All eight of our Community-Based Distributors (CBDs) of contraceptives have arrived in Belo sur Mer! This was no easy task. Loralety travelled over 50 kilometres by zebu cart. Lucienne, coming from the city of Morondava after the birth of her baby girl, rode down in an SUV (only a 4-wheel drive vehicle can handle the terrain). Dophine walked 25 kilometres down the beach. Several others spent the day on sailing pirogues.
Each is sure that their’s was the most difficult route. They banter playfully as they stretch out, exhausted, on foam mattresses in our office. It’s not the Holiday Inn, but they didn’t come to get pampered. They came to get trained to administer Depo-Provera injections, so that they can go back to their villages with more family planning options to offer. These eight women were chosen by their peers to serve as CBDs, or community health agents, and they take the role seriously.
We’ve taken out the foam mattresses and slid desks in for the training. I kick it off with a few remarks about the Safidy programme’s progress, then hand the floor to our two trainers. One is Dr. Perlette of MAHEFA/Saragna (a programme funded by USAID and managed by the John Snow Institute) from Morondava, and the other is Dr. Harnosy, the head of the public health centre here in Belo. We make introductions and hand out name-tags, including the name of the village that each CBD represents. They’ll wear the name-tags all week, even going to the market to buy rice. It’s a badge of honour.
We finish the training pre-test and explain Depo-Provera, an injection which gradually releases a hormone that inhibits ovulation and therefore stops women from getting pregnant.
The doctors are good at encouraging CBD participation. Clementine knows the most – she and four other CBDs already received basic instruction on Depo at a previous training session, and she clearly hasn’t forgotten any of it – but they don’t let her go it alone. They ask Dophine how long a Depo injection protects against pregnancy, and when she replies three months, Dr. Perlette says “misaotra tompoko,” thanking her formally for participating. “But to be more precise, let’s say 12 weeks.”
Coffee break. I ask Dr. Perlette where she studied medicine, and to my surprise, she says Moscow. She was sent there in the early 1980s, when President Didier Ratsiraka was building close ties with the USSR. She spoke not a word of Russian when she arrived, but picked it up in intensive language courses, and ended up staying fifteen years, through the fall of the Soviet Union and the Yeltsin era. Now she’s back in rural Madagascar, teaching people what she learned.
She gives off no air of superiority. She’s got a light touch that wins over the CBDs (the “misaotra tompoko”-type courtesies go a long way). The only sign of a different background is an occasional word choice. Talking about menstruation, she uses the official Malagasy word fadimbolana; the women pause for a second and translate what she said into their Vezo dialect: fandehana lio.
We’re looking at materials produced by MAHEFA, including laminated papers with colour-coordinated questions for CBDs to ask incoming clients: Did you begin your period in the last five days? If yes, arrows point to a green text box, the next question. If no, they lead to a red box with a different set of instructions. Everything is simple, practical. The whole first sheet is aimed at determining if the client could be pregnant. If so, she’s not eligible to receive Depo. Some of the questions are about sexual activity, and the CBD from Belalanda keeps cutting up, then looking down with a wry smile as the other women laugh. Some humour is universal.
Dr. Harnosy has two CBDs come forward to role play, one acting as a client, the other, Elmentiny, reading through yes/no prompts as the CBD. When it’s established that the client is not pregnant, Elmentiny moves to a set of seven questions about the client’s health. If the answer to any of the questions is yes, then Depo is not the right choice, at least not today, not without consulting a medical professional first. Dr. Harnosy has Elmentiny read the questions aloud. Have you had a baby in the last three weeks? Have you suffered from high blood pressure? Etc. She stands nervously and reads slowly, but gets the words out clear enough, understood. By local standards she’s well-educated, and that’s one reason why she was chosen to be a CBD.
It’s practice time! We slice unripe papayas in half and set them up to simulate a shoulder and upper arm. There are fourteen steps to the shot-giving process. 1. Wash your hands; 2. Dry them by air; 3. Check expiration date on Depo bottle; and so on. Each CBD has a step-by-step picture guide, and the doctors run them through it. They shake the bottle three times to mix it up. They swab the outer shoulder (err, the papaya) in a circular motion, gradually pushing dirt away from a centre point. They inject the syringe into the papaya in a smooth forward motion. The needles go in a safety box, and the women go back to wash their hands again.
Round two with the papaya. Dr. Perlette keeps putting it up against her shoulder and correcting the placement of their shots.
More coffee from our friend Dédé. Two CBDs nurse their children, and the women chat about what age a child should begin sitting upright. Loralety’s one-year-old sees something amiss in my appearance – my pale white skin, or my “yellow” hair, perhaps – and turns her head to cry into her mother’s bosom, to much amusement.
“Role play. Start from the beginning, as you would when a new client comes in the door.”
Lily’s first. She runs through contraceptive options with her pretend client, Rodia (another CBD), getting caught up in a long-winded explanation of Vakana, a bead-counting necklace that allows a woman to track her ovulation period. Clementine interrupts: “This is good, but we should be focusing on Depo; that’s what we’re getting trained on. Vakana is just a last resort, for women not comfortable with modern methods.” Someone jokes that Clementine should be a trainer. She takes over as acting CBD and tells Rodia to ask about Depo, starting with potential side effects. When weight gain is mentioned, the women joke that this will not bother them.
We’re at the clinic now to give Depo injections for real. Dr. Perlette shares a funny story about the first time she gave a shot. It sets the CBDs at ease.
First practice is on each other. Clementine sits down at the midwife’s desk and Dophine comes in as client. Presented with her options, Dophine selects Depo, and Clementine proceeds through the prompts in her manual, determining that Dophine is fit to have the shot. Everyone gathers to have a look as Clementine prepares. In America we’d consider it a grave invasion of privacy, but Dophine’s fine with the onlookers. The paparrazzi would be welcome here.
Afterwards, Dr. Harnosy gives Clementine a couple of pointers, and a score of three out of six, to indicate “moins de difficultés mais nécessite de l’assistance” on the government validation sheet. Six is the top score, but Clementine’s will go up with practice. After ten supervised/scored shots, she will be allowed to provide Depo on her own. This means that women in and around her village of Andranolava will have a new family planning option, one more effective than the pill, and one that doesn’t rely on women remembering to take a tablet every day.
Rodia is next. She looks like she’s about to cry, but it’s got nothing to do with the shot she’s about to give. She always looks like this. Her high cheekbones, deep inset eyes, and flushed cheeks belong on the cover of an indie music album. She’s laughing with her client, running through the fourteen steps with alacrity. The others see how easy it is and line up to give shots themselves. As the afternoon goes on they tease each other for little errors, but in a good way, like they are prodding one another to improve. Everyone gets in on the action, and the vibe in the room is one of a team on the rise.