Backup methods

* Backup methods include abstinence, male and female condoms, spermicides, and withdrawal.

Tell her that spermicides and withdrawal are the least effective contraceptive methods.

If possible, give her condoms.

Providing progestin-only injectables

When to start
Giving advice on side effects
Giving the injection
Supporting the user
“Come back any time”: reasons to return

When to start

Important: a woman can start injectables any time she wants if it is reasonably certain she is not pregnant. To be reasonably certain she is not pregnant, use the Pregnancy Checklist (see p. 372).

Woman’s situation	When to start
Having menstrual cycles or switching from a nonhormonal method	Any time of the month If she is starting within 7 days after the start of her monthly bleeding, no need for a backup method. If it is more than 7 days after the start of her monthly bleeding, she can start injectables any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days after the injection. Backup methods include abstinence, male and female condoms, spermicides, and withdrawal. Tell her that spermicides and withdrawal are the least effective contraceptive methods. If possible, give her condoms. If she is switching from an IUD, she can start injectables immediately (see Copper-Bearing IUD, Switching From an IUD to Another Method, p. 148).
Switching from a hormonal method	Immediately, if she has been using the hormonal method consistently and correctly or if it is otherwise reasonably certain she is not pregnant. No need to wait for her next monthly bleeding. No need for a backup method. If she is switching from another injectable, she can have the new injectable when the repeat injection would have been given. No need for a backup method.
Woman’s situation	When to start
Fully or nearly fully breastfeeding Less than 6 months after giving birth	If she gave birth less than 6 weeks ago, delay her first injection until at least 6 weeks after giving birth. If her monthly bleeding has not returned, she can start injectables any time between 6 weeks and 6 months. No need for a backup method. If her monthly bleeding has returned, she can start injectables as advised for women having menstrual cycles (see previous page).
More than 6 months after giving birth	If her monthly bleeding has not returned, she can start injectables any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days after the injection. If her monthly bleeding has returned, she can start injectables as advised for women having menstrual cycles (see previous page).
Partially breastfeeding Less than 6 weeks after giving birth	Delay her first injection until at least 6 weeks after giving birth.
More than 6 weeks after giving birth	If her monthly bleeding has not returned, she can start injectables any time it is reasonably certain she is not pregnant. Where a visit 6 weeks after childbirth is routinely recommended and other opportunities to obtain contraception limited, some providers and programs may give the first injection at the 6-week visit, without further evidence that the woman is not pregnant, if her monthly bleeding has not yet returned. She will need a backup method for the first 7 days after the injection. If her monthly bleeding has returned, she can start injectables as advised for women having menstrual cycles (see previous page).
Woman’s situation	When to start
Not breastfeeding Less than 4 weeks after giving birth	She can start injectables at any time. No need for a backup method.
More than 4 weeks after giving birth	If her monthly bleeding has not returned, she can start injectables any time it is reasonably certain she is not pregnant. Where a visit 6 weeks after childbirth is routinely recommended and other opportunities to obtain contraception limited, some providers and programs may give the first injection at the 6-week visit, without further evidence that the woman is not pregnant, if her monthly bleeding has not yet returned.She will need a backup method for the first 7 days after the injection. If her monthly bleeding has returned, she can start injectables as advised for women having menstrual cycles (see p. 68).
No monthly bleeding (not related to childbirth or breastfeeding)	She can start injectables any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days after the injection.
After miscarriage or abortion	Immediately. If she is starting within 7 days after first- or second-trimester miscarriage or abortion, no need for a backup method. If it is more than 7 days after first- or secondtrimester miscarriage or abortion, she can start injectables any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days after the injection.
After taking emergency contraceptive pills (ECPs)	She can start injectables on the same day as the ECPs, or if preferred, within 7 days after the start of her monthly bleeding. She will need a backup method for the first 7 days after the injection. She should return if she has signs or symptoms of pregnancy other than not having monthly bleeding (see p. 371 for common signs and symptoms of pregnancy).

Giving advice on side effects

Important: thorough counselling about bleeding changes and other side effects must come before giving the injection. Counselling about bleeding changes may be the most important help a woman needs to keep using the method.

Describe the most common side effects

For the first several months, irregular bleeding, prolonged bleeding, frequent bleeding. Later, no monthly bleeding.
Weight gain (about 1–2 kg per year), headaches, dizziness, and possibly other side effects.

Explain about these side effects

Side effects are not signs of illness.
Common, but some women do not have them.
The client can come back for help if side effects bother her.

Giving the injection

1. Obtain one dose of injectable, needle, and syringe

DMPA: 150 mg for injections into the muscle(intramuscular injection).

NET-EN: 200 mg for injections into the muscle.

If possible, use single-dose vials. Check expiration date. If using an open multidose vial, check that the vial is not leaking.

DMPA: A 2 ml syringe and a 21–23 gauge intramuscular needle.

NET-EN: A 2 or 5 ml syringe and a 19-gauge intramuscular needle. A narrower needle (21–23 gauge) also can be used.

For each injection use a disposable auto-disable syringe and needle from a new, sealed package (within expiration date and not damaged), if available.

2. Wash

Wash hands with soap and water, if possible.
If injection site is dirty, wash it with soap and water.
No need to wipe site with antiseptic.

3. Prepare vial

DMPA: Gently shake the vial.
NET-EN: Shaking the vial is not necessary.
No need to wipe top of vial with antiseptic.
If vial is cold, warm to skin temperature before giving the injection.

4. Fill syringe

Pierce top of vial with sterile needle and fill syringe with proper dose.

5. Inject formula

Insert sterile needle deep into the hip (ventrogluteal muscle), the upper arm (deltoid muscle), or the buttocks (gluteal muscle, upper outer portion), whichever the woman prefers. Inject the contents of the syringe.
Do not massage injection site.

Sites suitable for injection: side of abdomen, side of shoulder, side of hip

6. Dispose of disposable syringes and needles safely

Do not recap, bend, or break needles before disposal.
Place in a puncture-proof sharps container.
Do not reuse disposable syringes and needles. They are meant to be destroyed after a single use. Because of their shape, they are very difficult to disinfect. Therefore, reuse might transmit diseases such as HIV and hepatitis.
If reusable syringe and needle are used, they must be sterilized again after each use (see Infection Prevention in the Clinic, p. 312).

Supporting the user

Give specific instructions

Tell her not to massage the injection site.
Tell the client the name of the injection and agree on a date for her next injection.

“Come back any time”: reasons to return before the next injection

Assure every client that she is welcome to come back any time—for example, if she has problems, questions, or wants another method; she has a major change in health status; or she thinks she might be pregnant.

General health advice: Anyone who suddenly feels that something is seriously wrong with her health should immediately seek medical care from a nurse or doctor. Her contraceptive method is most likely not the cause of the condition, but she should tell the nurse or doctor what method she is using.

Planning the Next Injection

1. Agree on a date for her next injection in 3 months (13 weeks) for DMPA, or in 2 months (8 weeks) for NET-EN. Discuss how to remember the date, perhaps tying it to a holiday or other event.

2. Ask her to try to come on time. She may come up to 2 weeks early or2 weeks late and still get an injection.

3. She should come back no matter how late she is for her next injection. If more than 2 weeks late, she should abstain from sex or use condoms, spermicides, or withdrawal until she can get an injection. She can also consider emergency contraceptive pills if she is more than 2 weeks late and she has had unprotected sex in the past 5 days (see Emergency Contraceptive Pills, p. 45).

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