Afghanistan suffers from one of the highest rates of maternal mortality in the world. Almost 50 Afghan women die every day from complications related to childbirth. The causes range from a lack of family planning and emergency obstetric services to the social and economic barriers women face in accessing proper health care. A new study released yesterday in Kabul highlights what the United Nations calls the country's "ongoing humanitarian tragedy" of maternal mortality.
Kabul, 8 November 2002 (RFE/RL) -- A new study has confirmed scientifically what was already known anecdotally: Afghan women are dying in record numbers while giving birth.
An average of 1,600 women die in Afghanistan for every 100,000 live births -- a figure that suggests Afghanistan may be the worst place in the world for a woman to become pregnant. Afghanistan's maternal-mortality rate is twice as bad as the African country of Niger, 12 times worse than neighboring Iran, and 130 times higher than the United States.
The startling numbers are contained in a major report released yesterday in Kabul by the United Nations Children's Fund (UNICEF), the U.S. Centers for Disease Control and Prevention (CDC), and the Afghan Ministry of Public Health. It is the largest such study ever conducted in Afghanistan.
The conclusions of the new survey were so grim that Feroozuddin Ferooz, Afghanistan's deputy minister of public health, began a presentation of the report's findings at the Ministry of Public Health by calling for a moment of silence. "Our presence here is a sign of our commitment to improve the health status of mothers and to reduce the maternal mortality and morbidity in Afghanistan. Therefore, to mourn the deaths and suffering of our sisters and mothers in this beleaguered nation, I would like to start with a moment of silence," Ferooz said.
Earlier this year, from March through July, teams of health workers conducted what are called "verbal autopsies" -- interviewing surviving family members about a mother's death. The teams visited 13,000 households across Afghanistan, where they collected information on an estimated 85,000 women. The teams visited four provinces -- Kabul and Laghman in the east, Kandahar in the south, and Badakshan in the northeast -- sometimes resorting to horseback to interview families in difficult-to-reach areas.
They discovered that almost half of all deaths among women aged 15 to 49 that had occurred in these provinces from 1999 to 2002 came as a result of complications from pregnancy and childbirth.
Most women in Afghanistan deliver at home, often without a midwife. The study found that most deaths resulted from hemorrhaging or obstructed labor, and that almost 90 percent were preventable if the women had access to proper prenatal education, simple screening procedures for treatable complications, the opportunity for operative deliveries, or skilled birth attendants.
Tajwar Kakar, the deputy minister of women's affairs, also highlighted the role in maternal mortality of something as simple as proper nutrition. Many Afghan women survive on diets that consist mostly of bread and tea. "One of the important things that leads to maternal mortality is vitamin deficiency. Our mothers were deprived of having nutritious food and good health due to the past fighting, and so their body vitamin resources decreased. And these factors led them not to give birth to healthy children," Kakar said.
Not surprisingly, the study found that a mother was more likely to die during childbirth the farther she lived from health-care facilities. But UNICEF officials say even they were not prepared for the shocking conditions mothers face in the remote province of Badakshan. Dr. Suraya Dalil is project officer for UNICEF's Safe Motherhood program in Kabul. "The maternal mortality ratio increased with the increasing remoteness of the study population. This ratio in Kabul is 400 [deaths per 100,000 live births]. In Laghman, it is 800. In Kandahar, it is 2,200. And in Badakshan, it is alarming. It's 6,500 [deaths per 100,000 live births], the highest maternal-mortality ratio ever documented in the world," Dalil said.
The UNICEF report tells the story of Torab, who lived with his wife and four daughters in a village in Badakshan. His wife and fifth child died during labor because the baby was lying in the womb sideways. There was no way for Torab's wife to reach the nearest city, which was four days away by horseback. "Another problem is lack of clinics and hospitals in the remote areas of Afghanistan and in the villages, because the people cannot take their female patients to the centers due to lack of transportation," Kakar said.
Peter Huff-Rousselle is chief of operations for the United Nations Population Fund in Afghanistan. In an interview with RFE/RL, he said the value of the new UNICEF study is that it finally provides hard data so that the Afghan government, aid agencies, and nongovernmental organizations can begin to tackle the problem of maternal mortality head-on. "At the community level, it's totally obvious what a devastating effect all of this has had on families throughout the whole country. What we lack in this area, as with almost every other development area in Afghanistan, are hard facts and numbers to quantify the problem and to use as a solid basis for planning and prioritizing responses," Huff-Rousselle said.
Huff-Rousselle also noted that improving the rate of maternal mortality is not only linked to better medicine and education. He said the problem is also a human rights issue in Afghanistan.
The problem of maternal mortality in Afghanistan is complicated by the country's conservative Islamic traditions and an acute shortage of doctors, especially female doctors. In many parts of the country, especially in the south, social customs dictate that women cannot leave their homes without being accompanied by male family members, and pregnant women cannot be treated by male doctors. Many women are also forced to use midwives with little, if any, training. "At least as important are the social barriers, which becomes really a human rights issue within the context of the family and the community themselves, where women, particularly in recent years, have been systematically denied by their own families and communities access to health services. It's really considered inappropriate in many areas and in many families for a woman to seek outside care, particularly if there isn't a female service provider available," Huff-Rousselle said.
UNICEF and the CDC stressed that maternal mortality is not just a "woman's problem." The new study found that when the mother of a newborn infant dies, the child itself has only a 25 percent chance of surviving until its first birthday.
UNICEF Executive Director Carol Bellamy calls maternal mortality "arguably the most neglected health problem in the world," since the ramifications of a mother's death affect children, fathers, families, and entire communities.
UNICEF is working with the Afghan Ministry of Public Health to establish "centers of excellence" in emergency obstetrics care across the country. The first, at Kabul's Malalai Maternity Hospital, has already begun training staff. Plans are under way to set up similar centers in Kandahar, Herat, and Jalalabad.
Afghanistan's minister of public health, Sohaila Siddiqi, is also leading a delegation of senior ministers to Iran as part of the country's efforts to strengthen its reproductive-health programs. They are studying the approaches that Tehran has successfully used to combat many of the same problems now being faced by Afghanistan while working within similar conservative cultural restraints.