Intersectional analysis of the experiences of women who fail to conceive in low and middle income neighbourhoods of Delhi, India: Findings from a qualitative study.

BACKGROUND: Experiences of delayed conception and infertility have been reported among women. However, the concept of intersectionality is rarely utilised in studies of infertility, and it is particularly uncommon in research from low- and middle- income countries. RESEARCH QUESTION: What are the lived experiences of women with delayed conception in low to -middle income neighbourhoods of Delhi, India? METHODS: This was a qualitative study (n = 35) that recruited women who had failed to conceive after 18 months of regular unprotected sexual intercourse. Data were collected between February and July 2021. Data were collected through focus group discussions in low income to middle income neighbourhoods of Delhi, India. Analysis identified themes related to intersecting axes of inequality. RESULTS: The results showed that gender intersected with economics, masculinity, patriarchal norms and class to influence the experiences of women. The intersection of gender, economics and patriarchal norms compromised women's agency to be active generators of family income, and this dynamic was exacerbated by patrilocal residence. In addition, masculinity contributed to stigmatisation and blaming of women, due to the inaccurate perception that men did not contribute to a couple's infertility. The intersection of gender and social class in medical settings created barriers to women's access to medical information. CONCLUSION: Findings from this study provide representative examples of the variety of axes of inequality that shape women's experiences in the study setting. Although these findings may not be generalisable to all women who are experiencing delayed conception, they highlight a need for improved awareness and education on infertility, as well as a need to ensure the availability and accessibility of fertility care for couples in need.

Description of the methodology for developing and validating the WHO's family planning and comprehensive abortion care competencies for the primary health care workforce.

A qualified health workforce is essential to receiving effective, timely, affordable, equitable and respectful family planning and comprehensive abortion care. However, in many countries, health workers lack the competencies required to deliver quality family planning and comprehensive abortion care services. Competency-based education and learning aims to train and assess competencies. The theory-supported approach focuses on outcomes, emphasizes the learner's ability to perform, promotes learner-centeredness and links the health needs of the population to the competencies required of health workers. In 2011, the World Health Organization published a guidance document, Sexual and reproductive health - Core competencies in primary care, defining the competencies that primary care providers need to safely deliver sexual and reproductive health services at the community level and included family planning and comprehensive abortion care. In this article, we describe the methodology and process undertaken in 2020, by the World Health Organization to produce the family planning and comprehensive abortion care competencies guidance, filling gaps identified in the previous guidance document. The World Health Organization's Family Planning and Comprehensive Abortion Care toolkit for the primary health care workforce was published in 2022 and defines the key competencies for health workers in primary health care providing quality family planning and comprehensive abortion care services, as well as support for developing programmes and curricula for education and lifelong learning. The Toolkit is useful for practitioners, managers/supervisors and employers, educators, regulatory bodies, and policymakers. It is an important advance toward strengthening family planning and comprehensive abortion care services in primary health care.

The impact of cascade training-A FIGO and WHO Department of Sexual and Reproductive Health and Research collaboration to improve access to quality family planning globally.

Globally, there are considerable barriers to accessing safe and effective contraceptive methods. Increased awareness and utilization among obstetricians and gynecologists (OB/GYNs) and allied health professionals of the WHO's tools and guidelines on contraception is a possible avenue to changing this. A cascade-training model, based on regional training-of-trainer workshops followed by national workshops, was used to share key WHO global family planning tools and guidelines among OB/GYNs in 29 countries across three regions-Anglophone Africa, Middle East and Mediterraean, and Francophone West Africa. Monitoring and evaluation was performed through pre- and post-knowledge questionnaires as well as in-depth interviews of key informants before and after the training was instituted. The training increased both participants' knowledge and understanding of the relevant guidelines, as well as their confidence in using them. Qualitative data suggested that this improved in-country clinical practice and influenced national policy through dissemination and engagement with country leadership. The cascade-training model was a practical, locally adaptable means of disseminating up-to-date WHO family planning guidelines and tools. It resulted in sustainable changes in many participating countries, including training curriculum updates, policy changes, and increased government engagement with family planning. Future iterations of the initiative would benefit from additional support for multidisciplinary training.

Implementation strategies, facilitators, and barriers to scaling up and sustaining demand generation in family planning, a mixed-methods systematic review.

BACKGROUND: Demand generation aims to increase clients' desire to use family planning. The aim of this work was to systematically summarize strategies, facilitators, and barriers to scaling up and sustaining demand generation in family planning. METHODS: We searched electronic bibliographic databases from inception to October 2022. We included quantitative, qualitative, and mixed methods reports on demand generation strategies in family planning, regardless of country, language, publication status, or methodological limitations. We assessed abstracts, titles and full-text papers according to the inclusion criteria, extracted data, and assessed methodological quality of included reports. We used the convergent integrated approach and a deductive thematic synthesis to summarize demand generation themes and subthemes. We used the health system building blocks to synthesize the factors affecting implementation (barriers and facilitators). We used GRADE-CERQual to assess our confidence in the findings. RESULTS: Forty-six studies (published 1990-2022) were included: forty-one quantitative, one qualitative, and four mixed methods). Three were from one high-income country, and forty three from LMIC settings. Half of reports were judged to be of unclear risk of bias. There were unique yet interrelated strategies of scaling-up demand generation for family planning. Interpersonal communication strategies increase adoption and coverage of modern contraceptive methods, but the effect on sustainability is uncertain. Mass media exposure increases knowledge and positive attitudes and may increase the intention to use modern contraceptive methods. Demand-side financing approaches probably increase awareness of contraceptives and the use of modern contraceptive methods among poor clients. Multifaceted Demand generation approaches probably improve adoption, coverage and sustainability of modern methods use. Factors that influence the success of implementing these strategies include users knowledge about family planning methods, the availability of modern methods, and the accessibility to services. CONCLUSIONS: Demand generation strategies may function independently or supplement each other. The myriad of techniques of the different demand generation strategies, the complexities of family planning services, and human interactions defy simplistic conclusions on how a specific strategy or a bundle of strategies may succeed in increasing and sustaining family planning utilization. TRIAL REGISTRATION: Systematic review registration: Center for Open Science, osf.io/286j5.

Family planning could prevent one third of maternal deaths by allowing women to delay motherhood, avoid unintended pregnancies and subsequent abortions. Demand generation is one of the critical factors for increasing coverage and sustainability of family planning programs. Demand generation activities aim to increase clients' desire to use family planning by changing their attitudes or perceptions about FP or increasing their awareness or knowledge about FP methods and also by improving access to contraceptive services. Many demand generation activities also aim to shift social and cultural norms to affect individual behavior change. Scaling up demand generation and ensuring that demand for family planning is satisfied is essential for achieving universal access to reproductive health-care services. We systematically searched for and summarized reports of strategies to scale up demand generation for family planning. Available evidence shows that interpersonal communication strategies increase adoption and coverage of modern contraceptive methods, but the effect on sustainability is uncertain. Mass media exposure increases knowledge and positive attitudes and may increase the intention to use modern contraceptive methods. The effect of new media is uncertain. Demand-side financing approach probably increase awareness of contraceptives and the use of modern contraceptive methods among poor women. The most apparent factors influencing the success of implementing these strategies include knowledge about family planning methods, especially regarding side effects and health concerns, the availability of modern contraceptive methods, and the accessibility to family planning services.

Implementation strategies, facilitators, and barriers to scaling up and sustaining task-sharing in family planning: a protocol for a mixed-methods systematic review.

BACKGROUND: Ensuring access to quality family planning (FP) services is fundamental to achieving the Sustainable Development Goals (SDG) targets 3.1, 3.7, and 5.6, including universal access to reproductive health services. However, barriers such as health workforce shortages and restrictive policies on the role of mid and lower-level health workforce cadres limit access to contraceptives and FP in many settings. Workforce reorganization makes more efficient use of human resources. Consequently, the World Health Organization (WHO) recommends task-sharing for FP by different cadres. Evidence on the implementation strategies, facilitators, and barriers to scaling up and sustaining task-sharing could inform financing, implementation approaches, and technical assistance of national and global FP task-sharing programs. Therefore, this study aims to describe and assess the quality of the evidence on implementation strategies, facilitators, and barriers to scaling up and sustaining task-sharing in FP and the outcome of the scale-up/sustainability interventions. METHODS: This systematic review protocol was developed using relevant guidelines, including the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Protocols (PRISMA-P). A search of five databases, namely CINAHL (EBSCOhost), EMBASE (OvidSP), Global Health (OvidSP), MEDLINE (OvidSP), and Scopus ( www.scopus.com ), and gray literature resources will be conducted. Two independent reviewers will screen and select studies, assess their quality using the "Mixed Methods Appraisal Tool," and extract data from eligible studies. Publications or articles are eligible if they report implementation strategies, facilitators, or barriers to scaling up/sustainability of task-sharing in FP/contraception or the outcomes of the scale-up/sustainability interventions. A convergent synthesis that integrates qualitative, quantitative, descriptive, and mixed-methods data into one dataset will be used for analysis based on an a priori framework-the Cochrane Effective Practice and Organization of Care (EPOC) taxonomy of the health system framework. Two independent reviewers will assess the quality of evidence using the GRADE-CERQual guideline. DISCUSSION: To our knowledge, this systematic review of implementation strategies, facilitators, and barriers to scaling up and sustaining task-sharing in family planning is the first in this area. Our rigorous methodology based on up-to-date guidelines can help generate relevant recommendations to support interventions to scale up and sustain task-sharing in family planning. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022339885.

Implementation strategies, facilitators, and barriers to scaling up and sustaining post pregnancy family planning, a mixed-methods systematic review.

BACKGROUND: Post pregnancy family planning includes both postpartum and post-abortion periods. Post pregnancy women remain one of the most vulnerable groups with high unmet need for family planning. This review aimed to describe and assess the quality of the evidence on implementation strategies, facilitators, and barriers to scaling up and sustaining post pregnancy family planning. METHODS: Electronic bibliographic databases (MEDLINE, PubMed, Scopus, the Cochrane Library, and Global Index Medicus) were searched from inception to October 2022 for primary quantitative, qualitative, and mixed method reports on scaling up post pregnancy family planning. Abstracts, titles, and full-text papers were assessed according to the inclusion criteria to select studies regardless of country, language, publication status, or methodological limitations. Data were extracted and methodological quality assessed using the Mixed Methods Appraisal Tool. The convergent integrated approach and a deductive thematic synthesis were used to identify themes and sub-themes of strategies to scale up post pregnancy family planning. The health system building blocks were used to summarize barriers and facilitators. GRADE-CERQual was used to assess our confidence in the findings. RESULTS: Twenty-nine reports (published 2005-2022) were included: 19 quantitative, 7 qualitative, and 3 mixed methods. Seven were from high-income countries, and twenty-two from LMIC settings. Sixty percent of studies had an unclear risk of bias. The included reports used either separate or bundled strategies for scaling-up post pregnancy family planning. These included strategies for healthcare infrastructure, policy and regulation, financing, human resource, and people at the point of care. Strategies that target the point of care (women and / or their partners) contributed to 89.66% (26/29) of the reports either independently or as part of a bundle. Point of care strategies increase adoption and coverage of post pregnancy contraceptive methods. CONCLUSION: Post pregnancy family planning scaling up strategies, representing a range of styles and settings, were associated with improved post pregnancy contraceptive use. Factors that influence the success of implementing these strategies include issues related to counselling, integration in postnatal or post-abortion care, and religious and social norms. TRIAL REGISTRATION: Center for Open Science, OSF.IO/EDAKM.

Family planning could prevent one third of maternal deaths by allowing women to delay motherhood, avoid unintended pregnancies and subsequent abortions. Post pregnancy family planning includes both postpartum and post-abortion periods. Post pregnancy women remain one of the most vulnerable groups with high unmet need for family planning. Scaling up post pregnancy family planning is essential for achieving universal access to reproductive health-care services. Reports of strategies to scale up post pregnancy family planning were systematically reviewed and summarized. These included strategies for healthcare infrastructure, policy and regulation, financing, human resource, and people at the point of care. Strategies that target the point of care (women and/or their partners) contributed to 89.66% (26/29) of the reports either independently or as part of a bundle. Point of care strategies increase adoption and coverage of post pregnancy contraceptive methods. Certain factors influence the success of implementing these strategies, including issues related to counselling, integration in postnatal or post-abortion care, and religious and social norms.

Scoping review on the use of South-South learning exchange to scale up evidence-based practices in family planning.

BACKGROUND: South-South learning exchange (SSLE) is an interactive learning process where teams from low-income and middle-income countries exchange knowledge and experience to support one or both team's work towards a change in policies, programmes or practices. SSLE has been used by countries to improve family planning (FP) outcomes such as increased contraceptive prevalence rate and reduced unmet need for FP, but at present, there are no reviews that summarise its use. We conducted a scoping review with stakeholder consultations to summarise the use of SSLE to change FP outcomes. OBJECTIVE: To systematically identify and map the purposes, approaches, outputs, outcomes, enablers and barriers to using SSLE in FP. METHODS: A search was conducted on electronic databases, grey literature sources, websites and the reference list of included studies. The scoping review is based on an adapted version of Arksey and O'Malley's scoping review framework suggested by Levac et al. Experts were interviewed on their experiences in SSLE. RESULTS: The initial search yielded 1483 articles; however, only 29 were selected in the final analysis. The articles were published between 2008 and 2022. Most of the articles were reports, case studies or press releases, only two were peer-reviewed publications. Capacity building of FP providers, policy-makers and community was the most commonly reported purpose of SSLE, with study tours (57%) being the most common approach. Policy dialogue was the most common (45%) output and improved contraceptive prevalence was the most frequently reported outcome. The experiences of the 16 interviewed experts aligned with the scoping review findings. CONCLUSION: The evidence on the effectiveness of SSLE for addressing FP outcomes is very limited and of very low quality. We call on stakeholders conducting SSLE to document their experiences in detail, including the outcomes achieved.

Scoping review protocol to map evidence on South-South learning exchange in family planning.

INTRODUCTION: South-South learning exchange (SSLE) is an interactive learning process where stakeholder teams exchange knowledge and experience to help one, or both to work towards change, by identifying, adopting and/or strengthening implementation of a best practice. SSLE has been conducted between countries to share knowledge on best practices and policies in family planning. To the best of our knowledge, no scoping review has been conducted to synthesise evidence on SSLE in family planning. In this paper, we outline the protocol to conduct scoping review on SSLE in family planning. METHODS AND ANALYSIS: Arksey and O'Malley's scoping review framework with adaptions from Levac et al will be used to guide this scoping review. We will search electronic databases (Medline, Embase, CINAHL, Hinari, ProQuest DB, PUBMED, Web of Science and WorldCat), grey literature sources and reference lists of included studies. We will focus on literature published till August 2022. The abstract and title screening, full-text screening and data charting will be conducted by two independent reviewers. The findings will be summarised into a narrative based on thematic analysis. Stakeholder interviews will be conducted to understand their perception and experiences in applying SSLE in family planning. ETHICS AND DISSEMINATION: The ethics review committee at WHO, Geneva, has exempted this study from ethical approval (ERC.0003752). The findings from the study will provide useful insights into effective approaches, barriers, facilitators to conduct SSLE in family planning. This knowledge will be of significant public health relevance and will help in designing future learning exchanges between countries in the south to accelerate access to quality family planning services. The findings will be disseminated via peer-reviewed journals, conference proceedings, newsletters and workshops.

Determining the Impact of the COVID-19 Pandemic on Availability, Use, and Readiness of Family Planning and Contraceptive Services at Selected Primary Health Care Facilities in Africa and Asia: Protocol for a Mixed Methods Study.

BACKGROUND: The COVID-19 pandemic and the associated social restrictions may have disrupted the provision of essential services, including family planning (FP) and contraceptive services. This protocol is adapted from a generic study protocol titled "Health systems analysis and evaluations of the barriers to availability and readiness of sexual and reproductive health services in COVID-19 affected areas," conducted by the World Health Organization (WHO) Department of Reproductive Health and Research. OBJECTIVE: This study aims to assess the availability and use of FP and contraceptive services in primary health facilities during and after the COVID-19 pandemic; assess the risk perceptions of COVID-19 stigma, barriers to access, and quality of services from clients' and providers' perspectives in the COVID-19-affected areas; and assess the postpandemic recovery of the facilities in the provision of FP and contraceptive services. METHODS: In-depth interviews will be conducted with clients-women in the reproductive age group and their male partners who visit the selected health facilities for FP and contraceptive services-and health providers (the most knowledgeable person on FP and contraceptive service provision) at the selected health facilities. Focus group discussions will be conducted with clients at the selected health facilities and in the community. The in-depth interviews and focus group discussions will help to understand clients' and health service providers' perspectives of FP and contraceptive service availability and readiness in COVID-19-affected areas. A cross-sectional health facility assessment will be conducted in all the selected health facilities to determine the health facility infrastructure's ability and readiness to provide FP and contraceptive services and to capture the trends in FP and contraceptive services available during the COVID-19 pandemic. Scientific approval for this study is obtained from the WHO Research Project Review Panel, and the WHO Ethics Review Committee has given ethical approval in the 3 countries. RESULTS: Using a standardized research protocol will ensure that the results from this study can be compared across regions and countries. The study was funded in March 2021. It received ethics approval from the WHO Ethics Review Committee in February 2022. We completed data collection in September 2022. We plan to complete the data analysis by March 2023. We plan to publish the study results by Summer 2023. CONCLUSIONS: The findings from this study will provide a better understanding of the impact of the COVID-19 pandemic on FP and contraceptive services at the facility level, which will help policy makers and health managers develop and strengthen FP policies and services in health facilities to be more responsive to community needs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/43329.

Improving access to quality family planning services in Nepal and Sri Lanka: insights from a South-South learning exchange.

Nepal and Sri Lanka ministries of health shared best practices and learnings, in a South-South learning exchange (SSLE) to improve access to quality and rights-based family planning services. The SSLE between the two countries followed a five-step methodology designed by the WHO, under the Family Planning Accelerator project. SSLE between the two countries started in January 2020 and is still continuing. Both countries started implementation of the learnings (step 4) at the time of preparing this manuscript (December 2021). An independent consultant from Sri Lanka carried out an evaluation, to inform future SSLEs. The evaluation included a desk review on SSLE and family planning in both countries and key informant interviews with Sri Lanka Ministries Health, WHO CO, external partners. A final evaluation of the outcomes/impact is planned in December 2022. The SSLE resulted in a systematic cross-country transfer of knowledge and implementation of the learnings. Sri Lanka implemented a web-based system for logistics management of family planning commodities and Nepal commenced implementing integrated family planning services in a decentralised environment using a lifecycle approach to improve postpartum family planning uptake. The success of this SSLE is attributed to the rigorous methodology, country-led designing of the learning agenda and process, extensive communication amongst the teams, a focus on outcomes, commitment and leadership by ministries of health in both countries. Learning and technical assistance needs of countries can be met by SSLE if national contexts, availability of resources are considered.

Characteristics, experiences and actions taken by women to address delayed conception: A mixed-methods cross-sectional study protocol.

BACKGROUND: The impact of infertility on mental, emotional, physical and sexual health is grave, particularly in a pronatalist society. Literature is replete with evidence of wide ranging psychosocial consequences of infertility in women, indicating the need for identifying the gaps and designing appropriate context specific interventions to improve access and utilization of services. Data that are accessible, primarily from infertility clinics and women visiting hospitals for infertility treatment; information from community settings is rare. This is a protocol paper for a study to understand women's experiences and actions taken by them to cope with delayed conception. METHODS: Mixed-methods cross-sectional design is used to obtain deep insights into the experiences of delayed conception, coping mechanisms, medical assistance and other help sought. Information is also being obtained on socio-demographic profile, fertility intentions, fertility quality of life, general medical history, obstetric, gynecological and sexual history, substance use and mental health status. A sample of 1530 women will be administered 4 modules of a quantitative survey. Focus group discussions, about four or till saturation point, will be conducted using purposive sampling. The study is recruiting from a population of women who previously participated in the 'Women and Infants Integrated Interventions for Growth Study (WINGS) and failed to conceive during 18 months follow up period. Data collected through questionnaire will be assembled, cleaned, analyzed and reported. The findings will be disseminated through reports with the ethics review committee, government entities, academic and research publications. DISCUSSION: This study will provide insights on the experiences and coping strategies of women with delayed conception in the study community. Results will assist in designing appropriate interventions to meet the holistic health and psychosocial needs of women with delayed conception and promote sexual and reproductive health within the broader framework of Sustainable Development Goals and Universal health coverage. TRIAL REGISTRATION: Trial registration number: CTRI/2020/03/023955.

Prevalence of reproductive tract infections including sexually transmitted infections among married women in urban and peri-urban mid to low socioeconomic neighbourhoods of Delhi, North India: an observational study protocol.

INTRODUCTION: The Global Health Sector Strategy on sexually transmitted infections (STIs), endorsed by the World Health Assembly in 2016 aims to end STIs as public health threat by 2030. WHO conducts global estimates of prevalence to monitor progress towards achieving the same. However, limited laboratory confirmed data exist of STIs and reproductive tract infections (RTIs) apart from few prevalence surveys among key populations and clinic-based reports, including in India. Syndromic approach is the cornerstone of RTI/STI management and to maximise the diagnostic accuracy, there is a need to determine the main aetiologies of vaginal discharge. This study aims to estimate the prevalence of common STIs and RTIs and their aetiological organisms in symptomatic and asymptomatic women living in the urban and peri-urban, mid to low socioeconomic neighbourhoods of Delhi, North India. METHODS AND ANALYSIS: A cross-sectional study will be conducted among 440 married women who participated in the 'Women and Infants Integrated Interventions for Growth Study (WINGS)'. Information on sociodemographic profile, sexual and reproductive health will be collected, followed by examination and collection of vaginal swabs for nucleic acid amplification tests to diagnose Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis and microscopy to identify bacterial vaginosis and Candida albicans. Treatment will be as per the syndromic approach recommendations in the Indian National Guidelines. Data will be analysed to estimate prevalence, presence of symptoms and signs associated with laboratory confirmed RTIs/STIs using STATA V.16.0 (StataCorp). ETHICS AND DISSEMINATION: This study protocol has been approved by the ethics review committees of the WHO and Society for Applied Studies (SAS/ERC/RHR-RTI/STI/2020). Approval has been obtained by the WINGS investigators from SAS ethics research committee to share the contact details of the participants with the investigators. The findings will be published in peer-reviewed journals and disseminated through scientific conferences. TRIAL REGISTRATION NUMBER: CTRI/2020/03/023954.

Postpartum contraceptive practices among urban and peri-urban women in North India: a mixed-methods cohort study protocol.

BACKGROUND: Postpartum family planning (PPFP) helps women space childbirths, increase exclusive breastfeeding and prevent unintended pregnancies, leading to reduction in maternal, infant and child morbidities and mortality. Unmet need of family planning is highest among women in the postpartum period due to lack of knowledge, cultural and religious barriers, access barriers and low antenatal care service utilization. However, in spite of low prevalence of postpartum family planning practices, birth-to-birth interval is reportedly high in Delhi, India. This study explores the postpartum contraception practices and the relationship between use of postpartum contraception and subsequent child linear growth. METHODS: This is a mixed method cohort study on PPFP and is nested within an ongoing "Women and Infants Integrated Interventions for Growth Study" (WINGS). Married women aged 18-30 years who have delivered a live baby are recruited for quantitative interviews at 6 weeks, 6, 12, and 24 months postpartum. In-depth interviews are conducted with a randomly selected sub-sample of women at each of the four time points, 35 husbands and 20 local service providers to understand their perspectives on PPFP practices. DISCUSSION: The findings from the study will provide useful insights into couples' contraception preferences and choice of contraception, modern and traditional, initiation time and the effect of birth spacing and contraception use on subsequent linear growth of the child. This knowledge will be of significant public health relevance and will help in designing appropriate interventions for appropriate postpartum contraception use and delivery strategies. The study aims to work address the Sexual and Reproductive Health and Rights goal of promoting reproductive health, voluntary and safe sexual and reproductive choices for women. TRIAL REGISTRATION: Trial registration number: CTRI/2020/03/023954 .

Self-administered subcutaneous medroxyprogesterone acetate for improving contraceptive outcomes: a systematic review and meta-analysis.

BACKGROUND: Subcutaneous depot medroxyprogesterone acetate is an easy-to-use injectable contraceptive. A trained person can administer it, including women through self-injection. The objective of this systematic review and meta-analysis was to assess the effectiveness and safety of self-injection versus provider-administered subcutaneous depot medroxyprogesterone acetate for improving continuation of contraceptive use. METHODS: We searched for randomized controlled trials on November 1, 2020 in Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, Embase, Web of Science, Scopus, Open Grey, clinical trials registries, and reference lists of relevant studies. We did not impose any search restrictions. We included randomized trials comparing self- versus provider-administered subcutaneous depot medroxyprogesterone acetate. Two authors independently screened trials, extracted data, and assessed the risk of bias in the included studies. We used risk ratio and 95% confidence intervals for dichotomous outcomes. RESULTS: We identified 3 randomized trials (9 reports; 1264 participants). The risk of bias in the included studies was low except for performance bias and detection bias of participant-reported outcomes in unmasked trials. Self-administration, compared to provider-administration, increased continuation of contraceptive use (risk ratio 1.35; 95% confidence intervals 1.10-1.66); moderate-certainty evidence). Self-injection appears to be making more of an impact on continuation for younger women compared to women 25 years and older and on women living in low and middle income compared to high income countries. There was no subgroup difference by the type of care provider (community health worker vs. clinic-based provider). CONCLUSIONS: Self-injection of subcutaneous depot medroxyprogesterone acetate probably improves continuation of contraceptive use. The effects on other outcomes remain uncertain because of the very low certainty of evidence.