Is choosing self-injectable contraception associated with enhanced contraceptive agency? Findings from a 12-month cohort study in Uganda

OBJECTIVES: We compared changes in contraceptive agency among women initiating self-injectable contraception versus other methods. STUDY DESIGN: From 2022-2024, we conducted a prospective cohort study with a convenience sample from communities and health facilities in Eastern and Northern Uganda; participants had chosen a new method within the prior two weeks. We compared changes in Agency in Contraceptive Decisions Scale scores, on a scale of 0-3, at 6 and 12 months between self-injection choosers and choosers of any other method (including provider-administered injection) using mixed effects models controlling for confounding. In three secondary analyses, we restricted the comparison group to provider-administered injectable choosers, restricted the comparison to choosers of any provider-administered method, and restricted the sample to women who used their chosen method during follow-up. RESULTS: Among 216 self-injection choosers, agency scores increased from mean= 2.65(SD=0.35) to 2.74(SD=0.31) at six months and decreased to 2.71(SD=0.32) at 12 months; scores among 1612 women choosing other methods started lower and increased more gradually from mean= 2.61(SD=0.36) at baseline to 2.63(SD=0.35) at six months and 2.67(SD=0.24) at 12 months. Interaction terms examining whether rate of change in agency differed between self-injection and other method choosers had a p-value of 0.03 at six months and 0.85 at 12 months; restricting to provider-administered injectable users or any provider-administered method users did not change results while restricting to those who used their chosen method during follow-up increased the six-month interaction term p-value to 0.20. CONCLUSION: Small improvements in agency over six months among women choosing self-injection but not other methods corroborate its empowering potential. Less difference at 12 months suggests the effect may be limited to short-term improvements or stymied by lack of external enablers. IMPLICATIONS: Greater improvement in agency over time with choosing self-injection compared to other contraceptive methods suggests self-injection may be uniquely empowering and should be offered alongside other contraceptive options. Research comparing outcomes between self-injection programmatic approaches addressing structural and social barriers would shed light on additional opportunities to help interested individuals benefit from the technology.