Afghanistan Mortality Survey Reveals Substantial Improvements in Maternal Health
The 2010 Afghanistan Mortality Survey (AMS 2010) is Afghanistan's first comprehensive mortality survey. Implemented by the Afghan Public Health Institute (APHI), the Ministry of Public Health (MoPH), and the Central Statistics Organization (CSO), the national survey represents over 22,000 households, covering 87 percent of the total Afghan population. In addition to data on mortality and cause of death for mothers, children, and all adults, the survey includes data on fertility, family planning, and on the utilization of maternal and child health services.
Management Sciences for Health (MSH) played a significant role helping Afghans rebuild their health system.
A trusted partner in Afghanistan for nearly 40 years, MSH has worked with the Afghan Ministry of Public Health (MoPH), USAID, and a network of NGOs to help dramatically expand access to perinatal care, reduce child deaths, and increase use of modern contraception. MSH has strengthened the capacity of the ministry of health, trained community health workers (more than 25,000 are now active), and supported hundreds of health facilities. Today, in 24 provinces covering 77 percent of the population, MSH is helping to implement the MoPH’s basic package of health services.
MSH spoke with Dr. Hedayatullah Stanekzai, country director for the MSH-led BASICS project, and Senior Policy Advisor to the Minister of Public Health for Child Survival, about the results of the survey.
What makes the Afghanistan Mortality Survey and its results important?
Independent evaluation reports by Johns Hopkins University and the Indian Institute of Health Management Research had shown that Afghanistan had made tremendous progress in both the hospital sector and the primary healthcare service sector between 2004 and 2008. These reports were supported by Afghanistan’s own records (via Balanced Scorecard for Afghanistan indicators), but we needed a national survey to provide a complete picture of the impact of improvements to the health system on mortality and the quality of life of the Afghan people. AMS 2010 provides a clear picture of our people’s health status during the last 10 years, including the first ever look at the causes of mortality in Afghanistan.
In addition to mortality data, the survey provides data on access to improved sources of water, access to mobile phones, the proportion of women aged 12-49 without education, the proportion of orphans in the country, and many other indicators that are important for national planning purposes. This data allows us to see the impact of billions of dollars invested in health, education, agriculture, communication, and transportation in the past 10 years.
The AMS is the first Afghan survey to use gold standard methods of data collection, allowing its data to be used widely by international researchers. The World Health Organization has used the AMS data to estimate maternal mortality for Afghanistan in 2012.
Since this was the first comprehensive mortality survey of the country, to what data was the 2010 AMS compared?
AMS 2010 covered 10 years, allowing internal comparison of data over time. We also compared the AMS data with other surveys, including the Multiple Indicator Cluster Survey 2003, Afghanistan Health Survey 2006, and National Risk and Vulnerability Assessment 2007/08, but those comparisons are limited by methodological variation among the surveys.
One of the survey’s key findings is a drastic drop in maternal mortality. What factors could account for this drop?
The AMS 2010 found a maternal mortality rate of 327 deaths per 100,000 live births in the survey area. The survey did not include much of the country’s south and southeast, however, because of conflict in those regions. Accounting for those areas, the AMS estimates a country-wide rate of as high as 500 deaths per 100,000 live births. Even with this higher rate, the maternal mortality ratio in Afghanistan is now two-thirds less than a CDC/UNICEF study estimated in 2002 (1,600 deaths per 100,000 live births).
The AMS estimates appear to be consistent with rapid increases in antenatal care and assisted deliveries in Afghanistan in recent years. The rise in antenatal care and assisted deliveries has been possible because of a five-fold increase in the number of health facilities and about a six-fold increase in the number of midwives. We should not ignore major improvements in education, communication, roads, and transportation in the country in the last 10 years as well.
Despite the dramatic decline in maternal mortality in Afghanistan, the AMS shows pregnancy-related deaths remain a leading cause of death for women in their childbearing years. It is estimated that under current conditions approximately 1 in 50 women in Afghanistan will die of pregnancy-related causes during her lifetime. The lifetime risk of pregnancy-related death is five times as high in rural areas as in urban areas. It is important to note that the AMS estimates of pregnancy-related mortality in Afghanistan are higher than the estimates for Bangladesh, Nepal, and Pakistan.
What are some other key findings from the survey?
In addition to improvements in maternal mortality, the survey showed improvements in access to safe drinking water, a drop in fertility among all age groups, an increase in the age at first marriage among women, and an increase in the use of family planning and perinatal care services.
Child mortality also improved in the last decade, although it continues to be high. The survey estimated that the infant mortality rate is now approximately 77 deaths per 1,000 live births, down from 165 in 2000. The under-five mortality rate is approximately 97 deaths per 1,000 births, down from 257 in 2000.
What are the implications of the overall survey results for the future of health in Afghanistan?
Despite substantial gains in the health of the Afghan people, the AMS shows that significant challenges remain.
- Three-quarters of Afghan women have no education.
- In Afghanistan, 1 in 10 children does not live to see their 5th birthday.
- One in five Afghan women are using a modern method of family planning.
- One-third of births are delivered in a health facility.
- Injuries are responsible for 21 percent of deaths to males, compared to only 7 percent of female deaths.
- About 37 percent of mortality among females and 37 percent among males are due to non-communicable disease, mostly cardiovascular disease and cancers.
- One in five households have access to improved sanitation facilities (toilet).
Overall, Afghanistan will need to secure substantial investments to safeguard the gains in maternal and child health and ensure ongoing improvements.