Strategy Improving the Nutritional Status of Afghan Women of Reproductive Age
Ministry of Public Health
D. 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
January 2005
Mija-Tesse Ververs, Tufts University in collaboration with Unicef and the Public Nutrition Department, Ministry of Public Health, Afghanistan.
Preface
At 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
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
Healthy Women
a 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)
Executive Summary
Afghanistan 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 WRA
It 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
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 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.