This study received ethical approval from the Research Ethics Review Committee, Health and Hospital Management Program, Institute of Business Management, Karachi (IRB no. 20161–21588; approved on March 10 ^th 2021). The researcher informed the participants about the research objectives in their native language, and verbal consent for participation and data publication was obtained before proceeding to the discussion. After their consent was obtained, which the interviewer recorded in interview forms, the discussion was recorded for future transcription. The respondents of the study belonged to different demographic backgrounds (geographical Rural, Urban, and education) and participants did not want to disclose their identity in any way. Verbal consent was approved by the Research Ethics Review Committee.

This qualitative study used the focus group discussion (FGD) method by adopting a purposive sample technique instead of a statistically representative sample of a broader population ¹¹ to gain an in-depth understanding of social issues. FGD serves to solicit information regarding participants’ attitudes and perceptions, knowledge and experiences, and practices shared during interactions with different people. The technique assumes that during FGD, group dynamics will be activated to help identify and clarify shared knowledge among group members, which would otherwise be challenging to obtain through individual interviews ¹² . Participants were recruited following the guidance in “How to conduct FGD Methodological Manual” by Peter van Eeuwijk and Zuzanna Angehrn ¹² . Furthermore, they were recruited according to the inclusion criteria of being married, with the help of social mobilizers providing FP services in these areas. The number of participants was finalized considering the manual ¹² , and in each FGD, 9–13 women with different demographic characteristics, including education, parity, profession, and age, were included. According to a previous study, three FGDs are sufficient to reach saturation of codes ¹³ . Hence, three FGDs were conducted for this study.

The Government of Sindh introduced Sayana Press DMPA-SC in a few selected districts. The selection of areas for study from districts (Karachi, Hyderabad, and Sukkur) was intended to ensure adequate representation of urban and rural participation. The FGDs were conducted using a semi-structured field guide comprising an open-ended questionnaire developed through available literature. Its contents and face validity were evaluated, and a pilot test was performed through an internal testing process, as outlined by DeVon et al. ¹⁴ . First, the tool kit was finalized in English. It was then translated into Urdu and Sindhi. Considering cultural constraints, female data collectors with expertise in the above languages were engaged to conduct FGDs, during which they encouraged respondents to participate in the study. The participants were recruited with help from field workers during the last week of March 2021 at three sites, and data were collected and completed from April to May 2021. The researchers informed the participants about the research objectives in their native language and obtained their consent before proceeding to the discussion. After their consent was obtained, the discussion was recorded for future transcription. The total duration of all three FGDs was 143 minutes (not including the general introduction and rapport-building process, which were not recorded). The audio was initially transcribed in the original recorded language (Sindhi and Urdu) and later translated into English and cross-checked by professional linguists.

The researchers used the guidelines by Braun and Clark ¹⁵ and followed the following six defined steps:

The guidelines indicate that the researcher should become familiar with the dataset before starting the analysis. In the current study, the researchers had direct experience in the FP field and belonged to the local community. In this case, having a substantial understanding of the subject and the language used by the respondents was ensured. The researchers repeatedly read the transcripts and listened to the audio recordings to understand the responses in-depth.

Following the guidance of Braun and Clark ¹⁵ , this study used a top-down method for developing initial codes aligned with the research questions and objectives, applying a deductive approach. Each data segment relevant to the research objectives was evaluated and assigned codes. Open coding was used and modified throughout the process. This strategy helped to clarify how participants provided feedback regarding their access to the FP services, especially concerning the DMPA-IM injection and the side effects or disadvantages of the injection method.

Generally, themes are patterns relevant and notable to the research objectives. As Braun and Clarke provided no specific rules for themes except for using the nearest associations, this study created two major themes, considering the comparison between the two injection methods, one each for DMPA-IM and DMPA-SC, and recorded the coding in each area. The details of the coding are provided in Table 1. This approach is used when a study is driven by research questions ¹⁶ .

After gathering the codes in two broader areas, those with closer associations were grouped to develop subthemes aligned with the research objectives. This review process was performed considering specific vital questions, as discussed by Maguire and Delahunt ¹⁶ .

The details of the reviewed themes and subthemes were summarized following the codes, their meaning, and close associations, avoiding overlapping and considering the research objectives, as provided in Table 2.

This stage required the final refinement of the themes by identifying the essence of each theme. It primarily addressed the following questions:

These questions were examined and applied accordingly.

The final stage involved writing the study results, including its findings, conclusions, and recommendations. Next, the data were analyzed using NVivo software version 11 (RRID:SCR_014802) (free alternative, Taguette), as this has been used for similar research objectives that necessitated deductive and inductive codes, requiring deeper involvement in the analysis process. In addition, this method was utilized because it allowed an in-depth understanding of the data and the issue under investigation, which is paramount in qualitative research ¹⁷ . Finally, the results were recorded and presented accordingly.

Participants from the rural areas shared their dependency on public sector services, while 50% of the urban participants preferred selective private healthcare services. Accessibility and shortage of supplies were reported as challenges to accessing the injection method. According to a participant:

“ Civil hospital [government facility] is far from us. We face problems in reaching there, and sometimes when we go there, they have problems with availability and say injections are not available in stock.” (FGD-Hyd; Participant C).

Clients without financial support depend on the public sector for FP services because they lack options due to resource constraints. According to a participant:

“Those who had wakfa [Gap / FP services] are likely to be more satisfied with the services of private hospitals, but those who are poor like me remain satisfied with the government hospital because they have no other choice.” (FGD-Suk; Participant B).

Additionally, in rural areas, women primarily make decisions regarding FP services. Sometimes, they obtain their husband’s consent. In other cases, they decide without informing their partner. Furthermore, men are influenced by religious thoughts, as a participant shared:

“My husband says Allah [God] promised to give us food by hook or crook, then why do you want to have wakfa [FP services]? Now my husband does not know I had wakfa. But he is saying we will give birth to a little baby girl because all other children are young, and now we should have a little baby.” (FGD-Suk; Participant G)

These results align with previous research findings, suggesting that the family size is larger among families where the husband opposes contraceptives because of a perceived religious prohibition of their use ²⁰ .

Poverty was a complex challenge across all the FGDs. It was worse in rural areas, as a participant shared:

“Sometimes our children do not have a copy [notebook for writing] or pen, or sometimes they do not have a dress. So, we put more effort into making handicrafts and selling them. We fulfill our needs and hope for a brighter future for our children; it is not possible to spend money on FP services.” (FGD-Suk; Participant B)

Clients in rural and urban areas receive injectable contraceptives free of charge at public sector facilities and pay charges only for transportation. By contrast, while at private facilities, they must pay for both service charges and transportation costs. However, certain factors motivate clients who can afford to visit private health facilities. Regarding the comparison of public and private hospital services in terms of their availability, a participant shared:

“People with no financial issues go to private clinics to save time and believe that things that are free of cost are not reliable. I have experienced both private and public facilities, and I can surely say that government commodities are reliable, and their services are better than private facilities.” (FGD-Kar; Participant D)

It was found that even in the presence of substantial information regarding family planning methods in the community, it is still difficult to get agreement from female clients to start contraception. This perspective aligned with a previous study’s findings that women find accepting the FP method and its cost challenging ²¹ . According to a participant:

“Convincing women for FP is difficult; if it is hard to convince people to receive the free-of-charge FP method, it would be much harder to convince them to pay from their domestic earnings for FP.” (FGD-Kar; Participant E)

We also found that given the lack of options for FP, clients from all settings were willing to pay PKR 50–300 to only private providers as service charges for injectable contraceptives.

Women’s ability to travel is a significant barrier to accessing FP services, including DMPA-IM injection. According to a participant:

“Transportation and affordability are big issues. Do you know why? Suppose a woman has six children; take my example, I have six children, and my husband does not have any proper income. So, I can hardly pay the bus fare. If I request another woman to accompany me, I would have to pay her fare, too, because I am taking her for my FP, which is free of cost, but I cannot afford both expenses. If the government provides me with transportation facility, I could feel at ease that I received a method that is free of cost and my transportation is also free.” (FGD-Kar; Participant D)

These findings align with the results shared by male participants in a study conducted by Dr. Sara Saleem and colleagues in Pakistan ²¹ . Deciding on FP and the unavailability of counseling services were also reported as barriers in the study. According to a participant:

“Last December, I gave birth to a baby girl, and she suddenly died after birth because I had not planned my pregnancy or delivery. I mean to say that we women often take risks to have another child but do not come forward for the FP method. It is very difficult for us to decide about opting for FP methods. But the services of FP workers are very good, as they mobilize people to come forward, take a decision, and get FP method.” (FGD-Kar; Participant E)

Notably, women appreciated the role of health workers in mobilizing clients and helping them decide whether to access FP services.

Most participants shared that injectables can readily be accessed, while some reported that a shortage of supplies and perceived side effects are significant disadvantages. The injection method was preferred among participants. A few of the crucial benefits, according to the participants, included the following:

“Injection means three months of relaxation.” (FGD-Kar; Participant E).

“As I have observed, the injection is effective because I had also used pills, but it caused menstrual cycle two or three times in a month.” (FGD-Hyd; Participant A)

The leading client perception regarding existing DMPA-IM included changes in the menstrual cycle as disadvantages of injection, aligning with previous studies ²¹ . According to participants:

“There is a problem; I heard that the injections available in the government hospitals are not of good quality and are less effective. My aunt shared with me about her health and weakness, similar to what I felt, especially blood pressure problems, after using the injection method.” (FGD-Hyd; Participant C)

“Women do not get periods after taking an injection. In a month, we are fine for 10 days, but after 20 days, we start feeling ill.” (FGD-Suk; Participant G).

We found that participants in all settings showed moderate fear of self-injection. Information regarding the new method is minimal. Moreover, even those aware may not know about its self-injection features. After presenting a demonstration of the new method and observing Sayana Press physically, participants shared their concerns regarding self-injection, specifically the risk of an inaccurate prick, aligning with other studies conducted worldwide that revealed such fear associated with self-injection ^{11, 21} . Participants lacked information about the new method and its self-injection features. However, they showed a willingness to use the self-injection method after adequate training. According to participants:

“If I cannot inject others, then how can I do it for myself, and if I prick it wrong, what would I do? However, I can do it if someone trained me.” (FGD-Suk; Participant B).

“It will be beneficial for us since we are busy with in-house chores; if I forget the injection date, I start feeling fearful, and another point is that if we get an injection by a doctor, we feel ill or unhealthy. If we receive an injection for self-use, we will feel good. However, about the concern of self-administration, after a few times, it will be easy to perform, and finally, the fear will be over.” (FGD-Kar; Participant D).

Most participants appreciated the free services at the public sector health facilities. However, economically compromised clients have difficulty paying private providers to access the injection at a private facility. In addition, we found that the affordability of DMPA-SC is challenging in the private sector, especially for low-income clients. Participants also assumed that DMPA-SC must be expensive. According to participants:

“I think this must have a high price because this is a new method and has different features.” (FGD-Kar; Participant K)

“ Poor people cannot afford costly injections, and this seems costly.” (FGD-Suk; Participant G)

“I think if it is expensive, by hook or crook, we can manage to pay, but if there is a reaction, we may die or face complications.” (FGD-Hyd; Participant C)

This viewpoint is similar to the perceptions of Nigerian clients; the perceived cost to clients was among the most significant concerns ²³ . Participants in this study agreed to pay between PKR 50 and 300 (equivalent to 1 USD) as service charges to private providers. Others agreed to pay transportation costs to receive free public sector health facility services.

Clients preferred the self-injection method to avoid private providers’ transportation and service charges after adequate training. According to a participant:

“ To avoid transportation issues, especially for those women who go outside for services, home-based service is better.” (FGD-Kar; Participant C)

This opinion aligns with findings from a study in Ghana, where women preferred a home-based self-injection method to avoid transportation costs, waiting time at service providers, privacy, and unavailability of providers during their visit ²⁴ . In addition, most participants shared that accepting DMPA-SC is not concerning, especially at the community level. However, acceptance and threats from private providers were found in the current study. According to participants:

“Self-injection will decrease the number of clients coming for injection, so private service providers will spread misinformation about this new method; for example, they can strengthen the perception of inaccurate prick and its negative consequences.” (FDG-Kar; Participant I)

“Private doctors are charging a 50 rupees fee for injection and wish that more patients would come, so their business will go down with the self-injection method. However, the government doctor wishes that patients would not come to them and consider them a headache.” (FGD-Hyd; Participant B)

“The doctor would be angry about this if something went wrong. The best option is to get an injection from the doctor.” (FGD-Suk; Participant G)

The present study confirms the perceived likelihood of threat from the service providers for self-injections, aligning with the findings of Spieler ⁵ , who suggested that doctors, nurses, ministries of health, and midwives may feel threatened (because, historically, a medical doctor administers injections) and create a backlash against using a product that is self-injected ⁵ .

Most participants agreed to pay private providers PKR 50–300 (approximately 1 USD) as service charges. By contrast, others agreed to pay for the transportation cost if they did not have options for other methods. According to participants:

“The maximum that I can afford is 200 to 300 (PKR), but I will have an agreement with that doctor on stamp beforehand that if I become ill, then they will bear all expenses of my treatment, and it would be their responsibility.” (FGD-Suk; Participant G)

“Maximum of 200 to 250 (PKR) ; if it is more than this amount, up to 1,000 rupees, no one can buy or afford.” (FGD-Suk; Participant B)

“Normally an injection costs 150 to 200 rupees at a private clinic, so if it is safe, women can afford it.” (FGD-Kar; Participant K)

“If it is in our budget to get wakfa, we will purchase it; that is a maximum of 50 to 100 rupees.” (FGD-Hyd; Participant A)

This outcome is consistent with the findings of a previous study that the clients’ estimate of affordable pricing for three months of contraceptive injections in India and Nigeria ranges from 1.25 to 2.89 USD ²⁵ , matching the approximate price reported in this study (approximately 1 to 1.5 USD).

The clients preferred Sayana Press over DMPA-IM when choosing between injectable methods ²⁶ . The clients’ reported acceptability and satisfaction regarding Sayana Press was substantial ²⁷ , especially during its second dose in their homes, when this trend increased significantly ²⁴ . The current study confirms the lack of adequate information about its side effects and overall understanding of self-injection ^{4, 28} . According to a participant:

“After having the FP injection (DMPA-IM), I had cardio issues and felt continuous pain on the side on which the injection was received.”

This study thus demonstrates the need for accurate information and counseling regarding FP methods and side effects for the successful implementation of DMPA-SC. In addition, in some countries, increased knowledge of self-injection is high; however, the uptake is low ²⁸ . Hence, service access must be increased by engaging service providers, medical students, and community workers to improve the utility of Sayana Press, especially by promoting self-injection.