Sex Transm Infect 81:472-476 doi:10.1136/sti.2005.015107
  • Sex work

Acceptability and feasibility of continuous diaphragm use among sex workers in Madagascar

  1. F Behets1,2,
  2. A Norris Turner1,
  3. K Van Damme2,3,
  4. N L Rabenja3,
  5. N Ravelomanana3,
  6. K Zeller4,
  7. J R Rasolofomanana5
  1. 1Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
  2. 2Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
  3. 3UNC-MAD, Antananarivo, Madagascar
  4. 4William J Clinton Presidential Foundation, New York, NY, USA
  5. 5Institut National De Santé Publique et Communautaire, Ecole de Médecine, Antananarivo, Madagascar
  1. Correspondence to:
 Frieda Behets
 PhD, MPH, Department of Epidemiology, University of North Carolina at Chapel Hill, 2102-D McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC 27599-7435, USA; frieda_behets{at}
  • Accepted 9 April 2005


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.


  • Conflict of interest: No authors have any conflict of interest.