percent percent percent ALCS 2013 14 Main Report English 20151222

168 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 women who receive ante-natal care, there is still a long way to go. Although serious improvements have been made in the last few years, only slightly more than 1 in every 5 pregnant Afghan women makes the recommended four visits to a skilled health provider for an ante-natal check. 10.3.2 Skilled birth attendance and place of delivery The vast majority of obstetric complications can be prevented or dealt with by skilled birth attendants, in a hygienic and safe health facility. To avert maternal mortality and reduce levels of neonatal mortality, pregnant women should therefore have full access to skilled birth attendants in a safe and hygienic environment at the time of childbirth. In the 2013-14 ALCS, a question was asked to measure the proportion of births attended by a skilled health provider and another one to determine the place where the delivery took place. ANDS Indicator 9.d MDG Indicator 5.5 Ante-natal care coverage At least one visit:

63.2 percent

At least four visits:

22.7 percent

169 The percentage of births attended by skilled health personnel is an important indicator for monitoring progress towards MDG Target 5.a Reduce maternal mortality by 75 percent by 2015 . Skilled birth attendants include doctors, midwives and nurses. Community health workers CHWs are not considered to be skilled birth attendants. Currently, 45.2 percent of all births in Afghanistan are attended by skilled health personnel. Table 10.4 shows the percentage of women who gave birth to their last child in the last five years before the survey by the type of birth attendant for rural-urban residence and the Kuchi community. It shows large differences by residence type. The percentage rural women attended by skilled health personnel 37.0 percent is less than half of the corresponding proportion of urban women 81.7 percent. And Kuchi women are again more than half well serviced than rural women 15.4 percent. Figure 10.6 shows the proportion of women delivering with skilled birth attendance by province. Table 10.4: Women with a live birth in the five years preceding the survey, by type of birth attendant, and by residence in percentages Residence Total Doctor Nurse or Traditional Community Someone No one Skilled midwife birth health else attendance attendant worker National 100.0 12.1 33.1 45.0 0.7 8.2 0.9 45.2 Urban 100.0 29.1 52.6 13.3 0.5 4.2 0.3 81.7 Rural 100.0 8.0 29.0 53.7 0.8 7.6 0.9 37.0 Kuchi 100.0 2.3 13.1 50.7 1.0 31.0 2.1 15.4 In 2013-14, 12.1 percent of all births were attended by a doctor and 33.1 percent by a midwife or nurse. Community health workers assisted with very few deliveries 0.7 percent. The majority of women are still assisted during childbirth by traditional birth attendants 45.0 percent or by ‘someone else’ 8.2 percent. Less than 1 percent of women delivered their babies without any assistance. The pattern of birth attendance is quite different between rural and urban areas. While only 13.3 percent of children in urban areas are delivered by traditional birth attendants TBAs, the percentage was 53.7 percent in rural areas. An almost equal proportion of Kuchi mothers were assisted by TBAs. It is interesting that the ‘someone else’ category is so high in the Kuchi community 31.0 percent. This group of birth attendants is normally constituted of relatives or friends. ANDS Indicator 9.b MDG Indicator 5.2 Proportion of births attended by skilled health personnel

45.2 percent

170 Figure 10.6: Percentage of women with a live birth during the five years preceding the survey who delivered with skilled birth attendance, by province in percentages In recent years, Afghanistan has made significant progress to ensure delivery by skilled birth attendants and the achievement of the MDG 2015 target of 50 percent will be a close call. In 2006 – only 8 years before the 2013-14 ALCS – only 18.9 percent of women were attended by skilled health personnel during childbirth Figure 10.7 . Progress was most rapidly during the period 2006 to 2010, when skilled birth attendance more or less doubled. Since then continued progress has been made, although at a more modest pace. In general, younger women have less of a tendency to deliver their babies with the attendance of a skilled health professional; 48.2 percent of women 10 to 19 years old at the time of the survey, who delivered a baby in the five year period before the survey, sought the assistance of an unskilled birth attendant. In the age-groups 20-29, 30-39 and 40-49 years, this was respectively 52.5, 56,5 and 61.6 percent. 171 Figure 10.7: Utilisation of skilled birth attendants, by survey year in percentages a a Sources: MoPH 2007, CSO 2009, MoPH et al. 2011, CSO and UNICEF 2012, CSO 2014 Another discriminatory factor determining the presence of a skilled birth attendant during delivery is educational attainment. Figure 10.8 clearly shows that the higher the educational attainment of the expectant mother, the higher the likelihood that she will be assisted by a skilled health professional during childbirth. Women who have finished upper secondary education, Teacher college or university are assisted in more than 80 percent of cases by a skilled birth attendant. For women without any formal education this is only slightly more than 40 percent. Another interesting aspect is that women with higher education have a much higher chance of being attended by a doctor and not a midwife or nurse. The percentage of women with primary or lower secondary education, who are assisted during childbirth by a midwife or nurse is almost the same as for those with upper secondary education or Teacher college, but, the difference in skilled birth attendance is caused by a much lower presence of a doctor. Note that only 10.4 percent of women with no education were attended by a doctor. In 2006, 85.4 percent of women delivered in their home or at a relative ’s or neighbour’s home. A mere 14.6 percent got their babies in a hospital or a health clinic MoPH 2007. Since then, also in this area considerable progress has been made. According to the 2013-14 ALCS, 42.8 percent of all babies are now delivered in hospitals or public health facilities, and 56.6 percent of women still go through childbirth at home. This is an improvement compared to the results found in the 2011-12 NRVA, when 63 percent of all deliveries took place at home. 18.9 23.9 34.0 39.0 39.9 45.2 5 10 15 20 25 30 35 40 45 50 AHS 2006 NRVA 2007-08 AMS 2010 MICS 2010 NRVA 2011-12 ALCS 2013-14 P er ce n tag e 172 Figure 10.8: Women with a live birth during the five years preceding the survey who were attended by a skilled provider during delivery, by type of provider, and by educational attainment in percentages Figure 10.9 shows the difference in place of delivery between rural and urban residence and Kuchi. In urban centres 21.5 of women deliver their babies at home against 66.5 percent in public health facilities, 8.4 percent in private hospitals and 3.2 in other public health facilities. The situation in rural areas is completely different: here the percentage of home deliveries is about three times higher 64.8 percent, while only 28.1 percent of childbirths take place in public hospitals, 1.7 percent in private hospitals and 4.9 percent in other public health facilities. The large majority of Kuchi women deliver their babies at home 81.9 percent. Only 12.3 percent deliver in the safe environment of a public hospital or a private hospital 2.6 percent. A very close relationship exists between delivery at home and giving birth without a skilled health provider. It is clear that those provinces that have very high percentages of women who give birth without a skilled attendant, also score very high in terms of delivery at home. Seven provinces out of 34 score higher than 80 percent for both indicators. 54 Women and their newborn children in these provinces are at elevated risk for serious complications and death during childbirth. Next to these seven provinces many provinces show high percentages for both skilled birth attendance and unsafe place of birth. In fact, Kabul is the only province were both indicators are below 20 percent. 54 Nooristan, Ghor, Badghis, Daykundi, Badakhshan, Farah and Urozgan 10.4 27.8 28.9 34.2 42.6 45.2 31.8 47.7 46.7 49.2 46.5 42.5 10 20 30 40 50 60 70 80 90 100 None Primary Lower secondary Upper secondary Teacher college University P er ce n ta g e Doctor Nurse or Midwife 173 Figure 10.9: Women with a live birth during the five years preceding the survey, by place of delivery, and by residence in percentages Figure 10.10 summarises the developments in the main reproductive health indicators covered in the ALCS. The trends show large improvements in the performance of the health system for each of the indicators of skilled birth attendance, ante-natal care and institutional delivery. The percentage of women that received these health care services has tripled for the first indicator and even quadrupled for the latter two indicators compared to the situation in 2003. These improvements will have had major impacts on maternal mortality and morbidity. At the same time – considering international standards – the figures indicate that still a long way is to go to provide adequate health services to Afghanistan’s population. 56.6 21.5 64.8 81.9 35.4 66.5 28.1 12.3 8.4 10 20 30 40 50 60 70 80 90 100 National Urban Rural Kuchi P er ce n tag e At home Public hospital Other public health facility Private hospital Other 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