Perspectives on sexual and reproductive health self-care among women, healthcare providers, and other key informants: a mixed-methods study in South Africa and Zambia

The final quantitative sample for the COVID-19 module included 537 female participants, 342 in South Africa and 195 in Zambia (an 86% response rate from the 18-month CUBE survey participants). A subset of 39 women participated in the IDIs, 20 in South Africa and 19 in Zambia. Thirty-six KIs participated in the in-depth interviews, 16 in South Africa and 20 in Zambia. Among them were 15 healthcare providers, nine Ministry of Health officials or Program Managers, and 12 community advocates. All IDIs were conducted in-person, with the exception of seven KI IDIs in South Africa.

Survey respondents in South Africa were significantly younger, had higher levels of education and lower mean parity, and were more likely to be students and not living with their current partner compared to those in Zambia. Consistent with the main CUBE sample [25], no significant differences were found in the contraceptive methods used at CUBE enrollment between countries. However, at the time of the COVID survey module, respondents in Zambia were significantly more likely to report no method use and less likely to be using copper IUDs, DMPA-IM, and condoms, compared to those in South Africa (Table 1).

Table 1 COVID-19 survey module participant characteristics, by country; n (%)

Female IDI respondents were similar in overall demographics to the full survey sample, with respondents in Zambia slightly older with higher parity. However, more women interviewed in South Africa were currently not using an FP method than those interviewed in Zambia. KIs interviewed were overwhelmingly female and had mean ages in their 40s in both countries (Table 2).

Table 2 IDI participant characteristics, by country; nWomen’s interest in SRH self-care methods and services

Survey respondents in South Africa were more interested in getting instructions about and materials to use ECPs, subcutaneous injectables, and CycleBeads, while Zambian respondents were most likely to say that they wanted more information and access to condoms (Fig. 1). While still mentioned by approximately half of respondents, interest in condoms was the lowest of the methods mentioned in South Africa, followed by OCPs. In Zambia, only around a third of respondents were interested in subcutaneous injectables and CycleBeads. Most South African respondents were interested getting instructions and materials for pregnancy tests, pregnancy checklists, with almost all wanting information on managing contraceptive-related side effects or changes in menstruation (Fig. 2).

Fig. 1figure 1

Survey participant reported interest in getting instructions and materials for specific self-care contraceptive methods in South Africa (N = 342) and Zambia (N = 195)

Fig. 2figure 2

Survey participant reported interest in getting instructions and materials for FP-related self-care tests, tools, and information in South Africa (N = 342) and Zambia (N = 195)

Women’s use of SRH and contraceptive self-care methods and services

Of the 39 female IDI respondents, most reported limited use of self-care methods, with only a few women ever having used self-administered pregnancy tests (n = 4 in Zambia), HIV self-testing (n = 2 in Zambia), or ECPs (n = 2, one each in South Africa and Zambia). However, over a third of respondents in both countries had previously used male or female condoms. One respondent in South Africa discussed other traditional “self-care” remedies, such as taking over-the-counter antacids, aspirin, or antibacterial drugs to clean out the vagina and prevent pregnancy after sex, while ultimately acknowledging that these self-remedies do not always work. Overall, women’s IDI responses were very short, without much additional detail on their experiences with self-care methods.

Key informant opinions of and recommendations for SRH and contraceptive self-care methods and servicesSelf-care methods or services counseled on or provided

Key informants spoke to the specific SRH self-care services that they counsel on and/or provide to women. A couple of KIs reported counseling women on home pregnancy testing, since knowing their pregnancy status could help in a woman’s decision making and next steps.

If a client came in…late for a re-injection…usually you give the Depo and counsel the patient that, you know, “you need to do a pregnancy test in a month's time” ... And if [the] pregnancy test is negative, then it’s all well because you’ve already been injected and you are safe. But if it’s positive, “do you want to keep the pregnancy or don’t you want to keep the pregnancy.” If you do, then you wait and you go to antenatal clinic and register at 6 weeks and then you carry on the pregnancy. If you don’t want to keep the pregnancy, as soon as you do a pregnancy test, it’s positive, come back, [we’ll] give you a letter for the termination of the pregnancy… [Professional Nurse in South Africa]

Three KIs in both countries described providing HIV self-testing, especially as a resource for reducing volume in the clinic, but another KI in Zambia was concerned that people take them home, but do not use or waste them.

Some people really used…the self-test kits. But for some of them, they care nothing. Why? Because they sometimes could get the kit, but don’t bring their results back. Meaning that they got the test and just dumped them. [Community advocate in Zambia]

Counseling on contraceptive self-care was not universal across methods. Four KIs from both countries noted that condoms are the main self-care method they discuss with clients, especially if other methods are out of stock. Similarly, four KIs mentioned counseling on or providing ECPs. One KI in South Africa expressed discomfort with people using ECPs as their primary method, while another (also in South Africa) stated that information on ECPs should be widely disseminated, especially during COVID. Counseling on subcutaneous DMPA (DMPA-SC) for self-injection seemed to be related to its availability. Two Zambian KIs described providing DMPA-SC, while other KIs in both countries reported not having access to the product. One KI in Zambia noted how important the availability of self-care methods like DMPA-SC is in ensuring continued method use:

During the COVID-19 pandemic, we didn’t have methods...like the Sayana Press [brand name of DMPA-SC], which we can give to the women to be injecting to themselves at their homes, we never had during that period [the COVID-19 pandemic]. But the counseling was being done to them in case we have them so that they know how to inject themselves at home. [Midwife in Zambia]

Nine KIs, mostly in Zambia, emphasized that COVID-19 led to an increase in SRH self-care counseling, contraceptive method provision, and provision of other self-care resources. This included increased use of DMPA-SC, HIV self-testing, and provision of condoms and additional months of OCs to reduce the need to return to the facility for re-supply. One KI in Zambia also mentioned counseling clients that condoms and OCs can be obtained from private pharmacies if people do not want to come to the facilities because of COVID.

Self-care for some mothers that surely do not want to come to the facility, they come to seek guidance from us…We’ve advised a lot on the use of condoms for those that don’t want to come to the facility. They are afraid, they even say to us “we are afraid to come, we thinking maybe we can have this corona”. So we’ve advised them to use condoms if they are able to… or rather maybe, they can just purchase this Microgynon, Microlut, [brand names of OCs] from the pharmacies. [Registered nurse in Zambia]

Reasons for NOT counseling on or providing self-care methods or services

One KI in South Africa and two in Zambia reported that they do not counsel on or provide methods for self-care, because they are concerned that women may harm themselves and/or blame the provider for any difficulties they experience.

Usually we don’t advise any clients to go for self-care. We always tell them either to come here or go to the nearest facility around them instead of going for the over-the- counter self-care, because they might end up doing the wrong thing, which at the end of it all, it will fall back on us. [Registered Nurse in Zambia]

Another South African KI mentioned that they do not think people are necessarily that interested in self-care since there are so many locations to access health services.

Potential for women to self-remove IUDs

An area of inquiry that received a lot of feedback was the potential for IUD self-removal. After being introduced to the concept and preliminary evidence regarding IUD self-removal, only two KIs (one from each country) thought that women could possibly self-remove their IUDs if provided education, saying it would provide greater reproductive autonomy for some women:

We have not educated them on self-removal of IUDs, but I have an opinion to say if they can be educated, maybe do the demonstration…They can do it for themselves...If they are empowered, yes. They can do it…. That would give her a chance to say, “Okay, they have inserted it, but when I want to remove it, I will be able to remove it”. [Rural Clinic Manager in South Africa]

The majority of KIs in both countries felt that women should return to a health facility to have their IUDs removed and gave both provider-focused and women-focused reasons. For example, a couple of KIs in South Africa expressed how women coming back to the facility for IUD removal provides the opportunity for the provider to offer additional services:

For one, I think it’s a good opportunity to look at the cervix at that time and also the number of reasons why she’s removing it, if she’s removing it because she wants another pregnancy…I mean if she’s due for a Pap smear that’ll be an opportune moment to actually do a Pap smear for her, you could treat an STI if she had one…[Professional Nurse in South Africa]

Nine KIs (more in Zambia than South Africa) expressed concern that women might introduce infections or injure themselves by attempting or performing self-removal.

I think it’s not safe.... because with us, at the facility, you are able to examine the woman, and see if it is infected. So if they do it at home, they won’t even be able to see that there’s an infection or something. So maybe they can just even pull it out. Ya, which is not safe, and they may injure themselves and may traumatize themselves. And then here we use sterile equipment...when removing that. [Midwife in Zambia]

Other concerns brought up by KIs were related to women experiencing difficulty with self-removal, the length of the strings needed for self-removal (e.g., whether partners will be able to feel them), issues with partial removal, and partner interference with removal, as has been seen with some implant users.

A couple of KIs in South Africa questioned why self-removal of IUDs is needed, stating that they think people can wait or make a plan to get to a clinic if they really want removal. However, two KIs in South Africa acknowledged that even though they do not think self-removal is a good option in general, they recognized that getting removal in a private facility can be costly and that self-removal might be an option under COVID-19 conditions, possibly in consultation with a healthcare provider.

So I don’t think it’s a good idea, but, in times of a pandemic, which, you know, doesn’t happen every day… if the women is able to contact you telephonically… and discuss with you… it is an option, but I don’t think it should be routinely provided. [OB/GYN in South Africa]

Barriers to accessing self-care methods

KIs mentioned many barriers to accessing SRH and FP self-care methods or services, especially in South Africa. Respondents noted that access to ECPs and HIV and pregnancy tests were particularly limited due to cost of transport and lack of pharmacies in townships or rural areas, and these were compounded by COVID movement restrictions:

Emergency contraceptives under [COVID-19] lockdown [levelFootnote 2] 4 or 5, even 3, was actually difficult. Because access to town was a problem. To come, and you can imagine, there are no pharmacies in the townships, most of them...Patients would come asking for emergency contraceptives 96 hours later. And you tell them, “look, you’re late”… [OB/GYN in South Africa]

KIs also noted that while self-care methods might be more available in the private sector, that meant a cost that not everyone could afford.

Five KIs, mostly in Zambia, reported that they were concerned that women’s general lack of reproductive knowledge would limit their ability to use self-care methods or to use them correctly and other KIs reiterated that women did not understand what was meant by “self-care”:

Okay, you’ve mentioned a lot of things that fall under self-care. So looking at the community that we are catering for...it’s not a very, for lack of a better term, “learned community,” so we really don’t advise for them to start doing self-care because they might do it the very wrong way, and then they’ll come and blame us. [Certified midwife in Zambia]

Finally, one KI in South Africa mentioned that it may be better for some stigmatized services and populations (e.g., HIV self-testing for people who sell sex) to seek care at a facility, rather than self-care at-home or through mobile outreach where other people might see what they are using and ask questions.

Recommendations for expanding self-care in the futureFor disseminating information

KIs also provided recommendations for ways to disseminate information on self-care. One KI in South Africa mentioned radio spots that have been deployed regarding HIV self-testing as part of a national strategy and another mentioned social media (especially for youth), plus in-person counseling sessions with physical demonstration of the methods:

The best strength that you can actually teach them is when you…gather in one place and then you speak to them, and then you send the information. That’s sometimes more effective than we’ve seen because when we give even digital stuff without actually having a physical interaction with them, they don’t actually learn that way. But they learn more effectively when you see them, and they get to see the methods. So... when you speak about any...contraception they see them, they touch them, then they understand, “oh, that’s what it is”. [Community Advocate in South Africa]

Two KIs in Zambia suggested easy-to-follow, non-technical, possibly pictorial instructions for women to refer to if they forget how to use a method (particularly for DMPA-SC).

The kind of IEC [information, education, and communication] materials that could be used should be something that is simple to understand with the community because, if we put into technical language, not everyone knows how to read...It can be not only a cartoon, but in a way of messaging or breaking down into a cartoon or into different languages that they could read and relate. [Community Advocate in Zambia]

Making self-care methods more widely available

Finally, KIs shared their recommendations for making self-care methods more widely available. Suggestions included making all contraceptive methods more available on an outpatient basis and making people aware that self-care options are available and where they are available.

Okay, in order for there be a change or increase or anything like that…the youth has to be first aware that there are self-care services or management that are available out there…Like, the condoms, the only thing that they know about is where they can get [them] in the bathrooms or in health facilities, but all the other ones that you’ve mentioned, the calendars check, the pregnancy test, those things are not available. I don’t even know, even as you’re talking to me now, I’m wondering…where are those packs available? [Community Advocate in South Africa]

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