REFERENCE MANUAL

FOR
INJECTABLE CONTRACEPTIVE
(MPA)

March 2016

Family Planning Division

Ministy of Health and Family Welfare
Government of India
 REFERENCE MANUAL
FOR
INJECTABLE CONTRACEPTIVE
(MPA)

March 2016

Family Planning Division

Ministry of Health and Family Welfare
Government of India
March 2016

Ministry of Health & Family Welfare

Government of India, Nirman Bhawan, New Delhi -110101

Any part of this document may be reproduced and excerpts from it may be quoted without permission
provided the material is distributed free of cost and the source is acknowledged.
CONTENTS

MESSAGE

FOREWORD

PREFACE

ACKNOWLEDGMENT

INTRODUCTION 1

BACKGROUND 1

SCOPE OF THIS MANUAL 2

TARGET AUDIENCE 2

SECTION I: Technical Aspects of MPA Injectable Contraceptive

Chapter 1: Overview 5

Chapter 2: Medroxy Progesterone Acetate (MPA) 10

Chapter 3: Counselling 15

Chapter 4: Eligibility Criteria and Client’s Assessment 20

Chapter 5: Administering the Injection 22

Chapter 6: Follow Up Care 26

Chapter 7: Management of Side effects 28

Chapter 8: Special Issues on MPA 30

Chapter 9: Infection Prevention and Safe Injection Practices 33

SECTION II: Managerial Aspects for Quality MPA Services 39

Chapter 10: Program Determinants for Quality Services 41

10.1: Expansion of Basket of Choice 41

10.2: Determinants of Services 41

10.3: Quality Assurance in MPA Services 44

10.4: Key Areas and Standards for MPA Services 45

SECTION III: Capacity Building of Service Providers on MPA 47

Chapter 11: Training and Skill Development 49

11.1: Introduction 49

11.2: General Aspects of Training 49

11.3: Training Goal and Learning Objectives 50

11.4: Number of Trainees per Batch 50

11.5: Training Duration 50

11.6: Training Approach and Methodology 50

11.7: Evaluation of Knowledge and Skills 51

11.8: Roadmap for Training 52

11.9: Curriculum and Schedule of Training 52

Annexures 53

Annexure 1: Pregnancy Screening Checklist 55

Annexure 2: Medical Eligibility Criteria (MEC) WHO, 2015 57

Annexure 3: MPA Client Card and Instructions for Clients 63

Annexure 4: Frequently Asked Questions (FAQs) 65

Annexure 5 Myths and Misconceptions about MPA 74

Annexure 6: Role Play and Case Studies 76

Annexure 7: Competency-Based Checklist for Counselling and Technical Skills for MPA Injection 80

Annexure 8: Pre/Post-Test Questionnaire 84

Annexure 8(a): Answer Key Pre/Post-Test Questionnaire 88

Annexure 9: Evaluation of Training 92

Annexure 10: Post Training Follow up Checklist 94

Annexure 11: Format of Facility Register for MPA 96

Annexure 12: Course Outline (Session Plans) for MPA Training 97

References 102

List of Experts 106

ABBREVIATIONS

AIDS Acquired Immunodeficiency Syndrome

ANM Auxillary Nurse Midwife
ASHA Accredited Social Health Activist
BCC Behaviour Change Communication
CHC Community Health Centre
CPR Contraceptive Prevelance Rate
DCGI Drug Controller General of India
DFWO District Family Welfare Officer
DH District Hospital
DLHS District Level Household Survey
MPA Depo MedroxyProgestrone Acetate
DQAC District Quality Assurance Committee
FDA Food and Drug Administration
FOGSI Federation of Obstetric and Gynaecological Societies of India
FPAI Family Planning Association India
GMSD Government Medical Store Depot
Hb Haemoglobin
HIV Human Immunodeficiency Virus
IEC Information Education Communication
IM Intra Muscular
SC Sub Cutaneous
IP Infection Prevention
IUCD Intra Uterine Contraceptive Device
LHV Lady Health Visitor
LMP Last Menstrual Period
MEC Medical Eligibility Criteria
MO Medical Officer
MTP Medical Termination of Pregnancy
NFHS National Family Health Survey
NGO Non-Government Organization.
NHM National Health Mission
NSAID Non Steroidal Anti-Inflammatory Drug
OCP Oral Contraceptive Pills
PHC Primary Health Centre
POC Progestogen Only Contraceptive
POI Progestogen Only Injectable
PRB Population Reference Bureau
PSI Population Services International
QA Quality Assurance
RCH Reproductive and Child Health
RTI Reproductive Tract Infections
SC Sub Cutaneous
SC Sub Centre
SDH Sub District Hospital
SN Staff Nurse
SQAC State Quality Assurance committee
STI Sexually Transmitted Infections
TFR Total Fertility Rate
UNDP United Nations Development Program
UNFPA United Nation Population Funds
WHO World Health Organization
Introduction

Background
India was the first country in the world to launch a Family Planning Programme, as early as 1952, with the
main aim of controlling its population. India’s population has already reached 1.26 billion and considering
the high decadal growth rate of 17.64, the country’s population is slated to surpass that of China by 2028
(UNDP). The challenge now has extended beyond population stabilization to addressing sustainable
development goals for maternal and child health. Post the International Conference on Population and
Development (1994) Cairo, Family Planning emerged as a vital component in reducing maternal morbidity
and mortality. The London Summit on Family Planning (2012) buttressed this further and has succeeded
rightfully in bringing back the focus on Family Planning. Hence over the years India’s National Family
Planning Programme too has evolved with a shift in focus from merely population control to more critical
issues of saving the lives and improving the health of mothers and children through use of reversible
spacing methods leading to reduction in unwanted, closely spaced and mistimed pregnancies and thus
avoiding pregnancies with higher risks and chances of unsafe abortions.

Studies reveal that without contraceptive use the number of maternal deaths would have been 1.8 times
higher than at present. Thus contraceptive usage averted 44.3% of maternal deaths worldwide. Even
though, India has made considerable progress in reducing maternal mortality ratio, it still contributes 17%
of maternal deaths globally, according to a 2012 report of World Bank, UNFPA, WHO. Family Planning can
avert more than 30% of maternal deaths and 10% of child death if couples spaced their pregnancies more
than 2 years apart. A UNFPA Study has estimated that if the current unmet need for family planning could
be fulfilled within the next five years, the country can avert 35,000 maternal deaths and 12 lakhs infant
deaths.

Concerted efforts by the government have resulted in the decline of unmet need for family planning from
25.4% (DLHS-I) to 21.3% (DLHS-III) but approximately 4.2 crore couples still have an unmet need for
contraception (1.6 crore for spacing and 2.6 crore for limiting). Presently the spacing options are limited to
only condoms, IUCDs and Oral Pills contributing to 5.9%, 1.9% and 4.2% share of mCPR respectively.
Evidence of contraceptive method mix clearly indicates that with the addition of a single method there is a
linear increase in mCPR by 3-4%. It is therefore imperative to increase the basket of choices as well as the
service coverage simultaneously in the National Family Planning Program.

Introduction and widespread provision of new contraceptives can substantially contribute to achieving
this goal. Considerable scientific evidence is now available to address key concerns and accommodate
injectable contraceptive MPA in the National Family Planning Program. The growing availability and use
of MPA in the NGO/private sectors, combined with the strengthening of the health system under the
National Health Mission (NHM) has resulted in the overall improvement of infrastructure including
manpower in the public sector. International and National experiences confirm that MPA is acceptable to
women when offered with quality counselling and follow-up care. Women who are counselled about side-
effects are less likely to discontinue their use, more likely to become satisfied users and eventually become
its’ best promoters as a reversible contraceptive.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 1

The decision to add MPA in the National Family Planning Program thus has opened the way for clients to
avail of a safe, effective and hassle free method with full confidentiality.

Inclusion of injectable contraceptive in the basket of FP Choices would not only be consistent with the
GOI’s commitment to reduce unmet need for spacing but will also provide impetus to efforts for increasing
modern contraceptive usage in addition to addressing the new sustainable development goals.

Ensuring healthy timing and spacing of pregnancies is now considered the most important intervention
affecting reproductive, maternal, neonatal, child and adolescent health

Scope of this Manual

This manual seeks to provide the latest information on Depo MedroxyProgesterone Acetate (MPA)
injectable contraceptive that is safe and effective. This is in alignment with the focus of the government to
establish it as an important component of the basket of choice for spacing methods in the public sector in
India’s National Family Planning Programme. This manual addresses all the managerial, programmatic,
technical and counselling issues related to the injectable contraceptive MPA. It also lays down the training
strategy and curricula to train the service providers for quality service provision in a sensitive manner.

Target Audience
This comprehensive manual is meant to be used all over the country by all stakeholders, including
programme managers at the national, state, district and block levels, trainers and service providers at all
levels (medical doctors, nursing personnel and other paramedical), faculty of medical colleges as well as
clients who want to get acquainted with the program and be aware of their rights and responsibilities.

It can also be used for monitoring and ensuring quality service provision of MPA injectable contraceptive
by outlining the steps and mechanisms for measuring the quality of services provided at public health
facilities.

It will not only help in enhancing the knowledge and skills of service providers in providing quality
services but also empower the programme managers in scaling up the services in their states and districts
whichin turn will help to improve the acceptance and continuation rates leading to client satisfaction.

2 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

SECTION I:
Technical Aspects of
Injectable Contraceptive (MPA)
 Chapter 1

Overview

1.1 Historical Background

Development of a long-acting reversible contraceptive was a goal of family planning researchers for
many years. Long-acting progestins were recognized as the steroids suitable to fulfil this criterion
because they are effective, safe and their side effects are few. Shortly after oral contraceptives were
introduced, it was discovered that when a synthetic form of progesterone is injected
intramuscularly, it is released slowly into the blood stream and provides long lasting hormonal
activity. MPA (Depot MedroxyProgesterone Acetate) is one such synthetic progesterone, developed
in 1954 by the Upjohn Company for treatment of endometriosis and habitual or threatened
abortions. In early 1960s, it was noted that women receiving MPA for premature labour
subsequently had a marked delay in return of fertility. This observation led to the development of
MPA as a fertility-regulating agent. In the mid 1960s, Upjohn got a contraceptive product licence for
marketing MPA as a contraceptive in many countries. Since then MPA has become a popular
contraceptive and has been one of the most extensively researched drugs with an accumulated
research experience of over 3 million women months of use with more than a thousand published
scientific papers and reviews. It is now a widely used contraceptive and is approved for use in more
than 130 countries (WHO: Family Planning: A Global Handbook for Providers).

1.2 Global and National Experiences

1.2.1 Global Experiences

MPA is the fourth most prevalent contraceptive and is widely used as an effective, safe and
acceptable method of contraception across the world. It is estimated that currently, an
estimated 42 million women worldwide use injectables as a method of choice. Some of the
neighbouring countries offer MPA in their government-run family planning programs which
contributes significantly to their contraceptive method mix. MPA use is 31.9% in Indonesia,
28.9% in Bhutan, 14.8% in Sri Lanka, 14% in Thailand, 11.2% in Bangladesh and 9.2% in Nepal
(Population Reference Bureau 2013). Trend estimates suggest that acceptance is increasing
due to the reassuring World Health Organization (WHO) consensus regarding cancer risk,
changes in bone mineral density, metabolic effects, associated HIV risk etc. The 3 monthly
MPA was approved as a contraceptive by US FDA in February 1992.

Experiences from many countries of Asia, Africa and South America have also shown that
MPA can be delivered in non-clinical settings through community-based workers, after
appropriate training on counselling, client selection and screening, safe administration of
injection, follow-up care etc. with comparable rates of acceptability and continuation.

1.2.2 National Experiences

MPA was approved by the Drug Controller General of India (DCGI) in June 1993 for
marketing and use as an injectable contraceptive method. A Post-Marketing Surveillance of
MPA use on 1079 Indian women, to validate the efficacy, safety and acceptability of the drug as
contraceptive was carried out by Upjohn Company from 1994 to 1997, in 10 independent, well

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 5

 reputed private and NGO health centres across the country, co-ordinated by FOGSI. The
results demonstrated that 150 mg MPA injection is a safe and effective contraceptive and that
appropriate counselling on the expected side effects greatly increased the acceptability of the
method.

From 1994 onwards several operational research by Population Council, UNFPA,

EngenderHealth and DKT India were carried out and MPA service delivery in clinical setting
was started by some of the NGOs such as Parivar Sewa Sanstha and FPAI. Subsequently many
private providers under the banner of FOGSI/IMA also began providing MPA services
through their health facilities.

In 1999 the social marketing approach for MPA began by Social Marketing Organizations like
DKT-India, Janani, PHSI and PSI to improve access and availability of MPA. Training of
service providers was also supported which bolstered the confidence of the providers and the
use of MPA increased.

However, the lone efforts of the private sector to offer MPA to women has not been able to
cause any significant change in the overall contraceptive use as number of MPA users still
remain small. NFHS-3 (2005-06) showed acceptance is only 0.1%, which has increased from
0.004% as was in 2003 (PRB survey). One of the reasons for this slow increase has been the high
cost of the commodity and services which can be redressed by offering it free in the public
health system.

1.3 Consensus Statements

1.3.1 WHO Statement on Depot MedroxyProgesterone Acetate (MPA) – (October, 2015)

The purpose of this ‘Statement’ is to reiterate and clarify the existing (current) WHO position
based on published guidance that is still valid. WHO monitors the evidence closely and
updates its guidance as and when new evidence becomes available.

Depot MedroxyProgesterone Acetate (MPA) is a hormonal contraceptive with high

acceptability as it is provided by an injection every three months, which can be given outside
clinical facilities. It is also low cost and highly effective. It is a reversible method and women’s
chances of getting pregnant after stopping its use are no different from those who have not
used MPA.

WHO recommends MPA for-

1) Women aged 18 to 45 years of age; there should be no restrictions on the use of MPA, including
no restrictions on the duration of its use (Medical Eligibility Criteria[MEC] Category 1).
2) Among adolescents (menarche <18 years) and women over 45 years, the advantages of using
MPA generally outweigh the theoretical safety concerns regarding fracture risk (MEC
Category 2).
3) There should be no restriction on the use of MPA among women who are otherwise eligible to
use this method, including on duration of use.
4) There are no restrictions on the use of MPA for women at high risk of HIV (MEC Category 1).
Women and couples at high risk of HIV acquisition should also be informed about and have
access to HIV preventive measures, including male and female condoms irrespective of the

6 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 family planning method they choose.

1.3.2 Statement by Royal College of Gynaecologist (RCOG) London on Progestogen-only

Contraception (MPA) – (July, 2010)

1) Women and their partners should be advised that very long-acting reversible contraception
can be as effective as sterilization.
2) Women should be advised that return of fertility can be delayed for up to 1 year after
discontinuation of progestogen-only injectable contraception.
3) Women can be informed that there is no conclusive evidence of a link between progestogen-
only methods and breast cancer.
4) Progestogen-only methods may help to alleviate dysmenorrhoea.
5) Women should be advised that altered bleeding patterns are common with use of
Progestogen-Only Contraception (POC).
6) Women should be informed that the progestogen-only injectable is associated with a small
loss of BMD, which usually recovers after discontinuation.
7) Women who wish to continue using Depot MedroxyProgesterone Acetate (MPA) should be
reviewed every 2 years to assess the benefits and potential risks.
8) Users of MPA should be supported in their choice of whether or not to continue using MPA up
to a maximum recommended age of 50 years.
9) Women can be advised that although the data are limited, POC does not appear to increase the
risk of stroke or MI and there is little or no increase in venous thromboembolism risk.
10) Caution is required when prescribing MPA to women with cardiovascular risk factors due to
the effects of progestogen on lipids.

1.3.3 FOGSI Policy Statement on Long Acting Injectable Progestogens – (May, 2010)

1) FOGSI recognizes the scientific evidence supporting the use of long acting injectable
progestogens as a safe, effective, reversible long acting method of contraception.
2) Long acting injectable progestogens as a contraceptive method have been used since two
decades and are available worldwide in more than 100 countries.
3) The advantages of long acting injectable progestogens are that they are highly effective, safe,
long acting, easy to administer and easy to use method of contraception, a flexible option
when oestrogen-containing contraceptives are not favoured or medically contraindicated,
with no adverse effects on lactation.
4) For women they provide autonomy and choice with privacy about their use easily maintained
and as a reversible method which can be discontinued without having to seek provider
assistance.
5) Concern regarding menstrual disturbances and osteoporosis can be addressed by counselling
while those involving risk of malignancy have no proven scientific basis.
6) FOGSI believes that long acting injectable progestogens are an important component of the
contraceptive choices which should be available to the women of our country through both the
private and public sector.

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 Note: In line with WHO and RCOG Statements, other international professional bodies like
Australian and New Zealand College of Obstetricians & Gynaecologists (AZCOG); American
College of Obstetricians & Gynaecologists (ACOG) and The Society of Obstetrics & Gynaecologists
of Canada (SOGC) have also endorsed the above statements.

1.4 Injectable Contraceptives

The Injectable Contraceptives contain synthetic hormones resembling the natural female hormones.
When administered (IM/SC) there is a slow release of hormone into the blood stream and it provides
protection from pregnancy for a long duration of time to the client.

1.4.1 Types of Injectable Contraceptives

There are two main types of injectable contraceptives:

1) Progestogen-only Injectables (POI) containing only synthetic progesterone. They are of
two types:
a) Depot MedroxyProgesterone Acetate (MPA) – 3 monthly Injection.
b) Norethisteroneenanthate (NET-EN) – 2 monthly Injection.
2) Combined Injectables Contraceptive (CIC): containing estrogen (usually ethinylestradiol)
and progesterone - 1 monthly injection.

Under the National Family Planning program, MPA injectable contraceptive have been added to the basket of
choice and henceforth MPA will be discussed in this manual.

1.4.2 Routes of MPA Injectable Contraceptive

Depot MedroxyProgesterone Acetate can be given through intramuscular route (MPA-IM) or

subcutaneous route (MPA-SC).

1) Intramuscular MPA: available as

a) Single dose vial with disposable syringe and needle

b) Prefilled syringe with needle

2) Subcutaneous MPA: Prefilled auto disable syringe in Uniject system (squeezing bulb
pushes the fluid through the needle)

Needle Shield

Gap
Port Injector

Reservoir

Fig 1: Subcutaneous Medroxy Progesterone Acetate in Uniject system

8 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 1.4.2.1 Key Features of Uniject Injection System

This Uniject system has a thermoformed plastic laminate reservoir with ultra-thin
needle attached by a polyethylene port. It is designed for single use and immediate
disposal as it has a one-way valve and collapsible reservoir that cannot be re-filled.

1.4.2.2 Advantages of Uniject Injection System

• It is easy to use because it is prefilled and very easy to inject as squeezing the bulb
pushes fluid into the needle.
• It is non-reusable, hence one to one transmission of blood borne pathogens
through needle reuse is eliminated.
• It provides logistical benefits because Uniject is compact and smaller than a
syringe and vial, it is easier to transport and store. A study commissioned by PATH
found that MPA-SC in Uniject is 62 percent lighter and 25 percent less voluminous
than MPA-IM packed with vial and syringe.
• The formulation for subcutaneous injection provides slower and more sustained
absorption of the progestin than intramuscular MPA. This enables a 30 percent
lower dose of progestin (104 versus 150 mg) and reduces peak blood levels by half,
but with the same duration of effect as intramuscular MPA.

A waste management assessment showed that SC- MPA in Uniject generates 70

percent less waste by volume than the standard auto-disable syringe with an
empty MPA vial.

1.4.3 Comparing MPA Subcutaneous with MPA Intramuscular

Features MPA-SC MPA-IM

Packaging Available in single dose Available in single dose vials
prefilled auto disabled
injection device (Uniject)

Dosage Single dose contains 104 mg / Single dose contains 150 mg /

0.65 ml of Medroxy ml of Medroxy Progesterone
Progesterone Acetate, to be Acetate, to be administered
administered every 3 months. every 3 months.
Site of Administered subcutaneously Administered intramuscularly
Administration in outer anterior portion of in upper arm, hip or outer
thigh, abdomen or upper side of thigh.
outer portion of arm.

Mode of 1. Pierces the epidermal and 1. Given deep intra muscular

Administration dermal layers of the skin 2. Longer needle
and delivers drug in loose 3. Ease of administration-less
subcutaneous tissue. surface area and particular
2. Short needle landmarks needed to locate
3. Ease of administration- specific muscle.
more surface area available
& fewer landmarks needed
for SC injection.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 9

 Chapter 2

Medroxy Progesterone Acetate (MPA)

2.1 Composition
Injectable Contraceptive (MPA) is an aqueous suspension of microcrystal for depo injection of
pregnane 17 alfa – hydroxyprogesterone – derivative progestine medroxyprogesterone acetate.
MPA is a Progestogen-only Injectable (POI) given deep intra-muscular every three months

• Intramuscular one dose = one vial of 150 mg per 100 ml, aqueous suspension of MPA
• Subcutaneous one dose =104 mg per 0.65 ml suspension of MPA

Fig. 2 Injectable Contraceptive MPA (Antara) in the National Family Planning Program

2.1.1 Mechanism of Action of MPA

MPA acts in the following way:

• Inhibiting ovulation - by suppressing mid cycle peaks of LH and FSH
• Thickening of cervical mucus - due to depletion of oestrogen. The thick mucus prevents sperm
penetration into the upper reproductive tract.
• Thinning of endometrial lining - due to high progesterone and depleted oestrogen, making it
unfavourable for implantation of fertilized ovum.

2.2 Safety and Effectiveness

2.2.1 Safety

MPA is a safe contraceptive. Like other progestogen-only contraceptives women who want a
highly effective contraceptive can use it, including women who are breastfeeding or who are
not eligible to use estrogen-containing combined oral contraceptives. Studies by WHO on
over 3 million woman months of MPA use give reassurance that MPA presents no overall risks
for cancer, congenital malformation or infertility. Also extensive research has found that MPA
use:

• Exerts a strong protective effect against endometrial cancer, no overall increased risk of breast,
ovarian & cervical cancer similar to oral contraceptives.
• Has not been found to affect the risk of developing liver cancer in areas where hepatitis B is
endemic.
• Does not cause any significant changes in blood pressure or on the coagulation of the
fibrinolytic system affecting thrombosis.

10 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 • Keeps the fertility intact although it takes a woman few months (4 to 6) longer to become
pregnant after discontinuing MPA than after discontinuing COCs, IUDs or barrier methods.

Studies have found no differences in the health, growth, sexual development, aggression,
physical activity or sex role identity of teenage children exposed in utero to MPA as compared
with no in- utero exposure.

2.2.2 Effectiveness

It is a highly effective contraceptive method. With a standard regimen the first year
effectiveness is 99.7% when the drug is used correctly; however the effectiveness decreases in
typical use. The perfect use failure rate of 0.3% is lower in comparison to 0.5% of female
sterilization, 0.8% of IUCD and 0.3% of combined oral contraceptives (WHO: Family
Planning: A Global Handbook for Providers).
Effectiveness depends on timing of first injection, taking injections regularly on time, the
injection technique and post injection care.

2.3 Benefits – Contraceptive & Non-Contraceptive

2.3.1 Contraceptive Benefits

• Safe, highly effective with long term contraceptive benefits.

• Convenient and easy to use (does not require daily routine or additional supplies).
• Acts for 3 months with a grace period of 4 weeks.
• Completely reversible: 7-10 months from date of last injection (average 4-6 months after 3
months effectivity of last injection is over).
• A private and confidential method.
• Does not interfere with sexual intercourse/pleasure.
• Pelvic examination not required prior to use.
• Suitable for women who are not eligible to use an oestrogen containing contraceptive.
• Suitable for breast feeding women (after 6 weeks postpartum) as it does not affect quantity,
quality and composition of breast milk.
• Provides immediate postpartum (in non-breastfeeding women) and post-abortion
contraception.
• May be used by women at any age or parity if they are at risk of pregnancy.

2.3.2 Non-contraceptive Benefits

• May decrease menstrual cramps and reducepre-menstrual syndrome/tension.

• Improves anaemia by reducing menstrual blood loss due to menstrual changes such as
amenorrhea.
• Reduces the symptoms of endometriosis.
• Decreases benign breast disease and ovarian cyst.
• Helps prevent uterine tumours (fibroids).
• Reduces the incidence of symptomatic pelvic inflammatory disease (PID).
• Protect against endometrial cancer and possibly ovarian cancer.
• Reduces sickle-cell crises in women with sickle cell anaemia.
• Protects against ectopic pregnancy (since ovulation does not occur).

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 • Minimal drug interactions – no demonstrable interaction has been found between M PA a n d
antibiotics/enzyme-inducing drugs.

2.4 Limitations
MPA is an appropriate long acting contraceptive method suitable in majority of the women, however
it has some limitations like
• It does not protect against STI/RTI and HIV infection.
• Once taken its action cannot be stopped immediately.
• It causes changes in the menstrual cycle and bleeding due to its inevitable effect on a woman’s
body hormones.
• It has to be repeated every three months to achieve desired contraceptive effectiveness.
• Return of fertility takes 7-10 months from date of last injection (Average 4-6 months after 3 months
effectivity of last injection is over).
• Cannot be given in few medical conditions/diseases.

2.5 Return to Fertility

MPA may cause a delay in the return of fertility. Since one injection is effective for 3-4 months, the
return of fertility takes 7-10 months from date of last injection (average 4-6 months after 3 months
effectivity of last injection is over).
Studies have also shown that ovulation/fertility return is not affected by duration of MPA use or
women’s age.

2.6 Initiation
2.6.1 When to Start MPA Injection
A MPA injection can be started any time if it is reasonably certain that the woman is not
pregnant (Annexure 1).
A physical examination is always an important part of good reproductive health care but
recent scientific studies have shown it is not required for the provision of MPA.
The following table highlights different situations of women, when one can start the first dose
of MPA injection as an effective contraceptive method.

Woman’s situation When to start

Having menstrual • Can be started any day within 7 days of menstrual cycle with no
cycles or switching need for a backup method.
from a non hormonal • Can also be started any time later in the menstrual cycle (after 7
method days) if it is reasonably certain that the woman is not pregnant (no
history of unprotected sex since LMP). She will need a backup
method (e.g. condom) for the first 7 days after the injection.
• Can be started immediately, if she is switching from an IUCD.
• If starting after 7 days of menstrual cycle, she will need a backup
method (e.g. Condom) for next 7 days.
Switching from a • Can be started immediately, if she has been using the hormonal
hormonal method method consistently and correctly or if it is reasonably certain that
the woman is not pregnant. No need to wait for her next monthly
bleeding. No need for a backup method.

12 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 Woman’s situation When to start
Post-Partum Women breastfeeding
Less than 6 months • Wait until 6 weeks postpartum and then start MPA.
postpartum • Can be started any time between 6 weeks and 6 months, if she is
fully or nearly fully breastfeeding and her monthly bleeding has
not returned. No need for a backup method.
• Can be started at any time between 6 weeks and 6 months, if she is
partially breastfeeding and her monthly bleeding has not
returned and if it is reasonably certain that the woman is not
pregnant. She will need a backup method (e.g. Condom) for the
first 7 days after MPA injection.
• If her monthly bleeding has returned, she can start injectable as
advised for women having menstrual cycles.
More than 6 months • Can be started at any time, if her monthly bleeding has not
postpartum returned and if it is reasonably certain that the woman is not
pregnant. She will need a backup method (e.g. Condom) for the
first 7 days after MPA injection.
• If her monthly bleeding has returned, she can start injectable as
advised for women having menstrual cycles.
Post-Partum Women not breastfeeding
Less than 4 weeks • Can be started at any time. No need for a backup method.
after giving birth
More than 4 weeks • Can be started any time, if her monthly bleeding has not returned
after giving birth and if it is reasonably certain that the woman is not pregnant. She
will need a backup (e.g. Condom) method for the first 7 days after
the injection.
• If her monthly bleeding has returned, she can start injectable as
advised for women having menstrual cycles.
Other situations
No monthly bleeding • Can be started any time if it is reasonably certain that the woman
(not related to is not pregnant. She will need a backup method (e.g. Condom) for
childbirth the first 7 days after the injection.
or breastfeeding)
After miscarriage or • Can be started immediately after abortion or within 7 days of first
abortion or second-trimester miscarriage/abortion, with no need for a
backup method.
• Can also be started after more than 7 days of first or second
trimester miscarriage/abortion, any time, if it is reasonably certain
that the woman is not pregnant. She will need a backup method
(e.g. Condom) for the first 7 days after the injection.
After taking • Can be started on the same day as the ECPs.
Emergency • Can also be started within 7 days of monthly bleeding, a backup
Contraceptive Pills method (e.g. Condom) will be required for next 7 days. She
(ECPs) should be asked to return, if she has signs or symptoms of
pregnancy other than amenorrhoea.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 13

 2.6.2 Switching from MPA- SC to MPA- IM or Vice Versa
As the active ingredient in the IM and SC is identical, it is safe to switch back and forth between
IM and SC every three months with the same level of contraceptive protection. This switching
is safe and it does not decrease effectiveness, though switching should not be a routine
practice. If switching is necessary, the injection of the alternate mode should be administered
on the due date and duly recorded. Clients need to be explained and told about changed mode
of administration i.e. SC to IM or vice versa and the scheduled date for next injection.
Note: MPA-SC should not be used for IM administration and similarly MPA-IM should not be
used for MPA-SC administration.

14 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 Chapter 3

Counselling

3.1 Counselling
Counselling is defined as a facilitation process where a person (skilled service provider) explicitly
and purposefully gives his/her time, attention and skills to assist a client to explore their situation,
identify and act upon solutions within the limitations of their given environment. Counselling is a
very essential component of Family Planning Services and is a client centered approach that involves
communication between a service provider/counsellor and a client. Counselling enables the service
provider to understand clients’ perceptions, attitudes, values, beliefs, family planning needs and
preferences and accordingly can guide him/her towards decision making. The provider/counsellor
should be non-judgmental. Privacy (auditory and visual) and confidentiality should be maintained
during the process of counselling. Women/couples may have limited information about MPA which
is further compounded by misconceptions and concerns. These should be dispelled by providing
correct information to women, so that they are able to make an informed choice for MPA and
continue using it till they desire.

3.1.1 Benefits of Family Planning Counselling

• Increases acceptance
• Enhances continuation of methods
• Dispels myths/rumours and corrects misunderstandings about contraceptive methods
• Promotes effective use
• Increases client satisfaction

3.1.2 Decision-Making

Counselling helps the client to make voluntary decisions regarding:

• Whether to use contraception to delay, space or limit childbearing.
• Which method to use.
• Whether to continue using the method if side effects occur.
• Whether to switch methods when the current method is unsatisfactory.
• Whether to involve one’s partner(s) in reaching a decision.

3.1.3 Principles of FP Counselling

• Privacy.
• Confidentiality.
• Respectful, non-judgmental, accepting, and caring attitude.
• Simple culturally appropriate language easy for client to understand.
• Good verbal and non-verbal interpersonal communication skills.
• Brief, simple and specific information with key messages.
• Opportunity for client to ask questions and express any concerns.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 15

 • Effective use of audio-visual aids, anatomic models and contraceptive samples.
• Repeat key information shared by the client, show and confirm that you have understood
correctly what they are saying.
• Voluntary Informed Decision making by client.

3.2 Stages of Family Planning Counselling

3.2.1 Stage I: General - Counselling

During this stage, the provider creates the conditions that help a client select a family planning
method.
• Establish and maintain a warm, cordial relationship and listen to the client’ contraceptive
needs.
• Rule out pregnancy using the Pregnancy Checklist. (Annexure 1)
• Display all the methods using flip charts, actual methods, photographs, illustrations or
posters. Arrange by method type: Spacing (temporary/reversible methods) methods,
Limiting (permanent) methods.
• Set aside methods that are not appropriate for the client. It helps to avoid expanding on
methods that are not relevant to the client’s needs.
• Give information about the methods that have not been set aside, including their effectiveness.
• Ask the client to choose the method that is most convenient for her/him.
• Determine client’s medical eligibility for the chosen method.
• Give the client complete information about the method that is chosen. If client choose MPA
explain the information about the method as given in section 3.2.2.
• Check the client understands and reinforce key information.
• Make sure the client has made a definite decision.
• Encourage the client to involve her/his partner(s) in decisions about contraception either
through discussion or a visit to the facility.
• Assess STI/HIV risk, if the client has STI symptoms, refer or treat her/him syndromically (if
needed HIV counselling). Discuss triple protection. Offer condoms and instruct the client in
correct and consistent use.
Healthy Timing and Spacing of Pregnancy (HTSP) is important for the health of the mother
and baby. Following are the recommendations to a woman considering using a family
planning method of choice before trying to become pregnant again:
• Wait at least 24 months after child birth.
• Wait at least 6 months after miscarriage or abortion.
• Wait until the age of 18 years.

3.2.2 Stage II: Method Specific Counselling on MPA

The following information should be given so that the woman can make an informed decision
for MPA voluntarily.
• It is a three monthly injection hence injections need to be repeated every three months.
• It is best to take next injection on time, though it can be taken two weeks before or four weeks
after scheduled date.

16 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 • It is a safe and an effective method.
• It does not affect breast milk hence can be used safely by breastfeeding mothers.
• It causes menstrual changes like irregular/prolonged bleeding and amenorrhea which are
harmless and occur due to the effect of the method.
• Other minor effects may include change in weight, mood swings, headache and decrease in
bone mass.
• It is a reversible method but there is a delay in return to fertility and it takes 7-10 months from
date of last injection (average 4-6 months after 3 months effectivity of last injection is over).
When the woman wants to conceive, she should discuss it with her provider and discontinue
taking the method well in advance.
• It does not protect from HIV/STIs. Discuss that condoms need to be used if she needs
protection from them.

3.2.2.1 Counselling about Side Effects

During counselling special emphasis is needed for explaining the reason of menstrual
changes and other side effects that might occur. This understanding helps women to opt for
the method without getting worried about the side effects and also to cope with them when
they occur.
• Many women tend to worry about amenorrhoea as they do not even know process of
menstruation and many think it is the dirty blood that comes out of the body. Their
concerns/myths related to these changes are addressed in the section 3.3 at point no. 3.

• Women need to be told that absence of period occurs because that is the way the method
works and is not harmful. Reassure that periods resume after discontinuing MPA.

Explain the Process of Menstruation

Using simple language and examples explain:

“Every month a woman’s body prepares for conception. An ovum is released and the uterus
also prepares to nurture the baby. So its inner lining becomes thick and soft as it gets more
blood supply. If she does not conceive that month, this inner lining of blood is thrown out of
her body as menstrual flow. This is repeated every month, causing menstrual cycles.”

Explain Why Menstrual Changes Occur

With MPA, the monthly preparation for pregnancy in woman’s body does not occur. There is
no release of ovum and thickening of inner lining of uterus.
The menstrual cycle gradually comes to a stop after irregular bleeding for some time.
When the woman stops using it, body starts preparing for conception and menstrual cycle is
resumed.
Women can be explained that if they do not want to become pregnant, there is no
significance of menstruation.

3.2.2.2 Immediate Post Injection Counselling

Right after MPA injection is given to a woman, it is important to advise her.

• Not to massage or apply hot fomentation to the injection site as it may hasten the absorption
of MPA, due to which its effect may go away before 3 months.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 17

 • The injection needs to be repeated every 3 months so she should try to come for the next dose
on the date mentioned on the MPA client card. Tell her that in case she is unable to come on
the specified date due to some reason, she should still come for the injection, as it can be
given a few days earlier or later.
• Explain that menstrual changes are common with the method so she should not get unduly
alarmed if they occur.
• Tell her she can return any time, especially if she has concerns or problems.

3.2.3 Stage III: Follow-Up Counselling

During all repeat visits, follow-up counselling of the client is very important to ensure client
satisfaction and continuation of the accepted method. Every time the client comes to the health
facility, she should be counselled.

• Ask her experience and satisfaction with the method.

• Discuss if she has any side effects. If yes, ask how she feels about them.
• Ask if she has any questions/concerns about the method (Refer Section 3.3 and Annexure 4,5).
• Reassured about the side effects and her concerns/questions should be answered
appropriately.
• If she wants to continue the method and the next injection is due, give/help her to get it.
• In case the woman does not want to continue with the method, help her to choose another
method.

3.3 Myths and Misconceptions on MPA (Also refer to Annexure 4,5)

S. No Myth/Concern What to tell

1. Will irregular bleeding mean No, irregular bleeding with MPA use occurs due to the way
something harmful has the method works. It is not a sign of illness and it is harmless.
happened to me because of Irregular bleeding occurs only in the first few months of
using MPA? injection use because amenorrhea sets in after that.
2. Will stoppage of period mean MPA is a very effective method if taken on time every three
method has failed causing months. Therefore a chance of a pregnancy is very low.
pregnancy? Period stops because that is the way the method works.
3. Will stoppage of monthly No, blood coming out of the body every month as period is
bleeding lead to collection of normal blood and is not dirty. Monthly bleeding occurs
dirty blood in my body? because every month the inner lining of uterus becomes
thick and soft with increased blood supply in preparation of
pregnancy and this blood is flushed out of her body if she
does not conceive that month. A foetus is nurtured with this
blood, in case pregnancy occurs, so how can it be dirty?
With MPA, monthly bleeding stops because the bodily
preparation for conception comes to a halt.
When the woman discontinues using MPA, body again
starts preparing for conception and monthly bleeding
(period) is resumed.

18 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 S. No Myth/Concern Myth/Concern
4. Will stoppage of period No, there is no connection between a woman’s eye sight and
weaken my eye sight? period.
5. Will stoppage of period mean No, MPA does not cause menopause. It only temporarily
untimely menopause? stops period from occurring every month and once MPA use
is discontinued, period resume after few months.
6. Will stoppage of period lead No, MPA does not cause infertility. After discontinuing
to infertility? MPA, a woman can become pregnant if she wants to.
Pregnancy usually occurs 7-10 months from date of last
injection (Average 4-6 months after 3 months effectivity of
last injection is over).

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 19

 Chapter 4

Eligibility Criteria and Client’s Assessment

All women can use MPA safely except in certain physiological or medical conditions. Therefore,
assessment as per Medical Eligibility Criteria (MEC) is important.

4.1 Eligibility Criteria

MPA is safe for all women including who:
• Are of any age, including adolescents and women over 45 years old.
• Have or have not had children.
• Are unmarried.
• Have just had an abortion or miscarriage.
• Are smoker, regardless of age.
• Are breastfeeding (starting 6 weeks after child birth).
• Are at risk of STI/ HIV infection.
• Are infected with HIV, whether or not on antiretroviral therapy.

Women can begin MPA injection:

• Without a pelvic examination.
• Without any blood tests or other routine laboratory tests.
• Without cervical cancer screening.
• Without a breast examination.
• Even when she is not having monthly bleeding at the time of injection, if it is reasonablycertain
that the woman is not pregnant

There are only few medical and physiological conditions in which MPA is not recommended for the
woman e.g. breastfeeding woman less than six weeks postpartum, blood pressure 160/100 mm Hg or
more, unexplained vaginal bleeding etc.(Category IV as per WHO MEC).

Once a woman chooses MPA, it is important for the provider to ascertain if the method can be given
to her or not (Annexure1, 2).

4.2 Clinical Assessment and Screening of Clients

MPA can be administered by health care providers to clients who
were counselled about contraceptive options and have made an
informed & voluntary decision for its use. This can be done by
using a screening checklist, based on the contraceptive wheel of
GoI 2015 adapted from WHO MEC 2015 (Fig. 2, Annexure 2).

With the checklist, a few questions are asked and based on the
answers, it becomes clear whether MPA can be given to that
woman or not.

Fig. 3 WHO MEC Wheel

20 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 4.2.1 Demographic Information -The information required are: Client’s name, husband's name,
address and phone/mobile number, age, marital status, occupation, religion, educational
status, number of living children and age of youngest child. Contact telephone number of
ASHA/ANM (if available)

4.2.2 History

• Menstrual - date of Last Menstrual Period (LMP), menstrual cycle details including length of
cycle, duration and amount of flow, any dysmenorrhoea, regularity of periods, any
intermenstrual bleeding.
• Obstetric - number of pregnancies and living children and mode of delivery, date of last
childbirth, number and date of abortion/MTP, current pregnancy status.
• Breast feeding - full, partial or not at all.
• Contraceptive - when and what was the last contraceptive used. If discontinued, when and
why.
• Medical-
  History of illness and other medical conditions in the past or at present as mentioned under
the screening checklist as adapted from WHO MEC 2015 (Annexure 2). Rule out any febrile
illness or diabetes.
  Known allergies especially to progesterone or to constituents of injection.
  Current medications and reasons thereof.

4.2. 3 Physical Examination

Although a detailed examination is seldom necessary, it is a good practice to perform general

physical examination, abdominal, pelvis and any other examination as indicated by the
client's history.

• General Physical Examination: includes general condition, pulse, blood pressure,

respiratory rate, temperature, body weight, pallor, nutritional status etc.

• A Routine Abdominal Examination should be done.

• Pelvic Examination: It is not mandatory but the opportunity may be used to rule out STIs/RTIs or
other pelvic diseases.

4.2.4. Investigations

There is no necessity for laboratory investigations routinely. In cases where the possibility of
pregnancy is difficult to rule out, a pregnancy test should be done. If pregnancy testing is not
available, counsel the client to use a barrier method until her next menses to prevent
pregnancy and plan to start the injection from the next menstrual cycle.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 21

 Chapter 5

Administering the Injection

5.1 Storage of MPA Vials

MPA injection vials are to be stored preferably at room temperature between 150 to 300 Celsius in a
dry, dust free place and not exposed to extreme heat and cold.

Do not keep the injection vials in the refrigerator/freezer; instead keep outside in a cupboard away
from direct sunlight in a dry place.

5.2 Site of Injection

The injection site for MPA - IM is the upper arm (deltoid muscle), the buttocks (gluteal muscle, upper
outer portion) or thigh (outer anterior) (Fig. 4).The preferred, easily accessible and acceptable site is
deltoid muscle.

Deltoid Region Gluteal Region Outer side of thigh

Fig. 4 : Site of administration of MPA - IM

The injection site for MPA - SC is subcutaneous fat of abdomen (Below Umblicus), anterior outer part
of thigh or upper and outer part of arm. Avoid bony areas and the umbilicus. (Fig. 5)

The preferred, easily accessible and acceptable site should be taken into consideration before
administration of injection. Change the injection site with each injection. The area of skin must be
free from scars and skin conditions such as eczema or psoriasis.

A. Abdomen
(below umbilicus) C. Upper and
Outer part of arm
B. Anterior outer
part of thigh

Fig 5: Sites of administration of MPA- SC

5.3 Administration
5.3.1 MPA - IM

5.3.1.1 Pre-Injection Preparation

• Ensure client is properly counselled and has chosen MPA.
• Check vial for expiry date.
• Shake the vial well. If the vial is cold, warm to body temperature by rubbing

22 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 between palms before giving injection. Ensure that all the microcrystals are
dissolved completely in the fluid of the vial.
• Wash hands with soap and water.
• Withdraw full quantity of solution from the vial into the disposable syringe with
needle, taking care not to push any outside air into the vial.
• Clean the skin at the site of the injection with an antiseptic, removing any visible dirt
or soil. Allow the antiseptic to dry before administering the injection.
5.3.1.2 Administering the Dose/ Injection
• Insert sterile needle deep into the chosen site for injection i.e. the upper arm (deltoid
muscle), the buttocks (gluteal muscle, upper outer portion) or thigh (outer
anterior).
• Aspirate first to ensure that the needle is not in a vein.
• Inject the contents of the syringe fully.

5.3.2 MPA-SC

5.3.2.1 Pre-Injection Preparation

• Ensure client is counselled and expiry date of unject has been checked.
• Use an antiseptic swab to wipe the skin in the injection area, chosen by the client.
• Allow the skin to dry.

5.3.2.1.1 Preparing the Injector

When provider is ready to administer the injection, carefully tear open the
foil pouch and remove the injector. Do not remove the needle shield at this
stage.

Check the injector as follows

• The needle shield should be in the position shown in the diagram below
(Fig 5).
• There should be a gap between the needle shield and the port.
• If there is no gap discard the injector and use a new one.
• If the needle shield has come off the needle or is missing altogether,
discard the injector and use a new one.

Reservoir

Port

Gap Injector

Needle Shield

Fig 6: Diagrammatic representation of parts of Uniject

5.3.2.1.2 Mixing MPA-SC in Reservoir

• Hold the injector firmly by the port.
• Shake the injector vigorously for 30 seconds to mix
the medicine thoroughly.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 23

 • If there is any delay between mixing the medicine
and proceeding through the next step, repeat the
mixing procedure as above.

• Check the injector. The liquid contents should

appear white to off white and uniform. There
should be no leakage from any part.

• If any problem is observed discard the injector and use a new one.

5.3.2.1.3 Activating the Injector

• Hold the injector firmly by the port with one

hand.Take care not to squeeze the reservoir.

• Hold the needle shield with other hand. Gap will

be visible between the port and the end of the
needle shield.

• Push the needle shield towards the port. Continue

to push firmly until gap is closed between needle
shield and the port.The injector is now activated.

• Continue to hold the injector firmly by the port.

• Pull the needle shield away to remove it from

needle and discard.

5.3.2.2 Administering/Injecting the Dose

• Gently grasp and squeeze a large area of skin in the chosen

area between thumb and fore finger, pulling it away from
body.

• Hold the injector by port. Keep it as upright as possible with

needle pointing downwards.

• Insert the needle into the skin so that the needle tip is in the
subcutaneous tissue and the port just touches the skin.

• Hold the reservoir firmly between the thumb and the

forefinger. Squeeze the reservoir slowly to inject the
medicine. It should take 5-7 seconds.

• After the dose has been completely injected and the reservoir
has collapsed, gently pull the needle out of the skin.

• It is important that the full dose of medicine is given,

however small traces of white liquid may remain visibile
inside the edge. This is normal.

5.4 Post Injection Care:

• Do not massage the injection site; just leave the site as it is. If there is little oozing just apply gentle
pressure for few seconds.

• Ask the client to remain within facility for 5-10 minutes after receiving the injection.

24 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 • Check whether any medicine has leaked out of the injector or has appeared on the skin.

• If complete dose has not been administered then additional dose should not be given. Advise
client to use back up contraceptive method.

• Do not replace the needle shield after use.

• Use a clean cotton swab to press lightly on the injection area for a few seconds. Do not rub or
massage the injection site.

• Follow safe practice for disposal of used injector and needles. The MPA-SC Uniject syringe, after
use, should be placed in the container/box for disposal of sharps. The injector is for a single
injecion only. It should be never reused.

5.5 Post Injection Instructions

• Instruct client that she must come after 90 days for a repeat injection and give her the scheduled
date. Hand over the MPA Client Card to her after explaining its content to her.

• Inform the client that the effect of injection is immediate if given between 'day one' to 'day seven'
of her menstrual cycle or abortion. But if given after 'day seven' a backup contraceptive method
(e.g. condom) should be used for 7 days.

• Assure the client that she is welcome to come back any time, if she has any problem, wants
another method, has a major menstrual change, has a major change in health status or thinks
might be pregnant.

• Ensure post injection counselling.

Do not massage the injection site and do not apply hot fomentation after injection

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 25

 Chapter 6

Follow Up Care

Follow up of client is an important step for quality services and help clients to continue using the method
till they want protection from unwanted pregnancy. It is seen that MPA clients usually tend to discontinue
the method after a few injections as they get concerned with the side effects or may forget to come for repeat
injections. This leads to high dropouts, particularly after the first injection. Clients need a lot of reassurance
and reminders for continuing the method.

Clients can be supported for continuing use of the method by:

1. Mechanisms for continuity of care.

2. Effective follow-up of the client including management of side effects.

6.1 Mechanisms for Continuity of Care

• Discuss the importance of follow up visits with the client. Inform the client the date for next
injection and give MPA client card to her after explaining about its contents, with due date
mentioned on it.

• It is a good practice to note down client’s phone number in the register, if she agrees to share it.
Telephonic follow up can provide both reassurance and reminders for the next dose.

• Community Health Workers like ASHAs and ANMs can visit the client periodically and allay her
anxieties and concerns. This can minimize the number of dis-satisfied clients thus helping them
continue the method.

• Strictly maintain confidentiality of the acceptors/beneficiaries during every visit.

6.2 Effective Follow-Up of Client

Clients need repeat injections every three months. A few clients may come late for the repeat
injection and some may stop coming altogether; hence providers need to follow them up accordingly
to minimize the problems of method discontinuation.

6.2.1 Follow up of Clients (Coming on scheduled date for next injection i.e after 3 months).

Time of visit Action to be taken Points for reinforcement

At 3 months after last • Give MPA injection • Encourage her to come on time for
injection on the • No back up required next injection as per the date given on
scheduled date the MPA client card.
• Discuss if she is having any side
effects and counsel accordingly.

6.2.2 Follow Up of Defaulters

A defaulter is a client who does not return for the next injection on the scheduled date
(scheduled date is every 3 months/13 weeks) but comes for it within the grace period (grace
period is 2 weeks earlier and upto 4 weeks later from the scheduled date).

26 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 Time of visit Action to be taken Points for reinforcement
2 weeks earlier or up • Give MPA injection • Counsel her on the importance of
to 4 weeks later from • No back up required coming on time for next injection, as
the scheduled date per the date given on the MPA client
(within grace period) card. (If she has come two weeks
earlier then the follow up date will be
calculated two weeks earlier from the
next follow up date and four weeks
later if she comes four weeks late).
• Discuss if she is having any side
effect and counsel accordingly.

6.2.3 Follow Up of Drop Outs

A dropout is a MPA client who comes for the next injection after the grace period of 4 weeks is
over and more than 4 months have passed since she took her last injection.

Time of visit Action to be taken Points for reinforcement

More than 4 months • Rule out pregnancy • Ask reason for coming late.
from the date of last • If not pregnant, give • If returning within 4 months is a
injection. MPA Injection problem for the client, discuss other
• Advise back up contraceptive methods of FP.
method (e.g.
Condom) for next 7
days

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 27

 Chapter 7

Management of Side Effects

7.1 Introduction
The client satisfaction on continuing use of MPA depends on the ability of service providers to
counsel the client on the nature of side effects.

When side effects occur they are usually weeks or months following the injection of DPMA. Many
women stop using MPA due to fear and misunderstanding about side effects. To help clients
continue using MPA, it is important to counsel and manage the associated side effects, especially
menstrual changes.

There are no serious side effects of MPA, however a few women may experience some menstrual
irregularities in the form of irregular bleeding, prolonged bleeding or amenorrhea. Counselling
should resolve concerns of the women; however, if provider feels that the changes are of a serious
nature, client should be referred to a higher centre.

Approximately 50 percent of women will have amenorrhea after one year of use and over 70 percent
will report amenorrhea with longer duration of use .

7.2 Guidelines for Management of Side Effects

Based on WHO guidelines effective management of side effects can be done in the following way.
(WHO: Family Planning; A Global Handbook for Providers)

7.2.1 Menstrual Changes

• Counselling and reassurance during follow up visits is crucial to allay client’s anxiety.
• Assess the bleeding changes and rule out other gynaecological causes.
• Manage menstrual bleeding changes as described below.
• If next injection is due, give it and if client does not want to continue the method, discontinue
and help her choose another method.

7.2.1.1 Irregular Bleeding

• Reassure client that this is common, not harmful and usually settles with time.
• For modest short term relief give NSAIDs such as-
 Ibuprofen 400 mg 3 times a day for 5 days
or
 Mefenamic acid/Tranexamic Acid 500 mg 3 times a day for 5 day.

7.2.1.2 Prolonged/Heavy Bleeding (Bleeding longer than 8 days or twice than usual)

• Reassure the client.

• Give NSAID/Mefenamic/Tranexamic acid 500 mg 3 times a day for 5 days.
• If there is no response with NSAID, give 50 mcg of EthinylEstradiol daily for 21 days or
refer for further management.
• In addition, give iron tablets and suggest foods high in iron to prevent anaemia.

28 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 • If bleeding becomes a health threat or if the woman wants, help her choose another
method.

7.2.1.3 Amenorrhea
After assessing amenorrhoea and ruling out pregnancy, reassure the client that:
• Absence of period is common and not harmful.
• No medical treatment is necessary and there is no need to induce withdrawal
bleeding.
• There is no need to menstruate every month.
• It is similar to not having monthly bleeding during pregnancy/lactation.
• Blood is not building up inside her.
• Stoppage of period does not mean woman has become infertile.
• If amenorrhea is still unacceptable, discontinue the method and help her choose
another method.
• Menstruation is resumed after discontinuation of MPA.

7.2.2 Other Side Effects

7.2.2.1 Weight Gain

• Counsel the client that in some women, its use can lead to slight weight gain (1-2 kg
in one year). This is not significant.
• If the client has gained more than 1-2 kg weight, it could be due to other reasons like
diet and lack of physical activity. Review diet and counsel accordingly.

7.2.2.2 Headache

7.2.2.2.1 Non Migrainous Headache

• Reassure and suggest pain relievers like Ibuprofen, Paracetamol. Evaluate
headaches that worsened after starting injectable.

7.2.2.2.2 Migrainous Headache

• If without aura, method can be continued.
• If with aura, discontinue the method. Help her choose another method
without oestrogen hormone.

7.2.2.3 Changes in Mood or Sex drive

• Ask about changes in life that could affect mood or sex drive, including relationship
changes.

• Give support as appropriate.

• For severe mood changes, refer for care to higher center.

7.3 Problems not Related to MPA

Women may report problems which are not due to the method. However, these problems also
deserve the provider’s attention because they affect women’s satisfaction and use of injectable
contraceptive. If the client reports any problem with use of MPA, listen to her concerns, give her
appropriate advice/treatment. If problems continue or the client wishes, help her choose another
method.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 29

 Chapter 8

Special Issues on MPA

8.1 MPA & Bone Effects

Bone Mineral Density (BMD) refers to the amount of mineral matter per volume of bones and
directly correlates with the bone strength. Bone mineral density is influenced by many factors such
as gender, age, race, body mass index, hereditary factors, physical stress on bones related to physical
activity and weightbearing, nutritional factors such as dietary calcium and vitamin D, alcohol
consumption, smoking, corticosteroid exposure, sex hormones and physiological conditions such
as pregnancy, breastfeeding and menopause. There is a decrease in bone mineral density of 2-8 %
during pregnancy and 3-5 % during breastfeeding.

With use of MPA injectable contraceptive, bone mineral density decreases by 5-6% in 5 years, with
most loss happening in first 2 years. This is believed to be associated with MPA’s interference with
the production of the hormone estradiol, which is involved in bone mineral density development.
The use of MPA is associated with temporary decrease in bone mineral density (BMD), which is
reversible on discontinuation of MPA . There is no increase in fractures. Routine bone mineral
density monitoring is not recommended in any population using MPA.

8.1.1 MPA in Adolescents

Concerns are raised about the effects of MPA on later sexual development and reproductive
function. Adolescence (12-18) is a crucial period of skeletal development and sex hormones
play a key role in bone mass accrual. There is up to 50% increase in total body bone mass
between the ages of 12 and 18 years. Adolescent MPA users will show a slower increase in Bone
Mineral Density (BMD) values when used over 2 years period compared to non-hormonal
users. However, complete recovery of BMD was observed with follow up within 3-5 years and
there is no effect on subsequent fertility .

Sexually active adolescents have potentially high fertility rates and unwanted pregnancy/
abortion which has substantial medical, social and psychological impact. An effective and
easy to use contraceptive can help them in averting unwanted pregnancy. Therefore, WHO
recommends that MPA can be used safely in adolescence.

8.2 MPA in Women > 35 Years of Age

A natural decline in fertility occurs from mid-30s in women, however, an effective contraception is
required to prevent unintended pregnancies. At this age there is an increase in the risks of
chromosomal abnormalities, miscarriage and pregnancy related complications including maternal
morbidity and mortality during child birth. Special considerations in this age group include the
frequency of menstrual irregularity, sexual problems and the possibility of menopausal symptoms
including risk of cancers in reproductive organs, all of which may respond to MPA use.

In large trials, no substantial increase in the overall incidence of Venous Thrombo Embolism (VTE),
myocardial infarction or cerebrovascular accidents have been noted. Therefore, MPA is safe and an
effective available option for high risk women of over 35 years.

30 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 In healthy non-smoking peri-menopausal women, MPA can be the appropriate contraceptive
option. It may reduce vasomotor symptoms and effectively treat abnormal uterine bleeding and
prevent endometrial hyperplasia. The reduced risk of endometrial and ovarian cancers is of
particular importance to older women of reproductive age.

The potential benefit of decreased bleeding and endometrial protection outweighs the risk of
continuing use because arterial and venous cardiovascular events are not increased.

Women who wish to continue using MPA should be reviewed every 2 years to assess the benefits and
risks. Users of MPA should be supported in their choice of whether or not to continue using MPA
beyond 45 years of age.

8.3 MPA in Post Partum and Lactating Women

Postpartum period is a critical time period for initiating contraception that helps women space their
pregnancies adequately. The immediate postpartum period offers an ideal time for women to initiate
contraception because of easy access and convenience.

By six weeks of postpartum up to 40 percent of women will have had unprotected intercourse and
nearly 50 percent will have ovulated. Therefore, contraception in postpartum period is essential.
Traditionally, COCs have not been recommended as first choice for breast feeding women due to the
concerns that estrogenic component can reduce the volume of milk production and the caloric and
mineral content of the breastfeed.

The use of progestogen-only contraceptive has no adverse effect on the quantity, quality and
composition of breast milk as well as duration of lactation, once breast feeding has been established.
In lactating breast feeding women MPA can be started after 6 week post- partum whereas in non-
breast feeding women it can be started anytime within 4 weeks. No backup method is required.
However, after 4 weeks it can be started after ruling out pregnancy. Since, it is unlikely that a
lactating woman will conceive within 6 weeks post-partum, WHO recommends the use of MPA after
6 weeks post-partum, if a woman is fully or partially breast feeding. If the woman is not breast
feeding, she may start MPA at 4 weeks post-partum.

8.4 MPA in HIV Positive Women

WHO recommends that there is no contraindication to the use of MPA amongst women who may
have sexually transmitted infections and is a safe, category 1 option for women infected with HIV.
Condom use is strongly encouraged along with MPA. There is also no definitive evidence on the
possible interaction between MPA and anti-retroviral drugs. MPA represents preferable
contraceptive choice for women taking any antiretroviral treatment.

8.5 MPA and Cancer

MPA does not cause cancer and exerts a protective effect against risk of endometrial cancer. This
protective effect appears similar or even greater than that associated with combined oral
contraceptives and continues for at least 8 years after discontinuation of MPA (Thomas 1991).
There is no association between MPA use and the risk of ovarian and cervical cancer.

8.6 MPA and Cardio Vascular Diseases

There is insufficient data to indicate whether there is any relation between MPA use and
cardiovascular complications. Results of a WHO study suggest that there is little increased risk of

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 31

 cardiovascular disease associated with the use of progestogen-only contraceptive (MPA). MPA does
not produce the type of changes in blood clotting factors as observed with COCs. There is no
significant change in systolic or diastolic blood pressure in women using MPA.

8.6 MPA and Metabolic Effect (Weight Change)

The only metabolic effect is minor weight gain of 1-2 kgs after 1 year of use. Weight gain may also
occur due to other reasons e.g food intake and sedentary lifestyle. Only 2% of women stop using
MPA because of weight gain. Some MPA users may view weight gain as desirable, while others may
consider it disadvantageous or unacceptable. Minor alterations of lipid metabolism, fluid/nitrogen
balance, glucose tolerance, steroid metabolism and immune function have been recorded but are of
no clinical significance

8. 7 Failure and Risk of Exposure to Foetus in Utero

MPA has good efficacy as compared to other contraceptive methods. In the rare events of method
failure, woman receiving MPA while pregnant or a woman conceiving shortly after discontinuing
MPA there is no increased risk of congenital anomaly or effect on growth and development of
children. In case a pregnancy occurs during MPA use, the client should discontinue the use of MPA.
She can continue with pregnancy, if she wishes to.

32 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 Chapter 9

Infection Prevention and Safe Injection Practices

9.1 Infection Prevention

Health care facilities are primary settings for infection transmission. Therefore, it is mandatory to
practise appropriate infection-prevention procedures at all times, with all clients. The objectives of
infection prevention practices are to minimize the risk of transmission of infections including HIV,
Hepatitis B and C to service providers, clients and community, prevent spread of antibiotic-resistant
microorganisms, reduce the overall cost of health care services and provide high-quality, safe
services for greater client satisfaction.

The consistent use of recommended infection prevention practices is a critical component of quality
health services, as well as a basic right of every patient, client or staff member in a health care setting.

Key objectives of infection prevention in providing injectable contraceptive services are to:
• Reduce risk of infection due to injectable contraceptive services.
• Reduce risk of disease transmission to clients.
• Protect health care providers at all levels-doctors, nurses other service providers and
housekeeping staff from getting infection.

9.2 Standard Precautions

Standard Precautions for infection prevention include:
• Proper Hand washing
• Self-protection of health care providers by using protective attires
• Maintaining proper environmental asepsis
• Safe practices to prevent injuries from sharps
• Processing of instruments and reusable items
• Proper waste-disposal

9.3. Relevant and Important Standard Infection Prevention Practices for Administering
Injectable Contraceptive
9.3.1 Proper Hand Washing: Most effective way to reduce transmission of infection
• Routine hand wash with plain or antiseptic soap and running water before and after giving
injection, before wearing and after removing gloves, before and after examining, after having
any direct contact with a client and after contact with body fluids.
• Hand hygiene using alcohol based hand-rub (if available) is an accepted option especially
when running water supply is limited or client load is high.
• The duration of scrub should be 30-40 seconds both with soap & water and while using
alcohol.
• All six steps of proper hand wash should be followed for effective hand wash (Fig. 4).

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 • Hands should be dried with a clean personal towel or air-dried. Do not use towels which are
shared by others.
• Once hands are washed and dried, necessary task needs to be carried out e.g. injecting MPA,
taking care not to contaminate the hands by touching things.

A non-irritating alcohol hand-scrub solution can be prepared by adding (2 ml glycerine

in 100ml of 60-90% alcohol solution

Steps of effective hand washing

The following chart highlights the steps of an effective hand wash:

1 2

Wet hands with water. Apply enough soap to

cover all hand surfaces.

3 4 5

Rub hands palm to palm. right palm over left dorsum with palm to palm with fingers interlaced.
interlaced fingers and vice versa,

6 7 8

rotational rubbing backwards and

backs of fingers to opposing rotational rubbing of left thumb forwards with clasped fingers of right
palms with fingers interlocked, clasped in right palm and vice versa, hand in left palm and vice versa,

9 10 11

rinse hands with water, dry hands thoroughly use towel to turn off faucet.
with a single use towel,

40-60 seconds

12

Your hands are now safe.

Fig. 4: Adapted from WHO guidelines on hand hygiene in health care (advanced draft):
A summary, World Alliance for Patient Safety, World Health Organization, 2005

34 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 9.3.2 Environmental Asepsis

Health care workers should follow the following cleanliness protocols at all the facilities
• Wear protective attires including utility gloves while cleaning.
• Use a damp/wet cloth for scrubbing surfaces to reduce the spread of dust and
microorganisms.
• Scrub room surfaces from top to bottom so that dirt falls on the floor.
• Scrub the floor with a mop soaked in 0.5% chlorine solution (never use a broom).
• Use 0.5% chlorine solution* for decontamination, cleaning and managing body fluid spills.

Preparation of 0.5% chlorine solution*

a. Calcium Hypochlorite or Chlorinated lime:
If using bleaching powder: Use the formula – (0.5% active chlorine in powder) x 1000 = gm of
powder/litre of water. So, for bleaching powder with 35% available chlorine, the formula
will be: (0.5/35) x 1000 = 14.3/15 gm/litre of water
Dissolve three teaspoons of bleaching powder (15 gm of calcium hypochlorite) in one litre of
water. Increase quantity of chlorine in same proportion to prepare larger quantities of
solution e.g. 150 gms of bleaching powder for 10 liters of water.
b. Sodium Hypochlorite Solution
If using liquid hypochlorite solution/bleach: mix one (1) part of the solution to nine (9) parts
of water to make 0.5% chlorine solution (if solution has 5% active chlorine available)
OR
one part of liquid bleach to six parts of water (if solution has 3.5% active chlorine available).
Prepare chlorine solution only in plastic bucket or tub. Use only for 24 hours and then
discard it.

9.3.3 Safe Injection Practices

Sharps have the highest potential to spread infection by transferring the micro-organisms
directly into the blood and it is crucial that sharp items used during the procedure be handled
with great care to avoid chances of injury. The risks of transmission of infection from an
infected patient to the health worker following a needle-stick injury is estimated to be
• Hepatitis B: 9-30%% (up to 30%);
• Hepatitis C: 3-10% ;
• HIV: 0.3% -0.4% (mucous membrane exposure risk is 0.09%).

A safe injection is one that does not harm the recipient, does not expose the provider to any
avoidable risk and does not result in any waste that is dangerous for other people.

9.3.3. 1 Do’s & Don’ts for Safe Injections & Needles

Do’s
1. Do carry out hand hygiene for 30-40 seconds before & after giving an injection.
2. Do use sterilized disposable/auto disable syringe.
3. Safe handling of sharp instruments/syringes requires using the 'Hands Free
Technique' by placing them in a kidney tray.

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 4. Immediately after use, sharp objects such as needles, scalpel blades and other
sharp items should be disposed off in a puncture-resistant container with a lid
made of either metal or heavy rigid plastic or cardboard. These containers should
be filled upto not more than 3/4th level and sealed before it is disposed off. Any
delay in disposal of sharps will increase the chances of accidents.
5. Puncture-resistant containers should be kept in convenient areas, where sharp
objects are frequently used.
Don'ts
1. Do not take apart the needle and syringe.
2. Do not recap, bend or break or remove the needles from the syringe before
disposal. Where recapping is unavoidable, do use one hand technique.
3. Do not reuse the same syringe/needle to give injections to multiple people - even
if the needle is changed.

9.3.3.2 Management of Needle Stick Injury

• Immediately wash the wound with soap and water.

• Do not use any solution other than soap and water.
• Let the wound bleed freely for a few seconds – do not squeeze the puncture site or suck
blood with mouth.
In case, despite best efforts accidental exposure to needle pricks or cuts occurs, follow NACO
PEP guidelines.
9.2.4 Waste Management

Improper disposal of biomedical waste poses significant health risk to health personnel and
the community. Proper disposal of infectious waste is crucial in maintaining environmental
cleanliness. All healthcare facilities in the country are covered under Bio Medical Waste
Management and Handling Rules (1998), hence it is mandatory to manage waste as per the
guidelines of the local authorities.

All waste in a health facility can be divided into:

A. General wastes - It is the waste that poses no risk of injury or infections and is similar to
household trash. Examples include paper, boxes, packing materials, bottles, plastic containers
and food-related trash. It should be stored in black bins, which will be taken away by the
municipality.

B. Biomedical wastes - It is the waste that poses a risk to health care providers and to the
surrounding environment. These are materials generated in the diagnosis, treatment or
immunization of clients, including blood, blood products and other body fluids, as well as
material containing fresh or dried blood or body fluids, bandages, surgical sponges and
organic waste such as human tissue, body parts, placenta and products of conception.

9.2.4.1 Steps of Waste Management

1. Segregation - as wastes are to be segregated into infectious (solid and plastic) and non-
infectious waste, where it is generated at the health facility. Never mix infectious and
non-infectious wastes.

36 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 2. Collection and Storage - put infectious, non-infectious and sharp wastes in appropriate
containers (Fig. 5) such as-

a) Sharps: needles, blades, broken glass are to be collected in white or blue bins/bags.
Needles should be cut with a hub cutter (if available) before disposing off in blue bins. In
absence of white or blue bins/bags, puncture proof box should be used for disposal of
sharps.
b) Infectious plastic wastes like soiled and infected plastics, syringes, dressings, gloves,
fluid bottles, blood bags, urine bags are to be collected in red plastic bins/bags.
c) Solid anatomical or pathological waste like placenta, body parts, swabs, bandages,
dressings etc. are to be collected in yellow plastic bins/bags.
d) Non-infectious (General) waste like packaging material, cartons, fruit and vegetable
peels, left over food, syringe/needle wrappers and medicine covers are to be collected in
black plastic bins/ bags.

Always collect waste in covered and empty bins after they are filled up to 3/4th level. Never
store waste beyond 48 hrs.

Fig. 7: Coloured Bins for segregation of waste and puncture proof box for sharp

3. Transportation - The waste should be transported in closed containers as carrying in open

container may spill which will cause spread of infection. Also the containers with infectious
wastes should never be carried through crowded areas.

4. Disposal of Waste - The disposal should be as per GoI guidelines. Burning solid infectious
waste (including anatomical/pathological wastes) in an incinerator is the best option. But if
incinerator is not available, burying solid infectious waste on-site in a deep burial pit, as long
as it is secured with a fence or wall and away from any water source, is the next best option.
The waste should be covered with 10 to 30 centimeters (4 to 10 inches) of soil at the end of
each day. Plastics should be autoclaved or decontaminated and then shredded. Sharps are to
be disinfected with chlorine solution and dumped in the sharps pit. Liquid infectious waste,
after disinfecting with chlorine solution, should be poured down the drain connected to an
adequately treated sewer or pit latrine; burial with other infectious waste is an acceptable
alternative. General waste can be sent without any treatment to municipal dumps for final
disposal.

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SECTION II:
Managerial Aspects
for Quality MPA Services
 Chapter 10

Program Determinants for Quality Services

10.1 Expansion of Basket of Choice

National Family Planning programme has been adding methods to the basket of choice from time to
time, although they have been rather limited specially in the arena of spacing which is of vital
importance in impacting maternal and child morbidities and mortalities. It is also acknowledged
that multiple options make switching easier, reduce method specific discontinuation and improve
user satisfaction.

Envisioning this Government of India has introduced injectable contraceptive (MPA) in the public
sector under the program in 2016.

Program Managers at various levels must develop mechanisms and strategies for introduction,
adaptation, utilization and scaling up of injectable contraceptive services and strengthen practices to
improve access to quality MPA services.

10.2. Determinants of Services

It is important for program managers to ensure preparedness on various technical, proven
managerial approaches and issues related to MPA. Some of the crucial aspects of successful service
delivery and care is dependent on the knowledge, skill and attitude of the health care providers.
Therefore, there is a need to develop a cadre of properly trained service providers in the public
health facilities at different levels, through structured competency based training based on the
following requirements.

10.2.1 Identification of Service Delivery Sites

The MPA will be rolled out in a phased manner. In the first phase it will be introduced in
Medical Colleges and District Hospitals followed by SDH/CHC in the second phase and
gradually upto sub-centres in the third phase. The demand for logistics and training batches
will be calculated based on identification of these sites.

10.2.2 Eligibility of Providers

Doctors (MBBS and above, AYUSH), SN/LHV/ANM are eligible to administer injectable
contraceptive to the clients after obtaining required training and skills. However, it is
mandatory that the first shot of injection be administered under the guidance of a trained
MBBS doctor after proper screening. Subsequent shots may be administered by trained
AYUSH doctor, SN/LHV/ANM.

10.2.3 Assessment of Training Need

A situational analysis of the current status of service providers at different levels of health
facilities in the district will help in identifying training needs. This will help to determine and
plan the most appropriate interventions such as ‘Training of Trainers’ to develop a core group
of ‘trainers’ and competent service providers at various levels.

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 The State Program Managers and State Training Coordinator/s in consultation with the
District Chief Medical Officer should estimate the number to identify the availability of
service providers required for providing regular MPA injectable contraceptive services in
DH, SDH/CHCs and PHCs in their respective districts. Based upon the need of the districts
the doctors/SN/LHVs/ANMs can be trained. The training load can be calculated using the
following RAG analysis.

Calculation of the Training Load - for various categories of providers (Doctors, Nurses,
LHVs, ANMs etc.)

DH / SDH CHC PHC

Injectable
Contraceptive R A G R A G R A G

R- Required; A- Available; G – Gap

Note: For the First year of roll out there will be no available pool of providers, therefore
districts would need to saturate the District Hospitals and Medical Colleges.

10.2.4 Ensuring Regular Supply

An effective and efficient supply chain management is the key to successful

implementation of the injectable contraceptive program. Short supply or non-availability
of contraceptives may lead to unwanted pregnancies and an oversupply may lead to
wastage of the commodities. Thus the need to keep the right quantity of contraceptives,
available at various levels of the health system is imperative so that beneficiaries have an
easy access to the methods of their choice and as per their need and convenience and there
is least wastage.

10.2.4.1 Demand Estimation (Buffer Stock and Wastage)

To facilitate an uninterrupted supply and also to avoid stock outs of injectable

contraceptives (vials & syringes) to states, districts and sub-district level, buffer
stocks should be kept at each level. DFWOs/District Program Managers in
consultation with the various service delivery centres in their region should
identify the demand for MPA injection and syringes with needles. The estimates
need to be based on the number of eligible women, contraceptive prevalence and
method mix of various contraceptive methods as well as unmet needs in their
respective districts/ regions.
The estimate should be based on 3 doses per user with 25% of stock as buffer and
5% as wastage. Necessary measures should be taken to avoid wastage/damage of
the MPA vials and syringes during transportation and storing.
For disposing the expired injectable contraceptives and medical wastes, National
Standards for Disposal should be followed.

10.2.4.2 Transportation

The state should ensure that all the injectable contraceptives are transported from
state to district and the lower level along with other contraceptives in a covered
vehicle.

42 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 10.2.4.3 Warehouse

The Injectable Contraceptives (MPA vials and syringes) along with other
contraceptives should be stored safely and securely at:
• National level: GMSD/ hired central level warehouse (for buffer stock only)
• State level: State level warehouse
• District level: District level warehouse
• Block level: Block CHC/PHC store
• Sub Center Level: Sub Center (no. of vials & syringes as per beneficiary list only)

10.2.4.4 Storage

Proper storing measures should be adopted to avoid damage and wastage to the
injectable contraceptives (MPA vials & syringes). They should be kept
• Upright in a cool dry, well-ventilated warehouse/storeroom at room temperature
between 15-30oC.
• Away from direct sunlight or extreme heat and should not be kept in the
refrigerator/freezer.
• In a warehouse/store should be well equipped with exhaust fans. Additional fans
can be used during summer to keep the room at the desired temperature.
• In a store room which does not have any seepage.
• In a manner conducive for FEFO (First to Expire; First Out)

10.2.4. 5 Distribution

Supplies reach from manufacturers/suppliers to the state warehouse based on the

consignee list provided by the Family Planning Division, MoHFW, GoI. State has
to ensure further distribution to the district and block level stores.

The replenishment/further supply of the injectable contraceptives should be on

consumption basis only. Demand estimation at state has to be an outcome of
indent submitted by district based on the consumption and stock in hand at the
facility.

10.2.5 Records and Reporting System

Record keeping and reporting is an integral component of National Family Planning

Programme. Correct and timely reporting helps in monitoring of the program,
identification of gaps and effective implementation of the strategies.

The purpose of record keeping and reporting system is to collect information for
documenting relevant details of acceptors, follow-up with acceptors of the method
regarding their level of satisfaction, concerns, side-effects and continuation of subsequent
injections. These details help in generating information for reporting at various levels so as
to ensure timely decision making for addressing service and supply related issues.

10.2.5.1 Record Keeping

The relevant socio-demographic information of all clients receiving their first dose
of MPA injection should be recorded along with facility parameters. Subsequent

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 doses of MPA and all relevant information should also be documented in the same
register. The format for recording client information in facility is given in
Annexure 11.

10.2.5.3 Reporting System

All facilities should report MPA service delivery parameters/indicators regularly

to the concerned District Family Welfare Officer for consolidation. DFWOs would
further send the consolidated monthly report for the entire district to the State
Family Welfare Officer for compilation and onward submission to GoI.

Apart from service delivery reports, stock information should be regularly

updated at the facility level. The state should submit the quarterly stock report to
GoI along with the reporting of other contraceptives.

10.2.6 Community Engagement and Demand Generation

Creating demand is a key component for service uptake. Districts need to orient and make
all cadre of staff aware about the new contraceptives made available under National
Family Planning Program. Demand generation is a continuous activity and can be
accomplished by utilizing health workforce working at different levels.

The role of various health staff in community sensitization and demand generation is
highlighted below:
• ASHA/ANM at community level- awareness generation by counselling eligible couples
and family.
• RMNCH+A counsellors at facility level-awareness generation among eligible couples
visiting facility including postpartum women and ANC clients.
• Doctors and Staff Nurses- Referring the clients from various departments to RMNCH+A
counsellors (if available). Sensitize clients about benefits of new contraceptive. The facility-
based providers can support community-based providers, such as treating side effects, use
clinical judgment concerning medical eligibility in special cases, ruling out pregnancy in
women who are more than 4 weeks late for an injection of MPA and responding to any
concerns of clients, which are referred by the community-based providers. The facility also
can serve as a ‘depot’ for the community-based provider, which can be used for
refurbishing the supplies, supervision, training, and advice and submit their records &
reports.

States may also plan and budget IEC/BCC activity in their State PIPs.

10.3 Quality Assurance in MPA Services

Quality assurance is an inbuilt system for monitoring the implementation of standards and practices
of MPA injectable contraceptive service delivery. It should ensure safety of the client, service
providers and the community as well as client’s satisfaction with continued use.

DQAC members during their visit to facilities should ensure the adherence to quality standards
practised for MPA service delivery. Quality can be assured through regular monitoring and
addressing gaps in a timely manner. The key points to be covered during monitoring visits are.

• Availability of trained service provider

44 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 • Availability of injectable contraceptives (vials and syringes) and other supplies
• Availability of MPA client cards
• Availability of counselling tools e.g. flipbook and pamphlets
• Availability of reporting formats and registers
• IEC materials on MPA along with other contraceptives
There are no major complications/side-effects in case of MPA and rare chances of adverse events
which may require remedial actions at DQAC level. However, there should be emphasis on
counselling to address discontinuation as well as misconceptions related to perceived side effects
associated with MPA. The section 10.4 indicates the key areas and the standards to be addressed for
measuring the performance for MPA injectable contraceptive services for achieving the desired
quality of care.

10.4 Key Areas and Standards for MPA Services

Key Areas Standards for MPA Services

Infrastructure and • Availability of trained providers for FP services.
Human Resources • Availability of trained personnel for counselling services.
• The facility has adequate clean space for providing counselling and
services.
• The facility has sufficient supplies of MPA injection.
• The facility has Infection Prevention supplies including source of
running water.
• The facility has adequate light source (at least equivalent to three cell
torch light).
• Good storage principles are applied to contraceptives, essential drugs
and medical supplies.
• The facility has record keeping and reporting materials for MPA
services.
Client Focused • The facility has informational posters on MPA-Injectable
IEC Materials Contraceptive .
• There is information on client's rights regarding family planning.
• The facility has flip charts/IEC material and samples of family
planning methods for counselling particularly on MPA.
Management • There are written routine protocols/instructions for the delivery of
Systems MPA services.
• Screening and client cards are available for MPA clients.
• The facility has GoI prescribed MPA formats and registers in which
record of each MPA client is maintained .
• The records are reviewed and analysed regularly.
Infection • There is clean running water available in the facility (tap or a tank with
Prevention Practices tap).
• Facility for hand washing is readily available.
• The availability and use of antiseptics for skin as per the standards.
• The waste disposal system is according to standards guidelines, GoI.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 45

 Key Areas Standards for MPA Services
Family Planning Services
FP Counselling • There is a dedicated private space for counselling.
• The first port of call for all women coming for ANC, Immunization of
children and postnatal visits, should be the counsellor.
• The counsellor uses job-aids, BCC material etc. for counselling.
• The provider gives information about all the contraceptive methods
available in the facility, with its benefits, side effects and limitation.
Providing Injectable • Ensures client’s correct understanding about the method, including
Contraceptive possible side effects and delayed return to fertility.
to a New Client • The provider rules out pregnancy.
• The provider assesses the woman's eligibility for administering MPA
injection.
• Performs the pre injection tasks and gives injection as per guidelines.
• Provide post injection instructions and advice for the return and/or
follow up visits.
• Record of client is duly filled up & client card given to her
Follow Up/ • The provider finds out about the client's satisfaction with MPA
Management • Identifies and manages the side effects or problems as per standard
of Side Effects guidelines and refers, if required.
Continuation of • Reminders for timely administration of subsequent injections are
MPA Services given on phone or by field worker e.g. ASHA.
• Repeat dose of MPA is given as per the protocols as per the duration
after which client comes for it.
Change of the • Identifies and documents the reasons for discontinuation, if any.
Method • Counsel on other family planning methods and ensure switch over.

46 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

SECTION III:
Capacity Building of Service
Providers on MPA
 Chapter 11

Training and Skill Development

11.1 Introduction
Competency of providers in knowledge and skills is essential for providing quality family planning
services, therefore, there is a need to strengthen the capacity of service providers at all levels. This
training course is designed for service providers (Doctors, Staff Nurses, Lady Health Visitor (LHV)
and Auxiliary Nurse Midwives (ANMs) at all levels). Training emphasizes on doing, not just
knowing and uses competency-based evaluation of performance.

This course is based on the Competency-Based Training (CBT) approach.

• It is based on adult learning principles which means that it is interactive, relevant and practical in
which the trainer facilitates the learning experience rather than serving in the more traditional role
of an instructor or lecturer.
• It involves use of behaviour modelling to facilitate learning in a standardized way of performing a
skill or activity.
• Evaluation is based on how well the participant performs the procedure or activity, not just on
how much has been learned.

11.2 General Aspects of Training

11.2.1 Training Site Selection
• The facility for training should have a comfortable clean training hall to accommodate about
35 persons
• Availability of chairs, tables, light source, fans/AC, audio-visual facility and alternate source
of power.
• Space for providing refreshments and basic amenities such as toilets.
• Availability of at least two trainers per site.
Identification and designation of these training centres at State and District level will be the
responsibility of Director Family Welfare/SQAC and CMO/DQAC, whichever is applicable.

11.2.2 Criteria for Designation of ‘Trainers’

• Trained service providers (MBBS and above, AYUSH, Staff Nurses) with prior training
experience, good communication skills, well-versed with training skills and technique of
adult learning principles who have competency/proficiency in the skills of counselling.

• Can spare time and willing to conduct training, follow-up monitoring visits for on-site
support/hand-holding, if required.

• Can be designated as a trainer by Director Family Welfare/SQAC at State level and by

CMO/DQAC at District level.

11.2.3 Selection of ‘Trainees’

The intended trainees for this course are Doctors (MBBS/AYUSH), Staff Nurse (SN), Lady
Health Visitor (LHV), Auxiliary Nurse Midwife (ANM) committed to provide the above
methods after completion of the training.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 49

 While selecting trainees, priority should be given to service providers from institutions that
are committed to provide FP Services. Facilities nominating trainees should be able to
include injectable contraceptive MPA in basket of FP Services.

11.2.4 Equipment and Supplies for Training Sites

• Reference Manual for Injectable Contraceptives (MPA)

• Samples of all contraceptive methods including MPA injectable contraceptive
• Syringes 2 ml, with needles 21-23 gauze
• Cotton swabs and antiseptic solution
• Hand wash facility - running water, soap and clean towels
• Formats with role plays and case studies (Annexure 6)
• Pre/Post-Test formats, Training evaluation formats (Annexure 8, 8a, 9)
• LCD Projector and screen for power point presentation, extension board, power back up,
flip chart, flip stands, coloured markers etc.

11.3 Training Goal and Learning Objectives

The goal of training is to assist service providers in learning how to provide safe quality MPA
injectable contraceptive through improved work performance. To achieve the above goal, at the end
of competency based training participants will be able to:

• Acquire knowledge related to MPA.

• Demonstrate appropriate counselling for MPA.
• Assess client’s eligibility for MPA and provide the method as per standard procedure and
guidelines.
• Demonstrate appropriate safe injection and other standard IP practices.
• Describe how to provide follow-up care to MPA clients.
• Describe management of side effects/other issues related to MPA.
• Demonstrate correct record keeping and reporting of new and continuing MPA clients

11.4 Number of Trainees per Batch

Approximately 25 to 30

11.5 Training Duration

One full working day

11.6 Training Approach and Methodology

All training activities in this course should be conducted in an interactive, participatory manner as
suggested in the course outline. To accomplish this, the trainer should change roles throughout the
course. For example, the trainer is an instructor when presenting a classroom session, a facilitator
when conducting small group discussions or role plays. Finally, when objectively assessing
performance, the trainer serves as an evaluator.

Following training methodology will be used in this training course:

• Interactive presentations and group discussion
• Demonstration
• Individual and group exercises

50 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 • Role plays and case studies
• Counselling practice with real clients
A suggestive course outline (session plan) of MPA Training has been provided in Annexure 12.

11.6.1 Important Tips for the Trainers

• Familiarize with the content of all Sections and Annexures in the ‘Reference Manual for
Injectable Contraceptives (MPA), Pre/Post-test questionnaires, Competency based check
lists of injectable contraceptive, role plays and case studies, IP practice etc.
• Make necessary preparations in advance, as per the facilitator guide.
• Plan meeting with co-facilitators before each workshop for assigning responsibilities and to
clarify any doubts, concerns or reservations.
• Work together as a team subtly supporting each other in every session.
• Conduct wrap-up session at the end of each training day and start the next day with a re-cap
session to provide continuity in the training.
• Arrange a seating arrangement which is informal, preferably in a semi-circle, without any
podium for the trainers.
• Adopt a warm and friendly attitude towards the participants to make the training very
effective, and take care not to ridicule any trainee.
• Explain, demonstrate, answer questions, talk with participants about their answers to
exercises, get roleplays conducted and analyse them, lead group discussions, organize and
supervise clinical practice in out patient facility and generally give participants any help
they need to successfully complete the course.
• Using leading questions draw the relevant information related to the session from
participants and fill in the gaps, where necessary. This will help trainees to assimilate the
knowledge and experiences.

11.6.2 Adapt the Curriculum to Reflect the Participants’ Expectations.

Use the results of the small group exercise about participants' expectations. Although
trainers may not always be able to meet all of the participants’ needs and expectation,
knowing expectations helps in tailoring the training and add relevant information and
examples to the training sessions.

Language-Use non-technical simple language during the sessions so that participants are
exposed to and can gain practice with simple terminology that can be used during their
work.

11.7 Evaluation of Knowledge and Skills

Evaluation is a fundamental part of training. Proper evaluation helps ensure that the training is not
merely a one-time intervention but part of a broader strategy to develop participants’ skills and to
help them apply those skills upon return to their work-sites. Evaluation can also help to improve
future training activities. Evaluation of training includes:

• A pre and post-test of participants’ knowledge: This pre-test and post-test is designed to be given
at the beginning and end of the training course. The trainer can use the results to customize the
training to best suit the trainees e.g. spend more time in explaining content with maximum wrong
answers. Pre-test, post-test and their answers appear in this section.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 51

 • Continuous assessment of the training
• An assessment of the trainees by the trainer (Competency Based Checklist; Annexure 7)
• An assessment of the training by the participants (Evaluation of training; Annexure 9)
11.7.1 Training Follow-Up
For training to be truly successful, trainees must be able to use their new skills and
knowledge and apply them when they return to their jobs. Practice on job helps in gaining
competency and gradually proficiency in the skills. District training coordinator/CMO
should conduct follow up with in 2 to 3 months of completion of training (Annexure 10).
11.7.2 Certification
A certificate of attendance may be given to trainees who have participated in the training.

11.8 Roadmap for Training

The training strategy is to start with an orientation of Trainers and Program Managers at the
National level and State level followed by facility based training of service providers at district/sub
district level. This process would ultimately build a sustainable self-renewing system of DH/CHC
based trainers responsible for developing the capacity of competent service providers for FP
services.
11.9 Curriculum and Schedule of Training

Time Duration Points for reinforcement

9:00-9:30am 30 minutes • Welcome & Introduction,
• Participants' Expectations & Group Norms
9:30-9:50am 20 minutes • Pre Course Knowledge Assessment
9:50-10:20am 30 minutes • National Family Planning Programme and Need For Expanding
Contraceptive Choices
10:20-11:20am 60 minutes • Technical Aspects of MPA Injectable Contraceptive (IM and SC)
• Special Issues with Injectable Contraceptives
Tea Break-11:20-11:30 am
11:30-12:30pm 60 minutes • Counselling Clients on Family Planning Methods
• General Principles of Counselling
• Method Specific Counselling for MPA
• Practice by Participants through Role Play, using Competency Based
Checklist
12:30-1:15 pm 45 minutes • Eligibility Criteria and Client's Assessment for MPA Contraceptive
using WHO MEC
1:15-2:00 pm 45 minutes • Administering Injectable Contraceptives (IM and SC)
Lunch-2:00-2:45 pm
02:45-3:45 pm 60 minutes • Follow up care and Management of Side Effects of Injectable
Contraceptives
03:45-4:00 pm 15 minutes • Infection Prevention & Safe Injection Practice
Tea Break-4:00-4:10 pm
04:10-4:25 pm 15 minutes • Review Pre Course Knowledge Assessment
04:25-4:55 pm 30 minutes • Program Management & Quality Assurance Capacity Building of
Providers
04:55-5:10 pm 15 minutes • Record Keeping and Reporting Formats
05:10-5:40 pm 30 minutes • Post Course Knowledge Assessment, Course evaluation & closure

52 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

Annexures
 Annexure 1

Pregnancy Screening Checklist

How to Be Reasonably Sure that the Client is Not Pregnant ?

One can be reasonably sure that the client is not pregnant, if she has no signs or symptoms of
pregnancy (e.g., breast tenderness or nausea) and

• Has not had intercourse since her last menses; or

• Has been correctly and consistently using a reliable contraceptive method; or
• Is within the first 7 days after the start of her menses ; or
• Is within 4 weeks postpartum (for women who are not breastfeeding); or
• Is within the first 7 days post-abortion; or
• Is fully breast-feeding, is less than 6 months postpartum and has had no menstrual
bleeding.

1.1 Assessment of clients for MPA

To determine if the client is medically eligible to use MPA, ask questions 1–7. As soon as the client
answers YES to any question, stop, and follow the instructions below

NO 1. Have you ever had a stroke, blood clot in your legs or lungs, or heart attack? YES

NO 2. Have you ever been told you have breast cancer? YES

NO 3. Do you have a serious liver disease or jaundice (yellow skin or eyes)? YES

NO 4. Have you ever been told you have diabetes (high sugar in your blood)? YES

NO 5. Have you ever been told you have high blood pressure? YES

6. Do you have bleeding between menstrual periods, which is unusual for you,
NO YES
or bleeding after intercourse (sex)?
NO 7. Are you currently breastfeeding a baby less than 6 weeks old? YES

If the client answered NO If the client answered YES to any of the questions 1–3, she is not a good
to all of questions 1–7 the candidate for MPA. Counsel about other available methods or refer. If
client can use MPA. the client answered YES to any of questions 4–6, MPA cannot be initiated
Proceed to questions 8–13. without further evaluation. Evaluate or refer as appropriate and give
condoms to use in the meantime. If the client answered YES to question
7, instruct her to return for MPA as soon as possible after the baby is six
weeks old.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 55

Ask questions 8–13 to be reasonably sure that the client is not pregnant. As soon as the client answers
YES to any question, stop, and follow the instructions below

YES 8. Did your last menstrual period start within the past 7 days? NO

9. Did you have a baby less than 6 months age, are you fully or nearly-fully
YES NO
breastfeeding, and have you had no menstrual period since then?

10.Have you abstained from sexual intercourse since your last menstrual
YES NO
period or delivery?
YES 11. Have you had a baby in the last 4 weeks? NO

YES 12. Have you had a miscarriage or abortion in the last 7 days? NO

13. Have you been using a reliable contraceptive method consistently and
YES NO
correctly?

If the client answered YES to at least one of questions 8–13 and she is free If the client answered NO
of signs or symptoms of pregnancy, one can be reasonably sure that she is to all of questions 8–13
not pregnant. The client can start MPA now. If the client had her last pregnancy cannot be ruled
menstrual period within the past 7 days, she can start MPA- out. She must use a
IMmediately. No additional contraceptive protection is needed. If the pregnancy test or wait
client had her last menstrual period beyond 7 days, she can be given until her next menstrual
MPA now but instruct her that she must use condoms or abstain from sex period to be given MPA.
for the next 7 days. Give her condoms to use for the next 7 days. Give her condoms to use in
the meantime.

56 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 Annexure 2

Medical Eligibility Criteria (MEC) WHO, 2015

The WHO Medical Eligibility Criteria (MEC) form the scientific foundation for client assessment regarding
family planning methods. It gives detailed guidance regarding whether a woman with a certain condition
can safely use an injectable contraceptive of family planning. The MEC has four categories:

Category 1: Category 2:

A condition for which there is no restriction for the A condition where the advantages of using the
use of the contraceptive method. Safely use. method generally outweigh the theoretical or
proven risks. Generally use.

Category 3: Category 4:

A condition where the theoretical or proven risks A condition which represents an unacceptable
usually outweigh the advantages of using the health risk if the contraceptive method is used. Do
method. Generally do not use not use.

CONDITION CATEGORY
PERSONAL CHARACTERISTICS AND REPRODUCTIVE HISTORY
AGE
a) Menarche to < 18 years 2
b) 18 to 45 years 1
c) > 45 years 2
PARITY
a) Nulliparous 1
b) Parous 1
BREASTFEEDING
a) < 6 weeks postpartum 3
b) > or equal 6 weeks to < 6 months postpartum (primarily breast- 1
feeding)
c) > or equal 6 months postpartum 1

POSTPARTUM (NON- BREASTFEEDING WOMEN)

a) < 21 days 1
b) > or equal 21 days 1
POST ABORTION
a) First trimester 1
b) Second trimester 1
c) Immediate post-septic abortion 1
PAST ECTOPIC PREGNANCY 1
HISTORY OF PELVIC SURGERY 1
*I=Initiation, C=Continuation

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 CONDITION CATEGORY
SMOKING
a) Age < 35 years 1
b) Age > or equal 35 years 1
i) < 15 cigarettes/day
ii) > or equal 15 cigarettes/day 1

OBESITY
a) > or equal 30 kg/m2 BMI 1
b) Menarche to < 18 years and > or equal 30 kg/m2 BMI 1
CARDIOVASCULAR DISEASES
MULTIPLE RISK FACTORS FOR ARTERIAL CARDIOVASCULAR 3
DISEASE
(such as older age, smoking, diabetes, hypertension and known
dyslipidaemias)

HYPERTENSION 2
a) History of hypertension where blood pressure CANNOT be
evaluated (including hypertension in pregnancy)
b) Adequately controlled hypertension where blood pressure CAN be 2
evaluated
c) Elevated blood pressure levels (properly taken measurements)
2
i) systolic 140 - 159 or diastolic 90 - 99 mm Hg
3
ii) systolic > or equal 160 or diastolic > or equal 100mm Hg
d) Vascular disease 3
HISTORY OF HIGH BLOOD PRESSURE DURING PREGNANCY 1
(where current blood pressure is measurable and normal)
DEEP VEIN THROMBOSIS (DVT)/PULMONARY EMBOLISM (PE)
a) History of DVT/PE 2
b) Acute DVT/PE 3
c) DVT/PE and established on anticoagulant therapy 2
d) Family history(first degree relatives) 1
e) Major Surgery
i) With prolonged immobilization 2
ii) Without prolonged immobilization 1
f) Minor surgery without immobilization 1
KNOWN THROMBOGENIC MUTATIONS (e.g. factor V Leiden; 2
prothrombin Mutation; protein S, protein C and antithrombin deficiencies)
SUPERFICIAL VENOUS DISORDERS
a) Varicose veins 1
b) Superficial venous thrombosis 1
CURRENT AND HISTORY OF IS CHAEMIC HEART DISEASE 3
STROKE (HISTORY OF CEREBROVASCULAR ACCIDENT) 3
KNOWN DISLIPIDAEMIAS WITHOUT OTHER KNOWN 2
CARDIOVASCULAR RISK FACTORS
VALVULAR HEART DISEASE
a) Uncomplicated 1
*I=Initiation, C=Continuation

58 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

CONDITION CATEGORY
b) Complicated (pulmonary hypertension, risk of atrial fibrillation, 1
history of subacute bacterial endocarditis)
RHEUMATIC DISEASES
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) I* C*
a) Positive (or unknown) antiphospholipid antibodies 3 3
b) Severe Thrombocytopenia 3 3
c) Immunosuppressive treatment 2 2
d) None of the above 2 2
NEUROLOGIC CONDITIONS
HEADACHE I* C*
a) Non-migrainous (mild or severe) 1 1
b) Migraine
i) without aura 2 2
age < 35 years 2 2
age > or equal 35 years 2 3
ii) with aura, at any age
EPILEPSY 1
DEPRESSIVE DISORDERS
DEPRESSIVE DISORDERS 1
REPRODUCTIVE TRACT INFECTIONS AND DISORDERS
VAGINAL BLEEDING PATTERNS
a) Irregular pattern without heavy bleeding 2
b) Heavy or prolonged bleeding (includes regular and irregular 2
patterns)
UNEXPLAINED VAGINAL BLEEDING 3
(suspicious for serious condition) before evaluation
ENDOMETRIOSIS 1
BENIGN OVARIAN TUMOURS (including cysts) 1
SEVERE DYSMENORRHOEA 1
GESTATIONAL TROPHOBLASTIC DISEASE
a) Decreasing or undetectable B-HCG levels 2
b) Persistently elevated B-HCG levels or malignant disease 2
CERVICAL ECTROPION 1
CERVICAL INTRAEPITHELIAL NEOPLASIA (CIN) 2
BREAST DISEASE
a) Undiagnosed mass
b) Benign breast disease 2
c) Family history of cancer 1
d) Breast cancer 1
i) Current 4
ii) Past and no evidence of current disease for 5 years 3
ENDOMETRIAL CANCER 1
OVARIAN CANCER 1
*I=Initiation, C=Continuation

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 59

 CONDITION CATEGORY
UTERINE FIBROIDS
a) Without distortion of the uterine cavity 1
b) With distortion of the uterine cavity 1
PELVIC INFLAMMATORY DISEASE (PID)
a) Past PID (assuming no current risk factors for STIs) 1
i) With subsequent pregnancy 1
ii) Without subsequent pregnancy 1
b) PID - current
SEXUALLY TRANSMITTED INFECTIONS (STIS)
a) Current purulent cervicitis or chlamydial infection or gonorrhea 1
b) Other STIs (excluding HIV and hepatitis) 1
c) Vaginitis (including Trichomonas vaginalis and bacterial vaginosis) 1
d) Increased risk of STIs 1
HIV/AIDS
HIGH RISK OF HIV 1
ASYMPTOMATIC OR MILD HIV CLINICAL DISEASE 1
(WHO STAGE 1 OR 2)
SEVERE OR ADVANCED HIV CLINICAL DISEASE 1
(WHO STAGE 3 OR 4)
OTHER INFECTIONS
SCHISTOSOMIASIS
a) Uncomplicated 1
b) Fibrosis of the liver (if severe, see cirrhosis) 1
TUBERCULOSIS
a) Non-pelvic 1
b) Pelvic 1
MALARIA 1
ENDOCRINE CONDITIONS
DIABETES
a) History of gestational disease 1
b) Non-vascular disease
i) Non-insulin dependent 2
ii) Insulin dependent 2
c) Nephropathy/retinopathy/neuropathy 3
d) Other vascular disease or diabetes of > 20 years duration 3
THROID DISORDERS
a) Simple goiter 1
b) Hyperthyroid 1
c) Hypothyroid 1
GASTROINTESTINAL CONDITIONS
GALL BLADDER DISEASE
a) Symptomatic
i) treated by cholecystectomy 1
ii) medically treated 1
*I=Initiation, C=Continuation

60 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 CONDITION CATEGORY
iii) current 1
b) Asymptomatic 1
HISTORY OF CHOLESTASIS
a) Pregnancy related 1
b) Past-COC related 2
VIRAL HEPATITIS
a) Acute or flare 1
b) Carrier 1
c) Chronic 1
CIRRHOSIS
a) Mild (compensated) 1
b) Severe (decompensated) 3
LIVER TUMOURS
a) Benign 1
i) Focal nodular hyperplasia 1
ii) Hepatocellular adenoma
b) Malignant (hepatoma)
LIVER TUMOURS
a) Benign
i) Focal nodular hyperplasia 2
ii) Hepatocellular adenoma 3
b) Malignant (hepatoma) 3
ANAEMIAS
THALASSAEMIA 1
SICKLE CELL DISEASE 1
IRON-DEFICIENCY ANAEMIA 1
DRUG INTERACTIONS
ANTIRETROVIRAL THERAPY (ART)
a) Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
Abacavir (ABC) 1
Tenofovir (TDF) 1
Zidovudine (AZT) 1
Lamivudine (3TC) 1
Didanosine (DDI) 1
Emtricitabine (FTC) 1
Stavudine (D4T) 1
b) Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
Efavirenz (EFV) 1
Etravirine (ETR) 1
Nevirapine (NVP) 1
Rilpivirine (RPV) 1
c) Protease Inhibitors (PIs)
Ritonavir-boosted atazanavir (ATV/r) 1
Ritonavir-boosted darunavir (DRV/r) 1
Ritonavir (RTV) 1

*I=Initiation, C=Continuation

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CONDITION CATEGORY
d) Integrase inhibitors
Raltegravir (RAL) 1
ANTICONVULSANT THERAPY
a) Certain anticonvulsants (Phenytoin, Carbamazepine, Barbiturates, 1
Primidone, Topiramate, Oxcarbazepine)
b) Lamotrigine 1

ANTIMICROBIAL THERAPY
a) Broad-spectrum antibiotics 1
b) Antifungals 1
c) Antiparasitics 1
d) Rifampicin or rifabutin therapy 1
*I=Initiation, C=Continuation

62 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 Instructions for clients
MPA CARD
(Antara Program) • Once taken it is effective
for 3 months.
(To be kept in facility)
Intramuscular/Subcutaneous (Tick 3 the type • Return on scheduled date
of MPA administered) as decided with the
OPD/IPD Number……………………….....………
Name of Facility…………………………………… After Injection Do not
massage injection site
Client's Name…………………………..…………...
Client's Address…………………………………… Do not give hot fomentation
at the injection site
…………………………..Tel. No.……….…………
Client's Age…………………… Parity……………
Date of Last Child Birth/abortion………..……… • MPA does not affect breast milk
Family Planning Method used earlier (Tick3)
• MPA does not affect future pregnancy
Oral Pills Condom IUCD Not used
however some women may take 7-10
Must Know: Instructions for Provider months to conceive after injection
1) Each injection gives protection for 90 days (3
months). Decide on next date of Injection • There are some menstrual changes
with client. which are not harmful
2) MPA does not affect breast milk.
3) MPA does not cause infertility. Women can • Use backup method (like condom)
become pregnant after 7-10 months of last
if injection is taken after 7 days of

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

injection.
4) Menstrual irregularities are normal while using menses
MPA and are not dangerous.
5) Do not massage injection site.
6) Do not give hot fomentation at the injection site.
MPA Client Card and Instructions for Clients

7) Ask the client to use a backup method if injection

is given after 7 days of menses, provide condom
to such client.
8) Ask the client to report in following conditions:
• Irregular bleeding or amenorrhea
• Abnormal weight gain
• Headache
• Mood swings

63
Annexure 3
64
MPA CARD
(Antara Program)
Client Card (To be issued to client)

Advice

complaint

Due Date of
next injection
Advice, if any
Intramuscular/Subcutaneous (Tick 3 the type
of MPA administered)
OPD/IPD Number……………………….....………
Name of Facility……………………………………
Client's Name…………………………..…………...
Client's Address……………………………………

- PP/PA/interval
…………………………..Tel. No.……….…………

Timing of injection
Client's Age…………………… Parity…………… Other Complaint
Date of Last Child Birth/abortion………..………

Changes
Menstrual Any Complaint
Date of Injection Date of Injection

Type of Inj-(3): IM SC Type of Inj-(3): IM SC

BP
Weight BP Weight BP
Changes
Menstrual

Menstrual Changes(3):N Y Menstrual Changes(3):N Y

Blood Pressure
Advice Advice

Weight
Due Date of next injection Due Date of next injection
Mid-course Follow up Visit

Date of Injection Date of Injection

Blood

Weight
Record of MPA Injection
Pressure

Type
Type of Inj-(3): IM SC Type of Inj-(3): IM SC
Weight BP Weight BP

LMP
Menstrual Changes(3):N Y Menstrual Changes(3):N Y
Advice Advice
Weight

Type
Due Date of next injection Due Date of next injection

(IM/SC)
Date of Injection Date of Injection
Date of

Type of Inj-(3): IM SC Type of Inj-(3): IM SC

Follow up

Weight BP Weight BP
Due Date of Date of

Menstrual Changes(3):N Y Menstrual Changes(3):N Y

Advice Advice
Sno.

MPA

Date of Injection
Injection Injection Injection (IM/SC)

Record of First MPA Injection (The first injection should be given under the guidance of trained doctor)
2nd
3rd
4th
5th
6th

Due Date of next injection Due Date of next injection

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 Annexure 4

Frequently Asked Questions (FAQs)

Eligibility Criteria and Client Assessment:

1. Can a woman who is breastfeeding safely use MPA?

Answer: Yes. This is a good choice for a breastfeeding mother. Injection MPA is safe for both the mother
and the baby starting as early as 6 weeks after childbirth. It does not affect the quality and quantity of
milk production.

2. Can a woman who is at risk of Sexually Transmitted Infections (STIs) use Injection MPA?

Answer: Yes. Women at risk for STIs can use MPA. However, it does not protect against STI. A user of
MPA who may be at risk for STIs should be advised to use condoms correctly and consistently during
every sexual intercourse.

3. Can Injection MPA be given to a woman who wants protection from unwanted pregnancy only for 6
months?

Answer: No, Injection MPA will not be a suitable method in such a situation due to delayed return of
fertility (average 7-10 months after the last injection of MPA), even after one injection. There are other
more suitable FP methods to delay pregnancy.

4. Can MPA be given to a hypertensive woman who had Eclampsia during pregnancy?

Answer: Yes, MPA can be given to a woman who had eclampsia during pregnancy provided that
hypertension is in control. However, it cannot be given to women having uncontrolled hypertension
with B.P. 160/100 or more.

5. What are the FP options for spacing for a woman with uncontrolled high blood pressure?

Answer: The spacing options that can be given are IUCD, Centchroman, condoms, POPs. The
Combined hormonal Methods (COC like Mala N) and MPA are not to be given in such a case (WHO
MEC Category 3)

6. Can MPA be given to women with uncontrolled diabetes?

Answer: Yes, MPA can be given to women with diabetes, but it cannot be given if diabetes is of more
than 20 years duration or is vascular in nature accompanied with complications like kidney, eye or
nerve damage. Diabetic women should be counselled for need to consult an endocrinologist for
evaluation of any complication and proper management of diabetes.

7. What is the guideline for use of MPA by a woman who had eclampsia and was on ventilator with
cerebral infarct (CT scan confirmed) but not a clear stroke?

Answer: The specific condition is considered to be a cerebrovascular accident and falls under WHO
MEC Category 3, which means the use of method is generally not recommended unless other more
appropriate methods are not available or acceptable.

8. Can MPA-SC be administered to those women who cannot be given MPA-IM and vice-versa?

Answer: No, SC-MPA cannot be administered to those women who are not eligible to take MPA-IM
and vice versa.

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Administering MPA Injection:
9. Why is MPA started at 6 weeks postpartum for breastfeeding women whereas POPs can be given
immediately after birth?

Answer: The reason for not giving Injectable -MPA to breast feeding mothers during first 6 weeks
postpartum is due to a theoretical risk of the infant getting exposed to the steroid hormone, which the
newborn's immature system may not be able to metabolize (WHO MEC -5th edition 2015). Injection
MPA has a higher dose of the hormone, as compared to POPs, which contain very less amount of
progestin.

10. When can MPA be administered after a spontaneous or surgical abortion?

Answer: If it is a first or second trimester abortion, MPA can be given on the same day or within next 7
days and no back up method is required. If a woman comes after 7 days of abortion, MPA can still be
given if there is no history of contact since abortion. In this case, back up method for next 7 days will
however be required.

11. When can MPA be administered in case of a Medical Abortion?

Answer: For 1st trimester Medical Abortion with Mifepristone and Misoprostol, MPA can be
administered on 3rd day of Medical Abortion protocol, i.e the day on which Misoprostol is to be given.

(Source: Post Abortion Family Planning Technical Update Family Planning Division, Ministry of
Health and Family Welfare, Government of India)

12. Can air be introduced into MPA vial for smooth aspiration of the fluid from the vial into the
syringe?

Answer: No, atmospheric air should not be introduced into the vial as it may cause micro-organisms
present in the air to enter the sterile vial and contaminate the drug. This point is applicable for single or
multi dose vials of any drug.

13. Can Intramuscular MPA be administered subcutaneously as the chemical composition is same for
both the variety?

Answer: No, Intramuscular MPA should not be administered subcutaneously and vice versa. The
dose and size of needle for MPA-IM is different than that of MPA- SC.

14. What will happen if subcutaneous injectable contraceptive Medroxy Progesterone Acetate is
administered intramuscularly?

Answer: To ensure three months of contraceptive protection, Subcutaneous Injectable Contraceptive

Medroxy Progesterone Acetate must be administered subcutaneously only. If MPA is given in a
muscle, it may not provide protection for full three moths. However, the needle of MPA-SC is smaller
(3/8 inches) than the MPA-IM needle, so it is not likely to reach the muscle hence giving MPA-SC by IM
route is practically not possible.

15. Will administering 150 mg of intramuscular MPA through subcutaneous route not increase the
duration of action?

Answer: No, administering intramuscular dose through subcutaneous route does not increase the
duration of action. For every drug, including hormonal contraceptives, its optimal dose needs to be
given so that effectiveness is high and side effects are minimal. Increasing or decreasing the optimal
dose would affect effectiveness and side effects.

66 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

16. Is activation of Uniject system for MPA-SC necessary and how it is done?

Answer: Yes, “activation” of Uniject system is necessary to ensure free flow of aqueous suspension of
MPA from the reservoir into the needle while giving the subcutaneous injection. “Activation” is done
by pushing the needle shield towards the port so that the diaphragm inside the port is pierced by the
needle bud and a free passage is made for the liquid to flow freely into the needle while pressing the
bulb reservoir during SC administration.

17. If MPA-SC has longer plateau level in vivo, why is it administered every three months like MPA-
IM?

Answer: Blood level of progesterone after SC – MPA attains shorter peak compared to IM – MPA and
its clearance is slower and steady, but in both the routes the blood level of progesterone will drop down
to < 1mmol/L after 120 to 200 days. Therefore in both the routes MPA needs to be administered at 90
days interval.

18. Is there any difference in duration of effectivity of MPA-SC and MPA-IM?

Answer: No, there is no difference as they both are 3 monthly contraceptive injections.

Follow up Care and Management of Side Effects of MPA:

19. Why back up is required for next 7 days if MPA is given after Day 7 of MC?

Answer: There is a possibility that ovulation has already occurred by 7th day of the cycle, and also the
contraceptive effectiveness of MPA will require 12 to 24 hrs after the first injection. Therefore if MPA is
given after 7 day of the menstrual cycle, back up is necessary to protect her from unwanted pregnancy.

20. If a client develops an abscess at the site of MPA injection and abscess is drained, then when should
next dose be administered?

Answer: If a client develops an abscess at the site of MPA injection and abscess is drained, it is likely
that the drug may get drained out partially or completely from the site. Hence the contraceptive
protection cannot be guaranteed and an additional contraceptive is required.Give a back-up method
till her next menstrual cycle and then provide next dose or the method she chooses to use.

21. If a woman does not have monthly bleeding while using MPA, does this mean that she is pregnant?

Answer: No, Most women using MPA will not have monthly bleeding after getting her injections on
time and there are less chances of becoming pregnant. Reassurance to client may help but if required
offer her pregnancy test. Despite all this if she so desires help her choose another method.

22. Does Injectable MPA cause abortion?

Answer: No, Research on MPA, indicates that it does not disrupt an existing pregnancy nor cause an
abortion. DMPA should not be used to try to cause abortion.

23. Does Injectable MPA cause birth defects? Will the foetus be harmed if a woman accidentally uses
MPA while she is pregnant?

Answer: No. Evidence shows that MPA neither cause birth defects nor does it harm the foetus if a
woman becomes pregnant while using MPA or accidentally starts MPA when she is already pregnant.

24. Does Injectable MPA make a woman infertile?

Answer: No, Injectable MPA does not make a woman infertile however there may be delay in
regaining fertility after discontinuing MPA.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 67

25. How long does it take to become pregnant after discontinuing DMPA?

Answer: Women who discontinue MPA have to wait for on an average 4-6 months longer on average to
become pregnant than women who have used other methods. This means they become pregnant
about 7-10 months from date of last injection. A woman should not be worried if she has not conceived
for as long as even 12 months after discontinuation. The length of time a woman has used MPA makes
no difference to how quickly she becomes pregnant once she stops having injections. After stopping
MPA a woman may ovulate before her monthly bleeding returns and thus can become pregnant.

26. What if a woman returns for her next injection late or early?

Answer: In 2008 WHO revised its guidelines based on new research findings. The new guidelines
recommends giving a woman her next MPA injection, if she is up to 4 weeks late, without the need for
further evidence that she is not pregnant. Some women return even later for their repeat injection, in
such cases providers should assess for pregnancy, whether a woman is late for reinjection or not, her
next injection of MPA should be planned for 3 months later.

If she comes upto two week earlier, counsel her on the importance of coming on time for next injection,
as per the date given on the MPA card (If she has come two week earlier then the follow up date will be
calculated two week earlier from the next follow up date and four week later if she comes four weeks
late).

27. If a woman comes for her next MPA injection after the scheduled date but within the grace period of
4 weeks, can the injection be given to her? If yes, will a backup method be required?

Answer: Yes, next injection can be given to her and there is no need for a backup method as she has
come within the grace period. She should also be counselled and encouraged to come on the scheduled
date in future.

28. If a woman is given her next injection of MPA after the scheduled date but within the grace period
of 4 weeks, will she be reported as a continued client, defaulter, drop out or new user of MPA?

Answer: As the next dose has been given within the grace period, the woman will be considered as a
continued user. She is a defaulter for this particular dose because she has taken it within the grace
period and not on scheduled date. (Grace period is 2 weeks earlier and upto 4 weeks later than the
scheduled date).

29. If a woman comes for the next injection after the grace period of 4 weeks is over (i.e. more than 4
months have passed since the last injection), can the injection be given to her? If yes, will a back-up
method be required?

Answer: Yes, she can be given MPA if there is no history of contact after grace period ended. A back up
method for next 7 days will also be required.

30. If a woman is given MPA after the grace period of 4 weeks is over (i.e. more than 4 months have
passed since the last injection), how will the case be recorded? Will it be considered as a continuing
client or a drop out?

Answer: This case will be recorded as a new client and not a continuing client. She is a drop out client
for previous MPA use, due to passage of more than 4 months since last MPA injection.

31. Should pregnancy test be advised to an MPA client who is having amenorrhea and is worried that
she might have become pregnant?

Answer: No, there is no need for pregnancy test on a routine basis as amenorrhea is a reversible and

68 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 harmless effect of MPA. The Client should be counselled about this effect. However if a woman is
anxious even after follow up counseling and examination, pregnancy test can be done to allay her
anxiety.

32. If irregular bleeding in a breastfeeding woman on MPA does not improve with NSAIDs, can POPs
be given to manage the bleeding?

Answer: The chance of irregular bleeding with MPA in breastfeeding women is rare. Still, if there is
such a case and she does not improve with NSAIDs, examine and rule out any other cause of bleeding.
Then reassure her that bleeding will reduce or will stop after a few months.

Progestin Only Pills can be given but they produce only moderate improvement in
irregular/prolonged bleeding. It is the Estrogen pills which are most effective in reducing irregular
bleeding following MPA, though they are to be avoided during first six months of breastfeeding.
However next dose of MPA can be administered 2 weeks before the scheduled date to build higher
progesterone level which will stop the bleeding and make the woman amenorrheic.

33. Since high dose of progesterone is used to control DUB, can POP be given to control irregular
bleeding after MPA, just to increase the level of progesterone and make the woman amenorrheic?

Answer: No, administration of POP will have no effect as it contains small amount of Progesterone
and no Estrogen. The preferred drug is Estrogen to control irregular bleeding after MPA.

34. Are the menstrual changes with MPA-SC different from those of MPA-IM?

Answer: No, both MPA-IM and MPA-SC cause similar menstrual changes as the hormonal level in
blood is same.

Special Issues on MPA:

35. Does MPA cause cancer?

Answer: No, MPA does not cause cancer. In fact it has been demonstrated that it protects against
endometrial and ovarian cancer. A WHO collaborative study of neoplasia and steroid contraceptives
found no overall increased risk of breast cancer, no increased risk of invasive cervical cancer and no
increased risk of ovarian or liver cancer.

36. How does injectable MPA affect bone density?

Answer: Injectable MPA use decreases bone density. Research has not found that MPA users of any age
are likely to have more broken bones, however, when it is discontinued, bone density is restored for
women of reproductive age and after 2 to 3 years their bone density appears to be similar to that of
women who have not used it. In adolescents, it is not clear whether the loss in bone density prevents
them from reaching their potential peak bone mass.

37. Should BMD be measured periodically after giving MPA, say every 2 years?

Answer: No, there is no such guideline/protocol mandating BMD assessment every 2 years. However
based on clinical judgment providers may recommend for same in some cases.

38. What would be the status of BMD in women who become pregnant after stopping MPA?

Answer: There is no definitive evidence that BMD loss is more in women who became pregnant after
stopping MPA. There is slight loss of BMD during pregnancy (2-8 %) breastfeeding (3-5 %) and with

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 69

 use of MPA injectable contraceptive (5-6% in 5 years) which is reversible and can be compensated with
supplements.

By using an effective contraceptive method of choice, like MPA, a woman is protected from closely
spaced unwanted pregnancy and its consequences. (Please Refer to chapter 8 Special issues on MPA of
Reference Manual for Injectable Contraceptive MPA)

39. What would be MPA's effect on BMD during lactation?

Answer: There is no definitive evidence that MPA during lactation causes increased BMD loss. There is
slight loss of BMD during lactation (3-5 % over 6 months) and with use of MPA injectable contraceptive
(5-6% in 5 years) which is reversible and can be compensated with supplements. (Please Refer page 27
of Reference Manual for Injectable Contraceptive DMPA)

40. After how many injections of MPA will the protective effect against endometrial cancer continue
for 8 years after stopping method?

Answer: A study has shown that after using MPA for one year (at least 4 doses), the risk of endometrial
cancer reduces by 80% and this protective effect continues for at least 8 years after MPA use is
stopped.(Source: JFAM Pract. Nov.2004)

41. How does MPA reduce sickle cell crisis?

Answer: Progesterone hormone in MPA decreases sickling by stabilizing the cell membrane and
preventing RBCs from breaking down and clogging the blood vessels during the crisis and
suppressing the pain due to it.

42. How does MPA reduce epileptic seizures?

Answer: Progesterone seems to have a calming effect on the brain and thereby reduces epileptic
seizures.

43. Is there any drug interaction between MPA and anticonvulsants/ rifampicin or antipsychotics?

Answer: No, there is no known drug interaction between MPA and anticonvulsants or rifampicin or
antipsychotic drugs. The parenteral route of the progesterone in MPA bypasses the hepatic circulation,
thus there is no interaction with the hepatic enzymes. Therefore MPA can be given safely to women on
these drugs.

Oral Pills like COCs and POPs cannot be given to women on these drugs due to drug interaction with
these drugs.

44. How much weight do women gain when they use MPA?

Answer: Women may gain on an average 1–2 kg per year when using MPA. This weight gain may be
related to age, diet or sedentary lifestyle. At the same time, some users of MPA lose weight or have no
significant change in weight.

45. Does Injectable MPA change women's mood or sex drive?

Answer: Generally No, Some women using MPA report these complaints. The great majority of MPA
users do not report any such changes. However, it is difficult to tell whether such changes are due to
MPA or other reasons. Providers can help a client with these problems. There is no evidence that MPA
affect women's sexual behaviour.

70 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

46. Does MPA specifically cause depression?

Answer: No, MPA specifically does not cause depression, however it may cause mood swings in some
women. No study has shown it to cause or increase depression.

47. What is the correlation with use of Injectable MPA and risk of CA breast?

Answer: As per WHO MEC criteria MPA is not to be administered in women with recent or past h/o
breast cancer. Studies have shown that there is no correlation between use of MPA and increased
incidence of breast cancer. Few studies have shown that incidence of breast cancer with MPA use or
within 10 yrs. after stoppage of the drug are similar to COCs.

48. Does MPA-SC have a different effect on Bone Mineral Density compared to MPA-IM?

Answer: No, the effect of MPA-SC on bone density is similar to MPA-IM. Most studies have found that
women lose BMD while using MPA but regain all or partial BMD after discontinuation. According to
WHO, for women aged 18 to 45 years, there should be no restrictions on the use of MPA, including no
restrictions on the duration of its use; and the advantages for adolescents younger than 18 years of
using MPA generally outweigh the theoretical or proven risks, so they can also be given MPA.

49. Does Body Mass Index (BMI) affect the efficacy of MPA-SC?

Answer: No, Clinical studies to date demonstrate that the contraceptive efficacy of the active
ingredient in MPA-SC is not affected by body mass index (weight-to-height ratio).

Infection Prevention and Safe Injection Practices:

50. If hub /needle cutter is not available can puncture proof box be used for disposal of syringe and
needle?

Answer: Yes, if hub/needle cutter is not available puncture proof box can be used for segregation and
storage of used syringes. Before putting in puncture proof box, do not remove needle from syringe. A
puncture proof box can be prepared out of thick card board box or a plastic bottle can be used. Do not
use a glass container, as it can break. Dispose off puncture proof box safely when it is ¾ full.

51. Is antiseptic scrub as equally effective as washing hands with soap and water.

Answer: Yes, antiseptic scrub is equally as effective as washing hands with soap and water, but if
hands are visibly dirty, hand wash with soap and water should be done.

52. Do we have to wash our hands before and also after giving MPA injection?

Answer: Yes, hands should be washed both times, before and after giving MPA injections.

53. Should we use gloves while giving MPA injections?

Answer: No, one need not wear gloves while giving IM or SC injections of MPA but hands should be
washed properly following all six steps before and after giving injection.

54. What should be used to clean the injection site before administration of MPA injection?

Answer: Injection area should be cleaned with a swab of antiseptic.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 71

55. Can we use spirit or povidone iodine for cleaning injection site before administration of MPA?

Answer: Yes, both spirit or povidone iodine can be used as antiseptic solution. If spirit is used, it is
advised to wait till it dries and if Povidone iodine is used, wait for 2 minutes, so that free iodine is
released to make it effective.

Program Management:
56. How is MPA-SC different from MPA-IM?

Answer: There is no difference between MPA-SC and MPA-IM in terms of composition, mechanism of
action, safety, efficacy, benefits and side effects, except for the amount of drug and route of
administration. However, Uniject system of subcutaneous injectable contraceptive provides ease of
administration which minimizes chances of infection transmission and the potential to benefit system-
level logistics in terms of storage, transport, distribution and waste management.

57. Can a woman switch between MPA-IM and MPA-SC?

Answer: Yes, if necessary, because the active ingredient in the IM and SC formulations is identical, it is
safe to switch back and forth between these two formulations on a regular dosing schedule (i.e., every
three months) with the same level of contraceptive protection. Switching injectable is safe, and it does
not decrease effectiveness. If switching is necessary, the first injection of the new injectable should be
given when the next injection of the old formulation was due. Clients need to be informed and
explained about the name of the new injectable, and its injection schedule.

58. Is MPA-SC as effective as MPA-IM for contraceptive protection?

Answer: Yes, MPA-SC is as effective as MPA-IM. Studies have demonstrated that subcutaneous
injectable contraceptive Medroxy Progesterone Acetate (MPA-SC) provides efficacy, safety and
immediacy of contraceptive effect equivalent to the MPA-IM. In clinical trials, it effectively suppressed
ovulation for at least three months in all subjects regardless of ethnicity, race and body mass index.

59. Why do we need to keep the MPA I/M vial in an upright position?

Answer: MPA is an aqueous suspension of microcrystals which may stick around the cap area or in
deep corners of vial and may be unavailable during filling of the drug in the syringe, if the vial is not
kept straight.

60. Which type of supply of MPA-IM is currently available in public health facilities?

Answer: MPA-IM is available in single dose vial with disposable syringe & needle in public health
facilities.

61. How MPA vials should be stored in extremes of temperature (hilly cold terrains and hot zones in
summer)?

Answer: In cold terrains MPA vials are to be stored in wooden cupboard in closed room away from
extreme temperature, if needed some heating of the room can be done periodically. In hot zones, the
vials are to be stored in a well ventilated room away from direct sunlight and if needed some cooling of
the room could be done periodically.

62. If a woman receives first dose in a district hospital, can she take subsequent doses at a facility near
her place of residence?

Answer: Injectable Contraceptive MPA is being rolled out in a phase wise manner. For the first phase it
is upto DH and Medical Colleges and gradually will be rolled down to the SC level. Once it is available

72 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 at all level of facilities, it can be taken at any level of facility as per convenience.

63. Can ANM/LHV/SN give treatment for irregular bleeding after MPA injection?

Answer: ANM/LHV/SN can give treatment under the supervision of trained doctor

64. Is there any Telephonic Helpline for MPA clients?

Answer: Yes, the existing helpline under JSK has been strengthened for the same which bears the
telephone number1800 116 555

65. Why MPA register does not have a column for date of next injection?

Answer: MPA register format been kept simple with bare minimum information to avoid cluttering of
format. However date of next injection has been included in MPA card.

66. Can Nurses/LHVs become trainers for MPA?

Answer: Yes, the nurses & LHVs with prior experience of training, good communication, training
skills and attitude for conducting training be trained as trainer for MPA training as they are eligible to
administer the injections, counsel and follow up care

67. Whose responsibility is to provide Reference Manuals for the trainings?

Answer: Government of India approved sufficient budget for the printing of Reference Manuals and
conduction of training in each State PIPs, and respective state Govt has the responsibility to provide all
the Reference Manuals to the districts and its service providers.

68. What is the minimum number of trainers required for the trainings of MPA?

Answer: At least two trainers should be present throughout any training and facilitate it.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 73

 Annexure 5

Myths and Misconceptions about MPA

Myths/Misconceptions Facts and Realities

MPA causes infertility MPA users can expect to become pregnant within a year after discontinuing
their last injection. In a large study in Thailand, almost 70% of former MPA
users conceived within the first 12 months following discontinuation.
Moreover, 92% conceived within 24 months, compared with 93% of IUCD
users and 94% of COC users. There is no difference in the time it takes fertility
to return between long-term and short-term users and no difference between
women with and without amenorrhea.

MPA Research has clearly proven that MPA does not cause cancer. In fact, it has
causes cancer been demonstrated that it protects against endometrial cancer. A WHO
collaborative study of neoplasia and steroid contraceptives found no overall
increased risk of breast cancer, no increased risk of invasive cervical cancer
and no increased risk of ovarian or liver cancer.

MPA causes nausea Nausea is not common with MPA. In fact, many women on injectable
contraceptive reported increase in appetite.
MPA decreases amount Studies have shown that the amount of breast milk does not decrease when
of breast milk breastfeeding women use MPA. It has no effect on the composition of
breastmilk, initiation or duration of breastfeeding.
MPA affects women Amenorrhea is an expected result of using MPA because women do not
health by causing ovulate. This kind of amenorrhea is not harmful. It helps prevent anaemia
Amenorrhea and free women from the discomfort and inconvenience of monthly
bleeding.

MPA causes abnormal There is no evidence that MPA causes any abnormalities in infants. Studies
or deformed babies. done on infants who were exposed to MPA in utero showed no increase in
birth defects. These infants were followed until they were teenagers and the
research found that their long-term physical and intellectual development
was normal. It is worth noting that before MPA was recognized as a
contraceptive it was used in pregnant women to prevent miscarriage.
Clients need to stop There is no limit to the number of years MPA can be continuously used.
using MPA and have a Among healthy women it can be given until menopause, when contraception
‘rest’ after several is no longer needed.
injections.
MPA causes abortion MPA prevents ovulation. If no egg is released, no fertilization takes place
hence there are no chances of abortion.

74 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

Myths/Misconceptions Facts and Realities

MPA causes There is amenorrhea in pregnancy but not all amenorrhea is due to
amenorrhea, resulting pregnancy. The amenorrhea experienced with MPA use is due to the thinning
in pregnancy or a of the endometrium resulting from an increased level of progesterone.
tumour.

MPA causes anaemia During the first 3 - 6 months of MPA use, irregular bleeding may be
experienced in the form of spotting or minimal bleeding. But this usually
stops within a few months of continuous use of MPA. Since the bleeding is
minimal, it rarely results in anaemia. Anaemia, which is caused by blood loss
or iron deficiency, is actually prevented by MPA.
MPA causes masculine Studies have shown that the use of MPA does not cause any masculinizing
characteristics in effect.
females
MPA causes blood Amenorrhoea is caused by MPA use since it results in an atrophic
toxicity due to endometrium.
amenorrhoea.
MPA causes decrease in There may be other factors that result in a decrease in libido (e.g.,
libido. antihypertensive drugs, and exhaustion). However, MPA has a very minimal
effect on libido. On the contrary, the sense of security of not getting pregnant
may increase the libido of the client.
Was MPA banned in the No, in 1993 the MCRI approved MPA for use as a contraceptive, and it is
India because it was not available as a safe contraceptive. The decision to approve MPA came after an
considered safe? extensive review of the method as well as the unanimous recommendation
by an expert advisory medical panel.

MPA has just been MPA as a contraceptive method was developed in the 1960's. It has been
approved in public approved as a long-acting contraceptive method and is marketed in more
sector, it is still in the than 130 countries. To date, over 42 million women have used MPA, over
‘experimental’ stage 100,000 women have used it for more than 10 years, and currently between 8
and 9 million rely on MPA for contraceptive protection.
MPA causes onset of MPA does not affect menopause. The amenorrhea experienced with it only
menopause. occurs while using MPA. When a client discontinues using MPA, normal
menstruation will return.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 75

 Annexure 6

Role Play and Case Studies

6.1 Role Play

In a role-play two or more individuals enact parts in a scenario related to a training topic. The role-
play technique allows participants to ‘play’ the role of one or more individuals in a real life situation.
The role-play directly involves the participants in the training session. When the role-play involves
situations that participants are likely to encounter on their job. It can build self-confidence in training
situation hence are better prepared to deal with such incidents.

Since participants have a chance to put themselves in the other person’s position. By doing so, they
can empathize and at the end of the exercise is typically a practical doable answer and a real world
solutions. It provides an opportunity for learners to see how others might feel/behave in a given
situation helps to change participants’ attitude and enables participants to see the consequences of
their actions on others. It is stimulating and fun. It engages the group’s attention and simulates the
real world

The role-play is not without its disadvantages as it is done in an unreal or artificial atmosphere and
some participants may have difficulty visualizing themselves in an imaginary situation. The trainees
may feel very uncomfortable portraying any type of role. Without proper knowledge and
understanding in advance, the role-play is nothing more than a game. This method is much more
time consuming than other types of training. Role-plays may be made more effective if the
participants are given time to prepare.

6.2 Process of Conducting Role Play

Select any three participants for the role play. One to enact the role of a ‘client’, another as a
‘counsellor’ and the third person to be the ‘observer’. Select any of the sample role plays to be enacted
out from the options given below. Prepare the participants to understand the situation and their
respective roles, allowing only the ‘client’ to read through the case study.

Arrange the stage for optimal viewing and ensure that actors speak loudly and clearly. The
‘counsellor’ should enact the situation by assisting the client in the decision making process. Respect,
care, honesty and confidentiality should be emphasized and form the basis of the interaction with
the client.

The appointed ‘observer’ should share their observations about the role play which has been
enacted. Thank the actors and ask for their feedback. Finally ask the audience for their observations
of the role play and highlight the key principles as evinced from the play.

6.3 Sample MPA Role Plays

Counselling of Client

6.3.1 Role Play No. 1

A 35-year-old woman who smokes has heard that MPA may be a good method of family
planning. She asks that the service provider gives her information about MPA before making a
decision.

76 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 6.3.2 Role Play No. 2

A 27-year-old woman with one daughter comes to see you because she has heard about the
new “FP Injection" and wants to try it. She has an IUCD in place but doesn't like the menstrual
cramps and prolonged bleeding she is experiencing each month. The service provider
responds.

Selection of Client

6.3.3 Role Play No. 3

A 19-year-old comes to your facility requesting MPA. She had a baby three months ago. The
service provider will use the MPA checklist to screen her and see if it is an appropriate method
for her.

Management of Side Effects

6.3.4 Role Play No. 4

A 20-year-old woman who had her first MPA injection elsewhere three months ago comes to
see you. On the one hand, she likes the ‘Injection’ because she can use it without her mother-in-
law's knowledge. However, she is having a lot of menstrual irregularity about which she was
not forewarned, and she has heard that MPA causes permanent sterility. The service provider
responds.

6.3.5 Role Play No. 5

A 24-year-old woman has been using MPA very successfully since the birth of her daughter
three years ago. She has not had menses for the last two years. She and her husband want to
discuss the possibility of having another child. The service provider responds.

6.4 Case Study

A case study is a written description of a hypothetical situation that is used for analysis, discussion
and problem solving. It can be used to discuss common problems in a typical situation. It provides a
safe opportunity to develop problem-solving skills and promote group discussion.

The case study is another important technique that trainers should become familiar with and know
how to use properly. The case study is an actual presentation, either written or verbal, of an incident
that either did or could happen in related areas.

After having read or being given the case, small groups typically spend a prescribed period of time
discussing it and its possible solutions fully. Since the case should be an incident of relevance to the
training situation, its ‘real world’ application is obvious. The case study should be realistic so that
learner can relate to the situation .The trainers can select or write cases that are of relevance and
concern to the group at hand. If the case study does not reflect a real-life situation, trainees may view
the case as being too theoretical.

6.5 Process of Discussing Case Studies

• Introduce the case study

• Give the participants time to familiarize themselves with the case

• Present questions for the discussion or the problem to be solved

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 77

 • Give participants time to solve the problem/s

• Have some participants present their solutions/answers

• Ask the participants what they have learned from the exercise

• Ask them how the case might be relevant to their own environment, to their job experience

• Summarize

6.6 Sample MPA Case Studies

Selection of Client

6.6.1 MPA Case Study No. 1

Kavita is 20 years old. She delivered her second child 6 weeks ago and is breastfeeding. Her
first child died of diarrhea and dehydration at age of 8 months after Kavita weaned the baby
from breast milk to bottle when she was pregnant with the second child. Kavita has never used
a contraceptive method and now wishes to postpone her next pregnancy for three years. She
has heard about the new ‘injection’ and thinks this method may be a good one for her. Her
husband does not believe in using contraceptives and would like to conceive again soon to try
and have a son.

Discussion Questions

1. Is MPA an appropriate method for this woman? Why?

2. When could you give this woman her first injection?

3. What other spacing methods are appropriate for a 6 weeks postpartum woman?

4. What other spacing methods are appropriate for breastfeeding woman?

5. What are the advantages of MPA?

6.6.2 MPA Case Study No. 2

Neetu is a 23 year old mother of an 18 months old girl. She has been taking the OCP for 3
months but noticed she has nausea on the first day of starting a new pack. She would like to
switch to another method because of this. She plans to become pregnant again in about 6
months. She has heard that MPA is a good method for women who suffer from OCP side
effects and would like you to advise her on this.

Discussion questions:

1. Is MPA an appropriate method for this woman? Why?

2. What advice you would give her?

3. What are the disadvantages of MPA?

Management of Side Effects

6.6.3 MPA Case Study No. 3

Meenakshi is 20 years old and has a 1-year-old child. She started MPA six months ago but was
not given any information about side effects. She is due for her third injection today but missed
her menstrual period last month. She is very worried that she is pregnant even though she has

78 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 no symptoms of pregnancy. Otherwise, she likes the method and does not plan on getting
pregnant for at least two more years.

Discussion Questions

1. What advice would you give her about her missed period?

2. When should she stop using MPA if she wishes to get pregnant in two years?

6.6.4 MPA Case Study No. 4

Kiran is a 35-year-old woman with four children. She and her husband think they do not want
any more children but are not entirely certain, so she has been using MPA for 6 months. In the
past 3 months she has noticed a lot of light bleeding which hampers her day-to-day activities
such as cooking, social visits, coitus etc. She requests your advice. Apart from this, she and her
husband are very comfortable with MPA.

Discussion Questions:

1. Is spotting or light bleeding dangerous to health?

2. What advice will you give her? Give her three options.

3. Would you give her the same advice if she told you she was bleeding very heavily?

4. What advice would you give her if this were the case?

6.6.5 MPA Case Study No. 5

Kunti is on MPA since 2 months. She is having irregular bleeding /spotting. She is anxious
about it and visits her doctor.

Discussion Questions:

1. How should Kunti’s case be managed?

6.6.6 MPA Case Study No. 6

Deepa is on MPA. She was having irregular bleeding after first injection, for which Mefenamic
Acid was given to her. After 12 days, she comes to the doctor’s clinic again, saying that
bleeding is continuing. Deepa and her husband are very anxious about it.

Discussion Questions:

1. How should Deepa’s case be managed?

6.6.7 MPA Case Study No. 7

Farzana is on MPA since one year. Initially she had irregular bleeding for which you had
reassured her. Now she comes to your clinic and says that she has not had her menses since 2
months. Farzana is very worried that she might have become pregnant and visits her doctor.

Discussion Questions:

1. How should Farzana’s case be managed?

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 79

 Annexure 7

Competency-Based Checklist for Counselling

and Technical Skills for MPA Injection

Rate the performance of each step or task observed using the following rating scale:

1 Needs Improvement: Step or task not performed correctly or out of sequence (if necessary) or is
omitted

2 Competently Performed: Step or task performed correctly in proper sequence (if necessary) but
participant does not progress from step to step efficiently

3 Proficiently Performed: Step or task performed efficiently and precisely in proper sequence (if
necessary)

Step / tasks Cases Comment

Initial interview (client reception area) 1 2 3
1 Greets woman respectfully, makes her comfortable
and establish rapport.
2 Establishes purpose of the visit and answer questions.
3 Assures necessary privacy.
4 Provides general information about family planning.
5 Asks client about reproductive goals, to space or limit
births. Any method used currently or in past.
6 Give the woman information about the contraceptive
choices available and the risks and benefits for each.
Explain the difference between reversible and
permanent contraception. Correct rumors or
misinformation about all methods.
7 Helps client to make an informed choice.
Method specific counselling for MPA
8 Asks her if she knows about Injectable Contraceptive s.
Corrects any myths, rumours or misinformation she
may express.
9 Asks her past experience with Injectable ( if any)
10 Explains contraceptive & non-contraceptive benefits
of injectable.
11 Briefly explains how injectable works.
12 Explains potential common side effects of the injectable
contraceptive. Tells her that she may experience few (or
possibly none) of these but they can all be managed.
13 Reassures client that these side effects are not serious
and many will decrease or stop after a few months of
use.

80 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

Step / tasks Cases Comment
14 Describes the injection process and what the client
should expect during and after the procedure.
15 Responds to any questions or concerns the client may
have.
Pre procedure assessment
16 Screens client using ‘checklist for screening clients who
want to initiate Injectable’. Asks all questions on
checklist.
MPA specific tasks
17 Explains all sites where injection can be administered
and asks her preference. (Arm or buttock or thigh)
18 Shows sealed bottle and expiration date on label to
client.
19 Performs hand hygiene.
20 Cleans injection site with alcohol or antiseptic swab.
21 Rub bottle between palms or shakes gently. If vial is
cold, warm to skin temperature before giving the
injection.
22 Opens 2 ml sterile package of syringe with 21-23 gauge
intramuscular needle (attaches needle if needed).
23 Wipe rubber cover with an antiseptic. Inserts needle
into rubber cover of vial
24 Fills syringe with contents of the bottle. Expels air from
syringe.
25 Locates the exact site for injection preferred by client.
Wipe the site with an antiseptic.
26 Inserts needle deep into the muscle. Aspirate first to
ensure that the needle is not in the vein.
27 Gently presses the injection site with a clean cotton ball.
28 Places the used syringe into the sharps container.
29 Performs hand hygiene.
30 Instructs the client not to massage the site.
Post-injection tasks
31 Ensure that vital signs of client are monitored.
32 Tells the name of injection to client.
33 Calculate reinjection date (3 months or 13 weeks) and
agree on a date for next injection.
34 Assures her she is welcome to come back anytime if she has
problems, questions or wants another method.
35 Ensure that vital signs of client are monitored.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 81

Step / tasks Cases Comment
Waste management
36 Ensure that disposal of disposable needles and
syringes are as per guideline.
Post Injection Instruction
37 Emphasize on importance of MPA client card and date
of return for injection.
38 Emphasize on important instructions and asks the
client to repeat instructions.
39 Advise the client not to do hot fomentation.
40 Instructs client to return early if she has questions or
concerns.
41 Provides back-up method, if appropriate.
Counselling at the time of repeat Injection Visits
42 Asks how the client is doing with the method and
whether she is satisfied. Asks if she has any questions or
anything to discuss.
43 Asks especially if she is concerned about bleeding
changes. Gives her any information or help that she
needs.
44 Gives her the injection of MPA if she is up to 4 weeks
late or is up to 2 weeks early.
45 Plans for her next injection. Agrees on a date for her
next injection (in 3 months or 13 weeks for MPA.
Reminds her that she should try to come on time but she
should come back no matter how late she is.
46 Checks her blood pressure, if possible.
47 Asks a long-term client if she has had any new health
problems. Address problems as appropriate.
For new health problems that may require switching methods,
48 Asks a long-term client about major life changes that
may affect her needs particularly plans for having
children and STI/HIV risk. Follow up as needed.
Counselling a client who is more than 4 months late for injection
49 A client who is more than 4 weeks late for MPA,
provides injection only if:
• She has not had sex since 2 weeks after she should
have had her last injection, or
• She has used a backup method or has taken
emergency contraceptive pills (ECPs) after any
unprotected sex since 2 weeks after she should have
had her last injection.

82 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

Step / tasks Cases Comment
If the client is more than 4 weeks late for MPA and she does not meet above criteria
50 Takes additional steps to be reasonably certain that she
is not pregnant.
51 Discusses with the client why she was late and provides
solutions.
52 If coming back on time is often a problem, discusses
using a backup method when she is late for her next
injection, taking ECPs or choosing another method.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 83

 Annexure 8

Pre/Post - Test Questionnaire

Name: Time: 15 min

Designation:

Place of posting:

Date:

Pretest/Posttest: Please encircle

Please encircle most appropriate answer for each question. Please do not encircle more than one answer

1. MPA is composed of
a. Estrogen and progesterone
b. Synthetic progestin medroxyprogesterone acetate
c. Norethindrone enanthate
d. Synthetic estrogen derived from the natural hormone estrogen

2. Which of the following is NOT a mechanism of action for MPA?

a. Suppression of ovulation
b. Immobilizing sperms
c. Thickening of cervical mucus
d. Thinning of inner lining of uterus

3. The effectiveness of MPA if used correctly and consistently is:

a. 97%
b. 99.7%
c. 99%
d. 97.9%

4. The standard regime (dose and schedule) of MPA, given as Intramuscular injection or as
Subcutaneous injection, is
a. the same i.e. 150 mg of Medroxy Progesterone Acetate/ml to be given every 3 months
b. the same i.e. 200 mg of Medroxy Progesterone Acetate/ml to be given every 3 months.
c. for IM, it is 150 mg of Medroxy Progesterone Acetate/1ml every 3 months and for SC it is 104 mg/0.65
ml every 3 months
d. for IM, it is 150 mg. of Medroxy Progesterone Acetate/ml to be given every 3 months and for SC it
is 204 mg/ml every 3 months

5. Which of the following statements is true?

a. Subcutaneous MPA causes less side effects than Intramuscular MPA
b. Subcutaneous MPA causes less delay in return to fertility than Intramuscular MPA
c. Subcutaneous MPA acts for a longer duration than Intramuscular MPA
d. Subcutaneous MPA has same characteristics as those of Intramuscular MPA

84 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

6. Which of the following contraceptive methods is nearly as effective as MPA?
a. Combined Oral contraceptives
b. IUCD
c. Spermicides
d. Condoms
e. Standard Days Method

7. MPA may be appropriate for women who

a. Smoke cigarettes regardless of age or the number of cigarettes.
b. Have uncomplicated diabetes of less than 20 years
c. Are not married
d. Have just had an abortion or miscarriage
e. Have abnormal vaginal bleeding
f. All of above
g. Options - a, b, c & d

8. If a breast feeding woman comes for her first MPA injection 4 months after giving birth, and her
menses have not returned , can MPA be given to her today?
a. No because it can be given only after she has her first menstrual period
b. If she is fully breastfeeding i.e. 3 conditions of LAM are being met, MPA injection can be given today
and backup method is not required.
c. If the 3 conditions of LAM are being met, MPA injection can be given BUT backup method is required
till her menses return.
d. No because it can be given only after her baby is 6 months old.

9. When does fertility return after taking the last injection of MPA?
a. 7-10 months after taking the last injection of MPA
b. 5-6 months after taking the last injection of MPA
c. immediately after stopping the injection
d. fertility does not return as woman becomes infertile

10. Health benefits of MPA are:

a. Protects against endometrial cancer
b. Helps prevent Iron deficiency Anaemia
c. May reduce incidence of symptomatic PID
d. All of the above
e. None of the above

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 85

11. What monthly changes are not expected in menstrual cycle of clients who use MPA?
a. No change in bleeding pattern
b. Amenorrhoea
c. Irregular bleeding
d. Prolonged/ heavy bleeding

12. In which of the following situations can next dose of MPA be given?
a. Woman comes for next MPA injection after two and half months
b. Woman comes for next MPA injection after three months and five days
c. Woman comes for next MPA injection after four months
d. Woman comes for next MPA injection at four months and ten days and gives negative H/O
unprotected of intercourse,
e. Next dose can be given in all situations

13. Amenorrhea caused by MPA calls for

a. Discontinuation of method because woman is menopausal
b. Concern that it may be causing complications
c. Ruling out pregnancy and reassuring client
d. Giving women an estrogen tablet or injection

14. If a woman comes for MPA injection on day 10 of her menstrual cycle, can it be given to her?
a. No, she needs to come for MPA during day 1-7 of her next menstrual period
b. Yes, MPA can be given if there is no history of unprotected sex since her last period. Backup m e t h o d
is also required for next 7 days.
c. Yes, but she needs to be given a higher dose of MPA
d. Yes, she can be given MPA injection and no back up method is required

15. BMD loss with MPA

a. BMD decreases by 8-10% with five years of use and loss is irreversible
b. BMD decreases by 5-6% with five years of use and loss is reversible
c. BMD decreases by 10-15% with five years of use and is reversible
d. Huge loss of BMD, which can cause osteoporosis

16. In which of the following situations can next injection of MPA be given?
a. Woman comes for next MPA injection after two and a half months
b. Woman comes for next MPA injection after three months on scheduled date
c. Woman comes for next MPA injection after three months and five days
d. Woman comes for next MPA injection just after completing four months
e. Next dose can be given in all situations

86 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

17. Hepatitis-B has the …….% chance of transmission by sharps injury?
a. 3 – 4%
b. 10 – 30%
c. 10 – 12%
d. 50 – 60%

18. Informed written consent signed by client is required for providing

a. COC Pill
b. POP
c. Emergency contraceptive Pill
d. Injection MPA
e. Centchroman
h. IUCD
f. All of the above
g. None of the above

19. What are the post injection instructions to be given by the provider to MPA client?
a. Do not massage injection site
b. Do not apply hot fomentation
c. Expect menstrual changes and do not get unduly alarmed
d. To come on scheduled date for next injection
e. All of the above

20. Sharps (Needles and Vials) should be disposed off in

a. Red bins/bags
b. Black bins/bags
c. Blue or white bins/bags
d. Yellow bins/bags

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 87

 Annexure 8a

Answer Key Pre/Post - Test Questionnaire

Name: Time: 15 min

Designation:

Place of posting:

Date:

Pretest/Posttest: Please encircle

Please encircle most appropriate answer for each question. Please do not encircle more than one answer

1. MPA is composed of
a. Estrogen and progesterone
b. Synthetic progestin medroxyprogesterone acetate
c. Norethindrone enanthate
d. Synthetic estrogen derived from the natural hormone estrogen

2. Which of the following is NOT a mechanism of action for MPA?

a. Suppression of ovulation
b. Immobilizing sperms
c. Thickening of cervical mucus
d. Thinning of inner lining of uterus

3. The effectiveness of MPA if used correctly and consistently is:

a. 97%
b. 99.7%
c. 99%
d. 97.9%

4. The standard regime (dose and schedule) of MPA, given as Intramuscular injection or as
Subcutaneous injection, is
a. the same i.e. 150 mg of Medroxy Progesterone Acetate/ml to be given every 3 months
b. the same i.e. 200 mg of Medroxy Progesterone Acetate/ml to be given every 3 months.
c. for IM, it is 150 mg of Medroxy Progesterone Acetate/1ml every 3 months and for SC it is 104
mg/0.65 ml every 3 months
d. for IM, it is 150 mg. of Medroxy Progesterone Acetate/ml to be given every 3 months and for SC it is
204 mg/ml every 3 months

5. Which of the following statements is true?

a. Subcutaneous MPA causes less side effects than Intramuscular MPA
b. Subcutaneous MPA causes less delay in return to fertility than Intramuscular MPA
c. Subcutaneous MPA acts for a longer duration than Intramuscular MPA
d. Subcutaneous MPA has same characteristics as those of Intramuscular MPA

88 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

6. Which of the following contraceptive methods is nearly as effective as MPA?
a. Combined Oral contraceptives
b. IUCD
c. Spermicides
d. Condoms
e. Standard Days Method

7. MPA may be appropriate for women who

a. Smoke cigarettes regardless of age or the number of cigarettes.
b. Have uncomplicated diabetes of less than 20 years
c. Are not married
d. Have just had an abortion or miscarriage
e. Have abnormal vaginal bleeding
f. All of above
g. Options - a, b, c & d

8. If a breast feeding woman comes for her first MPA injection 4 months after giving birth, and her
menses have not returned , can MPA be given to her today?
a. No because it can be given only after she has her first menstrual period
b. If she is fully breastfeeding i.e. 3 conditions of LAM are being met, MPA injection can be given
today and backup method is not required.
c. If the 3 conditions of LAM are being met, MPA injection can be given BUT backup method is required
till her menses return.
d. No because it can be given only after her baby is 6 months old.

9. When does fertility return after taking the last injection of MPA?
a. 7-10 months after taking the last injection of MPA
b. 5-6 months after taking the last injection of MPA
c. immediately after stopping the injection
d. fertility does not return as woman becomes infertile

10. Health benefits of MPA are:

a. Protects against endometrial cancer
b. Helps prevent Iron deficiency Anaemia
c. May reduce incidence of symptomatic PID
d. All of the above
e. None of the above

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 89

11. What monthly changes are not expected in menstrual cycle of clients who use MPA?
a. No change in bleeding pattern
b. Amenorrhoea
c. Irregular bleeding
d. Prolonged/ heavy bleeding

12. In which of the following situations can next dose of MPA be given?
a. Woman comes for next MPA injection after two and half months
b. Woman comes for next MPA injection after three months and five days
c. Woman comes for next MPA injection after four months
d. Woman comes for next MPA injection at four months and ten days and gives negative H/O
unprotected of intercourse,
e. Next dose can be given in all situations

13. Amenorrhea caused by MPA calls for

a. Discontinuation of method because woman is menopausal
b. Concern that it may be causing complications
c. Ruling out pregnancy and reassuring client
d. Giving women an estrogen tablet or injection

14. If a woman comes for MPA injection on day 10 of her menstrual cycle, can it be given to her?
a. No, she needs to come for MPA during day 1-7 of her next menstrual period
b. Yes, MPA can be given if there is no history of unprotected sex since her last period. Backup
method is also required for next 7 days.
c. Yes, but she needs to be given a higher dose of MPA
d. Yes, she can be given MPA injection and no back up method is required

15. BMD loss with MPA

a. BMD decreases by 8-10% with five years of use and loss is irreversible
b. BMD decreases by 5-6% with five years of use and loss is reversible
c. BMD decreases by 10-15% with five years of use and is reversible
d. Huge loss of BMD, which can cause osteoporosis

16. In which of the following situations can next injection of MPA be given?
a. Woman comes for next MPA injection after two and a half months
b. Woman comes for next MPA injection after three months on scheduled date
c. Woman comes for next MPA injection after three months and five days
d. Woman comes for next MPA injection just after completing four months
e. Next dose can be given in all situations

90 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

17. Hepatitis-B has the …….% chance of transmission by sharps injury?
a. 3 – 4%
b. 10 – 30%
c. 10 – 12%
d. 50 – 60%

18. Informed written consent signed by client is required for providing

a. COC Pill
b. POP
c. Emergency contraceptive Pill
d. Injection MPA
e. Centchroman
h. IUCD
f. All of the above
g. None of the above

19. What are the post injection instructions to be given by the provider to MPA client?
a. Do not massage injection site
b. Do not apply hot fomentation
c. Expect menstrual changes and do not get unduly alarmed
d. To come on scheduled date for next injection
e. All of the above

20. Sharps (Needles and Vials) should be disposed off in

a. Red bins/bags
b. Black bins/bags
c. Blue or white bins/bags
d. Yellow bins/bags

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 91

 Annexure 9

Evaluation of Training

Name______________________________________________________Designation_____________________

Date_______________________________________________________District_________________________

Put (Tick P) in front of your response

S. No. Item Excellent Very Good Good Satisfactory Poor

1 Organization of the
workshop

2 Subject matter covered

3 Duration of workshop

Effectiveness of
4
facilitators
Overall evaluation of
5
workshop

6. Please share with us the sessions you found most useful (include reasons why)?

7. Please share with us the sessions that you found least useful (include reasons why)?

8. Please share any suggestions on how to improve the workshop or a particular session?

92 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

9. Please share how you will be using the knowledge gained in workshop to include MPA Services in
your work place?

10. What support you will need to provide MPA services in your work place?

11. Other Comments

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 93

 Annexure 10

Post Training Follow Up Checklist

Instructions to trainer:

• Complete one form per trainee during follow up (Telephonic/Visit). Form has three parts: Part I-
General assessment, Part II-Clinical Performance Assessment and Part III-Action Plan

• At the end of assessment review gaps identifiedwith trainee and share the actions recommended.

Part I: General Assessment

State District Facility Name
Facility type: Date of Trainings: Date of follow up:

No. of this Follow up 1st/2nd/3rd

(Tick (P) one Choice)
Person conducting follow up
Name:
Designation:

Name of the Trainee Designation:

Trainee is providing injectable contraceptive services? (Tick (P) one Choice) Yes /No
What are the numbers of services/procedures that were performed?
Procedure Last month Last quarter
Counselling
Injectable
If you are not providing any of the services, what difficulties have prevented you?
Tick (P) all that apply
1. Lack of supply of vials
2. Lack of supply of syringes
3. Lack of demand or clients seeking for the service
4. Time constraint due to excess workload
5. Service is not provided in the facility
6. Lack of confidence in skill
7. Other (specify) …………………………….………………………………………
If you are providing services, have you experienced any difficulties during service provision?
If yes, Tick (P) accordingly
1. Shortage of Supplies
2. Low case load
3. High case load
4. Lack of confidence in skill
5. Other (specify) ………………………………………………………..……………………………

94 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

Part II: Clinical Performance Assessment:

Observe the procedure based on the competency based checklist (in case a client is available), rate
trainee’s performance by checking in the appropriate box for the procedure. Please refer the
competency checklist as in Annexure 7. Based on assessment draw a plan of action

Part III: Action Plan

Table below should be utilized by trainer for developing action plan based on gaps identified from
above assessment for remedial actions and share with the trainee.

Trainers Action Plan

S.No. Gaps identified Support required Timeline Remarks
1.
2.
3.
4.
5.
Signature of the trainer

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 95

 Format of Facility Register for MPA (Antara Program)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34

96
Timing of Injection II Injection III Injection IV
Injection I
Follow up Follow up Follow up
Finding Finding Finding

LMP
Interval
Post-abortal

Client's Age
Post-partum
(IM/SC)

Annual S. No
(IM/SC)

Clients' Name
Blood Pressure

Last Child Birth

Date of Injection

Client’s Address

OPD No/IPD No.

Type of MPA

Body Weight

Telephone Number
Initial Body Weight

(whichever applicable)
Date of Injection

Menstrual Cycle
Date of Injection
Body Weight

Any Other finding

Menstrual Cycle
Date of Injection
Remarks, if any

Type of MPA Administered

Menstrual Cycle

Number of Living Children

Administered (IM/SC)
Any Other finding
Any Other finding

(Intramuscular- IM/Sub Cutaneous-SC)

Type of MPA Administered

Any Significant Medical History

Body Weight
Type of MPA Administered
Reason for Discontinuation

(in case of lactating women write LA)

Instruction Sheet:
Column 1: Fill the annual serial number, the number will be different for all the clients.
Column 2: Fill the OPD or IPD number, whichever is applicable for the client.
Column 3-7: Fill in the information of the client.
Format of Facility Register for MPA

Column 8: Mention the period (Month and Year) of last child birth.
Column 9: Mention the (Date, Month & Year) LMP. For women who are in Lactational Amenorrhoea please write LA in the respective column.
Column 10-11: Write the findings for Body weight (in kg) and Blood Pressure.
Column 12: Write any significant medical history.
Column 13, 18, 23, 28: Write IM/SC for the type of MPA administered
Column 14, 19, 24 and 29: Write the date of second, third and fourth injection (dd/mm/yy).
Column 15-17: Tick (3) the appropriate column.
Column 20-22; 25-27; 30-32: Write the follow up findings- (Menstrual Cycle-Irregular bleeding, prolonged bleeding and amenorrhea) (Write body
weight in kg) (Any other finding-Write any significant finding, Write NAD in case of no significant finding).
Column 33: Note the reasons for discontinuation.
Column 34: Note the additional remarks (in case the client discontinues injectable, write the contraceptive suggested).
Annexure 11

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 Duration Session Title Training Objectives Resource Materials
LCD projector, laptop, screen, flip charts for throughout the training
30 min Welcome & Introduction, • Open course with welcome of participants by organizers, lead trainers facilitate the • ·Welcome note,
Participants' Expectations introductions of all participants and trainers. • Flipchart and
markers
Training

& Group Norms • Ask participants' expectations and put up on a flip chart, enlist the
• Name badges
norms to be followed by brainstorming.
• Paste it papers
• Orient participants to the material in kit e.g. Reference Manual for
Injectable Contraceptive (MPA), pamphlets, sample of counselling aid etc.

20 min Pre Course Knowledge • Distribute the Pre-course knowledge assessment and tell its importance. Allow 15 • Copies of Pre-Test
Assessment. minutes for completing it. questionnaire

30 min National Family welfare • Using the PPT, discuss/explain National Family Welfare Program • PPT
programme and need for and need for expanding contraceptive choice. Global use of MPA in National Family
expanding contraceptive Welfare Program
choice

60 min Technical Aspects of MPA • Share historical background and types of injectable contraceptives. Discuss and • PPT
Injectable Contraceptive explain technical aspects of MPA(Both IM and SC): Mechanism of action, safety & • Handouts
(IM and SC) effectiveness, contraceptive and non-contraceptive benefits & limitations • Pregnancy Screening
Special Issues with Emphasize on the Return of fertility. Explain that return of fertility may take 7-10 Checklist
MPA months from date of last injection (average 4-6 months after 3 months effect of last • Sample of all
injection is over) and studies show that ovulation/fertility return is not affected by contraceptives
duration of MPA use or women's age.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

Course Outline (Session Plans) for MPA

• Explain initiation of MPA, including use of Pregnancy Checklist to be reasonably

certain that the woman is not pregnant.
• Explain issues related to Adolescents, women of age >35, post-partum women and
failure of pregnancy, Bone mineral density, cancer risk, HIV risk, metabolic effects
and cardiovascular effects, MPA failure one by one and clarify doubts if any.

Working Tea

60 min Counselling clients on • ·Review importance and purpose of counselling. Emphasise that provider's attitude • PPT
Family Planning methods towards clients have an effect on the quality ofcounselling and quality of care • Role Play
provided to clients. Review the basic principles of counselling. Discuss GATHER
approach including General principles of counselling

97
Annexure 12
 Duration Session Title Training Objectives Resource Materials
• General principles of • Explain points for Method specific counselling related to MPA, as given • Copies of checklists

98
counselling in Reference Manual for Injectable Contraceptive (MPA). and Reference
• Method specific Project through PPT each myth related to MPA and ask the group manuals
counselling for MPA for the fact. Then trainer should project the fact and explain. Now
Practice by explain how women can be counselled for menstrual changes in
Participants through
a simple non alarming way, by dispelling myths and explaining why
Role Play, using
menstruation occurs and why it stops with MPA.
Competency Based
• Ask participants to open the Competency –Based checklist for
Checklist
Counselling from Reference Manual for Injectable Contraceptive
(MPA) and quickly go through it upto point # 15. Emphasise that
each point is important while counselling.
• Project Role Play situation on FP counselling from Reference Manual for
Injectable Contraceptive (MPA). Get volunteers to enact in front of all the
participants. Remaining participants and trainer should observe the
role-play through checklist and after the role-play, facilitate a discussion
about what was done well, what was not done and what could be done
differently.
• After participants' feedback, trainer to provide necessary feedback,
as required.

45 min Eligibility criteria and • Discuss that once woman chooses MPA or any other method, • PPT
client assessment for provider needs to be sure she can be given the method chosen. For • Hand outs
injectable contraceptives • Pregnancy
this purpose, WHO has clear guidelines called MEC for contraceptive
using WHO MEC use. Screening Checklist
• WHO MEC wheel
• Explain 4 categories of WHO MEC. Point out that sometimes
providers unwittingly create medical barriers for contraceptive use
by denying methods in conditions where they can be given.
• Introduce the MEC Wheel, explain how it is used while screening
women for MPA or any other method
• Now discuss screening checklist for use of MPA (Annexure 1 in
Reference Manual for Injectable Contraceptive (MPA ) which is

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

based on WHO MEC.
 Duration Session Title Training Objectives Resource Materials

45 min Administering • Ask questions to participants to share their experience in giving IM and • PPT
Injectable Contraceptive SC injections. • All supplies/items
(IM and SC) • Discuss the following: Storage of MPA vials, pre injection preparation, for giving injection
site of injection (Both IM and SC). including sample
• Explain in details the preparation of injector, activation and of MPA
administration in case of SC Injectable
• Explain/Demonstrate the correct procedure for giving injection
and each participants to explain/demonstrate the actual injection
procedures, post-injection care/post injection instructions to the
client.

Lunch

60 min Follow Up Care of • Explain the importance of follow up care to clients and how it helps to • MPA Client
MPA Clients and continue using the method. Discuss ways for reminding clients to return card
Management of Side for repeat dose on time. Explain protocols for client coming on time,
Effects defaulters and dropouts.
• Discuss that side effects are the most common cause of discontinuation
and need to be managed timely in appropriate manner.
• List the possible side effects of MPA (refer from Reference Manual for

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

Injectable Contraceptive (MPA)).
• 3 Case Studies: Divide participants into small groups. Give one case
study (out of 3) to each group. Give 5-7 min to discuss management of
case. Trainer to discuss each case one by one and add when necessary.
• Explain management of menstrual changes one by one through PPT.
• End the session by emphasizing that for side effects, reassurance and
correct management can help clients to continue using the method and
decrease drop outs.

99
 Duration Session Title Training Objectives Resource Materials

100
15 min Prevention of Infection • Facilitate a recap of the general concepts of infection prevention as • Flip charts
& Safe Injection they relate to provision of MPA services Reference manual
practices Side
10 Min Tea Break
15 min Review Pre course • Read out the questions for which incorrect response have been • Filled pretest
knowledge assessment. written. Take a note of incorrect responses and explain Questionnaire
to the participants.

30 min Program management • Start the session by explaining the GoI plan to roll out new • Flip charts
& QA Capacity building contraceptives. Explain the plan for phase wise roll out of Injectables • Reference manual
of providers MPA. for Injectable
• Brainstorm on the determinants of quality family planning services.
Show slides on program determinants. Explain each determinant.
• Highlight the eligibility criteria for service providers in case of MPA.
• Highlight that regular uninterrupted supply is important for quality
services. Ask them to share what is to be done to ensure regular
supplies at state and district level. Explain the role of demand
estimation for Injectable and Oral contraceptives.
• Discuss how to procure and maintain stock of MPA and oral
contraceptives and clarify that in case of Injectable there is hardly any
adverse event and if any they are similar to any normal injection.
Emphasize role of SQAC/ DQAC
• For MPA ask them the key areas and standards to be met for quality
MPA services. Explain each key area with help of power point slides.
Share the reporting formats for both contraceptives. Refer to
reference manuals.

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

 Duration Session Title Training Objectives Resource Materials
15 min • Record Keeping and • Explain the importance of Record keeping. • Formats of
Reporting Formats • Share formats of register and MPA client card and discuss how to Register and
fill them up. Trainers may use an example for the same MPA client card
• Discuss the importance of assigning the one nodal person in the from Reference
health facility who will ensure that record of each new and repeat Manual for
client is recorded correctly in a timely manner. Injectable
Contraceptive
(MPA)

30 min • Post-Test, Course • Have participants fill-out and submit the course evaluation forms. • Post Test
Evaluation and • Closing remarks by training organizers. questionnaire
closure • Answer sheets
Evaluation forms

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

101
References

1. Saifuddin Ahmed, Qingfeng Li, Li Liu, Amy O Tsui. 2012. Maternal deaths averted by contraceptive
use: an analysis of 172 countries. Lancet. 380: 111–25
2. Population Foundation India. Evidences on Contraceptive Method Mix in developing countries:
South/ South-East Asia. [accessed on 11/3/2016] http://populationfoundation.in/wp-content/uploads
/2016/02/3-Contraceptive-Method-Mix-_Infographic_Final-1.pdf
3. Dr. R.K Srivastava et al. September 2012. Injectable Contraceptives to Expand the Basket of Choice
under Family Planning Programme: An Update. www.nifhw.org; accessed on 9/3/16
4. Jain J, Jakimiuk AJ, Bode FR, Ross D, Kaunitz AM. 2004. Contraceptive efficacy and safety of MPA-SC.
Pubmed. 70(4):269
5. Hubacher D, Lopez L, Steiner MJ, Dorflinger L. 2009. Menstrual pattern changes from levonorgestrel
subdermal implants and MPA: systematic review and evidence-based comparisons. Pubmed.
80(2):113-8
6. Association of Reproductive Health Professionals. [accessed on 20/1/2016] https://www. arhp.org/
Publications-and-Resources/Quick-Reference-Guide-for- Clinicians/choosing /Injectable;
7. Arias RD, Jain JK, Brucker C, Ross D, Ray A. September 2006. Changes in bleeding patterns with depot
medroxyprogesterone acetate subcutaneous injection 104 mg. Pubmed. 74(3):234-8.
8. Kaunitz AM, Arias R, McClung M. Feb 2008. Bone density recovery after depot medroxyprogesterone
acetate injectable contraception use. PubMed. 77 (2): 67–76.
9. Harel Z, Johnson CC, Gold MA, Chrome B, Peterson E, Burkman R et al. April 2010. Recovery of bone
mineral density in adolescents following use of Depot medroxyprogesterone acetate injections.
Pubmed. 81 (4): 281-91.
10. Contraceptive Technology and health series. [accessed on 22/1/16]
http://www.fhi360.org/sites/default/files/webpages/Modules/INJ/s2pg14.htm
11. Department of Health and Human Services. Updated July 2003. Exposure to Blood: What Healthcare
Personnel Need to know. [Accessed on 21/1/16]. Centers for Disease Control and prevention.
http://www.cdc.gov/HAI/pdfs/bbp/Exp_to_Blood.pdf
12. S AYA N A P R E S S 1 0 4 m g / 0 . 6 5 m l s u s p e n s i o n f o r i n j e c t i o n . A u g 2 0 1 6 .
https://www.medicines.org.uk/emc/medicine/27798. Accessed on 28 Sep 2016
13. SAYANA PRESS 104 mg/0.65 ml suspension for injection, Package Leaflet: Information for the user.
https://www.medicines.org.uk/emc/PIL.27799.latest.pdf accessed on 28 Sep 2016
14. Jain J et al. 2004. Contraception. Vol. 70(4):269-275.
15. Sandwich, UK: Pfizer Ltd. SAYANA®. Summary of Product Characteristics. July 2007.
16. Government of India. 2016. Reference Manual for Injectable Contraceptive DMPA.
17. Andrew M Kaunitz. Depot medroxyprogesterone acetate for contraception. Aug 2016.
http://www.uptodate.com/contents/-medroxyprogesterone-acetate-for-contraception accessed on 5
Oct 2016
18. Bonnie Keith. Home-based administration of depo-subQ provera 104™ in the Uniject™ injection
system. A literature review. July 2011.
19. Medicines and Healthcare Products Regulatory Agency. Public Assessment report 2011– Sayanaject
104 mg suspension for injection (Medroxyprogestrone Acetate), Pfizer ltd– UK/H/ 5497/001/ DC.

102 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

List of Experts
Dr. Alok Banerjee Dr. B. P. Singh Dr. Ravi Anand
Technical Advisor President Director, Technical & Operations
Parivar Sewa Sanstha Enable Health Society Abt Associates
New Delhi New Delhi New Delhi

Dr. Sunita Singal Dr. Saswati Das Dr. Vivek Yadav

Senior Clinical Advisor Director, Clinical Services and Associate Director
Engender Health Training Jhpiego Jhpiego
New Delhi New Delhi New Delhi

Dr. Abha Singh Dr. Suneeta Mittal Dr. Basab Mukherjee

Director & Professor Director and HOD, O & G Chairperson, Family Welfare
Dept of Obstertric and Gynaec Fortis Memorial Research Committee FOGSI
LHMC, New Delhi Institute, Gurgaon Kolkata, West Bengal

Dr. Malabika Roy Dr. Bulbul Sood Dr. Jyoti Vajpayee

Scientist G & Head Country Director FP Head
ICMR Jhpiego BMGF
New Delhi New Delhi New Delhi

Dr. Brinda Frey Dr. Loveleen Johri Dr. Vasanthi Krishnan

Director Clinical Services Senior Health & Policy Advisor Project Director
Engender Health Department of Health and Comprehensive Contraceptive
Lucknow Human Services, New Delhi Care Project IPAS, New Delhi

Dr. Shubhra Phillips Dr. Jyoti Sachdeva Dr. Minati Rath

Country Director Programme Officer Senior Clinical Officer
PCI New Delhi Jhpiego
New Delhi New Delhi

Dr. Pratima Mittal Dr. Ashim Ghatak Dr. Rupali Dewan

HOD, Dept. of O & G Chief Scientist & Head Dept. of O & G
Safdarjang Hospital CSIR- CDRI, Lucknow Safdarjang Hospital
New Delhi New Delhi

Dr. Rashmi Kukreja Dr. Rajkumar Dr. Shikha Srivastava

Health Advisor Programme Officer Advisor Technical Services
DFID Karnataka PSI
New Delhi Lucknow

Dr. Roli Seth Dr. Ajit K Mohanty Dr. Anita Verma

Deputy Director (CBQA) State Programme Officer CMO, NFSG
Abt Associates Odisha Family Welfare
Lucknow RML Hospital, New Delhi

106 REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA)

Dr. S R Kulkarni Dr. Teja Ram Dr. S. K. Sikdar
Scientist DC, FP DC, FP (I/C)
CSIR- CDRI MOHFW MOHFW
Lucknow

Support Extended By

Dr. Nidhi Bhatt Ms. Shilpa John Mr. Nadeem Akhtar Khan
Program Officer Consultant Program Manager
NTSU, FP FP Division NTSU, FP
MoHFW MoHFW MoHFW

Dr. Pragati Singh Ms. Shikha Bansal Dr. Upasna Naik

Lead Consultant Program Officer Program Officer
FP Division NTSU, FP NTSU, FP
MoHFW MoHFW MoHFW

REFERENCE MANUAL FOR INJECTABLE CONTRACEPTIVE (MPA) 107

March 2016
Family Planning Division
Ministy of Health and Family Welfare
Government of India