Achieving success with family planning in rural Afghanistan

227Bull World Health Organ 2010;88:227–231 | doi:10.2471/BLT.08.059410 Introduction Women in Afghanistan have a one-in-eight lifetime risk of maternal death, the second-highest in the world, resulting from a maternal mortality ratio of 1800 maternal deaths per 100 000 live births and a total fertility rate of 6.8 births.1,2 The potential impact of contraceptive use on maternal deaths in Afghanistan was unknown; however, global estimates are that up to 35% of maternal deaths could be averted by preventing unintended pregnancies.3 Donors and Afghan policymakers believed use of mod- ern contraceptives would be resisted and progress would be slow. After 23 years of conflict, rural services were contracted to nongovernmental organizations in the Ministry of Public Health’s new primary health-care initiative, the Basic Package of Health Services.4,5 Volunteer community health workers (CHWs) provided health care for women and children, in- cluding free contraceptives under Management Sciences for Health’s Rural Expansion of Afghanistan’s Community-based Health care (REACH) Project. Within REACH, Management Sciences for Health initi- ated the small Accelerating Contraceptive Use (ACU) project, funded by the William and Flora Hewlett Foundation to strengthen contraceptive services. CHWs in REACH pro- vided the majority of contraception under this project.4,6 The Ministry of Public Health encouraged us to initiate innovative measures to strengthen family planning. Achieving success with family planning in rural Afghanistan Douglas Huber,a Nika Saeedi b & Abdul Khalil Samadi c Problem Afghan women have one of the world’s highest lifetime risks of maternal death. Years of conflict have devastated the country’s health infrastructure. Total fertility was one of the world’s highest, contraceptive use was low and there were no Afghan models of success for family planning. Approach We worked closely with communities, providing information about the safety and non-harmful side-effects of contraceptives and improving access to injectable contraceptives, pills and condoms. Regular interaction with community leaders, mullahs (religious leaders), clinicians, community health workers and couples led to culturally acceptable innovations. A positive view of birth spacing was created by the messages that contraceptive use is 300 times safer than pregnancy in Afghanistan and that the Quran (the holy book of Islam) promotes two years of breastfeeding. Community health workers initiated the use of injectable contraceptives for the first time. Local setting The non-for-profit organization, Management Sciences for Health, Afghan nongovernmental organizations and the Ministry of Public Health implemented the Accelerating Contraceptive Use project in three rural areas with different ethnic populations. Relevant changes The contraceptive prevalence rate increased by 24–27% in 8 months in the project areas. Men supported modern contraceptives once they understood contraceptive safety, effectiveness and non-harmful side-effects. Injectable contraceptives contributed most to increases in contraceptive use. Lessons learnt Community health workers can rapidly increase contraceptive use in rural areas when given responsibility and guidance. Project innovations were adopted as best practices for national scale-up. Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español. .ةلاقلما هذهل لماكلا صنلا ةياهن في ةصلاخلا هذهل ةيبرعلا ةمجترلا a Management Sciences for Health, 784 Memorial Drive, Cambridge, MA, 02139, United States of America. b Early Recovery Team, Bureau for Crisis Prevention and Recovery, United Nations Development Programme, Kabul, Afghanistan. c STEP Health and Development Organization, Kabul, Afghanistan. Correspondence to Douglas Huber (e-mail: DouglasHuber777@yahoo.com). (Submitted: 24 September 2008 – Revised version received: 13 May 2009 – Accepted: 5 June 2009 – Published online: 8 December 2009 ) Methods For implementation of the ACU Project, we selected three REACH areas (Table 1) that had mature data reporting systems, no social marketing (such as selling contraceptives through pharmacies), good security and year-round access. Four Afghan nongovernmental organizations provided ser- vices: Coordination of Humanitarian Assistance, Bakhtar Development Foundation, STEP Health and Development Organization and the Agency for Assistance and Develop- ment of Afghanistan. One male and one female CHW served 100–150 households, each with one woman of reproductive age. REACH baseline and end-of-project surveys used lot quality assurance sampling to generate contraceptive preva- lence data from 13 provinces. Changes in contraceptive preva- lence rate were compared between REACH and the ACU Project, which monitored prevalence rates only from CHWs’ community maps. REACH data included women served by CHWs, clinics and a small portion served by neither. End-of-project contraceptive use was verified by visiting 10–15 reported users for each CHW (150 users per site). We conducted sequential sampling of user households using a random start. An outside interviewer questioned each user. Injection use was verified if she could produce her client card and her next three-month injection date had not passed. Pill users needed to show a currently used pack and be able 228 Bull World Health Organ 2010;88:227–231 | doi:10.2471/BLT.08.059410 Lessons from the field Family planning in rural Afghanistan Douglas Huber et al. to describe correct use. These probing questions provided greater assurance of actual use than typical surveys. Dialogues with community leaders, families, clinic staff and religious lead- ers provided a solid understanding for developing innovations, which were tested and accepted in the three areas over a period of 8 months. Many providers and community leaders believed contraception was more dangerous than pregnancy. Other mis- conceptions by doctors, midwives and communities included: (i) modern con- traceptives cause infertility; (ii) inject- able contraceptives reduce breast milk and should not be used postpartum until menstruation; (iii) women who work hard or have six or more children will expel an intrauterine device; and Table 1. Site information for the Accelerating Contraceptive Use project, Afghanistan Nongovernmental organization Location CHW Health posts Households in health post catchment areas Sect Ethnicity of the majority of the population served Agency for Assistance and Development of Afghanistan and Bakhtar Development Foundation Tormay, Ghazni province 20 10 732 Shi’a Hazara Coordination of Humanitarian Assistance Islam Qala, Herat province 15 10 840 Sunni and Shi’a Tajik, Pashtun and other STEP Health and Development Organization Farza, Kabul province 30 15 2136 Sunni Pashtun Total 65 35 3708 CHW, community health workers. (iv) progestin-only pills can be used interchangeably with combined pills. We updated contraceptive in- formation, used quotations from the Quran (the holy book of Islam) on birth spacing, and educated women and men about correct use and com- mon non-harmful side-effects. Short written guidance for couples on oral and injectable contraceptives was given to all 3708 families in the project. Each method had a verse from the Quran, approved by the mullahs (religious leaders), advocating two years of breast- feeding/pregnancy spacing. Messages for injectables stressed their effective- ness and safety, explained changes in menstrual bleeding and pointed out that a woman’s fertility returns about 7 months after the last injection. Similarly, we communicated that oral contraceptives are safe and effective if used every day, can be used at any age, fertility returns when stopped and that menstrual bleeding is usually reduced, which is normal and healthy. Simple instructions for use were included. Non-literate women found family members or neighbours who could read the instructions, and mul- lahs used the instructions to educate communities. Job aids for CHWs had similar information plus guidance on managing side-effects. Our estimate that contraceptive pills and injections were about 300 times safer than pregnancy was based on documented oral contraceptive mortality compared with Afghanistan’s maternal mortality ratio.7,8 We assumed five deaths attributable to contracep- tives per 100 000 woman-years, since medical screening and follow-up were basic, and 1500 deaths per 100 000 women not using contraceptives per year, assuming 85% would become pregnant. Our risk-benefit message was easily understood by providers and communities. Mullahs’ concerns centred on safety and infertility, rather than religion. Through dialogue, all 37 mullahs in the project areas accepted the concept of birth spacing using modern contra- ceptives. This does not imply that all Afghan mullahs will quickly endorse modern contraceptives. Birth spacing of 3–5 years com- pared with less than 15 months is associated with a 2.4-fold increase in child survival to 5 years and a 2.5-fold improvement in maternal survival.9 With this information, several mullahs began emphasizing the importance of birth spacing during Friday prayers.10 Fig. 1. Contraceptive prevalence rates in the Accelerating Contraceptive Use and the Rural Expansion of Afghanistan’s Community-based Health care projects, Afghanistan 0 Co nt ra ce pt iv e pr ev al en ce ra te 60 2004 M Agency for Assistance and Development of Afghanistan, and Bakhtar Development Foundation, in Tormay, Ghazni provincea Coordination of Humanitarian Assistance, in Islam Qala, Herat province50 40 30 20 10 STEP Health and Development Organization in Farza, Kabul province REACH project in 13 provinces, round 1 and 2 districtsb 16 9 20 24 26 34 44 51 A M J J A S O N D 2005 J F M A M J J A S O N D J F M A M J 2006 CHW, community health workers; REACH, Rural Expansion of Afghanistan’s Community-based Health care. a ACU project data represent remote rural households served almost exclusively by CHWs. b REACH project data represent households served by CHWs or clinical staff at health facilities, and some households with no ready access to services. 229Bull World Health Organ 2010;88:227–231 | doi:10.2471/BLT.08.059410 Lessons from the field Family planning in rural AfghanistanDouglas Huber et al. The Ministry of Public Health gave permission for CHWs to give the first injection of Depo-Provera® (medroxy- progesterone acetate) on a pilot basis. CHWs were previously restricted to giving only second and subsequent injections. Results The REACH Project achieved an in- crease of contraceptive use from 16% to 26%, over a period of 2 years in 13 provinces. The ACU Project increased contraceptive use by 24–27% in its three sites over 8 months (Fig. 1). Over- all, contraceptive users increased from 532 to 1469 among the 3708 women. In Farza, usage increased from 188 to 726 among 2136 women; in Islam Qala, from 168 to 370 among 840 women; and in Tormay, from 176 to 373 among 732 women. Use of injectable contraceptives increased most, which we attribute to training CHWs to initiate their use with good counselling. People wel- comed the introduction of injectables because walking to a clinic required a two-to-four-hour round trip. Oral contraceptive use varied, de- creasing slightly in Tormay, increasing substantially in Farza and changing little in Islam Qala (where injectables were popular). Condom use increased dra- matically in Tormay but remained low in other areas. The Hazara ethnic group from Tormay, many of whom went to the Islamic Republic of Iran during the Taliban regime, had experience with condoms. Mullahs also used condoms themselves and, in Tormay, pictorial instructions for condom use were accept- able when used by CHWs for teaching correct use. For a summary of the main lessons learnt see Box 1. Discussion The rapid uptake of contraceptives in conservative rural communities and the endorsement of this model by the Ministry for Public Health for national scale-up were unique for Afghanistan. We attribute these achievements to: (i) crafting family planning interven- tions after in-depth discussion with community leaders, both men and women; (ii) engaging women in super- vising CHWs and organizing women’s community health committees (shuras); Box 1. Summary of main lessons learnt • Traditional rural communities will rapidly accept modern contraceptives, particularly injectables, introduced by CHWs when people are educated about common non-harmful side-effects and correct use. • Medical misconceptions were more important than cultural and religious barriers. • Men’s involvement was vital in supporting their wives’ use of birth spacing. Once educated, men demonstrated positive practices about birth spacing for maternal and child health. CHW, community health workers. (iii) overcoming widespread misconcep- tions of infertility and harm from con- traceptives, some being inadvertently perpetuated by training on rare adverse effects and medical screening; (iv) us- ing international expertise to create positive, technically sound counselling messages; (v) emphasizing contracep- tive safety compared to pregnancy risk; (vi) educating people about birth spac- ing for child and maternal health consis- tent with Islamic teaching; (v) involving men, especially mullahs, in contracep- tive education and promotion of birth spacing; (vi) ensuring abundant contra- ceptive supplies; and (vii) collaborating closely with the Ministry for Public Health for approval of innovations and dissemination of findings. Meetings with religious and other community leaders, including health committees, CHWs and couples were important for developing trust and con- firming acceptance of innovations, such as permitting CHWs to initiate inject- able contraceptives. The use of injectables by CHWs has proved safe and acceptable in other rural Muslim populations.11,12 Recent community trials in Uganda show that CHWs compare favourably with clin- ics in standards of care for providing injectables.13 Study limitations include lack of a formal control group. However, having no competing inputs, changes can be attributed to the ACU Project. REACH provided a reasonable source for comparative data. Replication may be challenging, given the need for in-depth dialogue, international tech- nical expertise and skilled coaching. The project’s short life precluded data collection on long-term contraceptive prevalence rates. Sustainability could not be assessed, though the national expansion will produce information on future progress. Monitoring and evaluation were ongoing to ensure accurate recording of contraceptive users on commu- nity maps, track progress and support CHWs and communities. Skilled proj- ect managers, who related well to the community, learnt about misconcep- tions and devised effective interven- tions, contributed greatly. Sound job aids and information for households enabled rapid progress. Contraceptive use is crucial for reaching the United Nations’ Millen- nium Development Goals.3,14 Obstacles to contraception use include lack of access, misperceptions, low status of women, inappropriate standards and provider attitudes.15 This project’s flex- ible, culturally sensitive approach will apply in many rural societies. Conclusion Contraceptive use increases rapidly in rural settings when CHWs receive sup- port and guidance. Revitalizing family planning requires a new risk-benefit paradigm comparing contraceptive risks to those of pregnancy and refocus- ing on community needs rather than medical screening. Having seen that simplified delivery systems succeed, the Ministry of Public Health adopted the ACU Project model for scaling up contraceptive services nationwide. ■ Acknowledgements We thank the Ministry of Public Health of Afghanistan, the implementing Af- ghan nongovernmental organizations (Coordination of Humanitarian Assis- tance, Bakhtar Development Founda- tion, STEP Health and Development Organization, Agency for Assistance and Development of Afghanistan) and Management Sciences for Health col- leagues. Funding: The William and Flora Hewlett Foundation. Competing interests: None declared. 230 Bull World Health Organ 2010;88:227–231 | doi:10.2471/BLT.08.059410 Lessons from the field Family planning in rural Afghanistan Douglas Huber et al. Résumé Progrès de la planification familiale dans l'Afghanistan rural Problématique Les femmes afghanes sont parmi les plus exposées du monde au risque de décès maternel. Des années de conflit ont dévasté l'infrastructure sanitaire du pays. Au départ du projet, la fécondité totale était l'une des plus élevées au monde, l'utilisation de moyens contraceptifs était très limitée et il n'existait pas de modèle afghan de succès de la planification familiale. Démarche Nous avons col laboré étroitement avec les communautés, en fournissant des informations sur l'innocuité des contraceptifs et l'absence de danger de leurs effets secondaires et en améliorant l'accès aux contraceptifs injectables, aux pilules contraceptives et aux préservatifs. Des interactions régulières avec les dirigeants communautaires, avec les mollahs (chefs religieux), les cliniciens, les agents de santé communautaires et les couples ont permis de mettre en place des innovations culturellement acceptables. Une vision positive de l'espacement des naissances a été générée grâce aux messages suivants : l'usage de moyens contraceptifs est 300 fois plus sûr que la grossesse en Afghanistan et le Coran (livre sain de l'Islam) préconise deux années d'allaitement. Les agents de santé communautaires ont mis en route pour la première fois l'utilisation de contraceptifs injectables. Contexte local L'organisation à but non lucratif Management Sciences for Health (MSH), des organisations non gouvernementales afghanes et le Ministère de la santé publique ont lancé un projet d'accélération de l'usage des moyens contraceptifs dans trois régions rurales, abritant des populations d'origines ethniques différentes. Modifications pertinentes Le taux de prévalence de la contraception a augmenté de 24 à 27 points de pourcentages en 8 mois dans les régions bénéficiant du projet. Après avoir pris conscience de l'innocuité des moyens contraceptifs modernes, de leur efficacité et de l'absence de dangerosité de leurs effets secondaires, les hommes ont soutenu l'utilisation de ces moyens. Ce sont les contraceptifs injectables qui ont le plus contribué à l'accroissement de l'utilisation des moyens contraceptifs. Enseignements tirés Les agents de santé communautaires peuvent rapidement faire progresser l'utilisation des moyens contraceptifs dans les zones rurales si on leur donne des responsabilités et des orientations. Les innovations appliquées dans le cadre du projet ont été adoptées comme meilleures pratiques pour un élargissement à l'échelle nationale. Resumen Avances en materia de planificación familiar en el Afganistán rural Problema Las mujeres afganas sufren uno de los mayores riesgos de defunción materna de todo el mundo a lo largo de su vida. Los años de conflicto vividos por el país han devastado su infraestructura sanitaria. La fecundidad total era una de las mayores del mundo, se usaban poco los anticonceptivos, y no había modelos afganos para una planificación familiar eficaz. Enfoque Trabajamos en estrecha colaboración con las comunidades, suministrando información sobre la seguridad y la inocuidad de los efectos secundarios de los anticonceptivos y mejorando el acceso a anticonceptivos inyectables, píldoras y preservativos. La interacción regular con líderes comunitarios, mullahs (líderes religiosos), médicos, agentes de salud comunitarios y parejas propiciaron innovaciones culturalmente aceptables. Se creó una percepción positiva del espaciamiento de los nacimientos difundiendo el mensaje de que el uso de anticonceptivos es una opción 300 veces más segura que el embarazo en el Afganistán, y de que el Corán (el libro sagrado del Islam) propugna un periodo de dos años de lactancia materna. Los agentes de salud comunitarios empezaron a usar los anticonceptivos inyectables por vez primera. Contexto local La organización sin fines de lucro Management Sciences for Health, organizaciones no gubernamentales afganas y el Ministerio de Salud Pública pusieron en marcha el proyecto Acelerar el Uso de Anticonceptivos en tres zonas rurales con distintas poblaciones étnicas. Cambios destacables La prevalencia de uso de anticonceptivos aumentó en 24–27 puntos porcentuales en 8 meses en las zonas abarcadas por el proyecto. Los hombres respaldaron los anticonceptivos modernos una vez que comprendieron su seguridad, eficacia y carencia de efectos secundarios nocivos. El incremento del uso de anticonceptivos se debió sobre todo a los productos inyectables de este tipo. Enseñanzas extraídas Los agentes de salud comunitarios pueden extender rápidamente el uso de anticonceptivos en las zonas rurales si se les da la responsabilidad y la orientación oportunas. Las innovaciones introducidas en el marco del proyecto fueron adoptadas como prácticas óptimas para su expansión a nivel nacional. صخلم ناتسناغفأ في ةيفيرلا قطانلما في ةسرلأا ميظنت في حاجنلا قيقحت ىوتسم لىع تاهملأا تايفو رطاخم دشأ ةيناغفلأا ةأرلما هجاوت :ةلكشلما ةيساسلأا ةيحصلا ةينبلا يرمدت لىإ حلسلما عاصرلا تاونس تدأ دقو ،لماعلا ىوتسم لىع تلادعلما لىعأ نم كانه ةيلماجلإا باجنلإا تلادعم دعتو .دلبلل طيطختل ةحجان جذانم دجوت لاو ،لمحلا عناوم لماعتسا لقي ماك ،لماعلا .ةسرلأا ةملاسلا نع تامولعلما مهل اومدقو ،تاعمتجلما عم نوثحابلا نواعت :ةقيرطلا لمحلا عناوم لىع لوصحلا ينسحتو ،لمحلا عناولم ةرئاضلا يرغ راثلآاو عم مظتنلما لعافتلا ىدأ دقو .يركذلا لزاعلاو ،صارقلأاو ،نقحلل ةلباقلا جاوزلأاو ،عمتجلما ةحص في ينلماعلاو ،ءابطلأاو ،نيدلا ءمالعو ،عمتجلما ةداق ينب ةدعابلما لوح ةيباجيإ ةرظن تأشنو .ًايفاقث ةلوبقم تاراكتبا روهظ لىإ ًانمأ ثركأ لمحلا عناوم لماعتسا نأ لىإ يرشت لئاسر شرن قيرط نع تادلاولا عاضرلإا ززعي ميركلا نآرقلا نأو ،ناتسناغفأ في لمحلا نم ةرم 300 رادقبم مادختسا في ةرم لولأ عمتجلما ةحص في نولماعلا أدبو .ينماع ةدلم يعيبطلا .نقحلل ةلباقلا لمحلا عناوم 231Bull World Health Organ 2010;88:227–231 | doi:10.2471/BLT.08.059410 Lessons from the field Family planning in rural AfghanistanDouglas Huber et al. 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Stud Fam Plann 2006;37:87-98. doi:10.1111/j.1728- 4465.2006.00088.x PMID:16832983 لجأ نم ةيرادلإا مولعلا ،ةيحبرلا يرغ ةمظنلما تماق :ةيلحلما عاضولأا ذيفنتب ةماعلا ةحصلا ةرازوو ،ةيموكحلا يرغ ةيناغفلأا تماظنلماو ،ةحصلا تائف تاذ ةيفير قطانم ثلاث في لمحلا عناوم مادختسا عيسوتل عوشرم .ةفلتخم قارعأ نم ةيناكس قيبطت ةقطنم في لمحلا عناوم مادختسا لدعم دادزا :ةجتانلا تايرغتلا مادختسا لاجرلا معدو .روهش ةيناثم للاخ ةئلما يف 27-24 رادقبم عوشرلما مدعو ،اهتيلاعفو ،اهمادختسا ةملاسل مهمهفت روف ةثيدحلا لمحلا عناوم يه نقحلل ةلباقلا لمحلا عناوم تناكو .اهل ةرئاض ةيبناج ضارعأ دوجو .لمحلا عناوم مادختسا ةدايز في ًايرثأت ثركلأا مادختسا ةدايز عمتجلما ةحص في ينلماعلا ةعاطتسا في :ةدافتسلما سوردلا ةيلوؤسلما اوطعأ اذإ ةيفيرلا قطانلما في ةعسرلا هجو لىع لمحلا عناوم ميمعتل ةيلاثم تاسرمامك عوشرلما نع ةجتانلا تاراكتبلاا تذختاو .هيجوتلاو .ينطولا ديعصلا لىع ماهمادختسا