value of family planning for improving maternal health in rural Afghanistan: the example of Kandahar

Women in Afghanistan face some of the highest risks of maternal mortality and morbidity globally. The situation in rural parts of the country is particularly troubling, with women and girls residing in these areas suffering from much higher rates of death due to pregnancy-and delivery-related complications compared to urban areas. With a goal of increasing the contraceptive prevalence rate, particularly to assist in birth spacing, the Basic Package of Health Services seeks to provide access to family planning services equitably, regardless of ability to pay and with a special focus on rural and hard-to-reach populations. Using Maywand district in Kandahar province as a representative example of rural areas, we evaluate the benefits and assess the value [i.e., cost-effectiveness] of family planning for birth spacing and limiting, and to prevent pregnancy-related deaths. We synthesize the best available data to adapt a previously validated maternal mortality model to the situation of maternal health in Kandahar. Outcomes include total fertility rate [TFR], pregnancy-related complications, unsafe abortions, pregnancy-related deaths, maternal mortality ratio [MMR], lifetime risk of maternal death, and proportionate mortality ratio [proportion of deaths among women 15-49 years that are pregnancy-related]. We also estimate the life expectancy gains, years of life saved [YLS], and lifetime costs in order to assess the cost-effectiveness of family planning interventions. We compute the reduction in total fertility rate and pregnancy-related deaths and estimate the economic impact and cost-effectiveness of family planning interventions. Model-generated estimates of maternal mortality indicators, total fertility rate, and distribution of maternal death by cause closely approximated empiric data. Increasing family planning coverage from a baseline of 8% in rural Kandahar to 30% and 50%, would be expected to reduce the total fertility rate from 6.6 to 5.1 and 3.9, respectively, reduce maternal deaths by 21% and 40%, respectively, and reduce the proportionate mortality ratio from 45% to 38% and 31%, respectively. Incremental cost-effectiveness ratios of family planning strategies were below $145 per YLS, representing just a fraction of the per capita gross domestic product [GDP]. Extrapolating our results in rural Kandahar to the country as a whole, these strategies would prevent between 166,000 and 210,000 maternal deaths for a very modest investment and in the context of the current infrastructure. Of importance, further gains will require improvements in skilled birth attendants, care during labor and delivery, and access to emergency obstetrical care. Increasing access to family planning will improve the health of Afghan women, save lives and provide high value for the resources invested. Through the efficient use of public health resources, enhanced family planning efforts will improve the public health sector capacity to make necessary investments in skilled attendants, care during labor and delivery, and emergency obstetric care. These results provide strong support for the high value of family planning investments included in the Basic Package of Health Services

HIV knowledge, attitude, and risk perception among healthcare workers in Afghanistan Hospitals

The knowledge and attitudes of healthcare workers regarding HIV infection are important factors influencing the readiness of people living with HIV to access care, and the quality of the care they receive. In addition to factors such as stigma and bias, how healthcare workers perceive their own risks in relation to caring for HIV-positive patients may potentially influence their willingness to provide care and their attitudes towards HIV-infected patients. In Afghanistan, there is a lack of information on the prevalence of HIV in general population. The country, however, has many risk factors that could facilitate HIV transmission. To assess HIV-related knowledge, attitudes, and risk perception amongst healthcare workers in Afghanistan national and regional hospitals. A cross-sectional survey among healthcare workers was conducted in five large hospitals selected in Afghanistan. Approval was obtained from the Institutional Review Board of the Ministry of Public Health of Afghanistan and interviews were voluntary. Data analysis was conducted using STATA 11.0 to calculate frequencies and to perform cross-tabulation and logistic regressions with adjusted odd ratio and 95% confidence interval in order to detect statistical significance on differences in knowledge and attitude among healthcare workers in the targeted hospitals. Among 741 healthcare workers who participated in the study, 34.4% [255] correctly identified all correct modes of HIV transmission and 32.1% [238] correctly identified all incorrect modes of HIV transmission. Only 10.4% [77] correctly identified both correct and incorrect modes of HIV transmission. Nurses 12.3% [27] were most knowledgeable by correctly identifying all correct and incorrect modes of HIV transmission. The majority of healthcare workers expressed a willingness to care for people living with HIV. While 88% of healthcare workers believed that it is necessary to take extra infection precautions for people living with HIV, 76% presumed that people living with HIV should be nursed separately from other patients. Nearly 2 of every 3 Afghan healthcare workers in this sample lacked basic knowledge about the routes of transmission of HIV. These findings provide support for both improving the education of current healthcare workers, and integrating teaching modules that include the topics of disease transmission, clinical care, and universal precautions into curricula of health educational institutions