UNFPA 2008. The present – better evidence-based – NRVA estimate of 6.27 suggests a somewhat lower TFR, but still only ten countries rank higher in the UN list.
Within Afghanistan fertility is higher in rural areas with a TFR of 6.49 compared to urban ones 5.25, and highest among the Kuchi population, whose women have on average more than seven live births over the course of their lifetimes
see Table 3.6a. Education is also related to fertility levels, and women with primary schooling have on average one
fewer lifetime birth than women with no schooling a TFR of 5.49 compared to 6.53. Those with secondary schooling and college education have the lowest fertility levels, with an average of only four births during their lifetimes.
Table 3.6 Total Fertility Rate, by a residence, and b educational level of mother
a. Residence TFR
b. Education TFR
Urban 5.25
None 6.53
Rural 6.49
Primary 5.49
Kuchi 7.28
Secondary 4.01
College 4.10
Total 6.27
Total 6.27
The negative impact of high fertility and frequent or ill-timed pregnancies on maternal and child health and mortality is well documented. So is their effect on a variety of other development issues, including environmental degradation,
poverty at macro-economic level, as well as at levels of the community and family, malnutrition, and low educational attendance and attainment Moreland and Talbird 2006, UN Millennium Project 2006, World Bank 2007, Eastwood and
Lipton 2001. Consequently, progress on achieving many MDGs depend on addressing fertility in the implementation of Afghanistan’s development policies, particularly by reducing mortality, increasing education and improving access to
health services, especially those related to reproductive health and family planning.
3.4.2 Child mortality estimates
Infant- and under-five mortality rates are important factors in the explanation of natural population increase and are by far
the most important contributors to low life expectancy in most developing countries. In connection with this, they are also
among the most revealing indicators of the health status of a population and the functioning of a country’s health system.
The NRVA 20078 survey included an abbreviated birth history and child mortality section, as part of the women’s questionnaire. This section asked ever-married women of reproductive age about any births during their lifetimes, and
about their total number of children currently alive, as well as those dead, by sex. A full methodological elaboration is provided in Annex IV to this report.
Sources of error in mortality estimates
Annex IV discusses several sources of error that must be considered when calculating child mortality estimates for Afghanistan from a household survey. One of these related to reporting problems concerning the sex of the child. The
natural sex ratio at birth has been found in most settings to be approximately 105 boys for every 100 girls, and the most extreme estimates range from 104 to 107 boys per 100 girls Dubuc and Coleman 2007. As can be seen in Annex Table
A.III.2, the ratio of boys ever born to girls ever born is well above 1.05 for all age groups, at an average of 1.10. The ratio is particularly high among the younger age groups of women.
Sex ratios at birth that are highly skewed can be found in societies with a preference for sons, such as India and China, and may be due to sex-specific feticide. However, although there may be a preference for sons in Afghanistan, none
of these considerations can plausibly explain the too-high sex ratio at birth. The skewed ratio is most likely resulting from one or both of two phenomena: intentional misclassification of girls as boys e.g., due to the perceived shame of
having mostly or only girl children and underreporting of girl children, under the assumption that the total number of boys reported is correct Ministry of Public Health 2008. The former would affect sex-specific mortality ratios, but not the
overall mortality ratio, while the latter would likely affect female mortality ratios as well as the overall mortality ratio.
Population structure and change
17
Infant- and Under-five Mortality Rate
The Infant Mortality Rate IMR is defined as number of deaths
to children under twelve months of age per 1,000 live births. The
Under-ive Mortality Rate U5MR relates to the number of deaths to children under five years of age per 1,000 live births.
Population structure and change
18
There is also some evidence of underreporting of dead girls and misclassification of girls as boys when there are all or mostly girl children for a given mother. Sensitivity analyses that were conducted to model likely under-reporting of girls
indicate that final mortality estimates did not vary much across different assumptions about the possible missing girls, as the overall proportion of missing girls was not very high.
Final estimates and concluding notes
Based on the data presented from NRVA 20078, it is concluded that the best estimate of infant mortality in Afghanistan is 111 deaths per 1,000 live births and that for under-five mortality is 161 deaths per 1,000 live births. These figures for
males are 119 and 169, respectively, and are 102 and 153, respectively, for females, for a reference date of April 2004, as shown in
Table 3.7.
Table 3.7 Infant and child mortality estimates, by sex
Mortality indicator Sex
Boys Girls
Both Sexes Infant mortality rate
119 102
111 Under-five mortality rate
169 153
161 Reference period
April 2004
The estimates from NRVA 20078 data of infant and under-five mortality differ somewhat from the estimates based on the Afghan Health Survey AHS, which estimated infant- and under-five mortality rates at 129 and 191 per 1,000 live births,
respectively, for a similar reference date November 2004 Ministry of Public Health 2008. There are several possible reasons for differences between these and AHS estimates. First, the NRVA is a national estimate, including urban, rural
and Kuchi areas, while the AHS survey only sampled rural households. Second, the AHS used different age groups the youngest and second-youngest in calculations of mortality, which directly impacts the estimates, as the youngest
age category is known to have higher-than-average child mortality due to more first-time, higher-risk births. Finally, in addition to being a rural-only survey, the AHS excluded areas that were relatively insecure at the time of the survey,
including four southern provinces and one eastern one.
Earlier estimates used by the Ministry of Public Health suggested that the infant mortality in Afghanistan was 165 per 1,000 live births Government of Afghanistan 2009. Although methodological differences could contribute to the difference with the
present finding, it is also likely that children are benefiting from improved health care and access to vaccinations for diseases such as measles, polio and tetanus see also section 8.3 of this report. The estimates of mortality are not very comparable,
but the large difference the NRVA 20078 results are 33 percent lower suggests that infant mortality is declining.
Additional caution should be used in interpreting the mortality estimates, especially infant mortality rates. The Brass method assumes that fertility is relatively constant in the population, and that under-five mortality is constant or linearly
declining United Nations 1990b. Both these assumptions are tenuous in Afghanistan, particularly the first, given the likely declining fertility as seen in the previous section. In the absence of a functioning vital registration system in
Afghanistan, a household survey with a full pregnancy or birth history, including dates of children ever born, could produce more robust and accurate estimates of infant and under-five mortality levels.
MDG Indicator 4.1 – Under-five Mortality Rate – and 4.2 – Infant Mortality Rate
Despite possible improvement, only few countries in the world have child mortality rates as high as Afghanistan. For instance, only 11 countries worldwide have an under-five mortality higher than the rate of 161 indicated by the present analysis. The comparable figure for
Southern Asia is 77, still high compared to the total of 49 children dying before age 5 worldwide. The table below compares IMR and U5MR for Afghanistan and its neighbouring countries.
Country U5MR
IMR Afghanistan
161 111
Pakistan 94
67 Iran
35 30
Tajikistan 94
59
Source for other countries: UNFPA 2008
Population structure and change
19
3.5 Migration
3.5.1 General migration In-migration
Of Afghanistan’s 3.4 million households, a sizable proportion 13 percent has household
members who were living elsewhere sometime during the five years preceding
the survey
Table 3.8. They may be either internal or international migrants. This overall
percentage hides significant variation: 28 percent of Kuchi households have migrants.
Furthermore, rural households 13 percent are more migratory than urban households
10 percent. Especially in the western region – bordering Iran – households tend to be
quite migratory.
Table 3.8 Households, by migration status during past ive years, and by current residence
Residence Migration status of household
Without any migrant With migrants
All households Thousands
Percentages Thousands
Percentages Thousands
Percentages Urban
616 90
66 10
682 100
Rural 2,235
87 328
13 2,563
100 Kuchi
139 72
54 28
193 100
National 2,990
87 448
13 3,438
100
All in all, 730 thousand Afghans 6 percent lived somewhere else during the past five years, of which 46 percent lived abroad Tables 3.9 and
3.10. By comparison, other types of migration are relatively minor: rather surprisingly, rural to urban migration was almost negligible only 3 percent. In most developing countries rural-to-urban migration is the most
important type of move and also other research seems to indicate its importance in Afghanistan see e.g. AREU 2005. The reverse type of move was more frequent 14 percent. Obviously, Kuchi nomadic moves figure importantly as well,
but these too are dwarfed by immigration from abroad. There is some difference between women and men: among women, apart from international moves, Kuchi migration is most important.
Table 3.9 Population, by migration experience during past ive years, and by sex
Sex Migration experience
No migration With migration
Total Thousands
Percentages Thousands
Percentages Thousands
Percentages Male
5,572 91
565 9
6,137 100.0
Female 5,732
97 165
3 5,897
100.0 Both sexes
11,304 94
730 6
12,034 100.0
All over the world, people mostly migrate when they are young adults. We see this pattern reflected among the Afghan men. Like the latter, Afghan women too migrate young, but the difference in age distribution between migrant and non-
migrant women is small. There is also little difference in educational levels between in-migrants and non-migrants, although migrants slightly more often attended primary school, compared withnon-migrants.
Migration definitions
An in-migrant is defined as someone who during the past five years lived outside
the current area of residence for at least three consecutive months. In many cases this in-migrant is a ‘return-migrant’, that is someone who lived in the current area
of residence before. The term ‘in-migrant’ is used here irrespective of whether the migrant arrived from elsewhere within Afghanistan or from abroad.
An out-migrant is anyone aged 15 years or older who was a household member
one year ago but has moved away and is no longer considered a member of the household. Note that out-migration is under-estimated to the extent that complete
households have moved away. A seasonal migrant is someone who during the past twelve months spent at least
one month away from the household for seasonal work.
