When Lindsey Boynton was offered the option to give herself her birth control shot at home, she was surprised the option even existed.

The method — self-injected subcutaneous depot medroxyprogesterone acetate (DMPA-SC) — allowed Boynton to avoid traveling more than an hour from her Redwood City home to a clinic in San Francisco every 3 months. During the COVID pandemic, the convenience mattered even more.

“I was afraid of COVID,” she said. “I’d rather be at home doing it for myself.”

Boynton used the self-injectable version of Depo-Provera for nearly 2 years and said the experience was straightforward.

“I felt very confident to do it myself,” she said. “It was no problem.”

Her experience reflects what researchers say is a largely untapped opportunity in US contraceptive care: a method that patients can safely administer at home, but that many clinicians still do not routinely offer.

A new national study published in O&G Open found that while nearly 80% of clinicians surveyed were aware that patients can self-administer DMPA-SC, only about 35% actually prescribe it.

“This [contraceptive option] has been around for decades, we have great evidence about it, and still patients don’t know about it. It’s wild,” said study author Jennifer Karlin, PhD, MD, associate professor of family community medicine at the University of California San Francisco.

Karlin and her colleagues surveyed 422 clinicians and interviewed an additional 34. More than half of the clinicians aware of the drug (52.0%) reported learning about it during the COVID pandemic, when telehealth expansion and reduced in-person visits prompted greater interest in home-based care options. Among those who prescribe it, 76.9% began doing so after 2019.

Although the FDA approved self-injectable DMPA-SC in 2004, Karlin said outdated labeling continues to shape provider behavior. The drug’s FDA label specifies that it should only be administered by a provider, which she said may make some clinicians hesitant to prescribe it for self-use. But in 2021, the CDC recommended self-injection as an additional approach to administer the shot.

Prescribing Depends on Workflows and Insurance

Tammy Bennett, DNP, WHNP-BC, incoming director of education at the National Association of Nurse Practitioners in Women’s Health, said early barriers centered on insurance formularies.

While most state Medicaid programs have since added coverage, the study’s findings reflected this trend. Clinicians said they were more likely to prescribe DMPA-SC if Medicaid covered it (68.3% vs 28.9%; P = .039) and if private insurance coverage was available (76.7% vs 31.0%; P = .004).

Boynton said insurance was not a barrier when she used the method. At the time, she was covered by Medi-Cal (California’s version of Medicaid).

“Everything was very easy,” she said. “I had no costs.”

But when she later changed providers, the option disappeared.

Even when coverage is available, Bennett said provider education and entrenched clinical culture continue to slow adoption. She said that resistance often reflects discomfort with shifting control to patients.

“It was hard to kind of let go of that paternalistic culture and train some providers that it is safe for patients to inject their own medication,” Bennett said.

That cultural resistance mirrors patterns seen in the study.

Most clinicians (85.8%) said DMPA-SC self-administration would be appropriate for their patients, yet interviews revealed lingering concerns about patient ability to self-inject, remember dosing schedules, or manage supplies.

At the same time, clinicians predicted substantial patient interest. Respondents estimated that 43.7% of patients currently using intramuscular DMPA would be interested in switching to self-injection, and that 17.3% of patients not using any contraception might consider the option.

Still, only 39.7% of prescribing clinicians said they routinely discussed self-injectable DMPA at every contraceptive visit. Many limited counseling to patients already using injectable methods or seeking progestin-only contraception.

Clinicians interviewed for the study highlighted several persistent barriers: limited appointment time for injection training, lack of standardized electronic medical record tools, and inconsistent pharmacy stocking.

Among clinicians who were aware of self-injectable DMPA-SC, the strongest predictor of prescribing was whether their clinic had a formal workflow in place. Indeed, clinics with established self-injection workflows were far more likely to offer DMPA-SC than clinics without them (87.3% vs 33.5%; P < .001).

Karlin said this is the most actionable change clinics can make.

“Just create a workflow for them to order it. If it is integrated into the clinic, then clinicians will do it,” Karlin said, adding that implementation tools such as electronic health record (EHR) templates, prescribing language, and patient education materials already exist.

Bennett said that EHR systems remain a major bottleneck.

“That’s something policy-wise that should be changed,” she said, adding that early adopters had to manually add the medication to EHR formularies. “If you put in hydroxyprogesterone, have it pop up — do you want subq 104 mg or do you want the 150 mg IM [intramuscularly]?”

Awareness Gaps Persist

The study included clinicians from every US state except South Dakota and captured a wide range of practice settings, including primary care clinics, academic centers, Planned Parenthood sites, pharmacies, and federally qualified health centers.

Several professional and institutional factors were strongly associated with awareness.

Clinicians who completed reproductive health fellowships were significantly more likely to be aware of DMPA-SC self-administration than were those without fellowship training (P < .001).

Awareness was also higher among obstetrician-gynecologists than other specialties (87.6% vs 76.6%; P = .039).

Internal medicine clinicians were significantly less likely to be aware than clinicians in other specialties (52.4% vs 81.2%; P = .004), and pharmacists reported lower awareness than nonpharmacy clinicians (66.0% vs 84.1%; P = .026).

The study also found differences by clinician gender. Cisgender male and gender-diverse clinicians were significantly more likely to prescribe DMPA-SC than cisgender female clinicians, even when awareness was similar (P < .001).

Karlin said the knowledge gap is even wider outside family planning circles.

“That rate of awareness would have likely been 5% or less if we did a national study of primary care providers,” she said. “It’s really folks in the family planning world that even know about this.”

Bennett agreed. “In the southern states where I train, many are not familiar with all of the methods of contraception available,” she said, adding that unfamiliarity with clinical guidelines often signals limited exposure to newer contraceptive options.

Clinicians practicing in states with laws supportive of reproductive rights were more likely to prescribe self-injectable DMPA-SC than those in more restrictive states (49.7% vs 38.4%; P = .05).

Karlin said future research will test whether implementation toolkits improve clinician uptake and patient outcomes.

“What I’m hoping to do is bring in a workflow and the clinician script and then see if clinics are more likely to offer it,” she said. “And then if they do, find out if the outcomes for patients are actually better.” 

Boynton said, “I was just happy to do it at home and not have to travel,” she said. “The convenience of it was what was the most appealing to me.” 

For Bennett, expanding access ultimately comes down to shifting provider mindset.

“We can do this,” she said. “It’s not a new concept, it’s just new to certain providers who have always been more in control.” 

Karlin and Bennett did not report any potential conflicts of interest.

Lara Salahi is a health journalist based in Boston.