Short-Term Gains, Long-Term Risks? CHWs and Contraceptive Delivery in Burundi

A World Bank study found that training community health workers (CHWs) to administer Sayana Press in rural Burundi increased contraceptive uptake by 70%, but overall contraceptive coverage remained unchanged due to women switching from long-acting methods like implants and IUDs. The study highlights the need for balanced family planning strategies that expand access while ensuring sustainable contraceptive use.

A groundbreaking study conducted by the World Bank's Development Economics Impact Group, in collaboration with the University of Hannover and the Inter-American Development Bank, explores the role of community health workers (CHWs) in providing contraceptive injections in rural Burundi. The research, published as Policy Research Working Paper 11074, investigates whether training CHWs to administer a new injectable contraceptive, Sayana Press, can increase contraceptive uptake in remote areas where access to health centers is limited. Conducted as a cluster randomized controlled trial, the study provides valuable insights into the effectiveness of community-based contraception delivery and its broader implications for family planning policies in low-resource settings.

A Game-Changer in Contraceptive Delivery

The study found that authorizing CHWs to administer Sayana Press led to a 70 percent increase in the number of contraceptive injections provided each month. CHWs, after receiving comprehensive training, began offering home-based contraceptive services during their routine visits, making birth control more accessible, convenient, and private for women who might otherwise struggle to access health facilities. This intervention significantly reduced barriers such as long travel distances, transportation costs, and social stigma, all of which have been major obstacles to contraceptive use in rural Burundi.

Sayana Press, unlike traditional intramuscular contraceptive injections, is a subcutaneous injectable that comes in a pre-filled syringe, making it easier to administer by lower-skilled providers—including CHWs and, in some settings, even by the women themselves. This new method eliminates the need for highly trained medical professionals and allows contraception to be delivered in a more decentralized manner, particularly benefiting rural communities with limited healthcare infrastructure.

Why Overall Contraceptive Coverage Did Not Improve

Despite the dramatic increase in Sayana Press uptake, the study revealed that total contraceptive coverage did not significantly improve. The main reason was a substitution effect, where many women who would have chosen long-acting contraceptive methods like implants and intrauterine devices (IUDs) switched to Sayana Press instead. Long-acting contraceptive methods provide protection for several years, whereas Sayana Press requires renewal every three months. This shift raises concerns about the sustainability of contraceptive coverage, as women who opt for injectables must remain consistent with their follow-up doses to avoid unintended pregnancies.

The study also highlights the challenge of contraceptive discontinuation, as past research has shown that injectable users are more likely to stop using contraception compared to those who choose implants or IUDs. While Sayana Press makes contraception more accessible, the need for regular renewals increases the risk that some women may discontinue its use due to logistical challenges or forgetfulness.

Breaking Social Stigma with Home-Based Services

One of the most significant benefits of CHW-led contraceptive services was the ability to reduce the stigma surrounding family planning. In many parts of Burundi, contraceptive use is still viewed with suspicion, and women may face judgment or disapproval from family and community members if seen accessing birth control at a health center. By integrating contraceptive delivery into routine home visits, CHWs helped ensure that women could receive contraceptives discreetly, without attracting unwanted attention.

This model of delivery also offered greater bodily autonomy for women, as they could receive contraceptive renewals at home rather than having to negotiate with their partners or family members for permission to visit a health center. This could be a crucial factor in increasing women's reproductive choices, particularly in settings where male-dominated household decision-making limits women's access to contraception.

The Path Forward: Finding the Right Balance

While the study demonstrates the potential of CHW-led contraceptive delivery, it also underscores the importance of a balanced approach that does not unintentionally discourage the use of long-acting contraceptive methods. Policymakers need to ensure that CHWs not only provide Sayana Press but also educate women about the advantages and trade-offs of various contraceptive options. Future interventions could include:

• Integrating contraceptive counseling into CHW training to encourage informed decision-making among women.
• Expanding access to long-acting methods, ensuring that CHWs facilitate referrals for implants and IUDs rather than promoting only short-term solutions.
• Exploring self-administration models for Sayana Press, allowing women to inject themselves at home, which has been shown to improve continuation rates in other settings.
• Incentivizing CHWs to focus on contraceptive effectiveness, rather than just increasing the number of injections administered, by introducing performance-based rewards for comprehensive contraceptive education.

Ultimately, the study provides critical lessons for reproductive health programs across Sub-Saharan Africa and other low-income settings. While community-based contraceptive delivery can dramatically expand access, it must be designed strategically to prevent the unintended substitution of long-term contraceptive methods with short-term ones.

A New Era in Contraceptive Access?

The intervention in Burundi highlights the transformative potential of CHW-led contraceptive services, particularly in rural, underserved areas. By training CHWs to administer Sayana Press, more women gained access to contraception in a way that was more convenient, private, and stigma-free. However, the findings also caution against relying too heavily on short-term contraceptive solutions at the expense of long-acting, more reliable methods.

Future programs must strive to integrate accessibility with sustainability, ensuring that women have a full range of contraceptive options and receive the support needed to maintain consistent contraceptive use over time. If designed thoughtfully, community-led contraception programs could serve as a powerful tool in advancing reproductive health and empowering women to make informed choices about their futures.