Afghanistan: Improving maternal and newborn care - A focus on quality

This thesis examines the quality of maternal and newborn health (MNH) services in health facilities in Afghanistan. This information is essential to identify strengths and gaps in delivering high-quality MNH care and preventing stillbirths, and to improve health outcomes. Using the WHO Quality of Care framework, the analysis is structured around six interlinked domains: (1) evidence-based clinical practices; (2) health information systems; (3) competent and motivated human resources; (4) essential commodities, supplies, and financing; (5) respectful and dignified care; and (6) quality-adjusted coverage. The thesis addresses six research questions on facility readiness for postabortion care (PAC), determinants of intrapartum care quality, quality of postpartum hemorrhage (PPH) management, quality of maternal death documentation, potential impact of improved intervention coverage and quality, and the nature of respectful family-centered MNH care in Afghanistan. The study draws on a 2016 national MNH Quality of Care assessment, complemented by Lives Saved Tool (LiST) modelling (2023) and desk reviews. Findings show major gaps in MNH service quality across Afghanistan. Key challenges include shortages of essential medicines and supplies, weak supply chains, and limited training in lifesaving interventions such as misoprostol for PPH and PAC. Although family planning commodities are widely available, gaps in counselling and missed opportunities reduce service effectiveness. Integrating family planning and safe abortion care into MNH strategies is critical to reducing unintended pregnancies, unsafe abortions, and maternal mortality. Supportive supervision, mentorship, gender-sensitive practices, and positive working environments are important for sustaining quality improvements. Ongoing in-service training and leadership development are needed to strengthen adherence to clinical guidelines and promote respectful care. Major weaknesses in documentation and record-keeping compromise data quality, limiting reliable analysis and contributing to misclassification of maternal deaths. Strengthening data systems and fostering accountability are essential for improving decision-making and outcomes. LiST modelling suggests that achieving 90% coverage of key evidence-based MNH interventions by 2030 could reduce neonatal mortality from 36 to 16 per 1,000 live births and maternal mortality from 638 to 237 per 100,000 live births. Persistent gaps in referral systems, antenatal care, skilled birth attendance, and postnatal care highlight urgent priorities. Given Afghanistan’s donor-dependent health system and ongoing instability, sustained external financing, efficient domestic resource allocation, and cross-sector collaboration (e.g., WASH and education) are essential. Without significant investment in infrastructure, workforce capacity, and essential resources, maternal and neonatal mortality risks worsening by 2025.