Injectable Contraceptive Use Rises in Madagascar

Community-based distribution boosts rural access to family planning.

The best ambassadors of injectable contraceptives are the women who use them. — Ny Lova Rabenja, acting director of Family Health International's office in Madagascar

MARCH 2009 — Razery has four children, all younger than six. For many years, Razery did not use any form of contraception, because she lives 20 kilometers from the nearest clinic. As a mother who works long hours in the fields, she does not have time to make the journey there by foot. Poor access to family planning services is a common problem for many women living in rural Madagascar and elsewhere.

Razery's life changed when a woman in her village told her about an injectable contraceptive that lasts for three months. The neighbor — a community-based family planning agent offering pills and condoms — had recently been trained to provide injectables. In fact, the neighbor said, she was using the method herself and she could give Razery an injection at home. Razery started using the contraceptive almost immediately.

Similar stories are being told across rural Madagascar, because of efforts Family Health International (FHI) initiated with funding from the Contraceptive and Reproductive Health Technologies and Research Utilization program of the U.S. Agency for International Development (USAID).

Just 14 percent of women of childbearing age in Madagascar currently use modern methods of contraception. The government of Madagascar wants to increase that percentage.

To help, FHI, in partnership with Madagascar's Ministry of Health and Family Planning (MOH/FP), designed a program to teach non-medically trained health agents in rural parts of the country to administer injectable contraceptives to women who want to use the method.

The USAID-funded bilateral project Santénet, Population Services International, Action Santé Organisation Secours, and many other groups are also participating.

Injectable contraceptives — primarily in the form of depot medroxyprogesterone acetate (DMPA) — have rapidly become the most popular modern contraceptive in sub-Saharan Africa. They are safe, effective, and convenient, and they can be used discreetly, without a partner's knowledge. For these reasons the potential demand for DMPA is high in Madagascar and elsewhere.

Before the community distribution program began in 2006, women in Madagascar had to travel to health centers to receive DMPA. For rural women like Razery, that hurdle can effectively rule out method choice.

In its pilot phase the program tested the feasibility of training people in rural communities to dispense DMPA. The program also evaluated the acceptance of injectable contraception by women who were using other forms of birth control or none at all.

By the end of 2007, 62 local leaders in 13 rural communities had participated in training that refreshed their knowledge about family planning service delivery and taught them how to provide DMPA services.

Within six months, these community health workers provided DMPA to 1661 women, 41 percent of whom had not been using contraception. One district — Moramanga, in the Alaotra Mangoro region — accounted for 1,392 of the new DMPA users. This shift raised the district's overall percentage of women of childbearing age using contraception from 25 percent to 35 percent.

Given these results, the program expanded in 2008 from four districts in two regions to 21 districts in 11 regions. By the end of the year, 3945 women — more than double the number of clients served during the project's pilot phase — were DMPA clients.

This program's success suggests that the community-based distribution of DMPA is an effective family planning solution not just for Razery but also for many remote communities in Madagascar. Indeed, it should be effective wherever the need for family planning services is great and women live far from health centers that offer modern contraceptive methods.

PHOTO: A woman carries her baby across a makeshift bridge. (Kelsey Lynd, FHI/Madagascar)

Related Resources:
Community-Based Distribution (CBD) of DMPA (topic page)

Expanding Access to Injectable Contraceptives (Conclusions from June 2009 technical consultation at WHO)