Determinants of Institutional Delivery in Afghanistan: A Secondary Analysis of Multi Indicator Cluster Surevey(MICS) 2022 and 2023 Data

doi:10.21203/rs.3.rs-5008241/v1

Maternal mortality remains a critical public health issue in Afghanistan, with the country exhibiting one of the highest maternal mortality ratios (MMR) globally. Delivery of a baby within an institution is a vital indicator of maternal and newborn health. This study explored the association between institutional delivery and various socioeconomic factors, particularly maternal education, using data from the Multi-Indicator Cluster Survey (MICS) 2022 and 2023. We analyzed data from over 12578 women of childbearing age to determine the influence of education, economic status, and geographic location on institutional delivery rates. Our findings indicate that higher maternal education and better economic conditions significantly increase the likelihood of institutional delivery, whereas rural residency and lower socioeconomic status remain substantial barriers. This study underscores the need for targeted interventions to address educational disparities and economic inequalities to improve maternal and child health outcomes in Afghanistan. This study provides critical insights for policymakers and public health professionals aiming to reduce the MMR in Afghanistan by promoting education and socioeconomic development.

Institutional Delivery

Maternal Mortality

Maternal Education

Socioeconomic Factors

Afghanistan

MICS (Multi-Indicator Cluster Survey)

Cultural Determinants

Global and Local Context

Maternal mortality, particularly in low- and middle-income countries (LMICs), remains a significant global health challenge.¹ The World Health Organization (WHO) estimates that approximately 95% of maternal deaths occur in LMICs, with sub-Saharan Africa and South Asia bearing the highest burden.² Despite global efforts and a 34% reduction in maternal mortality between 2000 and 2020, Afghanistan continues to have one of the highest maternal mortality ratios in the world.^3,4 The maternal mortality ratio (MMR) in Afghanistan has decreased from 1346 per 100,000 live births in 2000 to an estimated 620 per 100,000 in 2023, mainly due to the implementation of the Basic Package of Health Services (BPHS).^3,5 However, this progress is insufficient to meet the Sustainable Development Goal (SDG) target of reducing global MMR to less than 70 per 100,000 live births by 2030.^3,6

Rationale and Significance

Education is a powerful determinant of health, particularly maternal health.^7,8 Studies have shown that women with higher education levels are more likely to seek and utilize healthcare services, including institutional delivery, which significantly reduces the risk of maternal and neonatal mortality.^9,10 In Afghanistan, where female literacy rates are low, understanding the impact of education on maternal health is crucial for designing effective public health interventions. Furthermore, the socioeconomic divide between urban and rural areas exacerbates health disparities.⁷ Rural women, who are often less educated and economically disadvantaged, face significant barriers to accessing healthcare services, leading to higher rates of home deliveries and maternal mortality.^5,7

This study provides a comprehensive analysis of the factors influencing institutional delivery in Afghanistan focusing on maternal education, economic status, and area of residence. By exploring these determinants, this study seeks to inform policies and programs to address health disparities and improve maternal health outcomes in Afghanistan.

Study Design

Utilizing the 2022/23 MICS survey data in Afghanistan, we conducted a secondary analysis focusing on institutional and home delivery as an outcome.

Multi-indicator cluster survey 2022/23 methodology

The MICS Afghanistan 2022/23 survey was conducted by the United Nations Children’s Fund (UNICEF) in collaboration with the National Statistics and Information Authority (NSIA) (UNICEF, 2023).⁹ Oversight was provided by a technical committee comprising MICS Head Quarter, UNICEF regional office teams, and staff from the UNICEF Afghanistan country office. The sample design aimed to provide estimates for various indicators at the national, urban-rural, and provincial levels. Using a two-stage sampling approach based on the 2019 Satellite Imagery frame, primary sampling units (enumeration areas) were systematically selected, resulting in a sample size of 23,568 households across 982 enumeration areas. A two-stage cluster sampling method was used for each province, and Afghanistan was divided into 34 provinces. Security issues prevented visits to the 10 selected enumeration areas. The non-self-weighting sample necessitated the use of sample weights to report results. Four questionnaires were employed by UNICEF and NSIA, covering the household demographics of individual women (15–49 years), children under 5 years, and children aged 5–17 years old (UNICEF, 2023).⁹

Dependent Variable

Place of delivery (Health facility vs. home delivery).

Independent Variables

Maternal education (no education, primary, lower secondary, upper

secondary, higher), economic status (wealth quintiles), area of residence (urban vs. rural), and the language spoken by the household head.

Analysis Plan

Quantitative data analysis was conducted using the STATA software. Proportions are presented for categorical variables, whereas means and standard deviations are reported for continuous data. A logistic regression was performed to assess the association between independent predictors and institutional delivery, adjusting for the survey design effect. A univariate approach was first applied to each predictor with the outcome variable, and then variables with a p-value less than 0.25 were included in the multivariate analysis. The final model fitted using forward procedures and the variables were retained variables with a p-value of ≤ 0.05. All the results were adjusted for survey design, including weighting and clustering effects.

Descriptive Analysis

Table 1 shows the overall percentages of births that took place in a health facility versus at home, along with confidence intervals. Overall, 66.3% of the women delivered at a health facility, while 33.7% delivered at home (Table 1).

Table 1

Coverage of Institutional Delivery in Afghanistan 2022/23:This table shows the overall percentages of births that took place in a health facility versus at home, along with confidence intervals.
Delivery Type	Proportion	Confidence Interval
		Lower Bound	Upper Bound
Institutional Delivery Home Delivery	66.33%	64.51%	68.09%
	33.67%	31.91%	35.49%

The sample size for this analysis included 12,587 women of childbearing age who had given birth in the past two years. Of these, 15.4% were from urban areas (N = 1,934), while 84.6% were from rural areas (N = 10,644). The average age of the women was 28.6 years. In terms of language, 34.66% were Dari-speaking (N = 4,360), 50.29% were Pashto-speaking (N = 6,326), 7% were Uzbeki-speaking (N = 884), 1.56% were Turkmani-speaking (N = 196), 2.67% were Nuristani-speaking (N = 336), 0.72% were Balochi-speaking (N = 91), and 2.59% were Pashaie-speaking (N = 326), while 0.47% spoke other languages (N = 59). Regarding education among the heads of households, 64.56% had pre-primary education (N = 8,120), 10.93% had primary education (N = 1,375), 6.15% had lower secondary education (N = 774), and 5.02% had upper secondary education (N = 322). Additionally, 7.8% had higher education (N = 981). Among the women, 80.39% had pre-primary education (N = 10,111), 8.42% had primary education (N = 1,059), 3.62% had lower secondary education (N = 455), and 5.02% had upper secondary education, while 2.56% had higher education (N = 322). In terms of the wealth index, 22.21% were in the poorest quintile (N = 2,793), 23.26% were in the second quintile (N = 2,926), 22.75% were in the middle quintile (N = 2,861), 18.73% were in the fourth quintile (N = 2,356), and 13.02% were in the richest quintile (N = 1,642).

Table 2 provides a detailed breakdown of the demographic and socioeconomic characteristics of the households and women included in the MICS 2023 survey in Afghanistan.

Table 2

Characteristics of households and women in MICS 2023 (N = 12587), Afghanistan
Characteristics of households, mothers	n	% (Sample)	% (Population)*
Head of Household Language
Dari	4,360	34.66	40.2
Pashto	6,326	50.29	48.2
Uzbeki	884	7.03	7.6
Turkmani	196	1.56	1.5
Nooristani	336	2.67	0.5
Balochi	91	0.72	0.4
Pashaie	326	2.59	1.3
Other Languages	59	0.47	0.3
Education of household head
Pre-primary/ECE or none	8,120	64.56	61.9
Primary	1,375	10.93	12.9
Lower Secondary	774	6.15	6.9
Upper Secondary	1,303	10.36	10.3
Higher	981	7.8	7.8
Don't know/Missing	25	0.2	0.2
Mother's Education
Pre-primary/ECE or none	10,111	80.39	76.2
Primary	1,059	8.42	10.3
Lower Secondary	455	3.62	4.6
Upper Secondary	631	5.02	5.8
Higher	322	2.56	3.2
Mean number of members in a household	12,578	10.85	10.39
Wealth index quintile
Poorest	2,793	22.21	20.9
Second	2,926	23.26	20.8
Middle	2,861	22.75	20.5
Fourth	2,356	18.73	19.7
Richest	1,642	13.05	18.2
Living area
Urban	1,934	15.4	23.1
Rural	10,644	84.6	76.9
Mean women age	12,578	28.6	28.4
%* Weighted percentage

The logistic regression analysis results provide important insights into the determinants of institutional delivery in Afghanistan.

Language of the Household Head

The language spoken by the household head was significantly associated with the likelihood of institutional delivery, as indicated by the Odds Ratios (ORs). For example, Nooristani-speaking households had significantly higher odds of not having institutional deliveries, with an adjusted OR of 7.54 (95% CI: 3.03, 18.74; p < 0.001), compared to women from Dari-speaking households. Conversely, Pashto-speaking households were associated with a higher likelihood of institutional deliveries, as shown by an adjusted OR of 0.79 (95% CI: 0.65, 0.95; p = 0.014). (Tables 3 and 4)

Women’s Education

Education level was a strong determinant of institutional delivery. Women with higher education levels were significantly more likely to deliver in a health facility. For example, women with higher education were 0.14 times less likely (95% CI: 0.07, 0.31; p < 0.001) to deliver at home compared to women with no formal education. (Tables 3 and 4)

Economic and Rural/Urban Status

Economic status also played a critical role. Women from the richest households were 0.09 times less likely (95% CI: 0.07, 0.13; p < 0.001) to have a home delivery compared to those from the poorest households. Conversely, those in rural areas were 1.89 times more likely (95% CI: 1.40, 2.55; p < 0.001) to have a home delivery compared to urban residents. (Tables 3 and 4)

Table 3

presents the cross-tabulation of sociodemographic variables with institutional delivery among Afghan women aged 15–49 years based on a sample size of 12,578 This table cross-tabulates different sociodemographic variables with the place of delivery, helping to see the relationships between these factors and whether the birth took place in a health facility or at home. The p-values are derived from chi-square tests applied to all categories.
Variables	Category	Institutional Delivery (N)	Institutional Delivery (%)	95% CI	Home Delivery (N)	Home Delivery (%)	95% CI	P-value
Head of the Household Language	Dari	3,444	68.5	[65.32, 71.58]	1,582	31.5	[28.42, 34.68]	< 0.001
	Pashto	3,929	65.2	[62.64, 67.67]	2,097	34.8	[32.33, 37.36]
	Uzbeki	661	69.2	[62.75, 74.97]	294	30.8	[25.03, 37.25]
	Turkmani	146	76.8	[64.84, 85.61]	44	23.2	[14.39, 35.16]
	Nooristani	11	18.3	[7.62, 37.83]	51	81.7	[62.17, 92.38]
	Balochi	28	61.8	[44.92, 76.17]	17	38.3	[23.83, 55.08]
	Pashaie	45	28.2	[19.07, 39.47]	115	71.8	[60.53, 80.93]
	Other Languages	31	74.3	[55.07, 87.20]	11	25.7	[12.80, 44.93]
Area	Urban	2,566	88.7	[85.50, 91.19]	326	11.4	[8.81, 14.50]	< 0.001
Area	Rural	5,730	59.6	[57.44, 61.74]	3,883	40.4	[38.26, 42.56]	< 0.001
Women's Education	No Education	5,829	61.2	[59.15, 63.14]	3,702	38.8	[36.86, 40.85]	< 0.001
	Primary	972	75.5	[71.13, 79.38]	316	24.5	[20.62, 28.87]
	Lower Secondary	475	83.5	[78.48, 87.54]	94	16.5	[12.46, 21.52]
	Upper Secondary	639	88.0	[84.05, 91.08]	87	12.0	[8.92, 15.95]
	Higher	381	96.7	[93.47, 98.32]	13	3.3	[1.68, 6.53]
Economic Status	Poorest	1,071	41.0	[37.95, 44.19]	1,539	59.0	[55.81, 62.05]	< 0.001
	Second	1,438	55.3	[52.11, 58.34]	1,165	44.8	[41.66, 47.89]
	Middle	1,720	67.2	[64.23, 70.05]	839	32.8	[29.95, 35.77]
	Fourth	1,952	79.4	[76.82, 81.78]	506	20.6	[18.22, 23.18]
	Richest	2,115	92.9	[90.70, 94.56]	162	7.1	[5.44, 9.30]

Table 4

Multivariate analysis of determinants of Institutional Delivery Among Afghan Women Aged 15–49 (n = 12,578) *This table provides both unadjusted and adjusted odds ratios with confidence intervals for each variable, summarizing the results of the univariate and multivariate logistic regression analyses.*
Variable	Category	Unadjusted Odds Ratio	95% CI Lower	95% CI Upper	P-Value	Adjusted Odds Ratio	95% CI Lower	95% CI Upper	P-Value
Head of the Household Language	Dari	1	-	-	-	1	-	-	-
	Pashto	1.16	0.96	1.40	0.116	0.79	0.65	0.95	0.014
	Uzbeki	0.97	0.70	1.34	0.853	0.75	0.55	1.03	0.071
	Turkmani	0.66	0.36	1.20	0.173	0.58	0.31	1.08	0.087
	Nooristani	9.72	3.54	26.70	< 0.001	7.54	3.03	18.74	< 0.001
	Balochi	1.35	0.67	2.71	0.400	0.70	0.37	1.30	0.261
	Pashaie	5.56	3.26	9.46	< 0.001	3.32	2.14	5.16	< 0.001
	Other Languages	0.75	0.31	1.81	0.526	1.01	0.34	2.97	0.987
Number of Members in the Household	Number	1.00	0.99	1.01	0.799	1.02	1.01	1.04	< 0.001
Women's Education	No Education	1	-	-	-	1	-	-	-
	Primary	0.51	0.41	0.64	< 0.001	0.70	0.57	0.86	0.001
	Lower Secondary	0.31	0.22	0.43	< 0.001	0.48	0.36	0.66	< 0.001
	Upper Secondary	0.21	0.15	0.30	< 0.001	0.40	0.28	0.58	< 0.001
	Higher	0.05	0.03	0.11	< 0.001	0.14	0.07	0.31	< 0.001
Economic Status	Poorest	1.00	-	-	-	1.00	-	-	-
	Second	0.56	0.48	0.67	< 0.001	0.58	0.49	0.69	< 0.001
	Middle	0.34	0.28	0.40	< 0.001	0.36	0.31	0.44	< 0.001
	Fourth	0.18	0.15	0.22	< 0.001	0.22	0.18	0.27	< 0.001
	Richest	0.05	0.04	0.07	< 0.001	0.09	0.07	0.13	< 0.001
Area	Urban	1.00	-	-	-	1.00	-	-	-
Area	Rural	5.29	3.94	7.11	< 0.001	1.89	1.40	2.55	< 0.001

The findings of this study have profound implications for public health policies in Afghanistan. The strong association between maternal education and institutional delivery underscores the critical need for policies prioritizing female education as a cornerstone of maternal health strategies. Research consistently demonstrates that educated women are more likely to seek and utilize healthcare services, including institutional delivery, which is vital for reducing maternal and neonatal mortality. ^(10,11,12) Therefore, expanding access to education for girls, particularly in rural areas, should be a top priority for the Afghan government and its international partners.

The economic disparities highlighted in this study provide a strong association of poverty with home delivery. Hence, it highlights that targeted financial support and incentives, such as conditional cash transfers or maternal and neonatal gift packs for healthcare services, could significantly increase institutional delivery rates among the poorest women.¹³ This is especially crucial in rural areas, where most home deliveries occur due to economic barriers such as transportation costs and the affordability of healthcare services.^13,14 Past interventions, such as the introduction of the Basic Package of Health Services (BPHS) and the Essential Package of Health Services (EPHS), have played a significant role in enhancing access to health facilities across Afghanistan. Still, more targeted efforts are needed to address persistent economic inequalities.¹⁵

Cultural barriers to institutional delivery, as evidenced by the disparities in delivery rates among different linguistic and ethnic groups, must also be addressed. Public health campaigns and interventions should be culturally sensitive and tailored to the specific needs of these communities.¹⁶ Engaging community leaders, leveraging local languages, and incorporating culturally relevant messaging in health promotion activities could enhance the effectiveness of these interventions.^17,18 For example, Turkmani-speaking families had the highest rates of institutional deliveries, while Nuristani-speaking families had the lowest, highlighting the need for culturally nuanced approaches to health promotion (UNICEF, 2023).⁹

Future research should focus on longitudinal studies to track the impact of educational and economic interventions on maternal health outcomes. Additionally, qualitative studies exploring cultural barriers to institutional delivery in different ethnic groups would provide valuable insights for designing more effective interventions. There is also a need to examine the impact of health system-strengthening initiatives, such as the expansion of midwifery services, on maternal health outcomes. For example, community midwifery education programs, supported by various donors, have been instrumental in improving access to maternal health services in Afghanistan.^19,20 Evaluating the long-term impact of such programs could inform future efforts to reduce maternal mortality in Afghanistan and other LMICs.

This study provides an in-depth analysis of the factors influencing institutional delivery in Afghanistan, focusing on maternal education, economic status, and geographic location. It highlights the critical importance of maternal education, economic empowerment, and culturally tailored interventions to improve institutional delivery rates and consequently, maternal and child health outcomes in Afghanistan. By addressing these determinants through targeted and culturally sensitive interventions, Afghanistan can make significant progress toward achieving the Sustainable Development Goals (SDGs) related to maternal health. The findings of this study should inform public health policy and program development in Afghanistan, focusing on reducing maternal mortality and promoting equitable access to healthcare for all women, regardless of their educational level, economic status, or cultural background.

Although Afghanistan has made progress in improving maternal health, significant challenges remain, particularly among rural and less-educated women. Future research should continue to explore the root causes of non-institutional deliveries and evaluate the long-term impacts of educational and economic interventions on maternal health outcomes. Continued efforts are necessary to ensure that all women in Afghanistan have access to safe institutional delivery services, ultimately reducing maternal and neonatal mortality.

Data Access Statement

The data utilized in this study were obtained from the Multi-Indicator Cluster Survey (MICS) 2022 and 2023, conducted by UNICEF in collaboration with the National Statistics and Information Authority (NSIA) of Afghanistan. These data are publicly available through UNICEF's MICS database (https://mics.unicef.org/) and can be accessed upon request and following proper data use protocols.

Ethics Statement

This study is based on secondary data analysis of publicly available data from the Multi-Indicator Cluster Survey (MICS) 2022 and 2023. UNICEF obtained ethical approval for the original MICS survey, and all procedures followed adhered to ethical standards involving informed consent from all participants. The analysis conducted in this study did not involve direct contact with human subjects, and therefore, additional ethical approval was not required.

Disclaimer

The views expressed in this paper are those of the authors and do not necessarily reflect the official policies or positions of affiliated organizations.

Competing Interests

The authors declare that they have no conflicts of interest.

Patient Consent for Publication

Not applicable.

Funding

This study was conducted without any specific grants from the public, commercial, or not-for-profit sectors.

Author Contribution

Humayoon Gardiwal served as the Principal Investigator, leading the research, conceptualizing and designing the study, and drafting the article. Ataullah Saeedzai developed the Methods section, and conducted data analysis and result tables, Mohammad Hassan Ukasha contributed to data visualization and manuscript writing, with Dr. Ferozuddin Feroz assisting in the writing process. Jo Knight reviewed the manuscript and provided insight. The remaining authors provided additional support throughout the study. All authors have agreed to submit this manuscript.

Acknowledgement

We are deeply grateful to UNICEF-Afghanistan for providing access to MICS 2023 data, which made this research possible. We also acknowledge the contributions of all women who participated in the survey, whose experiences informed us of this important work.

Data Availability

The data set was requested from UNICEF-MICS team and they authorized the team to use the data for the this specific purpose.

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No competing interests reported.

Determinants of Institutional Delivery in Afghanistan: A Secondary Analysis of Multi Indicator Cluster Surevey(MICS) 2022 and 2023 Data

Status:

Version 1

Abstract

INTRODUCTION