Madagascar Tests the CBD of DMPA

Initial success spurs plans for expansion.

Family Health Research: 2007, Vol. 1, Issue 2

Harimanana Ambohidray, a community-based family planning worker in Madagascar's Moramanga district, learned to give injections by practicing on papayas. She was one of 63 community-based distribution (CBD) workers trained in November 2006 to provide the injectable contraceptive depot-medroxyprogesterone acetate (DMPA) in rural Malagasy communities.

After the initial three-day training session, the CBD workers returned to their local health centers several times to administer their first six DMPA injections to clients. under the supervision of center staff. By the end of 2006, Ambohidray had completed the six injections and was certified to provide DMPA in her community. Just three months later, she had 31 DMPA clients.

Ambohidray and her fellow CBD workers are part of an introductory trial of the CBD of DMPA in Madagascar. This pilot project is a collaborative effort by FHI, the Madagascar Ministry of Health and Family Planning (MOHFP), a health project called SantéNet that is funded by the U.S. Agency for International Development, the Adventist Development Relief Association (ADRA), and Action Socio-sanitaire Organisation Secours (ASOS).

Photo credit: Kelsey Lynd/FHI

A community-based family planning worker prepares to give a practice injection as a trainer supervises during a three-day training session.

It is estimated that 23 percent of Malagasy women of reproductive age who do not want to become pregnant are not using a modern method of contraception. Madagascar's high total fertility rate (an average of more than five children per family) and annual population growth rate of over three percent also point to the need for innovative ways to increase contraceptive prevalence.

Representatives of FHI and its partners visited health centers and consulted with district health officers to choose 13 sites for the pilot project in two remote regions that had low contraceptive prevalence and limited access to health facilities. These regions, Anosy and Alaotra Mangory, also had CBD workers who were providing oral contraceptives and condoms and were counseling clients about other forms of contraception available at the health centers, including Madagascar's most popular method, DMPA.

FHI and its partners worked closely with mayors, village chiefs, community health center staff, and district health offices to build support for the community-based distribution of DMPA. A national steering committee led by the MOHFP held regional coordination meetings.

The CBD workers received their first 15 doses of DMPA at no cost from the MOHFP. After exhausting their initial supplies, they began purchasing DMPA from health centers for 150 ariary (about US$0.08) per dose. They sell injections to clients for 300 ariary per dose, receiving a 100 percent profit.

Resupply visits and monthly reporting to the local clinics ensure regular contact between the CBD workers and health center staff. Technical supervisors from ADRA and ASOS also visit CBD workers monthly to help them with any problems and to monitor their performance.

"We have been thorough in our monitoring visits," said Kelsey Lynd, FHI assistant program officer. "We sit down one-on-one or in small groups with all the CBD workers to find out their weaknesses and give them some refresher training, and also to honor their work."

Before the project began, some MOHFP officials had expressed reservations. "We were afraid that the CBDs [CBD workers] were not capable of giving injections," said Dr. Eugenie Rasamihajamanana, director of Mother and Child Health Division of the MOHFP, "but already during training we saw that CBDs could do this." Now the MOHFP plans to expand community-based distribution of DMPA to additional sites by 2008. This expansion will be guided by the results of a formal evaluation of the pilot project, which FHI will conduct in the summer of 2007.