Lifetime risk of maternal death in Afghanistan is the highest in the world: on average, one in six Afghan women die during pregnancy. Only war-ravaged Sierra Leone in Africa has rates that high. With one death for every 31 pregnancies, Pakistan is also one of the most dangerous places for expectant mothers.
Even some developed countries have relatively high rates of maternal death: One expectant American mother in 2,500 dies, compared to one per 29,000 in Sweden. Price Of Brain Drain
There is a link between the high maternal mortality rates in developing countries and the so-called "brain drain" -- the exodus of highly trained professionals from poor to rich countries in search of better opportunities.
The problem is particularly disheartening given the flood of health-care professionals, nurses and doctors, streaming out of these countries. In New York City alone, there are 600 licensed Ghanaian physicians. In all of Ghana, a relatively developed African country, there are only 2,500.
"One out of six women is destined to die in childbirth in Afghanistan today. That's an incredibly high number out of comparison: one out of six in Afghanistan, one out of 2,500 in the United States, one out of 29,000 in Sweden." -- Coleman
Geeta Rao Gupta, the president of the U.S.-based International Center for Research on Women, says that poor countries need only about $45 per person invested annually in basic health services to improve matters.
This is primarily a human rights issue, she said, that should be tackled first by governments, and then charities.
"It's governments' responsibility but certainly a foundation like the [Bill and Melinda] Gates Foundation could help enormously to make it happen, to get the momentum going in a country, to prove the point to a government that it can be addressed and here's how," Gupta says. "There are ways in which private money can be used to make that happen."
Because of the health-care brain drain, the money and effort poor countries spend on training doctors and nurses is being largely wasted, Gupta says. Countries like Ghana are being deprived of critical services they need to help lower high maternal-mortality rates. Iran's Success In Family Planning
Isobel Coleman, the director of Foreign Policy and Women Program at the Council on Foreign Relations, says Iran is an unusual model of maternal health.
"Iran is an interesting country because it has had one of the most successful family-planning programs in the history of the world," she says. "After the Islamic revolution in 1979, the new government in the early 1980s really went on a campaign of encouraging women to have babies -- this was during the Iran-Iraq War, when the country was suffering many casualties and many deaths of young men, and it was deemed a patriotic duty of women to reproduce and have many children and the population really went through the roof. And it was already high to begin with."
Coleman says that after the end of the war Iran's leaders realized that the enormous population boom could cause serious demographic problems. So in the mid-1990s they reversed course and embarked on an aggressive family-planning program.
Iran, Coleman says, is a startling example of how, through effective family planning and supportive government policies, the maternal death rate can be drastically reduced.
"In less than a decade it [the birthrate] went from one of the highest in the world to almost near a replacement level -- it's down around to 2.1 to 2.2 children per woman on average," Coleman says. "And as part of that it really was a very broad, wide, and effective community-based family-planning program that addressed maternal mortality and the maternal-mortality ratio within that country, but more broadly maternal health and access to family planning and contraceptives."
Today, Iran has a maternal-death rate of one in 370 births, which is high compared to developed Western countries, but much lower than its neighbors, Afghanistan and Pakistan. Lack Of Any Health-Care System
The situation in Afghanistan, however, Coleman says, is particularly grim due the lack of a comprehensive health system and very conservative cultural sensibilities.
"One out of six women is destined to die in childbirth in Afghanistan today," she notes. "That's an incredibly high number out of comparison: one out of six in Afghanistan, one out of 2,500 in the United States, one out of 29,000 in Sweden. So you really see the range in the world there. In Afghanistan, the issue is across all sectors of society, it's [a] lack of any type of health system to speak of. Outside of urban areas, women have very little access to any type of efficient health system."
The Afghan government, Coleman says, is well aware of the monumental challenges it is facing, not only with the maternal-mortality rate but with women's issues in general. At the same time, there is little that President Hamid Karzai's government can do in the short term to improve the situation.
"There are very few trained midwives and doctors in the country and the government is taking action to try to address that, but it's very expensive," she says. "And training of midwives, and improving girls' literacy, all of these things are what it is going to be required to address the frankly medieval maternal-mortality statistics in Afghanistan today."
Coleman says that problems with maternal mortality in Afghanistan are compounded by cultural values, such as poor treatment of women.
As a result, she says, women are not only deprived of the basic health care but are often malnourished during pregnancy and do not have access to obstetricians and medicines when emergencies occur.
In some parts of Afghanistan, she says, religious stigma toward gender separation is so deeply ingrained that a husband would rather let his wife die in childbirth than allow a male physician to treat her.