Date Published: June 11, 2019
Publisher: Public Library of Science
Author(s): Sarwat Mumtaz, Jinwook Bahk, Young-Ho Khang, Wu Zeng.
Advancing maternal health is central to global health policy-making; therefore, considerable efforts have been made to improve maternal health. Still, in many developing countries, particularly in Sub-Saharan Africa and South Asia, including Afghanistan, the maternal mortality ratio (MMR) remains high. The objective of this study was to examine the determinants and current status of the utilization of maternal healthcare in Afghanistan.
This study used the most recent data from the Afghanistan Demographic and Health Survey 2015. The unit of analysis for this study was women who had a live birth in the five years preceding the survey. The outcome variables were four or more antenatal care (ANC) visits, delivery assistance by a skilled birth attendant (SBA), and delivery by cesarean section (CS). The explanatory variables were basic sociodemographic characteristics of the mothers. We examined the sociodemographic characteristics of women utilizing ANC, SBA, and CS using descriptive statistics and estimated usage of ANC, SBA and CS after adjusting for maternal age and parity groups via direct standardization. Multivariable logistic regression models were employed to investigate the determinants of maternal healthcare variables.
Overall, 17.8% of women attended four or more ANC visits, 53.6% utilized an SBA, and 3.4% of women gave birth through CS. Women’s education, wealth status, urbanity, autonomy, and availability of their own transport were found to be the major determinants of service utilization.
This study underscores low utilization of maternal healthcare services with wide disparities in Afghanistan and highlighted the need for an adequate health strategy and policy implementation to improve maternal healthcare uptake.
Advancing maternal health is central to global health policy-making; therefore, considerable efforts have been made to improve maternal health, resulting in a remarkable decline in the maternal mortality ratio (MMR) from 385 to 216 deaths per 100,000 live births between 1990 and 2015 worldwide . The global burden of maternal deaths is still high in many developing countries, particularly in Sub-Saharan Africa and South Asia . More than 250,000 women died during pregnancy in 2015; mostly from preventable causes ranging from sepsis and eclampsia to obstructed labor and severe bleeding. These deaths could have been avoided if those women had access to maternal healthcare services, such as antenatal care (ANC), skilled birth attendant (SBA), and emergency obstetric care . Access to high-quality maternal healthcare irrespective of economic position and social group is the right of every woman around the globe . Empirical evidence suggests that many developing countries, including Afghanistan, have a persistently high burden of maternal mortality with huge regional and wealth disparities in maternal healthcare utilization [2, 4, 5].
Table 1 shows the percent distribution of sociodemographic characteristics of women aged 15 to 49 years who had a live birth in the five years preceding the AfDHS 2015, and the use of maternal healthcare (ANC, SBA, and CS) for their most recent birth. Among 19,642 women, 54% were in their 20s and 83% had no formal education, while 21% of their husbands were educated at the secondary level. Only 31% of women had the autonomy to decide alone or jointly with their husbands about how to spend the husband’s earnings. Approximately 15% of mothers had one child, 33% had four to six children, and almost 19% had more than seven children. Three-quarters of women lived in rural areas and 19% resided in the northern region. Only 11% of women were currently working, and 14% had their own transport. Table 1 also presents the percent distribution of women aged 15 to 49 years who had a live birth in the five years preceding the AfDHS 2015, who utilized maternal healthcare (ANC, SBA, and CS) for their most recent birth, according to their sociodemographic characteristics. Of the total of 19,642 women, 17.8% had attended four or more ANC visits, 53.6% had received delivery assistance from an SBA, and 3.4% gave birth through CS for their most recent delivery. Women with an age group 40–49 years had less usage of four or more ANC visits and SBA at childbirth. No major differences according to age group were observed in the utilization of CS. The proportions of women utilizing ANC, SBA, and CS were somewhat higher (22.6%, 66.1%, and 5.1%, respectively) for the first birth than for subsequent births. The utilization of ANC, SBA, and CS increased with the educational level of both women and their husbands. Women with the highest level of education had relatively high rates of ANC (52.4%), SBA (97.5%), and CS (12.3%). Likewise, maternal healthcare utilization was more common in the richest group. Rural disadvantages in the use of ANC, SBA, and CS were also found. Approximately 32% of urban women reported four or more ANC visits, while only 13.6% of rural women did so. Similarly, the rate of SBA was 81.0% in urban areas and 45.3% in rural areas. A similar pattern was found in the utilization of CS: 8.2% of total deliveries in urban areas were conducted by CS, while only 1.9% of total deliveries were by CS in rural areas. Regional and ethnic disparities in maternal healthcare usage were also found. Higher rates of ANC, SBA, and CS (33.1%, 79.0% and 8.9%, respectively) were seen in the capital region, whereas the lowest rates of ANC (5.5%), SBA (34.9%), and CS (1.3%) were found in the southern, western, and southeastern regions, respectively.No remarkable differences were observed in the utilization of maternal healthcare in working and non-working women. Women with their own transport showed more utilization of ANC, SBA and CS (20%, 68.0% and 5%, respectively). Similarly, women with more autonomy regarding their husband’s earnings had a greater tendency to receive ANC (23%), SBA (59%) and CS (4.5%).
This study identified low levels of having four or more ANC visits, SBA, and CS, together with a suboptimal coverage of these maternal healthcare services Afghanistan. We found that overall, only 18% of women attended four or more ANC visits, 53.6% received care by an SBA, and 3.4% of recent births were delivered by CS. With this small proportion of women using maternal healthcare, overall maternal health is at risk in Afghanistan, which accentuates the need to address the circumstances influencing the current low level of utilization of maternal healthcare services .
This study highlighted the low utilization of maternal healthcare (ANC, SBA, and CS), with wide disparities among certain socioeconomic determinants of health. Women’s education, wealth status, urbanity, and autonomy were found to be the major determinants of service utilization. This underscores the need for an adequate health strategy and the implementation of policies to raise awareness among communities to improve maternal healthcare uptake through multipurpose approaches to address both societal and medical issues faced by the women of Afghanistan. Access to emergency obstetric services should be ensured in remote locations to prevent obstetric complications. In conclusion, basic and comprehensive maternal healthcare services should be received by every woman to improve maternal health.