Opportunities to Improve FP Programming in Afghanistan
Publication date: 2019
Opportunities to Improve Family Planning Programming in Afghanistan Findings from a Secondary Analysis of the 2015 Afghanistan Demographic and Health Survey While Afghanistan has made considerable progress over the last decade to increase access to health services—including family planning—challenges remain. According to the 2015 Afghanistan Demographic and Health Survey (DHS), Afghanistan has a high total fertility rate of 5.3 children per woman (CSO, MOPH, and ICF 2017). One-third of children are born within 24 months of a previous birth, adversely affecting the health of the mother and the child. The government of the Islamic Republic of Afghanistan is committed to helping Afghans achieve their reproductive intentions and has set an objective to increase voluntary use of modern contraceptives from 20 percent in 2015 to 30 percent by 2020 (Government of Afghanistan 2018). The Sustaining Health Outcomes through the Private Sector (SHOPS) Plus project conducted a secondary analysis of the 2015 Afghanistan DHS data and facilitated participatory workshops to develop recommendations that public and private sector stakeholders can adopt to accelerate Afghanistan’s progress toward achieving its Family Planning 2020 commitments. Despite the desire of most Afghans to have a large family, a substantial unmet need for spacing births demonstrates the potential for increased voluntary uptake of modern contraceptives in Afghanistan. Focusing on those who intend to use contraception in the future could nearly double the country’s modern contraceptive prevalence rate in the near term. Limited method choice, gaps in service delivery, and the perception that injectable contraceptives are not suitable for spacing must be addressed among intenders in order to realize the potential. Key Findings P h o to : N ai m at R aw an • Nearly 75 percent of men and women reported either not wanting any more children or wanting to wait at least two years before the birth of their next child. • Intenders—women not currently using a contraceptive but intending to use one in the future—represent 17 percent of ever-married women in Afghanistan. • Intenders are young, with 65 percent under 30 years of age, and they primarily live in six provinces. Thirty-eight percent are postpartum amenorrheic and 61 percent wish to wait at least two years before having their next child. • Condoms and long-acting reversible contraceptives (LARCs) are underutilized by women from lower socioeconomic strata and in rural areas. Injectable contraceptives are underutilized by younger women and by women who wish to space births. 2 • Opportunities to Improve Family Planning Programming in Afghanistan Methods SHOPS Plus analyzed 2015 Afghanistan DHS data, which was released in 2017, from both the men’s and women’s surveys. The analysis shows the current and potential market for family planning in terms of socio- demographics, behavior, knowledge, fertility preferences and intentions, geography (including by urban/rural residence and province), women’s empowerment, exposure to media, and source of supply. SHOPS Plus applied proportions from the Afghanistan DHS to population size estimates of women of reproductive age from the United Nations Population Division (United Nations 2015) to estimate the absolute size of beneficiary segments identified through the analysis. SHOPS Plus facilitated a participatory workshop with in-country experts to obtain insights into the findings. Findings There is considerable opportunity to increase voluntary uptake of modern contraceptives In Afghanistan, 78 percent of ever-married women do not use any contraceptive method. Only 19 percent of ever-married women, or approximately one million women, use a modern contraceptive. Figure 1 presents contraceptive use among ever-married women and shows that the method mix is dominated by short-acting methods: condoms, oral contraceptive pills, and injectable contraceptives. Both the public and private sectors are important sources of family planning in Afghanistan. In the public sector, family planning services are provided as a part of the Basic Package of Health Services. Nongovernmental organizations such as the Afghan Family Guidance Association, Afghan Social Marketing Organization (ASMO), and Marie Stopes International provide the majority of family planning in the private sector. As in many other countries, the majority of condom and oral contraceptive pill users rely on the private sector, while the majority of injectable contraceptive, LARC, and sterilization users rely on the public sector. Importantly, discontinuation rates are low, with only about one in four women discontinuing a contraceptive within the first 12 months of starting a method. Low discontinuation rates suggests that enabling non-users to voluntarily adopt modern contraceptives will increase the modern contraceptive prevalence rate (mCPR). Afghans desire large families. More than half reported wanting five or more children. At the same time, nearly three-quarters reported that they either did not want any more children or would like to wait at least two years before the birth of their next child (Figure 2). Unlike some countries, both men and women are equal in their desire to delay or avoid another pregnancy. This indicates strong potential to increase voluntary uptake of modern contraception in Afghanistan. Figure 1. Contraceptive use among ever-married women Figure 2. Fertility intentions of women and men SHOPS Plus • 3 Figure 3. Percent who watch TV or listen to radio at least once a week Figure 4. User segments To understand the feasibility of using mass media to address informational and normative barriers to voluntary uptake of modern contraceptives, we examined education and exposure to television and radio programming. Figure 3 shows that four in five urban Afghans watch television or listen to the radio at least once a week. The reach of these media is much lower in rural areas. The fact that more than 80 percent of women and 50 percent of men received no education, points to the limited reach of print (e.g., newspapers, magazines, and brochures) or text-based (e.g., internet or mobile text messaging) communication. Targeting those who intend to use modern methods can quickly double mCPR Figure 4 segments ever-married women based on their contraceptive use and intentions: users of a modern method (19%), users of a traditional method (3%), women not currently using a modern contraceptive and intending to use contraceptives in the future to delay or avoid a pregnancy (17%), and those who do not intend to use a contraceptive in the future (61%). The segments point to two key implications: (1) those who intend to use contraceptives in the future are a group which, if prioritized by programs, could help double the mCPR with the least resource requirements, and (2) those who do not intend to use contraceptives in the future are the largest segment, and their needs and concerns cannot be ignored. Figure 5 presents reasons cited by women who do not currently use a contraceptive and do not intend to use one in the future. The two most frequently cited reasons were religious prohibition and family opposition to contraception. This helps clarify the apparent dichotomy that more than 60 percent of women do not intend to use contraceptives in the future (Figure 4), yet most women want to delay or avoid a pregnancy (Figure 2). Implementing strategies to address these significant religious and family opposition barriers is likely to increase voluntary demand for modern contraception. 4 • Opportunities to Improve Family Planning Programming in Afghanistan Figure 5. Reasons cited for not currently using a contraceptive by women who do not intend to use a contraceptive in the future Comparatively, intenders face fewer barriers: smaller proportions reported religious prohibition, family opposition, or concerns about method side effects. Analysis of socio- demographic characteristics and reproductive intentions among intenders demonstrates the importance of tailoring strategies to specifically meet their needs. As the box below shows, intenders are young, with 65 percent under the age of 30. Thirty-eight percent have recently given birth and have postpartum amenorrhea. Half are concentrated in six provinces and 61 percent wish to wait at least two years before having their next child. Profile of intenders • 65% are under 30 years of age • 38% have recently given birth • 61% want to wait at least 2 years before having next child • 74% live in rural areas • 51% live in these 6 provinces: Balkh, Faryab, Herat, Kabul, Kandahar, and Takhar Some methods are underutilized due to gaps in service delivery and method positioning SHOPS Plus compared the characteristics of users of each modern contraceptive to the characteristics of ever-married women and intenders. Similarities in characteristics suggests that the method is likely to be accessible to, and meet the needs of, ever-married women and intenders. Dissimilarities in characteristics suggest there may be gaps in service delivery or how the method is positioned. A workshop with local stakeholders validated the hypothesized gaps. SHOPS Plus • 5 Characteristics of condom users suggests possible gaps in condom delivery (Table 1). While nearly three-quarters of ever-married women live in rural areas, more than half of condom users come from urban areas. Similarly, while 40 percent of ever-married women belong to lower socioeconomic strata, less than 20 percent of condom users were from the lower two wealth quintiles. Discussions with in-country experts revealed a confluence of three factors resulting in lower access and use of condoms in rural areas: (1) private sector condom brands, including socially marketed brands, are sold primarily through pharmacies and there are very few pharmacies in rural areas, (2) male community health workers could offer free condoms provided by the public sector but do not see family planning as part of their scope, and (3) men do not feel comfortable approaching female community health workers for condoms. Table 1 also shows the socioeconomic strata and residence of LARC users. Similar to condom users, LARC users are wealthier and tend to reside in more urban areas relative to all ever-married women, possibly because there are fewer facilities with the capacity to provide these methods in rural areas. Table 1. Socioeconomic strata and residence of condom and LARC users relative to all ever-married women Socioeconomic strata All women Condom users LARC users Residence All women Condom users LARC users Upper three wealth quintiles Lower two wealth quintiles 60% 81% 80% Urban Rural 23% 51% 43% 40% 19% 20% 77% 49% 57% Characteristics of injectable contraceptive users were different from those of intenders in two key ways: age and fertility intentions (Table 2). Most intenders were 15–29 years old and wanted to space births, while most injectable contraceptive users were 30–49 years old and did not want any more children. Although appropriate for spacing and use while breastfeeding, a perception that injectable contraceptives are meant for those who do not want more children may inhibit intenders from adopting this method. Table 2. Age and fertility intentions of injectable contraceptive users relative to intenders Age Intenders Injectable contraceptive users Fertility intentions Intenders Injectable contraceptive users 15–29 years 30–49 years 65% 25% Want no more Want more/unsure 10% 60% 35% 75% 90% 40% 6 • Opportunities to Improve Family Planning Programming in Afghanistan Characteristics of condom and oral contraceptive pill users also suggests opportunities to improve targeting for commodities distributed by the public sector. As shown in Figure 6, nearly 80 percent of those who obtained free condoms from the public sector and nearly 60 percent of those who obtained free oral contraceptive pills were from the upper three wealth quintiles. Since condoms and oral contraceptive pills—particularly socially marketed brands—are inexpensive and easily available, the public sector has an opportunity to better target its resources by focusing distribution in lower-income communities and in areas where the availability of private sector products is poor. Figure 6. Wealth status of condom and pill users by source of product Given that a significant proportion of intenders recently gave birth, it is critical to ensure that the methods appropriate for breast-feeding women are widely available in both the public and private sectors. Oral contraceptive pills are the most popular method in Afghanistan, and most people rely on the private sector to obtain them. While the public sector offers both progestin-only pills, which are suitable for use during breastfeeding, as well as combined oral contraceptives, most oral contraceptive pills available in the private sector are combined oral contraceptives, which are not recommended for use by breast- feeding women. Thus, the availability of progestin-only pills in the private sector is one of the gaps in meeting the needs of intending users in Afghanistan. SHOPS Plus • 7 Recommendations Findings from SHOPS Plus’s analysis of Afghanistan DHS data revealed important policy and programmatic recommendations as outlined below. 1. Prioritize investments to increase voluntary uptake of modern contraceptives over investments to improve method continuation rates. Since first-year discontinuation rates among modern contraceptive users in Afghanistan is low, family planning programs should prioritize investments that enable non-users to voluntarily adopt a modern method. 2. Position family planning as a means of spacing births. Though most men and women desire five or more children, a majority of them desire not to have a child within two years of the preceding birth. Positioning family planning as a means to space births meets the needs of Afghans and is likely to be culturally acceptable. 3. Orient the family planning program to meet the needs of the intenders for quicker gains in the near term. Enabling intenders to adopt modern contraceptives will double Afghanistan’s mCPR. Intending couples face fewer barriers to adopting modern methods and are more likely to adopt one in the near term. Many intenders are young and have recently given birth. Implementers should orient social and behavior change communication, service delivery strategies, and the method mix to meet their needs. Further, more than half of the intenders live in just six provinces: Balkh, Faryab, Herat, Kabul, Kandahar, and Takhar. These provinces should be prioritized for introduction of new initiatives and for scaling up existing initiatives. 4. Initiate social and behavior change communication efforts to address normative and informational barriers of non-intenders. Non-intenders are the largest segment in Afghanistan, comprising more than 60 percent of all women, and they face deep-seated barriers to contraceptive use. Mobilizing support of religious leaders and family members for contraceptive use will enable non-intenders to achieve their reproductive intentions. Low mass media reach and education levels in rural areas present challenges to achieving this objective. Programs should consider innovative interpersonal approaches, such as mosque meetings and leveraging beauty salon workers, to provide family planning information that address these barriers. 5. Expand private sector condom distribution in non-pharmaceutical channels and increase engagement of male community health workers in family planning. Men in rural areas have lower access to family planning products because there are few pharmacies and male community health workers do not engage with family planning. Private sector condom marketers should expand distribution through non-pharmaceutical channels, such as general stores, to increase access to condoms among rural men. Public sector programs should also sensitize male community health workers on the vital role they can play in providing men in their communities with family planning products and information. 6. Strengthen postpartum family planning in public sector facilities offering maternity services. A significant proportion of intenders have recently given birth and desire to delay or avoid a pregnancy. Further, LARCs are underutilized by poorer and rural populations. Strengthening postpartum family planning, including provision of LARCs, in public sector facilities offering maternity services could provide an opportunity to increase access and use of LARCs among underserved populations and effectively meet the needs of intenders. 7. Support introduction of progestin-only pills in the private sector. Oral contraceptive pills are the most popular family planning method in Afghanistan. Combined oral contraceptives are available in the private sector but are not recommended for breast-feeding women. Progestin-only pills are recommended for breast-feeding women but are absent from the private sector. Social marketing programs should explore the feasibility of introducing progestin-only pills in the private sector to address this critical gap. 8. Reposition injectable contraceptives to also appeal to the needs of the intenders. Characteristics of injectable contraceptive users suggests that the method is perceived as suitable for older women who wish to limit further births. Though suitable to their needs, this perception is potentially a key barrier to the adoption of injectable contraceptives for intenders—many of whom are young, breast-feeding, and wishing to delay but not avoid another pregnancy. A potential strategy to increase the use of injectable contraceptives among young intenders is to reposition the currently available intramuscular injectable contraceptive as appropriate for birth spacing too. Introducing a subcutaneous injectable contraceptive may provide another opportunity to address this. The subcutaneous injectable contraceptive is a lower-dose formulation with fewer side effects than the intramuscular injectable contraceptive. The administration is also less painful and does not require visiting a service provider for an injection, so it may be appropriate for positioning as a method particularly suitable for young mothers. References CSO (Central Statistics Organization [Afghanistan]), MOPH (Ministry of Public Health [Afghanistan]), and ICF. 2017. Afghanistan Demographic and Health Survey 2015. Kabul, Afghanistan: Central Statistics Organization. Government of Afghanistan. 2018. Family Planning 2020 Commitment. United Nations, Department of Economic and Social Affairs, Population Division. 2015. World Population Prospects: The 2015 Revision, Volume I: Comprehensive Tables (ST/ESA/SER.A/379). Find Us SHOPSPlusProject.org Sustaining Health Outcomes through the Private Sector (SHOPS) Plus is a five-year cooperative agreement (AID- OAA-A-15-00067) funded by the United States Agency for International Development (USAID). The project strategically engages the private sector to improve health outcomes in family planning, HIV, maternal and child health, and other health areas. Abt Associates implements SHOPS Plus in collaboration with the American College of Nurse-Midwives, Avenir Health, Broad Branch Associates, Banyan Global, Insight Health Advisors, Iris Group, Population Services International, and the William Davidson Institute at the University of Michigan. This brief is made possible by the generous support of the American people through USAID. The contents are the responsibility of Abt Associates and do not necessarily reflect the views of USAID or the United States government. September 2019
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