swath of Nigeria and from both public and private sector channels. As Nigeria continues to scale DMPA-SC across the country through its total market approach ⁴⁰ , insights gained from the initial scale-up phase should be incorporated into future operational strategies, including the utility of the CBD approach to complement facility-based services, the centrality of the role of the provider within traditional facility-based care, and specific areas where training should be targeted to improve the quality of care for all women, especially younger ones.