Scaling up newborn care in Afghanistan: opportunities and challenges for the health sector

Abstract

Newborn health in Afghanistan is receiving increased attention, but reduction in newborn deaths there has not kept pace with declines in maternal and child mortality. Using the continuum of care and health systems building block frameworks, this article identifies, organizes and provides a synthesis of the available evidence on and gaps in coverage of care and health systems, programmes, policies and practices related to newborn health in Afghanistan. Newborn mortality in Afghanistan is related to the nation’s weak health system, itself associated with decades of conflict, low and uneven coverage of essential interventions, demand-side and cultural specificities, and compromised quality. A majority of deliveries still take place at home. Birth asphyxia, low birth weight, perinatal infections and poor post-natal care are responsible for many preventable newborn deaths. Though the situation has improved, there remain many opportunities to accelerate progress. Analyses conducted using the Lives Saved Tools suggest that an additional 10 405 newborn lives could be saved in Afghanistan in 5 years (2015–20), through reasonable increases in coverage of these high-impact interventions. A long-term vision and strong leadership are essential for the Ministry of Public Health to play an effective stewardship role in formulating related policy and strategy, setting standards and monitoring maternal and newborn services. Promotion of equitable access to health services, including health workforce planning, development and management, and the coordination of much-needed donor support are also imperative.

Afghanistan, neonatal health, maternal and child health, health systems

Key Messages

• Afghanistan’s health system has made impressive progress in the last decade; however, insecurity, complicated topography, social norms and other factors contribute to persisting low coverage of life-saving neonatal interventions.

• Modest increases in essential neonatal care interventions can save thousands of newborn lives per year in Afghanistan.

• Accelerated progress for newborn survival in Afghanistan requires scaling up availability, accessibility and quality of essential newborn care.

Introduction

As the proportion of young child deaths occurring in the newborn period (age 0–28 days) increases (Liu et al. 2015), more attention is now being directed at improving newborn survival. Since 2002, Afghanistan, notwithstanding political, security and economic challenges, has made impressive improvements in young child health, with a substantive fall in under-5 mortality (UNICEF 2014; WHO et al. 2014). Bringing more political attention to maternal, newborn and child health (MNCH), Afghanistan committed to implementing the United Nations Global Strategy for Women’s and Children’s Health in 2010, and to its 2015 revision (UNSG 2010, 2014), which introduced a focus on adolescents and new mortality targets for women, young children and newborns. The country pledged—as part of A Promise Renewed—to take action to accelerate progress on MNCH, and held a related national Call to Action meeting in Kabul in 2015. Afghanistan has also signed on to the global Every Newborn Action Plan (ENAP) (WHO and UNICEF 2015).

Newborn health, however, has received less attention, and the newborn mortality rate in Afghanistan has fallen more slowly, as observed in many low- and middle-income countries (LMICs) (Liu et al. 2015). Although under-5 child and infant mortality rates fell 47.4 and 43% from 1990 to 2012, respectively, newborn mortality declined only 29%, to 36 deaths per 1000 live births, over the same period (WHO 2014). An estimated 37 000 newborns die annually, in Afghanistan (UNICEF 2014). The county’s high burden of newborn death is also typical of nations experiencing recent political instability and conflict (Lawn et al. 2012).

Since 2002, Afghanistan’s Ministry of Public Health (MoPH) has been establishing and expanding basic and life-saving health interventions, especially in remote villages, where newborn, child and maternal mortality remain high. However, these areas remain characterized by high rates of fertility, low levels of antenatal and postnatal care and skilled birth attendance, young child malnutrition, and poor health service access, uptake and quality. Although assessments have been done on health service delivery through Afghanistan’s Basic Package of Health Services (Ameli and Newbrander 2008; Frost et al. 2016) and various surveys indicate improvements, no systematic assessment of newborn healthcare has been undertaken in Afghanistan, to identify areas of related weakness or suggest viable strategies for scale-up.

Using the continuum of care and WHO health systems building block frameworks, this article identifies, organizes and provides a synthesis of the available evidence on, and opportunities for improving newborn health in Afghanistan, focusing on coverage of care, health systems issues, programs, policies and practices.

Methods

Frameworks

We used two established frameworks to guide our analysis and the recommendations emanating.

The continuum of care framework

Empirical evidence has established that high impact, low-cost interventions reduce the three most common causes of newborn mortality in low-resource contexts: premature delivery, intrapartum complications and infection (Darmstadt et al. 2005; PMNCH 2011; Bhutta et al. 2014). These interventions may be delivered in the context of integrated service delivery packages for maternal and newborn health (MNH) (Table 1), forming a continuum of care spanning the period before conception to the end of the first month of life. Three modes of delivery of these interventions have been suggested: clinical care in health facilities, outreach or outpatient services, and interventions that can be implemented at household or community level (Kerber et al. 2007; Lawn et al. 2012). A continuum of care framework underscores the importance of life-cycle period and local context in considering the implementation and potential for implementation of these interventions.

Table 1

Framework to scale-up newborn health strategies for countries with >30 neonatal deaths per 1000 live births (adapted from Dickson et al. 2014)

Focus of strategies for scaling up			Equity, quality, supply and demand
Steps to scale-up		Health-systems building block	NMR more than 30 deaths per 1000 live births (‘strategies for this group of countries’)
Step 1: Assess the situation, determine priorities based on analyses, develop leadership	Community ownership and partnership	Leadership and governance	Increase the visibility of newborn issues in the context of reproductive, MNCH, engage stakeholders at all levels of care to raise awareness, ensure a coordinated convening group linked to the Ministry of Health, cultivate champions, strengthen the Neonatal Death Review Committee and closely follow up its action points Sharpen national plans and strategies, develop and promote evidence-based policies, and ensure adequate funding of key programmes
Step 2: Seize opportunities within the constraints of the existing health situation		Health financing	Increase government spending for health, allocate budget for newborn care, and seize opportunities to leverage additional resources for RMNCH initiatives Implement and expand pro-poor legislation and strategies (e.g. vouchers, community-based health insurance schemes, reimbursement of transport costs) and remove user fees Increase investment in family friendly care including infrastructure and technology in tertiary or specialized care centres Ensure financial protection for women and newborn babies needing emergency care
		Health workforce	Strengthen the role of community providers and families to implement clean birth practices, appropriate hygiene, and basic newborn care Strengthen and support community providers through regular supervisory visits and strengthen linkages with health facilities Implement national human resources strategies that provide incentives to increase availability of providers, attract and retain skilled providers (continuous training, task shifting, compulsory service in rural areas, pay increases, etc.) Increase availability of nursing and midwifery skills and competencies for obstetric and newborn interventions [neonatal resuscitation, KMC, safe oxygen management and breastfeeding support] through preservice and in-service Increase availability of specialists, e.g. obstetricians, neonatologists) in district and referral hospitals Establish learning centres at regional hospitals to improve quality and efficiency Increase efficiency and maintain skills and competencies of qualified health providers at all levels of care
Step 3: Systematically scale up care		Health service delivery	Address missed opportunities for facility births—improve emergency obstetric care (EmOC) and resuscitation Educate and engage communities to increase early demand for quality skilled care Built partnerships to strengthen linkages and referral systems between communities and primary health care facilities to reduce access delays Implement strategies to increase quality of care, availability of standards in health facilities, ensuring supervision and mentoring of health workers, maintaining patient-centered care and introducing maternal and perinatal audits Strengthen integrated management of newborn and childhood illness and routine postnatal care to ensure early detection of danger signs and improve case management of neonatal infections by skilled providers Increase MNH outreach services including ANC coverage of TT1, integrated management of childhood illness (IMCI), routine postnatal care (including extra care for small babies) and family planning Adapt KMC to the local context Address unhealthy birth practices, consider social marketing of clean birth kids Reach universal coverage of high-quality care for all newborn babies, including those who are preterm or ill, or both—use innovative approaches to reach the most marginalized groups Improve follow-up mechanisms for newborn babies in need of long-term quality care
			Increase coverage of comprehensive EmOC and emergency neonatal care at least at referral level (then to district level) Establish neonatal intensive care unit (NICUs) to increase extra care of small and ill babies Strengthen newborn component within integrated community case management (iCCM)/IMCI to scale up CCM of neonatal sepsis in hard-to reach areas with restricted access to health facilities Focus on quality ANC services to increase identification and treatment of women with pre-eclampsia and appropriate prevention of preterm labor Expand quality of care through perinatal audits Sustain long-term care and follow-up of premature babies with complications and early identification of impairment and disabilities
		Essential medical products and technologies	Strengthen procurement and supply chain for essential commodities
Step 4: Monitor coverage, measure effect and cost, improve data gaps		Health information systems	Improve data collection reporting, and use to improve service delivery Improve birth registration, improve collation of cause of death data (in facilities and communities), institute surveillance for key newborn interventions (e.g. survey modules for KMC) Establish countrywide Maternal Neonatal Death Surveillance and Reporting system

Health systems building blocks

Coverage of essential newborn health interventions across the life cycle is also associated with contextual factors, particularly the strengths and weaknesses of the local health system. A number of conceptualizations of health systems have been developed, but the one that has resonated most in recent years is the building blocks framework developed by WHO (2007) (Shakarishvili et al. 2010; van Olmen et al. 2012).

We reviewed the available evidence on each of the six building blocks as they apply to newborn health in Afghanistan (Table 2), taking a lead from the approaches outlined by global experts and reproduced in Table 1. We also included an additional focus on community ownership and participation, as a frequently perceived independent influence on population health in LMIC (Musinguzi et al. 2017).

Table 2

Integrated service delivery packages for MNCH (reproduced from Lawn et al. 2008)

	Reproductive care	Childbirth care		Emergency newborn care
CLINICAL	Family planning Management of STIs and HIV Post-abortion care, TOP where legal	Skilled care and immediate newborn care (hygiene, warmth, breastfeeding) and resuscitation) Antenatal steroids, antibiotics for pPROM PMTCT of HIV EmOC if needed		Extra care of pre-term babies including KMC Emergency care of sick newborns (context-specific e.g. CPAP)
	ANC			POSTNATAL CARE
OUTREACH	Family planning Prevention and management of STIs and HIV Peri-conceptual folic acid	Four-visit focused ANC package IPTp and bednets for malaria Prevention and management of STIs and HIV		Promotion healthy behaviors, e.g. hygiene, breastfeeding, warmth Early detection of and referral for illness Extra care of at risk mothers and babies PMTCT of HIV
FAMILY/COMMUNITY	Adolescent and pre-pregnancy nutrition Gender violence Education Prevention of STIs and HIV	Counseling and preparation for newborn care, breastfeeding and emergency preparedness	Where skilled care is not available, consider clean birth and immediate newborn care (hygiene, warmth, immediate breastfeeding)	Healthy home care including: Promoting preventive care including newborn care (hygiene, warmth), nutrition (exclusive breastfeeding, complementary feeding) and family planning Seeking curative services for women, babies and children including ORS for prevention of diarrhea and where referral is not available, consider case management for pneumonia, malaria and neonatal sepsis
Intersectoral: Improved living and working conditions including housing, water and sanitation, and nutrition. Education and empowerment, especially for girls, folate fortification, safe and health work environment, especially for pregnant women.
	Pre-pregnancy	Pregnancy	Birth	Newborn/postnatal

Source:Lawn et al. (2012). Adapted from Kerber et al. (2008), revised by Kinney et al. (2010), and PMNCH (2011).

Abbreviations: ANC, antenatal care; CPAP, continuous positive airway pressure; HIV, human immunodeficiency virus; IPTI, intermittent preventive treatment in infants; IPTp, intermittent preventive treatment during pregnancy for malaria; ORS, oral rehydration solution; PMTCT, prevention of mother-to-child transmission of HIV; pPROM, prelabor rupture of membranes; STI, sexually transmitted infection; TOP, termination of pregnancy.

Collection of data and evidence

Available information on the influences on, and delivery of health services affecting newborn health in Afghanistan was gathered, and categorized by four periods of the life-cycle: before conception, and during antenatal, intrapartum and postnatal care, and according to the six building blocks and community-level influences. Searches for peer-reviewed articles on newborn health in Afghanistan were conducted using PubMed with the key search terms: (neonate [All Fields] OR neonatal [All Fields] OR neonates [All Fields] OR newborn [All Fields] OR newborns [All Fields] AND afghanistan AND health AND humans) (see Supplementary Web Appendix S1 for flow diagram, and Supplementary Web Appendix S2 for final articles included). Key word searches related to each phase of the continuum of care and areas for scale-up, according to methods and standards established previously (Dickson et al. 2014) were conducted in GoogleScholar to supplement evidence on newborn health extracted from the PubMed search. Gray literature including policy and program documents was also captured by reviewing UNICEF Afghanistan’s internal documents on newborn health as well as through a review of resources in the Afghanistan MoPH. Only papers published or written since the nation’s political reformation in 2002 to April 2015 (date of searches) were included.

Data on neonatal mortality, health status and coverage of interventions was also extracted from national surveys and estimations that took place since 1990. Although data points were taken from a longer period than the peer reviewed literature to underline the dire situation before 2002, more recent studies were preferred because of their improved methodological foundation.

The studies and reports retained for analysis focused on newborn survival and health and the health system in Afghanistan.

Data and additional analysis

For secondary data analysis, evidence was organized and analyzed across the two frameworks selected. The impact of scaling up of essential newborn care interventions was also estimated using the Lives Saved Tool (LiST) (Boschi-Pinto et al. 2010; Winfrey et al. 2011). In consultation with a technical committee led by the Afghanistan MoPH, targets for two dates—2020 and 2030—were set, based on targets in existing commitments, frameworks and strategies. Two scenarios were modeled to estimate the impact of interventions: 2015–20, the timeframe of Afghanistan’s current Reproductive Health Strategy and National Health and Nutrition Strategy and also the end date for Afghanistan’s unique Millennium Development Goal targets (endorsed in 2004) (Afghanistan Ministry of Economy 2013), and 2015–30, the timeframe established by the sustainable development goals.

Expert review

A committee in the Afghanistan MoPH, led by the Reproductive Health Directorate, reviewed the analysis and provided substantive guidance and inputs into this report.

Results

Neonatal mortality in Afghanistan

Reduction of preventable neonatal mortality is one of several goals when improving the coverage rate of essential MNCH interventions across the continuum of care. Despite progress in reducing maternal and child mortality rates in the past decade, reduction in the newborn mortality rate has been comparatively slower, with an annual rate of reduction (ARR) of only 0.1%. In order to achieve a neonatal mortality rate (NMR) of 12 by 2030 in Afghanistan, the desired/expected average ARR is 5.2%, an average ARR of 11% is required (Figure 1) (UNICEF 2014).

Figure 1

Trends in under-five child and newborn morality in Afghanistan with future projections (UNICEF analysis based on United Nations Inter-agency Group for Child Mortality Estimation 2015)

The causes of these newborn deaths are largely preventable, as presented in Figure 2. Using data from a variety of sources, the low coverage of many of the interventions proven to prevent the commonest causes of newborn death, including in Afghanistan, is presented in Figure 3. According to a secondary analysis of the 2010 Afghanistan Mortality Survey, predictors of newborn death include birthweight, remoteness index, residence, wealth index, sanitation, and duration of pregnancy (Adegboye and Kotze 2014).

Figure 2

Estimated causes of neonatal and child mortality for Afghanistan (UNICEF 2015)

Figure 3

Coverage of newborn interventions in Afghanistan from recent nationwide surveys

Analyses conducted using LiST suggest that an additional 10 405 newborn lives could be saved in Afghanistan in 5 years (2015–20), through reasonable increases in coverage of these high-impact interventions. The 21 LiST interventions related to saving additional newborn lives are listed in descending order in Table 3. In terms of deaths prevented by intervention, seven¹ are associated with skilled birth attendance and institutional delivery, and account for ∼50% of the deaths potentially prevented. Improved intrapartum care to prevent asphyxia is a particular area of need. In addition to skilled birth attendance and institutional delivery, appropriate feeding, notably the promotion of early and exclusive breastfeeding, is also predicted to make a contribution to saving additional newborn lives.

Table 3

Additional deaths prevented in children under 1 month of age by intervention

	Intervention	Additional number of lives saved in the period 2015–20
1	Labor and delivery management	2560
2	Antenatal corticosteroids for preterm labor	1033
3	Full supportive care for prematurity	891
4	Promotion of breastfeeding	870
5	Neonatal resuscitation	703
6	TT1 vaccination	638
7	Clean postnatal practices	542
8	Chlorhexidine	527
9	Clean birth practices	480
10	Full supportive care for sepsis/pneumonia	424
11	KMC	353
12	Immediate assessment and stimulation	305
13	Thermal care	221
14	Antibiotics for pPRoM	219
15	Oral antibiotics	153
16	Micronutrient supplementation (multiple micronutrients + iron folate)	144
17	Oral rehydration solution (ORS)	116
18	Injectable antibiotics	110
19	Folic acid supplementation/fortification	87
20	Balanced energy supplementation	28
21	Syphilis detection and treatment	1
Total		10 405

In this scenario analysis of scaled up interventions, newborn deaths by cause are still largely associated with intrapartum management (Table 4). Asphyxia, a birth related cause, decreases over the period by >3000 deaths but is still causing the largest overall number of deaths in 2020, followed by prematurity and sepsis.

Table 4

Cause-specific deaths in children under one month of age by 2020 with scaling of essential interventions, as modeled by the LiST

	2015	2016	2017	2018	2019	2020
Neonatal asphyxia	10 228	9918	9623	9343	7436	7056
Neonatal prematurity	10 035	9394	8796	8237	7177	6669
Neonatal sepsis	6912	6330	5796	5304	4733	4315
Neonatal other	2435	2429	2426	2426	2427	2430
Neonatal congenital anomalies	2064	2042	2022	2005	1988	1973
Neonatal pneumonia	2232	2110	1996	1888	1785	1688
Neonatal tetanus	1201	1038	885	741	591	465
Neonatal diarrhea	542	498	456	417	379	344

Review of the available evidence on newborn death in Afghanistan by life-cycle framework

The pre-conception period

The annual population growth rate in Afghanistan is estimated at 2.7% associated with the high total fertility rate of 5.1 children per woman (Afghan Public Health Institute et al. 2011). High-fertility rates in Afghanistan are due in part to low contraceptive uptake (21.8% at the national level) with wide inter-provincial variation (almost 50% in western Herat province but only 2% in Paktika, in the southeast) (Afghan Public Health Institute et al. 2011). According to one predictive model, increasing contraceptive prevalence to 60% could prevent almost 320 000 infant deaths in Afghanistan over 5 years (Rahmani et al. 2013). Family planning and reproductive health services are not well integrated, a missed opportunity to raise awareness and prevent unintended pregnancies (Singh et al. 2013), particularly since family planning is considered a primary prevention measure to reduce newborn and child death (Liu et al. 2015).

Misconceptions on the risks and dangers associated with contraceptive use are prevalent in Afghanistan (Haider et al. 2009). Some evidence indicates that contraceptive use increases rapidly in rural Afghanistan when community health workers (CHWs) receive support and guidance (Huber et al. 2010).

Pre-conception nutrition is known to be associated with newborn outcomes (Mason et al. 2014). Anemia (hemoglobin < 2 g/dl), most commonly secondary to iron deficiency, is prevalent among women of reproductive age (15–49 years) (40.4%) and adolescent girls (10–19 years) (29.9%) in Afghanistan MoPH (2013). Additionally, knowledge of anemia is low, with under 40% of women of reproductive age aware of the condition (MoPH 2013). Given the empirical association between maternal anemia and low birthweight, premature delivery and newborn mortality (Rasmussen 2001), control of anemia is a priority in Afghanistan, using established approaches before and during pregnancy.

Antenatal care

Recent surveys show low coverage of antenatal care (ANC) in Afghanistan. Only 48–59% of women had at least one assessment during pregnancy by a doctor, nurse or midwife (Central Statistics Organization [CSO] 2012; MoPH 2013; APHI 2011) and only 16.4–18% of women report the recommended four or more ANC visits during their last pregnancy (MoPH 2013). The timing of first attendance for ANC is usually late, with only 24.7% attending during the first trimester (MoPH 2013). There are wide disparities in ANC coverage, with the lowest level in the southern region (31%) and highest in the central region (74%) (CSO 2012). ANC uptake is higher in urban (78%) than rural areas (46%) (CSO 2014).

ANC included the associated cost, distance and transportation problems, the perceived absence of need or a tradition of ANC, and in the south, insecurity due to conflict (APHI 2011). Disrespectful treatment was identified as another factor (Rahmani and Brekke 2013).

During ANC visits, 47.7% women received information and counseling about nutrition, rest (42.3%) and exclusive breastfeeding (15.5%). However, almost 21.9% reported receiving no relevant information during ANC visits (MoPH 2013; CSO 2014).

Intrapartum care

Although recent years have seen improvement in skilled birth attendance, rates remain very low in Afghanistan. Estimates range from 34.3 to 46% (Afghan Public Health Institute 2011; Johns Hopkins University [JHU] 2012). However, even the higher estimates mean a large proportion of women deliver at home with unskilled care, including by traditional birth attendants (CSO 2012) with some high-risk practices reported (Save the Children 2008). Coverage again ranges widely from 68% in the central region to 21% in the south. Women in Afghanistan deliver at home because of lack of transportation, economic problems, lack of awareness or low decision-making power in the household. Afghan women must typically receive permission from their husbands or mother-in-law to attend health facilities, even in emergency situations (Asia Foundation 2016).

Postnatal care

As in most low-income countries, a large proportion of newborn deaths in Afghanistan occur during the first 24 h following delivery (Lawn et al. 2005). Less than one-third (28%) of women received postnatal care for their last birth (Afghan Public Health Institute 2011). Only one in five women received postnatal care within 4 h of delivery, more than one in five (22%) received care within the first hours, and 2% of women are seen 2 days following delivery. Factors preventing women and newborns from getting medical advice or treatment during the postnatal period noted included lack of money (78%), distance and transportation to a health facility (70%), lack of medicines (30%) and security concerns (28%) (Afghan Public Health Institute 2011).

Appropriate rates of newborn feeding (early initiation and exclusive breastfeeding) have improved over the last few years but remain low. All three recent surveys measuring exclusive breastfeeding in the first 6 months reported a rate below 60% (MoPH 2013; CSO and UNICEF 2012; APHI et al. 2011).

Vaccination coverage is low in Afghanistan. According to a recent immunization coverage survey, only 58.6% of mothers and their newborn children were protected against tetanus at the time of delivery by Tetanus Toxoid (TT1) vaccine (MoPH and UNICEF 2013).

Review of the available evidence on newborn health in Afghanistan by WHO building block framework

Leadership and governance

Improving newborn health is already among the priorities of Afghanistan’s government: article 52 of the Constitution of Afghanistan stipulates that health is a fundamental human right and the Afghanistan National Development Strategy and National Action Plan for Women of Afghanistan recognize MNH as priority areas. The Government reiterated its political commitment to reduce maternal and newborn mortality at the 2014 World Health Assembly through endorsement of the ENAP and the National Reproductive Health Strategy 2012–16, with maternal and neonatal health as the first strategic component. In response to ENAP, the MoPH has developed the National Newborn Care Comprehensive Operational Plan for Afghanistan, which aims to significantly reduce preventable newborn deaths. A national standard newborn toolkit was developed and a ‘Center of Excellence’ for newborn care established in the major pediatric hospital in Kabul.

Despite progress in some areas and increased attention to newborn health, important policy gaps remain. Policies support the international code on marketing of breastmilk substitutes and community treatment of pneumonia with antibiotics, and chlorhexidine digluconate gel for cleaning the newborn umbilicus was recently added to the National Essential Drug List. The National Newborn Working Group is in the process of promoting its use by facility- and community-based health workers. However, no policies exist for kangaroo mother care (KMC) of low-birthweight/premature newborns, antenatal corticosteroids in management of preterm labor, or maternity protection (i.e. Convention 183) (Countdown MNCH 2014).

Many challenges exist for implementing existing and needed policies at decentralized levels in Afghanistan. However, one study found that consistent application of four ‘effective governing’ practices (sub-committees to oversee financial transparency and governance; collaboration with diverse stakeholders; sharper focus on community health needs, and more frequent presentation of service delivery data with increased use of data for decision-making) was associated with a 20% increase in ANC visits in pilot provinces (Anwari et al. 2015).

Financing

Health sector financing has risen substantially, with a rise from donors from $1.8 million in 2003 to $169 million in 2012 (Dalil et al. 2014). Despite large increases in the MoPH budget, out-of-pocket expenditures for health services are high, an estimated 73% of total health expenditure (MoPH 2013). Health service clients make unofficial payments to government facilities, including those run by non-governmental organizations, adding to the cost of care (Cockcroft et al. 2011).

Households in Afghanistan spend an average of US$41/capita/annum on health, in a nation with an average household size of 7.4 individuals (CSO 2014), and gross domestic product per capita of US$668 (UN Statistics Division 2014). Accordingly, such high expenses pose severe barriers to accessing care for individuals and reinforces inequity in health service uptake, especially affecting the rural poor (MoPH 2013). Conditional cash transfer pilots in Afghanistan have shown promising results (Lin and Salehi 2013).

Health workforce

Afghanistan has a shortage of skilled health workers, with 22 (including 7.4 volunteer CHWs) per 10 000 head of population (MoPH 2011); this is far below the WHO recommended minimum of 23 doctors, nurses and midwives per 10 000. Regional disparities mean there were only 16.7 public health workers (including unqualified support staff) per 10 000 in rural areas, where a majority (71%) of Afghanistan’s population resides (CSO 2014; Witter et al. 2015).

Afghanistan’s National Health Workforce Plan 2012–16 established goals for increasing qualified and gender-balanced health workers from 22 to 39 per 10 000, and (within this number) doctors/nurses/midwives from 7 to 13. It planned an almost doubling of the number of 119 951 public health staff.

A clear plan is needed to deliver basic essential newborn care in the facilities that do not presently have skilled birth attendants. However, there have been improvements in the availability of skilled birth attendants due to investment in community midwifery (Mohmand 2013). Between 2003 and 2012, the number of graduated midwives in Afghanistan increased from 467 to 3001 (MoPH [undated]). Two studies have emphasized the competency of these midwives (Partamin et al. 2012; Kim et al. 2013), and another noted that community selection of trainees significantly elevated the presence of trained midwives in high-risk rural communities, without compromising skills (Mansoor et al. 2011). However, another study found that lack of equipment and training for such staff compromise intrapartum care, affecting newborn outcomes (Guidotti et al. 2009).

Competency-based pre- and in-service training, complemented by supportive supervision, can build providers’ capacity, including for newborn resuscitation and other signal functions (Kim et al. 2013; Gabrysch et al. 2012) but remains a neglected area in Afghanistan. Each year universities and health institutions graduate doctors and allied health workers with poor competencies.

In Afghanistan, CHWs introduced in 2002 are volunteer village-based health workers supported by the MoPH to provide basic health education and simple medical treatment to community members. More than 28 000 CHWs have been trained and deployed in >11 000 health posts in all 34 provinces, especially in rural areas where a majority (71%) of Afghanistan’s population resides (CSO 2014). A qualitative study on the national CHW program in Afghanistan (Najafizada et al. 2014) found that female CHWs accomplished their tasks vis-à-vis MNCH with greater ease than male CHWs, as societal gender dynamics influenced task allocation. It noted that while volunteerism helps to deploy a larger number of CHWs, it also makes retention difficult.

Finally, continuous work is needed to attract and retain skilled female health workers. Insecurity and traditional attitudes to gender in Afghanistan require a multisectoral response and innovative strategies to reduce their impact. Within the health sector, midwife career advancement also impacts retention and requires attention (Wood et al. 2013).

Health service delivery

Although overall access to MNCH services has improved in recent years, and some studies suggest pro-poor distribution of health care (Steinhardt et al. 2008), the urban-rural differential remains a problem in Afghanistan, and equity-focused strategies are required. In particular, it is difficult for women in rural areas to access ANC and skilled maternity care, as described already (Afghan Public Health Institute 2011). Perceived poor quality of services, absenteeism and service providers’ attitudes towards health seekers can be major deterrents.

As the health sector looks to expand coverage and demand for MNCH services, quality of care is central to attracting clients and for improved health outcomes (Montgomery et al. 2014). However, by way of example, the cesarean section rate is low in Afghanistan (1.1% of births) due to lack of related skills and equipment (Jhpiego 2010). A high percentage of intrapartum stillbirths of normal birthweight also suggest a need for improved labor monitoring and surgical obstetric practices, and use of facility-based perinatal surveillance and audit to guide quality assurance initiatives (Kandasamy et al. 2009).

The working environment at health facilities and hospitals directly affects care provided. A recent Kabul hospital study revealed heavy workloads, a high proportion of complicated cases and poor staff organization affecting the quality of care, and that cultural values, social and family pressures influenced the motivation and priorities of healthcare providers (Arnold et al. 2015). Moreover, nepotism and cronyism affected clinical training, undermined the authority of management to improve standards of care and created an atmosphere of vulnerability for those without influential backers. In contrast, an approach piloted in Kunduz and Balkh provinces and in Kabul showed that measurable improvements in patient care can be improved while systematically building the capacity of the health system, through national leadership and policy making (Rahimzai et al. 2014). Afghanistan’s ongoing conflict and its unpredictability in some areas of the country also affects health service delivery, particularly for women accessing care during labor. The impact of insecurity on service continuity is most likely underreported in Afghanistan (Rubenstein and Bittle 2010).

Outreach services in Afghanistan’s so-called ‘white areas’ with no access to fixed facilities are conducted by several cadres of health workers, including community midwives and members of mobile health teams. An evaluation in 11 provinces of mobile health teams covering locations geographically far from health facilities concluded positive impacts in almost all the primary care indicators monitored in Afghanistan MoPH (2011). These included consultations, maternal health and immunization.

In another small study using direct clinical observation, all time intervals with the exception of ‘decision to skin incision’ were longer in the record reviews than in observed cases. It was also found that prior cesarean was the most common primary indication for all cases. Among newborns there were two stillbirths (7%) in observed births and seven (21%) in the record reviews (Evans et al. 2014).

Logistics, and essential medical products and technologies

General deficiencies exist in Afghanistan’s pharmaceutical sub-sector, in terms of implementation of policy, regulation and management. In general, the accessibility, affordability and availability of quality medicines varies widely by province (Harper and Strote 2012; Kohler et al. 2012) and Afghanistan is considered a chaotic and unregulated market (Paterson and Karimi 2005). As a consequence, the pharmaceutical market and supply system are flooded with substandard, counterfeit, and diverted medicines which affect all population groups, particularly vulnerable newborns. Work is ongoing for greater regulation and to develop local production (MoPH 2014); however, interim measures, especially to increase the availability and affordability of essential drugs are needed.

Gaps were present in the availability of several essential drugs specific to newborn care at the time of a nation-wide needs assessment (Jhpiego 2010). The most common cause of delay in the delivery of supplies overall was reported as administrative difficulties (27%) and inadequate transport (21%).

Health information systems

Major investments have supported the development of Afghanistan’s Health Management Information System (HMIS) in which a sub-set of indicators is collected for newborn health (MoPH 2015). Strengthening of monitoring systems and a culture of data use through HMIS at community, facility and district levels is a critical need for improving the quality of care. Options being considered include real-time monitoring of results and establishing accountability mechanisms for health facilities and provincial health departments. RMNCH Scorecards were launched mid-2015, and include indicators relevant to newborn care such as skilled birth attendance, low birth weight etc. (MoPH 2015). The Scorecards monitor district, provincial and national progress and performance by quarter, and preliminary results show they are effective tool in identifying areas (geographic and programmatic) requiring more attention, and for proxy measurements on quality of care. The Scorecards and other routine monitoring can improve awareness of standardized norms and practices, and identify the magnitude and nature of bottlenecks to newborn health (Singh et al. 2013).

A ‘balanced scorecard’ approach is being used to assess and improve health service capacity and service delivery using performance benchmarking in Afghanistan. According to a study reviewing performance over 5 years, reconfigurations are needed to integrate effectiveness and efficiency measures and accommodate changes in health systems policy and strategy architecture, though it is unclear how performance was rated for newborn health (Edward et al. 2011). More recently, the MoPH has instituted a third party monitoring mechanism to verify implementation of basic health services across the country, including maternity services and newborn care (MoPH 2015).

Community ownership and participation

Although not one of WHO’s six health system building blocks, this is a critical aspect of health system functioning, especially in low-income countries where access is a major limiting factor in health sector performance.

In Afghanistan, community-level influences exist on the demand for maternity and newborn services. Newborn and infant mortality rates are higher among the poorest quintile, and cultural restrictions on the mobility and decision-making capacity of women are significant constraints to them accessing maternity care. The practice of purdah, or seclusion of women, makes it difficult for them to obtain social and health services including MNH (Mansoor et al. 2011). Rural and poor populations have low awareness of the signs and symptoms of obstetric complications and the associated urgency (Hirose et al. 2015).

Demand side barriers at community level remain significant obstacles to improved newborn health. There is limited understanding of the importance of ANC and a lack of family support, funds and transportation lead to underuse of available care, especially by poorly educated rural women (Rahmani and Brekke 2013). Financial barriers and social norms are the most frequently mentioned; relative wealth is the most important determinant in seeking care outside the home, and in choice of provider (Mayhew et al. 2008; Steinhardt et al. 2008). The husband’s social network influenced delays in care-seeking during labor in one study of women who give birth at health facilities (Hirose et al. 2015). Several community-level factors and perceptions have been found to increase the number of institutional deliveries, including intensive community mobilization, provision of free services and transport facilities at night, maintaining privacy in the delivery room and the quality of services (Hadi et al. 2007). Fee removal appeared to be an influential factor to increase demand (Steinhardt et al. 2011).

Community participation facilitated the tasks of CHWs, but also posed challenges, such as traditional leaders influencing the recruitment of CHWs who may not be the most appropriate candidate for community health promotion (Najafizada et al. 2014). The MoPH is introducing a new community-based package for newborn care that emphasizes the importance of home visits for mothers and newborns to promote healthy behaviors and identify danger signs.

Discussion

Despite ongoing insecurity, Afghanistan is making progress in some areas of newborn care; for this progress to be reflected in improved health outcomes for newborns, it is necessary to examine and address bottlenecks to newborn care and implement strategies for scaling up. Using the bottleneck analysis for newborn care to accelerate scale-up (Dickson et al. 2014) initially introduced in Afghanistan in 2013, the following areas should be prioritized to improve newborn health outcomes and reduce mortality in Afghanistan.

To improve proximity to health facilities, especially in rural areas of Afghanistan, a recent study indicates a need to re-examine criteria for selecting and positioning basic and emergency obstetric and newborn care services at appropriate levels of the healthcare system, connected by appropriate communication and functional referral mechanisms (Kim et al. 2012).

Policy, implementation and oversight mechanisms must be strengthened to eliminate unofficial payments and reduce of out-of-pocket expenditures for improved neonatal health outcomes. Strengthening governance closer to delivery of health services could have positive implications not only for better use of resources but also for improved community perceptions.

Improvements in quality of neonatal care are also directly linked to improving supervision. Supportive supervision systems in the health system in Afghanistan can help to ensure that providers possess the knowledge, skills, and attitudes required to provide quality EmONC services (Kim et al. 2012). For midwives, in-service training and job rotation could help skilled birth attendants retain their skills, especially in managing common high-risk emergencies (Partamin et al. 2012; Turkmani et al. 2015).

Notwithstanding, midwives’ contribution in Afghanistan ranges from increased newborn care to changing community perceptions of women’s education and professional independence, which must continue to be reinforced (Turkmani et al. 2013). Advocacy to encourage family and community support for midwives working in rural facilities and providing benefits such as housing, education for their children, and employment for the accompanying male family member are measures likely to improve midwife retention in Afghanistan (Mansoor et al. 2013).

Mortality associated with cesarean section may be partly due to women coming late for obstetric care; however, increasing availability and utilization of cesarean section requires focus on quality, such as encouraging use of partographs and improving decision-making and documentation around cesarean section deliveries (Kim et al. 2012). A high percentage of intrapartum stillbirths among normal birth weight fetuses suggests a need for improved labor monitoring and surgical obstetric practices. A study concluded that the use of a facility-based perinatal surveillance system is critical in guiding such quality assurance initiatives (Kandasamy et al. 2009).

To link postnatal counseling to family planning, currently a weak area, one study underscored the importance of providing private spaces for postpartum family planning (counseling, along with involving husbands and mothers-in-law in counseling). Private spaces can increase the percentage of women receiving this counseling and, importantly, their preferred contraceptive method before discharge (Tawfik et al. 2014).

Though the situation has improved, there are many urgent opportunities for reducing the number of newborn deaths in Afghanistan. Newborn mortality is related to complex factors; a weak health system associated with decades of conflict, low and uneven coverage of essential interventions, demand-side and cultural specificities, and compromised quality. With a majority of deliveries still taking place at home, birth asphyxia, low birth weight, perinatal disorders and infections are causing many preventable newborn deaths.

A long-term vision and strong leadership are essential for the MoPH to play an effective stewardship role in formulating policy, strategy and setting standards to regulate and monitor MNCH services and promotion of equitable access, including through health workforce planning, development and management. To achieve these aims, the MoPH must build on and upgrade existing systems for health service delivery and performance monitoring, as well as further leverage global initiatives and partnerships for technical and financial resources.

Particular attention is required to strengthening access to and use of intrapartum services and comprehensive newborn care. A shift is required from the traditional facility-based health service delivery model to a demand-driven model that includes community-level care, awareness-raising, risk sensitization and women’s empowerment for decision-making.

Attention must also be paid to cross-sectoral areas such as sanitation and girls’ education, to improve rates of health-promoting behaviors and practices and address root causes of maternal and child mortality and morbidity.

Supplementary data

Supplementary data are available at Health Policy and Planning online.

Acknowledgements

The authors would like to specially thank Alyssa Sharkey and Deepika Attygalle (UNICEF Regional Office for South Asia) and Karen Edmond (UNICEF Afghanistan), for their valuable inputs, as well as Danzhen You and Lucia Hug (UNICEF Headquarters, Division of Data, Research and Policy) for guidance and support on mortality estimates and reduction rates. The authors would like to also thank colleagues and collaborators in the Ministry of Public Health, UNICEF and other UN agencies, USAID and all development partners working on the issue of newborn health in Afghanistan.

Conflict of interest statement. None declared.

Footnotes

1

These interventions include: labor and delivery management, full supportive care for prematurity, clean postnatal practices, clean birth practices, chlorhexidine, immediate assessment and stimulation and thermal care.