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Depo in Madagascar (no, not the animated movie about zoo animals) » Family Planning

Depo in Madagascar (no, not the animated movie about zoo animals)

October 29th, 2008 by maggie chen Leave a reply »

I was one of the kids who took International Public Health with Dr. Paul Wise last winter. For me, one of the most engaging lectures in that class was by Dr. Paul Blumenthal, an Ob/Gyn in the School of Medicine at Stanford. His talk was on reproductive health, and he covered a variety of issues and projects. One was on a simple way to do cervical cancer screening with an acetic acid wash. Another initiative he discussed trained women to administer Depo-Provera injections to other women in the community who desired contraception–in Madagascar.

I think Dr. Blumethal’s project in Madagascar is an awesome example of a community based system to offer family planning that does not depend on a clinic and brings the services literally to women’s doors. This initiative was one of the reasons that I wanted to blog on innovative ways to increase access to contraception. I’ve been having trouble finding an article or official write-up of the initiative, but I was able to get some more detail through Dr. Blumenthal’s ‘Letter from Madagascar.

Facing a fertility rate of 5.2 births per woman, the Ministry of Health and Family Planning set the goal of increasing contraceptive prevalence from 18% to 26% by 2008. Since 80% of the population in Madagascar lives in rural areas, the Ministry is focusing on distribution issues, especially of longer term methods, to achieve its goal. Says the Madagascar director for Marie Stopes International, “Reaching isolated communities is the real issue.”

One part of this larger push for family planning is the project that trains community based distributors (who already distribute oral contraceptives) to give Depo Provera injections on the typical 3-month cycle (1 shot every three months). Depo Provera is a progestin only method, and is administered via injection to the arm, hip, upper thigh, or abdomen. On a side note, the Ministry is also looking into distributing Implanon on a wider level to increase contraception use.

In writing about this project, it occurred to me that Madagascar was presented with a similar issue as that in Jamaica–lowering the fertility rate. The two countries took very different approaches to this issue, and I wonder if there is anything about the Madagascar approach that could be useful to the public health officials and politicians in Jamaica who seem to be focused on sterilization (Julia please correct me if I’m wrong).



  1. Max Romano says:

    One of my biggest concerns about Depo-Provera and Implanon is that they are very much health care provider-controlled methods of contraception, which means that women need to have access to a healthcare provider and the health care providers need to be supportive of the women’s choices. The barriers of gender, class, money, and geography all prevent women from going to doctors to request birth control, so easy-to-use and cheap contraceptive methods like condoms and diaphragms have certain clear advantages as “user-directed” contraceptives. In Madagascar, the idea of teaching some community members to administer Depo shots definitely makes that contraceptive method more egalitarian. The shots are still not completely “user-directed,” but it seems like a much better system than having doctors administer all shots. And a clear advantage over condoms is that they do not require the explicit consent of a sexual partner. Thanks for telling me about this.

  2. jliebner@stanford.edu says:

    Another aspect of administration of any injection-based drugs in rural areas is access not only to the drug, but also the needles. Is there any worry over reuse of needles and potential transmission of infectious diseases? As a note about possible applications to Jamaica, injection-based contraceptives are actually the most popular form of contraception among older (20+ years) women. The focus in Jamaica is what to do with high rates of pregnancy among adolescents, and as I gather, how to prevent seemingly “irresponsible” teenagers (who’ve had more than 3 kids) from having more children and contributing to the so called population problem. Perhaps an injection method that last for 3 months, and does not require daily or instance-based behaviors (the pill, condoms) may play a significant role to reduce pregnancies among teenagers who do not seem to obtain or use contraception when they engage in sexual behaviors. Good point – it definitely seems like a good potential way to target this age-specific problem.

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