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Reducing the maternal mortality rate in Afghanistan
Proposal to the Minister of Public Health
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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
Fitzwilliam Group
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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
Fitzwilliam Group
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The problem…..
• Every 30 minutes one woman dies in Afghanistan from pregnancy related causes
….Is this acceptable?
Fitzwilliam Group
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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.
Fitzwilliam Group
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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.
Fitzwilliam Group
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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
Fitzwilliam Group
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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
Fitzwilliam Group
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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)
Fitzwilliam Group
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Therefore…..
• Meeting the challenge of reducing maternal mortality will require political will, education, communication and changes in cultural practices.
Fitzwilliam Group
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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.
Fitzwilliam Group
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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)
Fitzwilliam Group
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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
Fitzwilliam Group
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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)
Fitzwilliam Group
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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
Fitzwilliam Group
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Fitzwilliam Group