Reproductive Health in Madagascar

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Amanda Klinger

Amanda Klinger

Dr. Amanda Klinger is a second year internal medicine resident at Beth Israel Deaconess Medical Center in Boston, MA. She has participated in global health research projects in Ghana and Madagascar during her time in medical school, working in a Ghanaian tertiary care hospital's Emergency Department and conducting reproductive health and family planning classes in northern Madagascar. She is a part of the Global Health Track in her residency program at BIDMC.
Amanda Klinger

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I vividly remember the beginning of my trip to Madagascar to perform reproductive health research. At the end of providing an update to my mentor on my experiences from my first week in Madagascar, he responds, “If arranging (reproductive health) classes for both boys and girls is too difficult, just focus on the girls.” As I hang up the phone, I feel the frown develop on my face. His words did not sit right to me; reproductive health affects BOTH sexes. I tell myself then and there that I will find a way to include both adolescent women and men in my research intervention during my time in Madagascar.

At the time, I was living in a village in northern Madagascar, where I had been tasked with providing reproductive health and family planning classes to adolescents in an attempt to increase knowledge, attitude, and self-efficacy surrounding these two areas. At the time, I felt that it was important to teach both women and men, because intuitively I felt that change would not occur if only half of the community was involved in my interventions. During my two months there, I discovered that this held true. When speaking with the girls in my classes, most of them mentioned that their partners were not always supportive of them using contraception, especially in the more rural villages, which led the girls to not seek out family planning services, or to try options that they could hide (e.g. Depo Provera shots given every 3 months). They felt that if their partners would support them taking contraception, they might use it more often. The male students were surprisingly even more engaged in contraceptive class discussions than the female students. They were interested in learning about the various methods to prevent pregnancy, and asked detailed questions about how to discuss these options with their partners.

Demand generation has been a neglected area of global health interventions. Although supply chain management has improved and community health worker capacity has been scaled up in many communities (including in Madagascar), a compensatory increase in uptake of services is not always seen. Demand generation interventions have often been neglected, partially accounting for this lack of uptake of various medical care options and interventions.

I experienced the lack of focus on demand generation first-hand in Madagascar. Although multiple international governmental and non-governmental organizations had a presence in the village in which I lived, and a local clinic existed with access to 2 trained doctors, free condoms, and contraception, focus group discussions with adolescents showed that there were many barriers to youth uptake of these methods. My study showed that there were knowledge gaps in available resources and perception of a lack of support among male partners and family members for female contraception (Klinger et al 2016). Many other studies have shown that contraception uptake is higher when partners are supportive and aware of contraceptive options (Ezeanolue et al 2015; Kabagenyi et al 2014).

Although many there have been many studies on barriers to uptake of medical care, more rigorous studies on behaviors affecting specific groups’ medical decision making need to be done to better tailor interventions. As Sgaier et al (2015) discuss and demonstrate, using an analytical framework with focused qualitative and quantitative behavioral research is necessary to create more effective interventions. This type of approach should be an important focus of global health research and demand-side interventions should be better funded to break the existing barriers to medical care.

As a health care practitioner both in America and abroad in Madagascar, I have seen that providing access to medical care does not directly lead to uptake and improvements in health outcomes. An increased focus on behavior science will help to generate the demand that is needed to make real change in public health outcomes.


Ezeanolue, E. E., Iwelunmor, J., Asaolu, I., Obiefune, M. C., Ezeanolue, C. O., Osuji, A., . . . Ehiri, J. E. (2015). Impact of male partner’s awareness and support for contraceptives on female intent to use contraceptives in southeast Nigeria. BMC Public Health, 15(1). doi:10.1186/s12889-015-2216-1

Kabagenyi, A., Jennings, L., Reid, A., Nalwadda, G., Ntozi, J., & Atuyambe, L. (2014). Barriers to male involvement in contraceptive uptake and reproductive health services: A qualitative study of men and women’s perceptions in two rural districts in Uganda. Reproductive Health Reprod Health, 11(1). doi:10.1186/1742-4755-11-21

Klinger, A., & Asgary, R. (2016). Perceptions and attitudes regarding sexually transmitted infection and family planning among adolescents in Northern Madagascar. Women & Health, 1-15. doi:10.1080/03630242.2016.1178684

Sgaier, S. K., Baer, J., Rutz, D. C., Njeuhmeli, E., Seifert-Ahanda, K., Basinga, P., . . . Laube, C. (2015). Toward a Systematic Approach to Generating Demand for Voluntary Medical Male Circumcision: Insights and Results From Field Studies. Global Health: Science and Practice, 3(2), 209-229. doi:10.9745/ghsp-d-15-00020