1. Reducing the maternal mortality rate in Afghanistan Proposal to the Minister of Public Health

3. 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

4. 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

5. The problem….. Every 30 minutes one woman dies in Afghanistan from pregnancy related causes ….Is this acceptable? Fitzwilliam Group

6. 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

7. 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

8. CountryMaternal mortality ratio (per 100,000 live births) 2000 Proportion of births attended by skilled health personnel (%) 2000-02 Afghanistan160014 Iran Pakistan Tajikistan Turkmenistan Uzbekistan 76 500 100 31 55 90 23 71 97 96 Table 8.1:Maternal mortality: international comparisons Fitzwilliam Group

9. 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

10. 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

11. Therefore….. Meeting the challenge of reducing maternal mortality will require political will, education, communication and changes in cultural practices. Fitzwilliam Group

12. 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

13. 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

14. 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

15. 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

16. 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