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Globally, few programs consider the needs of first-time young parents (FTYPs), who face disproportionate negative health consequences during pregnancy and childbirth. Scant evidence exists on FTYPs' broader health needs. Formative research in two regions of Madagascar used a socio-ecological lens to explore, via 44 interviews and 32 focus group discussions, the influences on FTYPs at the individual, couple, family, community, and system levels. We spoke with FTYPs who had, and who had not, used sexual and reproductive health (SRH) services, their parents/kin and influential adults, and community health workers and facility health providers. Data analysis, guided by a codebook, used Atlas.ti. Age, social position, and implicit power dynamics operating within and across socio-ecological levels affected FTYPs' service-seeking behaviors. The nature and extent of influence varied by health service type. Cross-cutting social factors affecting service use/non-use included gender dynamics, pressures from mothers, in-laws, and family tradition, and adolescent stigmatization for too-early pregnancy. Structural and economic factors included limited awareness of and lack of trust in available services, unfriendliness of services, and FTYPs' limited financial resources. A socio-ecological program perspective can inform tailoring of activities to address broader SRH issues, including how relationships, gender, power, and intergenerational dynamics influence service use.

Introduction: Tuberculosis infection may remain latent, but the disease is nevertheless a serious public health issue. Various epidemiological studies on pulmonary tuberculosis have considered the spatial component and taken it into account, revealing the tendency of this disease to cluster in particular locations. The aim was to assess the contribution of Knowledge Attitude and Practice (KAP) to the distribution of tuberculosis and to provide information for the improvement of the National Tuberculosis Program., Methods: We investigated the role of KAP to distribution patterns of pulmonary tuberculosis in Antananarivo. First, we performed spatial scanning of tuberculosis aggregation among permanent cases resident in Antananarivo Urban Township using the Kulldorff method, and then we carried out a quantitative study on KAP, involving TB patients. The KAP study in the population was based on qualitative methods with focus groups., Results: The disease still clusters in the same districts identified in the previous study. The principal cluster covered 22 neighborhoods. Most of them are part of the first district. A secondary cluster was found, involving 18 neighborhoods in the sixth district and two neighborhoods in the fifth. The relative risk was respectively 1.7 (p<10-6) in the principal cluster and 1.6 (p<10-3) in the secondary cluster. Our study showed that more was known about TB symptoms than about the duration of the disease or free treatment. Knowledge about TB was limited to that acquired at school or from relatives with TB. The attitude and practices of patients and the population in general indicated that there is still a stigma attached to tuberculosis., Conclusion: This type of survey can be conducted in remote zones where the tuberculosis-related KAP of the TB patients and the general population is less known or not documented; the findings could be used to adapt control measures to the local particularities.

Background: In Madagascar, where more than half of women give birth without skilled attendants, quality improvement of health services may ameliorate community perception of facility-based delivery care, thereby increasing the skilled birth attendance rate. For women who do deliver in a facility, a higher quality of services will lead to better outcomes, moving the country closer to reaching Millennium Development Goals 4 and 5. To guide the quality improvement processes at health facilities in Madagascar, this study assessed the quality of care at facilities with respect to interventions addressing the main causes of maternal and newborn complications with a focus on postpartum hemorrhage (PPH) and pre-eclampia/eclampsia (PE/E)., Methods: The study targeted all health facilities with a high volume of deliveries through inventories of medications and material, interviews with health providers, and observations of routine care and complicated cases. A total of 36 health facilities were included in the study, and interviews were carried out with 139 providers. Observations were made of 323 antenatal consultations and 347 labor and delivery clients, including 255 observations of the first stage of labor and 288 at the second or third stages., Results: The main challenges to providing high-quality services as revealed by the inventory are the low availability of clinical protocols and guidelines for providers, and syringes, needles, and IV infusion sets to give uterotonics. Also, communication equipment and emergency transport were available in half of facilities, and a safe water source within 500 meters was available in only 67%. Regarding provider knowledge as measured by the interviews, the strongest areas of knowledge were detection of lacerations and conducting a physical examination; the weakest were on management of uterine atony or of retained placenta, stabilizing the mother with magnesium sulphate and anti-hypertensives, initial steps in management of severe PE, management of convulsions, and essential equipment and supplies needed. Technical support or supervision of providers was often nonexistent or inadequate. Some aspects of the observed care were of moderately high quality, such as infection prevention and provision of prophylactic oxytocin. However, compliance with all elements of the active management of the third stage of labor (i.e., oxytocin within one minute of delivery, controlled cord traction, and uterine massage after delivery of the placenta) occurred in only 13% of observed deliveries. In only 48% of observed antenatal care consultations was blood pressure measured using correct technique, and in only 29% did the provider perform or refer the pregnant woman for proteinuria screening. During cases of postpartum hemorrhage management, manual removal of placenta (MRP) was attempted in five cases but in none was it carried out according to the guidelines. In several cases of severe pre-eclampsia and one case of eclampsia, magnesium sulphate, the drug of choice, was not given., Discussion: Overall, quality improvement is urgently needed to provide prophylactic oxytocin to all women within one minute of delivery, and to supply magnesium sulphate to all maternities for treatment of severe PE/E, among other interventions. To build on existing favorable policies to improve maternal and newborn health care in Madagascar, quality improvement efforts should target provider and facility readiness. In addition, national guidelines and protocols need to be updated and operationalized according to an appropriate national strategy that includes a budgeted action plan, follow-up, and performance-based recognition of providers and facilities. A national strategy is critical to ensure that all partners in the health system support it. An increase in the government's participation in funding for health (more than 12%, per the Abuja recommendation) would facilitate this program. Provider competencies can be maintained through regular practice with low-cost anatomical simulators and through use of regular updates and reminders to providers on clinical protocols via cell phones. In addition, accountability can be promoted by an adequate health management information system that collects data on the main causes of maternal and neonatal deaths, adequate supply at facilities of oxytocin, magnesium sulphate and other lifesaving drugs, and routine presentation of this information in regional and national fora.

Objectives: Bacterial vaginosis (BV) is a condition characterized by a disturbed vaginal ecosystem which fluctuates in response to extrinsic and intrinsic factors. BV recurrence is common. To explore whether consistent condom use was associated with BV occurrence or recurrence, we compared the effect of condom use on BV prevalence after 6 months, among women with and without BV at baseline., Methods: We used data from a randomized controlled trial, conducted among female sex workers in Madagascar during 2000-2001, that assessed the impact of adding clinic-based counselling to peer education on sexual risk behaviour and sexually transmitted infection incidence. BV was diagnosed at two time points (baseline and 6 months) according to modified Amsel criteria. Consistent condom users were women reporting no unprotected sex acts with clients in the past month or non-paying partners in the past year. Adjusted prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated using multivariable regression models., Results: At baseline, 563 (56%) women had BV. Of those, 360 (72%) had BV at 6 months, compared to 158 (39%) without BV at baseline. The adjusted 6-month PR for BV comparing consistent to inconsistent condom users was 0.99 (95% CI: 0.85-1.13) among women with BV at baseline and 0.57 (95% CI: 0.30-0.94) among women without BV at baseline., Conclusions: Consistent condom use was associated with reduced BV prevalence at 6 months for women who were BV-negative at baseline, but had no effect among women who were BV-positive at baseline. Male condoms appeared to protect against BV occurrence, but not BV recurrence.

Background: Persistent high levels of sexually transmitted infection (STI) in Madagascar indicate current prevention strategies are inadequate. STI/HIV prevention based in social venues may play an important role in reaching individuals at risk of infection. We identified venues where people meet sexual partners and measured the need and potential for venue-based prevention., Methods: Interviews were conducted in 7 Madagascar towns with 1) community informants to identify social venues, 2) individuals socializing at a sample of venues to assess sexual behavior among venue patrons, and 3) venue representatives to assess the potential for venue-based intervention., Results: Community informants identified numerous venues (range: 67-211 venues, depending on the town); streets, bars, and hotels were most commonly reported. Among 2982 individuals socializing at venues, 78% of men and 74% of women reported new sexual partnership or sex trade for money, goods, or services in the past 4 weeks and 19% of men and 18% of women reported symptoms suggestive of STI in the past 4 weeks. STI symptom levels were disproportionately high among respondents reporting either sex trade or new sexual partnership in the past 4 weeks. Twenty-eight percent of men and 41% of women reported condom use during the last sex act with a new partner. Although 24% to 45% of venues had hosted STI/HIV interventions, interventions were deemed possible at 73% to 90% venues according to 644 interviews with venue representatives., Conclusions: Venue-based intervention is possible and would reach a spectrum of populations vulnerable to STI/HIV including sex workers, their clients, and other high-risk populations.

To determine risk for drug-resistant malaria parasites entering Madagascar from Comoros Islands, we screened travelers. For the 141 Plasmodium falciparum isolates detected by real-time PCR, frequency of mutant alleles of genes associated with resistance to chloroquine and pyrimethamine was high. International-level antimalarial policy and a regional antimalarial forum are needed.

Objectives: The diaphragm, a woman controlled, reusable contraceptive device, might prevent some sexually transmitted infections (STIs). We assessed the acceptability and feasibility of use of silicone Wide-Seal Arcing Diaphragms (Milex Products, Chicago, IL, USA) by sex workers in Madagascar., Methods: Over 8 weeks, we evaluated method acceptability by examining patterns of and problems with women's diaphragm use. We also evaluated several measures of study feasibility, including recruitment and follow up methods., Results: 91 women from three cities (Antananarivo, Tamatave, and Mahajanga) participated, and 87 (96%) completed follow up. At enrolment, participants reported a median of six sex acts with five clients in the previous week. During the follow up period, participants reported a median of three sex acts with three clients during the previous 2 days, and self reported continuous diaphragm use during the previous day increased from 87% to 93%. Seven women became pregnant (incidence 53 pregnancies per 100 woman years). Self reported use of male condoms and diaphragms was fairly constant over the study period: women reported condom use in 61% to 70% of acts and diaphragms in 95% to 97% of acts. The number of participants reporting diaphragm problems decreased from 15 (16%) at the first visit to six (7%) at the final visit. 20 women (22%) needed replacement devices during follow up because their original diaphragms were lost, were the wrong size, or became seriously damaged., Conclusions: Given the high use and steady decrease in reported problems during the study, we believe diaphragms are acceptable and feasible in this resource poor, low education sex worker population.

Background: Too little is known about the many women who generate income in Madagascar by trading sex., Methods: Clinical and laboratory exams were offered to 493 non-care seeking female sex workers (SWs) in Antananarivo and 493 in Tamatave. SWs were recruited by peers in their community; they were interviewed, counselled and treated for sexually transmitted infections (STIs) at recruitment and re-evaluated 2 months later., Results: One hundred and eighty six (38%) of the SWs in Antananarivo and 113 (23%) in Tamatave did not complete primary school (P < 0.0001). The incidence rates per person per month in Antananarivo and Tamatave, respectively, were 0.09 and 0.08 for gonorrhoea; 0.05 and 0.03 for chlamydia; 0.24 and 0.15 for trichomoniasis; 0.07 and 0.05 for syphilis. At follow-up, consistent condom use with clients was reported by 56 (12%) SWs in Antananarivo and 137 (29%) in Tamatave (P < 0.0001); 320 (70%) SWs in Antananarivo and 11 (2%) in Tamatave reported sex with a non-paying partner in the past month (P < 0.0001). In Antananarivo, 422 (92%) of the SWs thought they were at no or low risk of having an STI compared to 100 (21%) in Tamatave (P = 0.02). At follow-up, 277 (61%) SWs reported no birth control for their last sex act in Antananarivo, compared to 26 (5%) in Tamatave (P < 0.0001). Socio-demographic and behavioural risk factors for incident gonorrhoea, chlamydia and trichomoniasis varied by city., Conclusions: Strategies to address the needs of women who trade sex should include educational and economic opportunities; should tackle male partners of SWs; promote dual protection against unintended pregnancy and STIs, while taking into account local socio-demographic and behavioural characteristics.

Background: Sex work is frequently one of the few options women in low-income countries have to generate income for themselves and their families. Treating and preventing sexually transmitted infections (STIs) among sex workers (SWs) is critical to protect the health of the women and their communities; it is also a cost-effective way to slow the spread of HIV. Outside occasional research settings however, SWs in low-income countries rarely have access to effective STI diagnosis., Objectives: To develop adequate, affordable, and acceptable STI control strategies for SWs., Methods: In collaboration with SWs we evaluated STIs and associated demographic, behavioural, and clinical characteristics in SWs living in two cities in Madagascar. Two months post-treatment and counselling, incident STIs and associated factors were determined. Evidence-based STI management guidelines were developed with SW representatives., Results: At baseline, two of 986 SWs were HIV+; 77.5% of the SWs in Antananarivo and 73.5% in Tamatave had at least one curable STI. Two months post-treatment, 64.9% of 458 SWs in Antananarivo and 57.4% of 481 women in Tamatave had at least one STI. The selected guidelines include speculum exams; syphilis treatment based on serologic screening; presumptive treatment for gonorrhoea, chlamydia, and trichomoniasis during initial visits, and individual risk-based treatment during 3-monthly follow-up visits. SWs were enthusiastic, productive partners., Conclusions: A major HIV epidemic can still be averted in Madagascar but effective STI control is needed nationwide. SWs and health professionals valued the participatory research and decision-making process. Similar approaches should be pursued in other resource-poor settings where sex work and STIs are common and appropriate STI diagnostics lacking.