Whenever we discuss pregnancy-related deaths, utilization of antenatal care (ANC) services is one of the established yardsticks for improving maternal health outcomes. ANC is a specific type of care given to pregnant women from the onset of pregnancy until delivery. It includes the prevention of maternal health risks, safe delivery, and good health of the newborn. The World Health Organization (WHO) recommends a minimum of eight ANC contacts with the first visit during the first 12 weeks of the gestational age.
ANC application is suboptimal, particularly in developing countries, leaving Afghanistan with no exception. In Afghanistan, the figures for such suboptimal utilization can be described from different perspectives. First, the utilization of ANC services during pregnancy was evident in approximately 60% of all pregnant women in 2015. Second, a vast majority of the pregnant women (82%) did not succeed to make the recommended ≥4 ANC visits.[2,3] Third, a significant number (66.9%) of the pregnant women presented late (>12 weeks) for their first ANC visit.[3,4] Fourth, the pregnant women receiving ANC services may not receive the quality care they need.[2,3] Fifth, ANC services are neither available nor accessible to a major proportion of pregnant women. These can be likely attributable to the enduring and immersing poverty, resource constraints, and a mismanaged health care system that engulfed the country in the past three decades. In this article, we describe unique challenges for ANC utilization in Afghanistan amid COVID-19 and the dethroning of the formally recognized Afghan government. Healthcare decision-makers need to acknowledge these critical challenges that may affect the utilization of ANC services in Afghanistan and address the same through evidence-based recommendations.
The COVID-19 pandemic has had profound health and economic implications in Afghanistan. During the COVID-19 pandemic, most public health services were interrupted. For instance, most healthcare resources and workers were redirected to the COVID-19 response, leaving limited resources for other health programs, including ANC services. Moreover, travel restrictions and limited availability of transportation made it difficult for pregnant women to access health facilities. As Afghanistan has no home-based care program for pregnant women, health facilities remain the only option for seeking healthcare services. In addition, some of the tertiary care centers and primary health care centers were transformed into COVID-19 hospitals, where access to ANC services became limited. Therefore, pregnant women in Afghanistan are less likely to utilize ANC services.
In August 2021, the Taliban came to power. Most of the international funds were averted, whereas healthcare services dependent on humanitarian non-governmental organizations (NGOs) are at their minimal functioning level.[5,6] This unwarned resource reduction critically affected healthcare services, including ANC services. During the last months of conflict and the Taliban’s takeover of Afghanistan, large proportions of the well-trained health workforce fled the country, and many of those who remained are unpaid for months, effectively halting ANC services. In recent months, challenges such as unemployment and poverty are increasing in Afghanistan, which is also impacting households as well as pregnant women.[5,6] Furthermore, as the country has experienced a 40-year continuous conflict, millions of people are internally displaced or have become refugees in other countries due to socio-economic challenges. Both internally displaced persons and refugees have limited access to health services.
In the face of COVID-19 and the dethroning of the internationally assisted Afghan government, these challenges continue to impact the health and well-being of pregnant women and children. Hence, we propose the following recommendations with the intent to enhance ANC utilization in these critical conditions.
- Introducing a community-based program such as home visits for pregnant women who are dwellers of remote residences or have no access to ANC services
- Leveraging the existing national program that provides equitable access across the country
- Scaling up appropriate education and training programs for healthcare workers to better prepare them for standard care
- Adopting a multi-sectoral collaboration for addressing social determinants of suboptimal utilization of ANC services
- Mobilizing community partners such as religious institutions and voluntary organizations to promote the utilization of ANC services in resource-limited settings
- Intensifying public awareness and health education programs to enhance the utilization of ANC services
- Convening the international community to assist the country’s healthcare system
- Prioritizing ANC services in health policy in the light of strengthening the existing program and advancing collaborations with international NGOs
ANC application is suboptimal in Afghanistan, whereas health resources and system capacities to address the same are limited. These gaps may now increase manifolds in the presence of the aforementioned challenges and result in higher adverse health outcomes among pregnant women. To maintain the gains in maternal health of the past decades, policymakers and international donors must address the need for appropriate and timely utilization of ANC services among pregnant women in the post-conflict setting. Nevertheless, health care deliverers may play a vital role in policy advocacy and health service delivery, promoting the utilization of ANC services in this post-conflict and resource-constraint setting. Additionally, the continuity of limited financial resources in Afghanistan makes even the best policies and plans difficult to implement.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
1. World Health Organization. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. Geneva, Switzerland: World Health Organization 2016.
2. Mumtaz S, Bahk J, Khang YH. Current status and determinants of maternal healthcare utilization in Afghanistan:Analysis from Afghanistan Demographic and Health Survey 2015. PLoS One 2019;14:e0217827.
3. Stanikzai MH, Wafa MH, Wasiq AW, Sayam H. Magnitude and determinants of antenatal care utilization in Kandahar city, Afghanistan. Obstet Gynecol Int 2021;2021:5201682. doi:10.1155/2021/5201682.
4. Samiah S, Stanikzai MH, Wasiq AW, Sayam H. Factors associated with late antenatal care initiation among pregnant women attending a comprehensive healthcare facility in Kandahar Province, Afghanistan. Indian J Public Health 2021;65:298–301.
5. Essar MY, Hasan MM, Islam Z, Riaz MMA, Aborode AT, Ahmad S. COVID-19 and multiple crises in Afghanistan:An urgent battle. Confl Health 2021;15:70. doi:10.1186/s13031-021-00406-0.
6. Ahmad A, Rassa N, Orcutt M, Blanchet K, Haqmal M. Urgent health and humanitarian needs of the Afghan population under the Taliban. Lancet 2021;398:822–5.