Afghanistan has undergone decades of war, displacement, and famine. The country's infrastructure and professional capacity have been devastated. This is especially true in the area of healthcare, where the shortage of medical facilities and health professionals has had a disastrous impact on the Afghan population. The vast majority of people in Afghanistan have no access to health services.

This problem falls heavily on Afghan women who have the second highest maternal mortality and morbidity in the world. By the time many of these women are brought to hospitals, it is too late. Contributing to the high rate of morbidity among Afghan women is the fact that many infections go undetected and untreated. This is partly due to a shortage of trained medical professionals. Many Afghan health providers have never received basic training in contraception, sexually transmitted infections, and HIV/AIDS. Afghan women's health problems are further exacerbated by the fact that they are among the world's most disempowered due to multiple gender-based restrictions and prolonged war and oppression.

One way to address maternal mortality is to provide quality family planning services to prevent unwanted pregnancies and to promote birth spacing. Family Health Alliance (FHA) staff has been involved in reproductive health programs in Afghanistan since 2003. Responding to a clear unmet need for clinical training among female providers, in 2005 FHA started to provide practical family planning training programs in Afghanistan.

From 2005-2007 during its summer training programs, FHA has provided clinical training to over 100 midwives and doctors from 20 different provinces and provided family planning services to over 1,000 women. The provinces include:

Baghlan Badakhshan Bagram Bamiyan Charikar Farah Faryab Ghazni Herat Kabul

Kandahar   Kapisa   Konduz   Logar   Mazar-e Sharif   Paktia   Panjshir   Parwan   Soroobi   Takhar

To reduce maternal mortality in Afghanistan by preventing unwanted pregnancies and promoting birth spacing through the expansion of family planning services.

The Female Provider Training Program seeks to increase knowledge and clinical skills among female Afghan doctors and midwives about infection prevention, correct use of medical instruments, family planning counseling strategies, family planning methods (particularly IUD insertion), detection and treatment of sexually transmitted infections (STIs), and prevention and education about HIV/AIDS. Training sessions include both theoretical and clinical components, with an emphasis on clinical skills.

One of the strengths of Family Health Alliance's (FHA) programs is its recognition of the challenges involved in providing training to post-conflict populations, such as health providers in Afghanistan. Populations exposed to great trauma and prolonged war often experience many negative emotions including feelings of exhaustion, low self-esteem, and depression leading to fatalistic views about the future. These emotions often result in the trainee's inability to recognize their own potential and their role as agents of change.

To increase knowledge and change behavior among such a population, it is important to utilize special teaching strategies to inspire, encourage, and enhance critical thinking and to assist in the learning process. FHA has designed and employs a unique empowerment model of teaching which includes role models, using Muslim health professionals, self-reliance, and teamwork strategies to address numerous challenges trainees face in a post-conflict environment.

FHA's female provider trainings utilizes a unique women's empowerment model in which women are empowered by learning about the concept of "agency" and the fact that they can make a difference in their lives and the lives of others. These strategies have resulted in a significant increase in knowledge and skills level among its trainees.

FHA uses a number of strategies to promote awareness and to assist the trainees to overcome the obstacles they face on a daily basis during the training programs. Women's empowerment strategies employed by FHA include:

1. Developing critical thinking skills by focusing on the status of Afghan women and comparing them with other women in the region
2. Fostering teamwork and personal responsibility by involving trainees in solving daily problems during the program
3. Role modeling by using other professional Muslim women trainers from neighboring Iran, who have overcome similar constraints
4. Encouraging individual consultations between trainers and trainees to identify and overcome hurdles in completing the program, such as obtaining husbands' permission
5. Overcoming fatalism by promoting women as agents of change and a culture of "it can be done"

Lessons Learned and Recommendations:

1. The results indicate that the training program can effectively help providers to develop a high degree of competency in clinical skills and to be able to detect and treat STIs among family planning clinic clients.
2. Education in STIs and HIV/AIDS, especially clinical skills in detection and treatment of STIs/RTIs, should be increased and incorporated into family planning training programs. It is also recommended that prescription of medication to treat the infections be standardized and closely monitored.
3. Because women are at risk of cross infection, health providers should be trained to ask if the woman with infection is in a polygamous marriage and to persuade her to encourage her co-wife/wives to seek treatment.
4. Utilizing empowerment strategies during the training program will enable the trainee's to actively participate in and complete the training programs. Participants will feel more engaged and their level of participation and learning is increased.

The training programs are guided by evidence based evaluation. Programs are evaluated using a pretest/post-test of trainees' knowledge and a clinical skills test. Post-test results have shown increased knowledge of family planning methods, counseling strategies, and STIs and HIV/AIDS. The clinical assessment evaluation has demonstrated a noticeable increase in the skills level of trainees in infection prevention procedures, correct use of medical instruments, counseling strategies, IUD insertion and removal methods, and detection and treatment of sexually transmitted infections. Trainees have also shown an increased understanding of the importance of utilizing women's empowerment strategies when interacting with their family planning clients.

In summer of 2007, Family Health Alliance (FHA) provided clinical training to 21 female midwives and doctors while providing services to over 180 family planning clients in two public hospitals.

In summer of 2006, Family Health Alliance (FHA) provided clinical training to 83 female midwives and doctors while providing services to over 381 family planning clients in three public hospitals.
The program was evaluated using a pretest/posttest of trainees' knowledge and a clinical skills test. A significant increase in trainee knowledge (from 53 to 89%) and average score of 86% in clinical skills test was achieved.

In summer of 2005, Family Health Alliance (FHA) provided clinical training to 47 female midwives and doctors while providing services to 315 family planning clients in two public hospitals.

The female family planning/reproductive health clinical training program is being expanded into other regions of Afghanistan. In Fall of 2008, the program will train female midwives and doctors in the western region of Herat.