MCSP Madagascar—Program Brief Tanora Mitsinjo Taranaka: Lessons Learned from an Integrated Approach to Increase Use of Health Services by First-Time Young Parents in Madagascar

The program interventions, which covered the 16 USAID priority regions, aligned with the Roadmap for the Campaign to Accelerate the Reduction of Maternal and Neonatal Mortality. The program focused on adolescent and youth health, particularly Strategy Three: "Providing essential integrated and quality services around pregnancy and childbirth focusing on adolescent and youth health." Madagascar has a large youth population, with 32% of the total population aged 10-24. Childbearing begins early, with 38.9% of women having already become mothers or being pregnant by age 19. Key reproductive life course milestones happen in rapid succession for young women, with sexual debut, marriage, and first birth happening between the ages of 17 and 19 on average. The maternal mortality ratio has remained unchanged over the last decade, at 478 deaths per 100,000 live births. Formative research conducted by MCSP in 2016 identified factors at individual, family, and community levels, and within healthcare that influence access to and use of healthcare by first-time young parents (FTYPs). The research found that community health workers (CHWs) are trusted sources of information for FTYPs and their family members. Many FTYPs are not aware of the availability and benefits of services in health centers. Even when FTYPs value services for the benefit of women's and children's health, they face supply-side barriers to service use, such as poor quality of reproductive, maternal, newborn, and child health (RMNCH) care. The MCSP designed an approach and tools for implementation that involved multisectoral adolescent sexual and reproductive health (ASRH) stakeholders from national, regional, and local levels. This integrated approach, called Tanora Mitsinjo Taranaka (TMT), was launched in two districts of Menabe (Miandrivazo and Morondava) in April 2017 under the leadership of the Ministry of Health. TMT aimed to create enabling environments and strengthen youth assets to allow FTYPs to realize their health choices and access care that is responsive to their needs. TMT was designed to build on an existing platform—the partnership between health workers and CHWs. The program trained 75 CHWs and 20 community actors from the Ministries of Youth, Education, Communication, and Population to engage FTYPs through meetings, home visits, and casual encounters. CHWs connected FTYPs to health centers through "invitation cards" and held community discussions with individuals identified via the formative research as influencing FTYPs' use of healthcare. The program also trained and supported 32 health providers to provide adolescent-responsive healthcare in 11 health facilities. Training focused on addressing provider bias toward young, particularly unmarried parents and FP clients to ensure welcoming, nonjudgmental care for FTYPs. As part of its broader RMNCH support, MCSP equipped facilities with technical materials, such as blood pressure cuffs and newborn resuscitation packs. TMT materials, including invitation cards, posters, and booklets, target FTYPs across key reproductive life moments and center on the advantages of visiting the health facility. To foster a supportive political environment, MCSP contributed financially and technically to the design of the National ASRH Strategic Plan, launched in February 2018, to emphasize a focus on age- and life stage-tailored approaches. MCSP also contributed to advocacy for the revision of a reproductive health law to take into account youth needs. The preliminary results and lessons of the proof of concept were derived from quarterly learning and review meetings with trained CHWs and health providers, qualitative documentation, and in-depth interviews with young mothers, young fathers, health providers, and national representatives. The study found that TMT was effective in engaging FTYPs and improving their use of healthcare services. The program also identified areas for improvement, including the need for additional training and support for CHWs and health providers.