Achieving maternal and child health gains in Afghanistan: a Countdown to 2015 country case study  Nadia Akseer, MSc, Ahmad S Salehi, MSc, S M Moazzem Hossain, MPH, M Taufiq Mashal, PhD, M Hafiz Rasooly, MSc, Zaid Bhatti, MSc, Arjumand Rizvi, MSc, Prof Zulfiqar A Bhutta, PhD  The Lancet Global Health  Volume 4, Issue 6, Pages e395-e413 (June 2016) DOI: 10.1016/S2214-109X(16)30002-X Copyright © 2016 Akseer et al. Open Access article distributed under the terms of CC BY Terms and Conditions

Figure 1 Mortality trends in Afghanistan from 2000 to 2015 (A) Maternal mortality trends in Afghanistan from 2000 to 2015.36,37 Maternal mortality ratios in 1990 were 1340 per 100 000 livebirths (according to the UN Maternal Mortality Estimation Inter-agency Group) and 501 per 100 000 livebirths (according to the Institute for Health Metrics and Evaluation). (B) Mortality trends of neonates and children younger than 5 years in Afghanistan from 2000 to 2015.35,38 UN MMEIG=UN Maternal Mortality Estimation Inter-agency Group. IHME=Institute for Health Metrics and Evaluation. IGME=UN Inter-agency Group for Child Mortality Estimation. The Lancet Global Health 2016 4, e395-e413DOI: (10.1016/S2214-109X(16)30002-X) Copyright © 2016 Akseer et al. Open Access article distributed under the terms of CC BY Terms and Conditions

Figure 2 Coverage of essential maternal and child vaccines in Afghanistan from 2000 to 20141,45–47,49,52 National survey versus WHO and UNICEF modelled estimates. Immunisation data from Multiple Indicator Cluster Surveys 2003–04 were excluded due to the known data quality issues. Childhood vaccine coverage (BCG, measles, DTP3, and polio3) was estimated for children 12–23 months in Afghanistan. TT2+ reflects the proportion of mothers receiving two or more doses of tetanus toxoid. DTP3=Diphtheria-tetanus-pertussis. Polio3=three doses of polio. TT2+=two or more doses of tetanus toxoid. *WHO and UNICEF modelled estimates were not available for TT2+ thus survey data are contrasted with official national administrative estimates. Hossain SMM, unpublished. The Lancet Global Health 2016 4, e395-e413DOI: (10.1016/S2214-109X(16)30002-X) Copyright © 2016 Akseer et al. Open Access article distributed under the terms of CC BY Terms and Conditions

Figure 3 Essential interventions coverage across wealth quintiles and provinces (A) Disparities in coverage interventions across the continuum of care by wealth quintiles.45 (B) Median national provincial coverage of interventions across the continuum of care. ANC 1+=women received at least one visit from skilled provider during pregnancy. ANC 4+=women received four or more visits during pregnancy. Pneumonia care=suspected pneumonia taken to an appropriate health provider. CPR=contraceptive prevalence rate. DTP3=three doses of diphtheria-tetanus-pertussis vaccine. Early breastfeeding=introduction of breastfeeding within 1 h of birth. Minimum meal frequency=proportion of children 6–23·9 months of age who receive solid, semi-solid, or soft foods or milk feeds the minimum number of times or more (two times for breastfed infants 6–8 months, three times for breastfed children 9–23 months, four times for non-breastfed children 6–23 months). Penta3=three doses of pentavalent vaccine. OPV3=three doses of oral polio vaccine. ORT=diarrhoea treated with oral rehydration. SBA=delivery by skilled birth attendance. Vitamin A=one dose of vitamin A during last 6 months. *Children aged 12–23 months. †Children aged 0–59 months. Hossain SMM, unpublished.45,51 The Lancet Global Health 2016 4, e395-e413DOI: (10.1016/S2214-109X(16)30002-X) Copyright © 2016 Akseer et al. Open Access article distributed under the terms of CC BY Terms and Conditions

Figure 4 Percentage change in skilled birth attendance between 2003 and 201044,45 The Lancet Global Health 2016 4, e395-e413DOI: (10.1016/S2214-109X(16)30002-X) Copyright © 2016 Akseer et al. Open Access article distributed under the terms of CC BY Terms and Conditions

Figure 5 Health policies and programmes in Afghanistan from 2000 to 2014 The Lancet Global Health 2016 4, e395-e413DOI: (10.1016/S2214-109X(16)30002-X) Copyright © 2016 Akseer et al. Open Access article distributed under the terms of CC BY Terms and Conditions

Figure 6 Trends in facility and community based human resources deployed from 2005 to 2013 Data for facility health workers reflect deployment for the Basic Package of Health Services only. Mashal T and Rasooly MH, unpublished. The Lancet Global Health 2016 4, e395-e413DOI: (10.1016/S2214-109X(16)30002-X) Copyright © 2016 Akseer et al. Open Access article distributed under the terms of CC BY Terms and Conditions

Figure 7 Maternal, neonatal, and post-neonatal deaths in children younger than 5 years averted by intervention packages 90%, 75%, and 50% coverage represent the number of deaths saved by increasing the present coverage of the intervention package to these respective amounts. A=optimisation of maternal nutrition and care preconception and during pregnancy. B=Expanded Antenatal Care Package. C=childbirth including maternal emergency obstetric care and immediate newborn care. D=postnatal care (including community newborn and child care). E=water, sanitation, and hygiene interventions. F=improving infant and young child feeding package. G=Expanded Immunization Package. H=case management. I=management of severe acute malnutrition. The Lancet Global Health 2016 4, e395-e413DOI: (10.1016/S2214-109X(16)30002-X) Copyright © 2016 Akseer et al. Open Access article distributed under the terms of CC BY Terms and Conditions