file · Web viewProgestin-Only Injectable (Injectables): Session Plan . Notes to Facilitator: The slides and session plan provide presentation support for conveying technical

Training Resource Package for Family Planning Progestin-Only Injectable Contraception (Injectables) Module

Progestin-Only Injectable (Injectables): Session Plan Notes to Facilitator:

The slides and session plan provide presentation support for conveying technical information and for conducting the interactive learning activities. The slides and session plan addresses only progestin-only injectables, specifically DMPA and NET-EN.

To use this presentation most effectively, please: Read the Progestin-Only Injectable Contraceptives Facilitator’s Guide for guidance

on selecting and adapting TRP materials for the learning needs of your audience. Next read this session plan, which includes detailed learning objectives for this

module and describes how to use the slide presentation and other materials required to prepare for and conduct the learning activities.

Training Process ResourcesSession I: Characteristics of Progestin-Only InjectablesSession Objective: Describe the characteristics of progestin-only injectables.

Welcome and Introduction (10 min.)

Greet participants and introduce yourself.

See the Conducting Training tab in the TRP website (available at: http://www.fptraining.org/content/conducting-training) for ice breaker options.

ObjectivesDiscussion (5 min.)

Explain:

Progestin-only injectable contraceptives are safe and highly effective, and many women find that they are convenient to use.

Injectables can be provided in different settings by a wide range of providers. Providers find that injectables are easy to provide, and many women find that they are easy to use.

The session is designed to address the objectives for this method listed in the Facilitator’s Guide and on the slide set.

This presentation provides an overview of the characteristics of this method. It also provides training on how to counsel, screen, and provide follow-up to clients who are interested in using progestin-only injectables as a way to regulate their fertility.

During this training you will learn and demonstrate these skills during role plays and other activities. You will also

Slides 2-3: Objectives

Last revised: 5 October 2018 Page 1 of 54

http://www.fptraining.org/content/conducting-training


Training Process Resourcesbe encouraged to think about what it will be like to perform these tasks on-the-job.

Review objectives with participants.

Solicit input about whether the planned objectives match participant’s expectations of the training.

Pre-Test Questionnaire (30 min.)

Evaluation Tool: The Progestin-Only Injectables Pre-Test

What Are Progestin-Only Injectables? Key Points for Providers and ClientsLecturette (5 min.)

Discuss the key points that are important for both clients and providers.

Return for injections regularly. Coming back every 3 months (13 weeks) for DMPA or every 2 months for NET-EN is important for greatest effectiveness.

Projestin- only injectables are very effective, and safe.

Do not cause any serious health problems, cancer, or infertility, nor do they produce any significant change in blood pressure.

For breastfeeding women, they do not affect the quality of the breast milk.

Possible side effects include weight gain, headaches, dizziness and changes in monthly bleeding.

Bleeding changes are common but not harmful. Typically, irregular bleeding for the first several months and then no monthly bleeding.

Injection can be as much as 4 weeks late for DMPA or 2 weeks late for NET-EN. Client should come back even if later.

Return of fertility is often delayed. It takes several months longer on average to become pregnant after stopping progestin-only injectables than after other methods.

Changes in monthly bleeding: The most commonly reported side effects of progestin-only injectables are menstrual changes. In the first three to six months, women using progestin-only injectables commonly experience irregular bleeding or spotting and prolonged bleeding.

Slides 4-5: Progestin-only Injectables: Key Points for Providers and Clients



Training Process ResourcesAfter one year, women commonly experience infrequent bleeding, irregular bleeding and amenorrhea

Injection can be as much as 4 weeks late for DMPA or 2 weeks late for NET-EN. Client should come back even if later.

Provide no protection from STIs/HIV. For STI/HIV/AIDS protection, also use condoms.

Note to facilitator: If participants also provide combined injectables (contain both estrogen and progestin and given monthly), clarify that although both are given by injection, they have many important differences. This presentation addresses only progestin-only injectables.

Types of Progestin-Only Injectables Discussion (5 min.) There are two types of progestin-only injectables: DMPA (depot medroxyprogesterone acetate) and NET-EN (has two chemical formulations: norethindrone enanthate and norethisterone enanthate). Each contain a progestin like the natural hormone progesterone in a woman’s body.

DMPA and NET-EN are given as intramuscular injections in one of three sites: the muscles of the upper arm, the muscle of the hip, or in the buttock.

A woman can decide where she prefers to receive the injection. Ask participants to consider how they will talk with their clients about where they prefer to have their injection. Remind participants that some clients will be anxious about receiving an injection, so being able to discuss how the procedure will be performed is an important part of making their clients feel comfortable.

DMPA (depot medroxyprogesterone): o Best known commercially as Depo-Provera, is the most

widely used injectable contraceptive. It is commonly known as the “shot”, the “jab”, Depo or Depo-Provera, Megestron and Petogen.

o Women using DMPA receive a deep intramuscular injection once every 13 weeks, or three months.

o The window for subsequent injections–how early or late the injection can be given while maintaining effective contraception–is up to two weeks early or four weeks late.

Slide 6: Types of Progestin-Only Injectables



Training Process Resourceso If a woman returns more than four weeks late, she can

receive an injection if the provider, using the pregnancy checklist, is reasonably sure she is not pregnant. The use of backup contraception for seven days should be advised, and the woman should be counseled that delaying injections increases the risk of pregnancy.

o Women on antiretroviral therapy should be encouraged to receive the next injection by the end of the three-month period.

o A new formulation of DMPA is available now. It is injected into the tissue just under the skin (subcutaneously) and is called Sayana Press (formerly depo-subQ in Uniject) . Like the intramuscular injection, it is given once every 13 weeks or three months. Because the dose of DMPA in this new formulation is smaller, it is expected to have fewer side effects; however contraceptive effectiveness remains the same.

NET-EN: <give locally available brand names, if different>

o Net_EN is also known as norethindrone enanthate, Noristerat, and Syngestal. A woman should receive an injection of NET-EN once every 8 weeks or two months.

o The window for subsequent injections–how early or late the injection can be given while maintaining effective contraception–is up to two weeks early or two weeks late.

o If a woman returns more than two weeks late, she can receive an injection if the provider, using the pregnancy checklist, is reasonably sure she is not pregnant. The use of backup contraception for seven days should be advised, and the woman should be counseled that delaying injections increases the risk of pregnancy.

o Women on antiretroviral therapy should be encouraged to receive the next injection by the end of the two-month period

DMPA and NET-EN share similar effectiveness, safety characteristics, and eligibility criteria.



Training Process Resources Reminder: progestin-only injectables are different from

combined injectable contraceptives. Combined injectables contain both a progestin and an estrogen. They are known as CICs or monthly injectables, because injectables are given once a month. This presentation addresses only progestin-only injectables.

Effectiveness of InjectablesDiscussion (10 min.)

The purpose of this discussion is to emphasize the effectiveness of progestin-only injectables.

The list on this slide categorizes contraceptive methods from most effective to least effective as commonly used. In this list, spermicides are the least effective method and the most effective methods are sterilization and implants.

Ask participants: Where would you put progestin-only injectables on this list? <after participants respond, click the mouse to reveal the answer>

Conclude by emphasizing that progestin-only injectables are at the top of the second tier of methods, as they are very effective methods of contraception. Only the intrauterine device (IUD), male and female sterilization, and implants are more effective than progestin-only injectables.

Emphasize that effectiveness depends on getting injections regularly. The risk of pregnancy is greatest when a woman misses an injection.

Optional: See Advanced Slide set to compare typical and perfect use effectiveness for all methods.

Slide 7: Effectiveness of Injectables

Optional Advanced Slide 2: Progestin-Only Injectables:Effectiveness

Relative Effectiveness of Family Planning (FP) MethodsLecturette (5 min.)

Explain that there is another way to look at effectiveness. In this slide we look at how effective FP methods are as they are commonly used.

The slide shows the number of women who would get pregnant if 1,000 women used a method for one year. So, if 1,000 fertile women who were having sex, but not using any protection from pregnancy, 850 of them would become pregnant.

But, if the same 1,000 women were using an injectable, 30

Slide 8: Relative Effectiveness of FP Methods



Training Process Resourceswould become pregnant.

As a part of good counseling, it is important to inform clients about how effective each method is.

Ask participants: • What if these same women were using the pill? How many

would become pregnant?

Method EffectivenessRole Play (20 min.)

The purpose of this activity is to give participants an opportunity to practice explaining the effectiveness of progestin-only injectables using two job aids: Comparing Effectiveness of Family Planning Methods and If 100 Women Use a Method for One Year, How Many Will Become Pregnant?

Explain that one of the charts shows the number of women who would be pregnant if they used the method perfectly (perfect use) or if they occasionally used the method incorrectly or forgot to use it sometimes.

Ask participants: Why is it difficult to use a method perfectly? Is it realistic to think that all methods will be used perfectly? Why or why not? How can a provider influence how effectively a woman uses the method she is given? (Answers should include how counseling about a method influences its use).

Distribute copies of these job aids for participants to use.

Remind participants that clients consider method effectiveness a key factor when making a decision about which method to use.

Explain that the chart on the previous slide is not necessarily easy for clients to understand. These two job aids present the information in a more understandable format.

Explain that: If 100 women use progestin-only injectables correctly for 1 year (having their injections on time), less than 1 woman will become pregnant.

Before practicing with the tools, ask participants to answer following questions:

1. How might you use these tools to help explain how effective progestin-only injectables are compared to other contraceptive methods?

Handout #1: Comparing Effectiveness of Family Planning Methods

Handout #2: If 100 Women Use a Method for One Year, How Many will Become Pregnant?



Training Process Resources2. How do these job aids compare with other ways you

have explained method effectiveness to clients?

Allow the groups to role play how to explain using the two job aids with clients for about 15 minutes.

Role Play Instructions:

Instruct participants to pair off with a person sitting next to them.

One person should play the role of the provider, while the other pretends to be a client.

Providers should use one of the job aids to explain implant effectiveness as if they were interacting with an actual client. Encourage “clients” to ask questions.

Give partners several minutes to practice.

To conclude the activity, ask participants to gather as a large group and talk about the experience. Find out how well they thought the tools worked, whether they were helpful to the clients, and what they learned from this experience.

Explaining How Injectables WorkLecturette (5 min.)

Explain that progestin-only injectables prevent pregnancy in two ways:

1. The primary mechanism of action is to suppress ovulation. Progestin causes the hypothalamus and the pituitary gland to reduce production of the hormones that are necessary for ovulation. Without ovulation, there is no egg to be fertilized.

2. Progestin also thickens the cervical mucus. The thickened mucus makes it more difficult for sperm to enter the uterine cavity. In the unlikely event that a woman does ovulate, this mucus barrier greatly reduces the chance that the egg will be fertilized.

Other contraceptive methods that work this way are implants and combined oral contraceptives (COCs).

Progestin-only injectables do not disrupt an existing pregnancy and do not harm a fetus if a woman is accidentally given this method when she is already pregnant. However, if it is determined that a woman who is using injectables is, indeed, pregnant, she should stop

Slide 9:Injectables: Mechanism of Action



Training Process Resourcesreceiving injections.

Note to facilitator: In many places it is a common myth that injectables will abort an existing pregnancy or harm a fetus, so it is important to counter this belief and emphasize the fact that progestin-only injectables do not disrupt an existing pregnancy or harm a fetus if a woman is already pregnant when she has receives an injection. More information about misconceptions and rumors about injectables will be discussed further in Session III.

Characteristics of Progestin-Only InjectablesBrainstorming (10 min.)

The purpose of this activity is to keep participants focused on how they translate technical information into concepts that their clients can understand.

Brainstorming instructions: Ask participants to brainstorm first a list of positive

characteristics (advantages) and then negative characteristics (limitations) of progestin-only injectables.

Write these suggested characteristics on a flip chart. Then show the slides of characteristics of progestin-only injectables and compare them to the list generated through brainstorming.

If you use the terms advantages and limitations, mention that the same characteristic of a FP method may be an advantage for one person and a limitation to another.

Discuss and correct any misconceptions and counter any myths that may arise about progestin-only injectables.

Remind participants that people with similar characteristics in similar situations may have very different reasons for making choices about contraceptive methods. When counseling clients it is important to help them consider how these method characteristics fit with their lifestyles and reproductive health goals and desires.

Slide 10: Characteristics of Progestin-Only Injectables

Health Benefits of Progestin-Only InjectablesLecturette (5 min.)

In addition to preventing pregnancy, progestin-only injectables provide a number of health benefits to users including:

o They help protect against endometrial cancer and uterine fibroids.

Slide 11: Progestin-Only Injectables: Health Benefits



Training Process Resourceso They may help protect against symptomatic pelvic

inflammatory disease (PID) and iron-deficiency anemia.

o They reduce sickle cell crises in women with sickle cell anemia2

o They also reduce the symptoms of endometriosis, including pelvic pain, and irregular bleeding.

NET-EN may offer many of the same health benefits as DMPA, but this list of benefits includes only those for which there is available research evidence.

Injectables and Risk of Breast CancerLecturette (5 min.)

Progestin-only injectables have no effect on a client’s overall risk of breast cancer. Older studies had found a somewhat increased risk of breast cancer among current users. But this finding was probably due to detection bias or accelerated growth of pre-existing tumors.

A recent large study found no increased cancer risk in current or past DMPA users regardless of age and duration of use.

No studies were done for NET-EN.

Slide 12: Injectables and Risk of Breast Cancer

Effect of DMPA on Bone DensityLecturette (10 min.)

Most studies have found that DMPA users have lower bone density than non-users, especially women age 21 or younger. A woman’s bones normally reach their maximum density during adolescence, but the use of DMPA during adolescence may affect peak bone mass.

Women who start using DMPA as adults appear to regain most of the lost bone after they stop using DMPA.

However, it is not yet known whether bone loss in adolescents and young women is completely reversible. One study found that adolescent NET-EN users recovered bone mass density after discontinuing.4 However, long-term studies are needed to determine whether DMPA use increases the risk of fracture, especially in women who begin using DMPA during adolescence.5 Currently, DMPA use is considered to be generally acceptable for adolescent clients, because preventing risks associated with unwanted pregnancy at a young age outweigh the

Slide 13: Effect of DMPA on Bone Density



Training Process Resourcestheoretical risk of fracture later in life.

Infant Exposure to DMPA/NET-EN During BreastfeedingLecturette (10 min.)

DMPA and NET-EN have been used extensively by women who are breastfeeding. Because DMPA and NET-EN are partially excreted through breastmilk, a breastfeeding infant swallows a small amount of hormone, which enters the child’s circulatory system. Studies have shown that DMPA has no adverse effects on the onset or duration of lactation; the quantity or quality of breastmilk; or the health and development of nursing infants.

Note to Facilitator: Slides 2 and 4 in session II represent the international consensus on the initiation of implants and breastfeeding as reflected in the WHO MEC. For further information on the initiation of implants and breastfeeding, see slide 10 in session II. This consideration will be more fully discussed at that time.

Slide 14: Infant Exposure to DMPA/NET-EN During Breastfeeding

Injectables: Return to FertilityLecturette (10 min.)

Return to fertility for injectables users depends on how long it takes a woman to fully metabolize the DMPA or NET-EN from her last injection. Because women differ in how they metabolize DMPA and NET-EN, there is considerable variability in how long it takes to become pregnant after discontinuation.

In the case of DMPA, on average, women can become pregnant nine to 10 months after their last DMPA injection. Some women may become pregnant as soon as four months after the last injection, but a small percentage may take as long as 18 months. The average time it takes to become pregnant after discontinuing injectables is about four months longer for DMPA users and about one month longer for NET-EN users than for women who use other modern methods. The difference in fertility between former DMPA users and former users of other contraceptives disappears approximately 16 months after discontinuation.

The length of time a woman has used DMPA or NET-EN makes no difference in return to fertility.

Because of the delay in return to fertility, women should be

Slide 15: Injectables: Return to Fertility



Training Process Resourcescounseled to consider discontinuing DMPA or NET-EN several months before the time they want to conceive.

Side Effects of InjectablesLecturette (10 min.)

As with many contraceptive methods, there are some side effects associated with progestin-only injectables.

The most commonly reported side effects of DMPA and NET-EN are menstrual changes, including prolonged, heavy or irregular bleeding, spotting, and amenorrhea.

o In the first three to six months, women using progestin-only injectables commonly experience irregular bleeding or spotting and prolonged bleeding.

o After one year , women commonly experience infrequent bleeding, irregular bleeding, and amenorrhea.

o Less than 10% of DMPA users have normal cycles in the first year of use (90% of users will have bleeding changes in the first year).

o Menstrual bleeding changes for any one client are unpredictable.

o About 47 percent of women, nearly half, develop amenorrhea and have no monthly bleedings after one year of DMPA use

DMPA and NET-EN users also commonly report weight gain, although some injectables users report weight loss while others report no change in weight.

Less commonly reported side effects are headaches; dizziness; abdominal bloating and discomfort; mood changes, such as anxiety; and changes in sex drive. It is difficult to determine wither a change in a woman’s mood or reduced sex drive is related to DMPA or NET-EN or to other reasons; there is no evidence that injectables affect a woman’s sexual behavior.

Typically, nine out of ten of injectables users report at least one side effect during the first year of use. In most cases, none of these side effects result in health risks. Nonetheless, some side effects, such as changes in bleeding, may have serious practical and social consequences for women.

Slide 16: Side Effects

Optional Advanced Slide 3: DMPA: Menstrual Bleeding Changes

Optional Advanced Slide 4: Comparing DMPA and NET-EN Side Effects



Training Process Resources About one third of users discontinue in the first year due to

side effects.

It is important to reassure clients that side effects are experienced by many women who use injectables and they are not signs of illness.

For more information on menstrual bleeding changes or a detailed comparison of side effects associated with DMPA and NET-EN, see Optional Advanced Slides 3 and 4.

Progestin-Only Injectables Fact Sheet Brainstorming (10 min.)

The purpose of this activity is to give participants an opportunity to review the characteristics of progestin-only injectables and explore the contents of the fact sheet.

Brainstorming instructions:

Introduce the fact sheet and ask participants to review the first page.

Ask participants if there are any additional comments or questions about the characteristics of implants.

Discuss and clarify as needed.

Ask participants to consider how they might be able to use the fact sheet in their work. Remind participants that although it might be useful for helping providers to remember important information to share with clients, the fact sheet is not intended to be used as a brochure to be distributed to clients.

Ask participants to review page two of the fact sheet. Inform the participants that the next segment of the training will address the issues outlined on page two of the fact sheet.

Slide 17: Group Activity: Injectables Fact Sheet

Handout #3: Fact Sheet: Progestin-Only Injectables



Session II: Who Can and Cannot Use Progestin-Only InjectablesSession II: Demonstrate how to screen clients for eligibility for progestin-only injectable use.Progestin-Only Injectables Are Safe For Most WomenLecturette (10 min.)

Most women can use progestin-only injectables safely and effectively, including women who:

o Have or have not had children

o Are not married

o Are of any age, including adolescents and women over 40 years old

o Smoke cigarettes, regardless of a woman’s age or number of cigarettes smoked

o Are infected with an STI or HIV, or have AIDS, including those on antiretroviral therapy

o Are postabortion

Slide 2: Progestin-Only Injectables Are Safe For Most Women

Who Should Not Use InjectablesLecturette (10 min.)

Use content on slides to present information.

Slides 3 and 4: Who Should Not Use Injectables

Medical Eligibility Criteria Brainstorming (25 min.)

This activity has two purposes:1. To give participants an opportunity to share what they

know about the eligibility criteria used in their national FP guidelines or the WHO medical eligibility criteria (WHO MEC) so that the facilitator can determine whether the participants understand the criteria and how they are used or whether they need additional background information before proceeding.

2. To introduce job aids that help participants understand eligibility criteria (and that they may also use at their worksites), such as the WHO Medical Eligibility Criteria Wheel for Contraceptive Use, or the Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use.

Brainstorming instructions:

• Use slides 6 and 7 to introduce the concept of medical eligibility and determine whether participants have an adequate foundation. Explain the 4 categories.

Slide 5: Medical Eligibility Criteria

Slides 6 and 7: WHO’s Medical Eligibility Criteria, Categories for IUDs, Hormonal and Barrier Methods

Slide 8: Category 1 Examples (not inclusive): Who Can Use DMPA and NET-EN

Slide 9: Category 2 Examples (not inclusive): Who Can Use DMPA and NET-EN

Slide 10: Category 3 and 4 Examples (not



• List 10-15 medical criteria on a flip chart. Ask participants to find the appropriate category on the WHO MEC Wheel or the Quick Reference Chart. If time allows, this exercise can be made into a game using teams to determine the correct answers. Ask several participants to share one thing that they know about the eligibility criteria in their national FP/RH guidelines (if they exist) or the WHO MEC.

NOTE: There are a few conditions that are categorized differently for NET-EN and DMPA for Categories 1 and 2 (they are noted in Slides 8 and 9).

Category 1: For women with these conditions or characteristics, the method presents no risk and can be used without restrictions.

o Use the MEC Quick Reference Chart (Handout # 5) to find other examples of Category 1 conditions that are not listed on this slide <non-migrainous headaches, at high risk for HIV, HIV infected, AIDS, superficial thrombophlebitis, complicated valvular heart disease, pelvic tuberculosis, iron-deficiency anemia and sickle cell disease, endometrial and ovarian cancer, mild cirrhosis, history of cholestasis related to pregnancy>.

Category 2: For women with these conditions or characteristics, the benefits of using the method generally outweigh the theoretical or proven risks.

o Other examples of Category 2 conditions that are not listed on this slide <migraines without an aura; migraines with aura/to initiate use; history of deep venous thrombosis (DVT); known hyperlipidemias; cervical cancer; an undiagnosed breast mass; irregular bleeding patterns; cholestasis related to oral contraceptives>.

Category 3: For women with these conditions or characteristics, the theoretical or proven risks of using the method usually outweigh the benefits. In settings where clinical judgment is limited, Category 3 conditions are treated in the same manner as Category 4 conditions. This means that women with Category 3 or Category 4 conditions should not use progestin-only injectables. Use the MEC Quick Reference Chart (Handout #5) to find the Category 3 conditions that are not included in this slide <past breast cancer with no evidence of current disease for five years, migraines with aura/to continue use, diabetes for more than 20

inclusive): Who Should Not Use DMPA and NET-EN

Handout #4: WHO Medical Eligibility Criteria Wheel for Contraceptive Use

Handout #5 The Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use



years duration, other vascular disease>

Note: The condition of breastfeeding before 6 weeks postpartum is a special case that merits further consideration. Based on theoretical (i.e. not proven) reasons having to do with the concern that progestogens may negatively affect the neonatal liver or brain, the WHO MEC has classified breastfeeding before 6 weeks postpartum as a category 3. WHO also notes that “in many settings pregnancy morbidity and mortality are high, and access to services is limited. Progestin-only contraceptives may be one of the few types of methods widely available and accessible to breastfeeding women immediately postpartum.” Reflecting this consideration, after careful evaluation of the evidence and their own health systems and settings, some countries have made different classifications. The United States Center for Disease control (CDC) gives the condition of breastfeeding at 0-4 weeks a Category 2 and from 4-6 weeks a Category 1. The United Kingdom’s Royal College of Obstetricians and Gynaecologists: Faculty of Sexual and Reproductive Health Care give it a Category 1 from birth onward. This distinction has important programmatic considerations because it would mean that progestin-only injectables could be offered in the immediate postpartum setting to women who wanted to receive them. The materials in this training package reflect the WHO classification, with room for discussion of the various options.

Category 4: For women with these conditions or characteristics, the method presents an unacceptable health risk and should not be used. Current breast cancer is the only Category 4 condition for injectables.

• Note that the MEC Quick Reference Chart (Handout #5) is not a comprehensive listing of all the conditions that WHO has categorized. Consult the WHO publication, Medical Eligibility Criteria for Contraceptive Use, for a comprehensive list and explanation.

• Demonstrate how to use the WHO MEC Wheel or the Quick Reference Chart. Explain that injectables are safe for the overwhelming majority of women. Use slides 9 and 10 to provide an overview of the medical eligibility criteria for progestin-only injectables.



Injectables Use by Women with HIV and AIDSLecturette (5 min.)

According to the WHO MEC, DMPA and NET-EN can be used without restrictions by women whit HIV and women who have AIDS; these are all Category 1 for both DMPA and NET-EN.

ARV therapy includes a variety of different treatments, but all regimens contain either NNRTI (non-nucleoside reverse transcriptase inhibitors) or PI (protease inhibitor). As noted earlier, NNRTIs and ritonavir or ritonavir-boosted PIs are Category 1 for DMPA and Category 2 for NET-EN. Research shows that these ARVs interact with both DMPA and NET-EN in a way that slightly reduces the blood concentration of progestin—but not to a degree that impairs contraceptive effectiveness. For more information, consult the WHO document, Medical Eligibility Criteria for Contraceptive Use.

Providers should encourage all women on ARV therapy to receive their injections by their scheduled reinjection dates to ensure maximum effectiveness.

Women with HIV who choose to use progestin-only injectables should be counseled about dual method use and advised to use condoms in addition to injectables. Condoms provide both additional protection from pregnancy in the event of late reinjection and protection from STI/HIV transmission between partners.

Slide 11: Injectables Use by Women with HIV and AIDS

Injectables Use by Postpartum WomenLecturette (5 min.)

Ask participants: Let us take a closer look at the conditions and categories pertaining to postpartum clients.

Use slide to present the following:

o Non-breastfeeding women can initiate injectables immediately postpartum.

Note to facilitator: Present and discuss your country’s guidelines regarding postpartum initiation of injectables and adapt the slide if needed to reflect the guidelines. In a number of countries, national guidelines allow for earlier initiation of injectables because the risks of unwanted pregnancies outweigh the risks associated with initiation during the early postpartum period.

Slide 12: Injectables Use by Postpartum Women



Understanding the Injectables ChecklistExperiential Learning Exercise (15 min.)

The purpose of this activity is to introduce participants to the Checklist for Screening Clients Who Want to Initiate DMPA or NET-EN, to provide an overview of its purpose, and to show how to use it.

Distribute an injectables checklist to each participant.

When introducing the checklist, mention that it should be used by providers to determine whether a client is medically eligible to use the method that she selected during an informed decision-making process.

The questions on the checklist identify women who have health conditions—WHO Category 3 or 4—that make it unsafe for them to use progestin-only injectables. The checklist also incorporates questions that allow a provider to determine with reasonable certainty that a client is not pregnant.

To use the checklist, providers ask the questions on the checklist and follow the instructions based on the client’s responses.

Explain that the medical eligibility questions, questions 1–9, are at the top of the checklist.

Ask participants to pair themselves with the person sitting next to them and take turns reading questions 1–9 on the checklist and finding the condition on the Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use. Ask the pairs to verify that all the category 3 and 4 conditions for progestin-only injectables on the MEC chart are represented in the questions on the checklist. Allow participants about three to four minutes to examine the checklist questions and compare them with the MEC chart.

Ask participants: o After examining the checklist and the MEC chart, are

you confident that the checklist questions address the conditions that prohibit safe use of progestin-only injectables? Explain why.

o How have you determined a client’s medical eligibility for progestin-only injectables in the past and how might the checklist facilitate that process?

Accept responses from several participants and discuss any concerns that participants may raise.

Slide 13: Understanding the Progestin-Only Injectables Checklist

Handout #5: Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use

Handout #6: Checklist for Screening Clients Who Want to Initiate DMPA or NET-EN



Draw attention to questions 10-15 and emphasize that providers should follow the instructions for this set of questions to identify women who are not pregnant or those who might be pregnant and require a pregnancy test to rule out pregnancy.

Tell providers that the final set of instructions provides details about initiating the method, especially whether the client will need to use a backup method initially.

Progestin-Only Injectables Eligibility Checklist (1)Brainstorming (10 min.)

Describe the following scenario: your client is a 28-year-old woman with two children; her youngest is six months old. She has been using condoms regularly but wants a more reliable method. She is currently seeing a doctor for a liver problem because she noticed her eyes had become yellow

Ask participants to consider the client description when answering the following question:

1. Which question(s) on the checklist addresses this client’s condition? Encourage participants to review the checklist and locate the question(s) relevant to this client’s situation, and ask them to read the explanation(s) for the question(s).

2. Considering the client’s condition and the explanation provided in the checklist, is this client a good candidate for progestin-only injectables? Review with the participants the reason the client is not medically eligible. She is not eligible because she would answer “Yes” to question 3: Do you have a serious liver disease or jaundice (yellow skin or eyes)? This question is intended to identify women who know that they currently have a serious liver disease and to distinguish between current, severe liver disease (such as severe cirrhosis or liver tumors) and some other liver problems (such as hepatitis or mild cirrhosis). Women with serious liver disease should not use DMPA, because DMPA is processed by the liver and its use may adversely affect women whose liver function is already weakened by the disease.

3. What would be your course of action for this client? Discuss with participants why the correct course of action is to counsel the client about other available

Handout #6: Checklist for Screening Clients Who Want to Initiate DMPA or NET-EN (also available in Handout #12, page 65)




contraceptive options, while her condition is being evaluated. She may be able to initiate injectables if severe cirrhosis or liver tumor are ruled out.


Facilitator: Describe the following scenario: Your client is a 23-year-

old woman who has malaria, finished her active pills in her COC pack yesterday, and wishes to switch to DMPA (or NET-EN). She has been using COCs consistently and correctly.

Ask participants to consider the client description when answering these questions:

1. Which question(s) on the checklist addresses this client’s condition?Encourage participants to review the checklist and determine that none of the medical eligibility questions (questions #1-9) ask about malaria. This client would answer “No” to all of these questions.

2. Considering the client’s condition and the explanation provided in the checklist, is this client a good candidate for an injectable?Review with the participants the reason the client is medically eligible. She is medically eligible to have a DMPA or NET-EN injection immediately. Although the client has malaria, malaria is not a condition that limits use of progestin-only injectables. Because the client would answer “No” to questions #1–9, she is medically eligible for injectables. She would also answer “Yes” to question 15, so the provider can be reasonably sure that she is not pregnant.

3. What would be your course of action for this client? Discuss with participants why the correct course of action is to counsel the client about using progestin-only injectables. If everything is acceptable to the client, the provider may give the client her first DMPA or NET-EN injection.

Handout #6: Checklist for Screening Clients Who Want to Initiate DMPA or NET-EN (also available in Handout #12, page 65)



Describe the following scenario: your client is a 32-year-old woman with three children. Her doctor told her that she has high blood pressure but she does not need any

Handout #6: Checklist for Screening Clients Who Want to Initiate DMPA or NET-EN



medication to control it. She started her period 10 days ago and has abstained from sex since then.

Ask participants to consider the client description when answering these questions:

1. Which question(s) on the checklist addresses this client’s condition?Encourage participants to review the checklist and locate the question(s) relevant to this client’s situation. After they have located it, ask them to read the explanation for question #5.

2. Considering the client’s condition and the explanation provided in the checklist, is this client a good candidate for an injectable?Review with the participants the reason the client is not medically eligible to start injectables immediately. She would answer “Yes” to question #5 because she has high blood pressure. The provider can be reasonably sure the client is not pregnant because she has not had intercourse since her last menses, and so would answer “Yes” to question #12.

3. What would be your course of action for this client? Discuss with participants why the correct course of action is to counsel the client about the need for further evaluation to determine if she is medically eligible to use progestin-only injectables. Because her doctor told the client that she does not need medication to control her blood pressure, it is likely that she will be eligible, but this needs to be confirmed. If the provider is able to evaluate her immediately, and determines that her blood pressure is less than 160/100 mm Hg, then she can have an injection that day. (In this case, because her menses started more than seven days ago, she should be counseled to use condoms or abstain for the next seven days). If the provider needs to refer her for evaluation, then he or she should offer the client condoms to use until she can be evaluated. The provider should also counsel the client about other available FP methods for which high blood pressure is not a contraindication, such as implants or a copper IUD, which she might be eligible to start immediately.

(also available in Handout #12, page 65)




Session III: Providing Progestin-Only InjectablesSession III Objective: Demonstrate how to provide progestin-only injectables.

When A Woman Can Start InjectablesLecturette (10 min.)

Injectables may be initiated without a pelvic exam; without blood tests or routine lab tests; without cervical cancer screening; without a breast exam.

Explain to participants that DMPA and NET-EN can be started anytime during the menstrual cycle as long as the provider can be reasonably sure the woman is not pregnant. You can be reasonably certain that a woman is not pregnant if any of these situations apply: o Her menstrual bleeding started within the past seven

days.

o The woman is fully breastfeeding, has no menses, and her baby is less than six months old.

o She has abstained from intercourse since her last menses or since delivery.

o She has given birth in the past four weeks.

o She had a miscarriage or an abortion in the past seven days.

o She has been using a reliable contraceptive method consistently and correctly.

o Note: If none of these situations apply, you can use a urine pregnancy test or conduct a bimanual pelvic exam to determine if the woman is pregnant. If nothing is available, you can ask the woman to come back during her next menses and provide her with a backup method to use in the meantime.

If DMPA or NET-EN are initiated during the first seven days of the menstrual cycle—where day one is the first day of bleeding—no backup contraceptive method is necessary.

If progestin-only injectables are initiated more than seven days after the start of woman’s monthly bleeding, advise her to use a backup contraceptive method such as condoms for the first seven days following the injection.

Ideally, postpartum women who are breastfeeding generally should not start using injectables until six weeks postpartum because of concerns the newborn infants will be exposed to DMPA or NET-EN received in

Slides 2-3: When to Start Injectables



breast milk. This represents the international consensus on the initiation of progestin-only injectables and breastfeeding as reflected in the WHO MEC. For further information on the initiation of implants and breastfeeding, see slide 10 in Session II. This consideration was more fully discussed at that time. Women who are exclusively breastfeeding a baby less than six months old and whose menses have not returned are protected from pregnancy by the lactational amenorrhea method (LAM). Refer to slide #10 in session II for a more detailed description about use of progestin only methods with postpartum breastfeeding women.

Postpartum women who are not breastfeeding may start progestin-only injectables immediately after giving birth. If a woman who is not breastfeeding wants to start using progestin-only injectables more than four weeks after she has given birth, it is necessary to rule out pregnancy before giving the injection.

Progestin-only injectables can be initiated immediately following an abortion or miscarriage without need for a backup method. If it is more than seven days after a first- or second-trimester miscarriage or abortion, a woman can start injectables any time it is reasonably certain she is not pregnant. She will need a backup method for the first seven days after the injection.

If a woman is switching to injectables from another hormonal method, she can have an injection of DMPA or NET-EN immediately, provided that she has been using the hormonal method consistently and correctly or if it is otherwise reasonably certain she is not pregnant. There is no need for her to wait for her next monthly bleeding. There is no need for her to use a backup method.

If she is switching from another injectable, she can have the new injectable when the repeat injection would have been given. No need for a backup method.

She can start injectables on the same day that she uses emergency contraceptive pills (ECPs), or, if she prefers, within seven days after the start of her monthly bleeding. She will need a backup method for the first seven days after the injection. She should return if she has signs or symptoms of pregnancy other than not having monthly bleeding.

Counseling about Progestin-Only Injectables: Describing Side Effects

Slide 4: Counseling about Progestin-Only



Lecturette (10 min.)

Counseling—both prior to the first injection and for women already using injectables—is the best way to help women manage the side effects associated with progestin-only injectables.

Before giving the injection, ensure that the client understands the most common side effects of progestin-only injectables, especially changes in bleeding patterns.

o Irregular bleeding: For the first several months: irregular bleeding (bleeding at unexpected times), prolonged bleeding, frequent bleeding. Later (after 12 months of use) no monthly bleeding at all.

o Weight gain: Gaining about 1–2 kg per year is also commonly experienced.

o Other side effects: Headaches, dizziness, abdominal bloating/discomfort, mood changes, and changes in sex drive are examples of less common side effects associated with progestin-only injectables.

Women who are considering using progestin-only injectables should be counseled that menstrual changes are expected and that these and other side effects are not signs of disease or health problems. Some women may not have any side effects.

After giving the injection, the practitioner should tell clients to come back if they have any questions or concerns. Ongoing counseling and reassurance should be provided if needed.

If the user continues to be concerned or if she finds the side effects unacceptable, it may be necessary to treat the side effects or advise the client to choose a different method.

Injectables: Describing Side Effects

Counseling about Progestin-Only Injectables: Getting Your InjectionLecturette (10 min.)

After a client has made an informed choice to use an injectable contraceptive, it is imporant that she know what will happen during insertion:

Injectables usually only take a few minutes to insert, but can sometimes take longer.

Complications related to the insertion are rare.

The provider will carefully clean the area on the arm, hip,

Slide 5: Counseling about Progestin-Only Injectables: Getting Your Injection



or buttock and will use sterile gloves and equipment.

The client will receive a small injection under the skin so that she will not feel the implant being inserted. The injection may sting a bit and the client will be awake during the procedure.

The client should not massage or rub the injection site after the injection, because that can cause the DMPA or NET-EN to be absorbed too quickly.

The client should expect menstrual bleeding changes such as longer periods of bleeding, bleeding at unexpected times, or no bleeding at all.

The client seek help from a provider at a health care facility if she is concerned that there is something seriously wrong with her health, such having severe headaches, severe abdominal pain, heavy or long bleeding (bleeding taht is more than eight days long or twice as heavy as usual), or yellow skin or eyes that may indicate a serious liver condition.

The client should keep in mind that injectables do not protect against STIs, including HIV, and should therefore consider using condoms to avoid infection.

The client should return for next injection on time. If she is late for reinjection, she should use condoms or abstain if she does not want to become pregnant.

Counseling about Progestin-Only Injectables: Post-Injection MessagesLecturette (10 min.)

After giving a client an injection of DMPA or NET-EN, counsel her about the following:

o Remember the type of injectable she received (DMPA or NET-EN).

o Do not massage the injection site, as that can cause the DMPA or NET-EN to be absorbed too quickly.

o Expect bleeding changes, such as prolonged, irregular or frequent bleeding for the first several months and, later, no monthly bleeding at all. These changes are not harmful to her health.

o Set a date for a reinjection. It is important to return on time, no more than four weeks late; always return for reinjection no matter how late.

Slide 6: Counseling about Progestin-Only Injectables: Post-Injection Messages



o Return if she has problems or concerns, especially if she develops new serious health problems or experiences bad headaches which follow a bright area of lost vision in one eye, also known as a migraine aura; or notices yellow skin or eyes that may indicate jaundice.

o Keep in mind that injectables do not protect against STIs including HIV and consider using condoms to avoid infection.

Counseling about Progestin-Only Injectables: Counseling Reduces DiscontinuationDiscussion (10 min.)

Ask participants: what do you think is the most common reason that women stop using injectables? <accept responses from several participants>

Although knowing how to give an injection safely is a very important skill, knowing how to counsel your clients appropriately is equally important.

A client’s satisfaction with any contraceptive method depends greatly on counseling. With injectable contraceptives, the quality of counseling has a large effect on whether women discontinue the method because of side effects.

Women’s concerns over prolonged or heavy bleeding should never be disregarded or considered unimportant

Changes in menstrual bleeding–such as prolonged, irregular, or frequent bleeding resulting from DMPA or NET-EN use–are the most common reason for discontinuation.

Women who are considering using DMPA or NET-EN should be counseled that such changes in bleeding are normal and expected; they are not signs of disease or health problems.

After injections begin, counseling and reassurance should be provided as needed. Providers should encourage women to return to clinic if they have questions or concerns about side effects.

Women are much more likely to continue using DMPA or NET-EN if they have received adequate counseling about the possibility and meaning of side effects. Researchers found that women who had been counseled about side effects were more than three times as likely to continue

Slide 7: Counseling about Progestin-Only Injectables:Counseling Reduces Discontinuation



using the method as women who had not been counseled. The sites that provided better counseling had lower discontinuation rates.

When a woman chooses an injectable contraceptive, the provider must be sure that she has made an informed choice to use the method and has carefully considered the factors listed on the slide.

If a DMPA or NET-EN user is experiencing severe bleeding, medical treatment or discontinuation of the injectable may be necessary, especially in cases where the woman has anemia.

Correcting Rumors and Misunderstandings about Progestin-Only InjectablesBrainstorming (20 min.)

Explain that rumors are unconfirmed stories that are transferred from one person to another by word of mouth. In general, rumors arise when:

An issue or information is important to people, but it has not been clearly explained.

There is nobody available who can clarify or correct the incorrect information.

The original source is perceived to be credible.

Clients have not been given enough options for contraceptive methods.

People are motivated to spread them for political reasons.

A misconception or misunderstanding is a mistaken interpretation of ideas or information. If a misconception is imbued with elaborate details and becomes a fanciful story, then it acquires the characteristics of a rumor.

Discuss methods for counteracting rumors and misinformation:

1. When a client mentions with a rumor, always listen politely. Don't laugh.

2. Define what a rumor or misconception is.

3. Find out where the rumor came from and talk with the people who started it or repeated it. Check whether there is some basis for the rumor.

4. Explain the facts.

5. Use strong scientific facts about FP methods to

Slide 8: Correcting Rumors and Misunderstandings



counteract misinformation.

6. Always tell the truth. Never try to hide side effects or problems that might occur with various methods.

7. Clarify information with the use of demonstrations and visual aids.

8. Give examples of people who are satisfied users of the method (only if they are willing to have their names used). This kind of personal testimonial is most convincing.

9. Reassure the client by examining her and telling her your findings.

10. Counsel the client about all available FP methods.

Ask participants: What are some common misconceptions about progestin-only injectables? < accept responses from several participants; click the mouse to reveal the answers>

Discuss common misconceptions about injectables including:

o Amenorrhea: One common misconception is about the amenorrhea that commonly occurs after a year of DMPA use. Some women fear that blood is building up in their bodies when they do not have their period. Absence of monthly bleeding due to injectables is not harmful. It is similar to not having periods during pregnancy. Blood does not build up in the woman’s body; the body simply stops producing menstrual blood.

o Abortion: Another misconception is that injectables can cause abortion, disrupting an existing pregnancy. Injectables do not do this–if a woman is accidentally given an injection when she is already pregnant, it will not interrupt the pregnancy of harm the developing fetus.

o Infertility: Although it can take an average of nine to ten months for a woman to become pregnant after her last DMPA injection or six months on average for women who use NET-EN, injectables do not cause permanent infertility. Injectables are a temporary method of contraception. The bleeding pattern that a woman had before she used injectables generally returns several months after the last injection.



o Cancer: DMPA and NET-EN do not cause cancer. In fact, it has been shown that DMPA protects against cancer of the lining of the womb, also known as endometrial cancer.

o Causes abnormalities in children: DMPA and NET-EN do not cause deformed babies if accidentally given to a pregnant woman. There is no evidence that DMPA or NET-EN causes abnormalities in children who are accidentally exposed to DMPA or NET-EN while in the womb.

o Discuss and clarify any other misconceptions participants may mention.

Refer back to the flipchart and ask participants how they could counteract each rumor or misconception.

Management of Side Effects: Bleeding Changes Lecturette (10 min.)

The best way to reduce the anxiety some women feel when they experience side effects is to provide reassurance and address her concerns through follow-up counseling.

Irregular bleeding: For complaints about irregular bleeding, which may be

defined as spotting or light bleeding at unexpected times that bothers the client, the provider should explain that this bleeding is common in the first few months of using injectables and reassure the client that it is not harmful and that it usually becomes less or stops after the first few months of use.

If the irregular bleeding is unacceptable, the provider may recommend 500 mg of mefenamic acid two times daily after meals, or 40 mg of valdecoxib daily, for five days. <use local brand names of these medications> Note that these are short-term treatments that are only mildly effective. Women who are experiencing irregular bleeding should not take aspirin, since it may increase bleeding.

Amenorrhea: Amenorrhea is another common side effect of injectables.

Some women consider amenorrhea to be an advantage of using injectables, but others may be concerned about this side effect. Amenorrhea associated with DMPA and NET-EN use does not present a health risk or require medical

Slides 9-10: Management of Side Effects: Bleeding Changes

Handout #7: Managing Any Problems



treatment.

If the provider has no reason to suspect pregnancy, counseling and reassurance are the only tools needed for management of amenorrhea. Women need to be reassured that amenorrhea is normal for DMPA and NET-EN users. Women should understand that in this case amenorrhea does not indicate pregnancy. Women may also need to be reassured that the absence of menses does not mean that toxic blood is building up inside their bodies, that they have become infertile, or that they have reached premature menopause.

This side effect is similar to not having monthly bleeding during pregnancy.

Heavy or prolonged bleeding:

If a client complains about heavy or prolonged bleeding, the provider should first reassure her that some women using progestin-only injectables experience heavy or prolonged bleeding, and that it is not harmful and usually becomes less or stops after a few months.

For modest, short term relief, she can try (one at a time), beginning when heavy bleeding starts:

o 500 mg of mefenamic acid two times daily after meals for five days

o 40 mg of valdecoxib daily, for five days

o COCs once a day for 21 days. (50 µgm of ethinyl estradiol daily for 21 days)

Women who are experiencing heavy bleeding should not take aspirin, since it may increase bleeding, not decrease it.

If bleeding is very prolonged or heavy—twice as much as usual or longer than eight days—the provider can suggest that the woman take iron tablets to help prevent anemia.

If irregular or heavy bleeding continues to bother the client beyond the first six months of injectables use, or starts after several months of normal monthly bleeding or amenorrhea, the provider should rule out a possible underlying condition unrelated to method use, such as uterine fibroids, a sexually transmitted infection, genital cancer, or pregnancy.

If side effects persist and are unacceptable to the client, the provider should help her choose another contraceptive method.

Management of Side Effects: Slide 11:



Other Side EffectsLecturette (10 min.)

There are several other side effects that clients who are using progestin-only injectables may experience, including headaches, abdominal bloating, changes in mood or sex drive, and weight gain.

Common headaches, dizziness: If a client experiences frequent headaches that are not migraines, reassure her that ordinary headaches do not indicate dangerous conditions and usually diminish over time. Standard doses of painkillers such as ibuprofen, paracetamol, or other pain relievers may be used to alleviate symptoms. However, evaluate headaches that get worse or occur more often after starting to use injectables. For dizziness, consider locally available remedies, such as <give example of a locally available remedy for dizziness>.

Abdominal bloating/discomfort: For abdominal bloating and discomfort, reassure the client that other injectables users have reported this and that it is not serious, and suggest locally available remedies. However, if abdominal pain becomes severe, refer at once for immediate diagnosis and care. This is especially true if the severe abdominal pain occurs with other signs or symptoms of ectopic pregnancy—abnormal vaginal bleeding or no monthly bleeding (especially if this is a change from her usual bleeding pattern), light-headedness, dizziness, or fainting. Ectopic pregnancy is rare but can be life-threatening.

Changes in mood or sex drive: For a client who experiences changes in mood or sex drive, ask about changes in her life that could affect her mood or sex drive, including changes in her relationship with her partner. Give support as appropriate. Clients who have serious mood changes, such as major depression, should be referred for care.

Weight gain: In case of weight gain, review the client’s diet and counsel her about healthy eating habits and exercise as a way to better control her weight.

If side effects persist and the client wants to stop using injectables, health providers should counsel her about non-hormonal options, and help the woman choose another method.

Management of Side Effects: Other Side Effects

Handout #7: Managing Any Problems

Problems That May Require Switching from Injectables to Another Method

Slide 12: Problems That May Require



Lecturette (10 min.)

There are some serious health problems which may require that a client stop using progestin-only injectables.

Unexplained vaginal bleeding: If a client experiences unexplained vaginal bleeding or heavy or prologned bleeding that is suggestive of a medical condition not related to the method, she may need to discontinue injectables. Refer the client or evaluate by taking her medical history and doing a pelvic examination. Diagnose and treat as appropriate. If no cause of bleeding can be found, consider stopping injectables to make the diangosis easier. Provide the client with another contraceptive method of her chocie until the condition is evaluated and treated. The alternative method should be something other than progestin-only implants or a copper-bearing or hormonal IUD. If the bleeding is caused by a sexually transmitted infection or PID, the client can continue using injectables during treatment.

Migranes: Women with migraine headaches without aura can continue using injectables. Although women who have migraine headaches with an aura can initiate injectables, if a women develops migraines with aura after starting injectables, do not give the next injection. Help her choose a non-hormonal method.

Certain serious health conditions: If a woman develops a serious health condition (susptected blocked or narrowed arteries, serious liver disease, severe high blood pressure, blood clots in the deep veins of the legs or lungs, severe liver disease, stroke, or damage to arteries, vision, kidneys or nervous system cause by diabetes), do not give the next injection. Help her choose a non-hormonal method.

Finally, if a woman is pregnant, stop injections. However, there are no known risks to a fetus conceived while a woman is using injectables.

Switching from Injectables to Another Method

How to Take DMPA: DMPA Injection ScheduleDiscussion (10 min.)

A woman should receive an injection of 150 mg DMPA once every three months or 13 weeks.

However, there is a safe window (“grace period”) for repeat injections—that is, how early or late the injection can be given while maintaining effective contraception.

For DMPA, this window is up to two weeks before or four

Slide 13: DMPA Injection Schedule



weeks after a scheduled reinjection date. For example, <pick up a calendar or point to one displayed in the room> let’s say a client named Gloria had her first DMPA injection on September 1. Her scheduled reinjection date would be 13 weeks after that, or December 1. Ask participants: When would the safe reinjection window start and end for Gloria? <allow for participant responses, and affirm the correct answer> It would begin November 17 and close December 29.

If Gloria returns more than four weeks late, or after December 29, she can still receive an injection if the provider can rule out pregnancy. If pregnancy is ruled out and she receives the injection, Gloria should use a backup method for the next seven days, and she should be counseled that delaying injections increases the risk of pregnancy.

How to Take NET-EN: NET-EN Injection ScheduleDiscussion (10 min.)

A woman should receive an injection of 200mg NET-EN once every eight weeks (or two months).

However, there is a safe window for repeat injections (“grace period”)—that is, how early or late the injection can be given while maintaining effective contraception.

The safe window for repeat injections for NET-EN is up to two weeks before or two weeks after a scheduled reinjection date

For DMPA, this window is up to two weeks before or four weeks after a scheduled reinjection date. For example, <pick up a calendar or point to one displayed in the room> let’s say a client named Martha had her first NET-EN injection on September 2. Her scheduled reinjection date would be eight weeks after that, or October 28. Ask participants: When would the safe reinjection window start and end for Martha? <allow for participant responses, and affirm the correct answer> It would begin October 14 and close on November 11.

If Martha returns more than two weeks late, or after November 11, she can still receive an injection if the provider can rule out pregnancy. If pregnancy is ruled out and she receives the injection, Martha should use a backup method for the next seven days, and she should be counseled that delaying injections increases the risk of pregnancy.

Slide 14: NET-EN Injection Schedule



Women who take certain medications, such as ARV therapy, or anti-seizure or TB medications, should be encouraged to receive the next injection by the end of the eight week period.

Managing Late InjectionsDiscussion (10 min.)

Ask participants: What should you do when a DMPA client returns more than four weeks late, or a NET-EN client returns more than two weeks late? <allow participants to respond>

There are two things you should do: First, rule out pregnancy and second, assess if returning within the reinjection window might remain a problem. If it will, discuss other method options that might be more suitable for the client.

To rule out pregnancy in this situation, providers have these four options, which are also described on page two of the DMPA and NET-EN job aids for reinjection (Handouts #14 and 15):

1. Use the modified pregnancy checklist.

2. Use a pregnancy test.

3. If a pregnancy test is not available, conduct a bimanual pelvic examination to determine the size of the uterus for comparison at a follow-up visit.

4. If a pregnancy test or bimanual pelvic examination are not available, do an abdominal examination and give her a backup method to use until her return visit for another abdominal examination in 12 to 14 weeks to see if the uterus could be located through the abdominal wall, or during her next menses, whichever comes first.

Slide 15: Managing Late Injections

Role Plays (30 min.)

Follow the step-by-step instructions in the Facilitator’s Guide section on facilitating role plays to prepare for and conduct this activity.

1. Review the instructions for the client, provider, and observer roles and the other learning resources developed for the activity.

2. View a demonstration role play and clarify any

Handout #8:Facilitating Role Plays

Handout #9:Role Play Scenarios



questions.

3. Conduct role plays in small groups based on the scenarios provided and discuss reactions.

4. Discuss the activity as a large group.

• Review Handouts #8 and #9 with participants. These include:

1. Seven different role play scenarios, each with a client information sheet and observer information sheet.

2. The instruction sheet that describes the roles of providers, clients, and observers.

3. The Role Play Observation Checklist.

4. Role play scenario/information sheets for clients and observers for the role plays you have selected or adapted from Handout #9: Role Play Scenarios.

• Use the following questions to help the small groups structure the feedback that they provide to each other after each role play.

o What was going on between the provider and client?

o What did the provider do that was effective in this situation?

o What might the provider consider doing differently if this situation were to happen again?

o How did the provider attend to the items on the counseling observation checklist and the case-specific observations included in the role play description?

• After the small groups conduct each role play, encourage the groups to talk about what happened during the role play from the perspective of the provider (self-assessment), the client (personal satisfaction with the interaction), and the observer (objective assessment using the Role Play Observation Checklist included in Handout #9, including the case-specific observations included in the role play description).

• Prepare a flip chart to display these discussion questions where the questions can easily be seen by all the participants in the small groups.

Case Studies(45 min.)

Handout #10:Using Case Studies

Handout #11:



• Divide Participants into 4 groups.

• Distribute Handout #10 and #11. Give 2 groups Case Study #1 and #2. Ask each group to review the case studies and answer the questions.

Allow each group 25 minutes to prepare their answers and five minutes to present their answers to the rest of the group.

Case Study #1 and #2

Progestin-Only Injectables: SummaryLecturette (5 min.)

In conclusion, progestin-only injectables have characteristics that make them a desirable method for many women.

o They are safe.

o They are highly effective.

o They are easy to use correctly.

o They can be delivered in both clinical and nonclinical settings.

o Appropriate counseling plays a key role in the provision of injectable contraceptives.

While it is relatively simple to administer injectables correctly, providers also need to counsel clients about the characteristics of progestin-only injectable contraceptives, with special attention to side effects, and be able to manage side effects.

Family planning programs that offer progestin-only injectable contraceptives give their clients more options for contraception.

Slide 16: Injectables: Summary

Post-Test and Course Evaluation (30 min.)

Evaluation Tool: The Progestin-Only Injectables Post-test, Applied Learning Case Studies, and Course Evaluation





Session IV: Practicing Provision of Progestin-Only Injectables Using a Conventional SyringeSession IV Objective: Demonstrate how to administer the injection, reinjections, and infection prevention.

Session Overview Lecturette (5 min.)

DMPA and NET-EN are given as intramuscular injections in one of three sites: the muscle of the upper arm, the muscle of the hip, or in the buttock. A woman can decide where she prefers to receive the injection. If one of your clients would prefer to receive her injection in a site where you have not been trained to give injections, refer her to a clinical provider that is trained accordingly.

This session describes the steps for injecting and re-injecting progestin-only injectables and for preventing infection during injection.

The information on slides #3-9 describes a 15-step process for giving injections. This practice can be greatly reduced for experienced clinicians who are used to giving injections in these injection sites.

Extensive practice on fruits or vegetables, observations of experienced clinicians, and supervised practice are necessary for the provider to be skillful in the injectable insertion and removal procedures.

During this session, we will first review the steps of injection, using the slides. This will be followed by a demonstration and return demonstration and practice by participants on fruits or vegetables, using competency-based checklists to monitor progress.

Most community health workers (CHWs) are only trained to provide injections in the arm. If a woman wishes to receive an injection in the hip or buttock and the CHW has not been trained to provide injections in this location, the woman should be referred.

Note to Facilitator: This session is focused solely on the mechanics of the clinical procedure of giving the injection and preventing infection during injection. Refer to Session III for guidance about counseling users and other injectable-related issues.

Slide 2: Overview

How to Give the Injection: Steps 1-2Lecturette (5 min.)

Slide 3: How to Give the



After counseling the client and determining her eligibility, it is then time to give the client the injection.

Before getting started, make sure you have everything you need organized and laid out in a clean uncluttered space.

First, if possible, wash your hands well with soap and water. Then let them dry in the air.

Note to facilitator: Ask participants to refer to Handout #13 during the lecturette about how to give DMPA and NET-EN injections. As you prepare for the demonstration, describe for the participants how you are arranging the materials that will be used—emphasize the importance of arranging everything that will be needed for the procedure in a clean uncluttered space. Demonstrate each of the steps―on a fruit or vegetable or a volunteer—as you review them. Tell the participants to pay close attention because they will be expected to demonstrate these steps during practice. Ensure that participants can see the demonstration and encourage them to ask questions

Injection: Steps 1-2

Handout #13: Job Aid: Giving the Injection


If the skin around the injection site is dirty, wash it with a cotton ball soaked in clean water. If the skin is not visibly dirty, there is no need to clean it before giving the injection.

Next, double-check the bottle for content and dose, and make sure that it is not past the expiration date.

Roll the bottle between the palms of your hands to mix the solution, or shake it gently. Do not shake it too vigorously or the contents will become frothy, making it difficult to extract the entire contents of the bottle. NET-EN does not need to be mixed, but rolling the bottle in the palms will warm the solution and make it easier to extract.

Note to facilitator: Program administrators must decide on the protocol to follow if a provider discovers that the product expiration date has passed. For example, a protocol might include these steps: 1) do not use the expired vial; 2) check your kit for other vials that have not expired and proceed with the injection; 3) if all product in the kit is expired, reschedule the injection during the reinjection window or refer the client to a clinic; and 4) return the expired vial(s) to your supervisor. Take this opportunity to explain the protocol to participants.

Slide 4: How to Give the Injection: Steps 3-5





Hold the bottle of DMPA or NET-EN and remove the plastic cap to expose the rubber cover. There is no need to wipe the top of the vial with antiseptic. If the vial is cold, warm it to skin temperature before giving the injection.

Carefully open the sterile package containing the syringe and the needle, and remove the syringe and needle from the package. If necessary, attach the needle to the syringe. Remove the needle shield from the needle.

Insert the needle into the bottle’s rubber cover, and empty the entire contents of the bottle into the syringe. Remove the needle from the bottle.

Hold the syringe upright and tap on the barrel to move any air into the tip. Expel the air from the syringe gently until you can see a drop of DMPA or NET-EN solution on the tip of the needle. Be careful not to contaminate the needle.

How to Give the Injection: Step 10Lecturette (5 min.)

DMPA and NET-EN are given as an intramuscular injection in one of three sites: the muscle of the upper arm, the muscle of the hip, or in the buttock. A woman can decide where she prefers to receive the injection.

Notes to facilitator:

Tell participants that they will have an opportunity to practice locating the injection site on each other.

Research evidence has identified two concerns with the buttock site: 1) the potential for sciatic nerve damage (due to the imprecise methods for determining the injection site) and 2) the potential that the injection would be given in fat rather than muscle (a concern because of the reduced effectiveness of DMPA/NET-EN). These issues should be taken into consideration when country/program level decisions are made. Intramuscular injection research citations are included in the References section of the Facilitator’s Guide.

Slide 6: How to Give the Injection: Step 10

How to Give the Injection: Step 11Lecturette (5 min.)

Insert the needle deeply so that the DMPA or NET-EN will be injected into the muscle―not into the skin or just under the skin.

Study these drawings to make sure that you understand

Slide 7: How to Give the Injection: Step 11



how to place the needle and hold the syringe.

The needle should go into the muscle straight―not at an angle. When inserting the needle, spread the skin with your fingers, hold the syringe like a dart, and use a dart-like motion to insert the needle at the injection site.

Note to facilitator: Tell participants that they will have an opportunity to practice holding the syringe properly and piercing the skin of fruit during their practice injections before beginning to inject humans.


Inject DMPA or NET-EN, emptying all of the contents of the syringe. Pull the needle out of the injection site.

After injecting the DMPA or NET-EN, gently press the injection site with a clean cotton ball or cloth for a few seconds if needed. Do not rub or massage. Remind the client not to massage the site after the injection, as this can cause the DMPA or NET-EN to be absorbed more quickly and make it less effective.

Note to facilitator: Modify this slide to depict only the injection site(s) that participants will be practicing.



Place the used syringe in a puncture-proof container. Use great care to avoid a needle-stick injury to yourself or others. The next slide gives detailed information regarding the safe handling of sharps.

Wash hands again with soap and water.

Note to facilitator: Ask participants if they have questions about any of the steps for giving an injection.


Practice Safe Handling of NeedlesLecturette (5 min.)

Safe handling and disposal of needles is an important responsibility. Before practicing with needles, it is important to learn how to handle them safely.

To avoid accidental needle-stick injuries, do not re-cap the needle after use. Immediately after use, place the used syringe in the sharps container.

Do not touch the needle. If you accidentally touch or stick

Slide 10: Practice Safe Handling of Needles



yourself with a needle, do not use the needle on a client. Discard the needle and use a fresh one.

Do not leave a needle inside the vial, to avoid contaminating both the needle and the contents of the vial.

Needles are also known as “sharps.” Sharps must be placed in a hard-walled container before disposal, to protect garbage handlers and others from injury. Always place used needles and syringes in the sharps container. Do not put anything into the sharps container other than needles and syringes.

Do not overfill the sharps container. When the sharps container is about three-quarters full, return the container to your supervisor or the health care facility and get a new one. Replacing the container at this stage prevents needle sticks if a provider tries to put a needle and syringe into an already-full container.

Local regulations on the disposal of sharps containers should be followed to ensure the health and safety of all members of the community.

Note to facilitator: Demonstrate for participants how to assemble a sharps container and show how full it should be before replacement. Program administrators must consider what type and size puncture-proof container is appropriate. If CHWs are moving from place to place to provide services, they must be issued portable sharps containers. Homemade portable sharps containers can be crafted from sturdy cardboard boxes or sturdy plastic bottles with wide mouths covered by tight-fitting caps. It is essential that homemade containers share the same safety features as the commercial-grade containers (e.g., container walls are sturdy enough to prevent needles from poking through, the syringes can be deposited in the container without forcing them, the needles and syringes cannot fall out, and the entire container can be disposed of when it is about three-quarters full).

Caring for a Needle Stick InjuryLecturette (5 min.)

In addition to HIV exposure, needle-stick injuries can result in exposure to other harmful viruses and bacteria. In the event of an injury with a needle that was used for injection, a provider should:

o Flush the injured area with running water and wash it with soap and water immediately.

o Avoid applying caustic agents, such as bleach, to the

Slide 11: Caring for a Needle Stick Injury



wound. Such agents may cause inflammation and potentially facilitate infection.

o Contact your supervisor and inform him/her about the injury. Check with the supervisor about what to do next, or follow the standard procedures for needle-stick injuries.

o If you cannot reach the supervisor or if you have concerns that you would like to discuss with a health care provider, seek counseling and care at a health facility.

Note to facilitator: If no standard procedures are available, use the following instructions: 1) immediately wash affected area, 2) contact a supervisor, 3) complete a needle-stick report, 4) encourage the provider to attend counseling, 5) request that the provider be tested for HIV, and 6) begin treatment if indicated.

Practice Finding the Injection Site (Arm) Demonstration/Return Demonstration (15 min.)

The purpose of this activity is to give participants an opportunity to observe the facilitator explaining and demonstrating how to locate the injection sites on the hip and/or buttock and then to practice it themselves with a partner. Tell the participants to refer to Step 10 of the Steps for Giving an Injection, which describes how to locate the injection site(s). Ask them to use the illustrations to follow along during the demonstration and practice.

Demonstrate that to locate the injection site in the deltoid muscle of the upper arm, participants should imagine drawing a box on their client’s upper arm. Find the knobby top of the arm (acromion process) marked with a red dot in the illustration. Place two fingers under the knobby top to locate the top of the imaginary box. The bottom of the box is an imaginary line that runs from the crease of the armpit from front to back. The sides of the box are imaginary lines that are formed when dividing the arm into three equal sections from front to back. The middle of the imaginary box marks the injection site.

Explain to participants that if a woman is very thin or frail—with very little muscle in her arm—they should consider on of the other injection sites (hip or buttocks).

Ask participants to take turns finding the injection site on their partner’s arm. Observe whether the participants are accurately finding the correct site; provide corrective feedback as needed.

Slide 12: Finding the Injection Site



Note to facilitator: Most CHWs give injections in the arm. If CHWs will be giving injections is the hip or buttock, they must receive instruction in locating the injection site and practice giving injections in those sites (see next slide).

Practice Finding the Injection Site (Hip and Buttock) Demonstration/Return Demonstration (15 min. for hip, 15 min. for buttock)

The purpose of this activity is to give participants an opportunity to observe the facilitator explaining and demonstrating how to locate the injection sites on the hip and/or buttock and then to practice it themselves with a partner. Tell the participants to refer to Step 10 of the Steps for Giving an Injection, which describes how to locate the injection site(s). Ask them to use the illustrations to follow along during the demonstration and practice.

Demonstrate that to locate the hip injection site (ventrogluteal muscle), participants should find the knobby top of the thigh bone marked with a red dot in the illustration. Place the palm of their hand over the knobby top of the thigh bone with the thumb pointed toward the front of the leg (or groin). All other fingers should be pointed towards the patient's head. Once the hand is in position they should keep their index finger in place and move their middle finger back towards the buttock as far as they are able to go. This forms the V-shape between the index and middle finger. The middle of the V-shape marks the injection site. Ask participants to take turns finding the injection site on their partner’s hip. Observe whether the participants are accurately finding the correct site; provide corrective feedback as needed.

Demonstrate that to locate the buttock injection site (dorsogluteal muscle), participants should draw an imaginary horizontal line across the buttocks from hip bone to hip bone. Then divide each buttock in half with an imaginary vertical line. The four imaginary sections of the buttock are referred to as quadrants. The proper location for an injection is in the upper outer quadrant of either buttock. Ask participants to take turns finding the injection site on their partner’s buttock. Observe whether the participants are accurately finding the correct site; provide corrective feedback as needed.

Note to facilitator: Some providers use a landmarking technique rather than quadrant-mapping to determine the injection site in the buttock. In this case, providers imagine drawing a diagonal line on the client’s buttock between the trochanter (the knobby top portion

Slide 13: Practice Finding the Injection Site



of the thigh bone) and the posterior iliac crest (pelvic bone; many people have ‘dimples’ over this bone). The providers then locate the center of the imaginary line, find a point one inch above the line; this is the injection site.

Using the DMPA Reinjection Job Aid Discussion (15 min.)

The purpose of this activity is to give participants an opportunity to use the reinjection job aid. Read the description of the first client and discuss how the job aid helps determine if the woman is eligible to receive a DMPA reinjection (e.g., based on the timing of the previous injection and whether she has developed a medical condition that prevents her from continuing to use DMPA). Ask participants to describe how they would use the job aid to make the decision. Repeat the same process for clients 2 and 3.

Client 1. Following the guidance in the job aid, the facilitator should have the participants follow these steps:

Count the number of weeks that have elapsed since the previous injection.

Conclude that approximately 8 weeks have passed since the previous injection, which is prior to the start of the reinjection window.

Inform the client that she is outside the reinjection window, and it is too early for her to receive another injection.

Remind the client that side effects, especially bleeding changes, are possible and reassure the client as appropriate.

Use the calendar to explain to the client when she should return for reinjection (her scheduled reinjection date is April 16, so she should return as close to that date as possible but not before April 2 or after May 14).

Remind the client that if she cannot return before May 14, she should use a backup method such as condoms until she can return for a reinjection; remind her that since DMPA does not protect against STIs, she may want to use condoms.

Client 2. Following the guidance provided in the job aid, the facilitator should have the participants follow these steps:


Conclude that approximately 17 weeks have elapsed since the previous injection, which is later than the planned

Slide 14: Using the DMPA Reinjection Job Aid

Handout #14A: Job Aid for Depo-Provera Reinjection- Clinicians

Handout #14B: Job Aid for Depo-Provera Reinjection- CHWs



reinjection date of May 6 but is within the reinjection window, which does not close until June 3.

Inform the client that although she has arrived late for her reinjection, it is within the reinjection window, so she may receive another injection if she has not developed any conditions that would make her medically ineligible.

Reassure the client that moodiness and bloating are common side effects experienced by DMPA users and present no health risk; ensure that the client has not developed any of the other health problems mentioned on the screening checklist; determine that the client can continue to use DMPA.

Because the client has opted to continue the method, give the reinjection and remind her that DMPA does not protect against STIs or HIV.

Use the calendar to determine that the client’s reinjection date is August 31.

Encourage the client to respect her new reinjection date. If she cannot return on her scheduled day, returning up to two weeks early or four weeks late is acceptable; she should come back regardless of how late she might be. Remind her that if she is more than four weeks late for the next injection, she should use a backup method such as condoms or abstinence to avoid unintended pregnancy.



Conclude that approximately 20 weeks have elapsed since the previous injection, which is later than the planned reinjection date of April 14 and outside the reinjection window, which closed on May 12.

Inform the client that she is outside the reinjection window and that you will ask her a series of questions to determine if she might be pregnant.

Use the pregnancy checklist on page 2, box 2 of the job aid to determine that the client is not pregnant, because she has been abstaining since the previous injection expired (during the time that her husband was away).

Ask the client if she is experiencing any new health problems to ensure that the client is still medically eligible.



Remind the client that side effects are possible and reassure the client as appropriate.

Give the reinjection and tell the client to use a backup method for the next seven days; remind her that DMPA does not protect against STIs or HIV.

Use the calendar to determine that the client’s next reinjection date is September 2.

Encourage the client to respect her new reinjection date. If she cannot return on her scheduled day, returning up to two weeks early or four weeks late is acceptable; she should come back regardless of how late she might be. If she is more than four weeks late for the next injection, encourage her to use a backup method such as condoms or abstinence.

Using the NET-EN Reinjection Job AidDiscussion (15 min.)

The purpose of this activity is to give participants an opportunity to use the reinjection job aid. Read the description of the first client and discuss how the job aid helps determine if the woman is eligible to receive a DMPA reinjection (e.g., based on the timing of the previous injection and whether she has developed a medical condition that prevents her from continuing to use DMPA). Ask participants to describe how they would use the job aid to make the decision. Repeat the same process for clients 2 and 3.

Client 1. Following the guidance in the job aid, the facilitator should have the participants follow these steps:


Conclude that approximately 5 weeks have passed since the previous injection, which is prior to the start of the reinjection window.

Inform the client that she is outside the reinjection window, and it is too early for her to receive another injection.

Remind the client that side effects, especially bleeding changes, are possible and reassure the client as appropriate.

Use the calendar to explain to the client when she should return for reinjection (her scheduled reinjection date is March 12, so she should return as close to that date as possible, but not before February 26 or after March 26).

Remind the client that if she cannot return before March 26, she should use a backup method such as condoms until

Slide 15: Using the NET-EN Reinjection Job Aid

Handout #15A: Job Aid for NET-EN Reinjection Clinicians

Handout #15B: Job Aid for NET-EN Reinjection CHWs



she can come back for reinjection; remind her that since NET-EN does not protect against STIs, she may want to use condoms.



Conclude that approximately 10 weeks have elapsed since the previous injection, which is later than the planned reinjection date of April 1 but within the reinjection window, which does not close until Apr 15.

Inform the client that although she has arrived late for her reinjection, it is within the reinjection window, so she may receive another injection if she has not developed any conditions that would make her medically ineligible.

Reassure the client that moodiness and bloating are common side effects experienced by NET-EN users and present no health risk; ensure that the client has not developed any of the other health problems mentioned on the screening checklist; determine that the client can continue to use NET-EN.

Because the client has opted to continue the method, give the reinjection and remind the client that NET-EN does not protect against STIs or HIV.

Use the calendar to determine that the client’s reinjection date is June 8.

Encourage the client to respect her new reinjection date. If she cannot make it on her scheduled day, returning up to two weeks early or two weeks late is acceptable; she should come back regardless of how late she might be. Remind her that if she is more than two weeks late for the next injection, she should use a backup method such as condoms or abstinence to avoid unintended pregnancy.



Conclude that approximately 13 weeks have elapsed since the previous injection, which is later than the planned reinjection date of March 10 and outside the reinjection window, which closed on March 24.



Inform the client that she is outside the reinjection window and that you will ask her a series of questions to determine if there is any chance that she may be pregnant.

Use the pregnancy checklist on page 2, box 2 of the job aid to determine that the client is not pregnant since she has been abstaining since the previous injection expired (during the time that her husband was away).

Ask the client if she is experiencing any new health problems to ensure that the client is still medically eligible.

Remind the client that side effects are possible and reassure the client as appropriate.

Give the reinjection and tell the client to use a backup method for the next seven days; remind her that NET-EN does not protect against STIs or HIV.

Use the calendar to determine that the client’s next reinjection date is June 11.

Encourage the client to respect her new reinjection date. If she cannot make it on her scheduled day, returning up to two weeks early or two weeks late is acceptable; she should come back regardless of how late she might be. If she is more than two weeks late for the next injection encourage her to use a backup method such as condoms or abstinence.

Demonstration Return Demonstration

Explain to the trainees that they will be practicing the steps that they saw on the slides. Explain that they will be using a checklist that has all of the steps included, as well as other things that are important for them to remember. Explain that the goal of the exercise is to practice until they become proficient in each skill and before they perform them in a clinical situation. Pass out the Competency Based Skills Checklist.

Using a piece of fruit or an anatomical model, demonstrate how you would give the injection. Ask a participant or co-trainer to sit at the head of the model and play the role of the client. Explain the procedure and talk to the role playing participant as s/he would to a real client.

Performs the procedure again but this time, ask a participant to verbally repeat the step-by-step procedure.

Note: Do not demonstrate the wrong procedure at any time. Ask the remaining trainees observe the learning

Evaluation Tool: Competency Based Skills Checklist for Progestin-only Injectable Contraceptives



participant and ask questions.

Ask a participant to perform the procedure while verbalizing the step-by-step procedure. Observe and listen, making corrections when necessary. Ask the other trainees in the group to observe, listen, and ask questions.

Ask the trainees to form pairs. Ask each participant to practice the demonstration with their partner. One partner should perform the demonstration and talk through the procedure while the other partner observes and critiques using the skills checklist. Ask partners to exchange roles until both feel competent. When both partners feel competent, ask them to perform the procedure and talk-through for you (the trainer) and assess their performance using the skills checklist.



Session V: Giving the Injection with Sayana PressSession V Objective: Demonstrate how to administer the injection with Sayana Press.

Introduction Discussion (15 min.)

This session describes the steps for injecting and re-injecting Sayana Press and for preventing infection during injection. Sayana Press is a new form of the progestin-only injectable contraceptive DMPA. It has been approved by the United States Food and Drug Administration (FDA) and the European Medicines Agency (EMA). Sayana Press consists of a low dose of DMPA in Uniject (a single-use, prefilled injection system). Sayana Press is injected into the fatty tissue directly under the skin (subcutaneous or SC injection) with a short needle (3/8 inches or 9.5 mm) instead of a deep intramuscular (IM) injection of Depo-Provera® or other brands of DMPA. Even though the dose of DMPA is smaller in Sayana Press, it is just as effective. Just like the DMPA given intramuscularly, it is given every 3 months. Sayana Press comes in a single dose, prefilled device that is small, easy to use and disposable. The Medical Eligibility Criteria for Sayana Press is just the same as for DMPA IM. The side effects are similar, except that there may be some mild skin irritation with Sayana Press.

Slide 2: Objectives

Handout #13:Giving the Injection


After counseling the client and determining her eligibility, it is then time to give the client the injection.

Present the steps used in giving the injection with Sayana Press1. Getting the supplies together.

o Injection device at room temperatureo Soapo Cotton swabs or cotton ballso Safe container for sharps disposal

2. Wash handso Wash hands—if possible, with soap—after you

have set out your supplies and before you give the injection.

o Let your hands dry in the air.o If the injection site is dirty, wash it with water on a

cotton swab or ball.o No need to wipe the site with antiseptic.

Note to facilitator: Ask participants to refer to Handout #13 during the lecturette about how to give the DMPA-SC injection.

Slide 3-4: How to Give the Injection




As you prepare for the demonstration, describe for the participants how you are arranging the materials that will be used—emphasize the importance of arranging everything that will be needed for the procedure in a clean uncluttered space. Demonstrate each of the steps―on a fruit or vegetable or a volunteer—as you review them. Tell the participants to pay close attention because they will be expected to demonstrate these steps during practice. Ensure that participants can see the demonstration and encourage them to ask questions


3. Ask where the client wants the injection. You can give the injection

o In the back of the upper armo In the abdomen (but not in the navel)o On the front of the thigh*

4. Open the poucho Check that the expiration date on the pouch has not

passedo Open the pouch by tearing the small notch and

remove the Sayana Press5. Mix the solution

o Hold the device by the port (see illustration on slide)

o Shake it hard for 30 secondso Check that the solution is mixed and there is no

damage or leaking.o Do not flick or bend the device. This can damage

the Device.

*Note: If your client is very thin and it is difficult to pinch enough fat at the site she prefers, ask her if you can try the other sites to get a better pinch. Remember that Sayana Press should NOT be injected in the buttocks, hip, or deltoid muscle like with depo-IM.




6. Activate the deviceo Hold the device by the porto Keep the device with the needle pointed upward to

avoid spilling the drugo Push the needle shield into the porto Continue to push firmly until the gap between the

needle shield and port is closed (see drawing 2).o Take off the needle shield.





Explain that there is a gap between the port and the reservoir where the DMPA is held. It is very important to close that gap because:

o This pushes the needle through the barrier that holds the DMPA.

o The DMPA goes into the needle and to the client7. Give the injection

o Gently pinch the skin at the injection site. (This helps to make sure that the drug is injected into fat and not into muscle.)

o Hold the port. Gently push the needle straight into the skin at a downward angle (never upward) until the port touches the skin.

o Squeeze the reservoir slowly. Take 5 to 7 seconds.o Pull out the needle.o Do not clean or massage the site after injecting

How to Give the Injection: Steps 8Lecturette (5 min.)

8. Discard the used deviceo Do not replace the needle shieldo Place the device in a safety box

Slide 11: How to Give the Injection


Practice Safe Handling of NeedlesLecturette (5 min.) (may skip if done as part of Session IV)

Safe handling and disposal of needles is an important responsibility. Before practicing with needles, it is important to learn how to handle them safely.

To avoid accidental needle-stick injuries, do not re-cap the needle after use. Immediately after use, place the used syringe in the sharps container.

Do not touch the needle. If you accidentally touch or stick yourself with a needle, do not use the needle on a client. Discard the needle and use a fresh one.

Do not leave a needle inside the vial, to avoid contaminating both the needle and the contents of the vial.

Needles are also known as “sharps.” Sharps must be placed in a hard-walled container before disposal, to protect garbage handlers and others from injury. Always place used needles and syringes in the sharps container. Do not put anything into the sharps container other than needles and syringes.

Do not overfill the sharps container. When the sharps

Slide 12: Practice Safe Handling of Needles



container is about three-quarters full, return the container to your supervisor or the health care facility and get a new one. Replacing the container at this stage prevents needle sticks if a provider tries to put a needle and syringe into an already-full container.

Local regulations on the disposal of sharps containers should be followed to ensure the health and safety of all members of the community.

Note to facilitator: Demonstrate for participants how to assemble a sharps container and show how full it should be before replacement. Program administrators must consider what type and size puncture-proof container is appropriate. If CHWs are moving from place to place to provide services, they must be issued portable sharps containers. Homemade portable sharps containers can be crafted from sturdy cardboard boxes or sturdy plastic bottles with wide mouths covered by tight-fitting caps. It is essential that homemade containers share the same safety features as the commercial-grade containers (e.g., container walls are sturdy enough to prevent needles from poking through, the syringes can be deposited in the container without forcing them, the needles and syringes cannot fall out, and the entire container can be disposed of when it is about three-quarters full).

Supporting the User (self-inject) Lecturette (15 min.)

Teaching clients to self-inject

Some clients will want to give themselves the injections. You can teach them how to do this. The following steps apply to self-injection with Sayana Press injection device.

1. Discuss plan for storage and disposal

o Storage. Discuss where the client can store the devices for at least 3 months that is out of the reach of children and animals and in moderate temperatures (not in direct sunlight or in a refrigerator).

o Disposal. Discuss how the client can dispose of the device in a container that has a lid and cannot be punctured and can be kept away from children.

2. Explain and show how to self-inject. Explain the important steps. Also explain and show the client how to do each of these steps. You can give the client a copy of these instructions and the pictures on the next page or a booklet of more detailed instructions. Explain how to read

Slide 13-15: Supporting the User




the instructions.

3. Go through the steps on Slides 14-15 on how to use the Sayana Press Injectable contraceptive device

Demonstration Return Demonstration

Explain to the trainees that they will be practicing the steps that they saw on the slides. Explain that they will be using a checklist that has all of the steps included, as well as other things that are important for them to remember. Explain that the goal of the exercise is to practice until they become proficient in each skill and before they perform them in a clinical situation.

Pass out the Competency Based Skills Checklist.

Using a piece of fruit or an anatomical model, demonstrate how you would give the injection. Ask a participant or co-trainer to sit at the head of the model and play the role of the client. Explain the procedure and talk to the role playing participant as s/he would to a real client.

Performs the procedure again but this time, ask a participant to verbally repeat the step-by-step procedure.

Note: Do not demonstrate the wrong procedure at any time. Ask the remaining trainees observe the learning participant and ask questions.

Ask a participant to perform the procedure while verbalizing the step-by-step procedure. Observe and listen, making corrections when necessary. Ask the other trainees in the group to observe, listen, and ask questions.

Ask the trainees to form pairs.

Ask each participant to practice the demonstration with their partner. One partner should perform the demonstration and talk through the procedure while the other partner observes and critiques using the skills checklist. Ask partners to exchange roles until both feel competent. When both partners feel competent, ask them to perform the procedure and talk-through for you (the trainer) and assess their performance using the skills checklist.

Evaluation Tool: Competency Based Skills Checklist for Progestin-only Injectable Contraceptives


Documents

file · Web viewProgestin-Only Injectable (Injectables): Session Plan . Notes to Facilitator: The slides and session plan provide presentation support for conveying technical