Afghanistan's Mullahs Help Accelerate Family Planning Use

Douglas Huber, MD, MScDouglas Huber, MD, MSc

Christian Connections for International HealthChristian Connections for International Healthwww.ccih.org

American Public Health Association, American Public Health Association, San Francisco, CA, 29 October, 2012San Francisco, CA, 29 October, 2012

Implemented by Management Sciences for Health, the Afghan Ministry of Implemented by Management Sciences for Health, the Afghan Ministry of Public Health and Afghan NGOsPublic Health and Afghan NGOs

Supported by the William and Flora Hewlett FoundationSupported by the William and Flora Hewlett Foundation

Why a pilot project on birth spacing?Why a pilot project on birth spacing?

Reduce maternal deaths through Reduce maternal deaths through increased contraception useincreased contraception use

Identify elements of success for family Identify elements of success for family planningplanning

Advocacy for contraceptive use with Advocacy for contraceptive use with community, religious leaders, and health community, religious leaders, and health professionals professionals

The fastest, easiest, cheapest way The fastest, easiest, cheapest way to prevent maternal deaths is with to prevent maternal deaths is with

contraceptioncontraception

One in seven women will die from pregnancy and One in seven women will die from pregnancy and childbirth in Afghanistanchildbirth in Afghanistan

Main messageMain message

Wait 2 years after childbirth before trying to Wait 2 years after childbirth before trying to become pregnant again, achieving 3 years birth become pregnant again, achieving 3 years birth spacing spacing

Effective contraceptive method needed for 18+ Effective contraceptive method needed for 18+ months, starting about 2 months after deliverymonths, starting about 2 months after delivery– (many Afghan women supplement (many Afghan women supplement

breastfeeding early)breastfeeding early)

3 years birth spacing important for child and 3 years birth spacing important for child and maternal health maternal health

Main approachMain approach Main message supported by Holy Quran:Main message supported by Holy Quran:

And mothers shall suckle their children two And mothers shall suckle their children two full years for those who wish to complete full years for those who wish to complete

breast-feeding breast-feeding Bagara (Sura 2:233) Bagara (Sura 2:233)

Birth spacing in community based on Birth spacing in community based on updating correct information on updating correct information on contraceptives contraceptives

Teachings of Islam and Rationale for Healthy Teachings of Islam and Rationale for Healthy Timing and Spacing of Pregnancy (HTSP)Timing and Spacing of Pregnancy (HTSP)

““The Prophet Mohammed taught the The Prophet Mohammed taught the importance of birth spacing 1400 years importance of birth spacing 1400 years before science documented the health before science documented the health benefits for women and children” benefits for women and children” Pashtoon Pashtoon Mullah, Farza, Kabul Pr.*Mullah, Farza, Kabul Pr.*

**Discussion in Farza when explaining improved health outcomes Discussion in Farza when explaining improved health outcomes with 3+ year birth intervals-D. Huber, 2005with 3+ year birth intervals-D. Huber, 2005

Contraceptive prevalence from community Contraceptive prevalence from community mapsmaps

Reception of Health Post SignsReception of Health Post Signs

The signboards helped improve The signboards helped improve effort and quality of CHWs work.effort and quality of CHWs work.

Visible for the newly returned Visible for the newly returned people.people.

Looks more official Looks more official     

Pilot InterventionsPilot Interventions

Injection initiative: CHWs giving first injection--Mullahs & Injection initiative: CHWs giving first injection--Mullahs & community approvalcommunity approval

Simple materialsSimple materials 1) essential contraceptive guidance for 1) essential contraceptive guidance for all households; 2) providers received same & all households; 2) providers received same & management of side effectsmanagement of side effects

Condom pictorial instructions: partial acceptance and Condom pictorial instructions: partial acceptance and use; religious leaders key use; religious leaders key

Community awarenessCommunity awareness

Midwife providing Midwife providing Injection of DMPA Injection of DMPA (Depo-Provera)(Depo-Provera)

Mullah (also a Mullah (also a CHW) CHW) demonstrating demonstrating injectable injectable contraceptioncontraception

Religious leaders awareness on FPReligious leaders awareness on FP

Mullah, Sayed Hasson:Mullah, Sayed Hasson: “I examined the issue of “I examined the issue of contraception planning from the perspective of Islam. contraception planning from the perspective of Islam. The prophet of Islam was aware that some Moslems The prophet of Islam was aware that some Moslems were using a simple method. He did not forbid them. were using a simple method. He did not forbid them. Also we can find verses in the Holy Quran that Also we can find verses in the Holy Quran that persuade people to prevent life risks. We see persuade people to prevent life risks. We see frequent births as a risk to life--these should be frequent births as a risk to life--these should be prevented. I always pass this message to the people prevented. I always pass this message to the people during Friday prayers. during Friday prayers.

Lessons learnedLessons learned

Correcting misinformation about contraceptives Correcting misinformation about contraceptives is very important for religious leaders, is very important for religious leaders, community, and health staffcommunity, and health staff

Brochures were effective--brief contraceptive Brochures were effective--brief contraceptive guidance for women, men and CHWs, including guidance for women, men and CHWs, including quote from Holy Quranquote from Holy Quran

CHWs were highly effective for increasing CHWs were highly effective for increasing contraceptive usecontraceptive use

Religious Leader Support for Afghan Religious Leader Support for Afghan Birth Spacing ProjectBirth Spacing Project

Approval of each innovation crucial for new Approval of each innovation crucial for new birth spacing initiative in communitybirth spacing initiative in community

RL needed correct information on methods—RL needed correct information on methods—of 37 mullahs in areas, none disapprovedof 37 mullahs in areas, none disapproved

RL educated communities for 3+ year birth RL educated communities for 3+ year birth intervals and need for contraceptionintervals and need for contraception

Advocated for contraceptive use on national Advocated for contraceptive use on national televisiontelevision

Scaling Up for SuccessScaling Up for Success

Ministry of Health endorsed project as a Ministry of Health endorsed project as a “best practice”“best practice”

USAID & international donors supported USAID & international donors supported expansion of FP through CHWsexpansion of FP through CHWs

Islamic leaders convened nationwide and Islamic leaders convened nationwide and supported family planning expansionsupported family planning expansion