Every 29 minutes
Last year, 1500 civilians were killed as a result of fighting between pro-government and anti-government elements in Afghanistan, the highest number since 2001. But there is another reason why Afghanistan is an unsafe country, a problem that takes some 24,000 civilian lives a year. Their deaths are less newsy; they make no banner headlines, lead to no talk shows, and generate little shock. These 24,000 were young Afghan mothers, all of whom died as a result of pregnancy and childbirth.
The maternal-mortality ratio in Afghanistan is around 1600 per 100,000 live births. In the remoter parts of the country it is several times this figure, reaching 6500 in the largely inaccessible northeastern province of Badakshan. Despite concerted attempts, and granted same success in certain areas, the underlying causes of the high maternal-mortality ratio (MMR) have not shown much change over the last seven years, since the fall of the Taliban and the influx of international aid. Afghanistan has the second-highest MMR in the world and the highest in the Asia-Pacific region. Further, the figure of 1600 is actually the lower estimate in a range of 1600-2200 – the upper estimate of which surpasses that of Sierra Leone, with an MMR of 2000 per 100,000 live births, officially the highest in the world.
In Afghanistan today, a woman giving birth is estimated to die every 29 minutes. According to the Kabul government, this extremely high MMR is due to a "tragic combination of poverty, conflict and cultural tradition". Each factor exacerbates the impact of the other, and the overall ratio is slow to change. Explaining the individual causes, Dr Malalai Ahmadzai, a specialist in maternal health with UNICEF in the country, says the barriers are extremely straightforward: the non-recognition of a medical problem due to lack of awareness, the insufficient training of birth attendants, or the complete absence of health facilities. "People here see birth as a natural phenomenon, a private matter," she says. "And so it complicates the decision of when to call for medical help."
Gender dynamics play a tragic role. Even where a problem may be recognised by the pregnant woman or other female members of the family, the decision to seek medical help rests with the male head of the household. That individual, meanwhile, may or may not recognise or accept the gravity of the situation. Furthermore, even when the condition is recognised and medical help is sought, there may simply be no medical help to access, either due to the remoteness, the difficulty of travel or the expense involved. "There are great disparities in health care because of the geography of our country," says Dr Ahmadzai. The absence of roads in much of rural Afghanistan can mean a journey lasting hours if not days, with some areas completely cut off during the winter. "Even after reaching the facility, the required medical care may not be available, even when the family can afford to pay."
Barren Wakhan
The health of the mother and infant can remain unaddressed even if a family reaches a functioning health post. If the only available help is a male doctor or nurse, a woman patient will most likely not be able to approach him. Indeed, cultural and social factors significantly add to the vulnerability of women in Afghanistan. Another factor is that most girls are married very young, and have children soon after marriage. An estimated 50 percent of girls below the age of 15 are already married, and some of them are as young as eight years old, according to the UN Fund for Population Activities. Social custom sets an excessively high value on childbearing, with the average number of children borne by an Afghan woman being 7.2 compared with 1.2 in Iran and 3.4 in Pakistan.
The young age of childbearing, coupled with quick successive pregnancies, inevitably make women in Afghanistan more vulnerable to maternal mortality. This risk is only heightened by poor levels of nutrition, especially in the more isolated rural areas with subsistence agriculture. This is starkly evident in the fields of Wakhan, in the northeastern corner of Afghanistan. Much of the food here, including vegetables and fruit, is transported by road and therefore difficult to access because of scarcity and high costs. The barren rocky landscape, located at the junction of the Pamir, Karakoram and Hindukush ranges, is inaccessible by road for five months of the year.
With the land remaining icy and snowbound for many months of the year, nutrition levels in Wakhan are very poor. Dr Abdul Momin Jalaly, Director of Public Health for the province of Badakshan, within which Wakhan lies, says the entire province suffers from malnutrition. "In the Wakhan-Pamir area, there is no fruit and it is impossible to grow vegetables. The difficulty of reaching the area means that produce from other markets also cannot reach there. Most women here suffer from anaemia and vitamin deficiency due to bad nutrition." The inaccessibility also means that trained health professionals are unwilling to be based there. "There are no roads in 12 districts of the province," says Jalaly. "People use donkeys and horses to travel, and there is no communication with this area from the end of autumn to the beginning of spring. Tangshao village in Darwaz, for example, can be reached only after 72 hours of walking." Little wonder that trained medical practitioners tend to forego the opportunity to work here.
Afghanistan has a severe shortage of trained, educated and skilled women in the health sector. Low literacy rates among girls have meant an absence of skilled female doctors and nurses; those with the means of obtaining an education are likely to be from urban centres, and unwilling to work in the remote areas. Meanwhile, qualified senior professionals have long since emigrated. In a 2005 report, Afghanistan was estimated to have just a single doctor per 10,000 people, compared to the average of 10.1 for all developing countries. New skilled professionals are difficult to find, since conservative mores have traditionally excluded girls from schooling, especially beyond the primary level. This practice has now been strengthened by the years of conflict and lack of security. In addition, the absence of educated women works as a vicious cycle. With not enough women teachers, there are fewer schools for girls, and even fewer at the secondary level. Parents prefer to have their girls stay at home as they reach puberty, and the long distances to school is a problem. The easier option is to keep the girls 'safe' by marrying them off.
Trivial 'ifs'
Since 2006, the Badakshan provincial government has been running a community midwifery school, run by the Aga Khan Health Services (AKHS), aimed specifically at training girls. But even for this community school, it has been difficult to find girls from the more remote districts. While most girls do not even complete primary school, applicants must have passed Class 9 in order to join the training.
In the village of Kipkut, halfway up the Wakhan Corridor, Christel Bosman, a doctor from Holland, has been working to train community health workers in basic gynaecology. In her small room in the village, she explains why she lives in this remote outpost. She had studied tropical medicine to become broad-based in her knowledge, and had worked with Afghan refugees in the Netherlands. That was her link to Afghanistan and Wakhan. Here, her primary focus is on bringing down the MMR, which she ascribes to some very basic factors. "High blood pressure, complications during childbirth and obstructed labour resulting in haemorrhage and blood loss are the main causes," she says. "In the Netherlands, it would mean a simple blood transfusion. Here, where can I get the blood?"
This particular day is a difficult one. Bosman has just learned of the death of one of her patients, Sahib Daulat, who died soon after childbirth. In this case, as in so many others, the family had delayed calling the doctor. By the time Bosman got to see her, Sahib Daulat had lost too much blood. "If they had only called me earlier, or if I only had access to a blood bank, I could have saved her," she says.
The difference between life and death is often a series of seemingly trivial 'ifs' for the young mothers of Afghanistan. As with Sahib Daulat, haemorrhage is the most common cause of death, at 38 percent, followed by obstructed labour at 26 percent. Afghan women have a 1-in-8 risk of maternal death, compared to the average risk of 1-in-59 for Southasian women. Following the only qualitative study of MMR (by UNICEF and the US Centers for Disease Control, in 2002), the lifetime risk of death from pregnancy and childbirth-related causes for Afghan mothers was estimated to be in the range of 1 in 6 to 1 in 9. The study also found that women of reproductive age were more likely to die from maternal causes than due to any other medical reason. Perhaps most importantly, 78 percent of the cases studied were estimated to have been preventable. According to the study, deaths could be averted if complications are prevented through improving the general health status, and if complications that occur are treated to reduce their severity. These efforts require a multisectoral approach to increase availability and accessibility of health care, states the study.
This emphasis on 'multisectoral responses' is important. "Health in Badakshan province is not just a small job for health providers," says Dr Jalaly. "If we do not have the support of other sectors, we cannot provide coverage. Road links, investment in agricultural and poverty reduction policies are all needed." Although the Kabul government claims to have provided health services that cover some 85 percent of the population, "the physical access to functional facilities is far more limited," the UNFPA's country director, Dr Ramesh Penumaka, said in a press conference earlier this year. According to the agency, only 18 percent of deliveries last year were attended by skilled birth attendants. Even this constitutes an important increase, however. Likewise, a modest increase has also been seen in the attention given to pregnant women during pregnancy by health professionals, which increased from an estimated four percent in 2001 to 30 percent in 2007.
Bamiyan kabilas
One of the projects that have significantly assisted in this increase is located in Bamiyan, in the centre of the country, the small town put on the international map by the destruction of its giant Buddhas by the Taliban in 2001. Here, Fatima Alizada, just out of her teens, has been attending midwifery classes for the past six months, after having completed her schooling. She is a student at one of the 19 midwifery schools set up by the Aga Khan Foundation. For Alizada, her education is not a textbook course, learned in the sanitised surroundings of a classroom. A year and a half ago, she was witness to the death of her neighbour, Hawagul, a young mother who had been unable to receive medical help during labour. She was 35 when she died. Though a traditional birth attendant was called in when Hawagul was in acute labour, the attendant did not have the skills necessary to treat the problem.
Supportive traditional practices, skills and knowledge may have been lost over decades of war, as populations were repeatedly displaced, disrupting the social networks as well as access to traditional materials and techniques. As yet, says Dr Ahmadzai, there has been no study of the traditional healing practices during pregnancy and childbirth that are practiced in different parts of Afghanistan. In some areas, however, traditional practices can be deathly. In the Wakhan area, for example, local superstition prevents a mother from breastfeeding her child for the first few days after birth, on the grounds that the milk is considered impure. Dr Alex Duncan, a British doctor who has worked in Wakhan for several years, says this belief persists despite attempts to explain that the first few days of life are the most important for an infant, in order that it can acquire a natural immunisation through breast milk. On the whole, says Dr Ahmadzai, "We have seen that the traditional birth attendants have not been able to reduce the maternal mortality, and this is where skilled midwives become necessary."
Alizada has a long, hard slog ahead of her before she can become a kabila, a midwife. Having completed six months of her training, she has another year to go before she graduates. But she has no doubts as to why she is here: "I would like to help people of this area," she says with conviction, "to help the mother and child." By rights, Alizada should not be here at the Bamiyan midwifery school; the school only takes students from Bamiyan, while she is from Dai Kundi province, to the southwest. However, Dai Kundi's acute poverty and inaccessibility, even more severe than that of Bamiyan, led the school administrators to make an exception for applicants from the province. According to the charitable organisation Oxfam, the people of Dai Kundi may be facing their worst overall conditions in two decades, as well as a potential humanitarian crisis due to food insecurity. The midwifery school also relaxed its stipulation that students needed to have completed Class 9, since in many of the remoter districts they could not find girls who had studied that far. "They do have to be literate, however, since they will need to study from books," says Farzana Dost, trainer and the deputy manager of the school.
To overcome social and cultural barriers, the selection of students involves the families as well as local community leaders and shuras (informal decision-making groups of elders), as well as the mayor from the local area. Dost says that it is only with the consent of each of these that the girls are allowed to take part in the training. This automatically overcomes one of the major barriers faced by most women – bedune mehram, or the lack of permission to leave their homes without the escort of a male member of the immediate family. Such an arrangement also ensures that the girls will be accepted back, and allowed to work as community midwives when they return to their villages. It is not just young girls who attend the school, however. The age of students range between 18 to 35, and ten of the current students are mothers themselves, for whom a crèche has been provided to assist them.
To make sure their students do return to help their communities, rather than leaving for more lucrative jobs in more attractive parts of the country, the certification is dependent upon the student's return to her own village or district. During the first two years of schooling, there was also a small stipend given to encourage girls to enrol. Happily, in the current third batch, this was not needed due to the large number of applicants – about 100 girls, of whom 25 were selected. Alizada herself was inspired to join by the examples of four girls of her area, who had attended the previous batch. Like the other students, Alizada lives in a hostel on the school grounds. When she finishes, Alizada will return to Dai Kundi's local basic health clinic as a trained midwife.
A man's issue
The impact of the Bamiyan school is already being felt. Most of the cases of complicated pregnancy that come to the province's only secondary-care hospital are now referred by the trained midwives who have graduated from the school, says the hospital's head doctor, Ghulam Mohammad Nadir. He also hopes that, over time, the presence of midwives will lessen the need for secondary health care entirely. Simple matters such as hygiene, the need for sterilisation during delivery and even nutrition can be communicated and observed in the home, without extra effort or expense. At the moment, Dr Nadir says, most families simply do not know what is required in a healthy diet. Many families own cattle and poultry for instance, but utilising the protein from milk and eggs, is not part of Afghan tradition. It is not just access to health care that decreases with remoteness, but also availability of knowledge.
Knowledge about birth spacing is another aspect that would reduce the number of pregnancies and improve the chances of survival for women of reproductive age. Again, however, cultural mores as well as religious conservatism make this one of the most challenging aspects. Two months ago, a woman health worker in Kandahar, in the southwest, was shot dead after the Taliban labelled her work in family planning and birth control as 'un-Islamic'. And, with increasing insecurity in many parts of the country, those involved in education and health services have come under renewed threat. In November, Minister of Health Mohammed Amin Fatemi drew attention to the decreasing availability of health-care professionals, warning that this trend could lead to worsening public health, and a spurt in disease spread. According to the Ministry of Public Health, at least 51 health centres were torched or damaged in armed attacks during the 18 months leading up to June 2008.
The increasing violence has also forced schools to shut down in many districts. According to the Ministry of Education, over 600 schools in 45 districts are now closed, affecting at least 300,000 children. These schools account for 80 percent of the academic institutions in the four provinces of Helmand, Kandahar, Zabul and Uruzgan, all in southern Afghanistan. The first casualty in the education system is inevitably girls' schools; in Helmand, where there are currently 54 schools in operation (compared with 223 in 2002), almost all are boys' schools. The long-term impact of this will, naturally, mean fewer educated girls and, incidentally, fewer women health professionals.
In the meantime, there has been no study since 2002 on maternal mortality, though one is currently slated for 2009-10. Either way, however, many suggest that the conception of maternal health as a problem in Afghanistan is still too limited. The issue of maternal health is not a 'women's issue', says UNFPA's Dr Penumaka. "The key to better maternal health lies with men. They have to be sensitive and aware of the health requirement and the needs of women. Maternal health is not really a woman's issue – it's really a man's issue." As such, meeting the challenge of reducing maternal mortality will require education, communication and changes in cultural practices. Due to cultural factors, there is very little communication about reproductive health and sexual behaviour within the family. In Afghanistan, the UN-developed Millennium Development Goal on MMR is to reduce the ratio by 50 percent between 2002 and 2015, well below the global target of reducing MMR by 75 percent in the same period. Yet the possibility of meeting even this target is judged to be merely a 'potential' rather than a probability.
The increasing number of skilled attendants at birth, the increasing recourse to health facilities, better vaccination and growing awareness collectively point to the hope that the ratio will eventually show a decline, says Dr Ahmadzai. But UNFPA cautions that several more decades will be needed before any major impact will be seen on maternal mortality in Afghanistan. In the meantime, with continuing conflict and decreasing services in the vulnerable areas, there are fears that even the small gains of the past seven years may soon be eroded. Yet this aspect of the 'collateral damage' of an ongoing conflict goes un-remarked upon, save for in the footnotes of public attention, tucked away in academic journals or sporadic reporting by the media.