Nasratullah Ansari

Introduction: After the Taliban took over the Afghan government in August 2021, funds for the public healthcare system were suspended, the economy collapsed and female education and mobility were restricted. We examined the impact of the takeover on the availability, accessibility, acceptability and quality of public healthcare in Afghanistan. Methods: We conducted a mixed-methods study to assess the impact of the Taliban takeover on Afghanistan’s public healthcare system. Key informant interviews with healthcare workers and managers were combined with interrupted time series analysis on maternal and child health services and the availability of medicines and healthcare workers from January 2019 to September 2023. Results: Disruptions in service provision and availability of healthcare workers were minimal, temporary and mostly due to interrupted funding. Following the political change, more patients visited public healthcare facilities as safety improved accessibility and private healthcare became less affordable. Acceptability and quality of care were affected by continued increased patient load, medicine shortages and insufficient training planning. Healthcare workers reported incidents where chaperones obstructed access to healthcare facilities for female patients and healthcare workers. Conclusion: Afghanistan’s public healthcare system showed incredible resilience amidst funding disruptions and conflict until 2023. Healthcare facilities and underserved communities are more accessible due to improved safety, but the increased patient load and economic collapse add pressure to the system. Development partners must safeguard access to and participation in healthcare for women.

During the past two decades, the Afghan government, along with the international community, has developed a system aimed at improving access to essential healthcare services under Afghanistan’s challenging sociopolitical and geographical circumstances. In 31 provinces, nonstate actors competed for fixed-term contracts to implement a predefined package of healthcare services. In three provinces, the government organized the provision of healthcare services. An independent third party monitored service provision, including access to medicines. This study examines the availability of essential medicines in Afghanistan’s public healthcare facilities and how this is shaped by sociopolitical challenges, geographical barriers, and the organization of the healthcare system. Between March and July 2021, enumerators collected data at 885 healthcare facilities across Afghanistan. For our analysis, we combined data on medicine availability and the functioning of the health system with publicly available information about geographical and sociopolitical factors, including security incidents. Using regression analysis, we identified facility-, district-, and provincial-level factors related to medicine availability in public healthcare facilities. On average, 70% of 31 selected essential medicines were available in 2021. The availability of medicines varied significantly between provinces and was considerably higher in those where services were contracted out to nonstate actors (n = 31; 91%) compared to provinces where service provision was organized by the government (n = 3; 9%). The most important drivers of variation in medicine availability included geographical barriers, securing and allocating funds at the provincial level, and organizing and sustaining physical capacity at the facility level. Insecurity was not a key factor driving variation in medicine availability. Despite the sociopolitical challenges in 2021, the availability of essential medicines in public healthcare facilities was relatively high. The results suggest that decentralized procurement of medicines by nonstate actors and timely payment of funds contribute to medicine availability. Strategies to improve medicine availability should target hard-to-reach areas and lower-level facilities.

Background: Hemorrhage is the leading cause of maternal mortality worldwide and accounts for 56% of maternal deaths in Afghanistan. Postpartum hemorrhage (PPH) is commonly caused by uterine atony, genital tract trauma, retained placenta, and coagulation disorders. The purpose of this study is to examine the quality of prevention, detection and management of PPH in both public and private hospitals in Afghanistan in 2016, and compare the quality of care in district hospitals with care in provincial, regional, and specialty hospitals. Methods: This study uses a subset of data from the 2016 Afghanistan National Maternal and Newborn Health Quality of Care Assessment. It covers a census of all accessible public hospitals, including 40 district hospitals, 27 provincial hospitals, five regional hospitals, and five specialty hospitals, as well as 10 purposively selected private hospitals. Results: All public and private hospitals reported 24 h/7 days a week service provision. Oxytocin was available in 90.0% of district hospitals, 89.2% of provincial, regional and specialty hospitals and all 10 private hospitals; misoprostol was available in 52.5% of district hospitals, 56.8% of provincial, regional and specialty hospitals and in all 10 private hospitals. For prevention of PPH, 73.3% women in district hospitals, 71.2% women at provincial, regional and specialty hospitals and 72.7% women at private hospital received uterotonics. Placenta and membranes were checked for completeness in almost half of women in all hospitals. Manual removal of placenta was performed in 97.8% women with retained placenta. Monitoring blood loss during the immediate postpartum period was performed in 48.4% of women in district hospitals, 36.9% of women in provincial, regional and specialty hospitals, and 43.3% in private hospitals. The most commonly observed cause of PPH was retained placenta followed by genital tract trauma and uterine atony. Conclusion: Gaps in performance of skilled birth attendants are substantial across public and private hospitals. Improving and retaining skills of health workers through on-site, continuous capacity development approaches and encouraging a culture of audit, learning and quality improvement may address clinical gaps and improve quality of PPH prevention, detection and management.

Objective To assess changes in readiness to provide emergency obstetric and newborn care (EmONC) in health facilities in Afghanistan between 2010 and 2016. Methods A secondary analysis was performed of a subset of data from cross-sectional health facility assessments conducted in December 2009 to February 2010 and May 2016 to January 2017. Interviews with health providers, facility inventory, and record review were conducted in both assessments. Descriptive statistics and χ² tests were used to compare readiness of EmONC at 59 public health facilities expected to provide comprehensive EmONC. Results The proportion of facilities reporting provision of uterotonic drugs, anticonvulsants, parenteral antibiotics, newborn resuscitation, and cesarean delivery did not change significantly between 2010 and 2016. Provision of assisted vaginal deliveries increased from 78% in 2010 to 98% in 2016 (PPPP=0.028). Conclusion Despite a few positive changes, readiness of EmONC services in Afghanistan in 2016 had declined from 2010 levels.

Afghanistan faces a high burden of maternal and neonatal morbidity and mortality. Hypertensive disorders of pregnancy, including pre-eclampsia and eclampsia (PE/E), are among the most common causes of maternal and neonatal complications. Hypertensive disorders of pregnancy can lead to fatal complications for both the mother and fetus. The 2016 Afghanistan National Maternal and Newborn Health Quality of Care Assessment assessed quality of early detection and management of PE/E in health facilities and skilled birth attendants’ (SBAs) perceptions of their working environment. All accessible public health facilities with an average of at least five births per day (n = 77), a nationally representative sample of public health facilities with less than five births per day (n = 149), and 20 purposively selected private health facilities were assessed. Methods included a facility inventory and record review, interviews with SBAs, and direct clinical observation of antenatal care (ANC), intrapartum care and immediate postnatal care (PNC), as well as severe PE/E case management. Most facilities had supplies and medicines for early detection and management of PE/E. At public health facilities, 357 of 414 (86.2%) clients observed during ANC consultations had their blood pressure checked and 159 (38.4%) were asked if they had experienced symptoms of PE/E. Only 553 of 734 (72.6%) SBAs interviewed were able to correctly identify severe pre-eclampsia described in a case scenario. Of 29 PE/E cases observed, 17 women (59%) received the correct loading dose of magnesium sulfate (MgSO4) and 12 women (41%) received the correct maintenance dose of MgSO4. At private health facilities, 39 of 45 ANC clients had their blood pressure checked and 9 of 45 (20%) were asked about symptoms of PE/E. Fifty-four of 64(84.4%) SBAs in private facilities correctly identified severe pre-eclampsia described in a case scenario. Notable gaps in SBAs’ knowledge and clinical practices in detection and management of PE/E in various health facilities increase the risk of maternal and perinatal mortality. Continuing education of health care providers and increased investment in focused quality improvement initiatives will be critical to improve the quality of health care services in Afghanistan.

Introduction: Afghanistan has a maternal mortality ratio of 400 per 100,000 live births. Hemorrhage is the leading cause of maternal death. Two‐thirds of births occur at home. A pilot program conducted from 2005 to 2007 demonstrated the effectiveness of using community health workers for advance distribution of misoprostol to pregnant women for self‐administration immediately following birth to prevent postpartum hemorrhage. The Ministry of Public Health requested an expansion of the pilot to study implementation on a larger scale before adopting the intervention as national policy. The purpose of this before‐and‐after study was to determine the effectiveness of advance distribution of misoprostol for self‐administration across 20 districts in Afghanistan and identify any adverse events that occurred during expansion.Methods: Cross‐sectional household surveys were conducted pre‐ (n = 408) and postintervention (n = 408) to assess the effect of the program on uterotonic use among women who had recently given birth. Maternal death audits and verbal autopsies were conducted to investigate peripartum maternal deaths that occurred during implementation in the 20 districts.Results: Uterotonic use among women in the sample increased from 50.3% preintervention to 74.3% postintervention. Because of a large‐scale investment in Afghanistan in training and deployment of community midwives, it was assumed that all women who gave birth in facilities received a uterotonic. A significant difference in uterotonic use at home births was observed among women who lived farthest from a health facility (> 90 minutes self‐reported travel time) compared to women who lived closer (88.5% vs 38.9%;P< .0001). All women who accepted misoprostol and gave birth at home used the drug. No maternal deaths were identified among those women who used misoprostol.Discussion: The results of this study build on the findings of the pilot program and provide evidence on the effectiveness, primarily measured by uterotonic use, of an expansion of advance distribution of misoprostol for self‐administration.

A paucity of skilled health providers is a considerable impediment to reducing maternal, infant, and under‐five mortality for many low‐resource countries. Although evidence supports the effectiveness of community health workers (CHWs) in delivering primary healthcare services, shifting tasks to this cadre from providers with advanced training has been pursued with overall caution—both because of difficulties determining an appropriate package of CHW services and to avoid overburdening the cadre. We reviewed programs in Rwanda, Afghanistan, Nigeria, and Nepal where tasks in delivery of health promotion information and distribution of commodities were transitioned to CHWs to reach underserved populations. The community‐based interventions were complementary to facility‐based interventions as part of a comprehensive approach to increase access to basic health services. Drawing on these experiences, we illuminate commonalities, lessons learned, and factors contributing to the programs’ implementation strategies to help inform practical application in other settings.

Complications of abortion are one of the leading causes of maternal mortality worldwide, along with hemorrhage, sepsis, and hypertensive diseases of pregnancy. In Afghanistan little data exist on the capacity of the health system to provide post-abortion care (PAC). This paper presents findings from a national emergency obstetric and neonatal care needs assessment related to PAC, with the aim of providing insight into the current situation and recommendations for improvement of PAC services. A national Emergency Obstetric and Neonatal Care Needs Assessment was conducted from December 2009 through February 2010 at 78 of the 127 facilities designated to provide emergency obstetric and neonatal care services in Afghanistan. Research tools were adapted from the Averting Maternal Death and Disability Program Needs Assessment Toolkit and national midwifery education assessment tools. Descriptive statistics were used to summarize facility characteristics, and linear regression models were used to assess the factors associated with providers’ PAC knowledge and skills. The average number of women receiving PAC in the past year in each facility was 244, with no significant difference across facility types. All facilities had at least one staff member who provided PAC services. Overall, 70% of providers reported having been trained in PAC and 68% felt confident in their ability to perform these services. On average, providers were able to identify 66% of the most common complications of unsafe or incomplete abortion and 57% of the steps to take in examining and managing women with these complications. Providers correctly demonstrated an average of 31% of the tasks required for PAC during a simulated procedure. Training was significantly associated with PAC knowledge and skills in multivariate regression models, but other provider and facility characteristics were not. While designated emergency obstetric facilities in Afghanistan generally have most supplies and equipment for PAC, the capacity of healthcare providers to deliver PAC is limited. Therefore, we strongly recommend training all skilled birth attendants in PAC services. In addition, a PAC training package should be integrated into pre-service medical education.

As part of a National Emergency Obstetric and Newborn Care (EmONC) Needs Assessment, a special study was undertaken in July 2010 to examine the quality of cesarean deliveries in Afghanistan and examine the utility of direct clinical observation as an assessment method in low-resource settings. This cross-sectional assessment of the quality of cesareans at 14 facilities in Afghanistan included a survey of surgeons regarding their routine cesarean practices, direct observation of 29 cesarean deliveries and comparison of observations with facility records for 34 additional cesareans conducted during the 3 days prior to the observation period at each facility. For both observed cases and record reviews, we assessed time intervals between specified points of care-arrival to the ward, first evaluation, detection of a complication, decision for cesarean, incision, and birth. All time intervals with the exception of “decision to skin incision” were longer in the record reviews than in observed cases. Prior cesarean was the most common primary indication for all cases. All mothers in both groups observed survived through one hour postpartum. Among newborns there were two stillbirths (7%) in observed births and seven (21%) record reviews. Although our sample is too small to show statistical significance, the difference is noteworthy. In six of the reviewed cesareans resulting in stillbirth, a fetal heart rate was recorded in the operating theater, although four were recorded as macerated. For the two fresh stillbirths, the cesarean surgeries were recorded as scheduled and not urgent. Direct observation of cesarean deliveries enabled us to assess a number of preoperative, postoperative, and intraoperative procedures that are often not described in medical records in low resource settings. Comparison of observations with findings from provider interviews and facility records allowed us to infer whether observed practices were typical of providers and facilities and detect potential Hawthorne effects.