[Community-based distribution of injectable contraceptives in an African setting: community trial in Madagascar]

Community-based distribution of family planning provides a way of reaching underserved populations in developing countries. This article reports findings from an introductory trial of community-based distribution of Depot Medroxyprogesterone Acetate (DMPA), a progestin-only injectable contraceptive. The project, conducted in Madagascar in 2007 in collaboration with the Malagasy government, was intended to test the safety, acceptability, and contribution to policy goals of adding contraceptive injections to the range of methods already offered by paraprofessional community-based health workers in rural areas. In total, 61 agents in 13 communities were trained and initiated service offering DMPA. The intervention was evaluated after 7 months. Data collection included interviews with agents, their supervisors, and a sample of 303 clients, and review of agents' records. In support of the objectives, the descriptive analysis primarily examined the quality of agents' services (safety), three-month reinjection rates (acceptability), and DMPA uptake (contribution). Interviews with agents to test knowledge about correct practices indicated that they are able to provide high quality services. To capture mastery of essential techniques, a composite quality score was calculated from agents' answers. The average score was 23.3 out a maximum possible of 27. All agents scored at least 18 points, and 80% of them received 22 points or more. Interviews with clients further confirmed that agents were competent. The majority of clients were satisfied with the services they received, and a very large proportion (94%) of the women eligible for a second injection received it from the agent. There were no complaints from the communities, and women reported that acceptability among their partners was also high. Finally, the program attracted new users: the 61 agents recruited a total of 1,662 women over six months, 41% of whom were not using family planning when they initiated DMPA. Encouraged by the findings from the pilot project, the Malagasy government has proceeded to expand the program. As of March 2010, a total of 1,109 agents had been trained. At the international level, this study further contributes to the growing body of evidence that well-trained community-based health workers can safely provide injectable contraceptives, potentially helping to increase contraceptive coverage in rural areas with a nationally scaled-up program. While community-based family planning services in Latin America and Asia have included injectables since the 1970s, experiences in sub-Saharan Africa have been very limited. Madagascar was one of the first countries, and several others (Ethiopia, Kenya, Nigeria, Malawi, Rwanda, Uganda, and Zambia) are beginning to include injectables in community-based family planning programs. Furthermore, a recent technical consultation convened by the World Health Organization concluded that global evidence supports the introduction, continuation, and scale-up of community-based provision of injectable contraceptives. Despite this momentum, further efforts are required to expand this approach and increase the choice of contraceptive methods available to underserved populations.