Beginning in March 2020, health care providers across Madagascar began injecting salt-filled condoms as part of an innovative training program aimed at sustaining women’s access to family planning, as the COVID-19 pandemic threatened years of progress in reproductive health. 

The pioneering initiative was an effort to speed the rollout of a self-injectable (SI) DMPA-SC (subcutaneous depot medroxyprogesterone acetate), a low-dose form of intramuscular DMPA that is delivered in a prefilled, easy-to-use injection system (BD Uniject™). 

Before 2000, Madagascar was one of the 75 countries where “less than half of the women with a demand for family planning were using modern methods”. But since 2012, Madagascar has made significant progress, satisfying the demand for contraception for 64.4 percent of those seeking it. This continued in November 2019 when Madagascar’s Ministry of Health, supported by PATH and JSI’s Access Collaborative, began to introduce self-injectable DMPA-SC. But, as the COVID-19 pandemic shut down in-person contact with health care providers, the Access Collaborative scrambled to identify virtual approaches and adapt materials and protocols to train providers to both give DMPA-SC injections to women and counsel women on how to self-inject. The adaptations mitigated losses to Madagascar’s family planning goals, and saw a significant number of women who adopted this method use modern contraceptives for the first time in their lives. It’s just Madagascar’s latest chapter in a three-year transformation in policy and practice to better empower women in their sexual and reproductive health.

To help providers learn how to teach women self-injection, the Access Collaborative developed a 10-step self-injection training tool. Steps include correct injection technique, how to handle the device, and proper disposal. When COVID-19 hit, health officials eyed this new program and saw a contraceptive option well-suited to lockdowns, it empowered women in their sexual and reproductive health and reduced the need for clinic visits and the associated COVID-risks. The MOH shifted its plans—now instead of a phased rollout, they’d offer DMPA-SC self-injection across the entire nation, and allow women to receive several months of supply. 

The MOH worked with the Access Collaborative country team to develop virtual supervision on the training. Supervisors listened over the phone while providers, using a condom filled with salt, demonstrated self-injection techniques with DMPA-SC, step-by-step. They also role-played how to instruct clients to self-inject and answer client questions. 

“This [training] approach is not difficult. It’s so simple and can adapt anywhere, as long as there’s connectivity. It has been a big success. In the midst of other difficulties during COVID, our activities are continuing, which enables us to support more women who want this method,” said Avotiana Rakotomanga, the JSI country coordinator for the Access Collaborative. 

The Access Collaborative found that the virtual training increased provider participation. Despite best efforts, in-person supervision prior to COVID only reached about half of those who needed it, mainly due to resource constraints (e.g., time, budget, shortage of staffing, difficulty with travel). However, through virtual supervision, district management teams were able to reach 100 percent of family planning providers. 

The program also acknowledges some challenges. Now that many women seek self-injection so providers say they don’t get to practice what they’ve learned with enough frequency. And women still must meet providers in person when first using DMPA-SC. But there have been increases in trainings and use. By the end of 2020, 28 out of 144 districts had trained providers (the goal in 2021 is 50 percent), and as of now, up to 24 percent of the women who have adopted a self-injection are new to family planning. 

“The number of new users is what gives me the most satisfaction. These are women, for whatever reason, who were ready and able to use self-injection, when before they didn’t use anything! That’s what really matters, getting ahold of these different options and building the programs that can deliver them so women can have these better choices for their health,” said Dr Sylvie Tidahy, SI Ambassador and also Director of DSFa/MOH (Directorate in charge of Family health and Family planning)