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10.3 Maternal health
In recent years, serious efforts have been made to reduce maternal mortality and to improve the reproductive health status of women in Afghanistan. Despite these efforts, maternal mortality remains
one of the highest in the world. A cooperation research project between WHO, UNICEF, UNFPA and the World Bank estimated the Maternal Mortality Ratio to be 460 maternal deaths per 100 thousand
births for Afghanistan in 2010. According to their estimates, the level of maternal mortality has come down by 65 percent from a very high level of 1,300 in 1990 to 460 in 2010 WHO, UNICEF, UNFPA
and World Bank 2012 A not fully representative survey in 2002 even suggested a Maternal Mortality Ratio of at least 1,600 per 100,000 births, which would imply that the life-time risk of women dying to
pregnancy-related causes was at least one in nine Bartlett et al. 2005. The reproductive health situation in Afghanistan is a complicated synergy of social, demographic,
medical, economic, cultural and gender factors. The next sections will go deeper into some of the components of reproductive health care. As much as possible comparisons will be made with conditions
observed in earlier surveys. 10.3.1 Ante-natal care
Ante-natal care ANC encompasses the total care a woman receives during pregnancy to ensure good health for both herself and her child at the time of delivery. In general terms, during ANC visits, the
health of the mother and the unborn child is monitored, i.e. pre-existing health conditions are identified, possible complications are detected, preventive actions are taken through vaccinations, micronutrient
supplements, etc., delivery for high risk births are planned and information is provided on family planning, mother and child health, breastfeeding etc.
Since the beginning of the new millennium, important progress has been made in monitoring the health of expectant mothers in Afghanistan. According to the Multiple Indicator Cluster Survey MICS in
2003, only 16 percent of women obtained ante-natal care. The NRVA in 2007-08 showed that 36 percent of pregnant women made use of skilled ANC services. In 2013-14, according to the ALCS, 63.0 percent
of pregnant women made at least one visit to a skilled ante-natal care provider doctor, nurse or midwife; 34.8 percent of women did not see anyone at all for ante-natal care, while 2.2 percent relied
on a traditional birth attendant or a community health worker 0.6 percent or
‘someone else’ 0.1 percent. The ALCS figures show that a further improvement has taken place since the NRVA 2011-12,
when 51 percent of expectant mothers reported at least one examination by a skilled medical provider.
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The National Reproductive Health Strategy of the Afghan Ministry of Public Health for 2010-2015 indicated that by 2013 the percentage of women receiving ante-natal care at least once should be
increased to 50 percent nationwide MoPH n.d., p. 3. ALCS results show that this target has been clearly reached and even significantly surpassed.
Large differences exist between urban and rural areas. In urban centers, 84.3 percent of pregnant women made at least one visit to a skilled ANC provider, against 57.6 in rural areas. Among Kuchi women,
only 42.6 percent visit an ANC provider, which is only about half the percentage of urban women. Among all three groups of expectant mothers, further improvement has been made during the last three
years CSO 2014, p. 92; see
Figure 10.3
. Most progress has been made among the Kuchi, where the number of pregnant women who received ante-natal care increased by almost 20 percentage points.
52
The figures of the NRVA 2011-12 come close to those of the 2010-2011 MICS, which showed a level of 47.9 percent of women using any skilled ANC CSO and UNICEF 2012.
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Ante-natal care by skilled health personnel is slightly higher among women in the younger age-groups: 65.7 of women in the age group 10-19 years and 64.6 percent of women aged 20-29 years old had an
ante-natal check by a skilled health professional, against 61.5 percent and 57.9 percent among women 30-39 and 40-49 years old.
Figure 10.3: Women with a live birth in the five years preceding the survey who reported at least one ante-natal examination by a skilled provider, by residence, and by survey in percentages
Educational attainment is an important discriminatory factor whether expectant mothers receive ante- natal care or not
Figure 10.4
. Among women with no formal education, 60.3 percent made a visit to a skilled medical provider during their last pregnancy. Women who had finished primary education scored
significantly higher 83.2 percent. Note that the difference between primary and secondary education is only marginal. Women who had finished Teacher College or University including post-graduate
studies scored considerably higher; 94 percent of women with high education visited a skilled ante- natal provider at least once during pregnancy. Although the figures for the highest educational levels
look very promising, one should keep in mind that these women only constitute a very small, privileged minority among all women; 91.6 percent of women who had a live birth during the last five years before
the survey indicated they had no formal education. Large differences exist between provinces in the provision of ante-natal care and the type of medical
professional who delivers the service. Among the 34 provinces in Afghanistan, in ten provinces more than half of all pregnant women did not see a medical provider for a pre-natal check. In four provinces
even less than 20 percent of women saw a medical provider before childbirth Nooristan, Kandahar, Daykundi, Badakhshan. On the other hand, Kabul, Nangarhar and Kunduz compare favourably with
around 10 percent or more of women who had at least one ante-natal check during pregnancy.
51.0 78.4
46.3
23.4 63.2
84.3
57.6 42.6
10 20
30 40
50 60
70 80
90
National Urban
Rural Kuchi
P er
ce n
tag e
NRVA 2011-12 ALCS-2013-14
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Figure 10.4: Women with a live birth in the five years preceding the survey who reported at least one ante-natal examination by a skilled provider, by highest educational attainment in percentages
According to the WHO ’s recommendations, essential ante-natal care can be given to pregnant women
with no complications during four visits, at specified intervals during pregnancy Villar and Bergsjø 2002. The WHO ante-natal care model clearly specifies what tests have to be performed during each
of the visits and is often referred to as ‘focused ante-natal care’. For 2011-12, the NRVA indicated that
only 9.9 percent of pregnant women made the recommended four visits to an ante-natal provider. In just a few years this percentage has increased to 22.7 percent.
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In urban areas, 43.9 percent of women have the minimum four visits, against 17.4 in rural areas. Only 11.7 percent of Kuchi pregnant women made
the four recommended ante-natal visits. On average, pregnant women residing in urban areas make 3.5 visits both to skilled and unskilled providers for ante-natal care, against 1.8 visits in rural areas and
1.3 among Kuchi women. The national average is 2.1 ante-natal visits. Closely related to the type of provider of ante-natal care is the average number of visits paid to an ante-
natal care provider per province. Again large differences can be noted between the different provinces
Figure 10.5
Kabul has the highest average number of ante-natal visits 4.1 visits per woman. Nine provinces score less than 1 ante-natal visit per pregnant woman.
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For the number of ante-natal visits, no distinction was made between skilled and unskilled providers, as the data did not allow to calculate the number of visits to each type of provider. As only about 2 percent pregnant
women visited unskilled medical providers, the bias introduced is very limited. 60.3
83.2 81.6
86.6 94.2
93.4
10 20
30 40
50 60
70 80
90 100
None Primary
Lower secondary
Upper secondary
Teacher college
University P
er ce
n tag
e
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Figure 10.5: Mean number of visits to ante-natal care providers, by province
Target 5.b of the Millennium Development Goals aims to reach universal access to
reproductive health for all women in 2015. Ante-natal care coverage is one of four
indicators to monitor progress towards Target 5.b. Measuring in terms of receiving at least one
visit, Afghanistan has achieved its target ahead
of schedule, and the NRVA 2011-12 indicator already surpassed its 2020 goal of 50 percent coverage. ALCS figures show that even though significant progress has been made to increase the percentage of
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