KAP SURVEY regarding REPRODUCTIVE HEALTH ppt

Characteristics of the survey population and health care seeking behaviour • The mean age of women interviewed was 28 years.. Safe delivery only women included who gave birth at least o

KAP SURVEY regarding REPRODUCTIVE HEALTH

International Centre for Reproductive Health, University of Ghent, Belgium

Dr Kathia van Egmond

ICRH International Centre for Reproductive Health, University Ghent IUD Intra Uterine Device

KAP Knowledge, Attitudes and Practices

MCH Mother and Child Health

RH Reproductive Health

STI Sexually Transmitted Infections

TBA Traditional Birth Attendant

UNFPA United Nations Population Fund

UNHCR United Nations High Commissioner for Refugees

UNICEF United Nations Children’s Fund

VLIR Flemish Inter-University Board

WHO World Health Organisation

7 Sexually Transmitted Infections p 36

FACTORS DETERMINING SOME RH INDICATORS p 41

A Factors associated with the use of RH services p 41

B Influence of formal education on RH parameters p 47

EXECUTIVE SUMMARY

A Introduction

Nearly any one is aware of the extremely bad reproductive health (RH) situation in Afghanistan The needs for RH care are enormous However improvement of reproductive health care is not an easy objective in Afghanistan of today A socially integrated and culturally well-accepted approach is essential for any initiative in the reproductive health care sector

In this perspective, we need a far better understanding of what women’s position in society currently is and what women actually want

The main objective of this KAP study (Knowledge, Attitudes and Practices) therefore consists in contributing to a better understanding of the way Afghan women perceive their reproductive health and reproductive health needs

A total of 468 Afghan women of reproductive age (15 to 49 years) have been interviewed They have been selected through systematic sampling of adult women attending four different health clinics in Kabul city (2 general outpatient clinics and 2 MCH clinics)

B Summary of the results

1 Characteristics of the survey population and health care seeking behaviour

• The mean age of women interviewed was 28 years The age category 15 to

19 years was underrepresented at all clinics

• 62 % of the interviewed women were illiterate and 64% never attended a regular school Among their husbands 31% appeared to be illiterate

• 86% of the women were married and among them, the mean age of marriage was 17.2 years old About one out of six women married at the age of 14 years or younger

• About 49% of the husbands had a more or less permanent and regular job, mostly in the private sector (small business)

• Near half of the women interviewed - all living in Kabul – were not born in Kabul And 25% of all women interviewed had arrived in Kabul over the past year, after the fall of the taleban regime

• In case of illness, more than half of the women went to the public health sector Another 42% went to seek care in the private health sector In average, women lived at 25 minutes walking distance from the respective health centres

• Almost 90% of all women interviewed had to ask permission of their husband

or of a male relative to go to a health centre

2 Obstetrical history

• 29% of the women said to be pregnant at the moment of interview

• 95% of all ever-married women had been pregnant before

• The average number of previous pregnancies per married woman was nearly

5 For women above the age of 35 years, the mean number of previous pregnancies exceeded 7

• About 86% of all previous pregnancies were reported to have resulted in live births

• In average, women were 18.8 years old when they delivered their first child

• The average interval between two deliveries has been estimated at 2.5 years The younger the women, the shorter the average duration was

• Of the total number of reported deliveries (n= 1777), two third had occurred

at home The other third in a health facility

• Only 16 % of all women said they had learned “how babies were made” when they were 15 years old

• In total, 29% of all interviewed women had lost at least one live born child The calculated neonatal and infant mortality rates were high within the surveyed population, but lower than the national estimates

Average number of previous pregnancies, living children and children

20 –

24 years

25 –

29 years

30 –

34 years

35 –

39 years

40 –

44 years

45 –

49 years

0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0

Mean number of previous

3 Antenatal Care (only women who gave birth at least once)

• 79% of the women attended antenatal consultations during their last pregnancy Most of them (86%) went to see a gynaecologist

• The first antenatal visit took place on average at 5 months pregnancy and the mean number of antenatal visits was 3.7

• 70% of the women reported to have received a tetanus vaccination at least once during their last pregnancy and on average 2.7 doses were administered

• The acceptability of antenatal care seemed good Almost all women said they would attend antenatal consultations again next time they were pregnant Only 1.3% reported accessibility to be an obstacle to antenatal care

• The three main reasons reported by the women for attending antenatal services were: 1) check the health of their unborn baby (39%), 2) medical treatment because of illness (28%) and 3) free vaccination (13%)

4 Safe delivery (only women included who gave birth at least once)

• Regarding their last delivery place, 59% of the women delivered at home From the 41% of the women who have given birth in a health structure, 87% went to a public health structure (hospital or health centre) Most of the women (83.5%) were satisfied with the care they had received in the health structure

• The reasons why the women delivered at home were various Geographic inaccessibility counted for 32%, cultural barriers for 18%, financial barriers for 17% and the bad security situation for 11% of all mentioned obstacles Even

if the women did not mention that they preferred to deliver at home, we presume this is an important factor, since 36% of the women said they would deliver at home again next time they were pregnant

• About 55% of the women reported to be involved in the decision-making regarding the place of birth of their children

• 56% of the last deliveries were assisted by skilled health personnel Logically almost all institutional deliveries were assisted by skilled staff, most often by a (gynaecologic) doctor (75%) But also 26% of all home deliveries were attended by skilled personnel, mainly midwifes

• Among the unskilled attendants, female relatives were most popular (48% of all home deliveries) Traditional Birth Attendants assisted in 17,5% of all reported last home deliveries

• Only 1.6% of the interviewed women delivered through caesarean section This percentage is low as according to ICPD+5, average national caesarean section rates vary between 5 and 15%

5 Maternal mortality

The maternal mortality rate among the surveyed population was - roughly estimated through the indirect sisterhood method - 1756/100.000 women of reproductive age (95% confidence interval = [840 to 3496])

Even if imprecise and not representative for the total population, it is a very high rate and coherent with recent published figures by UNICEF (1600 per 100.000 live births, 95% CI [1100 – 2000])

• 40% of the women considered their family size met (most of them being more than 30 years old), but only 23% were currently using a FP method, indicating there is still an unmet FP need

• Among the non – users of any FPmethod, 18% were pregnant 52% did not know about any method to delay or avoid pregnancy Lack of knowledge can therefore be considered as the most important obstacle to FP services Among the remaining 30%, most women wanted another child,

• 13% had fear of the side effects of contraceptives; 10% said they were culturally not allowed to use any FP method and 8% mentioned financial or geographic barriers

• 16% of all married women were using modern contraception and 7% a natural family planning method Among the modern methods, the IUD seemed most popular Among the natural methods, withdrawal was most mentioned, followed by periodic abstinence When asked which method the women would prefer to use, preference was given to modern family planning methods The relative preference given to a particular modern contraception method was very similar to the distribution of currently used methods

Child wish , FP use and Pregnancy

0% 16% 28% 52% 61% 78% 88%

0% 7% 26% 29% 38% 18% 50%

67% 42% 31% 21% 19% 8% 5%

15 – 19 years

20 – 24 years

25 – 29 years

30 – 34 years

35 – 39 years

40 – 44 years

45 – 49 years

7 Reproductive Tract Infections (RTI) /

Sexually Transmitted Infections (STI)

• Only 24% of the interviewed women said to have knowledge of any STI Among the STIs they knew, HIV / AIDS was the most mentioned (72%), followed by gonorrhoea

• The sources of information regarding STIs were - in order of importance- a person from a health facility (43%), followed by relatives (18%), radio (16%), reading (9%) and television (8%)

• Even women who knew about STIs, were badly informed on prevention mechanisms: 29% of them wrongly supposed they could avoid STIs through good general hygiene and bathing The use of a condom was very rarely mentioned as a prevention method for STIs

• 36% of the women had ever heard about HIV/AIDS and 80.5% of these women claimed to know the transmission ways of the virus Nevertheless their real knowledge turned out to be quite low Almost half of the women who claimed to know the ways of transmission, believed one could be infected with HIV/AIDS through kisses and hugs and 42% thought they could get infected through mosquito bites Only 19% gave correct answers

• 54% of the women said they knew what a condom was (Note: prompt knowledge among the interviewed women on condoms as FP method was 33%) Less than 25% of them said they had used or would be using a condom as protection against sexually transmitted infections

8 Health and Gender issues

• Most of the women considered themselves to be in “normal” health (between

“very bad” and “very good”) The perceived health condition one year earlier (just before American bombing started) was not significant better

• Only 25% of the women mentioned medical care as a priority to improve their health condition Improved access to drugs was perceived as much more needed than access to health structures The other priority needs concerned basic needs such as food, housing and money for daily survival 12% of the women said a better security situation was the most needed for being healthier

• 79% of the women interviewed agreed with the statement that “a woman should be allowed to choose a husband.” 87% agreed that “a woman should have the right to decide on her number of children”

• 76% of the women did agree with the statement that “it is wife’s duty to have sex with her husband, even if she does not want” 57% agreed even so with the idea that “a husband has the rights to beat his wife if she disobeys him.”

• Almost all women (98%) seem to perceive the importance of education, since

98 % agreed that all girls should learn to read and to write The mean age till which a girl should be attending school was 19.4 years according the interviewed women

• The best age for a girl to marry was considered 20.2 years, nearly 3 years older than the median age at which the interviewed women got married themselves

C Factors determining some reproductive health indicators:

• Multivariate analysis showed a strong positive and significant association between the educational level of the woman and most of the reproductive health parameters under study Use of antenatal care services (OR 4.8), institutional delivery (OR 2.3), skilled assistance at delivery (OR 2.1), use of family planning (OR 4.6) were all associated with schooling of the woman

• Attending antenatal care during the last pregnancy was found to be independently associated with institutional delivery (OR 2.8), skilled assistance at birth (OR 3.4) and better knowledge of FP methods

• Experience of some particular problems pre-, intra or post- partum, appeared not

to be significantly related with skilled birth attendance and/or delivery in a health facility Yet the questioned symptoms - like severe vaginal bleeding before or after delivery, high fever and weakness, general oedema and weakness, prolonged labour, convulsions / cramps - are considered as potentially dangerous, in which case institutional delivery were preferable

• Besides knowledge on any FP method, the use of FP methods was associated with educational level of the mother, older age and with the desired family size

• Overall, the use of reproductive health care services improved with the educational level of the mother Yet, only small differences were found between primary and secondary or higher education

• No association was found between the educational level of the women’s husband, husband’s literacy and profession, ethnical group, economical status… and the studied reproductive health parameters

D Conclusion and recommendations

This study shows that:

• The desired family size expressed by the Afghan women as well as the high fertility at young age reflects the importance and emphasis put on the reproductive role of the women in the Afghan society

• Even within this privileged group of women, maternal mortality rate was found

to be very high and the caesarean section rate far too low

• The knowledge on sexual and reproductive health in general and on more particular aspects like family planning and STIs is low Yet, this survey was held within a privileged group of women: living in Kabul and having access to primary health care We presume this knowledge to be even worse in rural areas

• Socio-cultural factors do play a very important role in the use and non-use of some reproductive health care services like emergency obstetrical care and family planning services

• Reproductive health should be seen in a broader perspective than just from a medical point of view Education and women’s social position are at least as important

This KAP survey did not assess potential barriers to reproductive health services like geographic accessibility, quality of services and staff training And surely this survey does not want to undermine the importance and need for appropriate medical services in Afghanistan The lack of health infrastructures, of trained health staff etc… do play a capital role in the utterly bad Afghan reproductive health indicators But besides that, we want to emphasize the influence of the entire society on the reproductive health indicators and the importance of a multi-sectoral approach in order to improve reproductive health in a context like Afghanistan

Education of girls / women, empowerment of the social position of women, and community education are three key elements in this process As such, one can expect that it will take many years of social investment and of commitment to peace before reproductive health can be achieved for the majority of Afghan women

INTRODUCTION

Many reproductive health indicators remain unknown in Afghanistan But partial as they are, the existing figures reflect a disastrous reproductive health situation

E.g mortality and morbidity rates for women and children are amongst the highest in

the world (source: UNICEF / WHO)

o Maternal mortality = 1.600 per 100,000 live births (highest in the world)

o Under 5 mortality = 257 per 1,000 live births (5th highest in the world)

o Infant mortality = 161 to 165 per 1,000 live births

The needs within the area of reproductive health care are enormous Yet, improving

RH is not an easy goal in Afghanistan Because of the multiple problems, any initiative to improve the RH status of the population will have to be socially integrated and culturally well accepted Understanding how women perceive their reproductive health and rights is an absolute condition for the success of a program considering the promotion of women’s health and rights

In this perspective, we need a far better understanding of what women’s position in society currently is and what women actually want

We hope this KAP study can contribute to this broader over-all goal of better health for the Afghan population

o To document the knowledge on family planning methods, on STIs, …

o To document prevailing opinions regarding gender issues

METHODOLOGY

Type of survey

Cross-sectional study with descriptive objectives

Selection of the clinics

Four health care facilities have been selected in Kabul:

• Two general outpatient clinics: Central Polyclinic and Qasabai polyclinic

• Two MCH clinics (Mother and Child Health Clinics): Karte Se and Qalae Zaman Khan

All four clinics were located within the urban area of Kabul city, but in different

geographical area and therefore serving different ethnical and socio-cultural groups

The two MCH clinics received support from international health agencies in terms of

medical supplies, incentives, training and supervision for the staff, equipment, …

The two polyclinics were not supported by any international agency at that time

All clinics were located at relatively considerable distance from one of the 3 public

hospitals in Kabul with obstetrical services (between 30 minutes (central polyclinic)

and 2 hours (Qasabai polyclinic) walking distance)

Selection of the women

From all the adult women presenting themselves at the above-mentioned 4 clinics, a

systematic sample was taken (sampling interval: average number of adult women

attending the clinic divided by 10)

Only women of reproductive age – between 15 years up to 49 years – were selected

for an interview

When a woman did not match the age criteria or refused to be interviewed, the next

woman attending the consultation was selected

The reason of refusal was noted in a separated sheet In total 18 women (mean age

34 years) refused the interview The reason given was always lack of time Four

hundred sixty eight accepted to participate

Time Frame

The survey was conducted between19 and 31 October 2002 in Kabul

Survey implementation

The survey questionnaire has been developed in English by ICRH in collaboration

with IbnSina Hereafter the questionnaire was translated in Dari

Four female medical surveyors have been selected (two medical doctors, one

medical student and one nurse) and trained during two days

One day field testing of the questionnaire in Dari was done in Kohte Ashrow clinic,

Wardak province

The survey implementation lasted 10 full days, with each surveyor doing about 10

interviews per day (in average 30 minutes per interview) Two IbnSina and one ICRH

staff member did the daily supervision, as well as the daily data entry in Epi-Info

Sample size

Health Centre Type Women

/ day

Sampling interval

Women interviewed

% of total

Period

This sample size permits to estimate most parameters with a precision of about 5%

(with alpha risk=5%)

Analysis

The data were entered in Epi-Info 6.04 Statistical analysis was carried out using the

SPSS 11.0 software package One-Way Anova for equality of means was used for

quantitative variables while chi-square test was used for qualitative data Multivariate

analysis was performed by using the logistic regression “enter” model P values less

than 0.05 were deemed statistically significant

SURVEY RESULTS

1 Characteristics of the Surveyed population

Age

The mean age of the interviewed women was 28.2 years old

Women attending MCH clinics were significantly younger than those attending the polyclinics (p=0.008)

N Mean Age S.D P 25 Median P 75 Min Max

AGE CATEGORIES

45

- 4

9 years

40

- 44 year s

35

- 39 year s

30

- 3

4 years

25

- 2

9 years

20

- 2

4 years

15

- 19

year s

The majority of the women interviewed were Tajik (62 %), followed by Pashtun (20

%) and then Hazara (17 %)

Ethnical groups Frequency Percent

Literacy and Schooling

Out of the 468 women interviewed, 27% declared to be able to read a newspaper

easily and 11% with some difficulty The remaining 62% was illiterate

64% did not attend a regular school From the 169 women who did go to school,

about 60% continued school after primary school

Schooling level Frequency Percent

Literacy among women attending the polyclinics was significantly higher than among

those attending the MCH clinics (chi square, p=0.001)

Easily With difficulty Not at all Able to read

newspaper N % N % N %

The female adult literacy rate found in this survey is low but still quite better than the

national estimates for the whole of Afghanistan: 16% (10 – 21%) for adult women

(source: UNICEF)

This can be explained by two selection bias:

o More literate women in urban areas like Kabul city

o More literate women attending health facilities

Marital status

Out of the 468 women between 15 and 49 years old, 86.3% were married

Marital status Frequency Percent

For the 419 ever married women, the mean age at marriage was 17.2 years 16,2%

of them married at the age of 14 years or younger

The mean age of marriage did not differ significantly among the four different health

Of the married women, 73 (15.6 %) reported their husband to be unemployed 46.6

% were unemployed since less than 6 months; 24.6 % between 6 months and 5

years and 28.8% were unemployed since 5 years and more

100 women or 24.9% said that their husbands were doing occasional labour 228 or

48.7% of women’s husbands were reported to have a more or less permanent

regular job

Profession of the husband

Most of the husbands had an income trough small private business More than a

quarter was on official government pay roll

Sector Clarification Frequency Percent

Informal sector Street vendor, daily worker, porter,

Literacy level and Schooling of husbands

Out of 401 married women, 56.4 % declared that their husbands were able to read a

newspaper easily and 13.0 % with some difficulty Only 30.7 % of the husbands

appeared to be illiterate

68.9 % of the husbands were reported to have been to a regular school

From the 276 husbands who did attend school, almost 75 % continued school after

No difference in literacy rate was found for the husbands of the interviewed women

attending polyclinics or MCH clinics (chi square, p=0.228)

As for the women, the literacy rates of the husbands was better than the national

estimates for the whole of Afghanistan: 46% (18 – 51%) for adult men (source:

UNICEF)

Living status

Out of 463 women, 237 or 51.2 % had been living in the place where they are living

now since birth

For the other 226 women, the time of arrival at the current place of living varied

o 82 or 36.3 % arrived into Kabul less than 6 months ago

o 33 or 14.6 % arrived between 6 months ago but less than 1 year ago

o 50 or 22.1 % arrived between one and five years ago

o 61 or 27.0 % arrived five years or more ago in Kabul

About 38% of these women said they were returnees; about 42 % called themselves

displaced because of war and about 20 % moved to Kabul for another reason

(economic displacement most frequently mentioned as well as for family reasons)

For the global surveyed population, the living status is reflected in the table below:

Living status Frequency Percent

Hence, nearly half of the interviewed women currently living in Kabul were not born

there Half of the women who arrived at a later moment (25% of the global surveyed

population) arrived in Kabul during the last year, after the fall of the taleban regime

These figures correspond with realities observed by other agencies: most of the

returnees are reported to end up in Kabul (UNHCR), visible overcrowding in Kabul

and rising number of homeless people in Kabul

This continuous influx of people in Kabul city puts serious constraints on the already

limited capacity of the health care system

Geographic accessibility of the health care facility

A question was asked regarding the distance between the health structure the

women were attending and their house The average walking distance was around

25 minutes Around 38 % of the interviewed women had to walk less than 15

minutes, but about 17% had to walk more than one hour to reach the health facility

Health care seeking behaviour

The first place the women mentioned to go to for treatment when they were sick, is

shown in the following table:

Sector Clarification Frequency Percent

Other

Private sector

SUBTOTAL private sector 196 42.2 %

Public sector

SUBTOTAL public sector 247 53.1 %

More than half of the women seemed to prefer the public health sector for treatment

in first instance Public primary health care services are usually inexpensive

Nevertheless, the table also shows the importance of the private sector as health

care provider in an urbanised area like Kabul city, despite the higher costs

Health care permission

Before going to a health centre, most of the women reported to have to ask

permission from either their husband or another male relative

From the women who did never or sometimes ask permission, 65.6% were 30 years

2 Obstetrical indicators

Pregnancies

Of 402 currently married women 116 women or 28.7 % said to be pregnant at the

time being while 9 (2.2%) did not know

The interviewed pregnant women were significantly younger than the non-pregnant

ones attending the consultations (anova p=0.000) About half of the currently

pregnant women (47.5 %) were 24 years old or younger

Of all 417 ever-married women (403 married and 14 widows), 95.2% had ever been

pregnant before (disregarding current pregnancies) The mean number of total

previous pregnancies per age group as well as the median and sum of previous

pregnancies is presented in following table

The national total fertility rate is estimated at 6.8 (Note: Total fertility rate= total

number of children a woman would have by the end of her reproductive period if she

experienced the currently prevailing age-specific fertility rates throughout her

% before pregnant

Mean # pregnanc

% women

> = 6 times pregnant

41% of the women who had ever been pregnant before had been pregnant at least

6 times This percentage increases to more than 60 % after the age of 30 years,

and to 75 % in women aged 40 and more

Pregnancy outcome

Of all counted pregnancies in the obstetrical history of the interviewed women, about

86% resulted in live births

Outcome of previous pregnancies Age category Sum all

Live births

85%

Still births 2%

Age of first delivery

For 387 (ever) married women who had been pregnant before, the mean age at first

delivery was 18.8 years (note: delivery has been defined as delivery of dead or live

born baby, but excluding abortions)

Teenage pregnancies – mother between 13 and 19 years old - are internationally

recognised as a risk factor for the mother as well as for the baby

Nevertheless, more than two third of the interviewed (ever) married women (67.2%)

had delivered their first child before the age of 20 years and almost 4% even before

the age of 15 years old

For 386 (ever) married women, the mean interval between their wedding age and

their age at first delivery was only 1.7 years (median 1 year)

Interval between deliveries

The mean interval between the consecutive deliveries has been calculated through dividing the time interval between the first and last delivery (in years) by the number

of previous deliveries minus 1

The average time between two deliveries has been estimated at about two and a half years only The younger the age of the woman, the shorter the interval between

her pregnancies appeared to be

Age category N Mean interval S.D

Home deliveries versus institutional deliveries

Out of a total of 1777 deliveries, 1196 or 67.3 % were reported to have occurred at home and 581 or 32.7 % in a health facility

From the 389 women who had ever given birth, 39.3 % delivered exclusively at home and only 18.8% delivered exclusively in a medical facility

41.9% of the women delivered some children at home and some in a health facility

Sexual education

Only 16.2 % of the women (73 on 451) said that they knew “how babies were made”

when they were 15 years old

The ones who were informed, got the information from a relative in 64% of all cases 31% were informed through the health centre

Breastfeeding knowledge

80.5 % of the women (363 on 451) said yes when they were asked whether anyone

had informed them of the benefits of breastfeeding their babies

69.5 % out of these 363 women got the information from someone from a health facility, 22 % from relative and 8.5 % through other channels (like books, radio and TV)

Child mortality

Of 389 interviewed mothers who delivered at least one live child , 114 women or

29.3% had lost at least one of their children

In total 185 dead children were counted among the surveyed population:

o After one day but within 7 days after birth: 18

o After one week but before the age of 1 year: 75

Taking in account the moment of the last delivery, the counted deaths results in following estimated mortality rates for the surveyed population:

Still birth rate

= still births / 1000 live births

= 24 still births per 1000 live births (95% C.I 16/1000 to 38/1000)

Perinatal mortality rate

= Deaths occurring during late pregnancy (at 22 completed weeks gestation and more), during childbirth and up to seven completed days of life / 1000 total births

= 50 perinatal deaths / 1000 births (95% C.I 37/1000 to 67/1000)

Early neonatal mortality rate

= deaths occurring within first 7 days after birth / 1000 live births

= 28 early neonatal deaths / 1000 live births (95% C.I 18/1000 to 41/1000)

Infant mortality rate

= deaths occurring before age of 1 year / 1000 live births

= 64 infant deaths / 1000 live births (95% C.I 47/1000 to 86/1000)

These estimates are better than the estimated national figures This was to be expected as the women surveyed belonged to a favoured group: living in Kabul city and having access to primary health care facility

Even within this privileged group indicators are very poor compared to international standards

The high neonatal mortality rates reflect a bad obstetric and paediatric care

system

National estimate (WHO/ UNICEF)

Surveyed population

Developed countries

Developing countries

3 Antenatal Care

Note: All questions in this and in the following chapter were related to the last pregnancy resulting in the delivery of a dead or live born child (thus with exclusion of abortions as well as current pregnancies)

In average the last delivery took place 2.6 years ago (N= 390 women; S.D 0.16;

median 2 years; P25 1 year; P75 3 years) Four women (1%) reported that their last baby was born death Probably the number of stillbirths is underestimated, and misclassified as abortions

Antenatal Care Attendance rate

Out of 389 women, 308 women or 79.2% attended the antenatal consultations during

their last pregnancy

The person the women went to see for antenatal care was:

- Traditional Birth Attendant (TBA): 2 or 0.6%

- Midwife: 28 or 9.1%

- General doctor: 7 or 2.3%

- Gynaecologist: 266 or 86.4%

- Other: 5 or 1.6%

Thus 77.6% of the women were attended at least once during last pregnancy by

skilled health personnel This is better than the world average that is 70% (98% in industrialized and 65% in developing countries)

Almost all antenatal care providers were female (only 5 or 1.6% were male (2 doctors and 3 gynaecologists))

First antenatal visit and regularity

The first antenatal visit took place in average at 5 months pregnancy

• 25.4 % went for first antenatal services during the first trimester

• 50.8 % went during second trimester

• 23.8 % went during the last trimester

In average 3.7 antenatal consultations took place during the last pregnancy for 307

women attending the ANC (P25: 3 visits ; median 3 visits; P75 5 visits)

But 34 women or 11.1% went only once for antenatal care On the other hand 25 interviewees or 8.2% did go a quite excessive number of times (7 visits or more)

1 visit 2 visits 3 visits 4 visits 5 visits More than 5

11.1 % 13.4 % 31.3 % 18.9 % 12.1 % 13.3%

Tetanus vaccination

Out of the 389 women, 70% received at least one tetanus vaccination during their

last pregnancy (in average 2.7 doses)

82.3% of the women had been vaccinated at least once in lifetime In average 4.6 doses were administered

Still 42.1% of the women had received only 3 doses or less till the moment of their last delivery

% received >= 1 tetanus vaccine

Mean doses received

Registered on vaccination card

Total (any time before last

delivery)

Reasons / obstacles to antenatal care

The acceptability of antenatal care services was apparently good and accessibility

did not seem to be a major problem

Out of 390 women, 349 women (89.5%) said they would attend antenatal

consultations next time they were pregnant, if they have the possibility to do so

Just 5.1% (20 women) said no and 5.4% (21 women) did not know

Among the mentioned barriers , only 14 % were related to lack of accessibility to

ANC

OBSTACLES Clarification frequency Percent

The main reason the women expressed for going to the antenatal consultations is

presented in the table below:

Reasons for ANC Frequency Percent

I am sick and want medical treatment for myself 104 28.4 %

4 Safe delivery

Last delivery place

Regarding the last place the interviewed women delivered, the majority of the women

said to have given birth at home

From the ones who delivered in a health institution, almost 87% choose for a public

A high percentage (83.5%) of the women who delivered in a health institution, were

(very) satisfied with the care they had received in that institution

Institutional delivery care

55.8 % of the last deliveries were assisted by skilled health personnel

In more than 99%, a female person assisted the last delivery (3 exceptions were

noted: 2 husbands and one male gynaecologist)

Skilled birth attendance occurred logically for almost all institutional deliveries

But also about 26 % (59 out of 229 women) of the women who delivered at home

were attended by a health professional Mostly midwifes were appealed to in this

case (2/3 of skilled deliveries at home)

Equally interesting is the fact that among the non-skilled personnel, female relatives

were usually assisting the home deliveries, twice as frequently as TBAs

Among the skilled personnel, gynaecologists were the most represented category of

health personnel

For home deliveries (%)

For institutional deliveries (%)

Total frequency

Total percent

Assistance at home deliveries

Gynaecol

5%

Traditional Birth Attendant18%

Nobody7%

Doctor0%

The percentage of births attended by skilled personnel for the surveyed population is

far higher than the national estimate of 8 to 11 %

This can be explained by following factors:

• More skilled health professionals are present in Kabul as well as 3 accessible

public maternity hospitals in Kabul city

• Selection bias: only women who have access to health facilities are included

in the survey

Main reason for not delivering in a health structure

Women who delivered at home were asked why they had not delivered in a health

facility The results show a variety of reasons Geographic inaccessibility represents

32.4 % of all causes; cultural and financial barriers represent respectively 17.8 % and

16.9 %

Clarification Frequency percent

Geographic

Financial

accessibility

Husband - family did not allow me to / I had no permission to go

Cultural

accessibility

Not the general way of doing – thinking over here 13 5.8 %

Personal

factors

Environmental

factors

Health care

related

We expect geographic inaccessibility to be over reported by the interviewed women since it is quite an ‘easy answer” A number of data confirm this:

- No difference in last delivery place was found between the 4 different clinics (However the distance between each clinic and the public maternity hospitals

is quite different: about 30 minutes for Central polyclinic and about 2 hours for people living in Qasabai polyclinic.) These differences in distance did not affect the percent home vs institutional deliveries in the different sites

- Transport is quite easy in Kabul Cars and taxi’s are everywhere

- About 36% of the women who delivered at home the last time (74 on 205 women), want to deliver again at home next time

This suggests that some women simply prefer to deliver at home This might

be the most important reason why women did not deliver in a health facility last time, even if they did not mention this explicitly as a reason

Problems during pregnancy, during or after delivery?

43.4 % (168 out of 387 women ) women reported to have had a problem before , during or after their last delivery

The women who had experienced any problem (168 women) responded positively to

a high percentage of potentially dangerous symptoms or signs, resumed in the next table:

Symptom YES

(n = 168)

NO (n = 168)

% of all women who delivered

Prolonged labour (contractions >

TOTAL (Any problem before,

during or after delivery)

Way of delivery

357 out of 383 women had delivered their last child in a “normal” way

Only 1.6% of the interviewed women delivered through caesarean section This

percentage is low and indicates that only a small proportion of all women with

pregnancy complications do reach the hospital

The caesarean section rate is an internationally recognised obstetric service

indicator The minimal international acceptable level (according ICPD +5) sets that

caesarean sections should account for 5 to 15 % of all births The rate found during

this survey is far below this figure

Quite surprisingly is the observation that forceps has been more used than vacuum

extractor This might reflect the lack of material resources of the Afghan reproductive

health care system and / or a different schooling of the gynaecologists

Way of delivery Percent (frequency) Specification Frequency (percent)

Normal delivery 93.2 % (n= 357)

With vacuum extractor

4 (22%) Assisted delivery 4.7 % (n= 18)

Women were asked where they would ideally deliver next time and who they would

like to assist their next delivery,

72.0 % of the women said they would like to deliver in a health facility next time

The table below shows the differences between the desired next delivery place

versus the place where the women delivered last time

About 36% of the women who delivered at home the last time (74 on 205 women),

want to deliver again at home next time Yet, the majority (57 %) prefers to give birth

in a health structure next time About 92 % of the women who delivered in a health

structure last time (140 out of 152 women) want to give birth in a health facility again

Most women would like to be delivered by a skilled health personnel (83.6%) More

than half of the women (51.7%) prefer a gynaecologist to assist their next delivery

Desired home delivery was strongly associated with desired attendance by a female

relative

For wished home delivery (%)

For wished institutional delivery (%)

Total frequency

Total percent

Female relative 58%

From the women who delivered without assistance of a skilled health personnel last

time (145 women), 34.5 % would again deliver without a skilled person next time, if

they would have all options open However about two third of these women (65.5 %)

seem to realize the importance of delivering with a skilled health personnel in the

future

Decision making regarding delivery place

In about 55 % of all cases, the women reported to decide themselves or to be

involved in the decision-making regarding the place of delivery

The woman’s husband appeared to be the second decision maker, followed by her

mother-in-law