afghanistan Reproductive Health at a December 2011 Country Context Afghanistan: MDG 5 Status

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1 Reproductive Health at a GLANCE December 211 afghanistan Country Context Afghanistan has had many positive achievements over the past decade, including more than 6.3 million students and teachers returning to school since 22, an additional 48, girls enrolling since 28, bringing the total number of girls in school to 2.68 million, and an additional 487,47 boys enrolling in 28, bringing the total number of boys in school to million. Although Afghanistan has faced civil war and political instability since the late 197 s and the government has found it challenging to restore delivery of basic services including food, shelter, and security, 1 in recent years, education and health care systems, in particular, are being revived and expanded. Still, three in five Afghan children are chronically undernourished, half of children under-five are underweight, and one-fifth of children die before their 5th birthday. 2, 3 Forty-two percent of the population subsists on less than US $1.25 per day. 4 Afghanistan s large share of youth population (46 percent of the country population is younger than 15 years old) 4 provides a window of opportunity for high growth and poverty reduction the demographic dividend. But for this opportunity to result in accelerated growth, the government needs to invest in the human capital formation of its youth. This is especially important in a context of decelerated growth rate arising from the global recession and the country s exposure to high volatility in commodity prices. Gender equality and women s empowerment are important for improving reproductive health. Higher levels of women s autonomy, education, wages, and labor market participation are associated with improved reproductive health outcomes. 5 Sex ratio, the number of males per 1 females in the population, is considered a summary measure of women s status because it reflects gender differences in survival rates; a sex ratio greater than 1 signals low status of women. With the exception of Nepal and Sri Lanka, sex ratio in South Asia is high. In 21, the sex ratio in Afghanistan was In Afghanistan, fewer girls are enrolled in secondary schools compared to boys with a ratio of female to male secondary enrollment of 49 percent. 4 Additionally, one third of adult women participate in the labor force. 4 THE WORLD BANK (Continued on page 2) Afghanistan: MDG 5 Status MDG 5A indicators Maternal Mortality Ratio (maternal deaths per 1, live 1,4 births) UN estimate a Births attended by skilled health personnel (percent) 34.3 MDG 5B indicators Contraceptive Prevalence Rate (percent) 21.8 Adolescent Fertility Rate (births per 1, women ages 15 19) 12 Antenatal care with health personnel (percent) 59.6 Unmet need for family planning (percent) Source: Table compiled from multiple sources. a The 21 AMS estimate is 297. Mdg Target 5A: Reduce by Three-quarters, between 199 and 215, the Maternal Mortality Ratio Based on the UN estimates, Afghanistan has made insufficient progress over the past two decades on maternal health and is not yet on track to achieve its 215 targets. 7 Figure 1 n Maternal mortality ratio and 215 target MDG Target Source: 21 WHO/UNICEF/UNFPA/World Bank MMR report. World Bank Support for Health in Afghanistan The Bank s latest Interim Strategy Note is for fiscal years 29 to 211. The Bank s new Country Assistance Strategy Progress Report under preparation (P125421) is scheduled to be approved by the Bank s executive Board on February 28, 212. Current Projects: P11658 Afghanistan Health (supplement II) ($2m) P1152 Afghanistan HIV/AIDS Prevention Project ($1m) P Strengthening. Health Activts. for Rural Poor ($27m) P12565 Supt to Basic Package of Health Services ($17.9m) P12669 Sharp Additional Financing ($44.1m) Pipeline Projects: None Previous Health Projects: None

2 n Key Challenges High fertility Fertility has declined over time but remains high overall. Total fertility rate (TFR) decreased from 6.6 births per woman in 28 4 to 5.1 births per woman in Fertility remains relatively constant among the wealth quintiles (Figure 2) and dwelling location (5.2 among rural dwellers and 4.7 among urban dwellers). However, TFR is 3.6 among women with secondary education, 2.8 among women with higher than secondary education, and 5.3 among women with no formal education. 6 Figure 2 n Total fertility rate by wealth quintile overall Adolescent fertility adversely affects not only young women s health, education and employment prospects but also that of their children. Births to women aged years old have the highest risk of infant and child mortality as well as a higher risk of morbidity and mortality for the young mother. 5, 8 In Afghanistan, adolescent fertility rate is high at 12 reported births per 1, women aged years. One fifth of women use modern contraception. Current use of contraception among married women is 22 percent. 6 More married women use modern contraceptive methods than traditional methods (2 percent and 2 percent, respectively). Injectables are the most commonly used method (7 percent), followed by the pill (5 percent). Use of long-term methods such as intrauterine device and implants are negligible. There are socioeconomic differences in the use of modern contraception among women: modern contraceptive use is 29 percent among women in the Continued from page 1 Economic progress and greater investment in human capital of women will not necessarily translate into better reproductive outcomes if women lack access to reproductive health services. It is thus important to ensure that health systems provide a basic package of reproductive health services, including family planning wealthiest quintile and 16 percent among those in the poorest quintile (Figure 3). 6 Similarly, just 19 percent of women with no education use modern contraception as compared to 32 percent of women with secondary education, and 17 percent for rural women versus 31 percent for urban women. 6 Abortion is illegal in Afghanistan and it is stigmatized. 6 Figure 3 n Use of contraceptives among married women by wealth quintile Overall (All methods) Modern Methods Poor pregnancy outcomes Traditional Methods 29.1 While the majority of pregnant women use antenatal care, institutional deliveries are less common. Sixty percent of pregnant women receive antenatal care from skilled medical personnel (doctor, nurse, or midwife) with 16 percent having the recommended four or more antenatal visits. 6 However, a smaller proportion, 34 percent deliver with the assistance of skilled medical personnel. While 68 percent of women in the wealthiest quintile delivered with skilled health personnel, only 12 percent of women in the poorest quintile obtained such assistance (Figure 4). Further, 61 percent of all pregnant women are anaemic (defined as haemoglobin < 11g/L) increasing their risk of preterm delivery, low birth weight babies, stillbirth and newborn death. 9 Figure 4 n Birth assisted by skilled health personnel (percentage) by wealth quintile % overall Among all women ages years who had given birth, 72 percent had no postnatal care within 6 weeks of delivery while.4 percent received postnatal check-up from a traditional birth attendant. 6

3 The majority of women interviewed report that accessibilityrelated factors were the main reasons for not seeking care for problems just before, during, or after delivery (Table 1). 6 Table 1 n Problems in accessing health care (women age 15 49) Reason % Accessibility Lack of money 64 Transportation problem 58 Too far 57 No one to accompany 13 Did not get permission 8 Service Related No female provider 16 Good service not available 12 Long waiting hours 6 Inconvenient service hours 5 Better service at home 5 Did not know where to go 4 Afraid of health facilities 1 Perception on Service Not necessary 27 Not customary 15 Was not life-threatening 5 Security Security reasons 13 Afraid of bad people 3 Other Other 3 Religious 2 Human resources for maternal health are limited with only.2 physicians per 1, population but nurses and midwives are slightly more common, at.5 per 1, population. 4 The high maternal mortality ratio at 14 maternal deaths per 1, live births indicates that access to and quality of emergency obstetric and neonatal care (EmONC) remains a challenge. 7 HIV prevalence is low in Afghanistan STIs/HIV/AIDS prevalence is low but unsafe practices increase risk for transmission. Little data exist regarding HIV/ AIDS in Afghanistan. Current estimates suggest that between 1, and 2, Afghans are infected with HIV, with transmission primarily stemming from intravenous drug use and transactional sex. 1 Many factors affect transmission of HIV in Afghanistan, including injection heroin use, displaced persons and refugees who may use sex as a source of income, low literacy and lack of HIV information and education, as well as a weak health system which does not have measures in place to prevent transfusion of HIV-infected blood. Development partners support for reproductive health in Afghanistan There are a number of development partners working closely with the government in the implementation of the National Health Sector Strategic Plan. 11 The management capacity of the Ministry of Health should be strengthened to effectively coordinate the activities of partners and civil society. Development partners support for reproductive health in Afghanistan WHO: UNFPA: UNICEF: USAID: DFID: SIDA: CIDA: AUSAID: GIZ: MSH: Marie Stopes International: IPPF: Technical Notes: Safe motherhood Reproductive health and rights Child protection; under-5 mortality Health systems strengthening; skilled birth attendance Child protection Women s rights; Girls education Healthcare workforce Safe Motherhood Gender mainstreaming Family Planning; Health Systems Strengthening FP training; Contraception distribution RH rights; educating & empowering youths re: STIs and HIV Improving Reproductive Health (RH) outcomes, as outlined in the RHAP, includes addressing high fertility, reducing unmet demand for contraception, improving pregnancy outcomes, and reducing STIs. The RHAP has identified 57 focus countries based on poor reproductive health outcomes, high maternal mortality, high fertility and weak health systems. Specifically, the RHAP identifies high priority countries as those where the MMR is higher than 22/1, live births and TFR is greater than 3.These countries are also a sub-group of the Countdown to 215 countries. Details of the RHAP are available at org/population. The Gender-related Development Index is a composite index developed by the UNDP that measures human development in the same dimensions as the HDI while adjusting for gender inequality. Its coverage is limited to 157 countries and areas for which the HDI rank was recalculated.

4 n Key Actions to Improve RH Outcomes Strengthen gender equality Support women and girls economic and social empowerment. Increase school enrollment of girls. Strengthen employment prospects for girls and women. Educate and raise awareness on the impact of early marriage and child-bearing. Educate and empower women and girls to make reproductive health choices. Build on advocacy and community participation, and involve men in supporting women s health and wellbeing. Reducing high fertility Provide quality family planning services that include counseling and advice, focusing on young and poor populations. Highlight the effectiveness of modern contraceptive methods and properly educate women on the health risks and benefits of such methods. Promote the use of ALL modern contraceptive methods, including long-term methods, through proper counseling which may entail training/re-training health care personnel. Secure reproductive health commodities and strengthen supply chain management to further increase contraceptive use as demand is generated. Reducing maternal mortality Strengthen the referral system by instituting emergency transport, training health personnel in appropriate referral procedures (referral protocols and recording of transfers) and establishing maternity waiting huts/homes at hospitals to accommodate women from remote communities who wish to stay close to the hospital prior to delivery. Generate demand for the service and address the perception that it not necessary to deliver at a health facility. This will require a combination of Behavior Change Communication (BCC) programs via mass media and community outreach as well as deploying midwives to assist women with home deliveries. During antenatal care, educate pregnant women about the importance of delivery with a skilled health personnel and getting postnatal check. Encourage and promote community participation in the care for pregnant women and their children. Address the inadequate human resources for health by training more midwives and deploying them to the poorest or hard-toreach districts. Promote institutional delivery through provider incentives and implement risk-pooling schemes. Provide vouchers to women in hard-to-reach areas for transport and/or to cover cost of delivery services. Reducing STIs/HIV/AIDS Integrate HIV/AIDS/STIs and family planning services in routine antenatal and postnatal care. Focus HIV/AIDS providing information, education and communication efforts on adolescents, youth, married women, and other high risk groups including IDUs, sex workers and their clients, and migrant workers. References: 1. United Nations Office of the High Commissioner for Human Rights. Human Rights Dimension of Poverty in Afghanistan. March Childinfo: Monitoring the Situation of Children and Women. Available at: < Accessed August 8, UNICEF Press Centre. Afghanistan s Maternal and Child Mortality Rates Soar. August 25. Available at media_27853.html. Accessed August 8, World Bank World Development Indicators. Washington DC. 5. World Bank, Engendering Development: Through Gender Equality in Rights, Resources, and Voice Afghanistan Mortality Survey (AMS), part of the worldwide Demographic and Health Surveys (DHS) project. Implemented by Indian Institute for Health Management Research (IIHMR) Trends in Maternal Mortality: : Estimates developed by WHO, UNICEF, UNFPA, and the World Bank 8. WHO 211. Making Pregnancy Safer: Adolescent Pregnancy. Geneva: WHO. Available at topics/adolescent_pregnancy/en/index.html. Accessed March 1, Worldwide prevalence of anaemia : WHO global database on anaemia / Edited by Bruno de Benoist, Erin McLean, Ines Egli and Mary Cogswell. Available at: Accessed October 19, World Bank. HIV/AIDS in Afghanistan. August 27. Available at < Resources/HIV-AIDS-brief-Aug7-AF.pdf>. Accessed August 8, Islamic Republic of Afghanistan Ministry of Public Health. 29. National Child and Adolescent Health Strategy Available at < Strategy_Afghanistan.pdf>. Accessed August 8, 211. Correspondence Details This profile was prepared by the World Bank (HDNHE, PRMGE, and SASHN) and Management Science for Health (MSH). For more information contact, Samuel Mills, Tel: , smills@ worldbank.org. This report is available on the following website: www. worldbank.org/population.

5 Afghanistan Reproductive Health Action Plan Indicators Indicator Year Level Indicator Year Level Total fertility rate (births per woman ages 15 49) Population, total (million) Adolescent fertility rate (births per 1, women ages 15 19) Population growth (annual %) Contraceptive prevalence (% of married women ages 15 49) Population ages 14 (% of total) Unmet need for contraceptives (%) Population ages (% of total) Median age at first birth (years) from DHS Population ages 65 and above (% of total) Median age at marriage (years) Age dependency ratio (% of working-age population) Mean ideal number of children for all women Urban population (% of total) 21 2 Antenatal care with health personnel (%) Mean size of households Births attended by skilled health personnel (%) GNI per capita, Atlas method (current US$) Proportion of pregnant women with hemoglobin <11 g/l GDP per capita (current US$) Maternal mortality ratio (maternal deaths/1, live births) GDP growth (annual %) Maternal mortality ratio (maternal deaths/1, live births) Population living below US$1.25 per day Maternal mortality ratio (maternal deaths/1, live births) 2 18 Labor force participation rate, female (% of female population ages 15 64) Maternal mortality ratio (maternal deaths/1, live births) Literacy rate, adult female (% of females ages 15 and above) Maternal mortality ratio (maternal deaths/1, live births) Total enrollment, primary (% net) Maternal mortality ratio (maternal deaths/1, live births) target Ratio of female to male primary enrollment (%) Infant mortality rate (per 1, live births) Ratio of female to male secondary enrollment (%) Newborns protected against tetanus (%) Gender Development Index (GDI) DPT3 immunization coverage (% by age 1) Health expenditure, total (% of GDP) Pregnant women living with HIV who received antiretroviral drugs (%) Health expenditure, public (% of GDP) Prevalence of HIV, total (% of population ages 15 49) Health expenditure per capita (current US$) Female adults with HIV (% of population ages 15+ with HIV) Physicians (per 1, population) Prevalence of HIV, female (% ages 15 24) Nurses and midwives (per 1, population) 29.5 Indicator Survey Year Total Poorest-Richest Difference Poorest/Richest Ratio Total fertility rate AMS Current use of contraception (Modern method) AMS Current use of contraception (Any method) AMS Unmet need for family planning (Total) Births attended by skilled health personnel (percent) AMS