Community-based provision of injectable contraceptives in Madagascar: 'task shifting' to expand access to injectable contraceptives.
BACKGROUND
Injectable contraceptives are now the most popular contraceptive methods in sub-Saharan Africa. Injectables have not been an option for African women lacking convenient access to health facilities, however, since very few family planning programmes permit community-based distribution (CBD) of injectables by non-medically trained workers. Committed to reducing unmet contraceptive need among remote, rural populations, the Ministry of Health and Family Planning (MOHFP) of Madagascar sought evidence regarding the safety, effectiveness and acceptability of CBD of injectables.


METHODS
The MOHFP joined implementing partners in training 61 experienced CBD agents from 13 communities in provision of injectables. Management mechanisms for injectables were added to the CBD programme's pre-existing systems for record keeping, commodity management and supervision. After 7 months of service provision, an evaluation team reviewed service records and interviewed CBD workers and their supervisors and clients.


RESULTS
CBD workers demonstrated competence in injection technique, counselling and management of clients' re-injection schedule. CBD of injectables appeared to increase contraceptive use, with 1662 women accepting injectables from a CBD worker. Of these, 41% were new family planning users. All CBD agents wished to continue providing this service, and most supervisors indicated the programme should continue. Nearly all clients interviewed said they intended to return to the CBD worker for re-injection and would recommend this service to a friend.


CONCLUSIONS
This experience from Madagascar is among the first evidence from sub-Saharan Africa documenting the feasibility, effectiveness and acceptability of CBD services for injectable contraceptives. This evidence influenced national and global policy makers to recommend expansion of the practice. CBD of injectables is an example of effective task shifting of a clinical practice as a means of extending services to underserved populations without further burdening clinicians.
Family Health International, Research Triangle Park, NC 27709, USA. thoke@fhi.org
Theresa H
TH
Hoke
Stephanie B
SB
Wheeler
Kelsey
K
Lynd
Mackenzie S
MS
Green
Bakolisoa Harimalala
BH
Razafindravony
Eugénie
E
Rasamihajamanana
Paul D
PD
Blumenthal
D000328:Adult; D003153:Community Health Services; D003268:Contraception Behavior; D003271:Contraceptive Agents, Female / Q000008:administration & dosage* / Q000600:supply & distribution*; D005193:Family Planning Services; D005260:Female; D006297:Health Services Accessibility / Q000458:organization & administration*; D006801:Humans; D007267:Injections; D007407:Interviews as Topic; D008270:Madagascar; D008875:Middle Aged; D055815:Young Adult
D003271:Contraceptive Agents, Female