By Andrew Bishop Mkandawire, FPAM SBCC Lead
Introduction
Girls and women in Malaŵi can now exercise their sexual and reproductive health power and decision with user friendly four-dose self-injection contraception that keep them away from the health worker and health facility for 12 months. Utility of this contraception is not affected with women’s education, social economic, political and cultural background.
The self-injection family planning method contains DMPA drug, progestin-only. There are two types, DMPA IM or Depo Provera and DMPA SC or Sayana Press that can be administered, DMPA SC Provider Initiated (PI), and self-administered DMPA SC Self Injection (SI), DISC2 (2022). A single dose, one injection, protects a woman for three months and four doses cover the whole year. The contraception self-injection concept can be related to how diabetic and arthritis drugs are self-administered, DISC2 (2023). The DMPA IM is injected in the muscles, shoulder area, while DMPA SC is injected on a fatty tissue around the navel and on the thigh. These sites are for self-injection but when it’s injected by a provider, the back arm is preferred.
FP2030 commitments is one of the key performance measures to check if Malaŵi is doing well in promoting use of modern family planning contraceptives. Currently uptake of contraceptives is at 48.9 % for all women and 71% for married women.

Tasimiya Bakali, married woman, DMPA SC SI client from T/A Malengachanzi, Nkhotakota. Photo: Franco Machande Jr
Challenges facing girls and women in reproductive health has pushed Malaŵi government to find most affordable family planning services that can be made available at all service delivery points. As of 2020, the teenage prevalence rate was pegged at 28.9%, neonatal mortality rate at 26/1000, infant mortality rate at 60/1000, and total fertility rate at 4.2, MICS (2020). However, The National Statistical Office (2024) indicates an increase in teenage (15-19) pregnancy prevalence rate now at 32% while neonatal mortality rate and infant mortality rates have dropped to 24/1,000 live births, and 35/1,000 live births respectively.
The uptake trends since 2019 have been fluctuating, indicating commodity acceptance although the uptake rates are relatively low as compared to administered contraception injections. The fourth quarter of 2019 recorded 36% service uptake which dropped below 26% from 2020 to April – June 2023. By July to September 2023 a spike of 30% was reached. The journey was attributed to increase in DMPA – SC PI (Provider Initiated) visits due to stockouts of DMPA IM, Depo Provera in 2022. The Moment of Truth (MoT) trainings for service providers that began in October 2022 also increased the number of service providers to serve more women with the new family planning method, Chirwa (2022).
Benefits
The DMPA-SC (Sayana Press) has many benefits for women. Injectables are highly demanded family planning method in Malaŵi so far with uptake of 52% among all women of reproductive age. The self-injection is discrete and confidential, giving women the power to choose and use the smart injection at their preferred space, Chirwa (2022). The self-administered injection reduces every-three-month visits to a health facility, thereby reducing transport expenditures, which draws attention to her health – seeking behavior. The self-injection contraception currently branded as Sayana Press is known to be time and resource saving as a woman can self-inject without interrupting her daily work schedules.

Expanding modern contraceptive mix for women in Malaŵi (MICS 2019/2020)
The pride and power women express by self-injecting has proven to generate self- confidence in women who end up with a sense of accomplishment and pride.
Eligibility to use
All women of reproductive age 10-49 interested to prevent unintended pregnancy can use the self-injection provided they meet the medical recommended criteria. Women breastfeeding a baby who is at least 6 weeks old, women who have not had children, women who do not want to use family planning containing other hormones like estrogen can opt for self-injection family planning method. Women who have sexually transmitted infections including HIV and those taking medicines including ARVs to treat HIV/AIDS are also eligible although duo protection is encouraged to prevent spread of venereal infections, DISC (2022).
Sayana Press is safe, effective, easy to use, long-lasting, reversible, and can be discontinued without a provider’s help. It doesn’t interfere with sex, and can be used privately.
Challenges
Not all women face similar side effects of DMPA SC SI. Some see prolonged or heavy vaginal bleeding, irregular bleeding, or spotting. Some women feel headaches and dizziness and some completely stop having menses. In some instances, other women gain weight. And some women have changes in mood and sex drive, and some have abdominal bloating and discomfort with the SI.
People react differently after the injection. Some women feel pain, tenderness, lump, persistent skin indentation/dimpling at an injection area but the most common side effect of DMPA-SC is itching for a while at the injection site according to NHS Foundation Trust (2021).
Health workers have noted that women who get counseling are likely to continue using SI than those who do not.
Conclusion
The self-injection contraception intends to improve access to contraceptives and empower women to choose their preferred contraceptive method. Chirwa (2022) explains that in Malaŵi, the SI availability is contributing to the re-commitment of raising the country’s modern contraceptive prevalence rate to 60% by 2030 from a baseline of 48.9% in 2020 with a focus among all women of childbearing age. This also responds development goal of Malaŵi Agenda 2063 which aims at having ‘A globally competitive and highly motivated human resources.’
The Ministry of Health in Malawi through Reproductive Health Directorate (RHD) rolled the introduction of DMPA – SC in a phased approach in 2018. By October 2018, service provision commenced with intent to raise the country’s DMPA SC self – Injection uptake from 29% in Jan to March 2024 as baseline by 2030.
Sources
Chirwa, Salamba, J. (2022) Self – Injection Advancement Strategy Template 2024 – 2025 [Presentation]. Lilongwe: Reproductive Health Directorate, Ministry of Health.
DISC2 (2022) Demand Generation Strategy Training for Health Educators [Presentation]. Nigeria: PSI, SFH, Children’s Investment Fund Foundation.
DISC2 (2023) Moment of Truth’ Mobilizer Package [Presentation]. Uganda: PSI, SFH, Children’s Investment Fund Foundation.
DISC2 (2023) Community mobilizers Flip Chart [Job Aid]. Nigeria: PSI, SFH, Children’s Investment Fund Foundation.
National Statistical Office. (2024) Malawi Demographic and Health Survey: Key Indicators Report. Zomba: National Statistical Office.
National Statistical Office. (2021) Multiple Indicator Cluster Survey (MICS) 2019 – 2020. Zomba: National Statistical Office.
NHS Foundation Trust (2021) Information About Self-Injecting Sayana Press. Central and Northwest London: NHS Foundation Trust