Collins, Lillian

Public Health



Madagascar - Maternal and Child Health Project, Madagascar

Jhpiego in Madagascar currently runs one project, MCHIP, which seeks to improve maternal and neonatal health. The country program focuses on training health care providers, community health agents, as well as lobbying and participating in influential technical advisory groups. The program has two exciting new initiatives that are new and trail-blazing in Madagascar: the introduction of a misoprostol for PPH as a pilot project in one district, and the introduction of chlorhexidine for the prevention of neonatal infections in one district. Jhpiego/Madagascar hopes to extend these projects to other areas after successful demonstration during the pilot projects. This year is a crucial time for seeking new funding sources, assuring optimal quality of our services through intensified supervision, and disseminating project results.

You are woken by the sound of bamboo horns, thumping, and distant music. It’s 5AM on June 26, 2013: Madagascar’s 53rd Independence Day. Every year on this day (at least, in the small coastal village of Feverive-Est) the youth beat the rooster to his song. It’s early rise for the independent, those who were released from French control in 1960, those who today will tell you they feel anything but free. I’ve heard it in passing and in drawn out conversations with my friends and colleagues: “freedom” is a farce. The young country was raised by corrupt politicians, and now in its prepubescent years suffers severe economic crisis.

Two days earlier, my Malagasy and French tutor, Juliette, stared purposefully out her classroom window searching for words to explain her frustration. “The country is full of gemstones, you know. We are rich. But the government doesn’t care about the people; they only care about money for themselves. It’s because of the French.” As she spoke, her eyes became like a line of wet laundry that had been caught in the midday rain although it was meant to dry in the sun –a visible drip of water longed to fall to the dirt, to admit defeat. Juliette never let a tear drop fall. She returned her attention to the elementary French pronunciation book opened on the table in front of her, and we continued my own defeat in vowel pronunciation.

Before arriving in Madagascar, I didn’t know what to expect. I knew that I was in for an adventure- one that would likely change my life. I could not have imagined the diversity in people, landscape, and culture that weave the fabric of life on this island nation. I had lived in a low-resource seting before, but this was my first opportunity to become immersed in a developing health system. I stepped onto Madagascar soil with book-smarts on global health, and walked away with experience and knowledge to catapult me into a career in the field.

As an intern with the Maternal and Child Health Integrated Programs and JHPIEGO, I contributed to end of pilot-phase evaluation, data analysis and reporting for a community-based distribution project of misoprostol for post-partum hemorrhage prevention. I also was involved with revising curriculum for midwifery institutions nationwide. The majority of this work took place in Antananarivo, the capital city in the highlands of Madagascar. For a little over one month, I lived in a small town on the eastern coast, Fenerive-Est. This was the setting for the postpartum hemorrhage prevention project.

The classes I took at Hopkins informed me of the natural course of labor as well as interventions that save lives when things go wrong: if a woman is bleeding too much, if there is obstructed labor, if the infant needs resuscitation, the list goes on and on. In Madagascar I saw the challenges to these interventions reaching those who need it in the context of a poor health system. I learned that being within 20 kilometers of a health facility does not mean receiving skilled care. In Fenerive-Est, the national highway is so fraught with potholes that it can take several hours by car, bicycle taxi, or on foot to travel that distance; in the rainy season, it may be impossible.  Even if a woman in labor reaches a health facility, there is a good chance that the facility will be empty, as doctors and midwives leave their post for training at least one week every month.  In this setting, interventions like misoprostol to prevent postpartum hemorrhage at home births saves lives –so much so, that the Malagasy project staff has named the drug Famonjy, which means “life-saving.” I was privileged to meet face-to-face with women who used Famonjy, as they and their families expressed gratitude for the program. Since the dissemination of results affirming the feasibility of community-based distribution of the drug, it is now in the hands of the Malagasy government to decide if they will register it so that others may be spared.

Flying over the western coast of Madagascar, headed to South Africa and then home, I couldn’t believe that my internship experience had come and gone. Today, Juliette’s words, “we are rich,” ring true. Madagascar is not only rich in gemstones but in music, beauty, perseverance, and innovation. Working in the country for a short time, I came to understand that strengthening the infrastructure of the health system is such a complicated task, but one that Malagasy people are committed to. We share this work: to reach those who most need life-saving health interventions. Contributing to this cause through a career in global health is incredibly rewarding, and I am thankful for having this opportunity through the Global Health Established Field Placement program. 


October 2022



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