Innovations in Family Planning

AFG

HA

NIS

TAN

NGOs Location CHWsHealthPosts

Households inHealth Post

Catchment AreasSect

Ethnicity of the Majority of the

Population Served

BDF & AADA

Tormay, Ghazni Province

20 10 732 Shi’ite Hazara

CHAIslam Qala,

Herat Province15 10 840

SunniandShi’ite

Tajik, Pashtun, and other

STEPFarza,

Kabul Province30 15 2,136 Sunni Pashtun

TOTAL 65 35 3,708

PROJECT AREAS: Islam Qala District inHerat Province, Tormay District in GhazniProvince, and Farza District in KabulProvince

NONGOVERNMENTALORGANIZATIONS:Four Afghan NGOs provided services:STEP Health and DevelopmentOrganization, the managing partner of thisproject; the Agency for Assistance andDevelopment of Afghanistan (AADA);Bakhtar Development Foundation (BDF);and Coordination of HumanitarianAssistance (CHA).

THE ACCELERATING CONTRACEPTIVE USE PROJECT(2004–2006)

IslamQala,Herat Province

Tormay,Ghazni Province

Farza,Kabul Province

Kabul

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With funding from the William and FloraHewlett Foundation, the AcceleratingContraceptive Use Project managed by

Management Sciences for Health (MSH) hascontributed to dramatic improvement in theacceptance of family planning services in parts ofAfghanistan. MSH applied years of experience inthe country—beginning in 1973—to strengthen thehealth system and improve access to and the qualityof services.

Given the country’s fragile health system,increasing contraceptive use was challenging:Afghanistan lacks qualified health professionals and isexperiencing an influx of returnees from neighboringcountries, and the infrastructure was devastatedduring the Soviet occupation and the Taliban regime.Postconflict Afghanistan has a total fertility rate of 6.7,close to the highest in the world, and a maternalmortality rate of 1,600 deaths per 100,000 live births,second highest in the world. Conventional wisdomsuggested that a cautious approach to family planningwould be necessary for cultural and religious reasons.However, many women and men in the three ruralproject areas wanted family planning, and theircommunities were open to the idea.

Eight months ago, talking about contraception was a taboo.Nowadays people easily talk about birth spacing. Birthspacing has become a value and people know it’s the mosteffective and quick way to reduce maternal and childdeath.

–The woleswal (mayor) of Farza in rural Kabul Province, Afghanistan

Innovations to Increase the Useof Family Planning

The Accelerating Contraceptive UseProject in Afghanistan

JANE SCHULER-REPP

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PROJECT ACHIEVEMENTS IN CONTRACEPTIVE USE

Most women in the distant areas where theAccelerating Contraceptive Use Project workedcannot access health services outside their

communities. To address this obstacle, the Ministry ofPublic Health adopted a policy to deploy 2 communityhealth workers (CHWs), 1 male and 1 female, forevery 100–150 households. More than one-half of the6,300 CHWs who are operating health posts in thecommunities are female. Contraceptives are providedalmost exclusively by CHWs, whose presence hasincreased access to contraceptives in rural Afghanistan.

Preventing maternal deaths. The project forestalled anestimated one-fourth of maternal deaths bypreventing unintended births in the project areas.Considerable time and resources are needed todevelop the clinical skills and infrastructure to treat themajor causes of maternal death: postpartumhemorrhage, obstructed labor, eclampsia (seizures),postpartum infection, and unsafe abortion. Preventingunintended pregnancies, therefore, is a vital part ofsafe motherhood strategies.

Better spacing of births leads to major improve-ments in children’s health as well: compared withchildren born less than 2 years after a previous birth,children born 3 to 4 years after a previous birth are2.4 times more likely to survive to age 5 (Setty-Venugopal and Upadhyay, “Birth Spacing: Three to FiveSaves Lives,” Population Reports 2002).

Meeting needs through diverse methods. The threeproject sites showed surprising diversity in use ofmodern contraceptive methods, given the similar

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Figure 1.

Project Sites and REACH Program SitesCONTRACEPTIVE USE

Before and during the Hewlett-funded project, the MSH REACH (Rural Expansionof Afghanistan’s Community-based Healthcare) Program achieved an impressiveincrease in contraceptive use in 13 provinces covering about one-third of thecountry. Building on those achievements, the Accelerating Contraceptive UseProject worked at three sites. Over eight months, the contraceptive prevalencerate increased by 24–27 percentage points in each of the sites.

DOUGLAS HUBER

ExpandingServices

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Married Women of Reproductive Age Using INJECTABLE CONTRACEPTIVES

Married Women of Reproductive Age UsingORAL CONTRACEPTIVES

Married Women of Reproductive Age Whose Husbands Are Using

CONDOMS

services in each. The lesson for health programs inAfghanistan is to be aware of the contraceptivepreferences of different communities and be flexible inthe methods offered and commodities provided.

The use of the injectable contraceptive Depo-Provera increased dramatically in each of the threesites over eight months (Figure 2). This increase wasattributable to CHWs initiating the use of injectablesand being prepared to explain common changes thatwomen experience when using injectables. Women,their husbands, and community leaders welcomed the

The fastest, easiest, cheapest way to reducematernal deaths in Afghanistan is withcontraception.

–Dr. Qudratullah MojadidiAfghan Obstetrician/Gynecologist, CURE Hospital

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OCT. 2005 JUNE 2006

Figure 2. Figure 3. Figure 4.

innovation of starting the injection at home, ratherthan going to the clinic, which could be a two-hourwalk each way. Injectable contraceptives were alsowelcome because of their high effectiveness and theneed for a repeat injection only every three months.

Oral contraceptive use showed diverse changes,decreasing in one area (Tormay) and increasingsubstantially in another (Farza). See Figure 3. In IslamQala there was little change, this area being the onewhere injectables showed the greatest increase, with27% of married women using injectables by June 2006.

Condom use increased dramatically in Tormaybut remained low in the other areas (Figure 4). Thisincrease can be explained by this population’sexperience with condoms in Iran, which was anasylum for many Hazara during the Taliban regime.Some religious leaders used condoms and set anexample for others. Tormay was the area where theuse of pictorial instructions for condom users wasmost acceptable. �

ABOVE:CHW demonstrating the correctuse of condoms. Both male andfemale CHWs received training onhow to use condoms usingpictorial instructions developed bythe project.

LEFT:Typical winter scene in FarzaDistrict. Heavy snow preventsmany clients from getting to healthfacilities, making the role of CHWsespecially important.

DOUGLAS HUBER

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Three components helped the project achievesuccess at both the community and policylevels:

� contraceptive technical expertise in designing safeand effective approaches to meeting birth-spacingneeds;

� knowledge gleaned from multiple internationalprograms about the elements of success;

� understanding of the community, which allowedthe project to design activities to break downbarriers to contraceptive use, fit the socioculturaland religious context, and engender trust in andsupport from community and religious leaders.

CREATING POSITIVE IMAGES OF FAMILY PLANNINGThe project used a variety of approaches tailored todifferent audiences to broaden the understandingand acceptance of family planning.

Promoting birth spacing in ways consistent withIslamic teachings. Health messages supporting useof contraception were consistent with teachings inIslam, a critical factor in our success. Religion becamea positive force in efforts to promote birth spacingand the health of women and children. UsingKoranic sayings directly in relation to the educationof men, women, and community leaders was accept-able and helpful.

Discussions with mullahs—Islamic teachers andleaders—and the Ministry of Religious Affairs showedthat their concerns about contraception weregenerally not related to religion, but rather to safety,

CENTER INSET:Dialogues with religious leadersinformed the project’s strategy andimplementation.

Applying NewApproaches

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based on misinformation and misunderstandingspervasive among providers and the rest of thecommunity. When given accurate information, the37 mullahs interviewed by project staff agreed withthe project’s efforts to promote birth spacing usingmodern contraceptives. This 100% concurrence wasachieved through dialogue; however, it does notmean that all mullahs in Afghanistan will quicklyendorse modern contraceptives.

Using dialogue to understand communities andmisconceptions about family planning. The projectassessed the communities through informal discus-sions with community leaders, families, clinic staff, andreligious leaders. These dialogues provided a solidunderstanding of the people, health care providers,

CARMEN URDANETA

DOUGLAS HUBER

We need contraceptives, but the people do notknow about them and do not have access. I willuse the time after Friday prayers to educate thecommunity. If you make a cassette about familyplanning, I will play it from the mosque.

–Mullah in Tormay, Ghazni Province

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and social and religious dimensions of the settings.This understanding supported the introduction ofinnovations in messages and services, which, onceaccepted, were then applied in several areas.

Discussions with clinic staff and public officialsrevealed the need for updated, accurate informationabout contraceptive methods. The project teamprovided clinical updates and public education toovercome misconceptions such as the following:

� Injectable contraceptives cause infertility andshould be used only by women who have morethan 4–6 children and are over 35 years of age.

� Injectable contraceptives decrease breast milk.

� Breastfeeding women should wait until they havemenstrual bleeding before starting injectablecontraceptives.

� IUDs should not be given to women who havehad 6 or more pregnancies.

� Women who work hard should not use the IUD.

� Women who have never been pregnant shouldnot use contraception.

� The minipill (progestin-only pill) can be usedinterchangeably with the standard pill (combinedoral contraceptive).

The project generated clear messages withquotations from the Koran and guidance for womenand men about the safety of contraceptives, theircorrect use, and how to deal with common sideeffects. Written materials on oral contraceptives andinjectables were provided to all 3,700 households inthe project areas. The cost of the flier was low (fourcents per household), so it will require minimalresources to expand this activity. If a woman couldnot read, she found a family member or neighborwho could help. Similar materials with additionalguidance for managing side effects were provided toCHWs and facility-based providers.

Providing accurate information to service providers.For providers, contraceptive technology updates withthe clinical staff of NGOs and the leading maternityhospital in Kabul promoted a proactive and positiveapproach to family planning. The updates emphasizedthe safety of contraceptives in relation to the risk ofpregnancy: contraceptives are 300 times safer thanpregnancy in Afghanistan. The updates also stressedthe nonharmful nature of common side effects and

I know about family planning. In fact mywife has been using injectable contraceptivesfor six months. See, here in my notebook Ikeep the date for her next injection to helpremind her.

–Senior imam in Islam Qala, Herat Province

ABOVE:A CHW prepares the first Depo-Provera injection for a client at herhealth post. Injectablecontraceptives became the mostpopular method in two out ofthree project sites.

TOP:Male community health workersreceive training on the injection ofDepo-Provera. After the training,the number of injectable usersdoubled.

DOUGLAS HUBER

NIKA SAEEDI

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their management, encouragement of women tocontinue contraceptive use, and the obligation ofhealth care providers to enable all women to havean adequate and healthy birth interval of 3 or moreyears by using 24 months of contraceptiveprotection (breastfeeding and modern methodscombined).

Adapting pictorial instructions for using condoms.Because many of the health care providers inAfghanistan did not give correct instructions aboutusing condoms, the project adapted pictorialinstructions from the World Health Organization.Simple diagrams of male anatomy were acceptable intwo project sites, provided that the diagrams wereused by the health worker only in discussion with thehusband or his wife. Sensitive use of the pictures—with individuals rather than groups, in separategroups for women and men, and by female CHWswith women—was important for their acceptance. Inone area the pictures were considered culturallyinappropriate and were not used. Where they wereused, particularly in Ghazni, condom use increasedrapidly and health workers found the instructionsvery useful.

BELOW:Project manager explains thedifference between combined oralcontraceptive pills and progestin-only pills to providers. Thisinformation on not interchangingthe two types of pills illustrateshow the project addressedcommon misconceptions.

Using television for public advocacy: The firstAfghan programs on contraception. The clinicianswho received contraceptive technical updates fromthe project participated in two widely viewed 30-minute national TV programs, providing informationfor the public by answering common questions aboutcontraception. The second program featured amullah, who delivered a compelling message on thepositive aspects of family planning in relation to Islam.

The feedback to the TV station was so positivethat the project was offered an additional 30 minutesof prime time to do a drama on contraceptiontopics. These TV programs were the first time acontraceptive topic was shown in Afghanistan. Theprograms, which could be seen in most ofAfghanistan and parts of Pakistan and Iran, werewatched by about 70% of TV viewers. �

I believe in family planning because it willimprove the health of children and women.I teach the people about birth control pills,injections, and condoms during Fridayprayers. I will lead our local action plan toeducate all the people in this area aboutfamily planning in the next two months.

–Mullah in Farza, Kabul Province

DOUGLAS HUBER

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Public acknowledgment of the elements ofsuccess in each community empoweredcommunity members, both men and women,

and helped them to believe in themselves. Instead offocusing on what they lacked, they started to seetheir progress and their ability to change. Inpostconflict Afghanistan, these people began tobelieve that they could plan for their lives and theirfamilies.

Developing trust. Regular visits to the project sitesand to homes and meetings with religious and other community leaders, including the healthcommittees (shura-e-sehi), were important fordeveloping trust and proposing innovations, such asCHWs introducing injectable contraceptives. Thesevisits also allowed us to verify the level of acceptancebefore introducing practices based on lessons learnedfrom other countries.

Involving both men and women. The increase incontraceptive use was made possible by working withboth men and women. We found that men werereceptive to involving women in promotion of birthspacing. Although women had been excluded frompublic gatherings until now, the NGO partnersactively engaged women throughout the project. Theproject NGOs organized women’s committees as aforum to discuss issues about contraceptives.

Facilitating changes in national policies.The projectfostered changes in national policies and practicesrelated to oral contraceptives and injectables, forexample, giving six rather than one cycle of pills pervisit and allowing CHWs to initiate the use of inject-ables. Our approach started at the grassroots level, byassisting the Ministry of Public Health to pilot-test theuse of CHWs for injectables. Then the project’s resultsled to changes in national policies, which providers inturn carried out at the community level.

Devoting time to supportive supervision. CHWsrequired a great deal of supportive supervision toperform tasks associated with contraception. Theywere far more comfortable with promoting childhealth—identifying and treating diarrhea and respir-atory infections and making referrals for immunizations.The NGOs could not provide all the supervision andcoaching necessary to enable the CHWs to rapidlyprogress in skills and competence for birth spacing.Project staff invested considerable time assistingNGOs in strengthening the performance of thesetasks.

On-site support of a CHW by project staffresulted in a surprising acceptance of injectables inseveral households. The CHW rapidly gainedconfidence and immediately provided injections toseveral other women. Through such experiences, welearned what CHWs needed to improve theirperformance.

Fostering Sustainability

ABOVE:Dr. Nadera Hayat Burhani, DeputyMinister for Reproductive Health,addressing the disseminationseminar on the project’s outcomes,October 2006

FARDIN WAEZI

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Using role models. Women were happy to sharetheir positive experiences with contraception. Otherwomen became interested in using contraceptionafter hearing the stories of these satisfied users, whowere very important for the community dynamic. Onthe community maps, it was easy to find patterns ofusers, such as clusters of injectable users, pill users,and condom users. These clusters showed thatneighborhood discussions were influential and can beused in expanding contraceptive use.

Developing the capacity of NGOs and the Ministryof Public Health. Field visits to NGOs includedMinistry staff members, which gave them a firsthandview of effective programmatic initiatives. The Ministryof Public Health was pleased to expand the emphasison the health benefits of contraceptive use, and someof the staff became advocates for birth spacing andincreased contraceptive use.

LOOKING AHEAD: NEW MSH PROJECT TO EXPANDCONTRACEPTIVE USEMSH has support from the William and Flora HewlettFoundation to continue this work in Afghanistanthrough November 2008. The emphasis will be on ex-panding and replicating these early successes for otherNGOs and the Ministry of Public Health. The MSHteam will continue to identify and implement innova-tions that will further expand contraceptive use. �

In Afghanistan, both REACH and the AcceleratingContraceptive Use Project adapted the MSHeligible couple (ELCO) map approach to track

the services covered by CHWs. The communitymaps indicated each house and key health measures,such as immunization status and contraceptivemethod used.

The maps also served as the source of data oncontraceptive use for the project evaluation. To verifythe contraceptive use rates reported by the CHWs,150 users from each of the three NGO sites (arandom sample of 10-15 contraceptive users foreach CHW) were individually interviewed. Inter-viewers asked if the woman was using oral contra-ceptives (had supplies on hand and could accuratelyexplain how she used the pills), injectables (had herreturn appointment card available and was not latefor her injection), or condoms (had supplies andconfirmed that the couple were using them). Basedon the verified findings from these samples, weapplied a correction factor to the data from thecommunity maps to determine the end-of-projectcontraceptive use rates in June 2006.

COMMUNITY MAPS:CHW explains the communitymap. The map was designed so thatnonliterate health workers canrecord essential information.

CARMEN URDANETA

Using Community Maps

SALLIE CRAIG HUBER

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This publication was made possible through financial assistance from theWilliam and Flora Hewlett Foundation.

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