Dying to Give Life: Maternal Mortality in Afghanistan

“One day, not so long ago, a woman showed up at the clinic showing signs of a complicated late-stage pregnancy. I asked her husband to let her come to the hospital for 10 days to deliver safely and get support, or she would die. The man told me that he did not have money for 10 days accommodation and he left the hospital with his wife. After 12 days the man transferred his wife to the hospital in a very serious condition. He had sought support of a local clinic, but there were no quality services and experts to manage this serious complication. Then the lady was transferred by shoulder to the hospital of Faizabad after more than one day of walking. At the same time the lady had serious bleeding. When she reached the hospital, she was in terminal shock. We tried to rescue her, her husband bought two pints of blood for 20000 Afs ($408). He had to sell his only land to raise this money. The woman died the next day and her baby died the day after that.”

—Dr. Hajira, a gynaecological surgeon in Faizabad

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BADAKHSHAN, Afghanistan — It juts like a finger, thrusting through the freezing and windswept Pamir Mountains: jabbing through the broad plateau of Tajikistan to the north and Pakistan to the south. From there it points inexorably east to China. In Badakhshan even the border seems to be admonishing the world for a tragedy that unfolds hourly in one of the most remote and backward provinces of one of the most troubled and impoverished places on earth: the conflict-prone country of Afghanistan.

Once part of the ancient Greek kingdom of Bactria and renowned in antiquity for the quality of its gemstones, Badakhshan has now earned the dubious distinction of being home to the highest maternal mortality rate in the world. For women struggling to bring new life into this austere and merciless land, Badakhshan’s harsh landscape and lack of infrastructure too often spells disaster for both mother and child. Few trucks, cars or other means of transportation, coupled with even fewer roads, results in delays that can easily lead to life-long disability or death. In winter, snow blocks the narrow paths that link mountain villages with main thoroughfares—often for as many as seven months at a stretch.

In Badakhshan, for every 100,000 babies born, 6,500 women will lose their lives: a crisis that healthcare workers maintain has as much to do with the low social and nutritional status of its victims as it does with the remote and rugged terrain. Of the thousands of infants left motherless, fully 75 per cent will also perish either during, or soon after, their mothers give birth. In Afghanistan as whole, a woman dies of pregnancy-related causes every 27 minutes of every day. In Badakhshan, a woman faces almost 600 times the risk of dying in childbirth than do her counterparts living in North America.

“It is terrible,” says Dr. Ibrahim Shinwari, a programme director for UNFPA, the United Nations Population Fund, in Afghanistan. “There are no roads. There is no helicopter. There is no transportation. These people really, really suffer”.

Apart from its vertiginous cliffs, poor roads and extreme weather, one of the most significant reasons behind the persistently high death rates is gender discrimination. In Afghanistan, men are considered superior to women, and sons are generally more prized than girls. In practical terms, this ‘son preference’ translates into high rates of female illiteracy, malnutrition and early marriage. Indeed, women are seen as little more than commodities who are often bought, sold or are given away to rival families or clans as a means of resolving conflicts. The strong conservative patriarchy of Afghanistan is deeply rooted in the history and culture and is justified through local interpretation of Islamic teachings. Because families are so poor, parents are more likely to pool scarce resources to send their boys to school and to ensure that they remain healthy. Girl children invariably do without. Indeed, so entrenched is the bias against girls and women, that Afghanistan is the one of only two countries where male life expectancy exceeds that of females.

One of the more pernicious aspects discrimination, however, lies in the widespread practice of child marriage. According to Shinwari, more than 40 per cent of Badakshani women are married before the age of 15 and often long before their immature bodies can cope with both the demands of sex and the rigours of childbirth. In Afghanistan overall, 40 per cent of girls are married before they reach the age of 18. In more outlying areas, poverty, lack of awareness and the need to “protect” young girls from premarital pregnancy, encourages many parents to marry their daughters off even younger—in some cases when they are no more than seven–years old. Many of the women and girls that eventually make it into Dr Shinwari’s clinic have been stunted by years of semi-starvation. This, coupled with poor infrastructure and the pressure to begin child bearing early, can be recipe for disaster.

Although maternal haemorrhage is the leading cause of maternal death in Afghanistan, in Badakhshan prolonged and obstructed labour accounts for most (30 per cent) maternal deaths. In the absence of emergency obstetric care, this can also lead to disabling and stigmatizing conditions such as obstetric fistula. Girls under the age of 15 are five times more likely to die in childbirth than women in their twenties.

Other factors include: limited access to what few health facilities are available, lack of skilled personnel, poverty, malnutrition, the low social status of women and girls and high illiteracy rates. A recent UNICEF survey revealed that of the mothers interviewed, only 3.3 per cent had given birth in a health facility. Lack of access to modern methods of family planning means many women are unable to choose when and how many children to have. Repeated pregnancies and deliveries can result in ‘maternal depletion’, which, in turn, increases the risk of complications. According to UNICEF, among married women, fully 97.6 per cent surveyed were not using any sort of contraceptive whatsoever, while 78 per cent had never even heard of family planning. Afghanistan has one of the highest fertility rates in the world with an average birth rate of 6.75 children per woman.

Since 2003, the UNFPA has been working in Badakshan to raise awareness, train health care personnel in emergency obstetric care and educating local leaders, women and their families of the necessity of family planning and adequate pre- and antenatal care. In tandem with the Ministry of Women’s Affairs, the organization has also launched a campaign, alerting both religious leaders and the public to the dangers posed by the practice. Child marriage was the focus of both Safe Motherhood and World Population Day. The UNFPA has also recently convened a conference that brought together mullahs from all over the country in an effort to persuade them to speak out against a practice that leads to the deaths of so many women each year.

In addition to supporting four regional health clinics and one hospital, UNFPA is also providing vocational training to local women in recognition of the link between economic independence and social and reproductive wellbeing. So far, local authorities have been “very co-operative” notes Shinwari, and women “eager” to learn.

Nevertheless, like the drifts that block all movement for more than half the year, obstacles are many. “Women are so dependent on men, and families are giving far more attention to their sons instead of their daughters,” says Shinwari. “Until girls are educated, fed properly and women are able to participate in social and economic life, high maternal mortality will remain a problem for many, many years.”

Contact Information:

Patricia Leidl, tel. +212-297-5088, leidl@unfpa.org