Kabul, Afghanistan b Anglophone Africa and Asia, ICF International, Calverton, MD, Published online: 05 Sep 2013.

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1 This article was downloaded by: [ ] On: 03 September 2015, At: 13:20 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: Registered office: 5 Howick Place, London, SW1P 1WG Click for updates Global Public Health: An International Journal for Research, Policy and Practice Publication details, including instructions for authors and subscription information: Success in reducing maternal and child mortality in Afghanistan Mohammad Hafiz Rasooly a, Pav Govindasamy b, Anwer Aqil c, Shea Rutstein b, Fred Arnold b, Bashiruddin Noormal a, Ann Way b, Susan Brock c & Ahmed Shadoul d a Research Department, Afghan National Public Health Institute, Kabul, Afghanistan b Anglophone Africa and Asia, ICF International, Calverton, MD, USA c Health and Education, USAID, Kabul, Afghanistan d WHO, Kabul, Afghanistan Published online: 05 Sep To cite this article: Mohammad Hafiz Rasooly, Pav Govindasamy, Anwer Aqil, Shea Rutstein, Fred Arnold, Bashiruddin Noormal, Ann Way, Susan Brock & Ahmed Shadoul (2014) Success in reducing maternal and child mortality in Afghanistan, Global Public Health: An International Journal for Research, Policy and Practice, 9:sup1, S29-S42, DOI: / To link to this article: PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the Content ) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.

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3 Global Public Health, 2014 Vol. 9, No. S1, S29 S42, Success in reducing maternal and child mortality in Afghanistan Mohammad Hafiz Rasooly a *, Pav Govindasamy b, Anwer Aqil c, Shea Rutstein b, Fred Arnold b, Bashiruddin Noormal a, Ann Way b, Susan Brock c and Ahmed Shadoul d a Research Department, Afghan National Public Health Institute, Kabul, Afghanistan; b Anglophone Africa and Asia, ICF International, Calverton, MD, USA; c Health and Education, USAID, Kabul, Afghanistan; d WHO, Kabul, Afghanistan (Received 4 March 2012; accepted 8 January 2013) After the collapse of the Taliban regime in 2002, Afghanistan adopted a new development path and billions of dollars were invested in rebuilding the country s economy and health systems with the help of donors. These investments have led to substantial improvements in maternal and child health in recent years and ultimately to a decrease in maternal and child mortality. The 2010 Afghanistan Mortality Survey (AMS) provides important new information on the levels and trends in these indicators. The AMS estimated that there are 327 maternal deaths for every 100,000 live births (95% confidence interval = ) and 97 deaths before the age of five years for every 1000 children born. Decreases in these mortality rates are consistent with changes in key determinants of mortality, including an increasing age at marriage, higher contraceptive use, lower fertility, better immunisation coverage, improvements in the percentage of women delivering in health facilities and receiving antenatal and postnatal care, involvement of community health workers and increasing access to the Basic Package of Health Services. Despite the impressive gains in these areas, many challenges remain. Further improvements in health services in Afghanistan will require sustained efforts on the part of both the Government of Afghanistan and international donors. Keywords: maternal mortality; infant; child; mortality; Afghanistan survey Background The almost 30-year-old war in Afghanistan devastated the country s infrastructure, economy, and social services, resulting in a low quality of life. The Taliban rule compounded the suffering of women by curtailing their access to already limited health services. Almost 75% of the districts in Afghanistan lacked maternal and child health services and most women delivered without the presence of a skilled birth attendant (SBA) (Maurice, 2001, Mayhew et al., 2008). Over the last 10 years, a number of surveys on maternal and child health have been conducted in Afghanistan. These surveys have used different methodologies (with respect to coverage and representativeness, direct and indirect estimation techniques, and adjustment of estimates), which make it difficult to assess trends. These surveys include the Multiple Indicator Cluster Surveys (MICS) in 2003 (Central Statistics Office [CSO] & United Nations Children s Fund [UNICEF], 2004) and (Central Statistics Office [CSO] & United Nations Children s Fund *Corresponding author. dochafez@yahoo.com 2013 Taylor & Francis

4 S30 M.H. Rasooly et al. [UNICEF], 2012), the Afghanistan Health Survey in 2006 (Johns Hopkins University Bloomberg School of Public Health [JHUBSPH] & Indian Institute of Health Management Research [IIHMR], 2008), the National Risk and Vulnerability Assessment (NRVA) in 2007/2008 (ICON-INSTITUTE, 2009), the Afghanistan Mortality Survey (AMS) in 2010 (APHI et al., 2011), and the 2002 Reproductive Age Mortality Survey (RAMOS) in four districts (Bartlett et al., 2005). All of those surveys have information on child mortality, but only the non-representative RAMOS includes information on maternal mortality. The Health Management Information System also collects maternal and neonatal mortality data from health facilities on a monthly basis, and national reports are made available on a quarterly basis (Ministry of Public Health [MoPH], 2011). Objectives In light of the scarcity of reliable national information on maternal mortality, adult mortality, and infant and child mortality, the Afghanistan Mortality Survey (AMS) was conducted in 2010 to provide information on the levels, trends, differentials, and causes of mortality and levels and differentials in related health and health care indicators. The purpose of this article is to present the AMS mortality estimates and trends, to assess their validity by comparison with trends in the proximate determinants of mortality, and to discuss the current situation of health and health care as it relates to maternal mortality and child mortality. Previous estimates of maternal and child mortality and health indicators are also discussed. Methods The current situation of health as it relates to maternal and child mortality is best represented by the results of the AMS undertaken in 2010; the report of this survey was released in 2011 (APHI et al., 2011). This survey was designed to be as nationally representative as possible given the security conditions at the time. The 2010 AMS sample was a stratified sample selected in two stages from the updated preparatory frame of the 2011 Population and Housing Census obtained from the Central Statistics Organization. In the first stage, 751 enumeration areas (EAs) were selected with probability proportional to size sampling. Stratification was achieved by separating each zone (North, Central, and South) into urban and rural areas (Figure 1). Because of the low urban proportion of the population of the country, the urban areas of each zone combined form a single sampling stratum, which is the urban stratum of the zone. The rural areas of each zone were further split into strata according to province, that is, the rural area of each province forms a sampling stratum. Due to security reasons, the rural areas of Kandahar, Helmand, and Zabul provinces in the South zone were excluded from the survey. In total, 34 sampling strata were created (three urban strata and 31 rural strata which correspond to the total number of provinces with their rural areas included in sample). Before the main survey was conducted, a household listing operation was carried out in all of the selected EAs in order to construct a full listing of households in the EA. In the second stage, 32 households were randomly selected from the updated listing for interview (Figure 2). In addition to the rural areas of the three South zone provinces, 34 sample EAs were not interviewed during fieldwork due to security reasons. In all, 87% of Afghanistan s population was covered by the survey, but in the South zone only 66% of the population was represented. The sample weights took into account the 34 EAs in the South zone that were included in the sample but were not interviewed, but

5 Global Public Health S31 Figure 1. Map of Afghanistan Depicting 2010 AMS Domains (zones) South, North and Central. the excluded rural areas of the three provinces were not taken into account in the weights, because they were not represented in the survey. Survey information was obtained by personally interviewing an adult household member (usually the male or female head of the household) with the household questionnaire and also interviewing women years of age with the woman s questionnaire. These questionnaires are based on the Demographic and Health Surveys Core Questionnaires, modified for use in Afghanistan. The household questionnaire obtained a list of all usual residents of the household and visitors who stayed in the household the night before the survey, a list of all other persons who lived in the household during the preceding five years, and a list of all deaths of household members that had occurred in the preceding five years. For each death that had occurred in the preceding three years, a verbal autopsy was performed to ascertain the cause of death. In addition, the household questionnaire obtained information on the personal characteristics of each member, such as sex, age, education and relationship to the head of the household, as well as dwelling characteristics, such as the source of Figure 2. AMS 2010 sample selection.

6 S32 M.H. Rasooly et al. drinking water, the type of sanitation facility, dwelling construction materials and household possessions (to determine the level of wealth of the household). The individual questionnaire asked women years of age about their background (age, education, ethnicity, and marital status), their use of health services, each of their children and the survival status of each child, and the survival status of their sisters and brothers (to determine adult and maternal mortality). The survey fieldwork was carried out by staff who were specially and intensively trained for three weeks through both classroom lectures and field practice. Overall, 22,351 households were interviewed, with a 99% response rate. Individual interviews were conducted with 47,848 women, with a 98% response rate. Results The results are organised in two sections. In the first section, data on maternal mortality levels, causes of maternal mortality, and factors affecting maternal mortality are presented. The purpose is to present the latest information from the AMS and examine the consistency between the AMS maternal mortality estimates and the determinants of maternal mortality. The second section presents the child mortality estimates and statistics on child health services following the same logic. Section I: maternal mortality estimates and factors affecting maternal mortality Maternal mortality The AMS identified 256 deaths that occurred during pregnancy, at delivery, or within the two months following delivery in the seven-year period preceding the 2010 survey. A seven-year period is taken as a compromise between the interest in having estimates that reflect the most recent conditions and ensuring that there are sufficient numbers of cases on which to base the estimates. From these deaths, it is estimated that the maternal mortality ratio (MMRatio) 1 at the national level averaged 327 maternal deaths per 100,000 live births during the seven years preceding the survey (Table 1). This estimate has a 95% confidence interval of deaths per 100,000 live births. There is a substantial difference in the MMRatio between urban and rural areas. The MMRatio is more than four times as high in rural areas as in urban areas. The Central zone has the lowest MMRatio, but the ratios are only slightly higher in the North zone and the South zone. Table 1. survey. Maternal mortality ratio by urban-rural residence and zone, 2010 Afghanistan mortality Area Maternal mortality ratio 95% confidence interval Residence Urban Rural Zone North Central South Total

7 Global Public Health S33 Because the AMS excluded the rural areas in three provinces in the South zone, there is likely to be an urban bias in reporting from the South zone. In addition, the survey showed that there is a relative underreporting of female births in the country as a whole, and particularly in the South zone. The normal sex ratio at birth worldwide is in the range of male births per 100 female births (Johansson & Nygren, 1991), but the sex ratio at birth reported in the AMS was 113 for Afghanistan overall, and was even higher in the South zone (124). These biases may have caused an underestimation in maternal and child mortality. Causes of maternal mortality Verbal autopsy data from the AMS showed that 41% of all deaths of women aged in the seven years preceding the survey were maternal deaths. The leading cause of maternal deaths was haemorrhage (56%), followed by pre-eclampsia/eclampsia (Table 2). These causes are similar to those found in other surveys (Bartlett et al., 2005; National Institute of Population Research and Training (NIPORT), Mitra and Associates, & Macro International, 2009; National Institute of Population Studies [NIPS] & Macro International, 2008). Factors affecting maternal mortality Although factors related to maternal mortality are manifold, it is useful to examine AMS indicators of those factors that are likely to be related to maternal mortality. Those indicators include the total fertility rate (TFR), contraceptive use, antenatal care (ANC), the use of SBAs during delivery, and emergency obstetric care. For improvements in maternal health (Millennium Development Goal 5), there is a consensus that the availability of SBAs is an important proximate indicator. Other relevant process indicators, such as ANC and contraceptive use, are also useful to examine. We present current estimates of these proximate indicators as another facet of the health situation in Afghanistan related to maternal mortality. Fertility. The timing and quantity of a woman s births affect her risk of dying from a maternal cause. It is well established that adolescent first births and births at older ages (40 years and over) increase the risk of a maternal death. Moreover, the more births a woman has, the more times she faces the risk of dying from a maternal cause. The value of the TFR is linked with both the quantity and timing of fertility. The TFR from the AMS at the national level was 5.1 children per woman for the three years preceding the survey (Table 3). This level is consistent with the TFR predicted by the proximate determinants of fertility model (Bongaarts, 1978). There is relatively little Table 2. Causes of maternal deaths, 2010 Afghanistan mortality survey. Cause Number % Haemorrhage Pre-eclampsia/eclampsia Prolonged or obstructed labour 7 11 Indirect causes 3 5 Sepsis/Infection 3 5 Other direct causes 2 4

8 S34 M.H. Rasooly et al. Table 3. Maternal health and service indicators, 2010 Afghanistan mortality survey. TFR Contraceptive prevalence rate a Antenatal care b Facility deliveries c Skilled birth attendance d Postnatal care e Residence Urban Rural Zone North Central South Mother s education No education Madrassa Primary Secondary Higher Wealth quintile Lowest Second Middle Fourth Highest Total TFR, total fertility rate. a Among currently married women age (modern methods). b Percentage of women who received antenatal care from a skilled provider for the last birth in the past five years. c Percentage of last births in the past five years delivered in a health facility. d Percentage of last births in the past five years delivered by a SBA. e Percentage of the mothers who received PNC from a skilled provider for last births in the past five years. difference in the TFRs between urban and rural areas, in different zones and among wealth quintiles. There are large differences in the TFR by education; the TFR is almost twice as high among illiterate women (5.3) as it is among women with higher education (2.8). However, most women of reproductive age (76%) have no education, and even in urban areas only 4% of women have more than a secondary education. Trend data from the AMS for the three successive five-year periods preceding the survey show that fertility has substantially declined among women in the reproductive age group. Earlier estimates from surveys conducted in Afghanistan indicate a decline in the TFR as well. The TFR decreased from 6.3 in the 2003 MICS survey (CSO & UNICEF, 2004) to 5.3 in the 2007/8 NRVA (ICON-INSTITUTE, 2009) and further to 5.1 in the 2010 AMS. 2 Contraception and marriage. The major contributing factors to the reduction in the TFR are the use of contraceptive methods and an increase in the age at marriage. At the time of the AMS survey, 22% of currently married women were using a contraceptive method and almost all of those (20%) were using a modern method of contraception (Table 3). Use of modern contraceptive methods is almost twice as high in urban areas as in rural areas, and is more than twice as high in the Central zone as in the North and South zones. As expected, higher rates of contraceptive use are observed among more educated women and among women in households in the highest wealth quintile. Use of modern

9 Global Public Health S35 contraceptive methods has increased steadily, from 10% in the 2003 MICS and 15% in the 2007/8 NRVA to 20% in the 2010 AMS. The MICS indicates a similar estimate of 21% (Figure 3). The increase in contraceptive use is also supported by annual household surveys that have been conducted since 2004 in 13 provinces, 3 which showed an increase in contraceptive prevalence from 24% in 2006 to 37% in 2010 (Partnership Contracts for Health [PCH], 2011). The use of contraception occurs more at the older reproductive ages (25% for married women 40 years and above) and among women with higher numbers of births (29% for women with five or more living children), and therefore contributes to reducing the risk of maternal mortality by reducing births at older ages and the number of times women face the risk of childbirth. AMS results also show that the age at first marriage for women has increased in the recent past. For example, the proportion of women married by age 15 decreased from 25% among women who were years old at the time of the survey to 4% among women aged 15 19, and 83% of women aged years remained single. This rise in age at first marriage has been an important factor in reducing the TFR and it is linked with a reduced risk of maternal mortality from adolescent births. The MICS survey shows similar results, with 80% of women aged remaining single and less than 2% of women aged having had a birth before 15 years of age. Antenatal care. ANC not only identifies high-risk pregnancies but also helps in monitoring pregnancies, preparing for delivery, and providing nutrition and other counselling. The AMS showed that women received ANC from a skilled provider for 60% of births in the last five years (Table 3). There is a wide difference in the use of ANC between urban areas (85%) and rural areas (54%). There is a strong positive relationship between both mother s level of education and wealth quintile, on the one hand, and the use of ANC services from skilled providers, on the other hand. ANC coverage has substantially increased over time. Based on the data by year of birth from the AMS, the percentage of births with ANC from a skilled provider increased from 57% in to 68% in The trends from other surveys show a similar rise in ANC coverage, from 16% for the five years preceding the 2003 MICS to 31% for the five years preceding the 2007/8 NRVA and 48% for births in the two years prior to the MICS (Figure 3). Figure 3. Trends in maternal health services ( ).

10 S36 M.H. Rasooly et al. Delivery care. Overall, one-third of deliveries in the five years before the 2010 AMS were assisted by a SBA and almost the same percentage of women delivered in a health facility (Table 3). The proportion of deliveries assisted by an SBA is almost three times as high in urban areas as in rural areas. As noted earlier for other maternal health indicators, both higher levels of education of mothers and higher wealth quintiles contribute to the use of SBAs during delivery. There has been a rapid increase in the use of SBAs, from 26% in to 42% in An increase is also evident for the five years preceding the 2003 MICS survey (14%), the 2007/8 NRVA survey (24%) the 2010 AMS (34%) and the two years preceding the MICS (39%) (Figure 3). The MICS also found that the percentage of births in the two years preceding the survey that occurred in health facilities is almost equal to that found by the 2010 AMS (33% and 34%, respectively). The sharp increase in delivery care particularly by SBAs in recent years is likely to be an important factor in the declining trend in maternal mortality. External comparison of maternal care and maternal mortality. Another way of assessing whether the MMRatio is likely to be reasonably accurate is to compare the relationship between maternal mortality and maternal health indicators in neighbouring countries with the estimates for Afghanistan. Figure 4 shows the relationship between the MMRatios and the level of ANC from a skilled provider for Afghanistan, Bangladesh, Nepal, and Pakistan. The regression line is based on the country estimates for the three South Asian countries excluding Afghanistan. The fact that the estimates of maternal mortality from the 2010 AMS (both including and excluding the South zone) fall very close to the regression line indicates that the MMRatio for Afghanistan from the 2010 AMS is consistent with the level of ANC from a skilled provider in Afghanistan. Figure 4. Relationship between the maternal mortality ratio (MMRatio) and Antenatal Care (ANC) from a skilled provider.

11 Global Public Health S37 Postnatal care. Postnatal care (PNC) is another important factor in the prevention and treatment of complications after delivery. More than one in four mothers reported having PNC from a skilled provider after their last delivery, but only 22% said they had a PNC visit within the first 24 hours of delivery (Table 3). PNC was twice as common in urban areas as in rural areas. As was the case for contraceptive prevalence, ANC, and deliveries by an SBA, more educated women and those in households with more wealth were more likely to receive timely PNC. PCH (2011) data from 13 provinces show that there has been an upwards trend in PNC from 24% in 2006 to 43% in Other factors. Supporting this increase in coverage of maternal health care has been a large expansion in the availability of health services overall and in maternal and child health services in particular. From fewer than 900 health facilities of all types in 2002 (Ministry of Health, 2002), Afghanistan has increased access to health care to 85% of the population (ICON-INSTITUTE, 2009) as a result of building or upgrading the network of health facilities. By 2011, the total number of health facilities had doubled. Afghanistan currently has a total of 472 health sub-centres; 812 basic health centres, which under the Basic Package of Health Services (BPHS) are minimally staffed by a nurse and a community midwife to provide antenatal, delivery and postpartum care, and other staff; 379 comprehensive health centres with doctors, nurses and midwives for assisting normal deliveries and some complications; 69 district hospitals providing all BPHS services, including comprehensive emergency obstetric care and staffed with female obstetricians/ gynaecologists, paediatricians, and other doctors, nurses and midwives; 28 provincial hospitals; 6 regional hospitals; and 24 national hospitals, in addition to 12,447 active health posts managed by male and female community health workers (CHWs) (MoPH, 2011), where female CHWs focus on providing care for normal deliveries, identifying danger signs, and referring potentially problematic pregnancies to health centres (Ministry of Public Health [MoPH], 2005). The number of nurses and midwives dramatically increased from 566 and 467, respectively, in 2002 (MoH, 2002) to 3651 nurses and 3100 midwives in Approximately 77 per cent of health facilities have at least one female health provider, which is essential for women to access health services given their mobility constraints (MoPH, 2011). Other possible factors that might have linked with maternal and child mortality reduction are increasing access to mobile phones (71%), increasing access to improved sources of drinking water (54%), and improved access to transportation and girls education (APHI et al., 2011). Section 2: Estimates and causes of infant and child mortality and related health care indicators Child mortality Neonatal mortality covers deaths within the first 28 days of childbirth. Neonatal deaths usually reflect biological causes and the level of PNC. The neonatal mortality rate from the 2010 AMS is 40 per 1000 live births. 4 As expected, neonatal mortality is higher for boys than for girls, and it is also higher in rural areas, for mothers with little or no education, for those in the lower wealth quintiles, and for the youngest (under age 20) and oldest (age 40 49) mothers (APHI et al., 2011). The infant mortality rate (IMR) and the under-five mortality rate were 77 and 97 per 1000 live births, respectively. The difference between the male and female infant and under-five mortality rates remains substantial over time, reflecting better female survival,

12 S38 M.H. Rasooly et al. as found all over the world because of the female biological advantage (APHI et al., 2011). In addition, urban mortality is lower than rural mortality for both infant and underfive mortality (Table 4). Regardless of different methodologies, all previous national surveys ( ) depict a clear downward trend of child mortality in Afghanistan (Figure 5). Similarly, trend data from the AMS excluding the South zone show that childhood mortality has substantially declined over time. For example, the infant mortality rate decreased by 16% and the under-five mortality rate decreased by 23% from the period years before the survey to the period 0 4 years before the survey. Both infant mortality and under-five mortality rates are higher in Afghanistan than in comparable South Asian countries. The most similar in levels is Pakistan, where the infant mortality rate for the five years preceding the Demographic and Health Survey was 78 deaths per 1000 births and the under-five mortality rate was 94 (NIPS and Macro International, 2008). From the India National Family Health Survey (NFHS-3), the rates were 57 and 74, respectively (International Institute for Population Sciences [IIPS] & Macro International, 2007); from the 2011 Nepal DHS, the rates were 46 and 54, respectively (MoHP et al., 2011), and from the 2007 Bangladesh DHS, the rates were 52 and 65, respectively (NIPORT et al., 2009). Causes of child death. In the 2010 AMS, a verbal autopsy was conducted for child deaths that occurred in the household in the three years preceding the survey. The results show that during the neonatal period, the principal causes of death were acute respiratory infections and other serious infections (38% of deaths), perinatal-related disorders (35%), and pre-term/low birth weight (12%). For non-neonatal deaths for children under-age five years, acute respiratory infection was the leading cause of death (31%), followed by other serious infections (16%), injuries (13%), and diarrhoea (10%). Table 4. Neonatal, infant and under-5 mortality, 2010 Afghanistan mortality survey. Neonatal mortality Infant mortality Under-5 mortality Child s sex Male Female Residence Urban Rural Mother s age at birth < Wealth quintile Lowest Second Middle Fourth Highest Note: This table is based on unadjusted mortality rates.

13 Global Public Health S39 Figure 5. Trend in child mortality Afghanistan (per 1000 live births). Health care related to infant and child mortality. Vaccinations are an important intervention that can reduce infant and child mortality. There have been rapid increases in vaccination coverage in recent years. For example, the coverage of DPT3 immunisations in children age months increased from 30% in 2003 to 43% in (CSO & UNICEF, 2004; ICON-INSTITUTE, 2009). The annual PCH Household Survey (PCH, 2011) in 13 provinces showed DPT3 coverage of 47% in 2009 and 42% in 2010, close to the NRVA estimate for WHO and UNICEF estimated of DPT3 coverage for ranged from 66 to 83% (United Nations Children s Fund [UNICEF] & World Health Organization [WHO], 2011; World Health Organization [WHO], 2011). However, the MICS estimated DPT3 coverage at only 40%. Infant and child mortality are also linked with treatment for acute respiratory infections (ARI) and diarrhoea. The disease early warning system established as the national diseases surveillance system in 2006 (Disease Early Warning System [DEWS], 2010) shows that diarrhoea and malaria cases decreased concurrently with the increased availability of treatment for these common childhood illnesses due to the implementation of the BPHS. While environmental health services, especially improved water supply and sanitation, are important contributors to reducing infant and child mortality, the AMS 2010 only provides estimates of coverage of those services at the time of the survey; 56% of the population had an improved source of water and 19% had an improved sanitation facility. There are no other data for determining trends that are useful for the evaluation of the validity of the 2010 AMS infant and child mortality results. Discussion Triangulation of information from various sources (surveys and service statistics) over a ten-year period confirms that there has been a substantial downward trend in maternal and child mortality in Afghanistan. While the current maternal and child health situation is substantially better than the situation in the recent past, and MMRatios and under-five mortality rates are below that of many sub-saharan countries, Afghanistan still has a way to go to improve both maternal and child health. The 2010 AMS estimated the MMRatio to be 327 deaths per 100,000 live births, which is quite high in comparison with other countries. The MMRatio in Afghanistan is exceeded by that of only three countries

14 S40 M.H. Rasooly et al. outside of sub-saharan Africa (United Nations Children s Fund [UNICEF], 2010). The AMS estimated the under-five mortality rate to be 97 deaths per 1000 live births. Outside of countries in sub-saharan Africa, this level is exceeded by only one country (United Nations Children s Fund [UNICEF], 2011). The levels and trends of maternal and child mortality are similar with the levels and trends of factors, such as the number of health facilities and trained health personnel, especially trained midwives, and the percentage of women receiving ANC, PNC, and skilled assistance at delivery. The decrease in the TFR and increases in age at marriage and contraceptive use are other factors that might explain the reduction in maternal and child mortality. Moreover, the introduction of the BPHS has contributed to the improvement of maternal and child health in the country and is being offered at four standard types of health facilities, ranging from outreach by CHWs to outpatient care at basic health centres to inpatient services at comprehensive health centres and district hospitals since CHWs play a positive role in creating public awareness, identifying danger signs of pregnancy and severely ill children, providing family planning, supporting National Immunisation Days, administration of Vitamin A, promoting use of oral rehydration salts (ORS), and treating mild illness cases and referring complicated cases to the nearest health centre (CHW, 2005), in turn contributing to a reduction in maternal and child mortality. The contribution of the provision of other important BPHS components such as antenatal, delivery and PNC; family planning; immunisation, nutrition, health education and Integrated Management of Child Illnesses through health facilities cannot be understated in lowering maternal and child mortality. In the absence of government health infrastructure after the Taliban, BPHS was contracted out to NGOs to facilitate rapid expansion and was financially supported by the US Agency for International Development (USAID), the European Community (EC), and the World Bank (Ministry of Public Health [MoPH], 2009; Sabri et al., 2007). Annually, the per capita cost of BPHS has been estimated between US$3.8 and US$5.1. Contributions vary by donors and they need to be sustained to continuously improve maternal and child health. Conclusions The levels of the MMRatio and the infant, child, and under-five mortality rates estimated from the 2010 AMS are plausible, and trends are consistent with trends in health service factors that are related to maternal and child mortality, such as use of contraception; use of antenatal, delivery and PNC services and the expansion of the availability of maternal and child health services with regard to the BPHS. Moreover, relationships between health care and maternal and child mortality are consistent with those found in other countries in the region, further reinforcing the credibility of the AMS estimates. However, despite the progress observed in maternal and child health in Afghanistan, many challenges remain. For example, less than 16% of women had four or more ANC visits, and half of the women did not get two doses of tetanus toxoid vaccine during their pregnancy for the last birth. In addition, more than two-thirds of births took place at home without having SBAs, and more than 70% of women did not receive PNC. Rural areas continue to lag behind urban areas in the availability and use of maternal health services. There is also much room for improvement with regard to environmental health. Almost half of the population does not have access to an improved source of drinking water, and only one in five households have access to an improved sanitation facility.

15 Global Public Health S41 Further improvements in health and reductions in mortality rates will require continued health system strengthening, increasing access to health services, improvements in women s social and economic well-being, and improvements in water and sanitation. The challenges ahead are substantial, and further improvements in health services in Afghanistan will require sustained efforts on the part of both the Government of Afghanistan and international donors. Notes 1. The MMRatio is based on deaths during pregnancy, at delivery, or within two months of delivery. This ratio is sometimes called the pregnancy-related mortality ratio. The 2010 AMS report also includes an alternative measure of maternal mortality based on deaths of women while pregnant or within 42 days of the termination of a pregnancy, excluding deaths from accidental or incidental causes (APHI et al., 2011). 2. The MICS does not provide information for calculating the TFR. 3. Badakhshan, Bamyan, Baghlan, Faryab, Ghazni, Hirat, Jawzjan, Khost, Kabul, Kandahar, Paktika, Paktya, and Takhar 4. Neonatal, infant and under-five mortality rates discussed here have been adjusted to reflect the best estimates, as described in APHI et al. (2011). References Afghan Public Health Institute (APHI/MoPH) [Afghanistan], Central Statistics Organization (CSO) [Afghanistan], ICF Macro, Indian Institute of Health Management Research (IIHMR) [India], & World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO) [Egypt]. (2011). Afghanistan mortality survey Calverton, MD: Authors. Bartlett, L. A., Mawji, S., Whitehead, S., Crouse, C., Dalil, S., Ionete, D., & the Afghan Maternal Mortality Study Team. (2005). Where giving birth is a forecast of death: Maternal mortality in four districts of Afghanistan, Lancet, 365(9462), doi: / S (05) Bongaarts, J. (1978). A framework for analyzing the proximate determinants of fertility. Population and Development Review, 4(1), doi: / Central Statistics Office (CSO) [Afghanistan], & United Nations Children s Fund (UNICEF). (2004). Moving beyond 2 decades of war: Progress of provinces. Multiple indicator cluster survey Kabul: Authors. Central Statistics Organization (CSO) [Afghanistan], & United Nations Children s Fund (UNICEF). (2012). Afghanistan multiple indicator cluster survey : Final report. Kabul: Authors. Community Health Worker (CHW). (2005). Training Manual Ministry of Public Health, Islamic Republic of Afghanistan. Retrieved from Afghan_manual_0.pdf Disease Early Warning System (DEWS). (2010). Annual report Afghanistan Public Health Institute, Ministry of Public Health. ICON-INSTITUTE. (2009). National risk and vulnerability assessment 2007/08: A profile of Afghanistan, main report. Cologne: Author. International Institute for Population Sciences (IIPS), & Macro International. (2007). National Family Health Survey (NFHS-3), : India: Volume I. Mumbai: IIPS. Johansson, S., & Nygren, O. (1991). The missing girls of China: A new demographic account. Population and Development Review, 17(1), doi: / Johns Hopkins University Bloomberg School of Public Health (JHUBSPH), & Indian Institute of Health Management Research (IIHMR). (2008). Afghanistan health survey 2006: Estimates of priority health indicators. Kabul: Ministry of Public Health. Maurice, J. (2001). WHO heads efforts to restore Afghanistan s shattered health. Bulletin of the World Health Organization, 79(12), Retrieved from 79(12)1174.pdf Mayhew, M., Hansen, P. M., Peters, D. H., Edward, A., Singh, L. P., Dwivedi, V., Burnham, G. (2008). Determinants of skilled birth attendant utilization in Afghanistan: A cross-sectional study. American Journal of Public Health, 98(10), doi: /ajph

16 S42 M.H. Rasooly et al. Ministry of Health. (2002). Afghanistan national health resource assessment. Prepared for the Ministry of Health by MSH, HANDS, and MSH/Europe, with support from USAID, EC, UNFPA, and JICA. Ministry of Health and Population (MoHP) [Nepal], New ERA, & ICF Macro. (2011). Nepal demographic and health survey 2011 preliminary report. Kathmandu: Authors. Ministry of Public Health (MoPH), Islamic Republic of Afghanistan. (2005). Community Health Worker (CHW) training manual. Islamic Republic of Afghanistan: Author. Ministry of Public Health (MoPH) [Afghanistan]. (2009). Basic package of health services Kabul: Author. Ministry of Public Health (MoPH) [Afghanistan]. (2011). Health management information system [HMIS]. Kabul, Afghanistan: HIS Publication. Retrieved from Media/Documents/HMISNEWSLETTERJUNE pdf National Institute of Population Research and Training (NIPORT), Mitra and Associates, & Macro International. (2009). Bangladesh demographic and health survey Dhaka and Calverton, MD: Authors. National Institute of Population Studies (NIPS) [Pakistan], & Macro International Inc. (2008). Pakistan demographic and health survey Islamabad: Authors. Partnership Contracts for Health (PCH). (2011). PCH 2010 household survey report. Kabul: Grants and Contacts Management Unit, Ministry of Public Health. Sabri, B., Siddiqi, S., Ahmed, A. M., Kakar, F. K., & Perrot, J. (2007). Towards sustainable delivery of health services in Afghanistan: Options for the future. Bulletin of the World Health Organization, 85(9), doi: /blt United Nations Children s Fund (UNICEF). (2010). Statistics by area/maternal health; estimates of maternal mortality 2008 (WHO/UNICEF/UNFPA/The World Bank). Retrieved from childinfo.org/maternal_mortality_countrydata.php United Nations Children s Fund (UNICEF). (2011). Statistics by area/child survival and health; trends in under-five mortality rates, Retrieved from mortality_ufmrcountrydata.php UNICEF, & World Health Organization (WHO). (2011). Immunization summary: A statistical reference containing data through Retrieved from UNICEF.pdf World Health Organization (WHO). (2011). Third dose of diphtheria toxoid, tetanus toxoid and pertussis vaccine; reported estimates of DTP3 coverage. Retrieved from immunization_monitoring/en/globalsummary/timeseries/tscoveragedtp3.htm