{"id":6531,"date":"2014-09-09T11:03:43","date_gmt":"2014-09-09T10:03:43","guid":{"rendered":"http:\/\/bvblog.wpengine.com\/?p=6531"},"modified":"2016-12-12T09:07:41","modified_gmt":"2016-12-12T09:07:41","slug":"increasing-choice","status":"publish","type":"post","link":"https:\/\/blog.blueventures.org\/en\/increasing-choice\/","title":{"rendered":"Increasing choice for women in Belo"},"content":{"rendered":"

By Eddie Carver<\/a>, Safidy Programme<\/a> Coordinator, Belo sur Mer, Madagascar<\/em><\/p>\n

August 4th<\/strong><\/p>\n

6pm<\/em><\/p>\n

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.<\/p>\n

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\u2019s not the Holiday Inn, but they didn\u2019t 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\u00a0community\u00a0health agents, and they take the role seriously.<\/p>\n

August 5th<\/strong><\/p>\n

8am<\/em><\/p>\n

We\u2019ve taken out the foam mattresses and slid desks in for the training. I kick it off with a few remarks about the Safidy programme\u2019s 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\u2019ll wear the name-tags all week, even going to the market to buy rice. It\u2019s a badge of honour.<\/p>\n

9am<\/em><\/p>\n

We finish the training pre-test and explain Depo-Provera, an injection which gradually releases a hormone that\u00a0inhibits ovulation and therefore stops women from getting pregnant.<\/p>\n

The doctors are good at encouraging CBD participation. Clementine knows the most \u2013 she and four other CBDs already received basic instruction on Depo at a previous training session, and she clearly hasn\u2019t forgotten any of it \u2013 but they don\u2019t 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 \u201cmisaotra tompoko<\/em>,\u201d thanking her formally for participating. \u201cBut to be more precise, let\u2019s say 12 weeks.\u201d<\/p>\n

10am<\/em><\/p>\n

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\u2019s back in rural Madagascar, teaching people what she learned.<\/p>\n

She gives off no air of superiority. She\u2019s got a light touch that wins over the CBDs (the \u201cmisaotra tompoko<\/em>\u201d-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<\/em>; the women pause for a second and translate what she said into their Vezo dialect: fandehana lio<\/em>.<\/p>\n

2.30pm<\/em><\/p>\n

We\u2019re 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\u2019s 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.<\/p>\n

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\u2019s established that the client is not pregnant, Elmentiny moves to a set of seven questions about the client\u2019s 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\u2019s well-educated, and that\u2019s one reason why she was chosen to be a CBD.<\/p>\n

4pm<\/em><\/p>\n

It\u2019s 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.<\/p>\n

August 6th<\/strong><\/p>\n

8am<\/em><\/p>\n

Round two with the papaya. Dr. Perlette keeps putting it up against her shoulder and correcting the placement of their shots.<\/p>\n

10am<\/em><\/p>\n

More coffee from our friend D\u00e9d\u00e9. Two CBDs nurse their children, and the women chat about what age a child should begin sitting upright. Loralety\u2019s one-year-old sees something amiss in my appearance – my pale white skin, or my \u201cyellow\u201d hair, perhaps – and turns her head to cry into her mother\u2019s bosom, to much amusement.<\/p>\n

10.30am<\/em><\/p>\n

\u201cRole play. Start from the beginning, as you would when a new client comes in the door.\u201d<\/p>\n

Lily\u2019s 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: \u201cThis is good, but we should be focusing on Depo; that\u2019s what we\u2019re getting trained on. Vakana is just a last resort, for women not comfortable with modern methods.\u201d 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.<\/p>\n

2.30pm<\/em><\/p>\n

We\u2019re 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.<\/p>\n

First practice is on each other. Clementine sits down at the midwife\u2019s 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\u2019d consider it a grave invasion of privacy, but Dophine\u2019s fine with the onlookers. The paparrazzi would be welcome here.<\/p>\n

Afterwards, Dr. Harnosy gives Clementine a couple of pointers, and a score of three out of six, to indicate \u201cmoins de difficult\u00e9s mais n\u00e9cessite de l\u2019assistance<\/em>\u201d on the government validation sheet. Six is the top score, but Clementine\u2019s 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\u2019t rely on women remembering to take a tablet every day.<\/p>\n

Rodia is next. She looks like she\u2019s about to cry, but it\u2019s got nothing to do with the shot she\u2019s 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\u2019s 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.<\/p>\n","protected":false},"excerpt":{"rendered":"

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