Maternal Survival in Afghanistan:Progress and Challenges

Mary Ellen StantonSenior Maternal Health AdvisorBureau for Global Health, USAID

Health in Afghanistan:How Can We Save Women’s Lives?

Women’s Policy, IncCanon House Office Building

July 20, 2010

Health Situation (2001-2002)

Fertility 6.8 children/women

No access to health care services for 1/3 population

Crumbling health infrastructure

Vast human resource needs

Photo: Linda Bartlett

Lifetime Risk of Maternal Death

1:8Afghanistan

1:4,800USA

Source: WHO/ UNICEF/UNFPA, The World Bank. Maternal Mortality Estimates 2005, App 8, pub 2007

The chance of a woman dying as a result of pregnancy is 600 x greater in Afghanistan than it is in the United States.

Maternal causes of death in Afghanistan 4 regions (n=154), 1999-2002

Cause of death Life Saving Interventions

- Family planningHemorrhage 33% - Active management of the

third stage of labor- Misoprostol

Obstructed labor 22% - Partograph- Cesarean section

Pregnancy induced hypertension

8% - Calcium supplementation- Magnesium sulfate

Sepsis 5% - Tetanus toxoid- Infection prevention- Antibiotics

Source: L Bartlett, 2002

Maternal Mortality and the Cycle of Poverty in Afghanistan

Financial and Human Cost

Hospital and funeral expenses

Lost wages

Lost education

Milk/formula expense plusmedical expenses

Lost education

Medical expenses

Remarriage expenses

Medical expenses andsocial exclusion

Family debt andcommunity impoverishment

Mother delivers life twins inhospital and dies

Father - Time off for birthand funeral

11-year old daughter -Leaves school to care for twins

Twins feed on goat milk andinfant formula, often ill

13-year old son -Leaves school to work

At 7 mos., smaller twin dies

Father remarries

At 13 years, surviving twinmarries, at 15, gives birth tobrain-damaged baby, suffersobstetric fistula, is cast out byhusband and returns to her father

Event in the Cycle of Poverty

Indicator Post-Taliban (2002)

Current Situation

(2009)Under-five mortality rate (deaths per 1,000 live births per year)

257/1,000 191/1,000 (26% reduction)

Access to basic services (% of population within 2 hours’ walk of a health facility)

9% 64%

Coverage of female health workers (% of facilities with a female health worker)

26% 85%

Use of antenatal services (% of pregnant women who use antenatal services)

5% 32%

Much has been achieved… much remains to be done

Ingredients of success formaternal and child health

• Government leadership

• Focus on rural health, equity

• BPHS: Basic Package of Health Services

• EPHS: Essential Package of Hospital Services

• Large-scale contracting capacity with NGOs

• Human resource policies

• Pharmaceutical policies • Clinic construction

• Social marketing of health products

• Recruitment, training & support of female community midwives & community health workers

Looking ahead…

• Security

• Expanded attention to midwifery education

• Family planning — more services to meet unmet need

• Focus on quality improvement, especially at referral level – prevention & treatment of obstetric complications

• Accountability to communities – working with religious and community leaders – on availability and quality of interpersonal care

• Seizing the opportunities and developing strategy for innovation such as mobile health/telemedicine

• Measuring impact– RAMOS II a possibility– National survey — all cause

mortality underway