The Afghanistan Mortality Survey (AMS) 2010 was designed to measure mortality levels and causes of death, with a special focus on maternal mortality. In addition, the data obtained in the survey can be used to derive mortality trends by age and sex as well as sub-national estimates. The study also provides current data on fertility and family planning behavior and on the utilization of maternal and child health services.
The specific objectives of the survey include the following:
- National estimates of maternal mortality; causes and determinants of mortality for adults, children, and infants by age, sex, and wealth status; and other key socioeconomic background variables;
- Estimates of indicators for the country as a whole, for the urban and the rural areas separately, and for each of the three survey domains of North, Central, and South, which were created by regrouping the eight geographic regions;
- Information on determinants of maternal health;
- Other demographic indicators, including life expectancy, crude birth and death rates, and fertility rates.
ORGANIZATION OF THE SURVEY
The AMS 2010 was carried out by the Afghan Public Health Institute (APHI) of the Ministry of Public Health (MoPH) and the Central Statistics Organization (CSO) Afghanistan. Technical assistance for the survey was provided by ICF Macro, the Indian Institute of Health Management Research (IIHMR) and the World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). The AMS 2010 is part of the worldwide MEASURE DHS project that assists countries in the collection of data to monitor and evaluate population, health, and nutrition programs. Financial support for the survey was received from USAID, and the United Nations Children’s Fund (UNICEF). WHO/EMRO’s contribution to the survey was supported with funds from USAID and the UK Department for International Development and the Health Metrics Network (DFID/HMN). Ethical approval for the survey was obtained from the institutional review boards at the MoPH, ICF Macro, IIHMR, and the WHO.
A steering committee was formed to coordinate, oversee, advise, and make decisions on all major aspects of the survey. The steering committee comprised representatives from various ministries and key stakeholders, including MoPH, CSO, USAID, ICF Macro, IIHMR, UNICEF, UNFPA, WHO, and local and international NGOs. A technical advisory group (TAG) made up of experts in the field of mortality and health was also formed to provide technical guidance throughout the survey, including reviewing the questionnaires, the tabulation plan for this final report, the final report, and the results of the survey.
Kind of data
Sample survey data [ssd]
Producers and sponsors
Indian Institute for Health Management Research (IIHMR)
Central Statistics Organization (CSO)
Coordination, and technical support
United States Agency for International Development
United Nations Children’s Fund
UK Department for International Development
Health Metrics Network
World Health Organization
The AMS 2010 is the first nationwide survey of its kind. A nationally representative sample of 24,032 households was selected. All women age 12-49 who were usual residents of the selected households or who slept in the households the night before the survey were eligible for the survey. The survey was designed to produce representative estimates of indicators for the country as a whole, for the urban and the rural areas separately, and for each of the three survey domains, which are regroupings of the eight geographical regions. The compositions of the domains are given below:
- The North, which combines the Northern region and the North Eastern region, consists of nine provinces: Badakhshan, Baghlan, Balkh, Faryab, Jawzjan, Kunduz, Samangan, Sari Pul, and Takhar.
- The Central, which combines the Western region, the Central Highland region, and the Capital region, consists of 12 provinces: Badghis, Bamyan, Daykundi, Farah, Ghor, Hirat, Kabul, Kapisa, Logar, Panjsher, Parwan, and Maydan Wardak.
- The South, which combines the Southern region, the South Eastern region, and the Eastern region, consists of 13 provinces: Ghazni, Hilmand, Kandahar, Khost, Kunar, Laghman, Nangarhar, Nimroz, Nuristan, Paktika, Paktya, Uruzgan, and Zabul.
The sample for the AMS 2010 is a stratified sample selected in two stages from the 2011 Population and Housing Census (PHC) preparatory frame obtained from the Central Statistics Organization (CSO). Stratification was achieved by separating each domain into urban and rural areas. Because of the low urban proportion for most of the provinces, the combined urban areas of each domain form a single sampling stratum, which is the urban stratum of the domain. On the other hand, the rural areas of each domain are further split into strata according to province; that is, the rural areas of each province form a sampling stratum. In total, 34 sampling strata have been created after excluding the rural areas of Hilmand, Kandahar, and Zabul from the domain of the south. Among the 34 sampling strata, 3 are urban strata, and the remaining 31 are rural strata, which correspond with the total number of provinces and their rural areas. Samples were selected independently in each sampling stratum by a twostage selection process. Implicit stratification and proportional allocation were achieved at each of the lower administrative levels within a sampling stratum, by sorting the sampling frame according to administrative units at different levels within each stratum, and by using a probability proportional to size selection at the first stage of sampling.
The primary sampling unit was the enumeration area (EA). After selection of the EA and before the main fieldwork, a household listing operation was carried out in the selected EAs to provide the most updated sampling frame for the selection of households in the second stage. The household listing operation consisted of (1) visiting each of the 751 selected EAs, (2) drawing a location map and a detailed sketch, and (3) recording on the household listing forms all structures found in the EA and all households residing in the structure with the address and the name of the household head. The resulting lists of households serve as the sampling frame for the selection of households at the second stage of sampling. In the second stage of sampling, a fixed number of 32 households was selected randomly in each selected cluster by an equal probability systematic sampling technique. The household selection procedure was carried out at the IIHMR office in Kabul prior to the start of fieldwork. An Excel spreadsheet prepared by ICF Macro to facilitate the household selection was used. A level of non response, or refusals on the part of households and individuals, had already been taken into consideration in the sample design and sample calculation.
The survey interviewers interviewed only pre-selected households, and no replacements of pre-selected households were made during the fieldwork, thus maintaining the representativeness of the final results from the survey for the country. Interviewers were also trained to optimize their effort to identify selected households and to ensure that individuals cooperated to minimize non-response. It is important to note here that interviewers in the AMS were not remunerated according to the number of questionnaires completed but given a daily per diem for the number of days they spent in the field; in addition, it is also important to note that respondents were neither compensated in any way for agreeing to be interviewed nor coerced into completing an interview.
For security reasons, the rural areas of Kandahar, Hilmand, and Zabul, which constitute less than 9 percent of the population, were excluded during sample design from the sample selection; however, the urban areas of these provinces were included. Of the 751 EAs that were included in the sample, 34 EAs (5 urban and 29 rural) were not surveyed. Six of the selected EAs in Ghazni, 16 in Paktika, 1 in Uruzgan, 3 in Kandahar, 3 in Daykundi, and 2 in Faryab were not surveyed because of the security situation. In addition, two EAs from Badakshan and one from Takhar were not surveyed because base maps from the CSO were unavailable. The non-surveyed EAs-which were primarily in rural areas-represent 4 percent of the total population of the country,
Table 1.1 - Sample coverage (Percentage of the population represented by the sample surveyed in the Afghanistan Mortality Survey, Afghanistan 2010)
Region / Urban / Rural / Total
North / 97 / 98 / 98
Central / 100 / 98 / 99
South / 94 / 63 / 66
Total / 98 / 84 / 87
Overall, approximately 13 percent of the country was not surveyed; most of these areas were in the South zone. As shown in Table 1.1, the survey covered only 66 percent of the population in the South zone. Sample weights were adjusted accordingly to take into account those EAs that were selected but not completed for security or other reasons.
Overall, the AMS 2010 covered 87 percent of the population of the country, 98 percent of the urban population and 84 percent of the rural population. Nevertheless, the lack of total coverage and the disproportionate exclusion of areas in the South, and particularly the rural South, should be taken into consideration when interpreting national level estimates of key demographic indicators and estimates for the South zone and regions within. For this reason key indicators will be presented for all Afghanistan and Afghanistan excluding the South zone. Despite these exclusions, the AMS is the most comprehensive mortality survey conducted in Afghanistan in the last few decades in terms of geographic coverage of the country.
Throughout this report, numbers in the tables reflect weighted numbers unless indicated otherwise. In most cases, percentages based on 25-49 cases are shown in parentheses and percentages based on fewer than 25 unweighted cases are suppressed and replaced with an asterisk, to caution readers when interpreting data that a percentage may not be statistically reliable. For child mortality rates, parentheses are used if based on 250-499 children exposed to the risk of mortality in any of the component rates, and suppressed if based on fewer than 250 children exposed to the risk of mortality in any of the component rates.
Gregorian calendar years are greater by approximately 621 years than the Afghan calendar years. However, the Afghan calendar years start in 1 Hammal which is approximately March 21 in the Gregorian calendar. Calculations in the tables are based on the Afghan calendar but in the report calendar years are presented in the Gregorian calendar with approximate reference to the Afghan calendar in parentheses.
For more detailed information, see Appendix A - SAMPLE IMPLEMENTATION of the Survey Report.
Deviations from sample design
This survey was completed in 87% of the country. However, the survey teams were unable to cover rural areas of Helmand, Kandahar and Zabul provinces for security reasons that account for 9% of the total population or one-third of the population of the south of Afghanistan. The insecurity compromised monitoring of field work especially in the South zone.
A total of 22,897 households were selected from the 717 completed clusters, of which 22,609 were found to be occupied during data collection. Of these occupied households, 22,351 were successfully interviewed, giving a household response rate of nearly 99 percent. In the selected households, 48,717 women were identified as eligible for the individual interview. Interviews were completed for 47,848 women, yielding an overall response rate of 98 percent. Response rates in urban areas (98 percent) were marginally lower than in rural areas (99 percent) for both households and eligible women. Response rates by zone and region are presented in Appendix Table A.1 of the survey report. The high response rates were due to several reasons: interviewers were instructed to make at least three callbacks, on different days and times, to complete an interview and minimize non-response; the vast majority of women were at home at the time of the survey; Afghans are hospitable people and were very welcoming of visitors into their homes. In addition, prior to the start of interviewing in a selected cluster, the village elder was contacted and the team leader explained the purpose of the survey and obtained his permission and cooperation to work in the cluster. In some instances, health workers from the selected clusters were called upon to assist with locating selected households. High household response rates were also recorded in the NRVA 2007/8 (91 percent), AHS 2006 (99 percent) and the MICS 2003 (99 percent). [Note: The AMS interviewed only pre-selected households with no replacements allowed. The NRVA 2007/8 recorded 91 percent response with households that were not found or that refused to be interviewed replaced from a pre-selected list of additional replacement households. It is unclear if a similar procedure was followed in the AHS 2006 or the MICS 2003.]
Dates of collection
Mode of data collection
Four questionnaires were administered in the AMS 2010: the Household Questionnaire, the Woman’s Questionnaire, the Verbal Autopsy (VA) Questionnaire and a Cluster Level Questionnaire. These questionnaires were based on the DHS model questionnaires and WHO VAs adapted to reflect the population and health issues relevant to Afghanistan. They were finalized at a series of meetings with MoPH and stakeholders from other government ministries and agencies, NGOs, and international donors. The survey questionnaires were then translated from English into the two main local languages—Pashto and Dari—and back translated into English by persons not involved in the original translation to ensure that nothing was lost in the translation before being pretested. Following the pretest, the questionnaires were revised to take into account lessons learnt during the pretest.
The Household Questionnaire was used to list all the usual members and visitors in the selected households and to identify women who were eligible for the individual interview. Some basic information was collected on the characteristics of each person listed, including age, sex, education, and relationship to the head of the household. The survival status of the parents was determined for all the listed members and visitors to the households. The Household Questionnaire also collected information on characteristics of the household’s dwelling unit, such as the source of water, type of toilet facilities, materials used for flooring, and ownership of various durable goods. Additionally, information pertaining to migration in the five years before the survey, household deaths for the same time frame, and health expenditures for inpatient and outpatient care were collected. [Data on health expenditures for inpatient and outpatient care was analyzed and reported in a separate document (MoPH GIRoA, 2011).]
The Woman’s Questionnaire was used to collect information from all women age 12-49, on their age, education, ethnicity, marital status, and sibling history (whether alive or dead). Ever-married women were also asked about their pregnancy history, the number of children they had in their lifetime, and the survival status of their children. Ever-married women who had given birth in the five years preceding the survey were also asked questions on maternal health care for their most recent birth. Currently married women were additionally asked about their knowledge and use of family planning methods. Each death that occurred in the selected households in the three years before the survey was followed up with one of three Verbal Autopsy Questionnaires, depending on the age at death: Form 1 for deaths to children 0-28 days; Form 2 for deaths to children 29 days-11 years; and Form 3 for deaths to adults age 12 years and above. An attempt was always made to interview the person(s) present at the time of death to ensure accurate information surrounding the circumstances that led to the death of the deceased.
The Cluster Level Questionnaire was used to gather information from the head of the village or some other knowledgeable informant, on access to basic amenities such as the presence of a cell phone signal, a paved road, a police station or post. In addition, information was collected on the largest medical facility, the highest level of school, and the frequency of public transport to and from the cluster. The questionnaire was also used to collect information on the availability of daily necessities, including petrol, vegetables, meats, bread, rice, and fuel for cooking.
The processing of the AMS 2010 data started on May 2, 2010. Completed questionnaires were returned periodically from the field to the IIHMR data processing center in Kabul, where they were entered and edited by 21 data processing personnel who were specially trained for this task. The data processing personnel included a supervisor, 5 office editors, and 15 data entry operators. There was 100 percent verification of data entry, that is, data for each questionnaire were entered twice by two separate data entry staff with a consistency check done to minimize data entry errors. Secondary editing was done following data entry to check for any errors or inconsistencies in the questionnaires. The concurrent processing of the data during fieldwork was an advantage because field check tables were generated early to monitor various data quality parameters. As a result, specific and ongoing feedback was given to the field teams to improve performance. Field check tables were run weekly and the results shared with MoPH, IIHMR and ICF Macro for review and follow-up action with teams in the field. The data entry and editing of the questionnaires was completed by January 15, 2011. ICF Macro provided technical support for data programming and processing.
See Appendix B - ESTIMATES OF SAMPLING ERRORS of the Survey Report.
Other forms of data appraisal
Wherever possible, results from the AMS 2010 are compared with results from a number of other surveys conducted in Afghanistan since 2003. Comparisons of the AMS 2010 data and data from other sources have to be interpreted with caution however, since the sample design, coverage and/or methodological approach to the estimation of key demographic and health indicators differ. A brief description of the four principal surveys to which AMS results will be most frequently compared follows to assist in placing comparisons within their proper context.
National Risk and Vulnerability Assessment (NRVA) 2007/8.
The NRVA was designed to provide representative data on key socioeconomic development indicators for Afghanistan, including 25 MDG indicators. The NRVA used the CSO pre-census household listing data to create a geographically ordered list of primary sampling units (PSUs), rural settlements and urban blocks with their estimated number of households from the 34 provinces and 11 urban centers (ICON-INSTITUTE, 2009). In addition, the NRVA 2007/8 sampled the Kuchi population or nomadic pastoralist population. The Kuchi population, considered one of the most vulnerable groups in the country, was not included in the CSO pre-census listing, which focused on the settled population; instead information from the National Multi-Sectoral Assessment for Kuchi (NMAK), which was conducted during the winter/spring of 2004 was used to determine the total size of the Kuchi population and to identify the summer locations from which the Kuchi population sample was drawn for the NRVA. Thus, national estimates of key indicators provided in the NRVA 2007/8 represent the situation among both settled and nomadic (Kuchi) populations. Fieldwork for the NRVA 2007/8 started in mid-August 2007 and ended in mid-August 2008, a period of 12 months. The survey sampled 2,441 PSUs and 20,576 households of which 19,528 households were from the settled urban and rural population and 131 PSUs comprising 1,048 households from the Kuchi population. The NRVA 2007/8 administered a 20-section Household Questionnaire with 14 sections administered by a male interviewer to the male head of the household and 6 sections by a female interviewer (in most parts of the country) to a female respondent. Two community-level questionnaires were also administered: one male and one female Shura questionnaire. With respect to comparisons between the NVRA and AMS 2010 results, the major difference lies in the fact that the AMS 2010 did not separately sample the nomadic Kuchi population while the NVRA included an explicit Kuchi population domain. The implications of this on the overall comparability between the NRVA 2007/8 and the AMS 2010 is not clear as the updated sampling frame used in the AMS 2010 may have included a proportion of the Kuchi population which had since become a part of the settled population. To the extent that the Kuchi population may be underrepresented in the AMS 2010, there may be a positive bias in the AMS indicators although the bias is not likely to be large.
Afghanistan Health Survey (AHS) 2006.
The AHS 2006 is a population-based rural survey designed to provide information on maternal and child health, child survival, family planning, health care utilization and related expenditures in Afghanistan. Sampling and selection in the AHS 2006 differed considerably from the AMS 2010 (JHBSPH and IIHMR, 2008) A key difference is the fact that the AHS 2006 entirely excluded the six largest cities (Kabul, Hirat, Mazar-e-Sharif, Kunduz, Jalalabad and Kandahar) from its sample design. The AHS also excluded 5 of the 34 provinces in the country. The precensus household listing conducted by the CSO between 2003 and 2005 that was used in the AHS 2006 also was not completed in all areas. The areas that were not covered included 17 districts mainly in Kandahar, Zabul and Hilmand, with one district missing from Ghazni and Hilmand. In addition, in one district in Daykundi, 26 villages were not enumerated (JHUBSPH and IIHMR, 2008). Finally, fieldwork was completed in only 397 clusters out of the 425 clusters selected for the AHS 2006; the remaining 28 clusters were not completed due to security reasons. The final sample included 8,278 households, with interviews of all ever-married women age 10-49, as well as interviews of primary caretakers of children 0-59 months. Data collection spanned three months from mid-September 2006 to mid-December 2006. Because of the exclusion of major urban areas from the AHS, comparisons of the AMS 2010 data to the AHS 2006 data are limited to rural areas. The results from the AHS 2006 are representative of 72 percent of the rural population of the country. In comparison, the AMS 2010 covered 84 percent of the rural population.
Multiple Indicator Cluster Survey (MICS) 2003.
The MICS 2003 is the first survey to be conducted in the country since decades of conflict and provides baseline data on key demographic and health indicators (CSO and UNICEF, 2004). The sampling frame for the 2003 MICS was derived from two sources: the 1979 Population Census conducted by CSO; and the National Immunization Day (NID) coverage data from the MoPH for Nuristan and the major cities due to the lack of a detailed breakdown of the population. The survey covered all 32 provinces in existence at that time in the country, and provides estimates of key indicators at the national, urban, rural and provincial levels. The Kuchi population is not covered in the sample as well as 10 percent of villages throughout the country for which census documents were missing. The survey sampled 765 PSUs, selected 21,038 households, and completed 20,806 households. Nevertheless, for various reasons, key findings from the MICS 2003 were considered flawed. A reanalysis of the data was carried out by CSO and UNICEF and modeled estimates of key indicators from the adjusted MICS 2003 data as well as from the 1997 and 2000 MICS5 were published in the Best Estimates of Social Indicators for Children 1990-2005 (UNICEF, 2006).
Reproductive Age Mortality Survey (RAMOS) in Four Districts (2002).
Bartlett and others carried out a study of women age 15–49 years who died between March 21, 1999, and March 21, 2002, in sampled villages in four selected districts in four provinces in Afghanistan (Bartlett et al., 2005). These districts were: Kabul city, Kabul province; Alisheng district, Laghman province; Maywand district, Kandahar province; and Ragh district, Badakshan province, with the selected sample representing less than 4 percent of the population of the country at that time. The districts were not selected randomly but were purposively selected to serve as proxies for urban, semirural, rural and very rural parts of the country, respectively. All 13,848 households in randomly selected villages in these four districts were surveyed and 294 deaths among women of reproductive age were investigated through verbal autopsy interviews of family members. Based on their findings of maternal deaths in these districts, the authors extrapolated the data to provide a national estimate of maternal mortality for the country.
Afghan Public Health Institute, Ministry of Public Health (APHI/MoPH) [Afghanistan], Central Statistics Organization (CSO) [Afghanistan], ICF Macro, Indian Institute of Health Management Research (IIHMR) [India], and World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO) [Egypt]. 2011. Afghanistan Mortality Survey 2010. Calverton, Maryland, USA: APHI/MoPH, CSO, ICF Macro, IIHMR and WHO/EMRO.
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The user of the data acknowledges that the original collector of the data, the authorized distributor of the data, and the relevant funding agency bear no responsibility for use of the data or for interpretations or inferences based upon such uses.