DEMOGRAPHIC

AND

HEALTH

SURVEYS

DHS WORKING PAPERS

2013 No. 97

Principal Authors

Mohammad Iqbal Aman

Bashir Noormal

Co-authors 

Khwaja Mir Islam Saeed

Mohammad Hafez Rasooly 

July 2013

This document was produced for review by the United States Agency for

International Development.

Maternal Health Care 

Trends in Afghanistan

Maternal Health Care Trends in Afghanistan 

Principal Authors 

Mohammad Iqbal Aman 

Bashir Noormal 

Co-authors 

Khwaja Mir Islam Saeed 

Mohammad Hafez Rasooly 

ICF International 

Calverton, Maryland, USA 

July 2013 

Corresponding author: Mohammad Iqbal Aman, DBA, MD, MPH, Afghan National Public Health Institute 

(ANPHI), Ministry of Public Health (MoPH). Tel: +93 700 615 156; Email: aman_iqbal@hotmail.com 
ACKNOWLEDGEMENTS 

We gratefully acknowledge USAID and ICF International for funding this research and 

for their technical support. The authors thank Bryant Robey for editing and Yuan Cheng for 

document production. 

The DHS Working Papers series is an unreviewed prepublication series of papers reporting on research in 

progress that is based on Demographic and Health Surveys (DHS) data. This research is carried out with 

support provided by the United States Agency for International Development (USAID) through the 

MEASURE DHS project (#GPO-C-00-08-00008-00). The views expressed are those of the authors and 

do not necessarily reflect the views of USAID or the United States Government. 

MEASURE DHS assists countries worldwide in the collection and use of data to monitor and evaluate 

population, health, and nutrition programs. Additional information about the MEASURE DHS project can 

be obtained by contacting MEASURE DHS, ICF International, 11785 Beltsville Drive, Suite 300, 

Calverton, MD 20705 (telephone: 301-572-0200; fax: 301-572-0999; e-mail: reports@measuredhs.com; 

internet: www.measuredhs.com). 
ABSTRACT 

Introduction: Afghanistan has long been recognized as having one of the highest levels 

of maternal mortality in the world. In Afghanistan an estimated 40% to 50% of women’s deaths 

during the childbearing years are related to complications during pregnancy and childbirth. The 

present study uses nationally representative data to describe and interpret trends in coverage of 

three key maternal health care services across provinces in Afghanistan, in order to contribute to 

evidence-based maternal health care planning and effective strategies to improve maternal health 

care in the provinces of the country. 

Method: This paper presents secondary analysis of data from the 2010 Afghanistan 

Mortality Survey (AMS). In order to assess maternal health care service utilization, this study 

examined women’s use of three essential maternal services: antenatal care (ANC), delivery care 

by a skilled birth attendant (SBA), and postnatal care (PNC). Two methods were used to 

compare coverage across provinces: first, provinces were compared in their overall coverage of 

maternal health services during the five years preceding the survey; and second, maternal health 

care utilization was disaggregated into one-year periods in order to examine trends in health care 

utilization by province during this five-year period. 

Results: Nationally, 60% of women reported that they received antenatal care from a 

skilled provider for their last live birth, 34% reported that their last live birth was delivered by a 

skilled provider, and 23% reported that they received postnatal care within two days following 

delivery of their last live birth. Eighteen percent of women received all three maternal services 

for their last live birth. Nationally, use of all three services increased by roughly 10% over the 

five years preceding the survey, but the extent of progress varied considerably across province. 

Conclusion: The study shows overall progress toward improving coverage of all three 

maternal health indicators (ANC, deliveries attended by SBAs, and PNC). This progress could be 

explained by substantial investments put in place during this period in reproductive health care 

and in rebuilding the health system. However, there is extensive variation in the extent of 

progress across provinces. Provinces with better maternal health care coverage and a higher rate 

of progress in coverage can be encouraged to share lessons learned from their experience with 

provinces with lower coverage and slower progress. 

1 

INTRODUCTION AND BACKGROUND 

Pregnancy and birth-related complications are leading causes of death among women of 

reproductive age in developing countries. In 2008 alone, an estimated 358,000 women 

worldwide died from complications related to pregnancy or childbirth (WHO et al. 2010). The 

vast majority of maternal deaths occur in developing countries, where hemorrhage, obstructed 

labor, eclampsia, abortion, sepsis, and infection are the main causes of pregnancy-related 

complications (WHO et al. 2010). 

When adequate health facilities, proper treatment, and emergency care are available, 

these complications should not lead to death. However, too often these essential maternal health 

care resources are not available or accessible to women in need. The fifth Millennium 

Development Goal (MDG)—to reduce maternal mortality by three-quarters between 1990 and 

2015—is one of the prime objectives of countries struggling with quality of health care for 

women (Eijk et al. 2006). To achieve this goal it is necessary to understand where gaps in service 

provision lie, to learn from the experience of areas that have succeeded in improving coverage of 

maternal health care, and to apply these lessons strategically in areas that have made less 

progress. 

Afghanistan has long been recognized as having one of the highest levels of maternal 

mortality in the world (WHO et al. 2010). In Afghanistan an estimated 40% to 50% of women’s 

deaths during the childbearing years are related to complications during pregnancy and childbirth 

(APHI/MOPH et al. 2011, MoPH 2006). According to the recent 2010 Afghanistan Mortality 

Survey (AMS), women’s risk of dying from complications during pregnancy or childbirth is very 

high, estimated at 327 deaths per 100,000 live births for the seven-year period preceding the 

survey (APHI/MOPH et al. 2011). This level of pregnancy-related mortality is higher than 

comparable estimates for surrounding countries, including Bangladesh, where the pregnancyrelated mortality ratio was estimated at 194 deaths per 100,000 live births, based on the 2010 

Bangladesh Demographic and Health Survey (DHS) (NIPORT et al. 2013), and Pakistan, where 

the ratio was estimated at 297 deaths per 100,000 live births, based on the 2006/7 Pakistan DHS 

(NIPS and MI 2008). 

Women in Afghanistan have only limited access to health care, due to several factors 

(UNICEF 2006, NRVA 2007). These factors include restricted mobility, few female health care 
2 

providers, few health care facilities that treat women, poor household incomes, difficulty 

accessing health care facilities, and little education (Lynn et al. 2002, Abreu 2011). Furthermore, 

maternal health outcomes and access to maternal health care vary throughout the country. The 

majority of provinces in Afghanistan are mountainous, with underdeveloped economies, poor 

health conditions, and inadequate maternal health care services (ANDS and JCMBS 2008). 

In order to address these geographic disparities, a strategic community-oriented package 

of health services, referred to as the Basic Package of Health Services (BPHS), was introduced in 

2003, with a focus on areas of major health need in vulnerable population groups, including 

mothers and children (Acerra et al. 2009). Equitable delivery of health services to vulnerable 

groups, particularly women of reproductive age, has been a longstanding priority for 

policymakers and public health managers in Afghanistan. 

Women’s risk of maternal death appears to have fallen substantially in Afghanistan in 

recent years. In 2003, for example, Afghanistan’s maternal mortality ratio was estimated at 1,600 

deaths per 100,000 live births, according to the Reproductive Age Mortality Survey (RAMOS) 

(Bartlett et al. 2005), nearly five times higher than the level estimated in 2010 (APHI/MoPH et 

al. 2011). Estimates of women’s lifetime risk of maternal death also have shown improvement in 

recent decades. Based on 1999–2002 data collected from four sites, Bartlett et al. (2005) 

estimated the lifetime risk of maternal death at between one in six and one in nine, whereas 

today, according to the 2010 AMS, approximately one in every 50 Afghan women dies of 

pregnancy-related causes. 

These improvements appear to be consistent with the level of skilled assistance during 

delivery, skilled birth attendance, and delivery in health facilities, all of which have increased 

rapidly in Afghanistan in recent years. Despite years of continuous conflict, Afghanistan has 

made significant progress in rebuilding its health system. The National Reproductive Health 

Strategy 2006–2009 has contributed to improving the health of the people of Afghanistan, 

especially women and children, through the implementation of the basic package of health 

services (BPHS) and the essential package of hospital services (EPHS) as the standard, agreedupon minimum package of health care services to be provided at each level of the health system. 

Between 2003 and 2012, the number of graduated midwives in Afghanistan increased 

from 467 to 3,001, according to the Afghan Midwifery Education and Accreditation Board report 
3 

(MoPH 2008). In addition, there has been a gradual increase in the number of births attended by 

skilled birth attendants (SBAs). In 2006 the Afghanistan household survey showed that 19% of 

births were attended by SBAs, while the National Risk and Vulnerability Assessment 2007/2008 

showed that 24% of women delivered with a skilled birth attendant (NRVA 2010). More 

recently, the Ministry of Public Health (MoPH) Partnership Contracts for Health 2010 

Household Survey showed that about one-third (34%) of deliveries were attended by an SBA 

(Huber et al. 2010). 

As stated in the Afghanistan National Development Strategy (ANDS and JCMBS 2008), 

understanding the demographic features of the country, with a focus on provincial needs, can 

contribute to responsive public health interventions at the national and provincial levels. 

Regional studies in other countries, including China, have reported substantial geographic 

variation in the use of health care services by women (Liu et al. 2011). While studies in 

Afghanistan have found that maternal health outcomes vary according to urban versus rural 

residence (MoPH 2008, MoPH 2010), no nationally representative studies appear to have 

examined province-level variation in maternal health care utilization. Therefore, the present 

study uses nationally representative data to describe and interpret trends in coverage of three key 

maternal health care services across provinces in Afghanistan, in order to contribute to evidencebased maternal health care planning and effective strategies to improve maternal health care in 

the provinces of the country. 
4 

METHODS 

This paper presents secondary analysis of data from the 2010 Afghanistan Mortality 

Survey (AMS). The AMS, completed in 2010, provides a unique opportunity to assess progress 

toward achieving improved maternal health and maternal health care, and to examine coverage at 

the provincial level as well as nationally. The AMS is a nationally representative household 

survey that collected information on mortality levels and causes, as well as information on 

fertility, family planning behavior, and utilization of maternal and child health services 

(APHI/MoPH et al. 2011). Within selected households, all women of age 12-49 who were either 

usual residents of the household or who slept there the night before the survey were eligible to be 

interviewed (APHI/MoPH et al. 2011). The sample for the AMS was selected using a two-stage 

stratified selection process, based on the 2011 Afghanistan Population and Housing Census 

(PHC) sampling frame obtained from the Central Statistics Organization (CSO) (APHI/MoPH et 

al. 2011). The sampling design and survey implementation procedures for the AMS are 

described in detail in the survey final report (APHI/MoPH et al. 2011). 

The survey was designed to generate estimates of indicators for the entire country, as 

well as for urban and rural settings, and for three geographic domains—the North Zone, Central 

Zone, and South Zone. The map displays the provinces of Afghanistan and outlines the three 

geographic domains used in the AMS. It is important to note that, due to serious known security 

concerns, the rural areas of three provinces, Kandahar, Helmand, and Zabul, which account for 

slightly less than 9% of the population, were excluded from the AMS sample. In addition to 

these areas, a small percentage of selected primary sampling units (34 of 751 selected PSUs) 

were not able to be surveyed, largely due to security problems in the south of the country. The 

survey ultimately covered about 87% of the total population of Afghanistan, and 66% of the 

population in the southern provinces (APHI/MoPH et al. 2011). The AMS sample included 

47,848 women age 12-49. For this study, the sample was restricted to the 16,988 women age 12-

49 years who had a live birth in the five years preceding the survey. This subsample was used to 

generate national estimates of maternal health care coverage. 
5 

In order to assess maternal health care service utilization, this study examined women’s 

use of three essential maternal services: antenatal care (ANC), delivery care by a skilled birth 

attendant (SBA), and postnatal care (PNC). To examine receipt of ANC, this study examined use 

of at least one antenatal visit with a doctor, nurse, or midwife, based on women’s responses to 

two questions regarding their last live birth: “Did you see anyone for antenatal care during this 

pregnancy?” and “Who did you see?” To examine delivery by an SBA, information on the 

delivery of women’s last live birth was used to identify women who reported that this birth was 

attended by either a doctor, nurse, or midwife, based on women’s response to the question: “Who 

assisted with the delivery of [name].” To examine PNC, women who said that someone checked 

on their health within two days of the delivery of their last live birth were identified, based on 

their response to the following two questions: “After [name] was born, did anyone check on your 

health?” and “How long after you delivered [name] did the first check on your health take 
6 

place?” (APHI/MoPH et al. 2011) Finally, the study examined receipt of all three key services—

the full continuum of maternal health care—as a fourth indicator. 

It should be noted that while delivery in a health facility is another commonly used 

maternal health indicator, this indicator was not included in the study’s assessment of maternal 

health care coverage, because home delivery is widely accepted in Afghanistan and current 

programs focus on use of SBAs rather than health facilities for deliveries. 

The approach used to compare coverage across provinces consisted of two methods: first, 

provinces were compared in their overall coverage of maternal health services during the five 

years preceding the survey; and second, maternal health care utilization was disaggregated into 

one-year periods in order to examine trends in health care utilization by province during this 

five-year period. To facilitate this comparison, provinces were ranked in terms of both methods 

of comparison—overall maternal care coverage and progress in achieving coverage. Provinces 

were first ranked according to performance on the indicators, and then the ranked provinces were 

put into three groups of equal size (two groups of 10 and one group of 11 provinces). The goal of 

this exercise was not to grade individual provinces’ performance but to use the rankings as an 

analytic tool to help compare provinces, to identify commonalities across provinces with similar 

performance, and to learn from areas with improved coverage in recent years as a guide for 

allocating resources and improving maternal health care programs. 

It was possible to examine 31 of Afghanistan’s 34 provinces (all except Kandahar, 

Helmand, and Zabul, where due to security problems only urban areas were sampled). However, 

in the examination of progress during the five-year period studied, estimates for an additional 

eight provinces were suppressed, due to insufficient sample size at the provincial level. If a 

province had fewer than 25 women age 12-49 with a birth in any one of the previous five years, 

or fewer than 40 cases in the either the first or fifth year (since these two years were used to 

assess trends), it was not possible to generate reliable estimates of trends in maternal health care 

coverage. The information for these provinces was included in national coverage estimates for 

progress, but their provincial estimates were suppressed. Despite these exclusions, the 23 

provinces are sufficient to provide a reasonable geographical representation of the country in 

studying use of maternal health care services. All tables reflect weighted percentages and 

population sizes. The analysis was conducted using SPSS, version 19. 
7 

RESULTS 

First, we present overall coverage of antenatal care (ANC), delivery assistance by a 

skilled birth attendant (SBA), use of postnatal care (PNC), and receipt of all three essential 

services for the most recent birth among women who gave birth during the five years preceding 

the survey, by province in Afghanistan. Second, we examine improvement in coverage of each 

indicator during this five-year period. 

Overall Coverage of Maternal Health Care 

Table 1 presents coverage estimates for all three key maternal health services (ANC, 

delivery by an SBA, and PNC), as well as the proportion of women who received the full 

continuum of care for their last live birth in the five years preceding the survey. Nationally, 60% 

of women reported that they received antenatal care from a skilled provider for their last live 

birth, 34% reported that their last live birth was delivered by a skilled provider, and 23% 

reported that they received postnatal care within two days following delivery of their last live 

birth. Eighteen percent of women received all three maternal services for their last live birth. 

Coverage of antenatal care is the highest of the four indicators, ranging from 13% in Nuristan to 

86% in Kabul. Coverage of skilled birth delivery ranges from as low as 2% in Daykundi to 75% 

in Kabul, and coverage of postnatal care ranges from 2% in Nuristan to 55% in Laghman. 

Antenatal care is an essential gateway to accessing further maternal care services. In all 

provinces except Logar and Khost, coverage of ANC is higher than coverage of delivery assisted 

by an SBA, which in turn is nearly uniformly higher than PNC coverage, with the exception of 

Laghman, Urozgan, and Daykundi provinces. The drop-off between the proportion of women 

receiving antenatal care and the proportion receiving postnatal care is notable. Nationally, among 

women who had at least one antenatal care visit and had a skilled provider for their last birth, no 

more than 30% proceeded to have postnatal care within two days of delivery. 
Table 1. Percentage of women age 15-49 who had a live birth in the five years preceding the survey and who received three types of 

maternal care services for their most recent birth, according to province, Afghanistan 2010* 

Region Province 

Percentage 

receiving 

antenatal care 

from a skilled 

provider 

Rank 

group 

Percentage 

delivered by 

a skilled 

provider 

Rank 

group 

Percentage 

receiving 

PNC within 2 

days following 

the birth 

Rank 

group 

Percentage 

receiving 

ANC, skilled 

attendance at 

birth and PNC Group 

Number 

of 

women 

Capital Kabul 86.4 1 74.9 1 43.2 1 38.1 1 1,757 

Capital Kapisa 62.0 2 24.5 2 15.7 3 12.3 3 316 Capital Logar 79.8 1 85.1 1 24.1 2 23.0 1 227 Capital Panjsher** 72.7 1 16.9 3 15.9 3 12.6 2 88 Capital Parwan 78.0 1 34.7 2 25.8 2 21.6 1 432 Capital Wardak 56.6 3 18.0 3 16.8 3 15.9 2 320 Central Highland Bamyan** 72.9 1 29.2 2 26.1 2 18.5 2 193 Central Highland Daykundi 37.9 3 2.2 3 5.6 3 0.0 3 364 Eastern Kunar 35.9 3 26.9 2 18.5 2 14.9 2 808 

Eastern Laghman 77.2 1 46.4 1 55.1 1 41.2 1 415 

Eastern Nangarhar 58.4 2 44.1 1 27.1 1 20.8 1 1,616 Eastern Nuristan 12.6 3 2.8 3 2.4 3 2.4 3 206 

North Eastern Badakhshan 47.0 3 9.5 3 9.3 3 5.3 3 752 North Eastern Baghlan 57.5 2 31.4 2 9.1 3 8.0 3 565 

North Eastern Kunduz 72.5 1 33.1 2 28.8 1 27.0 1 595 

North Eastern Takhar 57.2 2 23.5 3 17.6 2 12.4 3 700 Northern Balkh 79.1 1 43.0 1 21.3 2 17.5 2 843 

Northern Faryab 64.2 2 16.9 3 15.8 3 12.2 3 790 Northern Jawzjan 74.9 1 35.6 1 24.0 2 17.1 2 425 

Northern Samangan 65.8 2 30.4 2 19.5 2 11.4 3 286 

Northern Sari Pul 70.6 2 24.7 2 19.9 2 16.7 2 388 

South Eastern Khost 43.6 3 44.6 1 27.0 1 17.8 2 538 South Eastern Paktika 15.5 3 7.8 3 6.0 3 1.6 3 418 

South Eastern Paktya 73.6 1 21.2 3 20.1 2 15.8 2 589 

Southern Ghazni 48.0 3 30.9 2 29.5 1 23.2 1 497 

Southern Urozgan 62.2 2 48.1 1 49.6 1 38.5 1 230 Southern Nimroz ** 70.8 2 57.3 1 29.4 1 28.7 1 84 

 (Continued...) 

8 
Table 1. – Continued

Region Province 

Percentage 

receiving 

antenatal care 

from a skilled 

provider 

Rank 

group 

Percentage 

delivered by 

a skilled 

provider 

Rank 

group 

Percentage 

receiving 

PNC within 2 

days following 

the birth 

Rank 

group 

Percentage 

receiving 

ANC, skilled 

attendance at 

birth and PNC Group 

Number 

of 

women 

Western Badghis 16.3 3 4.8 3 2.9 3 1.4 3 387 Western Farah 46.6 3 27.7 2 26.4 1 19.7 2 420 

Western Ghor 14.9 3 5.4 3 5.5 3 2.1 3 400 

Western Herat 59.1 2 35.1 1 27.2 1 21.6 1 1,063 Total 59.6 34.3 23.4 18.4 16,998 *Three provinces (Zabul, Kandahar and Helmand) are not shown because the AMS sample included only urban areas. **Reader should exercise caution in interpreting the results for three provinces, as figures are based on a small number of unweighted cases: 58 women in 

Panjsher, 176 women in Bamyan, and 111 women in Nimroz. 

9 
10 

Another way to examine the continuum of care is by tracing provinces’ ranking across 

the three indicators of service coverage. Only nine provinces are consistent in their ranking for 

each indicator. Kabul and Laghman rank in the highest group for all indicators; Badakhshan, 

Badghis, Daykundi, Ghor, Nuristan, and Paktik rank in the lowest group for all indicators; and 

Sari Pul ranks in the middle group for all indicators. There is substantial variation in the ranking 

of other provinces across the indicators. Of interest, Ghazni, Farah, Kunar, and Khost rank in the 

lowest third in ANC coverage, but rank either in the first or second group for delivery care and 

postnatal care, and for receipt of all three services. In these provinces, women who access ANC 

are more likely to access the full continuum of maternal health care compared with women in 

other provinces, such as Balkh or Panjsher, that rank high in ANC coverage but rank lower in 

PNC coverage. 

Improvement in Coverage of Maternal Health Care, 2006-2011 

Another approach for examining provincial variation in maternal health care is to 

examine the trend or rate of progress in women’s use of these services over the five years 

preceding the survey. As Figure 1 shows, use of all three services increased steadily during this 

period. 

 
11 

Figure 1. Trends in maternal health services in the five years preceding the survey, Afghanistan 

AMS 2010 

Table 2 presents the trend in coverage of antenatal care by a skilled provider over the five 

years preceding the survey, by province. As a summary measure for improvement, the table also 

presents the percentage-point increase in ANC coverage between the earliest and most recent 

coverage estimates. Overall, there has been notable improvement in the percentage of women 

who received antenatal care from a skilled provider for their last live birth in the five years 

preceding the survey, from 54% of women whose last birth was 36-59 months before the survey 

to 65% of women whose last birth was 0-11 months before the survey. Provinces differed 

substantially in progress with ANC coverage, however, from an increase in coverage of 24 

percentage points in Kunduz to a decrease of 13 percentage points in Paktika. Table 2 also shows 

that several provinces that ranked lower in ANC coverage ranked higher in improvement in 

coverage over the survey period. 

 

0

10

20

30

40

50

60

70

80

90

100

36-59 months 24-35 months 12-23 months 0-11 months

Percentage of births

Timing of most recent birth in months before the survey

ANC

SBA at birth

PNC

Combined

maternal care

indicator
12 

Table 2. Trend in antenatal care coverage by province, Afghanistan 2005-2010 

Percentage of women age 12-49 who had a live birth in the five years preceding the survey who received antenatal 

care (ANC) from a skilled provider during pregnancy for the most recent birth by months of the birth before the 

survey, according to province, Afghanistan 2010*

Region Province 

Percentage of women who received 

antenatal care from a skilled provider 

for their last live birth, by the timing 

of the last live birth 

Rank 

group 

based on 

5-year 

coverage** 

Percentage 

point 

increase 

Rank group 

based on 

percentage 

point 

increase 

36-59 

months 

before 

the 

survey 

24-35 

months 

before 

the 

survey 

12-23 

months 

before 

the 

survey 

0-11 

months 

before 

the 

survey 

 

Capital Kabul 83.2 84.3 86.8 89.0 1 5.8 2 

Capital Parwan 76.8 68.9 82.2 80.3 1 3.5 3 

Central Highland Daykundi (41.1) (20.1) (31.6) (51.3) 3 10.2 2 

Eastern Kunar 28.8 35.9 36.8 40.9 3 12.1 1 

Eastern Laghman 78.1 68.3 75.8 83.4 1 5.3 2 

Eastern Nangarhar 49.4 58.7 56.5 67.0 2 17.6 1 

Eastern Badakhshan 40.6 44.6 50.4 51.1 3 10.5 2 

North Eastern Baghlan 53.1 (60.6) 50.1 64.3 2 11.2 2 

North Eastern Kunduz 57.8 71.4 81.9 81.4 1 23.6 1 

North Eastern Takhar 53.7 60.7 53.2 60.0 2 6.3 2 

Northern Balkh 71.1 77.1 80.6 84.2 1 13.1 1 

Northern Faryab 54.9 61.4 64.6 74.1 2 19.2 1 

Northern Jawzjan 64.6 74.4 81.9 78.2 1 13.6 1 

Northern Samangan 54.8 65.1 72.3 69.0 2 14.2 1 

Northern Sari Pul 54.5 72.6 73.2 76.2 2 21.7 1 

South Eastern Khost 41.6 45.0 47.8 36.5 3 -5.1 3 

South Eastern Paktika (19.7) 22.7 12.0 (6.3) 3 -13.4 3 

South Eastern Paktya 78.2 77.6 73.9 66.9 1 -11.3 3 

Southern Ghazni 54.6 49.1 48.3 43.6 3 -11.0 3 

Western Badghis 2.9 22.5 23.6 14.8 3 11.9 2 

Western Farah (48.7) 44.6 53.0 42.4 3 -6.3 3 

Western Ghor 12.0 18.6 16.9 13.2 3 1.2 3 

Western Herat 56.4 60.6 54.0 64.0 2 7.6 2 

Total 54.2 57.9 59.8 64.5 10.3 

Note: Figures in parentheses are based on fewer than 50 unweighted cases. 

*Estimates for 11 provinces are not shown. Three provinces (Zabul, Kandahar, and Helmand) are not shown 

because the AMS sample included only urban areas. Eight additional provinces are not shown (Kapisa, Wardak, 

Logar, Panjsher, Bamyan, Nuristan, Urozgan, and Nimroz) because the unweighted number of births during the year 

36-59 months prior to the survey or the year 0-11 months prior to the survey was less than 40, so that it was not 

possible to examine improvement during this period. 

**Coverage ranks are based on the 31 provinces included in Table 1, before excluding 8 additional provinces, as 

mentioned above. For this reason the groups are not of equal size in this table. 
13 

Three provinces in the highest rank group for overall ANC coverage also rank among the 

provinces with the most improvement in coverage: Balkh, Jawzjan, and Kunduz. Kunduz 

increased ANC coverage by over 20 percentage points during this five-year period. Also 

noteworthy is that Kunar, which ranks in the lowest group for overall ANC coverage, ranks in 

the highest group for improvement in coverage. 

Table 3 shows trends in coverage of births attended by skilled attendants over the five 

years preceding the survey, by province. Overall, there has been noteworthy improvement in the 

percentage of births attended by SBAs, from 29% of women whose last birth was 36-59 months 

before the survey to 41% of women whose last birth was 0-11 months before the survey. The 

improvement was greatest in Kunduz, at an increase of 35 percentage points in skilled attendance 

at delivery, and least in Farah, at a decrease of 1.4 percentage points. Some provinces, notably 

Faryab, that ranked lower in SBA coverage ranked higher in progress increasing skilled 

attendance at delivery. 

In general, the provinces with the strongest improvements in coverage of ANC also had 

strong improvements in the percentage of births delivered with a skilled birth attendant. Two 

exceptions are Kunar, which experienced a large increase in the coverage of ANC but essentially 

no change in coverage of skilled attendance at delivery, and Parwan, which showed almost no 

change in coverage of ANC but experienced a large improvement in skilled attendance at 

delivery, from 28% to 45%. 

 
14 

Table 3. Trend in use of a skilled attendant at birth by province, Afghanistan 2005-2010 

Percentage of women age 12-49 who had a live birth in the five years preceding the survey whose most recent birth 

was delivered by a skilled birth attendant, by months of the birth before the survey, according to province, 

Afghanistan 2010* 

 

Region 

 

Province 

Percentage of women whose last live 

birth was delivered by a skilled provider, 

by the timing of the last live birth 

Rank 

group 

based on 

5-year 

coverage 

 

Percentage 

point 

increase 

 

Rank 

group 

based on 

percentage 

point 

increase 

36-59 

months 

before 

the 

survey 

24-35 

months 

before 

the 

survey 

12-23 

months 

before 

the 

survey 

0-11 

months 

before 

the 

survey 

 

Capital Kabul 69.9 75.7 71.2 80.5 1 10.6 2 

Capital Parwan 27.8 31.1 29.6 45.0 2 17.2 1 

Central Highland Daykundi (2.1) (0) (0) (5.1) 3 3.0 3 

Eastern Kunar 27.4 30.6 24.3 26.5 2 -0.9 3 

Eastern Laghman 47.7 47.8 36.5 53.7 1 6.0 2 

Eastern Nangarhar 41.6 41.1 41.6 51.1 1 9.5 2 

Eastern Badakhshan 7.1 6.1 10.0 14.0 3 6.9 2 

North Eastern Baghlan 30.3 (28.7) 26.8 37.9 2 7.6 2 

North Eastern Kunduz 15.1 23.5 46.1 49.9 2 34.8 1 

North Eastern Takhar 18.1 13.2 27.4 29.2 3 11.1 1 

Northern Balkh 32.6 34.5 47.2 51.3 1 18.7 1 

Northern Faryab 10.3 14.6 20.0 22.0 3 11.7 1 

Northern Jawzjan 22.7 26.5 49.3 42.7 2 20.0 1 

Northern Samangan 15.7 30.6 26.8 45.5 2 29.8 1 

Northern Sari Pul 16.1 19.3 28.8 30.8 2 14.7 1 

South Eastern Khost 43.4 42.0 47.7 45.1 1 1.7 3 

South Eastern Paktika (2.0) 4.6 11.8 (10.4) 3 8.4 2 

South Eastern Paktya 20.1 16.0 22.6 24.0 3 3.9 2 

Southern Ghazni 30.9 32.3 27.0 32.7 2 1.8 3 

Western Badghis 3.3 4.9 6.4 4.4 3 1.1 3 

Western Farah (27.1) 28.2 30.2 25.7 2 -1.4 3 

Western Ghor 3.4 3.2 6.3 7.1 3 3.7 3 

Western Herat 33.8 32.4 31.7 41.4 1 7.6 2 

Total 28.5 30.5 34.1 41.4 12.9 

Note: Figures in parentheses are based on fewer than 50 unweighted cases. 

*Estimates for 11 provinces are not shown. Three provinces (Zabul, Kandahar and Helmand) are not shown 

because the AMS sample included only urban areas. Eight additional provinces are not shown (Kapisa, Wardak, 

Logar, Panjsher, Bamyan, Nuristan, Urozgan, and Nimroz) because the unweighted number of births during the 

year 36-59 months prior to the survey or the year 0-11 months prior to the survey was less than 40, so that it was 

not possible to examine improvement during this period. 

**Coverage ranks are based on the 31 provinces included in Table 1, before excluding 8 additional provinces, as 

mentioned above. For this reason the groups are not of equal size in this table. 

 
15 

In general, the provinces with the strongest improvements in coverage of ANC also had 

strong improvements in the percentage of births delivered with a skilled birth attendant. Two 

exceptions are Kunar, which experienced a large increase in the coverage of ANC but essentially 

no change in coverage of skilled attendance at delivery, and Parwan, which showed almost no 

change in coverage of ANC but experienced a large improvement in skilled attendance at 

delivery, from 28% to 45%. 

Table 4 presents trends in coverage of postnatal care (PNC) received by mothers over the 

five years preceding the survey, by province. As a whole, there has been a slight improvement in 

the percentage of mothers who received PNC, from 21% of women whose last birth was 36-59 

months before the survey to 28% of women whose last birth was 0-11 months before the survey, 

ranging among provinces from an increase of 29 percentage points in Kunduz to a decrease of 12 

percentage points in Farah. Faryab had low PNC coverage but experienced a substantial increase 

in coverage in the five years preceding the AMS (from 8% to 21%). The provinces of Daykundi, 

Kunar, Laghman, Baghlan, and Farah all experienced decreases in the coverage of PNC, which 

indicates a need for further investigation and corrective intervention. 

 
16 

Table 4. Trend in coverage of postnatal care for the mother by province, Afghanistan 2005-2010 

Percentage of women age 12-49 who had a live birth in the five years preceding the survey who received postnatal 

care (PNC) within two days of giving birth for the most recent birth by months of the birth before the survey, according 

to province, Afghanistan 2010 

 

Region

 

Province

Percentage of women who received 

postnatal care for their last live birth, by 

the timing of the last live birth

Rank 

group 

based on 

5-year 

coverage 

Percentage 

point 

increase 

Rank 

group 

based on 

percentage 

point 

increase 

36-59 

months 

before 

the 

survey 

24-35 

months 

before 

the 

survey 

12-23 

months 

before 

the 

survey 

0-11 

months 

before 

the 

survey 

 

Capital Kabul 43.1 45.7 39.4 45.1 1 2.0 2 

Capital Parwan 13.7 25.6 20.9 37.2 2 23.5 1 

Central Highland Daykundi (8.7) (2.1) (0.0) (8.3) 3 -0.4 3 

Eastern Kunar 22.9 15.7 14.7 21.7 2 -1.2 3 

Eastern Laghman 62.4 57.8 43.6 60.5 1 -1.9 3 

Eastern Nangarhar 28.9 26.0 21.8 31.6 1 2.7 2 

Eastern Badakhshan 4.8 3.9 14.1 12.3 3 7.5 2 

North Eastern Baghlan 13.1 (6.1) 7.2 10.7 3 -2.4 3 

North Eastern Kunduz 13.7 22.1 38.8 42.6 1 28.9 1 

North Eastern Takhar 13.2 10.5 21.0 21.4 2 8.2 1 

Northern Balkh 19.0 20.0 19.7 24.9 2 5.9 2 

Northern Faryab 8.3 13.2 20.6 20.5 3 12.2 1 

Northern Jawzjan 17.8 15.4 30.0 31.9 2 14.1 1 

Northern Samangan 12.4 19.3 16.2 28.5 2 16.1 1 

Northern Sari Pul 10.9 16.6 24.1 24.3 2 13.4 1 

South Eastern Khost 25.9 27.0 27.2 27.7 1 1.8 3 

South Eastern Paktika (4.0) 1.6 9.3 (8.4) 3 4.4 2 

South Eastern Paktya 22.5 14.9 19.3 23.6 2 1.1 3 

Southern Ghazni 29.2 31.9 22.7 33.0 1 3.8 2 

Western Badghis 0.0 4.0 4.1 3.0 3 3.0 2 

Western Farah (31.3) 27.9 31.1 19.6 1 -11.7 3 

Western Ghor 4.0 2.5 5.8 7.8 3 3.8 2 

Western Herat 25.8 22.2 26.4 33.4 1 7.6 1 

Total 20.7 21.2 22.4 27.8 7.1 

Note: Figures in parentheses are based on fewer than 50 unweighted cases. 

*Estimates for 11 provinces are not shown. Three provinces (Zabul, Kandahar and Helmand) are not shown 

because the AMS sample included only urban areas. Eight additional provinces are not shown (Kapisa, Wardak, 

Logar, Panjsher, Bamyan, Nuristan, Urozgan, and Nimroz) because the unweighted number of births during the 

year 36-59 months prior to the survey or the year 0-11 months prior to the survey was less than 40, so that it was 

not possible to examine improvement during this period. 

**Coverage ranks are based on the 31 provinces included in Table 1, before excluding 8 additional provinces, as 

mentioned above. Thus the groups are not of equal size in this table. 
17 

Table 5 shows that, overall, coverage of all three key maternal health care services 

increased during the five years preceding the survey, from 16% of women whose last birth was 

36-59 months before the survey to 23% of women whose last birth was 0-11 months before the 

survey. Progress ranged widely among provinces, from an increase of 27 percentage points in 

Kunduz to a decrease of 8 percentage points in Farah. Three provinces rank in the highest group 

both in coverage of all three maternal health services and improvement in coverage during the 

five-year period studied: Parwan, Kunduz, and Herat. In contrast, four other three provinces—

Baghlan, Daykundi, Badghis, and Paktika—rank in the lowest group in both overall coverage 

and in improvement in maternal health care coverage. 

 
18 

Table 5. Trend in continuum of care by province, Afghanistan 2005-2010 

Percentage of women age 12-49 who had a live birth in the five years preceding the survey who received all three 

key maternal health care services (ANC, delivered with a skilled provider and received PNC within two days of giving 

birth) for the most recent birth by months of the birth before the survey, according to province, Afghanistan 2010

 

Region Province 

Percentage of women who received all 

three key services for their last live 

birth, by the timing of the last live birth 

Rank 

group 

based on 

5-year 

coverage 

 

Percentage 

point 

increase 

 

Rank 

group 

based on 

percentage 

point 

increase 

36-59 

months 

before 

the 

survey 

24-35 

months 

before 

the 

survey 

12-23 

months 

before 

the 

survey 

0-11 

months 

before 

the 

survey 

 

Capital Kabul 36.9 39.0 35.2 40.7 1 3.8 2 

Capital Parwan 12.9 22.1 19.1 28.5 1 15.6 1 

Central Highland Daykundi (0) (0) (0) (0) 3 0.0 3 

Eastern Kunar 15.5 10.0 13.0 20.9 2 5.4 2 

Eastern Laghman 43.1 38.3 32.1 50.4 1 7.3 2 

Eastern Nangarhar 21.4 19.8 16.3 25.5 1 4.1 2 

Eastern Badakhshan 4.4 3.1 4.6 8.7 3 4.3 2 

North Eastern Baghlan 11.0 (5.6) 5.6 10.1 3 -0.9 3 

North Eastern Kunduz 12.8 20.8 36.5 39.7 1 26.9 1 

North Eastern Takhar 9.0 7.5 15.1 14.8 3 5.8 2 

Northern Balkh 12.2 16.2 18.4 21.1 2 8.9 1 

Northern Faryab 6.0 8.8 16.3 16.8 3 10.8 1 

Northern Jawzjan 10.4 9.0 21.7 26.1 2 15.7 1 

Northern Samangan 6.3 12.3 8.2 18.0 3 11.7 1 

Northern Sari Pul 9.0 14.1 20.6 20.0 2 11.0 1 

South Eastern Khost 18.4 18.6 19.4 13.6 2 -4.8 3 

South Eastern Paktika (0) 0.5 2.5 (2.8) 3 2.8 3 

South Eastern Paktya 15.3 13.3 15.4 18.9 2 3.6 2 

Southern Ghazni 25.8 23.7 18.5 24.4 1 -1.4 3 

Western Badghis 0.0 4.0 1.5 0.7 3 0.7 3 

Western Farah (21.9) 21.3 24.8 13.7 2 -8.2 3 

Western Ghor 0.0 1.0 2.3 3.9 3 3.9 2 

Western Herat 19.0 17.8 20.4 28.0 1 9.0 1 

Total 15.6 16.3 17.6 22.7 7.1 

Note: Figures in parentheses are based on fewer than 50 unweighted cases. 

*Estimates for 11 provinces are not shown. Three provinces (Zabul, Kandahar and Helmand) are not shown 

because the AMS sample included only urban areas. Eight additional provinces are not shown (Kapisa, Wardak, 

Logar, Panjsher, Bamyan, Nuristan, Urozgan, and Nimroz) because the unweighted number of births during the 

year 36-59 months prior to the survey or the year 0-11 months prior to the survey was less than 40, so that it was 

not possible to examine improvement during this period. 

**Coverage ranks are based on the 31 provinces included in Table 1, before excluding 8 additional provinces, as 

mentioned above. Thus the groups are not of equal size in this table. 
19 

DISCUSSION 

The study shows overall progress toward improving coverage of all three maternal health 

indicators (ANC, deliveries attended by SBAs, and PNC). On average, Tables 2-5 show an 

increase of roughly 10% in each of the indicators. This level of progress is not as substantial as 

might be expected, considering the major investments to support key health interventions in 

Afghanistan aimed at providing quality health care, with the main focus on improving the health 

of mothers and children under age 5. These interventions include the basic package of health 

services and the hospital reform project. 

Still, the findings indicate that the efforts toward improving and expanding access to 

maternal health care services throughout the country have had an impact. A similar positive trend 

in coverage of antenatal care and skilled assistance at delivery has been reported by the Health 

Management Information System (HMIS) in the Afghan Ministry of Public Health (MoPH). 

Also, the levels of ANC and skilled birth attendant coverage reported in the current study (Table 

4) agree with levels reported in the Multi Indicator Cluster Survey in Afghanistan (CSO and 

UNICEF 2012). 

Several factors could explain why ANC coverage is higher than for the other two 

maternal health care indicators: ANC is less expensive, is available at more health facilities than 

skilled birth care, and may have received more emphasis than PNC from the service delivery 

side, while women may be more highly motivated to seek ANC care during pregnancy compared 

with care after delivery. Nonetheless, over the five years preceding the 2010 AMS, coverage of 

deliveries by SBAs and coverage of PNC increased more rapidly than coverage of ANC. 

As mentioned above, the Ministry of Health’s HMIS data on coverage of ANC and 

deliveries with skilled attendance, which are collected at the health facility level, are largely 

consistent with the findings of this study, which are based on survey data. The HMIS data show 

that both the percentage of women receiving ANC and the percentage of deliveries attended by 

skilled attendants have increased across the whole country, by as much as 20% over the course 

of last six years, from 1384-1389 (corresponding to 2005-2009). 

The current study has the limitation of excluding 11 provinces, due to either security 

concerns or small sample size. Nevertheless, the results, which are based on a nationwide survey 
20 

capturing the coverage of maternal health care services, with household data from 23 provinces, 

can be considered the main source of information for assessing maternal health status in the 

various provinces in the country. 

The provincial comparison of maternal health care services further contributes to the 

evidence-based decisions of the Afghan Ministry of Public Health and supports its efforts to 

mobilize resources on an equitable basis across the country. Additionally, provinces with better 

maternal health care coverage and a higher rate of progress in coverage can be encouraged to 

share lessons learned from their experience with provinces with lower coverage and slower 

progress. Given the low coverage, and in a few cases the decline, in use of postnatal care (PNC) 

in most of the provinces, it could be recommended that further studies be conducted in these 

provinces looking at potential reasons for low use of these services, in order to find ways to 

tackle the barriers accordingly. Studying the lessons learned from provinces with relative high 

rates of PNC use would also provide insights to the MoPH in order to get a sense of the 

discrepancies in the use of PNC in the provinces with low rates of PNC. 

Additionally, it would perhaps be of interest to the MoPH of Afghanistan to conduct an 

assessment of health care delivery in the provinces where low rates of ANC coverage are 

evident, including a review of the portfolio of the NGOs delivering health care and the provincial 

public health office. 

 
21 

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