Addressing maternal nutrition service delivery gaps in Afghanistan: Policy and programming opportunities
Dr Zakia Maroof is a Nutrition Specialist working with UNICEF Afghanistan.
Dr Homayoun Ludin is an Afghan doctor working with the Ministry of Public Health.
Dr Zelaikha Anwari is an Afghan doctor serving as a Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) director in the Ministry of Public Health since February 2015.
Suzanne Fuhrman is a Nutrition Manager working with UNICEF Afghanistan.
Maureen Gallagher is Chief of Nutrition Section with UNICEF Afghanistan.
Background
Afghanistan is entering its fourth decade of unrest and conflict; 40 years that have left an indelible impact on the country’s women and children. The year 2018 was especially challenging, with a spike in violence, unprecedented levels of drought and food insecurity, increased poverty and a higher number of security incidents compared to past years. Strategic roads that link the different regions and provinces have become highly insecure, adding complexity to programme implementation and further hampering the access of women and children to basic health and social services. Over half of the country’s population (54.5%) live below the poverty line1.
Although there has been much progress in the Afghan health system in the last 15 years, the country continues to have a fragile and challenging healthcare environment and still has among the highest maternal and newborn mortality rates globally. Afghanistan also has among the worst coverage of maternal and child health (MCH) services in the world. Key indicators of service coverage, such as receipt of four or more visits of antenatal care (20.9%), women who deliver in a health facility (56.3%), and those who receive care from a skilled birth attendant (58.8%), remain low2. Only 37.4% of women receive any postnatal care from a skilled health provider, with major disparities and much poorer service provision in conflict-affected and remote areas2. Other important barriers are poverty and women’s lack of decision-making power in the family.
Building an enabling environment at the policy level
Afghanistan joined the SUN Movement in 2018, raising the nutrition agenda to a higher political level. At the same time, it established a multisector nutrition platform, the Afghanistan Food Security and Nutrition Agenda (AFSEN-A), in which 14 ministries, UN agencies and partner organisations discuss joint work to improve the nutrition situation in the country.
Several recent policy decisions show an increasing national commitment to maternal nutrition. Improving maternal nutrition is a core component of the revised National Nutrition Strategy (2019-2023), and the National Nutrition Promotion Strategic Plan (2019-2023; still being finalised) includes specific activities to address current gaps in the Ministry of Public Health’s (MoPH) nutrition promotion; for example, adolescent girls (aged 10-19 years) taking iron and folic acid (IFA) weekly supplementation, and pregnant women taking IFA supplements during pregnancy are key behaviours in the strategy.
Maternal nutrition is included in the revised Infant and Young Child Feeding Strategy, now called the Maternal, Infant, and Young Child Nutrition (MIYCN) Strategy. Moreover, weekly IFA supplementation for adolescent girls has been integrated into the National School Health Policy, ensuring the continuum between adolescent and maternal nutrition. Weekly IFA supplementation is currently available only for school-going adolescent girls, but the 2019 plan includes expansion to out-of-school adolescent girls.
Packaging health services
Afghanistan has faced significant challenges in rebuilding its health system in a fragile-state setting since the Government and international donors and partners began the work in 2001. The MoPH developed the Basic Package of Health Services (BPHS) to delineate the services that should be provided at each level of primary healthcare facility, which includes district hospitals, comprehensive health centres, mobile health teams, basic health centres, health sub-centres and health posts (the latter being the lowest level of service delivery, where volunteer Community Health Workers (CHW) make home visits). The Essential Package of Hospital Services (EPHS) was endorsed in 2005 to provide tertiary-level health services for all Afghan citizens.
BPHS and EPHS nutrition interventions for pregnant postpartum women include: promotion of iodised salt and a balanced diet of micronutrient-rich foods through health education sessions; one-to-one nutrition counselling and food demonstrations; and IFA supplementation. However, to date maternal nutrition interventions have not been prioritised by the non-governmental organisations that are contracted to implement the BPHS and EPHS, and there are no specific indicators currently in place to monitor intervention coverage. For example, antenatal care (ANC) visits are used as a proxy indicator for IFA supplementation, despite evidence that IFA is not always available in health facilities and distribution is sometimes below the required recommendations.
Improving the continuum of maternal nutrition care in service delivery
One of the main gaps in the provision of health and nutrition services in Afghanistan was the provision of one-to-one counselling based on actual client needs. This was not always possible due to the high volume of patients, time pressures for midwives and nurses, and the lack of counselling skills of existing health staff. To address this need, in 2016 the MoPH approved the recruitment of paid female nutrition counsellors for all primary healthcare facilities in 18 out of 34 provinces.
Around 1,500 of this nutrition-specific cadre were recruited and received a 28-day comprehensive nutrition training package, including maternal nutrition. Their services in the 18 provinces were assessed before the initiative was expanded to the entire country. The results of this assessment confirmed that clients regularly gave positive feedback on information and advice they received from nutrition counsellors, and that the counsellors play a positive role in increasing the awareness of nutrition practices.
Following this assessment, nutrition counsellors are now being recruited for the remaining 16 provinces. Based on recommendations, a refresher training is planned for the cadre in the initial 18 provinces. In addition, UNICEF and other development partners have supported the recruitment of one mentor per province to provide on-the-job support to nutrition counsellors as part of their one-year, capacity-building plan.
One-to-one nutrition counselling
The main role of nutrition counsellors is providing individual counselling to women who are pregnant, exclusively breastfeeding and/or nursing and feeding young children. Counselling includes promoting the consumption of micronutrient-rich foods. Nutrition counsellors coordinate with midwives, nurses and vaccinators to ensure there are no missed opportunities to provide nutrition information and advice to women who visit the facility for different reasons. The nutrition counsellors also provide outreach work and, where possible, attend CHW meetings and meet with health shuras3 to share information on nutrition.
The nutrition counsellors will be supported through capacity-building programmes to improve delivery of activities at community level. It is hoped this will assist in building awareness on nutrition, including the importance of maternal nutrition; not only for the mothers themselves, but also for the wellbeing of their children. The counsellors are based in health facilities and link with communities through community health supervisors, whose key role is to supervise and mentor CHWs.
Strengthening service-provision monitoring and tracking
Nutrition counsellors are one of the contact points for distributing the Maternal and Child Health Handbook to women. The handbook is the country’s first-ever home-based maternal, child, health and nutrition record. It combines birth registration, pregnancy monitoring, birth monitoring, vaccination, growth monitoring and childhood-illness monitoring. The handbook also includes messages on maternal nutrition for easy reference for women and families to read and put into practice at home. It has been introduced in three provinces in 2019 and introduction will expand in phases to all provinces by the end of 2021.
The current policy is for pregnant women to attend four ANC visits; however, there are plans to increase this to eight ANC visits, as recommended by WHO, although this may be difficult to achieve due to access issues to health facilities. One way to overcome this constraint is to use the monthly growth monitoring and promotion and food demonstration sessions of the Community Based Nutrition Package (CBNP)4 to provide a regular contact point between pregnant women and CHWs at the community level. CHWs are the volunteer health and nutrition service providers who are closest to communities. However, many partners are working with the same CHWs through convergent and coordinated approaches, which can sometimes overburden the workload of these volunteers.
Challenges to maternal nutrition programming
Access is a particular challenge in the insecure and fragile context of Afghanistan, since government staff and development partners are unable to travel to some parts of the country. Such security limitations make monitoring of maternal nutrition activities very difficult and affect the quality of the services provided; for example, they mean restricted travel for the female nutrition counsellor mentors recruited to provide support to nutrition counsellors.
Administrative data on the coverage of maternal nutrition interventions is lacking as there is currently no indicator in the health management information system. It is important to address this gap to elevate the importance of and build greater accountability for the delivery of maternal nutrition interventions in the health system. In addition, impact indicators such as anaemia prevalence are not regularly integrated into national health surveys. Other challenges to improving maternal nutrition concern irregular supplies of IFA in health facilities, which affects the coverage and continuity of supplementation. The promotion of iodised salt also remains an issue due to several factors, including the higher cost of iodised salt compared to regular salt.
Opportunities for scaling up maternal nutrition services
The Government and its partners have identified several opportunities to integrate all maternal and child nutrition-related activities in a unified package, so that mothers and children receive the complete package of services at each contact point. After finalisation of the MIYCN strategy and operational guidance, comprehensive training will be provided to all relevant health staff on all components of IYCF and caring, with the addition of maternal nutrition. The nutrition counsellors have already been trained and deployed in 18 provinces, with recruitment in process for the remaining provinces.
Linkage and referral between health facilities and communities through the CBNP for increasing antenatal coverage at community level are being considered, including expanding four ANC visits to eight ANC key contact points. Finally, national information systems are under review, which will be an opportunity to integrate indicators to monitor the coverage of maternal nutrition interventions.
Footnotes
1Afghanistan Living Conditions Survey (2016/17).
2Afghanistan Health Survey (2018).
3Health shuras are community volunteers (usually elders) who meet to discuss health-related issues of community members.
4The CBNP includes regular home visits, aside from the monthly community gatherings, for those children who are in the yellow bar (at risk category) of the growth monitoring and promotion card. During these home visits, the families will be followed up, consulted and encouraged to practice what they have learned during the monthly community gatherings to help their children gain weight.