Summary

Over 90% of the population in the Anosy region of Madagascar live in extreme poverty, with severe lack of access to and investment in health services. Women are particularly disadvantaged – the region suffers some of the highest levels of maternal and child mortality in the country, with around 20% of deaths in women aged 15-24 related to pregnancy or birth. This health situation is exacerbated by the effects of the ongoing political crisis, with subsequent budget cuts to public services and withdrawal of international aid. Previous platforms for coordinating health services have collapsed with little indication this situation will improve in the near future. A comprehensive evaluation of health services therefore needs to be undertaken, from which Azafady can develop a coordinated maternal and child health intervention strategy, including advocacy to other stakeholders and potential partners, and the direct provision of health programmes.

Project Votsira aims to explore the full birth cycle from pregnancy to antenatal care, maternal health, birthing, postpartum, neonatal, post-pregnancy family planning and paediatric health. It will enable Azafady to build a comprehensive picture of the social and economic factors (e.g poverty, inadequate access to information and services, ongoing lack of state health service delivery) affecting maternal and child health in Anosy, and to determine what is required to build community and institutional capacity in order to sustainably improve access to and quality of primary health care for women and children in Fort Dauphin. It will bring together members from all sectors of society through interactive research activities including detailed case studies and focus groups. It will look at informal support structures including community midwives and examine why these are chosen in preference over formalised health services, and the various risks and benefits involved in each choice.

Varying vulnerabilities between different subpopulations will be identified and analysed with the participation of local people to inform the focus of future strategy. Cultural traditions and behaviours that impact on maternal and child health and access to services will also be analysed. The strategy resulting from this project is anticipated to include advocacy to other stakeholders and agencies, coordination of service delivery, community capacity building and provision of direct health intervention projects.

Project Aim

To research the factors that affect women and children's access to health services in Fort Dauphin, and to develop a comprehensive long-term coordinated intervention to reduce maternal and child mortality.

Principal activities

Questionnaires, focus groups, enquiry action groups, in-depth profiling, semi-structured interviews
Over 100 pregnant women and 100 mothers of children under 5 will be invited to participate through questionnaires, focus groups and enquiry action groups. This project will also follow 10 pregnant women, 10 mothers of children under 1, and 5 mothers of children under 5 in an in-depth profiling exercise for one year through their pregnancy and birth or for one year of their child's life.

50 men who are partners / husbands of these pregnant women or mothers will also participate though questionnaires, focus groups and enquiry action groups to understand the role men play in decisions relating to maternal and child health and access to services.

20 formally trained / community midwives will be brought together in a series of focus groups, enquiry action groups and semi-structured interviews to understand common practices and traditions, share experience, and map service quality and access.

20 public service representatives including the regional Ministry of Health, doctors from the public hospital and community health centres will be brought together in enquiry action groups to understand government strategy and service provision, and any conflicts of these agendas with on the ground needs. 10 agency partners including Population Services International and Marie Stopes will be invited to participate in focus groups and enquiry action groups in order to create links between service users, service providers and civil society, and map service practice, quality and access.

50 civil society representatives from Fort Dauphin including opinion leaders and members of women's associations will be brought together through focus groups and enquiry action groups in order to understand cultural norms and traditions, and social pressures on decisions relating to pregnancy, birth and child health.

Interactive feedback and planning sessions
Participants, stakeholders and beneficiaries will be invited to interactive feedback and planning sessions in order to include them in the verification of the research findings and ensure their ownership of the information gathered through Project Votsira. Their active participation in these sessions will be encouraged in order to ensure their direct input into defining the outcomes of Project Votsira in terms of the future strategy for a comprehensive long-term coordinated maternal and child health programme in Fort Dauphin.

Creation of a community health platform
Project Votsira will involve a diverse range of stakeholders and local partners across the range of the project's activities including the regional Ministry of Health, community midwives, local opinion leaders, community associations and public health service providers including doctors, the public hospital and community health centres. The following corporations, NGOs and civil society organisations will also be invited to participate: Marie Stopes, Population Services International, Santenet, Cielo Terra and the social development team of QMM (local subsidiary of mining company Rio Tinto). This project will bring together these organisations through focus groups and enquiry action groups to identify their various roles, responsibilities and capacities. This network will then be supported to form a long-term community health platform for Fort Dauphin, with Azafady advocating where appropriate for the targeting of each agency's resources to meet the specific needs of local women and children as identified through Project Votsira.