Afghanistans Experience in Reducing Maternal Mortality

Presented by Dr. Sadia Fayaq Ayubi Reproductive Health Director Afghanistan Ministry of Public Health
May 2012
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Presentation Overview
Overview of Afghanistan Background of maternal health and health system What was done Afghanistan Mortality Survey Methodology Results Limitations Factors contributing to a reduction in maternal mortality Next steps for the national program Remaining challenges
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Background: Afghanistans Maternal Health Profile in 2002/2003

8%

Estimated 26,000 women dying from pregnancy related causes per year 1 woman dying every 27 minutes 78% of deaths are preventable

9% 4% 5% 38%

10%
Haemorrhage Obstruction

26%

PIH Sepsis Other direct Indirect Unclear

Source: Bartlett et al 2005

Results From Various Surveys

Reproductive Health Indicators

2003 MICS

2005 NRVA

2006 AHS

2007 NRVA

Maternal Mortality Ratio Antenatal Care Coverage Skilled Birth Attendance Contraceptive Prevalence Rate Proportion of unmet need for family planning Knowledge about contraception among ever married women Infant mortality rate (per 1000 live births) Total Fertility Rate Proportion of Pregnant Women Receiving 2TT Lifetime Risk of Pregnancy Life Expectancy

1600 4.6 6.0 2 23 28 165 6.6 33 1/9 46 years

12.6 8.4 6 -

32.3 18.9 15.4% 129 6.3 -

36.5 23.9 22.8 111 6.2 5

The Model: What Was Done

Strengthen the health system: Develop polices and guidelines that support best practices and create an enabling environment: o Basic Package of Health Services (BPHS) o Essential Package of Hospital Services (EPHS), National RH Strategy, maternal and RH service delivery guidelines, National Midwifery Education Policy Increase access to and use of health services: Support education and deployment of large numbers of qualified and competent midwives to work in underserved areas Scale up and strengthen community-based health care Generate demand for services and expand behavior change communication and community mobilization activities Develop a community health nursing education program
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Afghanistan Health System

The Model: What was Done

Standardize and improve quality of maternal and RH services: Strengthen BEmONC and CEmONC services Establish National Midwifery and Nursing Education Accreditation Board Utilize performance standards for primary health providers and improve supportive supervision Strengthen in-service training with competency-based learning materials
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Afghan Mortality Survey (AMS)

Timing: April December 2010 Purpose: To provide current information on
Child, maternal and adult mortality Causes of mortality and life expectancy Marriage, fertility and family planning Maternal health and socio-economic indicators

Geographic locations: National Implemented by MoPH & CSO with technical assistance from Macro ICF, IIHMR, WHO & UNFPA Funded by USAID, UNICEF & WHO

AMS: Methodology
24,032 households in all 34 provinces Excluded rural areas Helmand, Kandahar and Zabul for security reasons (9% of total population) Quality Control:
Field supervisors and editors Field monitors MoPH monitoring Office editors and database check table
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AMS: Results

Reproductive Health Indicators

2003 MICS

2005 NRVA

2006 AHS

2007 NRVA

2010 AMS

Maternal Mortality Ratio

1600

327 60

Antenatal Care Coverage

Skilled Birth Attendance Contraceptive Prevalence Rate Proportion of unmet need for family planning Knowledge about contraception among ever married women Infant mortality rate (per 1000 live births) Total Fertility Rate Proportion of Pregnant Women Receiving 2TT Lifetime Risk of Pregnancy Life Expectancy

4.6
6.0 2 23 28 165 6.6 33 1/9 46 years

12.6
8.4 6 -

32.3
18.9 15.4% 129 6.3 -

36.5
23.9 22.8 111 6.2 -

34
20% 92%
77 5.1

50 1/50 M 62.3 years F 61.5 years

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How Does Afghanistan Compare in Maternal Mortality Ratio?

Deaths per 100,000 live births

Data source: AMS 2010; Stratified et al. (2011) for Bangladesh 2010; and DHS Survey reports for Nepal an Pakistan

AMS: Limitations
The survey did not cover onethird of the population in the South, due to insecurity Mothers did not always report all child deaths, particularly girl child deaths in the south Mothers could not remember the exact date of birth or death of their children in the south Immediate newborn death was not always reported

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Factors Contributing to a Reduction in Maternal Mortality

Government made reduction of maternal mortality a priority in the Afghan National Development Strategy, Kabul Conference and MDG summits Clear policies, strategies and action plans MoPH, donors and all health partners were committed Afghanistan developed a model health system Initiatives such as community midwifery education, which increased the number of midwives from 467 in 2003 to 3200 now Focus on key maternal health services at the community level Scaled up Emergency Obstetric Care 14 Improved quality of health services

Factors Contributing to a Reduction in Maternal Mortality

Messages on ANC, birth planning, knowledge of danger signs. BCC & IEC campaigns Trained community midwives Trained and supported health posts Implemented pilot projects, such as Prevention PPH at home births, maternity waiting homes, PPFP, results based financing, Family Health House program CHWs give contraception
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Next Steps for the National Program

1. Continue to increase the proportion of births attended by skilled providers 2. Increase access to & availability of essential emergency obstetric services (especially basic) 3. Increase the number of appropriately staffed and equipped health facilities that are able to provide EOC services

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Next Steps for the National Program

4. Improve the quality of EmONC services, according to national clinical and managerial standards Increase community participation in the provision of maternal, neonatal & child health (MNCH) services Strengthen the referral system Improve monitoring & evaluation of MNCH services and use of data Increase demand for MNCH services

5.

6. 7.

8.

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Remaining Challenges
Despite our gains, there is still a long way to go. 2/3 of women still give birth at home without a midwife or skilled attendant; more than half of the women under age 20 have no formal education; maternal mortality is still unacceptably high. Addressing the health inequities between rural and impoverished women and urban area.

Which Afghan women are most at risk of dying in pregnancy and childbirth?
Girls who marry early Women living in remote areas with limited access to emergency obstetric care Women in lower income groups with malnutrition & high fertility Women with no education These challenges require a multi-sector approach!
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Remaining Challenges
Need for greater numbers of qualified female health workers in the rural areas BPHS coverage still needs to be increased Persistent insecurity challenges impacts supervision, recruitment and retention of staff and service delivery coverage The gains are fragile and donor resources are declining. Substantial investments must be maintained to safeguard these hard-won gains. 20

Thank You! Questions?

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