Reducing the maternal mortality rate in Afghanistan

Proposal to the Minister of Public Health

Country Overview

• Located in South Central Asia

• Population 22.2 million

• GDP $190 US per capita

• Divided into 33 provinces

• Literacy rate 28.7%

• More than 85% of women are illiterate

• Predominately Muslim

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The health system….• National and Provincial level health services• Health service provision has been contracted to

non-Government organisations (77% of population covered)

• Ministry of Public Health predominately undertakes a policy role

• Basic, Comprehensive and Hospital based services with defined catchment areas

• National health care financing policy currently under development

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The problem…..

• Every 30 minutes one woman dies in Afghanistan from pregnancy related causes

….Is this acceptable?

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Defining the problem…..

• Afghanistan has the highest rate of maternal mortality of any country except Sierra Leone and Angola.

• Overall maternal mortality is estimated at 1600 to 2200 deaths per 100,000 live births.

• Parts of Badakhshan province have the highest maternal mortality rates ever recorded, with nearly 7% of mothers dying in childbirth.

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Defining the problem…..• As a result of the low level of female education and

gender segregation:– fewer than 15% of births are attended by medically trained

personnel (who must be female), – only 10% by a traditional midwife; – 75% of births are attended only by family members.

• Nearly 16% of Afghan girls are married before the age of 15 and 52% are married before their eighteenth birthday.

• In some of the country's most populous provinces, where indebtedness is high over half of girls are married off young for economic reasons, to pay off debts or earn brideprice for family subsistence.

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Country Maternal mortality ratio (per 100,000 live births)

2000

Proportion of births attended by skilled

health personnel (%)

2000-02

Afghanistan 1600 14

Iran

Pakistan

Tajikistan

Turkmenistan

Uzbekistan

76

500

100

31

55

90

23

71

97

96

Table 8.1:Maternal mortality: international comparisons

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Causes of mortality…..Direct causes• Hemorrhage• Obstructed labour• Infection• Unsafe abortion• Hypertensive disorders of pregnancy

Indirect causes• Disease eg tuberculosis, malaria and

other infectious diseases

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Issues to consider…..

• In Afghanistan three delays are responsible for the high rate of maternal mortality– Delays in recognizing the problem– Delay in accessing health facilities – Delays at health facilities due to lack

of:• Knowledge of professional staff• Equipment• Staff (particularly female)

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Therefore…..

• Meeting the challenge of reducing maternal mortality will require political will, education, communication and changes in cultural practices.

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Key intervention• Improved knowledge and attitudes leading to behavior change at

the local community and individual level which will lead to:– Families understanding the need for attendance at maternity services– Pregnant women are empowered to attend services

• This behavior change will impact on the health system through:– Increased demand for services– Increased need for additional health staff (particularly female) and

infrastructure

• It is our contention that some of this capacity already exists within the health system while other capacity can be funded at a reasonable cost.

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Key strategies….

Phase One• Strengthen reproductive health services

Phase Two• Develop and implement a community education

campaign to promote attendance at health facilities through a radio medium

• Strengthen existing local health committees through communication, revitalisation of purpose and provision of resources (such as birth planning kits)

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Communication….Approach• Step One

– Policy advocacy– Draft proposal to Minister of Public Health technical staff– Discussion with key persuaders regarding taking the proposal forward

including funding sources.– One on one meetings with

• Ministers (Finance, Public Health, Culture, Religious affairs, etc)• Potential Funders• Heads of Training Institutions• Relevant professional authorities in country

– Group meeting with relevant stakeholders– Cabinet submission– Parliament

• Step Two– Inform the Nation – media (radio), word of mouth, key connectors

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Communication….

• Step Two target audiences– Mavens (Traditional Birth Attendants and local

Health Committees)– Persuaders (Health professionals, Community

Mid-wives)– Connectors (Media – predominately radio)– Resistors (Traditional Family groups)

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Measuring Outcomes….

• Extent of achievement of Millennium Development Goals incuding Improve Maternal Health (Goal 5)

• Relevant series of questions within the Demographic Health Survey

• National Health Risk and Vulnerability Survey

• Multiple Indicator Cluster Survey

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