Centring Women's Experience in Contraceptive Self-Care

Project Overview

The Delivering Innovations in Self-Care (DISC) programme was a multi-country initiative led by Population Services International (PSI) to expand access to contraceptive self-injection and strengthen broader self-care approaches in sexual and reproductive health. Pivot Consulting served as the Evidence and Learning Partner for the project.

Implemented across Nigeria and Uganda, the programme focused on supporting women, particularly young women and mothers, to take greater control over their reproductive health. This included enabling the safe and informed use of self-injectable contraception, while strengthening the health systems, provider practices, and community-level dynamics that shaped women’s ability to access and sustain self-care.

The programme sought to address a set of interconnected challenges: how women experienced and made decisions about self-care; how provider interactions and health system structures influenced those decisions; and how concepts such as agency, choice, and empowerment could be understood and measured in ways that reflected women’s lived realities.

Within this broader programme, Pivot Collective was engaged to support key components of the evidence and learning agenda.

Our Role

Pivot Collective partnered with PSI as an evidence and adaptive learning partner on the DISC programme, supporting the design, implementation, and evolution of its learning systems across multiple phases.

A central component of this work focused on the development of contextually grounded empowerment metrics. Across Uganda and Nigeria, Pivot designed and led a participatory research process to explore how women understand and experience power, agency, and decision-making in relation to their sexual and reproductive health. Using creative, dialogic methods, including participatory workshops, theatre, and visual mapping, the research centred women’s lived experiences and enabled participants to actively interpret and analyse their own insights.

This work was accompanied by a strong focus on capacity strengthening, with Pivot designing and delivering both online and in-person training for DISC teams in qualitative and participatory research methods. These processes supported programme staff and in-country teams to actively engage in data collection, reflection, and interpretation, embedding learning within the programme rather than positioning it as an external function.

Insights from this process informed the development of locally relevant, theoretically grounded empowerment metrics, designed to be integrated into DISC’s tracking systems. Iterative feedback loops with participants and programme teams ensured that these metrics remained responsive to context and grounded in lived experience.

Building on this foundation, Pivot also supported a major implementation-focused innovation and learning process, known as the ‘Moment of Truth’ study. This work aimed to strengthen the provider–client interaction at the point where women decide whether to take up self-injection, addressing key behavioural and relational barriers within service delivery.

Rather than a standalone study, this was designed as an embedded adaptive learning process, combining innovation design, real-time evidence generation, and iterative refinement. Pivot co-developed and tested different models of provider support, focusing on strengthening provider confidence, empathy, and counselling practices. The study used a mixed-methods implementation design, including observation, interviews, training assessments, and analysis of routine service data, with findings continuously fed back into programme adaptation.

Across both workstreams, Pivot played a key role in evidence synthesis and knowledge translation, supporting the DISC team to interpret emerging insights, adapt interventions in real time, and translate learning into practical tools, technical outputs, and contributions to the wider field of self-care and women’s empowerment.

What We Learned

Work across the DISC programme highlighted how complex it is to support and understand women’s experiences of power, choice, and care within self-care interventions.

One key insight was that these experiences are deeply shaped by context. Participatory research across Uganda and Nigeria showed that women’s experiences of power are shaped by their relationships, life stage, and social context, and can shift over time. Decisions are often made within constraints, and can involve negotiation, compromise, or risk. Rather than a straightforward progression toward greater autonomy, what emerged was a more relational and situated understanding of power, one that is shaped by social expectations, economic realities, and the dynamics of care and responsibility. This challenged more simplified ideas of “empowerment” as something that can be easily achieved or measured, and reinforced the importance of starting from lived experience.

The work also showed the limits of standard measurement approaches. While established frameworks and indicators are useful, they often miss the relational and social dynamics that shape how decisions are actually made. Combining quantitative data with qualitative, participatory research made it possible to see a fuller picture, including how programmes are experienced on the ground, and where unintended effects might emerge.

The ‘Moment of Truth’ study further demonstrated that provider–client interactions are pivotal, but not sufficient on their own to drive change. Strengthening provider confidence, empathy, and counselling practices improved the quality of engagement with clients and supported increased uptake of self-injection in some contexts. At the same time, broader system factors, including commodity availability, cost, space for private counselling, and community dynamics, continued to shape outcomes. This points to the need for integrated approaches that address both interpersonal and structural dimensions of service delivery.

Across both workstreams, the importance of adaptive learning and structured sense-making emerged as a key insight. Different forms of evidence often revealed different, and sometimes competing, perspectives on programme performance. Creating space for teams to engage collectively with these insights allowed for a more nuanced understanding of what was working, for whom, and under what conditions. This process supported more grounded decision-making and helped to identify where adaptation was needed.

Finally, the work reinforced that implementation rarely unfolds as planned. Gaps between design and reality are inevitable, particularly in complex systems. Approaches that allow for ongoing learning, reflection, and adaptation are better able to respond to these dynamics and support programmes that are more attuned to the contexts in which they operate.