174
Figure 10.10: Trends in selected reproductive health indicators in percentages
a,b
a
NRVA 2011-12 uses births in the last five years, MICS 2010 and 2003, AHS 2006 and NRVA 2007-08 and 2005 use births in the last two years. AHS uses births of only pregnant women,
other surveys use those of ever-married women.
b
Sources: CSO and UNICEF 2003, CSO 2007, MoPH 2007, CSO 2009, MoPH et al. 2011, CSO 2014, CSO and UNICEF 2012, CSO 2014
10.4 Breastfeeding
Breastfeeding is well known to improve the nutrition status and the growth and health of infants and young children. As breastfeeding protects babies from diarrhea and other infectious diseases and
stimulates the immune system, it plays a vital role in the survival of children during the first years of life. In order to maximise the benefits of breastfeeding for the health of the child, the WHO and UNICEF
have jointly come up with a set of recommendations on breastfeeding practices WHO 2002. WHOUNICEF recommends exclusive breastfeeding, i.e. breastfeeding with no other food or drink
– not even water
– with the exception of oral rehydration solutions, vitamins, minerals and medicines, for a period of six months. After six months of exclusive breastfeeding, mothers should continue to
breastfeed their children for two years or more, together with safe and healthy complementary food. Because of the benefits of colostrum, it is recommended that the newborn is put to the breast during the
first hour after birth. Breastfeeding is not only the ideal nourishment for infants; it also has many health and emotional benefits for the mother. It decreases blood loss after birth, avoids too short birth intervals
through delays in the return to fertility post-partum amenorrhea and even lowers long-term risks of breast and ovarian cancer.
In the ALCS 2013-14, women who gave birth to a child during the last five years before the survey were asked a series of questions about the breastfeeding of the last child. In Afghanistan, the vast majority of
women initiate breastfeeding their children after birth; 93.2 percent of all women indicated that they breastfed their last born child. Almost no difference was observed in the initiation of breastfeeding
between urban 92.4 percent, rural 93.4 percent and Kuchi women 94.2 percent.
Table 10.5
shows the reason why some women do not breastfeed their children, by age of mother. The most important reason for not breastfeeding the child is lack of milk 57.4 percent. Other important
10 20
30 40
50 60
70
MICS 2003
NRVA 2005
AHS 2006
NRVA 2007-08
MICS 2010
NRVA 2011-12
AHS 2012
ALCS 2013-14
P er
ce nta
g e
Ante-natal care Skilled birth attendance
Institutional delivery
175
reasons are death of the child 13.0 percent, baby too sick 12.0 percent and mother too sick 14.7 percent. All these reasons are non-voluntarily; actually only 0.3 percent of women who did not
breastfeed their babies indicated they did not want too. This clearly shows the almost universal character of breastfeeding in Afghanistan. Women, who did not breastfeed, do so because of external reasons.
Table 10.5: Women with a live birth during the five years preceding the survey, by five-year age- groups, and by reason for not breastfeeding the child in percentages
Reason Total
15-19 20-24
25-29 30-34
35-39 40-44
45-49 Total
100.0 100.0
100.0 100.0
100.0 100.0
100.0 100.0
Baby died 13.0
30.1 12.0
8.7 13.0
15.4 14.6
14.1 Baby too sick
12.0 10.5
11.1 11.2
9.1 16.4
11.6 15.2
Did not have milk 57.4
47.4 58.3
60.5 61.0
52.9 57.7
47.1 Mother too sick
14.7 9.8
15.8 14.0
14.6 14.5
14.1 22.5
Did not want to 0.3
0.0 0.0
0.9 0.0
0.0 0.0
0.0 Had to work
0.1 0.0
0.0 0.2
0.0 0.0
0.0 0.0
Other reason 2.1
2.1 2.8
3.7 0.8
0.8 1.9
1.2 Dont know
0.5 0.0
0.0 0.8
1.5 0.0
0.0 0.0
There are many reasons why a baby should be put to the breast during the first hour of life: the baby should receive the colostrum first breast milk as soon as possible after birth, as it is rich in nutrients
and protects against many infections, suckling stimulates the contraction of the uterus which stimulates the delivery of the placenta and reduces maternal bleeding, breastfeeding reduces stress in the newborn
baby and stimulates the immediate bonding between the mother and her newborn child UNICEF 2007. The ALCS 2013-14 indicates that about a third of all babies 33.2 percent born in Afghanistan and who
receive breastfeeding are breastfed within the first hour after birth. Another 24.2 percent are put to the breast between one and two hours after birth and another 14.9 percent between two and three hours.
Overall, breastfeeding is initiated for 90.5 percent of all babies during the first day of life, another 5.5 are breastfed for the first time during the second day of life and another 2.5 percent during the third day.
Little difference exists between rural and urban residence and the Kuchi population. It is interesting that the results on the percentage of children who were first breastfed within an hour after birth is quite
different from the 2010-11 Multiple Indicator Cluster Survey CSO and UNICEF 2012. Where ALCS found that 33.2 percent of births were put to the breast within an hour after birth, the MICS found 53.6
percent for the same indicator. The percentage of babies in MICS who were breastfed within the first day of life came much closer to
the ALCS figure: 84.5 percent MICS against 90.5 percent ALCS. It is unclear what caused the significant differences between both surveys. Questions in both surveys about the initiation of
breastfeeding were quite similar; the only difference is that the question in MICS is restricted to women who had a baby in the last two years, while the ALCS question is asked to women with a birth in the
last five years before the survey. Breastmilk contains all nutrients and liquids a young child needs. No other drinks are necessary during
the first six months of life. Providing a baby less than 6 months old with any other liquids or food increases the risks of diarrhea and other serious infections. To measure the timing of adding other liquids
than breastfeeding to young childrens diet, a question was asked whether during the first three days of live, the child was given anything to drink other than breastmilk. In addition it was asked how many
days the mother fed the baby only breastmilk before giving other liquids. The proportion of young
176
mothers who give young babies other liquids is quite high: 38.1 percent of women indicated that they gave the child other liquids than breastmilk to drink within the first three days of life.
One cannot simply calculate the mean or median duration of breastfeeding before the child is introduced to other liquids from retrospective information, because part of the data is censored, i.e. a number of
children in the survey have not yet been introduced to other liquids. Therefore it is necessary to use life table
55
techniques to investigate the child ’s age when women introduce liquids to their newborn babies.
In this life table analysis a fictive cohort of 100,000 newborn babies is followed with respect to the number who are still being breastfed at the beginning of each month, without being given other liquids.
Children who died were not included in the analysis. The results for the first year of life are depicted in
Figure 10.11
. The life table analysis shows that already during the first month 14.3 percent of children get other liquids. Note that this result seems contradictory compared to the result presented above where
it was found that 38.1 percent of children got other liquids to drink within the first three days of life. However, it is quite possible that many of these children were given something to drink because the
mother could not immediately give breastfeeding, but that children were returned to a full breastfeeding diet once the process started.
After three months of life, out of an initial life table population of 100,000 newborn children, 79,471 did not get other liquids than breastmilk. A big drop occurs between months 5 and 6 when the proportion
of children who are not introduced to other liquids drops below 50 percent. Actually, the median duration of breastfeeding without other liquids is 5.9 months. A large group of children apparently continues to
depend solely on breastmilk for liquid consumption even after the first year of life. After 12 months 37,717 children of the life table population were not yet introduced to other liquids.
Another important aspect to study breastfeeding behaviour is to look at the timing at which other foods are introduced. As mentioned, it is recommended that a child gets exclusive breastfeeding for a period
of six months. However, if supplementary food is not introduced soon after and the child has to rely solely on breastmilk between the ages of 6 and 24 months, the child may become malnourished and in
fact, literally starve at the breast. Again a life table analysis was performed in which the attrition factor is the moment the child is introduced to solid food.
The results of the life table show that during the first months of life very few children are introduced to supplementary food
Figure 10.12
. After 3 months of life, slightly more than one percent of mothers introduced their newborn babies to solid food. After the fifth month of life many children start eating
solid food. After 5 months of life still 90.8 percent of children were not yet introduced to solid food. This percentage decreased to 80.1 percent after six months and to 42.8 percent after seven months. An
interesting aspect of the life table analysis is that a substantial proportion of children are introduced to solid food at quite a late stage. At age 9 months 23.1 percent of children did not get supplementary food
and at 12 months this is still 12.7 percent. Perhaps this is due to misreporting by the young mothers, but it is apparent that also the 2010-11 MICS came up with similar results. In our opinion, this is certainly
an area where more research is needed to see if this is indeed an existing pattern or just a flaw in the data when such questions are asked in surveys in Afghanistan.
55
For an introduction to life table techniques see for instance Preston, Heuveline and Guillot 2001.
177
Figure 10.11: Number of children in the life table population who are still breastfed at the beginning of the age interval month without other liquids being given
Figure 10.12: Number of children in the life table population who are still breastfed at the beginning of the age interval month without supplementary food being given
The weaning pattern of children in Afghanistan is depicted in
Figure 10.13
. The curve presented is again based on the survivorship function of a life table analysis in which the attrition event is the age in months
at which the child is weaned and no longer receives any breastfeeding. In this case the survivorship function indicates the number of children who are still breastfed at the beginning of the one month age
interval. The median age at which young children are weaned is 24.2 months. Only a very small proportion of
children are weaned at very young ages. At the age of three months 1.5 percent of children who were initially breastfed no longer receive breastfeeding. At ages 6 and 12 months, these percentages are
respectively 2.7 percent and 6.1 percent. There is no doubt that some digit preference at 18 months and 24 months is present, given the rapid drop of children still being breastfed at these ages. However, it is
clear that a substantial proportion of women continue to breastfeed beyond two years. About one in four
10,000 20,000
30,000 40,000
50,000 60,000
70,000 80,000
90,000 100,000
1 2
3 4
5 6
7 8
9 10
11 12
Nu m
b er
o f
ch ild
ren
Age in months
10,000 20,000
30,000 40,000
50,000 60,000
70,000 80,000
90,000 100,000
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Nu
m b
er o
f ch
ild ren
Age in months
178
women is still breastfeeding when the child is 26 months old. Finally, the main indicators of breastfeeding of Afghan children is summarised in
Table 10.6
.
Figure 10.13: Number of children in the life table population who are still breastfed at the beginning of the age interval month
Table 10.6: Indicators breastfeeding and child feeding
Indicator Indicator description
Value Children ever breastfed
Percentage of women with a live birth in the last five years who breastfed their last live-born child any time
93.2 Early initiation of
breastfeeding Percentage of women with a live birth in the last two years who
put their last newborn to the breast within one hour of birth 33.2
Exclusive breastfeeding under 6 months of age
Percentage of infants at 6 months of age who did not receive solid food life table population
80.1 Continued breastfeeding at 1
year of age Percentage of infants still breastfed at exact age 1 life table
population 93.9
Continued breastfeeding at 2 years of age
Percentage of infants still breastfed at exact age 2 life table population
54.7 Median duration of
breastfeeding The age in months when 50 percent of children did not receive
breast milk any more 24.2
Median age at which children get other liquids to drink
The age in months when 50 percent of children received other liquids beside breast milk
5.9 10,000
20,000 30,000
40,000 50,000
60,000 70,000
80,000 90,000
100,000
3 6
9 12
15 18
21 24
27 30
33 36
39 42
45 48
Nu m
b er
o f
ch ild
ren
Age in months
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11 GENDER EQUITY AND WOMEN’S DEVELOPMENT
Summary . According to the 2014 Human Development Report, Afghanistan occupies position 169 out of
187 countries and is the lowest ranked non-African country. Within the difficult situation of Afghan society, especially women occupy a detrimental position and many live in deprived and secluded
circumstances. However, despite the vulnerable position of women within society in various fields some clear signs of improvement are visible.
In the ALCS 2013-14, special attention was paid to assess the living conditions of Afghan women. The position of women is clearly shown by the peculiar series of age-specific sex ratios in the population.
When most countries show sex ratios well below 100 at older ages, in Afghanistan the sex ratios become very high after age 50. This is most probably caused by the omission due to purdah of older women in the
survey and to the very high maternal mortality ratios of women in the past. In earlier studies in Afghanistan, also a significant proportion of females were missed in surveys. The very fact that especially
older women are completely missed for canvassing is a clear indication of their deprived position within the household.
Marriage for women in Afghanistan is almost universal with a very young pattern of first marriage. Traditionally many girls were given in marriage at very young ages below age 15. A very young age at
marriage coupled with a large age difference with a sometimes much older husband forced women into a subordinate role in the family, leaving very little negotiating power in terms of household decisions,
sexuality and fertility. There is evidence that in recent years the number of girls who marry at a very young age is declining. According to the ALCS 2013-14, the percentage of girls in the age group 20 to 24
years old, who married before age 16 has dropped to 12.1 percent. Polygamy is another practice that undermines the position of women. Currently, 8 percent of women live in a polygamous union. There is
no evidence that over the years the proportion of women in a polygamous union has decreased. Our figures even show that the percentage of women in older age groups living in a polygamous marriage
was lower than at the younger age groups.
Despite improvements in recent years, illiteracy among women remains very high. Only 19 percent of women aged 15 years and older can read and write. Literacy among 10 to 14 year old girls is 41 percent.
Although large differences between boys and girls remain, the literacy gender index is much higher in the youngest age group 0.71 in age group 10-14 years than in all others e.g. 0.45 in age group 20-24
years. This indicates a significant improvement. However, compared to ALCS 2011-12, the net primary attendance rate has slightly deteriorated and currently stands at 62 percent for boys and 46 percent for
girls, implying a gender parity index of 0.71. The weak position of girls is demonstrated by the fact that 33 percent of girls had to give up education because the family did not approve and that 10 percent of
girls had to stop their schooling because of marriage. Despite progress, young women still lag behind men in terms of education beyond primary school. For instance, 26 percent of boys finished upper
secondary school against only 10 percent of girls.
The labour market in Afghanistan shows strong inequality between the sexes. While men have a labour force participation rate of 81 percent, women score much lower with only 29 percent. Unemployment is
more than twice as high among women than among men 37 percent against 18 percent. The MDG indictor measuring progress toward gender equality and women’s empowerment is a low 10 percent,
down from 11 percent in NRVA 2011-12. Women have a relatively high aspiration to work for money: 40 percent of women in urban areas, 45 percent in rural areas and 36 percent among the Kuchi would like
to work for money.
The position of women is determined by the way they can make decisions on how to spend money they earned themselves. In general, urban women have more decision power on how to spend their money: 48
percent of urban women indicate they alone can decide how the money is spend, against 31 percent in rural areas and only 6 percent among the Kuchi population. Even in the urban areas less than half of the
women can decide independently on how to spend their money. The level of freedom of movement remains
180
very restricted with three quarters of women not leaving the dwelling without the company of another person. Levels of seclusion remain high: about 50 percent of women leave the house four times or less
per month, while 12 percent of women indicate they never left the house in a whole month.
The health position of women is not discussed in this chapter but in chapter 11 on health. However, some health aspects are closely related to the position of women and deserve some attention here. In the 2013-
14 ALCS a question was asked about womens use of the health system and why they would not seek medical attention when needed. The most important reason why women did not seek medical attention
was that it was too expensive to get medical attention; 40 percent of women indicated this as the first reason. Pre-coded reasons that are closely connected to deprivation of women are
‘no female medical staff’, ‘no one to accompany’, ‘husband or family did not allow’ and ‘traditional constraints’. Of these
categories, ‘no one to accompany’ is the most important with 2 percent as the first reason and 6 percent as the second reason. Our results clearly show that poverty and geographical isolation are much more
important reasons than gender deprivation to explain why women often do not get the medical attention they need when they are sick or injured. These results confirm the findings of the NRVA 2007-08 when
expenses and distance were also found to be the major constraints for women to use health services.
It is interesting that despite the huge differences in social position and status, the priorities for development activities for men and women come very close together. Both indicate that the most
important way in which the government can assist their community is by the construction or repair of local roads. Also other priorities score quite similar for men and women alike. This is a clear indication
that despite the detrimental position of women vis à vis men both sexes continue to suffer from high levels of poverty and deprivation and need similar actions to improve their condition.
11.1 Introduction
