Jennifer Karlin, MD, PhD, explains barriers, biases for user-administered injectable contraceptives

A national mixed-methods study published in O & G Open identified gaps between awareness and use of subcutaneous depot medroxyprogesterone acetate (DMPA) for user-administration, despite years of evidence supporting its safety and effectiveness. Study co-author Jennifer Karlin, MD, PhD, associate professor at the University of California, San Francisco, and colleagues surveyed 422 family planning experts and conducted interviews with 34 clinicians to understand barriers and facilitators to prescribing self-injected DMPA.

“During the COVID-19 pandemic there was, as everyone remembers, a lot of social distancing… and I thought to myself, ‘Oh, there is a subcutaneous formulation of depot medroxyprogesterone acetate… and it can be used for self-administration. We know there’s good data about that, and no one is using that,’” said Karlin.

At her clinic at UCSF, Karlin discovered that Medi-Cal did not initially cover the subcutaneous formulation. “So I reached out to Medi-Cal and convinced them that we should be covering the subcutaneous version during COVID, which they did, and now it’s actually expanded so that it is covered by our California state Medicaid program.”

She then led an implementation project offering patients the option to switch from intramuscular to subcutaneous self-injection. “And lo and behold, they did,” she said. Similar projects emerged nationwide during the pandemic, as clinics sought ways to maintain contraceptive access without in-person visits.

In the national study, 74.5% of clinicians reported awareness of subcutaneous DMPA for user administration, but only 34.8% actively prescribed it. About one-quarter of respondents were unaware of the option, and 52% of those who were aware said they learned about it during the COVID-19 pandemic.

Awareness was more likely among clinicians who completed a reproductive health fellowship, specialized in obstetrics and gynecology, saw higher volumes of contraceptive visits, or worked in Title X–funded clinics, Planned Parenthood, or freestanding clinics. Negative predictors of awareness included internal medicine specialization, pharmacy-based practice, and having fewer contraceptive options available.

Even among clinicians who were aware, multiple systemic factors influenced whether they prescribed it. Positive predictors of prescribing included being gender-diverse or male, having access to subcutaneous DMPA–specific workflows, and having Medicaid and private insurance coverage. Living in a state with abortion restrictions was a negative predictor of prescribing.

From the interviews, clinicians often cited patient-related concerns. Karlin said many providers believed, “‘My patients just don’t know about it… My patients are going to forget to give it to themselves because it’s every 3 months. They’re going to forget how to do it.’ [But], we now have 1 out of 8 people in the United States who are on a GLP-1, which is an injectable… and the time that [GLP-1] injectables came out is so much shorter than the amount of time that DMPA subcutaneous has been around.”

Karlin added, “It’s just kind of amazing when you think of some of the biases that we put up as providers ourselves to patients who are looking for contraceptive options that are autonomous.”

Reference:

Chase C, An-Lin C, Creason L, Karlin J. Barriers and facilitators to expanding user-administered injectiable contraceptives in the United States. O & G Open. 3(1):e141. February 2026. doi:10.1097/og9.0000000000000141