Strategy INWRA - وزارت صحت...

Ministry of Public HealthD. G. Preventive Medicine and PHC

Public Nutrition Department

Improving the Nutritional Status of

Afghan Women of

Reproductive Age

Recommendations towards the Development of a Maternal Nutrition Strategy

Strategy Improving the Nutritional Status of Afghan Women of Reproductive Age

January 2005Mija-Tesse Ververs, Tufts University in collaboration with Unicef and the Public Nutrition Department, Ministry of Public Health, Afghanistan.

of 83


PrefaceAt the United Nations Millennium Summit in 2000, heads of state and government from 189 countries adopted the Millennium Declaration with 8 Millennium Development Goals (MDGs). All countries declared to fully commit themselves towards achieving these goals. One goal is to improve maternal health, i.e. to reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio. In this light a project has been undertaken in October 2004 until January 2005 by TUFTS University in collaboration with the Afghan Ministry of Public Health and UNICEF. The project, funded by the American Red Cross, had a specific focus on Afghan women and aimed at Developing an Integrated Framework and Strategy for Improving Maternal Nutritional Status in Afghanistan. Improving the maternal health status in Afghanistan contributes to the reduction of maternal mortality. This report shows how this can be achieved. Through extensive literature research on evidence based approaches and analyses of experiences in countries with similar health problems an initial framework of possible strategies was developed. Subsequently, a Consultative Meeting was held on Improvement of the Nutritional Status of Women of Reproductive Age (WRA) in Kabul 27-28 November 2004. Amongst the participants were representatives of five different Ministries, three UN agencies and various NGOs working on maternal health. The meeting resulted in a selection of Priority Strategies for Afghanistan that were seen as feasible and culturally appropriate. The selected strategies focus on the immediate health problems women face in Afghanistan. During the project end 2004 and beginning 2005 there were some major changes that made an exact formulation of the implementation of the strategies not possible. Amongst others, the Basic Package of Health Services (BPHS) was under revision (1), a new Minister of Health and deputy ministers were appointed after the elections, some major organisational changes were under consideration (currently the organigramme of the Ministry of Public Health is under revision) as well as changes in the work of the Performance-based Partnership Agreements (PPA). In addition to the development of an Integrated Framework and Strategy for Improving Maternal Nutritional Status in Afghanistan, the project aimed at building capacity amongst stakeholders in maternal nutrition, specifically amongst the members of the Public Nutrition Department team within the Ministry of Public Health. On 17 and 18 January 2005 the priority strategies for Afghanistan were presented by the Public Nutrition Dept from MoPH in collaboration with Unicef to respectively senior staff of MoPH and other Ministries and to senior Unicef staff.

Kabul, January 2005

of 83


Acknowledgments

First of all my gratitude goes towards the members of the Public Nutrition Department team and in particular Drs Zarmina Safi, Najeebullah Najeeb, Roya Mutahar. Their role has been vital throughout the process and their strong commitment has lead to the success of the first step towards reducing malnutrition amongst women of reproductive age. At the end of the project they have shown to be fully capable and determined to take the project forward into its implementation. I thank both the deputy-ministers Dr Kakal and Dr Nodra, for their statement to give high priority to improving the maternal health through nutritional approaches, in particular through supplementation.Furthermore I want to thank form Tufts University Diane Holland for logistical support and literature search and her approachable attitude throughout the project and Emily Tarr for her contribution to the glossary. Special appreciation I owe to Dr Zakia Maroof (Unicef) and Dr Zarmina Safi who showed not only to be great organisers of meetings and presentations, they also were very dedicated mothers and excellent speakers themselves with great devotion to the improvement of the nutritional status of Afghan women.I want to thank Chris Hirabayashi from Unicef for his very positive reception of all the recommendations and for his assurance that Unicef will commit itself to immediate action on the supplementation issues.Special thanks I address to Annalies Borrel (Tufts University) who supervised the project in a condition that could not have been more appropriate: pregnant. Her enthusiasm and dedication were tremendous and because her steadfastness this whole project went ahead.Seldom I have worked with more dedicated people than Fitsum Assefa (Nutritionist Unicef); her endless energy and strong perseverance never decreased. Her contributions were not only large and of high quality, she also showed an enthusiasm and a ‘fighting’ spirit I have hardly ever experienced before amongst professionals. At last, I want to thank the people attending the Consultative Meeting as well as all those Afghan women who shared their experiences with me and contributed to a better definition of the most appropriate strategies.

Mija-Tesse Ververs, January 2005

of 83


Healthy Womena healthy society…Source: Health Department of the Ministry of Women Affairs, 2004

"Women's deprivation in terms of nutrition and health care rebounds on society in the form of ill-health of their offspring — males and females alike." — Siddiq Osmani and Amartya Sen (2)

of 83


Executive SummaryAfghanistan has one of the highest maternal mortality rates in the world (1600/100,000 live births per year). Hemorrhage and obstructed labour are causing most of the deaths. Both causes have a strong relation with nutrition: for example, anaemia (especially iron deficiency anaemia) and stunting (cephalo-pelvic disproportion)

The nutritional situation of many Afghan Women of Reproductive age (WRA) is far from optimal:- 70% of Afghan women suffer from iron deficiency anaemia- Depending on the area 20% of WRA is chronic energy deficient - Up to 20% women in some areas report suffering from night blindness associated with vitamin A deficiency - Depending on the area visible goiter is prevalent up to 65% amongst WRAIt is estimated that one out of each five infants are born with Low Birth Weight due to the poor health status of their mothers.

The impact on the Afghan society of this widespread malnutrition amongst WRA is tremendous. Anaemia alone causes many maternal and foetal deaths as well as reduction of work capacity and productivity of women (which has subsequently an effect on domestic work, care for children, and physical and mental work). Both anaemia and vit A deficiency result in the birth of Low Birth Weight infants (and their survival chances are substantially reduced). Vit A deficiency in pregnant and lactating women results in vit A deficiency in infants and many die from increased susceptibility to infection. Unicef estimates that approx. 500,000 Afghan babies are born each year with intellectual impairment due to iodine deficiency in their mothers.

Causes of malnutrition amongst Afghan women are multiple. Most deficiencies concern insufficient intake of good quality food: they consume little or no meat or other animal products, nor enough green/orange vegetables or fruits. The prioritisation of women’s access to food in the family is low - they eat after others eat. Often they have a low intake compared to increased needs: pregnancy, lactation, adolescence. Many pregnant and lactating women do not have enough physical rest and their relatively higher energy expenditure compared to the relatively low caloric intake can make them energy deficient.Many Afghan women suffer from a so-called ‘Maternal Nutritional Depletion Syndrome’: Frequent pregnancies with relatively short birth intervals and overlap of lactation with the next pregnancy causes absence of a time to recover nutritionally in the reproductive cycle. An aggravating factor is the little health awareness amongst both women and their families. Many women have no idea what the consequences are of anaemia or goiter or how to prevent them.

Between October 2004 until January 2005 a consultant from Tufts University in collaboration with the Afghan Ministry of Public Health and Unicef worked on a project aiming to develop a strategy for improving the maternal nutritional status in Afghanistan. During the project the following objectives were selected to focus on:

To reduce maternal mortality To improve nutritional status of WRA To reduce prevalence of anaemia amongst WRA To lower incidence of Low Birth Weight babies

of 83


Through extensive literature research many strategies were scrutinised on efficacy and effectiveness. There was not one intervention that could achieve all abovementioned objectives and therefore six different strategies were selected. They were regarded as the most effective for WRA, feasible, appropriate and culturally correct for the Afghan context.

The fundaments of those priority strategies encompass Supplementation, Fortification and Health education as the overall support strategy.The most important and cost-effective strategy for Afghanistan is daily iron/folate supplementation for any pregnant and lactating woman (during at least 6 months in pregnancy, and continuing to 3 months postpartum). This can largely contribute to reduction of anaemia prevalence and maternal mortality. By installing an Anaemia Task Force under the Ministry of Public Health a national programme can be designed that endorses the supplementation throughout Afghanistan through community health workers, health educators, (community) midwives, nurses, and physicians (mostly via the public Basic Package of Health Services system). In addition, a national anaemia programme should include a social marketing campaign in which through engagement of the private sector and pharmacist/drug vendors a major coverage of women at risk will be ensured.

Secondly, Vit A supplementation post-partum needs to be immediately re-inforced whilst in place on paper in many health facilities but not practiced for unclear reasons. This supplementation has a proven positive effect on infant (if breastfed) and maternal morbidity and mortality. A design of a National Vit A post-partum Programme is needed to speed up this in principle very simple and straightforward intervention; such a programme restates the protocol in all clinics where delivery care is performed and where perinatal consultations take place in and outside the BPHS system, guarantees the supplies of the right dosage, informs the nurses/(community) midwives, physicians and the community health workers etc.

From all food-based approaches such as flour fortification with various nutrients, food diversification, and salt fortification with iodine the latter is the most urgent and proven to be efficacious and effective in reducing iodine deficiency. Unicef and the Public Nutrition Dept are implementing a salt iodisation campaign but a refreshing information campaign targeted at both the stakeholders including the public could help because of the general public health urgency of iodine deficiency disorders throughout Afghanistan. It is important that the Ministry of Public Health and Unicef evaluate whether a special campaign is needed for supplementation of iodine in antenatal care (on case by case basis through consultation) for pregnant women, especially in the areas that are currently weak on salt iodisation.Food diversification programmes cannot have an immediate impact on the large scale of malnutrition amongst WRA and more research is urgently needed on dietary habits of Afghan WRA and which food security interventions can have an impact on food consumption AND nutritional status of WRA.

Low Birth Weight babies have increased risk on disease and death and are likely, if they survive early childhood, to become stunted children and adolescents, with high risk on obstructed labour, maternal mortality and if malnutrition remains manifest during pregnancy they give birth to again babies with low birth weight. This Intergenerational Cycle of Malnutrition can partially be broken through if infants are exclusively breastfed up to 6 months of age and properly weaned. Since a woman’s height can be mainly

of 83


increased with adequate nutrition to the age of 3 years of her childhood, good feeding practices in early childhood can prevent stunting and therefore obstructed labour. In addition, immediate post-partum breastfeeding reduces the risk of hemorrhage. Therefore a so-called ‘life-cycle’ strategy aims at general morbidity and mortality reduction in (early) childhood and reduces the chance of maternal mortality once the girl becomes pregnant. The strategy requires the establishment of Guidelines for Afghanistan on how to counsel mothers and other family members on breastfeeding, complementary feeding and maternal nutrition during pregnancy and lactation. Furthermore, the strategy pleas for immediate harmonisation of the messages on breastfeeding and weaning throughout Afghanistan.

Another strategy concerns Health Education including awareness of nutritional problems amongst WRA, dietary advice messages, advice on supplementation, etc and it aims to support all other selected approaches and is crucial for their effectiveness. For example, a selection of 10 key nutritional/health messages is needed and they should concern anaemia/iron/folate supplementation, breastfeeding/weaning practices, goitre/iodised salt etc. The messages intend to improve the health of WRA but are not necessarily addressed to them. In addition, there is an urgent need to compile a document (especially for community health workers and (community) midwives) to be used on community base in the health posts and basic health centres aiming to address all above critical nutritional issues with WRA, their husbands and mothers-in-law.

Another supplementation strategy concerns the administration of Unicef/WHO’s multi-micronutrient supplement to pregnant (especially), lactating women and adolescent girls. The aim of supplementation is to reduce the prevalence of many vitamin and mineral deficiencies, such as iodine and Vit A deficiencies and scurvy with only one intervention. The other aim of its use is to replace iron/folate tablets in the fight against anaemia once having been proven to be as efficacious and effective as the classic iron/folate supplements. This should be considered because of the low reporting of side-effects (such as gastro-intestinal discomfort) compared to iron/folate tablets. However, there is urgent need for proof if the dosage of iron in this multi-micronutrient formula is sufficient in reducing anaemia in the same way as with current dosage of single iron/folate supplementation. This strategy suggests a small pilot study with Afghan women.

It should be noted that apart from nutrition related interventions birth spacing (family planning) will have a major impact on improving the nutritional status of women.

The implementation of these strategies requires significant input from especially the Ministry of Public Health (in particular the Public Nutrition and Reproductive Health Departments), Unicef and the Nutrition Task Group (the Working Groups on Micronutrient Deficiency Diseases Working Group and on Infant Feeding and Child Caring Practices).

Today the intention should be to minimise the many currently missed opportunities that exist in improving the nutritional status of WRA. On the short term the focus needs to be on supplementation in particular, whilst developing parallel new strategies that result in nutritional gains through more food based programmes.

*********

of 83


ContentsList of Abbreviations 10

1. Introduction 11

2. Current Situation of Afghan Women of Reproductive Age in relation to Health and Nutrition 122.1 Introduction 122.2 Maternal Mortality 122.3 Malnutrition 142.4 Anaemia 152.5 Vitamin A Deficiency 192.6 Iodine Deficiency Disorders 192.7 Folate deficiency 202.8 Reproductive Health and the Life-Cycle 202.9 Mental Health of Afghan Women 222.10 Health education and awareness 222.11 Food access, availability and use 242.12 Causes listed by Afghan health and food professionals 252.13 Conceptual framework of causes and consequences of malnutrition of Afghan women 25

3. Inventory of Current Interventions and Constraints 27

4. Evidence Based Strategies and their Application in Afghanistan 334.1 Introduction 334.2 Macro-nutrient supplementation 354.3 Micro-nutrient supplementation 364.3.1 Oral iron supplementation 364.3.2 Multiple micronutrient supplementation 394.3.3 Oral Vitamin A supplementation 404.4 Food-based approaches 414.4.1 Food fortification with nutrients 414.4.1.1 Iron 414.4.1.2 Iodine and other nutrients 424.4.2 Food-diversification 434.4.3 Other Food-based approaches 454.5 Conclusions 45

5. Recommendation for Priority Strategies for Afghanistan 485.1 Selected strategies and their rationale 485.2 Public Nutrition Policy and Strategy on WRA 50

6. Mechanisms for Coordination, Implementation and Plan of Action for Recommended Strategies 536.1 Introduction – the BPHS under revision 536.2 Strategy One: Iron/Folic acid supplementation 546.2.1 Objective 546.2.2 Plan of Action 546.2.3 Stakeholders 576.2.4 Potential constraints of a National Anaemia Programme and solutions 576.2.5 (Pre-)conditions for a successful National Anaemia Programme 586.2.6 Time frame 606.2.7 Monitoring and Evaluation 606.2.8 Human Resources 626.3. Strategy Two: Unicef/WHO’s multi-micronutrient supplementation 626.3.1 Objective 626.3.2 Plan of Action 626.3.3 Stakeholders 636.3.4 Time frame 636.3.5 Monitoring and Evaluation 63

of 83


6.4 Strategy Three: Vit A supplementation post-partum (and during pregnancy) 636.4.1 Objective 636.4.2 Plan of Action 646.4.3 Stakeholders 656.4.4 Time frame 656.4.5 Monitoring and Evaluation 656.5 Strategy Four: Food-based approaches incl. flour fortification with various nutrients, food diversification, salt fortification with iodine 656.5.1 Flour fortification 656.5.2 Food diversification 666.5.3 Salt fortification 676.6 Strategy Five: LBW/life-cycle approach including infant and child care; including immediate post-partum breastfeeding and exclusive breastfeeding 696.6.1 Objective 696.6.2 Plan of Action 696.6.3 Stakeholders 706.6.4 Time frame 706.6.5 Monitoring and Evaluation 716.7 Strategy Six: Health education including awareness of nutritional problems amongst WRA, dietary advice messages, advice on supplementation, etc 716.7.1 Objective 716.7.2 Plan of Action 716.7.3 Stakeholders 726.7.4 Time frame 726.7.5 Monitoring and Evaluation 73

7. Training and Capacity Building 74

8. Monitoring the Nutritional Status of WRA 75

Glossary 76

References 79

AnnexesAnnex 1. List of Participants Consultative Meeting on Improving Nutritional Status of Women of Reproductive Age in Kabul 27-28 November 2004.Annex 2. Maternal Mortality in Afghanistan Annex 3. Data on BMI presented during Consultative Meeting Kabul 27-28 November2004, Public Nutrition Dept, MoPHAnnex 4. MUAC data from mothers (15-49 years)Annex 5. Visible Goitre amongst Mothers or WRAAnnex 6. Prenatal and post-partum consultationsAnnex 7. Composition of the WHO/UNICEF/UNU multiple micronutrient supplementAnnex 8. Summary of information gaps and research needs relative to the efficacy and effectiveness of food-based approaches for reducing iron deficienciesAnnex 9. Summary of information gaps and research needs relative to the efficacy and effectiveness of food-based approaches for reducing vitamin A deficiencies Annex 10. Overview of objectives and activities on WRA of various ministerial departmentsAnnex 11. Listing of relevant background documentation on Improvement of Nutrition of Women of Reproductive AgeAnnex 12. Listing of some relevant background documentation on non-nutritional interventions with substantial positive impact on the nutritional status of WRAAnnex 13. Examples of phases needed for a National Anaemia Programme based on collaborative work of all stakeholders during the Consultative Meeting.Annex 14. Example of developed material on dietary advice for pregnant and lactating Afghan women

*********

of 83


List of Abbreviations

BHC Basic Health CentreBMI Body Mass IndexBPHS Basic Package of Health ServicesCED Chronic Energy DeficiencyCHW Community Health WorkerCHC Comprehensive Health CentreCMW Community MidwifeEPI Expanded Programme on ImmunisationFAO Food and Agriculture OrganisationHMIS Health Management and Information SystemIDD Iodine Deficiency DisordersIEC Information, Education and CommunicationIU International UnitsLBW Low Birth WeightMAAH Ministry of Agriculture and Animal Husbandry

(Ministry of Agriculture and Food from January 2005 onwards)MCH Mother and Child HealthMoPH Ministry of Public HealthMRRD Ministry of Rural Rehabilitation and DevelopmentMUAC Mid-Upper CircumferenceMWA Ministry of Women AffairsNGO Non-Governmental OrganisationPNO Public Nutrition OfficerTBA Traditional Birth AttendantTFR Total Fertility RateUNICEF UN Children’s FundUSI Universal Salt IodisationWFP World Food ProgrammeWHO World Health OrganisationWRA Women of Reproductive Age

of 83


1. IntroductionThis report is written for all governmental policy makers in Afghanistan as well as United Nations agencies and Non-Governmental Organisations (NGOs) who are engaged in improving the health of Women of Reproductive Age (WRA). The report shows how this can be done in particular through a nutritional approach and what the consequences are if no changes are made.Chapter 2 describes the current situation of Afghan WRA in relation to health and nutrition. Data on malnutrition, micro-nutrient status, (reproductive) health problems food security and awareness of health problems are provided and the causes. In addition, each paragraph describes the consequences of current ‘state-of-the-art’.Chapter 3 gives an overview of what has been done so far in Afghanistan on improving the nutritional status of WRA directly and indirectly as well as the lessons learnt. It also gives an inventory of the ‘mandate’ of some Ministries, UN agencies and NGOs working with and for WRA. This inventory was compiled during the Consultative Meeting in November 2004 in Kabul.Chapter 4 provides detailed information of approaches that could be used for the improvement of the nutritional status of WRA and whether they actually have been proven to be successful in their aims. Strengths and weaknesses of strategies like Macro-nutrient supplementation and Micro-nutrient supplementation as well as many different food-based approaches are valued on their potentially usefulness for Afghanistan.Chapter 5 describes which nutritional strategies should be applied in the current context of Afghanistan for WRA, in the short- and the long-term. The formulated rationale is based on the end conclusions of all previous chapters.Chapter 6 goes into more detail for each suggested strategy and formulates suggestions of ways of implementing the various approaches (plan of action, time frame, stakeholders etc); the information is based on the outcomes of the Consultative Meeting.Chapter 7 briefly discusses training needs and capacity building for various health professionals.

of 83


2. Current Situation of Afghan Women of Reproductive Age in relation to Health and Nutrition

2.1 Introduction

In the following paragraphs a description is given of the specific food and nutritional situation of WRA, as well as of a broader reproductive health picture of Afghan women. Occasionally it is compared to other countries.In 2003 the total Afghan population is estimated to be approximately 24.5 million people, 56 % are female. From all the women 42% are aged 15 – 49 years, i.e. women of reproductive age. Twenty percent of the total population are women aged 15 – 49 years (3).

2.2 Maternal MortalityThe Maternal Mortality Ratio in Afghanistan is estimated to be approximately 1600 per 100,000 live births per year (5)(see Annex 2). Afghanistan has one of the highest maternal mortality in the world.

Maternal mortality estimates of various other countries in 2000 by WHO/Unicef/UNFPA (per 100,000 live births per year).Azerbaijan 94

Iraq 250

Pakistan 500

Somalia 1100

Tajikistan 100

Uzbekistan 24

There are five primary causes for maternal mortality (6):- induced abortion- infection after childbirth (‘puerperal infection’)- pregnancy induced hypertension (toxaemia, pre-eclampsia, eclampsia)- hemorrhage (intra- and post partum) - obstructed labour

The latter two have a strong relation with nutrition therefore they are important to consider in any strategy on improvement of nutrition of women of women of reproductive

of 83


age (WRA). Also the latter two are the major causes in Afghanistan of maternal mortality: hemorrhage 40%, obstructed labour 21% (5).In a Maternal Mortality Study in Afghanistan (1999-2002) results show (5):

50% of deaths amongst women was pregnancy/delivery related Causes comprised 30-50% hemorrhage and 21% obstructed labour Three quarters of the newborns did not survive: most died within first month

Comparing the causes of maternal mortality worldwide (4), Afghanistan scores high on hemorrhage and especially on obstetric labour. Underlying problems relate to the health status of the mother, while others are closely linked to socio-economic and cultural factors. Some of the factors that threaten a woman's survival in childbirth in Afghanistan are early marriage and pregnancy, high fertility, low rates of literacy and awareness, inadequate nutrition, little or no ante-natal care, poor or non-existent roads and transportation, lack of mobility due to cultural norms, and lack of essential health services (7).

The death of a mother in Afghanistan has major consequences and not only for her newborn baby but for the rest of her family too. Unicef states in its situation analysis in February 2004 (7):

‘ If the baby survives its mother's death, it is unlikely to live for more than a few months as it will die of starvation without the mother's milk. If the woman has other children, their chances of being well cared for suddenly deteriorate. The father and other members of the family do their best to look after them but when the father remarries, his new wife is unlikely to pay much attention to another woman's children. She will be busy having babies of her own and taking care of them. The task of caring for children is the work of women so the father has little direct influence over their well being. Their protection dies with their mother. ‘

of 83


Therefore it is not surprising that both Afghan men and women in many communities identify maternal mortality as their greatest health problem.

Unicef claims that 70% of the maternal deaths are preventable being caused by basic barriers including lack of knowledge of maternal health issues, lack of access to health facilities and ill-equipped health centres and lack of trained medical staff (8).

2.3 Malnutrition

In various nutritional surveys done since 2000 throughout Afghanistan 4-10% of the women measured suffered from moderate to severe chronic energy deficiency1 (see Annex 3). The total number of WRA suffering from CED (BMI2<18.5), including mild CED, is much higher, up to 20% amongst women 15-49 years. Figure 1a gives a comparison with other countries.

Figure 1a. Chronic Energy Deficiency prevalence in various regions.

88

Chronic Energy Deficiencyin Women 15-49 Years Old

41.1 40.5

18.722.4

14.6

7.2

0

25

50

S Asia SE Asia China SS Africa C Amer. S. Amer.

ACC/SCN, 1992

Percent WomenBMI<18.5 kg/m2

The main causes of women in Afghanistan to become malnourished is related to insufficient food intake compared with what they need. And those needs are largely increased during pregnancy, lactation, and adolescence where growth still is not

1 The following categories of adult nutritional status are used (CED is Chronic Energy Deficiency):CED Grade III severe BMI < 16.0 kg/m²CED Grade II moderate 16.0 < BMI < 17.0 kg/m²CED Grade I mild 17.0 < BMI < 18.5 kg/m²Normal nutritional status 18.5 < BMI < 25.0 kg/m²

2 BMI = Weight in kg/(Height in m)2

of 83


completed. Likewise, if their energy expenditure is higher then what they eat, as is very often the case during pregnancy, women have a high risk of becoming relatively energy deficient. This underlines the importance of rest during both pregnancy (and lactation) to save energy for the foetus. However, Afghan pregnant women have seldom enough means to rest.

The consequences chronic energy deficient women experience comprise (9):• Higher prevalence of infections because of reduced immuno-competence.• Increased risk of mortality. • Increased risk of giving birth to low birth weight babies. Low birth weight is a well-

known risk factor for neonatal and infant mortality.

In similar nutritional surveys done since 2000 throughout Afghanistan 8-10% of the women measured had a MUAC < 21 cm (3-19%)(see Annex 4). MUAC is another anthropometric measurement that reflects both fat and lean tissue stores; a low maternal MUAC is a risk indicator for low- birth-weight babies (10,11,12). In 2001 the WHO measured the incidence of Low Birth Weight in Afghanistan as 20% (13).

The mean age at marriage is 17 years in Afghanistan. However, there are significant differences per province. Thirteen percent of Aghan girls are married between 13-14 years (in Badghis this is 28%, in Bamyan 27%, in Baghlan 22%, in Samangam 22%, in Kandahar and Badakhstan 21%)(3,7).Especially in times of drought families incur severe debt and some tend to marry their daughters at extremely young ages as a means of repaying part of these debts. In this way families increase their revenues and have one mouth less to feed in times of food stress (14,15). These girls are still in their adolescence and their growth is still ongoing. An early pregnancy therefore puts those early married at high risk for malnutrition: they need additional nutrients for their pregnancy and for their own growth.In Afghanistan if women provide breastfeeding they tend to give it for a long time; in one study it was found that about 70% of the sampled children continued to be breast fed up to 24 months of age, while about 30% continued breast feeding up to the age of 30 months (16). This implies that, if breastfeeding is practised, the women have increased nutritional needs throughout the lactation period. To prevent malnutrition amongst those women again sufficient food (both quantity and quality) and sufficient rest are essential.

2.4 Anaemia

In Afghanistan 70% of women suffer from iron-deficient anaemia (8); in previous surveys from 2000 it was found that 55%-91% in pregnant women in Eastern and South-eastern region were anaemic (17). Figure 1b shows the comparison of anaemia prevalence in different regions of the world and illustrates the very high prevalence in Afghanistan.

of 83


Figure 1b Prevalence of anaemia in various regions in the world.

1717

Prevalence of Anemiain Women 15-49 years old

0

35

70

S/SE Asia Africa China LAC E Asia

Non-PregnantPregnant

ACC/SCN, 1992

Percent

Causes of anaemia of women concern (6):- Deficiency of dietary iron

o Low bioavailability (Dietary phytate and other Fe absorption inhibitors like tannins in tea)

o Low dietary Fe intake- Folate and vit B12 deficiency- Malaria- Loss of iron through parasitic infections (hookworms etc)

In Afghanistan inadequate intake and absorption of dietary iron is a major problem amongst women; especially because of the low intakes of animal products and ascorbic acid (vit C) containing foods, as well as high intake of substantial iron inhibitors as present in tea. Therefore the iron absorption from food is low by Afghan women.

Examples of diets with estimated overall iron bioavailability (Food and Agriculture Organization/World Health Organization, 1988)(cf.o.c 18)Typical diet Bioavailability of

IronCereal-based, roots or tubers and legumes, with negligible meat, fish or ascorbic acid-rich foods.

Low (5 % absorption)

Cereal-based, roots or tubers, with small quantities of food of animal origin, or containing ascorbic acid, or a diet with still higher levels of foods of animal origin or ascorbic acid but also large amounts of tea or coffee consumed with meals

Intermediate (10% absorption)

Diverse diet containing generous quantities of meat, poultry and fish or foods containing high amounts of ascorbic acid.

High (15% absorption)6

of 83


Many Afghan women are likely to have a diet with a low to intermediate absorption of iron. In addition, malaria causes anaemia by destruction of red blood cells; especially in the North, North-eastern and Eastern parts in Afghanistan malarial infection is a problem. Particularly malaria caused by Plasmodium falciparum (present in Afghanistan from May to November below an altitude of 2000 m) can lead to very severe anaemia3.

Figure 2.

88

Dietary Iron RequirementsThroughout the Life Cycle

0

2

4

6

8

10

12

0 10 20 30 40 50 60 70

MenWomen

Required iron intake(mg Fe/1000 kcal)

Stoltzfus, 1997Age (years)

Pregnancy

The number of pregnancies per Afghan woman are high. During seven nutritional surveys4 among children 6-59 months and their mothers during the year 2000 in six main cities of Afghanistan it was found that mothers who were around 45 years tended to have had around 10 or more pregnancies. The maximum number of pregnancies reported were 15 to 17 (19).

Following the figure 2 by Stoltzfus the amount of dietary iron needed is substantial during pregnancy (9). But when these dietary requirements are extrapolated on the Afghan women their realistic needs might more look like figure 3 assuming even that the woman is not suffering from any disease that requires additional iron intake.

Figure 3. Adjustment of Figure 2: dietary iron needs for Afghan women with an average of 6 pregnancies.3 http://www.aims.org.af/sectoral_activities/health/who_activities/WHO_MALARIA_PF.pdf 4 Compilation of the nutritional surveys conducted by Action contre la Faim in Kabul, Kandahar, Herat, Faizabad, Mazar and Jalalabad cities, ACF and WFP 2000 Kabul (in February and in October n=854), Kandahar (May n=390), Herat (July n=900), Faizabad (September n=922), Mazar (November n=872), and Jalalabad (December n=913).)

of 83

http://www.aims.org.af/sectoral_activities/health/who_activities/WHO_MALARIA_PF.pdf


Consequences of maternal anaemia:Directly to the woman

Anaemic women are more likely to die from blood loss during or after the delivery5 (and since obstetric hemorrhage is the leading cause of maternal deaths in Afghanistan, anaemia is a major burden for the Afghan society).

Severe anaemia can cause maternal mortality (20); Severe anaemia can lead to heart failure or circulatory shock at the time of labour and delivery.

Anaemic women are more susceptible to puerperial infections Physical work capacity and fitness are reduced in anaemic women because iron

is needed by the blood to carry oxygen (through hemoglobin) to the brain and muscles and by the muscles for normal functioning. Therefore productivity, domestic work, care for children, any physical or mental work etc will be affected.

Every year in Afghanistan it is estimated that almost 3000 Afghan women die in pregnancy and childbirth due to severe anaemia (54).

Directly to the foetus Anaemic women transfer less iron to their foetus. These infants are at increased

risk of becoming iron-depleted and developing anaemia in early infancy.5 Anaemia causes hemorrhage: the uterus muscles do not contract well (due to low oxygen concentration with low hemoglobin levels) during delivery and therefore blood vessels in between these muscles remain open during delivery – analogy: water dam (vessels) cannot be closed -> bleeding.Since the uterus muscle will not be able to do its contractions strong enough during labour the baby stays in the uterus – analogy: muscle has no power anymore (no oxygen) like a car without petrol. This will lead to prolonged labour/obstructed labour.

of 83


Anaemic women are more likely to deliver low birth weight infants. Low birth weight infants have an increased risk of death during the neonatal

period (increased neonatal mortality) Anaemic children have an impaired cognition and show lower intellectual scores

than non-anaemic children.

It is estimated that approximately 28,000 infants each year in Afghanistan are at increased risk of death immediately before or after birth(54).

2.5 Vitamin A Deficiency

Up to 20% women in some areas report suffering from night blindness associated with vitamin A deficiency (21). A prevalence of clinical vit A Deficiency >1% indicates a public health problem (22).

Causes of vit A deficiency of Afghan WRA include inadequate intake (especially from animal food products), high number of pregnancies and exposure to recurrent infections.

Consequences of Vitamin A Deficiency in pregnancy include:Directly to the woman• Increased risk of night blindness. • Increased risk of maternal mortality, miscarriage, stillbirth, and low birth weight.

Directly to the foetus/infant:• Reduced transfer of vitamin A to foetus• Low vitamin A concentration in breast milk

In general vit A deficiency results in higher susceptibility to infections because of the reduced immuno-competence. In Afghanistan Unicef estimates that more than 50,000 children die each year from increased susceptibility to infection and approximately 50% of Afghan children grow up with lowered immunity leading tofrequent diseases and poor growth (54).

2.6 Iodine Deficiency Disorders (IDD)

The prevalence of visible goitre amongst WRA varies per region throughout Afghanistan from a few percentages up to two-third (see Annex 5). Visible goitre is a ‘tip of the iceberg’ and many more WRA are suffering from lighter but still serious manifestations of iodine deficiency. Preliminary results from a Unicef/CDC micronutrient survey in June 2004 reveals very low urinary iodine amongst the different age groups and gives proof that sub-clinical iodine deficiency is universal and serious.

The main cause of IDD in Afghanistan is the low intake of iodine via food; in particular the absence of iodine in salt. Salt in Afghanistan needs iodisation and Unicef together with Ministry of Health are co-ordinating the implementation of a massive USI campaign (= Universal Salt Iodisation).

of 83


As a consequence of dietary iodine deficiency during pregnancy the development of the foetus is hindered and this results in the birth of cretins (newborns with extreme forms of brain damage and physical impairment) and infants who show severe forms of mental retardation (9). The mental retardation resulting from iodine deficiency during pregnancy is irreversible. Iodine deficiency is the most prevalent cause of preventable mental retardation in Afghanistan. Endemic cretinism is prevented by the correction of iodine deficiency, especially in women before and during pregnancy.Unicef estimated that from the 1 million babies born each year in Afghanistan 500,000 Afghan babies are born each year with some kind of intellectual impairment. In countries where the goiter rate is >10%, as in Afghanistan (50%), more moderate forms of iodine deficiency are so widespread that it lowers the national IQ by 10-15 points.

2.7 Folate deficiency

There is no data on the folate status of Afghan women. However, Afghan pregnant and lactating women are at increased risk of folic acid deficiency because their dietary folic acid intake is likely to be insufficient to meet their physiological requirements. Their dietary intakes are low wherever effective access to folate-rich foods (fruits, vegetables, certain legumes and whole grains) is limited and where cooking practices lead to high loss (9).

Consequences of folate (or folic acid) deficiency during pregnancy include:• Maternal anaemia. Folic acid deficiency causes megaloblastic anaemia because

of folic acid’s role in DNA synthesis. Folic acid deficiency interferes with DNA synthesis, causing abnormal cell replication.

• Neural tube defects. Low folic acid levels around the time of conception may cause neural tube defects in infants. Folic acid supplementation of women during the peri-conceptional period reduces the incidence of neural tube defects such as anencephaly and spina bifida.

• Low birth-weight. Low folic acid levels are associated with an increased risk of low birth weight.

2.8 Reproductive Health and the Life-Cycle

The Total Fertility rate (TFR)6 in Afghanistan, measured in 2003 is 6.3 (urban 6.00, rural 6.38)(3). This can be read as that all Afghan women on average give birth to more than 6 babies during their reproductive years. Table 1 shows TFR data of some other countries (23).

Table 1.Total Fertility rate from various countries

Country 1998 TFR

6 The Total Fertility Rate is the number of children that would be born per woman if she were to live to the end of her child-bearing years and bear children at each age.

of 83


Afghanistan 6.0

Bangladesh 3.3

Cambodia 5.8

China 1.8

India 3.2

Indonesia 2.6

Iran 4.3

Laos 5.7

Nepal 4.9

Pakistan 4.9

The highest prevalence of pregnancies in Afghanistan is found in the age groups 25-29 and 30-34 years. Pregnancy is less common in women 40 years of age and older. As expected, the average total number of pregnancies and births increases with age; it reaches a plateau in women 40-44 years of age (24).The Afghan women are at high risk of ‘Maternal Nutritional Depletion Syndrome’; the frequent number of pregnancies with relatively short birth intervals and the overlap of lactation with the next pregnancy cause an absence of a nutritionally-important recuperative interval in the reproductive cycle. The consequences are that many Afghan women are having, at best, a borderline physical condition (25).

This phenomenon results in the so-called Intergenerational Cycle of Malnutrition (26):

Poor Nutrition Throughout the Life Cycle

of 83


Source: Adapted from the ACC/SCN-appointed Commission on the Nutrition Challenges of the 21st Century.

Most rural Afghan women have no voice in family planning within their families, although many women have reported that they want to learn more about options for birth control and introduce birth spacing methods (27,28). If birth spacing is not practised and WRA keep a poor nutritional status this cycle of malnutrition is maintained and the Afghan children are more likely to face cognitive impairments, short stature, lower resistance to infections, and a higher risk of disease and death throughout their lives (26).

2.9 Mental Health of Afghan Women

In a study on mental health in Afghanistan in 2002 three-quarter of the (non-disabled) women older than14 years were suffering from depression. Half of them had Post-Traumatic Stress Disorder and 84% suffered from anxiety/nervousness. In general the study showed that women in Afghanistan were at higher risk for psychiatric morbidity and lower social functioning due to many years of war and Taliban ruling (29). The women affected by mental health problems are at high risk that their mental capacity affects the quality of care of their children.

2.10 Health education and awareness

In 2003 on average 86% (65% urban, 93% rural) of the most recent (=in the last 2 years) deliveries were assisted by unskilled birth attendant7. And 84% (62% urban, 92% urban) of the women had not taken any ante-natal consultations from doctor/trained birth attendant during the last pregnancy (3). This means that in general pregnant women are very difficult to reach by formal health service providers. Meaning also that any health messages to improve her nutritional status should come from parallel systems like private sector, health educators, mosques etc.

7 assisted by 'Traditional Birth Attendant', 'Family members' etc

of 83


In a six cities study it was found that only 5 – 27% of the women had at least one postnatal consultation by a qualified doctor/nurse within 10 days postpartum (see Annex 6). Therefore the chances that vit A was provided to Afghan women post-partum are small for the majority.

During a Health and Nutrition survey in an IDP camp in Kandahar province women were asked whether they ever heard any health messages about anaemia (n=192) (16): 82% answered ‘no’. From 64 women 69% did not know how to prevent anaemia; 12% mentioned pills and 20% to improve one’s diet.Women were asked whether they had any knowledge on effects of anaemia; from the 68 women mentioned

• Fatigue 31%• Poor growth 10%• Poor learning 4%• Other 6%• Don’t know 49%

During the same survey women were also asked whether they had ever heard any health messages about goitre/IDD (n=184): 97% answered ‘no’.92% of the women had no knowledge on how to prevent goitre (n=38).

In a study on knowledge and attitudes Afghan men and women in Kabul, Badakhshan and Kandahar were interviewed in 2002 (28). Obstetric complications leading to maternal deaths were listed by women and men as the most critical health problem in their communities. Anaemia was one of the most common complaints of women in every community interviewed. Women ranked this as a critical problem and a leading cause of illness and death. Women preferred to eat less food in their 9th month of pregnancy: they are too uncomfortable to eat and they are afraid of having a large baby. Fear of death during delivery was a major cause of anxiety for most women we interviewed (except for the urban middle class of Kabul).Few women had any health information about safe motherhood and no one could list danger signs of problem deliveries. Long labour and bleeding was regarded as normal at birth and many women continued to have abnormal bleeding long after delivery. Women generally did not breast feed immediately after delivery. The most common practice was to wait about 12 hours after delivery before breast feeding8. Babies would be giving black tea or butter. Many women complained that they could not breastfeed as they have little or no milk9.

In many areas in Afghanistan there are strong beliefs on what food to avoid or to eat during pregnancy and lactation (30). In a study in 2003 on post-partum diet results showed diet restrictions and beliefs about the effects of “hot” and “cold” foods influenced what breastfeeding mothers eat.Food beliefs were related to encourage the flow of breast milk, cleaning their wombs by stimulating vaginal discharge and curing post-partum fevers and shivers etc.

In the Ghor province another study found that, in case of health problems, the first person to be consulted by the family was the Mullah, secondly the ‘pharmacist’/drug vendor and thirdly the doctor (15).

8 Immediate breastfeeding reduces the post-partum hemorrhage9 If colostrum is discarded the infant’s immunity system is severely weakened.

of 83


The health education is generally spoken very low in Afghanistan, women hardly attend formal health facilities and cultural beliefs are strongly imbedded and not always in line with formal health messages by the Ministry of Health. This has some major negative consequences for the health of all women and their children: health problems are not recognised, not adequately treated, and not easily prevented if those health issues are not regarded as a problem.

2.11 Food access, availability and use

Cereals, predominantly wheat and rice, account for an average of 80 percent of daily energy intake for Afghan families; the intake of micronutrient-rich foods is limited (cf o.c. 14). Intra-household food distribution patterns, which generally favour men and children in Afghanistan, are likely to contribute to increasing women’s nutritional risk. Women have a limited influence on decision-making within the household, particularly with respect to how resources are spent and what foods are purchased, as these decisions are largely taken by men (21).

Preliminary analysis of the National Rural Vulnerability Assessment, a rural survey undertaken in every Afghan province, findings shows of all consumed calories by families less than 3% comes from meat/fish and 2% from vegetables (14). Food sources in Afghanistan are potentially very diverse, as livestock and poultry provide good protein sources (meat and milk) and orchards and gardens supply a diversity of fruits and vegetables rich in micronutrients. But many factors affect the capacity of some populations to diversify their diet (14):

- many areas are physically isolated due to the mountainous terrain, lack of roads, and snow during winter months. This may limit access to markets and opportunities for trade.

- winters can last up to six months with extreme temperatures inhibiting most fruit and vegetable cultivation for half of the year.

- successive droughts in the past have resulted in a reduction in harvests from fruit trees, which were customarily preserved and consumed during the lengthy winters.

- many households have poor purchasing power.- cultural beliefs influence and limit the consumption or micronutrient-rich foods

during periods of the year. For example, vegetables are consumed less during the winter because they are considered “cold” foods.

In addition, the National Risk and Vulnerability Assessment showed that 40% of rural households reported reduced consumption and deteriorating dietary diversity in response to shocks (27).

This implies that if families have already access to sufficient food, the availability of diversified food products is relatively limited and women in general will have the least use of high quality food products.

2.12 Causes listed by Afghan health and food professionals

of 83


During the Consultative Meeting in November 2004 an inventory was made by all Afghan participants from Ministries, NGOs and UN agencies on main causes of the overall poor nutritional status of WRA (Table 2).

Table 2. An overview of main causes given by Afghan health and food professionals on the poor nutritional status of WRA.

Micronutrient deficiency disorders, especially iron deficiency anaemia and iodine deficiency disorders related to low food intake of micronutrients and to frequent illness

Food intake – low quality and quantity, cultural practices regarding food, esp. in pregnancy

Hygiene and sanitation - limited access to safe water General status of the country - drought, poverty, war Low health literacy and limited nutrition education/awareness of food

practices/intake for women, especially in rural areas Prioritization of women’s access to food in family is low - they eat after others eat Birth intervals are short, high fertility, due to cultural practice/limited access to

family planning Clinical treatment for iron deficiency anaemia is not standard - limited education

of health clinic workers Lack of access to care - logistical, cultural, financial High load of work for women, even during pregnancy Low status of women in family and community

2.13 Conceptual framework of causes and consequences of malnutrition of Afghan women

The following page shows an overview with direct and indirect causes and consequences of malnutrition of Afghan women in a conceptual framework. In particular, it emphasises the major consequences on the children in Afghanistan when their mothers are malnourished.

of 83


Causes and Consequences for the Afghan Society of Malnutrition amongst Women of Reproductive Age

of 83

Foetal mortality and morbidity

- Impaired immunity- Stillbirth, miscarriage- Intellectual impairment- Neural tube defects- Low Birth Weight

Maternal Mortality:- High infant mortality- High risk of mortality for other children

Maternal Morbidity:- Low productivity of women- Decreased care of children- Intergenerational malnutrition (low birth

weight infants)

Foetal Morbidity:- High risk of infant mortality- Intergenerational malnutrition: low birth weight

infants → growth failure children → small, impaired cognition, high risk of disease/death

- girls: small → obstructed labour, death or low birth weight

Maternal mortality and morbidity

- Hemorrhage- Obstructed labour- Impaired cognition- Nightblindness- Constant fatigue

Maternal Malnutrition in Afghan Women- Anaemia- Iodine Deficiency Disorder- Vit A deficiency- Folate deficiency- Chronic Energy Deficiency

Inability to meet (increased) biological needs (pregnant/lactating women, adolescent girls, Women of Reproductive Age in general)

Disease - Limited access to/utilisation of health care- Little health awareness amongst both women and

their husbands- Poor sanitary conditions- Increased health risks due to pregnancy

Lack of access, availability and consumption of food (low quality/quantity food, little or no meat or other animal products, not enough green/orange vegetables or fruits)

Specific for Afghan women/girls- Low prioritisation of women within family (women and

girls eat last)- Low intake of nutrients compared to increased needs:

pregnancy, lactation, adolescence (example: Higher energy expenditure compared to caloric intake – not enough physical rest during pregnancy => energy deficient)

General for Afghan families- Poor purchasing power in family- Geographical constraints: limited access to markets for

quality food - Climatological constraints: winter impedes cultivation

of most fruit and vegetable for half of the year, drought reduces harvest


3. Inventory of Current Interventions and ConstraintsDuring the Consultative Meeting in November a detailed inventory was made of all activities currently undertaken by the various Ministries, UN agencies and NGOs that benefit directly or indirectly WRA. In tables 3, 4 and 5 for each ministry, agency or NGO a description is given of the organisation’s objectives specifically related to WRA and the current programmes on improvement of nutritional status of WRA (directly or indirectly, facility based or community based).10

Table 3.United Nations AgenciesUNAgency

Section/Dept. Objectives of this Dept./SectionSpecifically related to WRA

Current programmes on Improvement of Nutritional Status of WRA

WHO Maternal Child Health (MCH)

To provide Technical support for MoPH and related organizations concerning improvementof women health in Afghanistan.

WHO is not an implementing agency so WHO is working in close collaboration with actors that have programmes such as Women and Reproductive Health Dept., the Dept for Public Nutrition, Dept. for Child and Adolescent health. WHO provides technical and financial support for developing standard policy and strategies within MoPH for the Afghan Government.

UNICEF Nutrition/Education/Water and Sanitation (WES)MCH

To Reduce Maternal/Child Morbidity and Mortality rate

Nutrition: Food fortification, USICapacity building: Providing workshops on maternal nutritionEPI: TT vaccinationWES: Providing safe drinking water/HygieneeducationEducation: Literacy Programme(MCH: mostly emergency obstetric care )

WFP Health/Education

To improve the health and nutrition status of vulnerable women; to provide food for women to improve their health; to establish flour fortification.

WFP provides ‘food basket’ through supplementary food programme where the malnutrition rate is high;Provision of food for caretakers, hospital patients,TB patients, in which vulnerable women are included.Four fortification project started from March 2004 in Kabul and Badakhshan. Women are getting fortified wheat bread through urban vulnerability bakery projects.Food for training programmes.

Table 4. Non-Governmental OrganisationsNGO Section/Dept. Objectives of this

Dept./SectionSpecifically related to WRA

Current programmes on Improvement of Nutritional Status of WRA

BRAC Health To alleviate poverty and empower the poor, especially women through community based health programmes.

Addition to the health programme, BRAC has other programmes like Microfinance, in which the health programme is integrated. BRAC microfinance programme has village organizations with female members. The CHW of BRAC are female. Village organisation members are attending regular weekly meetings, which provides opportunities to deliver messagesregarding the women health.

10 update from November 2004.

of 83


CAF Health To reduce morbidity and mortality among WRA.

The interventions to improve nutritional status of women is practiced by CAF through the life-cycle approach of women.(Early) childhood: integrated management of childhood diseases through facilities and community which includes supplementation of Vit.APrevention/treatment of malaria and parasitic diseases, screening for malnutrition.Adolescence: Prevention/treatment

ACF Nutrition/Health education/Psychosocial care

To treat , protect, and detect severe malnourished children; to improve nutritional status and to prevent malnutrition of women in Afghanistan.

Nutrition surveillance, food distribution, pre- and postnatal care as well as distribution of drugs and delivery of packages to the mothers in remote areas, lactation counselling, nutrition education promotion, psychosocial activities with women, improving caring practices including improving relationship of the mothers with their children and other family members, work with religious leaders, distribution of micronutrients to the pregnant and lactating women, food security (distribution of seeds, kitchen gardening, food diversity, and poultry keeping).

SC-UK Health To improve community health care services and to strengthen emergency obstetric care in two provinces in order to reduce maternal and infant mortality rate

Services to improve nutrition status of WRA 1- MCH services - Antenatal care (distribution of Fe-Folic for pregnant women in each visit - identify pregnancy related problem - vaccination e.g TT for women - treatment of iodine deficiency and malaria - education on simple diseases, nutrition, hygiene, Postnatal care - providing vit A and iron/folate for post partum mothers, - education on nutrition, hygiene, newborn care and family planning 2- Training of CHWs - improve health education in community - improve referral system in health facilities 3- Develop and distribution of IEC messages to all health facilities in two provinces.

SC-US Health To improve the health status of children under 5 and WRA

Programme based on community through CHW indirectly with children and directly with women. Activities: 1- health education for increasing awareness (child problems e.g. ARI, CDD, Nutrition, immunization…), for WRA (health education regarding danger sign during pregnancy, nutrition, rest) and follow up 2- capacity building of MoPH regarding (community) integrated management of childhood diseases which focus on children under 5 and women of WRA. 3- Development of health education material

of 83


AHDS Reproductive Health

To improve health of WRA by: - Coordination of activities- Management, planning, monitoring and reporting of reproductive health activities for two BPHS projects, and midwifery training- Training and motivation of female staff

1. BPHS project for all Kandahar and Uruzgan provinces2. Midwifery training3. Mobile health teams- activities related to WRA at the health facility level beside free treatment of common diseased e.g. antenatal care, safe delivery care, post natal care, health education on nutrition and health related issues and growth and monitoring, family planning, immunization for women and children, food demonstration sessions at weekly based) - activities related to community level e.g. health education and antenatal care through BPHS , treatment of patients and free medication by CHWs, immunization, family planning, proper referral of complicated cased by community health workers.

Table 5 provides an overview of objectives and activities on WRA of various ministerial departments (more detail and examples are provided in annex 10).

Table 5 MinistriesMinistry Relation of programmes to WRAMinistry of Rural Rehabilitation and Development (MRRD)

Most programmes are aiming at general economic development and concern improving access to infrastructure, health and hygiene; act as a safety net for vulnerable groups; aim at developing capacity of government; improve livelihoods of vulnerable groups; aim to gather information and analysis for response.

Ministry of Agriculture and Animal Husbandry (MAAH)

Programmes are planned that aim to link health and food security programmes as well as nutrition education programmes concerning the use of food products.

Ministry of Women’s Affairs Health Department

Programmes in 32 provinces, aim is general education of women (including health related issues to pregnancy and childbirth); currently there are 600 health educators. MoPH and WHO provide contents of health related messages.

Ministry of Information and Education

Provides broadcasting space for messages presented by MoPH and others. There is one specific programme “Women in Society” broadcasted on TV, messages related to women’s status, role in society, problems etc Radio and magazines have sometimes also space in their publications for these messages.

Ministry of Religious Affairs Each Friday the Mullahs give specific messages, some times these messages relate to women’s health and are in line with Sharia law and the Koran; however the messages are not necessarily provided on a regular base or standardized.

Ministry of Health Public Nutrition

Department

Planning, M&E, and HMIS Department

On the 2003-2006 Policy of this department a specific objective is included on improving the nutritional status of WRA (see paragraph 5.2)

The HMIS collects data on absence/presence of anaemia in pregnant women; and in theory whether iron/folate supplements to pregnant/lactating women and vit A post-partum is provided.

of 83


Reproductive Health Department

Essential Drugs Dept

Information, Education and Communication (IEC)

Primary Health Care Dept

Safe Motherhood and Obstetric Care programmes; antenatal and postnatal health care services (including vit A, iron/folate supplementation and health/nutritional education)

Drug Quality Control Laboratory: checking working agents and concentrations of drugs, amongst others antibiotics, iron/folate supplements etc

Production of IEC material together with the various MoPH

departments

Engaged in defining job description and curriculum for CHW and their kit as part of the Community Health Task Force

Ministry of Social Affairs Dept of Kindergarten

Health and nutrition education through facilities (schools, hospitals) and communities with mothers

Furthermore there is a Nutrition Task Group with various Working Groups (WG) each with their own specific terms of reference. This Task Force is lead by the Public Nutrition Dept (MoPH). Two are specifically related to WRA: the Micronutrient Deficiency Diseases WG and the Infant Feeding and Child Caring Practices.

Workging Group

Terms of Reference Chairs Members in April 2003

Micronutrient Deficiency Diseases

Ensure implementation of Universal Salt Iodization (USI) strategy

Develop and endorse draft legislation of salt iodization

Develop national protocols for treatment and prevention of Micronutrient Deficiency Diseases

Develop strategy for local fortification Develop strategies against iron deficiency

anaemia Develop protocols for assessment

methodology/conduct surveys Develop and implement appropriate training

Public Nutrition Dept (MoPH) and Nutrition (UNICEF)

WHO, WFP, MAAH, Ministry of Planning , Ministry of Women’s Affairs, Ministry of Mining, Ministry of Trade and Commerce, Ministry of Food Stuff and Light Industry, ACF, FOCUS, Concern, USAID, CDCet al

Infant Feeding and Child Caring Practices

Develop a better understanding of infant feeding and childcare practices in Afghanistan.

Develop and implement strategy for behavioural change communication at health facility and household levels.

Strengthen the capacity of health workers, community workers and NGO members in promoting best practices in infant feeding and childcare practices.

Develop, implement and monitor national guidelines and policy on infant feeding and national code on marketing of breast-milk substitutes

Public Nutrition Dept (MoPH) and Nutrition (UNICEF)

WHO, ACF, SC-US, BRAC, IBN SINA, AHDS, WVI, SC-UK, IAM et al

April 2003

of 83


Many programme initiatives have been undertaken during the last few years in Afghanistan aiming at (in)directly improving health, food security and nutrition of women. A number of constraints have been encountered during the implementation phase of these programmes. During the Consultative Meeting in November 2004 a compilation was made of the main constraints and lessons learnt (Table 6). The majority of the programmes are not directly intended for WRA to benefit specifically.

Table 6. Main constraints/lessons learnt encountered during implementation of programmes in Afghanistan aiming to (in)directly improve the health, nutrition and food security of WRA.Health education/awareness Programmes

- sometimes use of wrong health messages or lack of good/strong messages or lack of harmonization of messages used (messages from mosques or NGOs not necessarily in line with messages from MoPH/WHO)- lack or poor quality of tools to measure behavioural change- to evaluate change in knowledge was perhaps possible, but it appeared impossible to measure behavioural change, also because the change might occur only over a long period- insufficient involvement of husbands and mothers-in-law- media-‘darkness’ in rural areas with limited access to TV/radio- illiteracy defines the way how messages ought to be delivered- cultural factors in access and implementation of messages not necessarily taken into account

Supplementary Feeding Programmes

- difficulties in getting information on access, coverage, effectiveness- problems concerning supplies- not necessarily effective for women- real impact of these programmes unknown- reduced access to beneficiaries due to security constraints- often only outcomes are measured, not impact- not necessarily meeting needs of rural population

Universal Salt Iodisation Programmes

- lack of law enforcement- monitoring constraints (for example to check whether salt contains enough iodine at factory level; monitoring needs to be strongly decentralised and is responsibility of MoPH)- needs strong private sector engagement- lack of knowledge of IDD resulting in low demand for iodised salt- quality control problems at factory level- needs strong inter-ministerial collaboration- lack of strong demand for the product - legislation lacking behind

Food based Programmes - food diversification cannot work in areas where food

of 83


(various) access is a problem to many people- strong rooted food habits can impede any change: many people perceive the consumption of fruit/vegetables as a low priority- climate conditions hamper availability of certain valuable food products- limited impact because of small scale implementation, for example with flour fortification

Ante- and Post Natal Care Programmes

- health facility based and poorly visited: for example, post-partum vit A can sometimes only be provided if women come for another reasons than post-natal care to a health facility- anaemia by many people not regarded as a health problem; low motivation to prevent this- problems in accessing health care services- incomplete/disrupted supplies of iron/folate supplements (for example: an anaemic woman might only receive enough tablets for one month)- lack of female staff

Family Planning Programmes - lack of acceptance of activities related to Family Planning by community/elders- birth spacing not everywhere accepted

Basic Package of Health Services (BPHS)

- NGOs have been contracted at different times under different versions of BPHS - Lack of standards, in process of implementation, coordination mechanisms limited

General - lack of community based approach or if this approach is applied it is resources intensive (home by home and village by village).- Individuals need to understand the importance of personal health- difficult to measure impact of programmes- budget constraints- intake of certain drugs seen as low priority- strong imbedded beliefs and resistance to accept new ideas and large geographical differences in levels of ‘liberalisation’

An overall weakness of all those programmes is that many messages used are either not congruent or not accepted by major decision makers in women’s health.

of 83


4. Evidence Based Strategies and their Application in Afghanistan4.1 Introduction

The following chapter will look at the various strategies that are aiming at the improvement of the nutritional status of WRA; a literature analysis was performed with the objective to find efficacious and effective interventions that have proven their merits over time. The results of this analysis were presented during the Consultative Meeting in Kabul with the main stakeholders in November 2004 and are partially discussed here. In the following paragraphs the evidence-based strategies are discussed and selected according to their appropriateness for Afghanistan taking into consideration the constraints.

Note: in this document often the terms efficacy/efficacious and effectiveness/effective are used. The terms can be explained in a simple way with the following example:Efficacy – a health worker gives a Fe/FA tablet to an anaemic woman, every day for a period of time this health worker comes and sees that the women takes it. The worker also makes sure that the woman does not change her nutritional behaviour at all and that her normal condition remains totally unchanged. The worker measures after a while the Hb level in the woman’s blood. It shows that she is no longer anaemic. This intervention is therefore efficacious, and the efficacy of this approach has been proven.Effectiveness – a health worker gives a pot of Fe/FA tablets to an anaemic pregnant woman and tells her too take every day a tablet for a certain period of time. The worker also asks the women not to change her nutritional behaviour and that she does as always. The worker asks the woman to come back after a while and then measures her Hb. The health worker sees she is still anaemic. The woman tells the worker that she often forgot the tablets and that she felt sick after taking. This intervention was not effective, but as such the tablets could work efficacious to treat her anaemia. For making this intervention effective the health worker should have perhaps told the woman on the side-effects of the tablets, the importance for her baby etc etc. A different approach by the health worker, for instance also involving her husband and explaining him the health benefits for his wife, might have changed the effectiveness of the intervention.Efficacy studies are mostly done in a very ‘controlled’ environment, where effectiveness studies relate more to ‘free life’ settings.

It is important to distinguish that there are nutrition/food and non-nutrition/food related interventions that can achieve improvement of the nutritional status of WRA.

Non-nutrition/food related interventions that have proven to be effective in the improvement of the nutritional status of WRA include birth spacing, malaria prevention and treatment and anti-helminthic treatment (and immediate post-partum breastfeeding). These interventions can be more effective than some of the nutrition/food related interventions, especially in fighting anaemia amongst WRA (see Annex 12). Nutrition/food related interventions that are thought to be effective in the improvement of the nutritional status of WRA include:

1. Iron/folate supplementation2. Flour fortification with Fe and other nutrients3. Food diversification4. Dietary advice

of 83


5. Salt iodisation6. Double salt fortification (Iodine, iron)7. Triple salt fortification (Iodine, iron, vit.A)8. Multi-micronutrient UNIMMAP supplementation9. Animal/poultry project etc10. Supplementary feeding (rations)11. Vit A supplementation postpartum and/or during pregnancy12. And various other food-based strategies

It is extremely important to distinguish between different interventions and their objectives: Reduction of Maternal Mortality Reduction of Low Birth Weight (LBW) Improvement of general nutritional status of WRA Reduction of one specific micronutrient deficiency Reduction of anaemia among WRASome aim at improving especially foetal outcomes, others more at improving maternal outcomes. Interventions aiming at a decrease in LBW incidence are outcome measures directly beneficial to the newborn (and indirectly to the mother) but aim to target women/girls. Reduction of Maternal Mortality directly benefits the women and they are directly targeted at women, either during the early childhood of a woman or later.

There is not one intervention that can achieve all abovementioned objectives: An intervention aiming at reduction of LBW incidence might have no impact on reduction of anaemia. Likewise, an intervention aiming at the reduction of Maternal Mortality might have no impact on improvement of the overall micronutrient status WRA.

Some interventions are more successful at community level and/or at (health) facility level and/or at private sector level and/or at other levels

Many of the interventions aiming at reduction of maternal mortality are not food-nutrition related except those that deal with improving maternal height and weight and that prevent/treat anaemia, vit A and iodine deficiency.

Reduction of LBW incidence is related to reduction of intra-uterine growth retardation and the most important determinants are caloric intake/gestational nutrition (in case of malnutrition), gestational weight gain, pre-pregnancy weight and height.

The following part looks exclusively at nutrition-food related interventions and includes conclusions on the usefulness aiming to improve the nutritional status of WRA.

On maternal mortality and LBW the literature shows that

Nutritional interventions can reduce Maternal Mortality by - Prevention and treatment of anaemia - Improving maternal height and weight - Prevention and treatment of vit A and iodine deficiency

of 83


and

Nutritional interventions can reduce incidence of LBW by - Increasing caloric intake (if woman is malnourished) and/or by- Reducing energy expenditure and/or by- Reducing caloric depletion (delaying the first pregnancy and increasing birth

intervals)- Ensuring a good micronutrient status Note: Those interventions aim, amongst others, at sufficient weight gain during pregnancy and are associated with LBW, as are pre-pregnancy weight and height.

All above interventions could start when women reach their reproductive age, except maternal height: a woman’s height can be mainly increased with increased food intake up to age of 3 years of her childhood. This means that to increase maternal height, (and low stature is associated with LBW), only interventions at early infancy are really effective.Pre-pregnancy weight/maternal weight can also be increased before women reach their reproductive age.

4.2 Macro-nutrient supplementation

A review of available evidence from controlled trials on the effects of energy and protein supplementation during pregnancy on the outcome of pregnancy shows that balanced energy/protein supplementation modestly improves foetal growth but is unlikely to be of long-term benefit to pregnant women or their infants.It is concluded that supplementation with protein and energy during the third trimester of pregnancy may be worthwhile in case of serious undernutrition only (31,32).

If short stature is associated with LBW the question remains if nutrition can correct the height of a child/adolescent. However, the following conclusions have been drawn:As mentioned in paragraph 4.1 adult height can be mainly increased with increased food intake up to age of 3 years. There is little evidence to suggest that the growth retardation suffered in early childhood can be significantly compensated for in adolescence, and there are no known studies to determine whether groups of growth-retarded children respond to nutritional and health interventions with compensatory catch-up growth during adolescence. Early childhood growth failure, manifested by stunting, may to a large extent be irreversible (6,25,33).

Supplementary feeding for pregnant and lactating women have proven to have a strong and consistent positive effect on the motor development of infants (34).

An evaluation of Emergency Supplementary Feeding Programmes (SFP) in Afghanistan from 2002-2003 by the MoPH stated that (35):

‘In the past SFPs in Afghanistan were featured by ‘the high proportion of defaulters, largely explained by poor acceptability and accessibility……, this is a result of a number of diverse factors, including cultural constraints that women face that specifically affects their physical mobility and participation in health-seeking behaviours, long distances to travel to the SFPs and difficulties with

of 83


transportation, traditional health-care seeking behaviours, lack of understanding or awareness of the SFP programmes.’One of the conclusions of the evaluation stated: ‘Pregnant and lactating women are generally considered to be nutritionally at-risk in Afghanistan, and while usually included as a priority group in SFPs, further studies are required to better understand the impact of and limitations of supplementary feeding for these women.’

The following conclusions can be drawn for macronutrient supplementation programmes in Afghanistan:

Macronutrient supplementation, as done in Supplementary Feeding Programmes (SFP), are possibly only efficacious and effective in energy-deficit pregnant women in terms of impact on LBW.

It might be useful for lactating women or non-pregnant women with low weight.

Therefore SFP in Afghanistan should only aim at Energy-deficit pregnant women, lactating women or non-pregnant women with low

weight. Exclusion of primigravidae women with height of <1.5 m (unless they have good

access to effective operative obstetric care)11.

However, today in Afghanistan there is A lack of impact studies No information available who benefits directly from rations provided during SFPs to

women (who receives the ration really, what is done with the food, who consumes it, does it serve as a source to get better quality food, is it substituting other food, is the nutritional status of the women improved, etc).

Therefore first good pilot programmes in Afghanistan are needed where impact of intra-household distribution after distribution of dry rations in SFPs and impact on women’s nutritional status are measured.

4.3 Micro-nutrient supplementation

4.3.1 Oral iron supplementation

Randomized, controlled, clinical trials show that iron supplementation of pregnant women improves hemoglobin (Hb) and iron status (22). Efficacy increases with iron doses of up to 60 mg/d. Where iron supplementation has not been effective this has been due predominantly to programmatic constraints. Maternal iron supplementation during pregnancy can improve both maternal and infant iron status for up to about six months postpartum. Daily supplementation during pregnancy is more effective than weekly supplementation for preventing especially severe anaemia. The total amount of iron consumed is the most important predictor of the maternal hemoglobin response.

11 because of possible risks that, for those women, macronutrient supplementation will result in bigger fetus (i.e. head circumference) and therefore might cause obstructed labour.

of 83


Both moderate and severe anaemia is associated with lower productivity, even in tasks requiring moderate effort such as factory work and housework. Efficacy trials have shown that iron supplements improve the work performance of anaemic individuals. For children and adolescents, weekly intake of iron supplements improves iron status almost as well as daily intake (35).

Programme interventions that have been successful in reducing anaemia among adolescents and adult women have been viewed as among the most highly cost-effective interventions for women. The World Bank stated in 1993 that with a delivery cost of $2-4 per person annually, iron supplementation costs just $13 per DALY (disability-adjusted life year) saved, based on infant deaths averted (25).

There is inconclusive evidence whether supplementation of anaemic or non-anaemic pregnant women with iron, folic acid or both increases birth weight (36,37). Nor is it clear whether iron/folate supplementation (and other micronutrients) increase growth in very young primigravidae and reduce the incidence of Cephalo-Pelvic Disproportion/prolonged labour/operative delivery (38).

The WHO states that focused supplementation of particular micronutrients can be an important component of health services for pregnant women, particularly in cases where communities suffer from extreme poverty and malnutrition. The current WHO recommendation is (39):Iron supplementation to prevent iron deficiency anaemia Pregnant women should routinely receive iron supplements in almost all contextsferrous salt + folic acid

tablet equivalent to 60 mg iron + 400 micrograms folic acid

Prevalence of anaemia < 40%: 60 mg iron + 400 micrograms folic acid daily during 6 months in pregnancyPrevalence of anaemia ≥ 40% (As in AFGHANISTAN) : 60 mg iron + 400 micrograms folic acid daily during 6 months in pregnancy, and continuing to 3 months postpartum

If a full course of treatment (6 months duration) cannot be achieved in pregnancy, continue to supplement during the postpartum period for 6 months or, increase the dose to 120 mg iron in pregnancy.

However, in a recent overview in February 2004 on efficacy and effectiveness of interventions to control iron deficiency and iron deficiency anaemia it is concluded that the use of iron supplements during pregnancy has been shown to be efficacious in reducing anaemia, but pooled data from the past 30 years do not conclusively demonstrate programme effectiveness (40). The sometimes marginal effectiveness are due to a variety of contributing factors, including the following (6,38,40):• A lack of the supplements themselves, as a result of poor or ineffective procurement and distribution systems.• Failure to use specific indicators of iron deficiency in monitoring or evaluating programs. Anaemia is often used as a proxy for iron deficiency anaemia. However, because the aetiology of anaemia is often multi-factorial, supplementation with iron alone will be inadequate to prevent and control anaemia where iron deficiency is not the only cause of anaemia.• Failure to concentrate efforts on the individuals who are iron deficient. Although the overall effectiveness of iron supplementation programs targeting all pregnant women may be limited, the benefit to iron-deficient individuals can be significant.

of 83

http://mednet3.who.int/Eml/medicines_link.asp?drugId=139


• Poor compliance with the supplementation regimen.• Absence of counselling on possible negative side effects, such as nausea, constipation, and diarrhea.• Poor access to and use of prenatal health care services and sometimes limited opening hours• Constraints on quantities of supplements given per visits

The following conclusions can be drawn for iron/folate supplementation programmes in Afghanistan: Iron/folate supplementation (preferably daily) is efficacious in hemoglobin status

improvement => reduction of anaemia. High priority should be given to correcting severe anaemia in pregnant women if the

objective is reduction of maternal mortality. Correcting anaemia (both moderate and severe) improves productivity (this can

include housework, labour, child care activities, etc). Reducing anaemia among adolescents and adult women is seen as the most highly

cost-effective interventions for women.

In Afghanistan where 70% of women suffer from iron-deficient anaemia Pregnant women should routinely take 60 mg iron + 400 micrograms folic acid daily

during 6 months in pregnancy, and continuing to 3 months postpartum. Experts strongly advocate to give also Iron/Folic acid supplementation for Women of

Reproductive Age prior to and between pregnancies:Periodic supplementation (60 mg of iron and 400 μg folic acid) daily for 3 months for:

Girls during adolescence Women of childbearing age in general

From experiences in other countries successful iron/folate supplementation programmes are based on inclusion of many of the following elements (25,41):

1. Health workers were strongly motivated to control anaemia. 2. Anaemia is recognized as nutritional deficiency in the community.3. Iron supplementation was very closely bound to prenatal care and it was a good

incentive to start and continue with the prenatal visits4. Availability of the supplement 5. Continuing monitoring and counselling.6. Community sensitization to secure their involvement7. Baseline study approach : baseline study on the knowledge of women on

anaemia and iron+folic acid8. Selection and quality training of traditional birth attendants in charge of the

distribution of iron+folic acid, distribution of tablets and monitoring. 9. Male involvement in male dominated cultures10. Community demand creation is vital to long-term success. 11. Flexible, preventive supplementation administered by community-based

organisations. Where attendance at clinics is low, village health workers, midwives or birth attendants may facilitate distribution and compliance.

Any iron/folate supplementation programme In Afghanistan should take these criteria into account.

of 83


4.3.2 Multiple micronutrient supplementation

A special multiple micronutrient tablet is designed by UNICEF/UNU/WHO for use by pregnant (especially), lactating women and adolescent girls. The UNIMMAP tablet was formulated which would provide ten vitamins and five minerals in sufficient amounts to meet the recommended daily allowance for a pregnant woman (42,43) (see Annex 7). Calcium was excluded for two reasons: because the resulting tablet would have been too large, and because calcium can reduce the absorption of iron and zinc, two essential minerals that may already have effects on the absorption of each other.

One of the most important objectives with this multi-micronutrient supplement is to prevent LBW (42).

The tablets shoud be used:- For pregnant women it concerns UNIMMAP tablet supplementation once per day throughout pregnancy (‘as long as possible during pregnancy’).- For lactating women UNIMMAP tablet supplementation once per day until three months postpartum.- For adolescent girls possibly once weekly as a way of improving micronutrient status prior to a potential pregnancy.

Currently the efficacy of the UNICEF/UNU/WHO multiple micronutrient preparation for use in pregnancy is evaluated in Bangladesh, Burkina Faso, China, Guinea Bissau, Indonesia, Nepal and Pakistan. Most of the efficacy trial results are only to be expected within the next 3 years.

In addition, effectiveness trials are also initiated. UNICEF invited nine countries to develop approaches to provide multiple micronutrient supplements through programmes, and thereby provide plausible evidence of their effectiveness at preventing low birth weight and other adverse pregnancy outcomes when given in practice. These countries are Bangladesh, India, Indonesia, Madagascar, Mozambique, Nepal, the Philippines, Tanzania and Viet Nam and Niger. These effectiveness trials incorporate the multiple micronutrient supplements into ongoing safe motherhood or antenatal care services. In addition to the multiple micronutrient supplement, other interventions encouraged include prevention of early marriage and childbearing, promotion of increased child spacing, increased rest and food during pregnancy, improved reproductive health, deworming, and malaria control as appropriate. Pre-pregnancy weight, weight gain during pregnancy and birth weight were recommended as critical indicators that will show effectiveness of the supplement and other strategies.Both these previously mentioned efficacy and effectiveness trials will contribute significantly to international understanding of the role of multiple micronutrients in optimizing foetal development (42).

Some preliminary results (42):Evidence from the effectiveness studies reviewed at a meeting in Bangkok in June 2004 showed some positive outcomes from the use of multiple micronutrient supplements compared with iron/folate tablets alone, including one or more of the following: reduced neonatal mortality, increased birth weight, weight gain in pregnancy, increased compliance, and fewer reported side effects. Importantly, no harmful effects of using

of 83


multiple micronutrient supplements were reported. Full efficacy trials are under way and some preliminary results appear to support the benefits shown in the effectiveness trials. Whilst the rigour and validity of these research findings may not be optimal, there is enough preliminary evidence and theoretical justification to advocate greater action in the use of multiple micronutrient supplements, especially during the critical periods of pregnancy and infancy. Multiple micronutrient supplements similar to those used in these trials are widely used with no adverse effects. Based on these considerations and using the principle of “tolerable imprecision” the people involved state that UNICEF/WHO/UNU multiple micronutrient supplement should be used during pregnancy whenever feasible in place of iron and folate supplements, especially in emergencies.

Others add that in general supplements containing multiple vitamins and minerals could be more effective for improving hemoglobin response than iron alone, because several nutrients are required for hemoglobin synthesis (22). Multiple micronutrient deficiencies often occur simultaneously and should be prevented and treated.

The costs are not much higher of tablet itself if added nutrients are purchased in bulk as compared to iron/folate tablets. However, now the costs are about 8-10 fold higher. Cost of the delivery system is similar for both iron/folate and micronutrient supplements (25,42).

The following conclusions can be drawn for multiple micronutrients supplementation programmes in Afghanistan:

A special formula is designed by UNICEF/UNU/WHO for use by pregnant (especially), lactating women and adolescent girls.

Effectiveness and efficacy trials are under way with this formula but preliminary results show reduced neonatal mortality, increased birth weight, weight gain in pregnancy, increased compliance, and fewer reported side effects and no harmful effects.

Great potential for Afghanistan in the future, especially because of the generally poor micronutrient status of WRA

The approach is similar as with Iron/folate supplements

4.3.3 Oral Vitamin A supplementation

Various big trials suggested beneficial effects of vitamin A supplementation during pregnancy: Maternal mortality from pregnancy-related causes was reduced by 40% with weekly vitamin A supplements and 49% with weekly beta-carotene supplements, in an area of rural Nepal with high Vit A deficiency. However, further trials are needed to determine whether use of vitamin A supplements in pregnant women can reduce maternal mortality and morbidity and by what mechanism (22,44). High dose vitamin A supplements cannot be given safely to pregnant women. Maternal supplementation postpartum has proven to improve both maternal and infant vitamin A status (45): • Postpartum dosing improves maternal vitamin A status and increases the vitamin A content of breast milk.• Postpartum dosing improves infant vitamin A status and may help prevent vitamin A deficiency in high-risk infants.• Postpartum dosing may decrease infant morbidity and mortality.• Postpartum dosing may improve maternal health

of 83


The current WHO recommendation on Vitamin A supplementation is (46):Maternal supplementation during pregnancyFor fertile women, independent of their vit A status, 10 000 IU (3000 microgram RE) daily during pregnancy

Where Vit A deficiency is endemic:- daily supplement not exceeding 10 000 IU (3000 microgram RE) daily at any time during pregnancyOR- weekly supplement not exceeding 25 000 IU vit A (8500 microgram RE)

Supplementation for mothers postpartumBreastfeeding mothers: single high dose (above 25 000 IU and usually at level of 200 000 IU) before 2 months postpartumNon-breastfeeding mothers: single high dose (above 25 000 IU and usually at level of 200 000 IU) before 1 month postpartum

It can be concluded that WRA in Afghanistan and their infants are at higher risk of morbidity and mortality with vitamin A deficiency. Vit A supplementation postpartum is proven to be efficacious for improving both maternal and infant vitamin A status, esp. where intake with food is poor, as in Afghanistan.The question remains whether the effects of vitamin A supplementation during pregnancy on maternal and foetal outcomes are so substantial that it would justify a large scale low-dose-vitamine A-during-pregnancy supplementation. The study In Nepal where vitamin A and/or beta-carotene significantly reduced MMR in women with and without night blindness clearly justifies it (55,56).

4.4 Food-based approaches

4.4.1 Food fortification with nutrients

4.4.1.1 Iron

Food fortification is often suggested as the best long-term approach to increase iron intake. However, few data are available to show the efficacy of increased iron intake from iron-fortified food—either targeted food or staple food—in improving iron status. It is important to bear in mind that efficacy has been demonstrated only for water-soluble iron compounds added to condiments (soy-sauce, salt, etc). The efficacy of less soluble iron compounds (that are not freely water soluble or are insoluble in water) added to cereal flours is unknown.No large-scale iron fortification programs have been evaluated for effectiveness. Compliance with food fortification programs can be assumed to be considerably better than with iron supplementation, because less active involvement by the consumer is required. Although iron supplementation has been demonstrated to be efficacious in many studies, more information is needed about the efficacy of food fortification (40).

Case study

of 83


In 1994 in Nicaragua the Ministry of Health developed the National Micronutrient Plan which focused on three interventions for anaemia control: iron supplementation of pregnant women and children under five, fortification of wheat flour with iron and B vitamins, and a communications strategy to generate demand for iron supplements and improve dietary iron intake. Supplementation policies were formulated, guidelines for health personnel prepared, and extensive training of health professionals and MoPH service personnel completed. Mandatory fortification of wheat flour was established in 1997 but the iron compound used was later found to be poorly absorbed and a more bio-available compound was introduced in October 2003. The national anaemia rates dropped to 16% in women and to 23% in children. The significant progress in reducing anaemia may be attributed to effective supplementation and food fortification. However it is unclear what contributed mostly (41).

The following conclusions can be drawn from iron fortification programmes for Afghanistan: The current pilot projects in Afghanistan on wheat flour fortification with iron should give results to decide if this intervention strategy in combating anaemia is efficacious and effective for Afghanistan. Potential difficulties of these pilot projects are to measure the impact on hemoglobin status of the recipients of fortified flour and the extent of the decentralised flour milling in the Afghan rural areas. Until those results are not available, no scaling-up of these projects would be justified in Afghanistan.

4.4.1.2 Iodine and other nutrients

Salt iodization is by far the most important population-based intervention to combat iodine deficiency disorders and has been efficacious where iodine concentrations in the salt were at appropriate levels at the time of consumption. Cretinism results from maternal iodine deficiency during pregnancy. It can be prevented by supplementing the mother during pregnancy, preferably during the first trimester and no later than the second trimester. Supplementation in late pregnancy, if that is the first time the mother can be reached, may still provide some small benefits for infant function. In an iodine deficient region, iodine supplementation, even in the last half of pregnancy substantially reduced infant mortality and improved birth weight (22).

Double fortification or even triple of salt with Iodine, iron and possibly vit A have proven to be efficacious and could be considered in Afghanistan in the long run (47). In India double fortification of salt, with iodine and iron has proven to be effective for improving hemoglobin concentrations (22).

It can be concluded that fortification of- Salt with Iodine is efficacious and effective in reducing maternal mortality and

cretinism- Salt with Iodine AND Iron (‘double fortification’) works similar and additionally

reduces anaemia- Salt with Iodine AND Iron AND vit A (‘triple fortification’) has very promising

results

4.4.2 Food-diversification

of 83


The FAO acknowledges that in certain circumstances there is a need for supplementation and other public health measures in trying to reduce micronutrient deficiencies (18). In using food-based approaches FAO primarily advocates dietary diversification and fortification.Increasing dietary diversification is the most important factor in providing a wide range of micronutrients, BUT to achieve this objective in a development context requires an adequate supply, access and consumption of a variety of foods. Food-based approaches include assessing dietary consumption, expanding and diversifying food production, improving food processing, preservation, storage and marketing, and improving food preparation.

Except for iron fortification, there have been few attempts to assess the effectiveness of food-based strategies to improve iron status. Increasing intake of vitamin C, through local foods, is probably an inadequate strategy to improve iron status where iron deficiency is prevalent. Targeting animal products to those with the highest iron requirements, and supporting the production of poultry, small livestock and fish, would increase the intake of absorbable iron and other micronutrients (22).The best dietary advice to enhance bioavailability of iron is to include an ascorbic acid source and meat in a meal. Meat also increases vit A intake. Betacarotene, in the absence of meat is the major dietary source of vitamin A in developing countries. A good daily dietary mixture contains staple + pulse + green leafy vegetables or an orange vegetable or fruit at one meal. Drinking tea or coffee at the same meal or shortly after has a marked inhibitory effect on iron absorption.

A diet with a nutrient density which is just barely adequate in energy terms for an adult cannot meet the iron and folic acid needs of a pregnant woman, even if consumed in amounts adequate to meet their energy needs. Pregnant women will need relatively larger proportions (relative to their requirements for energy-providing foods) of foods rich in vitamin A, iron, calcium and folic acid, e.g. milk, yellow fruits and green vegetables. This situation is particularly acute with respect to micronutrients such as folic acid, vitamin B12 and vitamin A when these nutrients are derived from foods such as fruit and vegetables which do not contribute significantly to energy intake.

Methods such as germination, malting and fermentation have been found to enhance iron absorption by increasing vitamin C content or by lowering the tannin or phytic acid content, or both). Soaking of grains and legumes, a fairly typical household practice, has been shown to remove certain anti-nutrients which can inhibit non-haem-Fe absorption (18).

The main cause of Vit A deficiency is low intake of animal products. Beta-carotene is the main provitamin A in plants. Although some plants are very high in beta-carotene, this is generally less well absorbed by humans than retinol. Beta-carotene from fruits and squashes is substantially better absorbed than that from leaves and vegetables in general. However, the recent finding that the bioconversion of provitamin A in dark green leafy vegetables is even less than one quarter of that previously thought, has raised doubts about the degree of efficacy of certain diet modification approaches in improving vitamin A status.However, food-based strategies might have good potential for preventing Vit A deficiency. Some of food-based interventions have been implemented on a large scale, but few have been evaluated adequately. Food-based approaches need to be pursued

of 83


more vigorously so that they become a larger part of the longer term strategy for alleviating Vit A deficiency (22).

In a review of recent evidence on food-based strategies to help reduce Vitamin A and Iron Deficiencies many concerns were expressed (48). The review analyses many studies and wonders whether food-based strategies can really reduce micronutrient malnutrition?Although the technologies and strategies examined in this review potentially address many concerns about the intake and bioavailability of vitamin A and iron among impoverished populations, enormous information gaps still exist concerning the efficacy and the effectiveness of most of the strategies reviewed, even approaches as popular as home gardening promotion. Significant progress has been achieved in the past 10 years in the design and implementation of food-based approaches, particularly the new generation of projects that integrate production, nutrition education, and behavioral change strategies. Yet, little has been done to assess the impact of these combined strategies on the diets and nutritional status of at-risk populations. In the end, the same question posed in reviews published decades ago remains: what can food-based interventions to control vitamin A and iron deficiency really achieve? Food-based approaches are an essential part of the long-term global strategy to alleviate micronutrient deficiencies, but their real potential has not been explored adequately (48).

Food-based strategies to control vitamin A and iron deficiencies are at different stages of development. Experience with vitamin A programs is generally more advanced than with strategies to address iron deficiency.In Annexes 8 and 9 a review of recent evidence is provided which gives a summary of where current knowledge stands regarding the food-based strategies reviewed for vitamin A and iron (48); the research that still needs to be done to achieve progress and to improve the understanding of the potential of food-based approaches is also summarized for each micronutrient and each strategy.

Dietary advice aiming at improvement of somebody’s nutritional status aims at behavioural change (i.e. usually increased consumption of certain types of foods)While there have been many nutrition-related communications projects implemented during the last 10-15 years, generally little emphasis has been placed on evaluating their impact. Firstly, behavioural change effects have in the past been difficult to attribute conclusively to projects. Secondly, consumption is difficult to measure, and measurement often relies on reported intake, which may be inaccurate. Some experts plead that the operational effectiveness of interventions aimed at dietary modification through behavioural change needs to be better documented (25).To what extent can dietary advice really can prevent anaemia is not clear and remains one of the important research questions (38).

The following conclusions can be drawn from food diversification programmes for Afghanistan:

They are potentially useful in improving the general micronutrient status of WRA BUT to achieve this objective in Afghanistan adequate supply, access and actual

consumption by WRA of a variety of foods are required To reduce anaemia, vit A and iodine deficiency the best dietary advice for Afghan

women would be to consume more meat (especially), fruit, orange/dark green leafy vegetables, iodised salt and during the meals less tea

of 83


The reality remains that for various reasons many women will be unable to access those food products.

Currently there is insufficient information available what food/nutrition beliefs and practices there are amongst Afghan people that might provide opportunities to ‘correct’ towards a better nutritional status of WRA.

It is therefore doubtful that food diversification is really effective and feasible in improving the iron (and vit A) status for WRA in Afghanistan on a short term where anaemia is prevalent at such a large scale.

4.4.3 Other Food-based approaches

Research has proven that women’s control over household income has been found to influence child nutrition positively, but empirical effect on their own nutritional status is limited. Additionally research show increased female wages are associated with an improvement of nutrient intakes of most household members, little positive effect was found on nutrient intakes of women themselves (49).A small animal husbandry project in Malawi has proven not to be without major problems in areas prone to drought; the impact on the hemoglobin status of the pregnant women is not yet known (50).

case study

SMALL ANIMAL REVOLVING FUND ADDRESSES IRON DEFICIENCY ANAEMIA IN MALAWI The small animal revolving fund is an innovative strategy to increase household access to animal source foods in a sustainable way. A project in Malawi focused on promoting small animal husbandry (poultry, rabbits, guinea fowl, goats) for household consumption to increase iron intake from animal source foods, and provided inputs to women in a revolving fund manner. One objective of the programme was the reduction of iron deficiency anaemia among women. During the severe 1999 food shortage, many households sold or consumed all their animals, resulting in a significant set-back to the revolving fund system. A second distribution of animals was completed in 2002. This strategy is to be expected to contribute to the reduction of anaemia in pregnant women. World Vision Malawi (50). It can be concluded that food-based/income generation strategies could be an essential part of the long-term strategy to alleviate micronutrient deficiencies in Afghanistan and their real potential has not been explored adequately.But the efficacy and the effectiveness of many food-based strategies are still unlcear. Some of the income generation/animal husbandry strategies might be useful to improve micronutrient status of some family members or might increase family’s incomes, but it is unclear how the health of Afghan WRA can really directly benefit.

4.5 Conclusions

In Tables 7, 8 and 9 all reviewed interventions are listed and scored on their usefulness aiming at reduction of anaemia, maternal mortality, LBW incidence and improvement of the general nutritional status of women of reproductive age. Table 7 shows the effectiveness and efficacy of various interventions on reduction of anaemia as well as their impact on the general nutritional status of WRA.

of 83


Table 7Improvement of the nutritional status of women of reproductive age

Impact on anaemia reduction

Impact on general nutritional status

of WRANutrition/Food related interventions efficacy effectivenessIron/folate supplementation ++ +/- +Flour fortification with iron and other nutrients +/- ? +/-Food diversification +? ? +?Dietary advice +? ? +Salt iodisation ++Double salt fortification (I, Fe) ++ ++? ++?Triple salt fortification (I, Fe, vit.A) ++ in children ? ++?Unicef multi-micronutrient supplement (UNIMMAP) ++? ? ++?Animal/poultry project ? ? ?Supplementary feeding (rations) ? ? ?Vit A supplementation postpartum ++ Non-Nutrition/Food related interventionsBirth spacing ++ ++Malaria prevention/treatment ++ +Deworming/anti-helminthic treatment ++Reduced workload (Decreased energy expenditure) + ++

Table 8 lists approaches that have proven to have an impact on the reduction of maternal mortality.

Table 8Impact on maternal mortality reduction Nutrition/Food related interventionsGood nutrition especially for <3 years old children (reduction of short stature; reduction risk obstructed labour)Treating/preventing anaemia including iron deficiency and its causes (see above)Immediate postpartum breastfeeding (hemorrhage risk reduction)Increasing pre-pregnancy weightPrevention and treatment of Vit A and Iodine deficiency

In addition, any intervention that generally treat and prevent infection after childbirth (‘puerperal infection’), pregnancy induced hypertension (toxaemia, pre-eclampsia, eclampsia), hemorrhage (intra- and post partum) and obstructed labour are efficacious in reducing the maternal mortality rate. Table 9 shows efficacious strategies aiming at reducing the incidence of LBW.

Table 9Impact on LBW

of 83


Macronutrient supplementation (only in famine conditions; possibly increased obstructed labour for short primigravidae)Intervention aiming at increasing pre-pregnancy weight Intervention aiming at increasing height especially in early childhood Reduced workload (Decreased energy expenditure)Ensuring adequate intake of macro- and micronutrients during pregnancy

It should be stressed that some intervention strategies might not be the first choice or even questionable for improving the nutritional status of WRA, but they might well be the first choice if other objectives are set or other groups are targeted.

of 83


5. Recommendation for Priority Strategies for Afghanistan5.1 Selected strategies and their rationale

Most of the selected strategies are ‘symptomatic treatments’ and do little or nothing to address the causes of the relatively poor nutritional status of Afghan WRA. However, at this stage it is unethical not to take immediate action in the form of, for example, micronutrient supplementation; at the same time strategies that address (intermediate) causes should be initiated.

The best strategies for Afghanistan should include the most efficacious, effective approaches and feasible for the context. In this chapter only Nutrition/Food related interventions are discussed. It should be noted that not selected strategies might well be effective or efficacious in reduction of health and nutritional problems; however they might not necessarily achieve the best health gains for women of reproductive age in particular.

The following selection of priority strategies are selected because they have proven to work in other countries with similar problems and/or context, are cost-effective (iron/folate supplementation!), are in theory already included in many policies of the Afghan MoPH, and are supported by various other ministries. The fundaments of the priority strategies encompass

• Supplementation• Fortification • Health education as the overall support strategy

These strategies are seen as appropriate, culturally correct and useful for Afghanistan and aim as a package at reduction of maternal mortality, improvement of the nutritional status of WRA, reduction of prevalence of anaemia amongst WRA and reduction of incidence of Low Birth Weight babies:

Iron/folate supplementation during pregnancy (and WRA in general)Rationale:During pregnancy

- Strategy to be proven efficacious and effective if well programmed- Strategy for the short- and long term- Important because of the vast public health implications anaemia has in

Afghanistan- One of the global priorities (Millenium Development Goals)- WHO: advises this for every country with anaemia prevalence >40%, practised in

many countries globally, but not getting enough attention in Afghanistan - Strategy that is already in place on paper within BPHS on all health facilities

levels- Impact potentially enormous of fighting anaemia among Afghan WRA

To all Afghan WRA/adolescent girls regardless their hemoglobin status- Strategy to be explored once the national programme of supplementation during

pregnancy (and lactation) is in place

of 83


Unicef/WHO’s multi-micronutrient supplementationRationale:

- Strategy to be explored parallel to iron/folate supplementation- Strategy for the long term but pilot study should be done on mid term- Could eventually replace iron/folate supplementation which could be especially

effective in improving all major micronutrients that currently are low in diets of WRA. However there is urgent need for proof if dosage of iron is sufficient in reducing anaemia in same way as with current dosage of single iron/folate supplementation.

- Impact potentially enormous on fighting anaemia, vit A and iodine deficiency disorders among Afghan WRA

Vit A supplementation post-partum (and during pregnancy)Rationale:Post-partum supplementation

- Strategy for the short- and long term- Important because of the vast public health implications vit A deficiency has in

Afghanistan- Strategy that is already on paper in place within BPHS on higher health facility

level where delivery care is provided; same for lower facility levels: but hardly anyone is doing it.

- Impact potentially enormous on both improving vit A status of Afghan mothers and their infants and worth doing regardless if any impact is expected on other maternal outcomes such as mortality or LBW etc

During pregnancy- Strategy that should be explored on short term on feasibility for Afghanistan;

scientifically it could be justified, however the implications of it are considerable. If the Unicef/WHO’s multi-micronutrient supplementation trial proves to be effective too many separate vertical supplementation programmes could be avoided and vit A during pregnancy could be provided in the multiple nutrient formula.

Food-based approaches incl. flour fortification with various nutrients, food diversification, salt fortification with iodine

Rationale:Salt fortification

- Strategy proven to be efficacious and effective- Strategy already implemented throughout Afghanistan but need wide support

through any other parallel nutritional programme whether health facility or community based

- Impact enormous on reduction of IDD in WRA- Double fortification programmes should be explored on mid term (for

implementation on long term) once the USI has been widely implemented.

Food diversification – long term strategy that will serve possibly all household members; urgent pilot studies are needed with adequate evaluation components aiming to assess the value for WRA.

of 83


Flour fortification – short and long term strategy currently in pilot phase; only if results in Afghanistan support improvement of nutritional status of WRA this strategy should be included in WRA-programmes.

LBW/life-cycle approach including infant and child care; this includes immediate post-partum breastfeeding and exclusive breastfeeding

Rationale:- Strategy that implies a long term approach and with impact on LBW or maternal

mortality only measurable one generation later (at earliest)- Strategy aiming at infant-girls-to-become-mothers- It can normalise both stature and possibly pre-pregnancy weight- Potentially major impact on reduction of LBW and maternal mortality, as well as

on child health

Health education incl awareness of nutritional problems amongst WRA, including dietary advice messages, advice on supplementation etc

Rationale:- Strategy for the short- and long term- Strategy that aims to support all other selected approaches and crucial for their

effectiveness- Strategy that already exists in many programmes, both national and NGO

supported- In areas with limited food availability programmes on dietary advice should not be

done without first successful food diversification programmes

5.2 Public Nutrition Policy and Strategy on WRA

In the Public Nutrition Policy and Strategy for 2003-2006 from the Public Nutrition Department/MoPH seven objectives are described including one specific on WRA and reduction of LBW (21).

Public Nutrition Policy and Strategy, Objectives 2003-2006 (21)1. Ensure that the prevalence of acute malnutrition or wasting (< -2 z-score, weight

for height), is reduced to and remains below 5% for all children under five years old throughout the year.

2. Ensure that more than 90% of households have access to iodized salt throughout the country.

3. Prevent and control outbreaks of micronutrient deficiency diseases, particularly scurvy.

4. Improve nutritional status of women of childbearing age and reduce risk of low-birth weight (LBW).

5. Increase prevalence of exclusive breastfeeding for 0-6 months from 30-35% to over 60%.

6. Reduce mortality associated with severe malnutrition, specifically in relation increasing access to treatment facilities and to reducing case-fatalities to acceptable targets within treatment facilities for severe malnutrition.

of 83


7. Increase knowledge, awareness, skills and capacity in public nutrition among the general population as well as among all nutrition related service providers including those involved in agriculture, health, rural development, economic development, trade.

Programmes based on objectives 3 and 7 will contribute largely to improvement of the nutritional status of WRA and therefore should be supported and continued nationally.For programmes that aim to reach objective 4, specific strategies/activities were formulated for 2003-2006 (see Table 10 left column). The selected strategies for Afghanistan in paragraph 5.1 match most of those activities formulated in the nutrition policy, however they stress sometimes different priorities. Table 10 shows some suggested adjustments for the nutrition policy 2003-2006.

Table 10.Strategies/Activities in Nutrition Policy 2003-2006 in order to Improve nutritional status of women of childbearing age and reduce risk of low-birth weight (by ‘Reducing nutritional risks for women throughout their life-cycle through implementation of integrated health, nutrition and food security interventions.‘)

Comments on the base of the selection process of strategies to reduce maternal mortality, LBW incidence, prevalence of anaemia and to improve the general nutritional status of WRA (as selected in this strategy report, paragraph 5.1).

1. Facilitate and support increase in women’s daily food intake during pregnancy, in terms of quality and quantity, through improved household food security and appropriate intra-household distribution.

So far literature showed that WRA included in household food security programmes not necessarily benefited health-wise from these programmes. In November 2004 a consultant from Tufts University and URD started to work on this and results for potential strategies are expected in February 2005.

2. Folic/iron supplements are provided throughout pregnancy and iron supplements are provided for three months beyond pregnancy through antenatal care.

The selected strategy on Iron/folate supplementation during pregnancy (and WRA in general) is fully in line with this.Depending on lactation the supplementation should be given not later than 1 or 2 months postpartum.

3. Provision of Vitamin A supplements to women soon after birth (and before eight weeks post-partum) through antenatal care.

The selected strategy on Vit A supplementation post-partum (and during pregnancy) is fully in line with this.

4. Facilitate and support improved access to micronutrients for women through food diversification (equitable intra-household distribution, market access, improved household food security), parasitic control, improvement in hygiene behaviours.

Food diversification might have limited impact on improving nutritional status of Afghan WRA/ on the short term, but it could be considered on the long run.If proven efficacious flour fortification could be another approach aiming at improving the general nutritional status of WRAHealth education incl awareness of nutritional problems amongst WRA, including dietary advice messages, advice on supplementation as well as introduction of Unicef/WHO’s multi-micronutrient supplementation might be good short and long term approaches

5. Facilitate and support access to iodized The selected strategy Food-based approaches

of 83


salt for women. incl. salt fortification with iodine is fully in line with this.

6. Support women to exclusively breastfeed for six months, to contribute to longer birth-spacing.

The selected strategy LBW/life-cycle including infant and child care (this includes immediate post-partum breastfeeding and exclusive breastfeeding) is fully in line with this as is health education.

7. In extremely food insecure areas, support and promote distribution of dry ration food supplement to women through pregnancy and until infant’s reaches 6 months of age.

Afghan WRA might not necessarily benefit health-wise of this strategy, in theory they would; if more research is done on intra-household distribution and what the actual impact is of the macronutrient supplementation on WRA it can be reconsidered.

8. Contribute to further understanding effective interventions to improve women’s nutritional status in Afghanistan.

This report is the first step in an ongoing process in learning lessons on ‘what works for Afghan women’…

9. Undertake research to document prevalence and aetiology of low-birth weight (LBW) and formulate appropriate response to address the problem.

The selected best strategies will contribute to reduction of LBW in Afghanistan on the long term. This strategy report is a first attempt to describe LBW aetiology in Afghanistan. The Health Management Information System (HMIS) Guideline currently plans to register LBW incidence at higher health facility levels (only). It will still take time to have a good HMI System in place that will register maternal and foetal outcomes related to nutritional interventions on community level.

On the short term the Public Nutrition Policy and Strategy objective (2005-2006) could be reformulated. Instead of ‘Improve nutritional status of women of childbearing age and reduce risk of low-birth weight (LBW)’ it can be formulated as: ‘Improve nutritional status of WRA, in particular for pregnant and lactation women by preventing and reducing prevalence of anaemia, IDD, vit A, folate and chronic energy deficiency as well as improving feeding and care practices in early childhood with the aim of reducing maternal and foetal mortality and morbidity.

Related to the other objectives as marked in the Public Nutrition Policy and Strategy 2003-2006 (21) also other strategies are (in)directly relevant to the strategies selected for Afghanistan for WRA:Strategy 3: Improve household food security specifically in relation to improving access, availability and diversity of food.Strategy 8: Prevention, reduction and elimination of Iodine Deficiency Disorders (IDDs) through Universal Salt Iodization (USI).Strategy 9: Prevention, reduction and treatment of other Micronutrient Deficiency Diseases including Vitamin A Deficiencies (VAD), iron deficiency anaemia (IDA), Vitamin C deficiency (scurvy) and Vitamin B deficiencies through integrated strategy of treatment, supplementation, fortification, education and food based approaches.Strategy 11: Support and promote optimal practices for infant and young child feeding, including appropriate caring practicesStrategy 13: Ensure that appropriate social mobilization, nutrition education and communication and advocacy are use used to promote improved nutritional status through general media and through all levels of health facility.

of 83


6. Mechanisms for Coordination, Implementation and Plan of Action for Recommended Strategies 6.1 Introduction – the BPHS under revision

In Afghanistan the Basic Package of Health Services provides a standardized package of basic services which forms the core of service delivery at four standard levels of health facilities within the health system: the health post, basic health centre (BHC), comprehensive health centre (CHC), and district hospital (DH). At the time this strategy paper was written the BPHS, as formulated in 2003 (1) was under revision by the Executive Board of the Ministry of Health. The final job description and staffing of each health facility (especially health post and basic health centre) were not yet finalised.However, on many principles there was agreement and some of those that are relevant to the strategy for improving the nutritional status of WRA are mentioned here12 (see Glossary for all descriptions of the posts):

- 90% of deliveries in Afghanistan take place with so-called traditional birth attendants (TBAs); they have no formal training in perinatal care; ideally their role will be diminished over time and taken over by community midwives (CMW) and midwives

- all existing TBAs should be encouraged to become CHW or CMW if they are eligible for the training;

- the current TBAs cannot replace CHW in health posts; TBAs as such now lack still the skills to be CHW

- CHW are the core workers in the community and function on health post level- CHWs are ideally trained as couples and do outreach- CMW will formally be the designated person to be engaged in delivery care on

the level of basic health centres (and CHC)The Information, Education and Communication (IEC) components are not yet defined.

Concerning the selected strategies for WRA, the following services of the BPHS are more or less relevant and are planned to be delivered by each health facility level13

(Note: this is not the full table of all services provided by BPHS): INTERVENTIONS AND SERVICES PROVIDED

HEALTH FACILITY LEVELHEALTH POST BASIC HEALTH

CENTRECOMPREHENSIVE HEALTH CENTRE

DISTRICT HOSPITAL


Yes Yes Yes Yes

Antenatal visits--weight, height measurement

Yes Yes Yes Yes

Provide family planning Yes condom Condom/DMPA Condom/DMPA Condom/DMPATreatment of intestinal worms Yes Yes Yes YesTreatment of malaria Endemic/

PresumptivePresumptive Yes-based on lab Yes-based on lab

Iron and folic acid supplementation to pregnant women

Yes Yes Yes Yes

12 BPHS Presentation to the Executive Board, 20-27 November 200413 The table contains a selection of the revised and provisional BPHS as presented to the Executive Board, 20-27 November 2004.

of 83


Multi-micronutrient supplementation

Yes Yes Yes Yes

Diagnosis of anaemia Yes – Clinical Yes-Clinical/lab Yes-Blood test Yes-Blood testTreatment of anaemia Yes-Iron/folic Yes-Iron/folic Yes-Iron

/folic/blood(acute blood loss)

Yes-Iron/folic/blood (acute bloodloss)

Promotion of Iodized salt Yes Yes Yes YesPromotion of balanced of micronutrient-rich foods

Yes Yes Yes Yes

Micronutrient Deficiency Diseases Diagnosis and treatment

Identify and refer Yes Yes Yes

Vitamin A supplementation Yes Yes Yes YesSupport and promote Exclusive breastfeeding:

YesYes

Yes Yes – with BFHI where applicable

Promotion Maternal Nutritional status

Yes Yes Yes Yes

Screening: Screening and referral of at risk using MUAC, or weight/height, or clinical signs of micronutrient deficiency diseases

Yes Yes Yes Yes

In the following paragraphs for each selected strategy a more detailed description is given on the implementation methods. If relevant, the services as marked above will be discussed in detail.

6.2 Strategy One: Iron/Folic acid supplementation

6.2.1 Objective

The main objective of the Iron/Folic acid supplementation is to prevent iron deficiency anaemia and treat severe anaemia among WRA throughout Afghanistan.‘The fight against anaemia’ should concern a national programme. Remote areas and areas with high population concentration should be prioritised.

6.2.2 Plan of Action

There is an immediate need to endorse iron/folate supplementation and to make an operational strategy.This can be done by installing an Anaemia Task Force:- Coordinated by Public Nutrition Dept, or Reproductive Health Dept or other lead agency- Supported by Unicef/WHO

This Task Force ensures the design of a National Anaemia Programme and includes many different elements such as supply of supplements with right dosage, IEC, standardisation of training curricula for CHWs, (community) midwives, nurses, healthvolunteers, PNOs, Social marketing, Monitoring and evaluation etc, etc.

of 83


The Programme should have different approaches for areas with different infrastructures: BPHS and non-BPHS areas.

In table 11 an example is given for an approach where BPHS is functioning. High priority should be given to start supplementation via BPHS at community and facility level; it is claimed that BPHS is currently implemented in about 60% of the country. Rationale to work through BPHS:- Structure is perfect for implementing supplementation up to community level (CHW, BHC and CHC)- Structure is suitable for referral of severe anaemia- According to Afghan constitution all services under BPHS are for free- Iron/folate supplementation is part of core mandate of BPHS within Maternal/Newborn Health and Public Nutrition services

Table 11. Example of strategy for Iron/folate Supplementation where BPHS is functioning.In basic health centre, comprehensive health centre, and district hospitals iron/folate supplementation should be given to any anaemic woman (diagnosis based on test results). If at health post level anaemia is suspected on clinical grounds, the woman should be treated by the CHW.However, diagnostic facilities are limited at lower levels of health services (health post with CHW and basic health facility with nurse and community midwife) and the prevalence of anaemia in Afghanistan is high; therefore the CHW and (community) midwives should provide standard 60 mg iron + 400 micrograms folic acid daily for any pregnant and lactating woman (during at least 6 months in pregnancy, and continuing to 3 months postpartum), regardless their actual hemoglobin status.

The interventions per facility could be rephrased as:INTERVENTIONS AND SERVICES PROVIDED



DISTRICT HOSPITAL

Diagnosis of anaemia Yes – Clinical Yes-Clinical/lab Yes-Blood test Yes-Blood testStandard Iron and folic acid supplementation to pregnant women and lactating women 3 (-614) months postpartum

Yes Yes Yes, if tested anaemic*

Yes, if tested anaemic*

*the numbers of tested women that will be anaemic are likely to be very high; if tests are temporarily unavailable the standard protocol should apply.

In slightly less than half of Afghanistan BPHS is not (yet) functioning and other means to provide iron/folate supplementation should be considered. Table 12 gives an example of strategies for Iron/folate Supplementation where BPHS is not functioning. In cities like Kandahar, Heart, Jawzjan, Polichumria, Khunduz, Logar, Wardek and many other cities the private sector is the predominant provider of services. The Anaemia Task Force should define a clear strategy for working with the private sector (including issues such as conflict of interest- i.e. prevention of diseases might not be in the best interest of private sector, ‘profit’ as incentive etc (see below)). It should also review existing

14 If a full course of treatment (6 months duration) cannot be achieved in pregnancy, supplementation should continue during the postpartum period for 6 months or, the dose should be increased to 120 mg iron in pregnancy.

of 83


government structure in cities and identify mechanism of supplementation (facility and community level).

Table 12. Example of strategies for Iron/folate Supplementation where BPHS is NOT functioning.The following actions should be undertaken:- Review of existing structures potentially useful for iron/folate supplementation- Establish feasible mechanism structure (e.g. community volunteer, Iron/folate focal person?, use of existing system of functioning health educators from Ministry of Women Affairs (see table 5 chapter 3)). In areas where CHW are not operational especially health educators (MWA) and private sector could play a major role and apply the same posology: 60 mg iron + 400 micrograms folic acid daily for any pregnant and lactating woman (during at least 6 months in pregnancy, and continuing to 3 months postpartum).- Explore the feasibility of pulse immunisation15 using already existing community volunteers/focal person (facility) - Review the role of private sector

In both urban and rural areas where private sector is the main health service provider a clear strategy for working with private sector should be defined. A way to work with the private sector is called ‘social marketing’; this refers to the use of commercial marketing concepts and tools in programs designed to influence individuals' behaviour to improve their well being and that of the society16. Social marketing can be an effective way in Afghanistan of motivating low-income families and high-risk women to adopt healthy behaviour, i.e. preventing and treating anaemia. Social marketing combines education/creation of health awareness to motivate healthy behaviour with the provision of the iron/folate supplementation. Communication is essential as are low prices of the iron/folate supplements, which are possibly subsidised. The idea is that the supplements should not be given away for free outside the existing health facilities in order to keep its ‘value’ also within the families. The supplements remain for free if provided within health facilities (for example by CHW) or by health educators from MWA. Where the private sector can play a major role is exactly there where there are no functioning health facilities so this would not necessarily be problematic. The local commercial infrastructure in Afghanistan, such as formal and informal, governmental and non-governmental pharmacists, drug vendors, would all be well financially motivated to stock and sell the iron/folate products. Therefore the supplements should become available in hundreds of pharmacies and commercial outlets.From one health seeking behaviour study in Afghanistan (Ghor) it was found that after the Mullah, the ‘pharmacist/drug vendor’ was consulted the most when health problems occurred (15). The engagement of the private sector and these pharmacist/drug vendors in particular, could ensure a major coverage of women at risk. A national anaemia programme should have a special focus on this strategy.

6.2.3 Stakeholders

15 Pulse immunisation is the support system to routine immunisation where a team, attached to EPI facility, conduct a (monthly) outreach for EPI services.16 http://www.psi.org/resources/pubs/what_is_sm.html#1

of 83


The stakeholders that will be strongly involved in a national anaemia programme are: The Afghan Community All BPHS implementing NGOs and MoPH MoPH technical departments: Public Nutrition Dept, Dept of Reproductive Health,

Dept of Essential Drugs, Dept of Information, Education and Communication, PHC Dept, Dept of Child and Adolescent Health

MRRD (health education) Ministry of Women Affairs (Health educators) National Solidarity Programme17 (community shura) UN agencies (technical support, supplies, monitoring) Association of Pharmacists Ministry of Religious Affairs (health messages)etc

An Anaemia Task Force should therefore ideally have representatives of these groups.

6.2.4 Potential constraints of a National Anaemia Programme and solutions

In paragraph 4.3.1 it is emphasised that there are many potential constraints and obstacles to effectively implement an iron/folate supplementation programme. If from the beginning a national anaemia programme does not take into account those constraints, the chances of success for such a programme are heavily reduced. An Anaemia Task Force should consider the following main constraints that are specific for the Afghan context prior to any programming as well as the potential solutions as suggested here (based on the outcomes of the Consultative Meeting):

Lack of coordination Suggested solution: Defining who is the lead agency and capacity of lead agency on technical, coordination, etc. (potential solution: identify a lead agency/ies, clear Terms of reference, ensure the lead agency has the technical and coordination capacity, establish coordination mechanisms at all levels, continuous review of the effectiveness of coordination and technical support mechanism).The MoPH, and in particular the Public Nutrition Dept could take the lead together with Unicef. Inaddition, clear Terms of Reference for the Anaemia Task Force are essential.

Current lack of appropriate dosage of iron/folate supplements on the free market: 60 mg iron + 400 micrograms folic acid18. This dosage is both needed within all health facilities as agreed upon in the BPHS and as described in WHO’s essential drugs’ list

Current MoPH and BPHS donor limited capacity for supplying iron/folate tablets Problems of management of supplies: e.g. timely distribution, bureaucracy etc.

Suggested solution: Temporarily alternative supplier e.g. UNICEF, but with clear plan to ensure capacity of MoPH and BPHS donor to phase out. Use of one ‘brand’ for Afghanistan and ensure its quality. Supplies provided by Unicef both for health facilities and health educators as well as for private sector (with subsidized prices).

17 The National Solidarity Programme is a World Bank funded project that attempts to use participatory approach in problem identification, implementation and management at village level through community shura/counsel; women are a part of this shura.18 A quick survey in pharmacies in Kabul in November 2004 showed none of the iron, folate, and combined iron/folate supplements contained the right dosage. Supplements came from Iran and Pakistan often contained more than double the desired concentrations (findings based on what the package declared).

of 83


Design of clear supply system and ensure the system is understood/communication to periphery level on system, policy, trouble shooting, monitoring etc.)

Sustainability: BPHS is only a 3 years pilot project, its future depends on donor commitment, the constitution on free health services and how coordinating and implementing partners will proceed after 3 years. This will have major consequences for iron/folate supplementation via BPHS.

Suggested solution: To ensure that discussion on health financing initiative include micronutrient supplementation to women, create strong demand from community thus they demand supplementation either from private or government facilities.

Inexperience with working with private sector for large Public Health programmes in Afghanistan

Suggested solution: Ad hoc technical support required of organisations/experts with broad experience in provision of iron/folate supplementation via private sector through social marketing

Supplementation with iron alone inadequate to prevent and control anaemia where iron deficiency is not the only cause of anaemia

Suggested solution: Additional activities such as birth spacing, anti-helmintic treatment, malaria treatment and prevention should receive strong implementation booster and are performed on most health facility levels (as planned, see overview services paragraph 6.1). However, there where BPHS is still non-existing the chances are lower that these programmes can be implemented with substantial impact on the short term.

How to monitor impact of iron/folate supplementation Suggested solution: To define confounding factors, perform baseline surveys on knowledge of WRA on anaemia and hemoglobin status, regular quality control of the selected brand provided nationally (check on counterfeit), ensure the monitoring system is sensitive to project, consider capacity building in monitoring, etc…); start with ‘controllable’ pilot projects in some provinces where access constraints for monitoring are limited (see further under monitoring and evaluation).

Risk of overloading CHW and therefore relying heavily on them within BPHS system on iron/folate supplementation where they have already so many tasks

Suggested solution: This is a so-called ‘priority’ problem: fighting anaemia by means of supplementation is the most cost-effective health intervention for WRA and to prioritise this within the CHW tasks is a matter of political choice. Anaemia is easily preventable and curable; an anaemic mother can never provide sufficient health/nutritional care to her children or family in general.

6.2.5 (Pre-)conditions for a successful National Anaemia Programme

In paragraph 4.3.1 also a list was provided of the conditions to meet to make iron/folate supplementation programmes successful; the list was based on experiences worldwide in combating anaemia. In Table 13 the current suggested strategy is assessed against those conditions and suggestions are included to achieve the conditions.

of 83


Table 13. Conditions to meet in order to make iron/folate supplementation programmes successfulPre-requisite How to achieve Health workers were strongly motivated to control anaemia

Include a strong iron/folate supplementation rationale in training curricula of CHW, (community) midwives, health educators, PNOs, formal pharmacists, medical doctors with emphasis on impact on the Afghan society of such a programme.

Anaemia is recognized as nutritional deficiency in the community.

Set up of IEC strategy both via CHW, (community) midwives, health educators, PNOs, and inclusion of all drug vendors/pharmacists

Iron supplementation was very closely bound to prenatal care and it was a good incentive to start and continue with the prenatal visits

CHW, (community) midwives, and health educators play crucial roles in referring pregnant women to health facilities with a functioning perinatal care. In Afghanistan the supplementation programme might not necessarily be successful in increasing the utilisation of antenatal service since many of the barriers are not taken away.

Availability of the supplement Addressed aboveContinuing monitoring and counselling.

Monitoring of outcome measures most likely to occur only on health facility levels higher than health posts (see paragraph 6.2.6). Monitoring of perception by community should be done regularly.Counselling on each health facility level

Community sensitization to secure their involvement

CHW, (community) midwives, and health educators form the core in creating the community awareness as well as work through the mosques

Baseline study on the knowledge of women on anaemia and iron/folate

Include in pilot testing phase; results should be used to refine IEC strategy

Selection and quality training of traditional birth attendants in charge of the distribution of iron+folic acid, distribution of tablets and monitoring.

TBAs are not formally included in the national health system in Afghanistan (BPHS). Their roles will be partially taken over on the long term by (community) midwives. Their inclusion is dependant on how the MoPH sees the role of TBAs/Dahias

Male involvement in male dominated cultures

More than half of the CHWs are male who can address community elders/mullahs etc; Ministry of Religious Affairs should be strongly involved concerning the messages provided through the mosques. PNOs (95% male) should address the issue on provincial levels with community leaders and mosques.

Community demand creation is vital to long-term success.

Social marketing approaches will be helpful on demand creation if well implemented. Community awareness of the problem/consequences of iron deficiency anaemia and the benefits from supplementation could create community demand; Perception of community on problems/consequences and suggested solutions should be regularly measured.

Flexible, preventive supplementation administered by community-based organisations. Where atten-dance at clinics is low, village health workers, midwives or birth attendants may facilitate distribution and compliance.

The whole principle of the suggested approach with CHW, (community) midwives, and health educators as well as inclusion of the private sector is based on the current behavioural practice in Afghanistan where clinic attendance is low.Supplementation to adolescents via schools is an additional option to consider.

6.2.6 Time frame

of 83


Prior to the implementation of a National Anaemia Programme an Anaemia Task Force will be needed to prepare and draft the programme. This can only be done if the reduction of anaemia amongst WRA is adopted as a national priority. The Anaemia Task Force need a clear mandate with well defined Terms of Reference.

Immediate action is needed on: Deputy Ministers of MoPH provide political commitment for fighting anaemia, in

particular amongst WRA. Definition of leading MoPH department and agency (Unicef) Definition of Terms of Reference for Anaemia Task Force Establishment of Anaemia Task Force19

Subsequently, once the Task Force has been establishment and the Terms of Reference agreed upon a planning of activities should be established. The aim is a National Anaemia Programme; prior to that preparation phase and a large scale pilot should be considered. The lessons learnt from a large scale pilot could be incorporated in the national programme. Annex 13 provides an overview of possible phases with action points needed for a National Anaemia Programme based on collaborative work of all stakeholders during the Consultative Meeting in Kabul.

6.2.7 Monitoring and Evaluation

Monitoring and Evaluation of iron/folate supplementation include focus on- Process (e.g. coverage, acceptability, perception, compliance, etc..)as well as- Impact (Iron status).Monitoring and Evaluation are both crucial in the pilot project prior to the national programme as well the programme itself. Figure 4 shows the various components of process and impact needed to monitor and evaluate the iron/folate supplementation (51).

Indicators aiming to see whether the process goes according to plan and that should be measured periodically (with short or long time intervals)20: Earmarked budget expenditure Procurement and quality of supplements Functioning of distribution system and storage Availability of supplements at distribution points Quality and quantity of training activities planned and conducted for health care workers and

others as needed Knowledge, attitudes, and practices of all involved health care workers/drug

vendors/pharmacists Quality and functioning of IEC strategy Community health awareness/education programmes in place Knowledge, attitudes, and practices of community leaders, family

decision makers, and mothers, pregnant women etc Number of supplements distributed

19 the task force can be part of the Reproductive Health Task Force or separate20 Indicators adjusted for Afghanistan from reference 51.

of 83


Number of supplements reported received/Number of supplements consumed by pregnant and lactating women, by WRA in general

Programme coverage (percentage of intended recipients who actually received supplements)

The Health Management Information System (HMIS) being set up and collects data from within the BPHS system. The selection of indicators is not yet finalised. Certainly anaemia will be one of the indicators but it is not yet clear on which health facility levels it will be recorded and to what detail. For the moment HMIS registers in some BPHS facilities on simple presence/absence of anaemia amongst WRA will give some indication on the prevalence of anaemia amongst health facility users and possibly some trends might be detected over time. However, a supplementation programme goes beyond the borders of the BPHS areas; therefore periodically conducted surveys of iron deficiency anaemia prevalence (stand-alone surveys or included in planned (demographic and) health surveys with hemoglobin measurements are needed in the initial years of the pilot and national programme.

Figure 4. Components of process and impact needed to monitor and evaluate iron/folate supplementation programmes (51).

6.2.8 Human Resources

of 83


Commitment from various stakeholders is essential for the national programme. In addition, commitment of staff partially of fully dedicated to the preparation and implementation phase is crucial. The Anaemia Task Force needs to consider appointing one fully dedicated person from MoPH for streamlining and coordination of all activities and who liaises between all MoPH’s Departments as well as between MoPH and the various others ministries. This ‘Iron/folate Supplementation Officer’ will also coordinate with NGOs, private sector and will work together with WHO and Unicef

Unicef is currently revising the staffing under the Nutrition Section and will have one full time (local) staff member fully dedicated to supplementation (including vit A post-partum); one for fortification (and one mother/child care practices)

Additional expertise has to be called in on social marketing/engagement in private sector, national programming of iron/folate supplementation, price subsidies policies, etc

6.3. Strategy Two: Unicef/WHO’s multi-micronutrient supplementation

6.3.1 Objective

The aim of the use of Unicef/WHO’s multi-micronutrient supplementation is to reduce the prevalence of many vitamin and mineral deficiencies, such as IDD, Vit A deficiency and scurvy with only one intervention. Afghanistan is a country in which many different micronutrient deficiencies have manifested. For reasons explained in paragraph 2.11 it is unlikely that the quality of food will improve in the short tem, if at all in the next five years. The use of the supplementation does not limit itself to exclusively WRA but to all people affected by micronutrient deficiencies.The other aim of its use is to replace iron/folate tablets in the fight against anaemia after having been proven to be as efficacious and effective as the classic iron/folate supplements. This should be considered because of the low reporting of side-effects (such as gastro-intestinal discomfort) compared to iron/folate tablets.


The iron concentration in the Unicef/WHO formula is half of the ‘classic’ iron/folate supplementation; research, currently performed in various countries, on the efficacy and effectiveness should be narrowly followed especially to decide whether it can replace iron/folate tablets in the fight against anaemia.The use of Unicef/WHO’s multi-micronutrient supplementation should be explored as soon as possible: A small simple (!) pilot study is urgently needed and should be done prior to or at latest parallel to the pilots on iron/folate supplementation. Acceptability tests can already be done; for example, in the Afghan scurvy belt where vit C tablets are distributed during wintertime as a large scale public health intervention. The multi-micronutrient tablet could be used instead of vit C tablets. Especially because the quality of food in the scurvy belt is such that various other micronutrients are likely to be lacking in the diet of most people and WRA in particular.

of 83


In the BPHS system the new formula can be selected as the multi-micronutrient supplementation in the kits of the CHW as well as in all the other health facilities, since micro-nutrient supplementation is one of their tasks:

INTERVENTIONS AND SERVICES PROVIDED



DISTRICT HOSPITAL

Multi-micronutrient supplementation

Yes Yes Yes Yes

Micronutrient Deficiency Diseases Diagnosis and treatment


6.3.3 Stakeholders

Especially Unicef can contribute largely to the development of a multi-micronutrient supplementation programme both by direct follow up with its headquarter staff that are doing research with the new formula as well as by introducing and co-ordinating the pilot studies/acceptability tests. Unicef could also play a key role in acquiring supplies and to reduction of the cost factor by ordering large supplies for Afghanistan.The Public Nutrition Dept of MoPH takes the lead and collaborates with the Nutrition Task Force WG on Micronutrient Deficiency Diseases.

6.3.4 Time frame

The pilot test and acceptability test could be set up soon and the tests as such will have to be outsourced to external research institutes/NGOs.Results of such a study will be vital to decide whether to replace the iron/folate tablets with this micronutrient formula in the combat against anaemia.


No monitoring and evaluation system is in place within the HMIS on micronutrient deficiencies, except on presence/absence of anaemia. Ideally maternal and foetal outcomes (LBW, maternal mortality - if given to pregnant women) and prevalence data on IDD, Vit A deficiency and scurvy (if given to a wider population group) should be measured but pilots will ideally be held on community level where this information is more difficult to obtain. The pilot test will give information on the feasibility of collecting (qualitative and quantitative) data on process and impact of the use of the multi-micronutrient supplement.

6.4 Strategy Three: Vit A supplementation post-partum (and during pregnancy)

6.4.1 Objective

This strategy aims at immediate endorsing the vit A post-partum supplementation that is already on paper in all BPHS facilities. Vit A given post-partum has a proven positive effect on child survival when breastfed and maternal morbidity.

of 83



An immediate analysis in delivery care units is needed why the post-partum vit A provision currently is not done, whilst in every protocol of the BPHS facilities.




DISTRICT HOSPITAL


Yes Yes Yes Yes

Antenatal visits--weight, height measurement

Yes Yes Yes Yes

Vitamin A supplementation post-partum, children

Yes Yes Yes Yes

For example, there is a need to immediately clarify the availability 200,000 IU vit A in health facilities, as well whether protocols are known etc. Such an analysis contributes to finding the best mechanisms to re-inforce the supplementation.

A design of a National Vit A post-partum Programme is needed to speed up this in principle very simple and straightforward intervention. The programme should restate the protocol, guarantee the supplies of the right dosage, inform the nurses/(community) midwives and physicians etc.The national programme should state that Vit A supplementation post-partum should be done in all clinics where delivery care is performed and where perinatal consultations take place in and outside the BPHS system. However, it is not realistic that all health facilities outside the BPHS system will be able to immediately include vit A supplementation post-partum on the short term. The national programme should address solutions how to supply/motivate post-partum provision of vit A in all systems outside BPHS. The Postpartum Care Working Group, coordinated by WHO-Afghanistan should work on how to reach agreement on who can supply vit A post-partum on community level outside the BPHS system and the best approach on mid- and long term.

In addition, an immediate clarification is needed on of role of vit A supplementation of CHW. It is in their job description, but for the time it is being ‘frozen’ in their tasks and the inclusion of the supplies are suspended for their ‘medical’ kits because it is planned that vit A supplementation would be given to all mothers post-partum during the National Immunisation Days21 (NID). However, at present it seems that also the NIDs are excluding the vit A supplementation and this leads to a vacuum in the responsibilities of administering vit A post-partum throughout Afghanistan.In order to prevent any overdosage or unnecessary exclusion a temporarily policy could be put in place that both CHWs and during NIDs provide vit A during the first 42 days post-partum (during the so-called ‘chilla’ period). This can be done until the EPI programmes have been well developed.

As stated in paragraph 4.3.3 Vit A supplementation during pregnancy could be explored. However, in order to avoid too many vertical supplementation programmes

21 National Immunisation Days are currently used to reach children < 5 years and mothers of infants of 1-2 months of age for the administration of polio vaccins.

of 83


during pregnancy a shift towards Unicef/WHO’s multi-micronutrient should be the first choice of intervention. Supplementation will become then an integrated approach in which VAD and anaemia will be tackled simultaneously (as well as IDD, scurvy, folate deficiency etc).

6.4.3 Stakeholders

Reproductive Health Department of Ministry of Health hosts a Reproductive Health Task Force (RHTF); one working group for this task force developed the national operational standards of postpartum care (52). These standards, now to be made obligatory throughout Afghanistan, include post-partum vit A supplementation. The Reproductive Health Dept should take immediately the lead to guide the National Vit A post-partum together with Unicef, assisted by WHO-Afghanistan.The role of the private sector in vit A provision post-partum should be explored and the Afghan Society of Obstetricians and Gynaecologists should be included in the debate.

The role of the current TBAs/Dahias and whether they will have a role within the BPHS until enough community midwives will be trained has yet to be clarified. The current revision of the BPHS should be used for the clarification; the outcome of this process has consequences whether TBAs/Dahias will be formally recognised on their role in vit A supplementation post-partum.

6.4.4 Time frame

On January 17 and 18 both Unicef and MoPH, during the presentation by the Public Nutrition Dept on maternal malnutrition, have stated that the vitamin A supplementation post-partum is an immediate priority and instant steps would be taken to take action.


Each delivery care facility, private or public, should register the supplementation of vit A post-partum, also in order to justify the consumptions of supplies. This should start off within the BPHS system, ideally via HMIS (this is currently NOT included within HMIS!). Additionally, on the long term a registration system on vaccination cards (of child/mother) could be introduced. For the moment the best monitoring system is the supply/demand scheme of the high vit A dosage.

6.5 Strategy Four: Food-based approaches incl. flour fortification with various nutrients, food diversification, salt fortification with iodine

6.5.1 Flour fortification

The objective of flour fortification with various micronutrients is to improve the nutritional status of the population; it is not aiming specifically at WRA. To support this approach in the strategy for Afghan WRA to improve their nutritional status is too early. This does not mean that the approach should be excluded in other nutritional programmes with different objectives.

of 83


WFP is co-ordinating pilot projects in Afghanistan and positive results on efficacy and effectiveness (especially in reduction of anaemia amongst all household members) could justify to scale up those projects. However, until this very date no results have been disseminated on these projects.

Until that moment the following activities could be explored with regard to WRA and flour fortification (Note: it goes beyond the objective of this document to map out here a complete plan for flour fortification in Afghanistan): The Nutrition Task Force Working Group on Micronutrient Deficiency Diseases included in their mandate to develop a strategy for local fortification; this group could advocate for more results/pilots on flour fortification in Afghanistan (together with all the stakeholders as listed in chapter 3). Clarification is needed which Ministry is co-ordinating which part of the process of flour fortification; who coordinates health impact results, who coordinates private mills in relation to fortification, who is in charge of quality control etc. It is important to explore the potential benefits of iron fortified flour and the negative effect of the simultaneous high tea consumption on health, in particular anaemia.The WG should ask the leading Ministry and WFP to explore the different strategies for urban areas (more imported flour, more centralised milling of wheat) and for rural areas (decentralised milling with thousands of small mills; flour for intra-/inter-community consumption). In addition, more information needs to be obtained on current practice of import of fortified flour. There is currently a policy in Uzbekistan, Tajikistan, Kyrgyz Republic and Kazakhstan to voluntary fortify wheat flour with 55 ppm electrolytic iron. In Iran it is now proposed to fortify wheat flour with 30 ppm ferrous sulphate22. More information is needed on the flour flow in Afghanistan before a judgement can be given whether fortified flour is feasible as an anaemia reduction strategy for both WRA and their family members.

6.5.2 Food diversification

To include food diversification in a strategy to improve the nutritional status of WRA aims to improve the consumption by diversified/good quality/nutritious food by women. However, bringing in good quality food into the household does not necessarily imply those products to be consumed by women. There is an urgent need for more information on:

- dietary habits of Afghan WRA- existing food security interventions that have an impact on food consumption

AND nutritional status of WRAA consultant from Tufts University and URD started to work on this and results for strategies are expected in February 2005. It will be important to integrate nutrition objectives into food security interventions, in policy objectives in agriculture and rural development. Additionally it is essential to raise more awareness at all levels (from policy to community) of the importance of food diversification in general with MAAH, MoPH, MRRD, Private sector, NGOs, Ministry of Information and Education, MWA.

22 The recommended level of iron to be added according to. WHO-EMRO is 30 ppm ferrous sulphate (elemental iron powders should be double the dosage of ferrous fumarate or sulphate). Source: Wheat Flour Fortification Standards and Practices in Different Countries, as of June, 2003. http://www.sph.emory.edu/wheatflour/Training/Resources/FortStds2.pdf

of 83


Parallel to this it is needed to develop more pilot programmes that:- Explore how availability and access to good quality food in particular by WRA could be achieved (are Afghan WRA likely to benefit from home gardening, from germination projects, from ‘conservation of food for winter time’ –projects, etc?) and how?- Look at innovative ways to absorb the shocks and/or to guarantee intake of sufficient calories for WRA and ideally a minimum of some ‘high quality’ food products in areas prone to drought or harsh winter conditions.

The activities marked in Strategy 3 Public Nutrition Policy and Strategy, Objectives 2003-2006 (21) ‘Improve household food security specifically in relation to improving access, availability and diversity of food’ should be reviewed and prioritised on evidence based(!) merits.

The results of consultant’s work will be crucial in setting the direction for the coming years on (evidence-based) food diversification approaches.

6.5.3 Salt fortification

The Afghan MoPH and Unicef have started a national programme ‘Universal Salt Iodisation’ (USI) and the programme has made enormous progress in fighting IDD. This programme should be continued and incorporated in any strategy for WRA. Objective/ strategy

Current Activity

Agencies/ stakeholders

Lessons learnt (see table 6)

Future plan

To eliminate IDDs

- Supply of iodised salt (local production)- Raising awareness

UNICEF, MoPH, private sector, WHO, WFP, MAAH, Ministry of Planning, Ministry of Women’s Affairs, Ministry of Mining, Ministry of Trade and Commerce, Ministry of Food Stuff and Light Industry, NGOs, donors

- legislation lacking behind- lack of law enforcement- monitoring constraints - needs strong private sector engagement- lack of knowledge of IDD resulting in low demand for iodised salt- quality control problems at factory level- needs strong inter-ministerial collaboration- lack of strong demand for the product

- Need to reinforce legislation + enforcement (through social mobilisation)- Need to strongly decentralise monitoring- Health education/awareness need booster

The USI is not aiming exclusively at WRA but has a major impact on maternal and foetal outcomes. Of specific interest is the double fortification (iodine, iron) for WRA and the additional contribution it will have on anaemia reduction. Once the current national USI programme has entered a more routine phase and is widely implemented, the double fortification programmes could be explored. In principle scaling up single to double fortification is a relatively simple exercise changing ‘only’ the fortified ingredients. However, it can have major cost implications23 and therefore its feasibility for Afghanistan should be well assessed beforehand.The Public Nutrition Dept (MoPH) and Nutrition (UNICEF) are key actors and co-ordinate the USI for Afghanistan. The Nutrition Task Force WG on Micronutrient Deficiency Diseases has the mandate to ensure implementation of Universal Salt Iodization (USI) strategy and develop and endorse draft legislation of salt iodization.

23 Since iodine and iron can interact the iron component needs to be encapsulated.

of 83


The roles of CHWs (in particular, but also of other workers at different health facility level) can actively contribute to awareness of IDD and the use of iodised salt at community level (see their mandate below on IDD):




DISTRICT HOSPITAL


Yes Yes Yes Yes

Promotion of Iodized salt Yes Yes Yes YesMicronutrient Deficiency Diseases Diagnosis and treatment


In addition PNOs, health educators, salt traders, mosques can contribute to awareness of the urgent necessity to use iodised salt. The PNOs will have additionally a monitoring task in factories at provincial level.A refreshing information campaign targeted at both the stakeholders including the public should be done frequently because of the general public health urgency of IDD throughout Afghanistan.For all details on the currently implemented USI programme is referred to MoPH and Unicef since a full description on the programme is beyond the objectives of this report strategy (see also the Public Nutrition Policy and Strategy, Objectives 2003-2006 (21) in which one of the objectives is to ensure that more than 90% of households have access to iodized salt throughout the country and see the matching activities).

The WG on Micronutrient Deficiency Diseases together with Unicef and the Dept of Reproductive Health need urgently to clarify whether a special campaign is needed for supplementation of iodine in antenatal care (on case by case basis through consultation) for pregnant women, especially in the areas that are currently weak on USI. Targeting on goitre alone amongst pregnant women is not sufficient since so many women are iodine deficient without having yet developed visible goitre. In various provinces the IDD problems are very serious (see Annex 5) and universal (paragraph 2.6!) and positioning to be actively engaged in a parallel ‘fighting IDD’ to the USI campaign needs to be considered on the short term. The impact of individual supplementation is tremendous in terms of public health and economical gains; as soon as possible a feasibility assessment should be done and the following aspects should be considered:

- risks of individual iodine supplementation for the women (risk-benefit analysis)- whether an individual approach might take away the attention for USI- accessibility/supply to pocket areas that have no iodised salt- to include other high risk groups (all children under 14 years)

of 83


6.6 Strategy Five: LBW/life-cycle approach including infant and child care; including immediate post-partum breastfeeding and exclusive breastfeeding

6.6.1 Objective

The 'life-cycle approach’ aims at breaking through the negative spiral from LBW at birth, increased early childhood morbidity and mortality, stunted children and adolescents, malnourishment during pregnancy, obstructed labour, maternal mortality or LBW, etc.The ultimate impact of those programmes, potentially reduction of LBW and maternal mortality on a sufficient scale, can not be measured within the first few generations. But this strategy aims also at general morbidity and mortality reduction in (early) childhood and is therefore important within other strategies too.


Programmes for this strategy are already more or less implemented by various different departments of the MoPH and NGOs, but on an insufficient scale.The work of the Nutrition Task Force Working Group on Infant Feeding and Child Caring Practices should be reinforced and play a major role and its current mandate should be reinforced as soon as possible:

Develop a better understanding of infant feeding and childcare practices in Afghanistan.

Develop and implement strategy for behavioural change communication at health facility and household levels.

Strengthen the capacity of health workers, community workers and NGO members in promoting best practices in infant feeding and childcare practices.

Develop, implement and monitor national guidelines and policy on infant feeding and weaning.

Finalise the national code on marketing of breast-milk substitutes (Breastmilk Substitutes Code).

The various basic policies already exist, such as Nutrition policy and Interim policy on promotion, protection and support of Exclusive Breastfeeding. However, there is an urgent need to draft Guidelines for Afghanistan on how to counsel mothers and other family members on breastfeeding, complementary feeding and maternal nutrition during pregnancy and lactation. The WG can co-ordinate the drafting of these guidelines.In Strategy 11 of the Public Nutrition Policy and Strategy, Objectives 2003-2006 (21) ‘Support and promote optimal practices for infant and young child feeding, including appropriate caring practices’ the related activities should be reviewed, selected and prioritised according to evidence based effectiveness.

There is a critical need to harmonise the messages on breastfeeding and weaning practices with MoPH, MWA, Ministry of Religious Affairs, Ministry of Labour and Social Affairs (kindergarten), WHO, Unicef, NGOs, maternity hospitals and MoPH’s IEC Dept. Especially because on both issues there are strong cultural beliefs imbedded in the Afghan cultural.

of 83


In 1991, Unicef and WHO launched worldwide The Baby-Friendly Hospital Initiative (BFHI). In Afghanistan the Baby-Friendly-Hospitals Initiative was implemented in 6 hospitals a few years ago. The philosophy behind it is to ensure that all maternity units, whether free standing or in a hospital, become centres of breastfeeding support. A maternity facility can be designated 'baby-friendly' when it does not accept free or low-cost breastmilk substitutes, feeding bottles or teats, and has implemented 10 specific steps to support successful breastfeeding (see Table 14).

Table 14.Ten steps to successful breastfeeding

Have a written breastfeeding policy that is routinely communicated to all health care staff. Train all health care staff in skills necessary to implement this policy. Inform all pregnant women about the benefits and management of breastfeeding. Help mothers initiate breastfeeding within one half-hour of birth. Show mothers how to breastfeed and maintain lactation, even if they should be separated from their

infants. Give newborn infants no food or drink other than breastmilk, unless medically indicated. Practice rooming in - that is, allow mothers and infants to remain together 24 hours a day. Encourage breastfeeding on demand. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.

Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic

Whilst the concept was good this initiative failed in Afghanistan because its unsuccessful implementation and monitoring. Reproductive Health Dept and Unicef/WHO should re-evaluate this initiative for Afghanistan.

6.6.3 Stakeholders

The Public Nutrition Dept within MoPH supported by the Nutrition Dept of Unicef could take up the coordination role. Other important stakeholders include MoPH’s Dept of Reproductive Health, Dept of Child and Adolescent Health, IEC Dept, Ministry of Labour and Social Affairs (kindergarten and orphanages), Ministry of Education, Ministry of Information and Culture, MWA, Ministry of Justice (implementation of Code on Breastmilk Substitutes), NGOs, maternity hospitals and the private sector.Among all those stakeholders there is a need to increase awareness on the importance of the life-cycle approach and the impact of inter-generational malnutrition.CHW, health educators, PNOs, NGOs, obstetricians/gynaecologists, high level staff of MoPH should receive a refresher/introduction training of the importance of exclusive breastfeeding/correct timing and practice of weaning, etc. Additionally, a stronger mobilisation of mass media and mosques is needed in transferring messages on (exclusive, immediate post-partum) breastfeeding.

6.6.4 Time frame

The urgently needed Guidelines for Afghanistan on how to counsel the mothers on breastfeeding, complementary feeding and maternal nutrition during pregnancy and lactation should be developed in 2005/2006.

of 83

http://www.unicef.org/programme/breastfeeding/baby.htm#10%2310

http://www.unicef.org/programme/breastfeeding/baby.htm#10%2310



In theory, about 19% reduction in infant mortality can be achieved through exclusive breastfeeding (13%) and appropriate weaning (6%)(53). Obviously it will be hard to measure an impact like this where so many other factors play a role. An outcome indicator should be the prevalence of exclusive breastfeeding for 0-6 months in a predefined area (for instance 80% of all women who gave birth in health facilities have infants that are exclusively breastfed until 6 months of age). Likewise a target should be set for immediate post-partum breastfeeding.The HMIS includes no data collection on this and progress in the number of infants exclusively breastfed is best done via regular surveys (by NGOs, Unicef). Collection on immediate post-partum breastfeeding should be done in health facility centres where delivery care is provided.

6.7 Strategy Six: Health education including awareness of nutritional problems amongst WRA, dietary advice messages, advice on supplementation, etc

6.7.1 Objective

This strategy aims to support all other selected approaches and is crucial for their effectiveness.Health problems in Afghanistan are not recognised, not adequately treated, and not easily prevented if those health issues are not regarded as a problem. This means that awareness of those WRA related problems will be an imperative. To make Afghan women, husbands and mothers-in-law aware of issues like anaemia, goitre, it needs a concerted action in which many governmental and non-governmental structures need to be mobilised, whilst existing community networks/structures will be used as well as the private sector. This strategy is the most integrated one and some work has already been done by various NGOs and MoPH departments.


The most important activity is the harmonisation of health/nutritional messages related to WRA, life-cycle approach etc. For example, a selection of 10 key messages is needed and they should concern anaemia/iron/folate supplementation, breastfeeding/weaning practices, goitre/iodised salt etc. Important to note is that the messages intend to improve the health of WRA but are not necessarily addressed to them.

Formative research will be needed prior to compiling the key messages and material should be pre-tested (appropriate material for different delivery mechanisms and religion/culture and tools should be explored).

A multiple angle approach is needed for best impact; on various levels transmitters of those health/nutritional/food related messages for WRA should be operational with the objective to improve nutritional status of WRA by provoking change in nutritional practice

of 83


at the family level and increasing knowledge of key decision makers. The intermediaries of the WRA related messages include

Community level:- CHWs- Imam/mullah- Community leaders- Health educators- Community midwives

Higher facility level: health facility (CHC and BHC) and school (curriculum) Mass media: TV, radio, newspapers (private and government)

The IEC Dept and the Public Nutrition Dept from MoPH should work on image/poster materials for pregnant and lactating women and this material can be used at each health facility level. It is extremely important in health education to come with a small selection of clear, concise and simple health messages.

This strategy should work especially through CHW and (community) midwives as well as health educators (MWA). For example, dietary advice (such as to consume more meat (especially), fruit, orange/dark green leafy vegetables, iodised salt and less tea during the meals) to mothers-in-law and husbands (as stated in 4.4.2) could be provided for pregnant and lactating women. Annex 14 shows an example of a recently developed poster.24

Note: It would be helpful to formalise a set of Recommended Daily Allowances (RDAs) of nutrients for the Afghan population and in particular for WRA, pregnant and lactating women. Those RDAs are already available globally (WHO/FAO) and could be used with or without adjustment to the specific Afghan context. Such a set of RDAs creates a national nutritional framework that supports/justifies nutritional interventions for WRA and children.

6.7.3 Stakeholders

Message development is a national ‘exercise’ and the harmonisation should be a coordinated by MoPH (in particular the Depts of Public Nutrition, Reproductive Health and IEC) together with Ministry of Education, Ministry of Information and Culture, MWA, MRRD, Ministry of Religious Affairs, private sector, WHO, WFP, Unicef and NGOs.Crucial is the active involvement and consent of the Ministry of Religious Affairs, especially for those messages addressed at husbands.

6.7.4 Time frame

Many key messages will be needed and developed over time for the various ‘vertical’ programmes such as the National Anaemia Programme, vit A post-partum supplementation programme etc. But regardless the timing of these programmes the

24These websites provide simple and concise dietary messages for pregnant/lactating women that can be used as a base for Afghanistan after some adjustments:http://www.linkagesproject.org/media/publications/Technical%20Reports/MaternalNutritionDietaryGuide.pdfhttp://www.linkagesproject.org/media/publications/frequently%20asked%20questions/FAQMatNutEng.pdf

of 83

http://www.linkagesproject.org/media/publications/frequently%20asked%20questions/FAQMatNutEng.pdf

http://www.linkagesproject.org/media/publications/Technical%20Reports/MaternalNutritionDietaryGuide.pdf


development of the 10 key messages remain essential as long all stakeholders are well consulted and consensus is reached.


The quality and quantity of messages provided and received could be measured through ad hoc qualitative surveys. The MoPH needs additional expertise on measuring behavioural change and should not aim only at change within the WRA group but also at other key decision makers in family such as husbands and mothers-in-law. Some small in-depth research is needed on the cultural and economic factors that prevent families from changing their behaviour, even if their knowledge and skills are improved.

of 83


7. Training and Capacity BuildingA high priority for Afghanistan is now the training of sufficient health workers that will work formally through the BPHS system such as CHWs, (community) midwives, nurses and doctors on the issues as iron/folate and vit A supplementation, life-cycle approach and general health/nutritional awareness. This should only happen though an integrated training process in which all subjects related to the nutrition of WRA are discussed instead of each separately in different training programmes.As soon as possible material on nutrition of WRA and in particular for pregnant and lactating women needs to be developed, both to use for the women and their families and for health workers.

One of the first priorities today is to review the training curricula and national guidelines for these health professionals on nutrition for WRA. Especially for the CHWs and the (community) midwives there is an immediate need to compile a document (for CHWs 1-2 pages; for (community) midwives 5-10 pages) to be used on community base in the health posts and basic health centres.A 1-2 days (refresher) training could be developed on specific WRA (health and) nutrition issues.The same applies for the health educators from the MWA and the PNO functioning on provincial level. Health educators (and PNOs) can play a major role in areas where BPHS is not functioning. PNOs can as well take the lead in training/informing the private sector whether it concerns the drug vendors, drug traders or private health workers.

In order to establish an effective and comprehensive National Anaemia Programme additional capacity building is needed for members of the Anaemia Task Force and senior health staff of MoPH. Globally there is sufficient material available on iron/folate which can be made available to IEC by Unicef and WHO.

In general, all health professionals engaged in early childhood and child health should be more informed on the importance of the life-cycle approach, the consequences of inter-generational malnutrition, and the importance of good nutrition for children and pregnant/lactating women. The World Breastfeeding Week could be a good entry for this.

In annex 11 a listing of relevant background documentation on Improvement of Nutrition of Women of Reproductive Age is provided that can be assessed by internet or can be physically obtained from the Public Nutrition Dept which serves as a resource centre on material about nutrition and WRA.

of 83


8. Monitoring the Nutritional Status of WRAA database on nutritional and reproductive health data of Afghan WRA should be installed. The Public Nutrition Dept could compile the nutritional related data. This document provides a national general ‘baseline’. Through the HMIS no nutritional related data will be collected except absence/presence of anaemia in pregnant women attending BPHS health facilities.Neither is the current HMIS sensitive yet for process measures nor for impact on community level after the implementation of the various strategies aiming at WRA.

For the moment specific surveys authorised by MoPH and Unicef/WHO are likely to be the best ways of monitoring and evaluation of the nutritional status of Afghan WRA.NGOs can contribute largely to more nutritional related date on WRA through regular reporting of their results.

The following combination of information gathering initiatives will provide data on food, nutritional and reproductive health of WRA. The third column contains newly proposed indicators for Afghanistan on the short term.

Data source Description of indicators if relevant for WRA

Additionally proposed through this document for general monitoring purpose (on short term)

HMIS(MoPH)

LBW in BPHS delivery care services Absence/presence of anaemia of

pregnant women Some anthropometrical data of women (Some) causes of maternal mortality

Vit A post-partum to mothers in BPHS

Iron/folate supplementation to WRA delivery care services

Immediate post-partum breastfeeding in delivery care services

Multiple Indicator Cluster Survey(annually; Unicef)

Reproductive health data (pregnancy, delivery)

Demographic data (incl. TFR) Breastfeeding practices (incl.exclusive) Salt use

Maternal Mortality Anaemia prevalence amongst WRA Use by pregnant/lactating women

of iron/folate tablets Use of pre- and post-natal delivery

careAd hoc surveys from NGOs/research agencies et al

Reproductive health data (pregnancy, delivery

Breastfeeding practices Formative research on beliefs, practices

concerning breastfeeding, foods/diets and health seeking behaviour etc

Anthropometry amongst mothers of children under 5 years

Maternal mortality Prevalence of night blindness, goitre

amongst WRA Micro-nutrient status

Dietary behaviour of WRA Awareness of certain

health/nutritional messages

Vulnerability Assessments etc

General information on food/diets on household level

Utilisation of various food products by WRA

In addition, growth monitoring and in particular height of girls could serve as an impact measure of interventions aiming to reduce stunting and obstructed labour.

of 83


GlossaryAnaemiaAnaemia and Iron Deficiency are the most prevalent nutritional deficiencies in the world. The body uses iron to produce hemoglobin, a protein that transports oxygen from the lungs to other tissues in the body via the blood stream, and anaemia is defined as having a hemoglobin level below a specific level (less than 12 grams of hemoglobin per deciliter of blood [g/dl] in non-pregnant women; less than 10 g/dl in pregnant women).

Basic Package of Health Services (BPHS)The Basic Package of Health Services provides a standardized package of basic services in Afghanistan which forms the core of service delivery in all primary health care facilities and it is offered at four standard levels of health facilities within the health system: the health post, basic health centre, comprehensive health centre, and district hospital.

Body Mass Index (BMI)An indirect measure of lean body mass and body fat mass calculated by taking weight in kilos divided by squared height in meters. It is a reliable way to measure malnutrition (like chronic energy deficiency) in adults but should not be used for pregnant/lactating women or those with oedema. The BMI of pregnant and lactating women is relatively higher because of their relatively higher weight; for this category there has been, until now, no good cut-off points defined under which they could be considered malnourished.

Community Health Workers (CHW) The Community Health Worker (CHW) is a man or a woman selected by the community and trained for provision of the Basic Package of Health Services (BPHS) defined for that level. The CHW will work under the supervision of Basic Health Centre (BHC) staff, and will have a limited list of essential drugs and supplies. The CHW will work in concert with the BHC team to conduct specific promotional, educational, and service activities to improve the overall health and well-being of the population. CHWs should be couples and work as such, covering 100 to 150 families. Currently 1000 CHWs are trained by individual NGOs based on a performance-based partnership agreement; their training (up to 8 weeks) is founded on a national curriculum from the MoPH, drafted by the Community Health Care Task Force. Formally they fall under the Primary Health Care Dept. It is estimated that Afghanistan needs over 20,000 CHWs. Until today their renumeration is under discussion and not yet clarified.

(Community) MidwivesWomen trained as community midwives work on Basic Health Centre (BHC) and Comprehensive Health Centre (CHC) level. Women trained as midwives work on District Hospital and Provincial Hospital level and possibly also in Comprehensive Health Centres. Their training is based on a national curriculum from the MoPH. By 2006 300-350 community midwives and 800 midwives will be trained.

Effectiveness (Effective) and Efficacy (Efficacious)See paragraph 4.1

Food diversification: improving the supply, access and consumption of micronutrient-rich foods so as to reduce micronutrient-deficiency disorders, such as vit A and iron deficiency.

Formative researchFormative research is done in order to understand behavioural, structural, or systemic factors that influence decisions and actions. It helps organisations to understand the interests, attributes and needs of different populations and persons in their community. Formative research is research that occurs before a program is designed and implemented, or while a program is being conducted. Formative research can help to

of 83


• define and understand populations at greatest risk for a certain disease, condition, etc• create programs that are specific to the needs of those populations• ensure programs are acceptable and feasible to clients before launching• improve the relationship between clients and organisations.Formative research should be an integral part of developing or adapting programmes, and should be used while the programme is on-going to help refine and improve programme activities.

Health educatorsIn each province (32 out of 34 provinces) there is a branch of the Ministry of Women Affairs (MWA) under which health educators operate. The branches coordinate the health educators’ outreach work; they are trained (currently 600) on issues like breastfeeding, malaria, malnutrition and food, family planning, pregnancy referrals to health facilities etc. Health educators currently cover approx. 25,000 women spread over most provinces.

Hemorrhage (intra-, post-partum)One of the major causes of maternal mortality worldwide, causing about 25% of maternal deaths. Post-partum hemorrhage is a loss of blood after the birth of more than 500 ml for a vaginal delivery. Common causes are a failure of the uterus to constrict and stop the bleeding, lacerations of the cervix/vagina and failure to deliver the placenta. Intra-partum hemorrhage is bleeding during pregnancy, often indicating a problem relating to the placenta.

Iodine Deficiency Disorders (IDD)Inadequate iodine causes enlargement of the thyroid gland, a condition known as goitre. IDD is particularly problematic in pregnant women due to serious effects to the foetus, including higher risk of stillbirth, low birth weight, infant mortality, impaired mental function and retarded development. The retardation of growth and mental development in the child of a woman with IDD is called cretinism. An intake of 150 micrograms per day is recommended to provide an adequate amount for use by the thyroid.

Low Birth Weight (LBW)Weight below 2500 gram of child at birth; often caused by intra-uterine growth retardation or short gestational age.

Maternal MortalityAnnual number of deaths of women from pregnancy-related causes, when pregnant or within 42 days of termination of pregnancy (per 100,000 live births).

Mid-Upper Arm Circumference (MUAC)A way to measure nutritional status; should only be used as a screening tool for entry of children and/or pregnant/lactating women into a feeding programme—not as a main indicator of malnutrition in a survey. The circumference of the mid upper arm is measured using an insertion tape or MUAC strip.

Neural tube defects: a defect in the formation of the neural tube occurring during early development of the foetus. It results in various nervous system disorders, such as spina bifida. Folate deficiency in a pregnant woman increases the risk that the foetus will develop this disorder.

Obstructed labourA labour in which something—such as the pelvic bone or the baby’s shoulders—prevents the normal process of labour and delivery.

Post-traumatic stress disorder (PTSD)An anxiety disorder that a person may develop after experiencing or witnessing an extreme, overwhelming traumatic event during which they felt intense fear, helplessness, or horror. The dominant features of posttraumatic stress disorder are emotional numbing (i.e., emotional non-

of 83


responsiveness), hyper-arousal (e.g., irritability, on constant alert for danger), and re-experiencing of the trauma (e.g., flashbacks, intrusive emotions).

Provincial Nutrition OfficerThe Provincial Nutrition Officer (PNO) supports, facilitates and monitors the implementation of public nutrition interventions at provincial and district level, in line with MoPH policies, guidelines and protocols and in partnership with both Kabul level and Provincial level Ministries of Public Health. Key tasks of PNO include Information gathering and sharing, technical support and training. PNOs are trained by MoPH. Currently there are 22 PNOs (including one female) in place and another 12 are planned for 2005, one per province. From those 22 17 are informal part-time and 3 formal full-time PNOs, all received very basic nutritional training so far.

Social marketing is the use of commercial marketing concepts and tools in programs designed to influence individuals' behavior to improve their well being and that of society.

Supplementary Feeding Programme (SFP)There are two types of SFPs—targeted and blanket. Targeted SFPs are intended to help cure malnutrition by providing a food supplement for mild and moderately malnourished children and for pregnant/lactating women. Blanket SFPs are intended to help prevent malnutrition by providing a supplement to all members of a specified group such as all children under five years of age, all pregnant/lactating women, etc.

Total Fertility Rate The Total Fertility Rate is the number of children that would be born per woman if she were to live to the end of her child-bearing years and bear children at each age in accordance with current age-specific fertility rates.

Vitamin A deficiency (VAD)Symptoms include poor growth, night blindness, blindness, follicular hyperkeratosis (marked by dry, bumpy and rough skin) and xerophthalmia (condition marked by dryness of the cornea and eye membranes, making it vulnerable to bacterial infections and possibly blindness). A serum retinol concentration of less than or equal to 0.70 micromol/L are used as the cut-off for hypovitaminosis A.The recommended daily intake of Vit A for pregnant and lactating women is respectively 770 and 1300 micrograms/day. A very high dose of Vit A might cause birth defects if taken by a pregnant woman.

Women of Reproductive Age (WRA) Most commonly defined as women between the ages of 15 and 49, but sometimes as those between 15 and 44.

of 83


References

1. A Basic Package of Health Services for Afghanistan March 2003/1382. Transitional Islamic Government of Afghanistan, Ministry of Health.2. Hidden Penalties of Gender Inequality: The Fetal Origins of Ill-Health. Osmani S, Sen A. Economics and Human Biology 1, no. 1 (2003): 105-21.3. Afghanistan – Progress of Provinces. Multiple Indicator Cluster Survey 2003. Transitional Islamic State of Afghanistan, Central Office of Statistics, UNICEF.4. Coverage of Maternal Care: A Listing of Available Information, Fourth Edition. World Health Organization, Geneva, 1997.5. Maternal Mortality in Afghanistan. Results of a study by Afghan Ministry of Public Health, UNICEF and CDC. November 2002.6. Nutrition and maternal mortality in the developing world. Rush D. Am J Clin Nutr 2000;72:212S-40S.7. Changing Lives – children in Afghanistan – an opportunity analysis. Unicef February 2004.8. Afghanistan Health and Nutrition Fact Sheet. Unicef, March 2004 .9. Maternal Nutrition – Issues and Intervention. The Linkages Project, Academy for Educational Development July 2004. http://www.linkagesproject.org/media/publications/ Technical%20Reports/ MatNutSlideShowEnglishwithnotes.ppt10. Nutrition interventions for pregnant and lactating women in relief situations. The assessment of need and impact. Ververs MT. Thesis London School of Hygiene & Tropical Medicine 1997.11. Maternal Anthropometry and Pregnancy Outcomes: a WHO Collaborative Study. Bull WHO 1995; 73(Suppl): 1- 98.12. Maternal Nutrition and Pregnancy Outcomes: anthropometric assessment. Krasovec K, Anderson MA. Washington DC: Pan American Health Organisation (PAHO), 1991. Scientific Publication No. 529.13. Reproductive Health Indicators for Afghanistan. Factsheet, WHO, September 200114. Towards a Public Nutrition Response in Afghanistan; Evolutions in Nutritional Assessment and Response. Dufour C, Borrel A. In: Reconstructing Afghanistan: what crisis in agriculture and food security? Pain A (Eds). In press15. Regards Croisés à Chaghcharan. Province de Ghor, Afghanistan. Hancart-Petitet P. Medecins du Monde, Octobre 2002. 16. Health and Nutrition survey, Panjwaie IDP camp, Kandahar province. Ministry of Health/UNICEF, December 2002.17. Afghanistan. Multiple Indicator Cluster Survey 2000. UNICEF.18. Food-based strategies to meet the challenges of micronutrient malnutrition in the developing world. Tontisirin K, Nantel G, Bhattacharjee L. Food and Nutrition Division, FAO, Rome. Proc Nutr Soc (2002), 61, 243–250. 19. Compilation of the nutritional surveys conducted by Action Contre la Faim in Kabul, Kandahar, Herat, Faizabad, Mazar and Jalalabad cities, ACF and WFP 2000.20. Defining iron deficiency anemia in public health terms: summary of evidence and proposed new framework. Stoltzfus RJ. J Nutr 2001 131: 697S-701S21. Public Nutrition Policy and Strategy 2003-2006. Public Nutrition Department, Ministry of Health, Afghanistan. June 2004.22. What Works? A Review of the Efficacy and Effectiveness of Nutrition Interventions. Lindsay H. Allen and Stuart R. Gillespie. United Nations Administrative Committee on Coordination, Sub-Committee on Nutrition (ACC/SCN) in collaboration with the Asian Development Bank (ADB). 2001

of 83

http://www.linkagesproject.org/media/publications/%20Technical%20Reports/%20MatNutSlideShowEnglishwithnotes.ppt

http://www.linkagesproject.org/media/publications/%20Technical%20Reports/%20MatNutSlideShowEnglishwithnotes.ppt


23. World population profile: 1998. McDevitt, Thomas M Washington, DC: U.S. Government Printing Office, 1999, p.A40.24. Nutrition and Health Survey. Badghis Province, Afghanistan. February – March 2002. UNICEF and U.S. Centers for Disease Control and Prevention (CDC).25. Improving Adolescent and Maternal Nutrition: An Overview of Benefits and Options. Gillespie S.R. UNICEF Staff Working Paper 97-002, UNICEF 1997 New York26. Nutrition of Women and Adolescent Girls: Why It Matters. July 2003. Ransom EI, Elder LK. http://www.prb.org/Template.cfm?Section=PRB&template=/ContentManagement/ ContentDisplay.cfm&ContentID=959727. National Risk and Vulnerability Assessment 2003 (NRVA), An Overview of Findings and Initial Policy Insights. Afghanistan28. And We Have Babies Until We Die - Qualitative Survey of Maternal Mortality In Three Areas of Afghanistan. Omidian.P, CeReTechs. UNICEF Afghanistan September 2002.29. Mental Health, Social Functioning, and Disability in Postwar Afghanistan, Lopes Cardozo B. JAMA. 2004;292:575-584.30. Research Findings on Breastfeeding and Weaning Beliefs and Practices (Andkhoy, Khancharbagh, Qaramqul, and Qurghan districts Jawzjan Province, Northern Afghanistan. Save the Children Federation, Inc. (SC/US). April 2003.31. Maternal and newborn health Postpartum care of the mother and newborn: a practical guide Department of Reproductive Health and Research (RHR), World Health Organization.32. Determinants of low birth weight: methodological assessment and meta-analysis. Kramer M. Bull WHO 1987; 65 (5): 663-737. 33. Physical Status: The Use and Interpretation of Anthropometry: Report of a WHO Expert Committee. WHO Technical Report Series No. 854. WHO: Geneva 1995. http://whqlibdoc.who.int/trs/WHO_TRS_854.pdf34. Strategies, Policies and Programs to Improve the Nutrition of Women and Girls. Nestel P. January 2000, draft. Food and Nutrition Technical Assistance Project (FANTA), Academy for Educational Development. Washington, DC.35. Evaluation of Emergency Supplementary Feeding Programmes in Afghanistan; January 2002 to June 2003, Ministry of Health in collaboration with Tufts University and UNICEF, July 200436. Is there a causal relationship between iron deficiency or iron-deficiency anemia and weight at birth, length of gestation and perinatal mortality? Rasmussen KM. J Nutr 2001;131:590S–603S.37. New evidence that maternal iron supplementation improves birth weight, which raises new scientific questions. Rasmussen KM, Stoltzfus RJ. Am J Clin Nutr 2003; 78: 673-74. 38. How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence. Carroli G, Rooney C, Villar J. Paediatr Perinat Epidemiol. 2001 Jan;15 Suppl 1:1-42. Review.39. Reduction of maternal mortality. A joint WHO/UNFPA/UNICEF/World Bank statement. 1999 ISBN 9241561955. http://www.who.int/reproductive-health/publications/reduction_of_maternal_mortality/reduction_maternal_mortality_chap3.htm40. Efficacy and effectiveness of interventions to control iron deficiency and iron deficiency Anemia. Davidsson L,Nestel P. INACG/ILSI Human Nutrition Institute February 2004

of 83

http://www.who.int/reproductive-health/publications/reduction_of_maternal_mortality/reduction_maternal_mortality_chap3.htm

http://www.who.int/reproductive-health/publications/reduction_of_maternal_mortality/reduction_maternal_mortality_chap3.htm

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11243499

http://www.who.int/reproductive-health/MNBH/index.htm

http://www.prb.org/Template.cfm?Section=PRB&template=/ContentManagement/%20ContentDisplay.cfm&ContentID=9597

http://www.prb.org/Template.cfm?Section=PRB&template=/ContentManagement/%20ContentDisplay.cfm&ContentID=9597


41. 2004 INACG SYMPOSIUM IRON DEFICIENCY IN EARLY LIFE: CHALLENGES AND PROGRESS. 18 NOVEMBER 2004, LIMA, PERU, Abstracts. Http://www.ilsi.org/file/INACGPeruabstracts.pdfIn particular the following abstracts:PATTERNS OF COMPLIANCE TO MATERNAL IRON SUPPLEMENTATION. N Zavaleta, LE Caulfield, T Garcia, A Figueroa. Insituto de Investigacion Nutricional Lima and, Ctr for Human Nutr, Johns Hopkins School of Public Health, Baltimore.COMMUNITY-BASED DISTRIBUTION OF IRON+FOLIC ACID IN NIGER: SUCCESS AND CHALLENGES. X Crespin, H Harouna, A MamadoulTaïbou, N Zagré, SK Baker Helen Keller International, Niger, (SKB) HKI Regional Office, Dakar, Senegal.ANEMIA RATES SIGNIFICANTLY REDUCED IN NICARAGUA. J Bonilla, A Barrera, A Largaespada, GE Navas, J Mora. USAID/MOST, Nicaragua Ministry of Health, Institute of Nutrition of Central America and Panama (INCAP).42. The UNICEF/UNU/WHO Study Team. Report of a meeting held on 21st-23rd June, 2004 in Bangkok, Thailand organised by the Centre for International Child Health, Institute of Child Health, University College London and UNICEF, Bangkok (not yet published).43. Value of micronutrient supplement tested by Unicef, more efficacious than Fe-FA supplements for both maternal and child survival and development outcomes. Shrimpton R and Schultink W. Proc Nutr Soc 2002,61;223-229.44. Vitamin A supplementation during pregnancy (Cochrane Review). Van den Broek N, Kulier R, Gülmezoglu AM, Villar J. In: The Cochrane Library, Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd.45. FAQ #4 Maternal postpartum vitamin A dosing programs: What are the expected impacts of a maternal postpartum vitamin A dosing program on the health and nutrition of the mother and the child? How do these programs work? What are the current guidelines for these programs? MOST, The USAID Micronutrient Program 2000 http://www.mostproject.org/faq4.1for%20phil.pdf46. Safe vitamin A dosage during pregnancy and lactation. Geneva, World Health Organization, 1998 (Document WHO/NUT/98.4). http://whqlibdoc.who.int/hq/1998/WHO_NUT_98.4.pdf47. Triple fortification of salt with microcapsules of iodine, iron, and vitamin A. Zimmermann MB et al Am J Clin Nutr. 2004 Nov;80(5):1283-90).48. Can Food-Based Strategies Help Reduce Vitamin A and Iron Deficiencies? A Review of Recent Evidence. Ruel MT. International Food Policy Research Institute Washington, D.C. December 2001.49. Improving the nutrition of women in the third world. Leslie, J. In Pinstrup Anderson, P et al (Eds) Child Growth and Nutrition in Developing Countries: Priorities for Action. Cornell University Press, Ithaca, New York 199550. SMALL ANIMAL REVOLVING FUND ADDRESSES IRON DEFICIENCY IN MALAWI. R Namarika,et al. World Vision Malawi, Lilongwe, Malawi, World Vision Canada, Mississauga, Canada. 2004 INACG SYMPOSIUM IRON DEFICIENCY IN EARLY LIFE: CHALLENGES AND PROGRESS 18 NOVEMBER 2004, LIMA, PERU, Abstracts. Http://www.ilsi.org/file/INACGPeruabstracts.pdf51. Guidelines for the Use of Iron Supplements to Prevent and Treat Iron Deficiency Anemia. Stoltzfus RJ, Dreyfuss ML. International Nutritional Anemia Consultative Group (INACG) 1998.52. National Standards for Reproductive Health Services Postpartum Care Services. Reproductive Health Task Force Department of Women and Reproductive Health, General Directorate for Health Care and Promotion, Ministry of Health. Transitional Islamic Government of AFGHANISTAN. Final Draft December 2003.

of 83

http://www.ilsi.org/file/INACGPeruabstracts.pdf

http://whqlibdoc.who.int/hq/1998/WHO_NUT_98.4.pdf

http://www.ilsi.org/file/INACGPeruabstracts.pdf


53. How many child deaths can we prevent this year? Jones G, Steketee RW, Black RE, et al. Lancet 2003; 362: 65–71.54. Vitamin and Mineral Deficiency – A damage assessment report for Afghanistan. Leadership Briefing. Unicef and Micronutrient Initiative, 2004.55. Double blind, cluster randomised trial of low dose supplementation with vitamin A or beta carotene on mortality related to pregnancy in Nepal. The NNIPS-2 Study Group. West KP Jr, Katz J, Khatry SK, et al. BMJ. 1999 Feb 27;318(7183):570-5.56. Night blindness during pregnancy and subsequent mortality among women in Nepal: effects of vitamin A and beta-carotene supplementation. Christian P, West KP Jr, Khatry SK, et al. Am J Epidemiol. 2000 Sep 15;152(6):542-7.

of 83

Strategy INWRA - وزارت صحت...

Documents

Transcript of Strategy INWRA - وزارت صحت...