Abstract
BackgroundIn the past fifteen years, Afghanistan has made substantial progress in extending primary health care. However, coverage of essential health interventions proven to improve maternal and neonatal health outcomes, particularly skilled birth attendance, remains unacceptably low. This is especially true for those in the poorest quintile of the population. This cross-sectional quantitative and qualitative study assessed barriers associated with care-seeking for institutional delivery among rural Afghan women in three provinces.MethodsThe study was conducted from November to December 2016 in 12 districts across three provinces – Badghis, Bamyan, and Kandahar – which are predominately rural. Districts were used as the primary sampling unit with district-level sample sizes reflecting the ratio of that district’s population to provincial population. Villages within these districts, the secondary sampling units, were randomly selected. A household survey was used to collect data on: demographics, socio-economic status, childbearing history, health transport and service costs, maternal health seeking behavior and barriers to service uptake. Data on barriers to facility delivery were compared across provinces using chi square tests.ResultsOf the 2479 women of child bearing age interviewed, one-third were from each province (33% n = 813 Badghis, 34% n = 840 Bamyan, 33% n = 824 Kandahar). Among those respondents who had delivered none of their children in a health center, money to pay for services appeared to be most important barrier to accessing institutional delivery (56%, n = 558). No transportation available was the second most widely cited reason (37%, n = 368), followed by family restrictions (n = 30%, n = 302). Respondents in Badghis reported the highest levels of barriers compared to the other two provinces. Respondents in Badghis were more likely to report familial or cultural constraints as the most important barrier to institutional delivery (43%) compared to Bamyan (2%) and Kandahar (12%) (p < 0.001).ConclusionsDespite the socio-demographic and geographic diversity of the three provinces under study, the top barriers to institutional delivery reported in all three areas are consistent with available evidence, namely, that distance, transport cost and transport availability are the main factors limiting institutional delivery. Proven and promising approaches to overcome these barriers to institutional delivery in Afghanistan should be explored and studied.
Highlights
In the past fifteen years, Afghanistan has made substantial progress in extending primary health care
Overall we found that the proportion of women reporting barriers to institutional delivery were 1.3–10.0 fold lower in Kandahar and Bamyan provinces than in Badghis province (Table 3)
This study contributes to understanding the barriers to institutional delivery in Afghanistan in rural locations of three provinces
Summary
In the past fifteen years, Afghanistan has made substantial progress in extending primary health care. Coverage of essential health interventions proven to improve maternal and neonatal health outcomes, skilled birth attendance, remains unacceptably low. This is especially true for those in the poorest quintile of the population. In the past fifteen years, Afghanistan has made substantial progress in extending primary health care through its ‘basic package of health services’ (BPHS) [3, 4] including improved availability of public facilities across the country [5]. Coverage of essential health interventions proven to improve maternal and neonatal health outcomes, skilled birth attendance, remains unacceptably low among populations in the poorest quintile (22%) as compared to the richest (82%) and the rate of change in overall improvements for this indicator appears to be decreasing [8]. Global evidence suggests that the “best intrapartum-care strategy is likely to be one in which women routinely choose to deliver in a health centre, with midwives as the main providers, but with other attendants working with them in a team” [9]
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