93616 Knowledge Brief Health, Nutrition and Population Global Practice AFGHANISTAN: MATERNAL AND REPRODUCTIVE HEALTH AT A GLANCE Sameh El-Saharty, Naoko Ohno, Intissar Sarker, Federica Secci, and Sayed Ghulam November 2014 KEY MESSAGES: Country Context • Afghanistan has made progress towards Afghanistan suffers from poverty and low human the MDGs, especially in education and development aggravated by 23 years of conflict . In 2012, the population was 29 million and per capita income health; however, widespread gender gaps US$268. Economic growth was estimated at 3.6 percent remain and the country suffers from in 2013, down from 14.4 percent in 2012. The transition poverty and low human development, led to investor and consumer wariness.1, 2 aggravated by years of conflict. Poverty reduction has stagnated at about 36 percent • Maternal mortality rate is 400 deaths per since 2007-08, while inequality increased (NRVA 2011- 100,000 live births in 2013, representing a 12). The Gini coefficient rose from 29.7 in 2007-08 to 31.6 decline of 67 percent from 1990. in 2011-12. The large youth population — 47 percent is under 15 — is an opportunity to benefit from the • Fertility declined but remains high at 5.1, demographic dividend through high growth and poverty while contraceptive prevalence rate reduction.1, 2 The country ranks 175 out of 187 countries in the human development index. increased to 21%. Sixty-three percent of women sought ANC from a qualified Afghanistan has progressed toward the MDGs over provider and nearly 39% of births were the decade, particularly in education and health. In attended by qualified providers. 2001, no girls attended formal schools and boys’ enrollment was 1 million. By 2013, 9.1 million pupils were • Wide gaps in access to maternal health enrolled and 3.6 million were girls. However, education services remain by geography and wealth attainment remains low. Female literacy rate is 13 percent, one of the poorest in the world. Between 2003 quintile. and 2011, maternal and child mortality fell sharply. The • Undernutrition is a major challenge for U5MR and IMR dropped from 257 and 165 per 1,000 live births to 97 and 77 respectively.1, 2 women of age 15-49. Gender equality and women’s empowerment are • Afghanistan would need to focus on important determinants of reproductive health. improving access to maternal, neonatal, Decades of the Taliban’s retrogressive policies resulted in and child health in urban and rural areas; widespread gender gaps in health, education, access to promoting multisectorial coordination; and resources, economic opportunities, and political voice and increasing attention to service quality. power. Afghanistan ranks 175 out of 186 countries on the Gender Inequality Index (2012).3 Page 1 HNPGP Knowledge Brief MDG Target 5a: Reduce the MMR by three-quarters, between 1990 and 2015 The MMR has declined from 1,200 deaths per 100,000 Birth intervals of less than 24 months are considered live births in 1990 to 400 in 2013 (figure 1). According too short: 37.4 percent of children are born within 24 to the latest Interagency estimates, Afghanistan is months of the previous birth. The median number of “making progress” toward achieving MDG5. The MMR months since the preceding birth is 26.7 months.5 declined 67 percent with an average annual decline of 4.7 percent between 1990 and 2013.4 The median age at first marriage among women aged 25-49 is 17.7 years and the median age at first birth among the same cohort is 20 years. Early childbearing affects maternal health outcomes. The share of women age 15-19 that have begun childbearing is 12.1 percent. 5 The adolescent fertility rate is high at 86.8 births per 1,000 women age 15–19.1 Pregnancy Outcomes Complete and timely antenatal care (ANC) is a necessary component for positive pregnancy outcomes. As of 2010, 63.4 percent of women sought ANC from a qualified provider. About 16 percent of women received the recommended four or more ANC visits; 89.5 percent of women had their blood pressure measured (one of the components in the package of ANC services). The top reasons for not seeking ANC are: lack Fertility of money (50 percent), distance to a facility (49 percent), transport problems (48 percent), no need for services (41 Fertility has been slowly declining but remains high. percent), and not customary (22 percent).5 Between 1990 and 2012, the total fertility rate (TFR) declined from 7.7 to 5.1 (figure 2).1 Skilled birth attendance (SBA) is critical for reducing maternal deaths. SBA by qualified providers increased The contraceptive prevalence rate (CPR) has been from 12.4 percent in 2000 to 38.6 percent in 2011 (figure increasing over the past 14 years. The CPR (any 3).1 The majority of births are delivered at home, with method) increased from 4.9 percent in 2000 to 21.2 institutional delivery accounting for only 32.4 percent of all percent in 2011 (figure 2). 1 Modern methods are the main births (27.3 percent in public sector facilities and 5.1 choice of contraceptives and are used by 19.9 percent of percent in private sector facilities). The leading reasons currently married women. Injectables (7.2 percent), the pill for not delivering in a health facility are lack of money, (6 percent), and LAM (4 percent) are the most commonly distance and transport (about 50 percent each). Other used form of modern methods. Traditional methods are important reasons are: not necessary (35.2 percent) and used by 1.9 percent of currently married women.5 not customary (19 percent). Page 2 HNPGP Knowledge Brief Postnatal care is another important component for Similar disparities are also found in skilled birth maternal health, especially for managing post- attendance: 70.9 percent of urban women are assisted delivery complications. It is recommended that during delivery by a qualified provider but only 25.7 postnatal care for mothers occur within the first two days percent of rural women (figure 6).5 of delivery. Of women, 23.4 percent sought this type of care from a qualified provider within the first two days of delivery.5 Equity in Access to Maternal Health Services Inequity in access to maternal health services is a barrier toward MDG 5. While utilization of antenatal care has been increasing, wide disparities remain. Women in urban areas were more likely to seek antenatal care (84.9 percent) from a qualified provider than their rural counterparts (53.6 percent) (figure 4).5 Considerable variations in SBA are also seen among wealth quintiles. Women in the richest quintile were almost seven times more likely than women in the poorest quintile to have SBA. Only 11.7 percent of women in the poorest quintile received SBA compared with 80 percent in the richest quintile (figure 7).5 There is also a large gap between wealth quintiles in receiving antenatal care: 77.9 percent of women in the richest quintile received ANC from a qualified provider, compared to 44 percent of women in the poorest (figure 5).5 Page 3 HNPGP Knowledge Brief Key Strategies to Improve Maternal and Reproductive Health Outcomes Improve access to maternal, neonatal, and child health (MNCH) in urban and rural areas by strengthening urban health with a focus on MNCH; institutionalizing Community Midwifery Education; ensuring twenty-four hour EmOC services at the basic health services (BHS) level; and strengthening the use of mobile technology for SRH services. Promote multisectoral coordination to improve MNCH by introducing a National Intersectoral High Commission on Health led by the Ministry of Health; implementing multisectoral national campaigns to promote public awareness and advocacy on MNCH; strengthening routine data collection systems to monitor nutrition; and increasing involvement of the private sector to strengthen family planning. Nutrition Increasing attention to service quality by adopting Undernutrition is another major challenge facing women guidelines for preeclampsia management at all levels; of age 15-49 in Afghanistan. Vit-D deficiency is and expanding and strengthening maternal death widespread. Almost 95% of Afghan woman are Vit-D investigation. deficient. Fifteen percent of women of age 15-49 are suffering from Iron Deficiency Anemia. Besides micronutrient deficiency, some 8% of Afghan woman are of shorter stature (less than 145 cm) and overall BMI for References: this age category is 22.6%. 1 World Bank. World Development Indicators 2013: Accessed 9 April 2014 2 Afghanistan:Country Program Snapshot. March 2014, the World Bank 3 UNDP. 2013 Human Development Report Gender Inequality Index 4 WHO, UNICEF, UNFPA and The World Bank. 2014. Trends in Maternal Mortality: 1990 to 2013: World Health Organization 5 Afghan Public Health Institute, Ministry of Public Health (APHI/MoPH) [Afghanistan], Central Statistics Organization (CSO) [Afghanistan], ICF Macro, Indian Institute of Health Management Research (IIHMR) [India], and World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO) [Egypt]. 2011. Afghanistan Mortality Survey 2010. Calverton, Maryland, USA: APHI/MoPH, CSO, ICF Macro, IIHMR and WHO/EMRO. For more information on this topic, go to: www.worldbank.org/health. Page 4