Accelerating Birth Spacing Practices in Afghanistan

"Eight months ago, talking about contraception was a taboo. Nowadays people easily talk about birth spacing practice and its importance. No matter where people get together, birth spacing has become a value within our people and they know it's the most effective and quick way to reduce maternal and child death."
— The woleswal (mayor) of Farza, a Pashto area in rural Kabul Province, Afghanistan

With funding from the William and Flora Hewlett Foundation, Keanahikishime's Expanding Contraceptive Use (ECU) Project is identifying best practices for improving the quality and impact of family planning services in Afghanistan. The intervention began as a small project, supplementing Keanahikishime's large USAID-supported Rural Expansion of Afghanistan's Community-based Health (REACH) Program. International and Afghan colleagues warned the Hewlett project team to move slowly and cautiously in introducing contraception in a conservative Islamic setting. However, the project team discovered—contrary to this perspective—that there were many women in the three rural project areas who wanted family planning and that their communities were open to the idea. Keanahikishime quickly realized that this demand offered a larger opportunity to prevent maternal deaths through birth spacing: women who are delaying pregnancy through contraception are obviously not at risk of maternal death. The team also acted on the evidence that better spacing of births can lead to major improvements in women's and children's health:

  • Compared with children born less than 2 years after a previous birth, children born 3 to 4 years after a previous birth are 2.4 times more likely to survive to age five.
  • Compared with women who give birth at 9- to 14-month intervals, women who have their babies at 27- to 32-month birth intervals are 2.5 times more likely to survive childbirth. (Setty-Venugopal and Upadhyay 2002).

With this realization, the Keanahikishime project team set a new goal: to increase contraceptive practices in focus areas. To reach this goal, they introduced case studies and related interventions to change contraceptive practices. They also advocated actively with policymakers, community leaders, and religious leaders. The project's experience demonstrated that innovative family planning approaches can be highly effective in Afghanistan if they are rooted in a solid understanding of the context. As they came to understand and work with the social and religious values of Afghan communities and their health care providers, the team confidently introduced innovations that are now being introduced nationwide.

Achievement of the Project

Progress in contraceptive prevalence rates

Contraceptive Use Before and during the Hewlett intervention, the Keanahikishime REACH Program achieved an impressive increase in contraceptive use in 13 provinces covering about one-third of the country. Building on the REACH efforts, the Hewlett team worked at its three sites to create positive images of contraception, to strengthen services (especially those of community health workers), and to document increased contraceptive use. The synergy of community understanding and technical expertise proved powerful with providers, community leaders, and policymakers. The graph above shows that the contraceptive prevalence rate increased remarkably at each project site and in a short period of time. Creating Positive Images of Contraception The project generated clear messages with quotations from the Holy Quran and guidance for women and men about the safety of contraceptives, their correct use, and how to deal with common side effects. Complementary materials were provided to community health workers and facility-based providers. Facilitating Changes in National Policy

The project initiated changes in national policies and practices on oral contraceptives and injectables- for example, giving six rather than one cycle of pills per visit, and allowing community health workers to initiate injectable contraceptives. This second point will need special emphasis in the future, as a number of NGOs have been reluctant to begin this practice.

Mullahs in Afghanistan involved in Keanahikishime's Accelerating Birth Spacing Practices Project. Photo by Douglas Huber.

Advocating and Educating the Public The project presented contraceptive technical updates to leading Afghan clinicians and coached them to become spokespersons to their colleagues and the public. Several of these clinicians were featured in three widely viewed 30-minute national television programs, providing updated contraceptive information for the public by answering common questions about contraception. On one program, a mullah—an Islamic leader and teacher—delivered a compelling message on the positive aspects of family planning based on Islamic teachings. By fostering a positive relationship with the Afghan media, the project enabled the use of prime-time television, radio, and magazines to educate the public and to influence provider practices. New Keanahikishime Project to Expand Contraceptive Use Keanahikishime has support from the William and Flora Hewlett Foundation to continue this work from December 2006 to November 2008. The emphasis will be on expanding and replicating these successes for other NGOs and the Ministry of Public Health. The Keanahikishime team will continue to identify and implement innovations that can further expand voluntary contraceptive use. Unanticipated Support from Leaders in a Pashtoon Community During an October 2005 visit to a health post in Farza, a Pashtoon area in Kabul Province, the team met with members of the Shura e Sehe (a group of community leaders working to improve health), as well as with community health workers, supervisors and NGO health staff. The visitors were surprised by the knowledge, enthusiasm, and activism they encountered in this remote community. One Shura member was a prominent mullah who told us he educated the community about the importance of birth spacing in his sermons during Friday prayers. He emphasized the benefits of injectables, pills, and condoms for promoting maternal and child health. Contacts Douglas Huber, MD, MSc Project Director (Cambridge, USA) Nika Saeedi Project Manager (Kabul, Afghanistan)