Evidence
Commentary on selected evidence
With advice from topic experts we selected 1 study for further commentary.
Progestogen-only injectable contraceptives
We selected a systematic review by Kim et al. (2016) for a full commentary because subcutaneous depo-medroxyprogesterone acetate (sc‑DMPA) was launched in 2013 and received its licence for self-administration in 2015.
What the guideline recommends
There are no current recommendations relating to self-administration of sc‑DMPA. The current recommendations address the risks and benefits of the intramuscular (im) injection of DMPA in section 1.4 of NICE guideline CG30; however, sc‑DMPA may have different risks and side effects (see summary of product characteristics). A NICE evidence summary on sc-DMPA describes the safety and effectiveness of sc‑DMPA.
Methods
Kim et al. undertook literature searches on PubMed, Popline, Cochrane, CINAHL and Embase databases (from inception to October 2015), to identify randomised controlled trials and comparative observational studies that investigated continuation rates, safety or satisfaction of women's self-administration of sc‑DMPA compared with im‑ or sc‑DMPA administered by a healthcare provider. Hand-searching of reference lists from identified key review articles was also performed. Two authors independently assessed the overall quality of the evidence by using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.
Results
One randomised controlled trial (n=132 participants) and 2 observational studies (1 cohort study, n=128 participants; 1 crossover study, n=16 participants) were included. Two studies evaluated the self-administration of sc‑DMPA, compared with sc‑DMPA or im‑DMPA administered by a healthcare provider; the third study evaluated the self-administration of sc‑DMPA compared with im‑DMPA administered by a nurse. Data could not be pooled because of heterogeneity in interventions and study designs.
The overall result showed that there may be little or no difference in continuation rates when women self-administer sc‑DMPA compared with im‑ or sc‑administration by healthcare providers. In the randomised controlled trial, the uninterrupted DMPA use at 1 year was 28/61 in self-administered sc‑group compared with 14/29 in healthcare administered group, p=0.70. In the cohort study, the discontinuation rate at 12 months was 7/58 compared with 14/64 for self-administered and healthcare administered respectively p=0.23. In the crossover study, the continuation rates were reported to be similar in self-administration and nurse administration group, but numerical data were not reported.
Information about serious adverse events were not reported in any of the included studies, therefore 'safety' could not be estimated. The overall effectiveness of the intervention and women's satisfaction on the methods of administration were either uncertain or no difference was observed.
Strengths and limitations
Strengths
Population and important outcomes considered in the article matched those specified in the review questions for NICE guideline CG30.
Limitations
Limited search terms were used. The included studies were small studies with low statistical power. Based on the authors' assessment using GRADE, the methodological quality across the 3 included studies was low and very low. In 2/3 included studies, women were already using DMPA and therefore could have been motivated to continue with the intervention. No exclusion criteria specified. Studies were heterogeneous and data could not be pooled.
Impact on guideline
The systematic review targeted the population and important outcomes specified in the review questions for NICE guideline CG30. However, there are no recommendations currently regarding the self-administration of sc‑DMPA and new evidence does not definitively establish the basis for recommending the practice.
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