Afghanistan has made progress toward improving maternal and child well-being in recent years, despite considerable political upheaval and poverty, according to a comprehensive, systematic case study mainly based on national survey data.1 Between 2003 and 2015, the country’s mortality rate among children younger than five fell by 29%. Coverage of antenatal care, skilled birth attendance and health facility birth among pregnant women aged 15–49 tripled between 2003 and 2012, and coverage of basic vaccinations of young children doubled over the period. In addition, between 2005 and 2013, the number of deployed health care professionals increased substantially. Maternal literacy, deployment of community midwives and proximity to a facility were all positively associated with gains in skilled birth attendance and facility birth.

For the case study, data were drawn largely from 11 nationally representative surveys conducted in Afghanistan between 2003 and 2013—a period following the 2001 end of Taliban control, when the country experienced an influx of international development assistance and concerted efforts to rebuild its nearly destroyed health infrastructure. Investigators estimated national and provincial time trends in key reproductive, maternal and child health indicators, and used linear regression analysis to identify factors associated with changes in the receipt of key interventions. Additional data were taken from third-party surveys to assess health system performance and from the Afghan Ministry of Public Health to evaluate human resources. Main analyses focused on maternal outcomes among women of reproductive age (15–49 years) and outcomes among children younger than five.

The investigators found conflicting results on maternal mortality trends. Data from the United Nations showed a 64% decrease in the maternal mortality ratio between 2000 and 2015 (from 1,100 to 396 deaths per 100,000 live births), which would have been enough to meet the national target set for 2015. Data from the Institute for Health Metrics and Evaluation, however, showed a 24% increase in the maternal mortality ratio between 2003 and 2013 (from 716 to 885).

Between 2003 and 2015, the mortality rates of children younger than five years and of infants younger than one month fell by 29% (from 128 to 91 deaths per 1,000 live births) and 27% (from 50 to 36 per 1,000), respectively. The declines missed national targets set for these metrics for 2015, and trends suggest that the pace will not be sufficient to achieve 2020 targets.

The proportion of women using any contraceptive method more than doubled between 2003 and 2012, from 10% to 22%. Over the same period, the proportion of women who received at least two antenatal care visits increased from 16% to 53%, the proportion who had a skilled attendant at delivery increased from 14% to 46%, and the proportion who gave birth in a health facility increased from 13% to 39%. In addition, among children aged 12–23 months, coverage of the basic vaccines from the Expanded Programme of Immunisation (i.e., tuberculosis; measles; diphtheria, tetanus and pertussis; and polio) doubled between 2000 and 2014, from about 40% to 80%, depending on the vaccine.

The data showed persistent, often marked disparities over time in intervention coverage according to socioeconomic status: For example, the proportion of women delivering with a skilled birth attendant ranged from roughly 15% for those in the poorest wealth quintile to about 80% for those in the richest. In addition, both intervention coverage and changes in coverage over time varied across provinces; a third of provinces saw the proportion of women delivering with a skilled birth attendant increase by more than 30% between 2003 and 2010, while nearly half (many in remote regions) saw little to no gain.

Between 2005 and 2013, the population of health care professionals working in facilities and community settings grew dramatically. Sharp increases were seen nationally in the numbers of nurses (from 738 to 5,766), midwives (from 211 to 3,333), general physicians (from 403 to 5,990) and community health workers (from 2,682 to 28,837).

In multivariate analyses, for every 10 additional midwives deployed per 100,000 population in a province during 2003–2010, the proportion of women who gave birth with a skilled birth attendant increased by 12%; for every 10 additional nurses active in a province, the outcome rose by 31%. Increases in skilled birth attendance were also seen per 10-point increase in the quality of care (7%) and per 10% rise in the proportion of mothers with some formal education (6%); on the other hand, a 10-kilometer increase in distance to a health care facility was associated with a 17% decrease in the outcome. Collectively, these factors explained 52% of the variation in change in skilled birth attendance.

Results were similar with respect to the factors associated with the change in the proportion of pregnant women giving birth in a facility between 2003 and 2010. Increases were seen with each 10 additional midwives deployed per 100,000 population (7%) and with each 10% rise in the proportion of mothers with some formal education (1%); on the other hand, facility birth decreased with each 10-minute increase in travel time to a facility (3%) and with increased deaths among armed forces personnel, a proxy for conflict (2%). Collectively, these factors explained 48% of the variation in change in facility birth.

According to the authors, taken together, the study’s findings show progress toward improving maternal and child health in Afghanistan, and they can be used to help set agendas, develop policies and inform programming. In particular, the authors note that the data suggest that inequitable access to health care remains problematic. They acknowledge the study’s limitations, which include the limited amount of reliable data available and the possibility that the multivariate analyses at the provincial level may not apply at the household level. “To maintain and further accelerate health and development gains,” the authors conclude, “future strategies in Afghanistan will need to focus on investments in improving social determinants of health and targeted cost-effective interventions to address major causes of maternal and newborn mortality.”—S. London