Lessons learned from a public sector community-based distribution program for scaling up DMPA-SC contraceptive services in Nigeria

Background: From August 2016 to December 2017, the United Nations Population Fund (UNFPA) in Nigeria, through three implementing partners, scaled up the public sector delivery of subcutaneous depot medroxyprogesterone acetate (DMPA-SC, brand name Sayana Press) across 10 states. The public sector program featured a proactive community-based distribution (CBD) model, led by community health extension workers (CHEWs) and supported by community health volunteers (CHVs). Methods: We conducted monitoring and evaluation (M&E) alongside program implementation to understand the program’s reach, particularly in terms of clients served, and their proportions of new users of modern contraception and younger women. Key performance indicators (KPIs) were calculated from end-user data digitized from client registers. To evaluate performance trends over time and understand geographic variation, we analyzed quarterly data in Excel and Stata 15, and complemented these analyses with data from interviews conducted periodically with program staff and performance documentation submitted by implementing partners. Results: The program reached 144,505 clients, of whom 88% (n=127,315) were women. Among women reached, 92% (n=116,614) chose DMPA-SC. The program reached a high percentage of new users of modern contraception: 80% (n=93,075) of DMPA-SC clients were new users, as were 80% (n=111,350) of overall clients. However, only 26% (n=36,313) of clients were under 25. From performance reports and interviews with program staff, many involved credited the CBD model with reaching a client base largely comprised of new users of modern contraception. Conclusions: Our analysis of the Nigeria public sector DMPA-SC program suggests that the combination of DMPA-SC and proactive CBD may accelerate contraceptive uptake and reduce unmet need in Nigeria. While some strategies for increasing the cost-efficiency of the CBD emerged, future research on this delivery model should focus on key concerns about the modality’s sustainability.