Afghanistan is among worst places on globe for women's health, say UNICEF and CDC

Joint Press Release
NEW YORK / KABUL, 6 November 2002

• Surveys conducted by UNICEF and the U.S. Centers for Disease Control and Prevention (CDC) in four parts of Afghanistan have found that Afghan women suffer from one of the highest levels of maternal mortality in the world, with almost half of all deaths among women aged 15 to 49 coming as a result of pregnancy and childbirth.

UNICEF Executive Director Carol Bellamy said the surveys - the largest of their kind ever conducted in Afghanistan - reveal an "ongoing humanitarian tragedy for Afghan women and children, one that needs to be publicized and overcome."

US Department of Health and Human Services Secretary Tommy G. Thompson, who recently visited Afghanistan, said, "War and the Taliban have devastated Afghanistan and its medical infrastructure, and the nation's health challenges are most serious for its women and children. The United States is committed to reversing these heartbreaking conditions and to helping restore health to the women and children in Afghanistan." The US Department of Health and Human Services oversees the CDC.

The surveys, conducted jointly by UNICEF and CDC, cover four provinces ranging from rural to urban settings: Kabul, Laghman, Kandahar and Badakshan. The research was carried out between March and July 2002, together with the Afghanistan Ministry of Health and with support from female Afghan health workers.

The surveys found an average of 1,600 maternal deaths per 100,000 live births - a figure that suggests Afghanistan may well be the worst place in the world for a woman to become pregnant. Globally, little progress has been made in reducing maternal mortality. An estimated 515,000 women still die each year as a result of pregnancy and childbirth.

"For the Afghan women of childbearing age included in our surveys, the leading cause of death was pregnancy and childbirth," said Linda Bartlett, M.D., a medical officer with CDC's reproductive health program and leader of the surveys. "These women are dying needlessly. Most of these deaths could have been avoided, which suggests important opportunities for prevention."

In some remote regions, UNICEF and CDC health workers, including Bartlett, traveled house-to-house for several days on horseback to interview families about the deaths of women in their communities. The report examines data from 13,000 households, where family members provided information on an estimated 85,000 women. Families were asked about causes of death among women of reproductive age who died during the years 1999 to 2002.

"These extraordinary surveys speak volumes about the challenges facing women and girls in Afghanistan," Bellamy said. "Taliban restrictions on women, coupled with 20 years of war, have set back women's health status immeasurably. With new leadership and ongoing assistance from the international community, Afghanistan has a prime opportunity to reverse this record, starting now. But investment in basic health care will only be beneficial to women if they are supported in accessing that care."

Link Between Mothers and Children

In issuing the report today at UNICEF headquarters, the two agencies stressed that maternal mortality is not just a "woman's problem." The study revealed that when the mother of a newborn infant dies, the child has only one chance in four of surviving until its first birthday.

"The loss of a mother at birth is one of the most traumatizing and critical events of a child's life," Bellamy stated. "Maternal mortality not only affects women, it affects children, fathers, families and entire communities. Maternal mortality is arguably the most neglected health problem in the world," she said.

Additional findings of the report:

• Most maternal deaths were preventable.
  
  
• Only 7 percent of women who died gave birth with the help of a skilled birth attendant.
  
  
• Many of the women who died were between the ages of 20 and 29. Only 4 per cent of them were literate; 26 per cent of their husbands were literate.
  
  
• Maternal mortality rates varied substantially by region, reflecting differences in access to resources and health care between urban and rural areas.

As a result of the findings, UNICEF and CDC recommended the following:

• Establishing health care services in remote areas properly equipped with essential drugs and equipment, with capacity to undertake cesarean sections, assisted delivery, and safe blood transfusions, and with efforts to increase women's use of such support services.
  
  
• Training skilled female birth attendants, nurses and midwives.
  
  
• Providing education programmes for women and their families to help them recognize the signs of normal as well as abnormal pregnancies and pregnancy complications.
  
  
• Providing treatment for complications such as pre-eclampsia, anemia and malaria and increasing access to quality antenatal care.
  
  
• Building and repairing roads to improve access to health care facilities in rural areas.

"It is terrible that women are dying in the act of giving birth," said UNICEF Representative Eric Laroche, who leads UNICEF's country program in Afghanistan. "UNICEF is deeply committed to helping Afghanistan improve the health of women and children, and a key to progress is lowering maternal deaths. This must be a priority."

Background on the situation of children in Afghanistan:

Millions of Afghans, at least half of them children, are at high risk. Under-five mortality in Afghanistan is estimated at about 257 per 1,000 live births, or one in every four children. This is the fourth highest child mortality rate in the world after Sierra Leone, Angola and Niger. Meanwhile, one of every two Afghan children is malnourished and an estimated 40 per cent of children die from diarrhoea and acute respiratory infections. Clean water and adequate sanitation facilities are also in short supply -- with only 13 per cent of the population with access to safe drinking water and 12 per cent with access to adequate sanitation facilities.

For further information, please contact:

Jehane Sedky-Lavandero, UNICEF Media, New York,
212-326-7269, jsedky@unicef.org

Chulho Hyun, UNICEF Media, Kabul,
+937 027 8493, chyun@unicef.org

Laura Leathers, CDC Press Office,
770-488-5131, lwl2@cdc.gov

William Pierce, U.S. Department of Health and Human Services,
202-690-6343

*****

Linda Bartlett, MD, MHSc,
Sara Whitehead, MD, MPH,
Chadd Crouse, MSc.,
Sonya Bowens, MSc.,
US Centers for Disease Control and Prevention

Shairose Mawji, BN, MPH,
Denisa Ionete, MBBS,
Peter Salama, MBBS, MPH
UNICEF

Introduction

For over two decades, Afghanistan has been challenged by war, drought, famine and civil instability, which have decimated the infrastructure necessary for a healthy, stable and productive society. When a community is faced with such challenges, its women and children are often the most vulnerable. Women in Afghanistan have been particularly vulnerable to limited health care access because of several factors. These factors include restricted mobility and reduced numbers of female health care providers and of health care facilities that treat women. As a result, for Afghan women, the risk of death from complications of pregnancy or childbirth (maternal deaths) is very high.

To help prevent further maternal deaths, UNICEF Afghanistan requested technical assistance from CDC's reproductive health program to conduct a study about maternal mortality. This report summarizes the results of this study, including the magnitude of maternal mortality, causes of maternal deaths, and an assessment of preventability. This study is a collaboration between the Afghan Ministry of Public Health, UNICEF and CDC. Findings from the study will be used to guide maternal health programs and services in Afghanistan.

Methods

From March to July, 2002, a women's mortality survey was conducted in four provinces in Afghanistan. The study consisted of two stages: 1) identifying deaths among women of reproductive age ( 15-49 years old); and 2) investigating these women's deaths.

The study was conducted in four provinces: Kabul, Laghman, Kandahar and Badakshan. These provinces were selected to represent a spectrum of urban to rural development, as an indicator of access to health care providers and facilities. In each province, one district was selected, and within this district villages were selected.

For the first stage of the study, death identification, all families in the randomly selected villages were visited by Afghan female interviewers, trained by UNICEF. These interviewers asked the families about births and deaths in the family during the three-year study period (April 1999 to March 2002). About 13,000 families were visited, providing information on over 85,000 individuals.

For the second stage of the study, families of women who died were interviewed by one of a team of physicians and midwives from CDC and UNICEF using a technique called verbal autopsy. In a verbal autopsy, the interviewer asks questions about the symptoms a woman experienced around the time of her death so that the cause of death can be determined. In addition, the interviewer asked questions about risk factors for death, barriers to health care access, potential preventability of the death, and about the survival of the children of women who had died. We determined whether a woman's death could be prevented by reviewing the circumstances of each death, its cause, the quality and availability of health care services, the family's perception of preventability and the interviewer's perceptions of barriers to health care.

Mohammad lost his wife in labour, her baby undelivered. He walked from his home in remote Badakshan, in the snow, for 5 days trying to reach a health care worker. There is no means of transportation across the mountains here in the winter time. When Mohammad finally reached the only village where there were limited medical services, the only health care worker was already attending to another serious patient and could not leave. Mohammad returned to his village, only to receive news that his wife and her unborn child had died. Their three year old daughter is now left without a mother.

We used a framework to assess three categories of barriers to health care access. At the first level, the barriers included failure to recognize the existence of a problem or deciding not to seek health care either because the pregnant woman, her family, or her home birth attendants did not know the normal processes or complications of pregnancy, labor, delivery, or the postpartum period; and a lack of decision-making ability or empowerment once a problem had been recognized. Second-level barriers included not reaching health care once a decision had been made to seek care either because it was not affordable or because emergency transport was not available. Third-level barriers included not receiving quality and timely treatment.

Torab lives with his four daughters in a remote village in Badakshan. Their mother died in childbirth due to obstructed labour. She was in labour for two days but all those around her assumed that the birth would be a normal one. Eventually Torab decided to seek help from a health care worker and it became apparent that the baby was in lying sideways in the womb. There was no way for Torab's wife to reach the nearest city - four days away by horseback - for an operation. The family called the Mullah and prayed for her. She and her baby both died two days later, the baby still undelivered.

Results

Number of Deaths

There were 356 families that identified a woman of reproductive age who had died during the study period. Of these deaths, 295 (83 per cent) were investigated through verbal autopsy interviews. In most of the cases where we did not investigate a reported death, it was because of security issues or because the family involved had moved and was not available for interviews.

Mullah lost his first wife in childbirth and one month prior to the maternal mortality survey, he lost his second wife in childbirth as well. He explains how difficult life is for them, there is no access to health care services, "It's too far and expensive to go to the nearest main town", he explains "and in the winter time, we have no way to travel". His first wife died of Eclampsia and his second wife from post-partum hemorrhage. He says, "It is up to Allah first to help us"' and then the doctors can help.

Key Findings

1. Using findings from this study, we estimate that the maternal mortality ratio (MMR: maternal deaths per 100,000 live births) in Afghanistan is 1600 per 100,000 live births (95% confidence interval [CI] = 1100-2000.) This is one of the highest levels of maternal mortality reported globally. However, important differences exist between urban and rural areas in our study: in Kabul, the MMR was 400 (95% CI 200-600); Laghman was 800 (400 -1100); Kandahar was 2200 (1150 -3000); Badakshan was 6500 (5000-8000). The MMR in Badakshan is the highest ever reported globally, highlighting not only the importance of this health issue in Afghanistan, but also that great variation in health exists within Afghanistan.

2. Furthermore, we estimate that among women of childbearing age who die in Afghanistan, almost half (48%; 95% CI= 39-58 %) will die from complications of pregnancy or childbirth. These figures also differ greatly by region: the proportion of women who died of maternal causes ranged from 16 per cent in Kabul, where at least one maternity hospital was functional, to 64 per cent in Badakshan, where health care access was profoundly limited. This proportion for Badakshan is the also highest proportion of deaths due to maternal mortality reported in the world.

3. In our study population, if a newborn's mother died of maternal causes, the baby had only one chance in four of living until its first birthday. Most of these infants died in the first month of life from acute malnutrition due to lack of breast milk.

4. Most (about 70 per cent) of the women who died experienced barriers at all three levels.

5. Among the women who died in this study, about 87 per cent of maternal deaths were considered preventable.

6. About half of the women in Kabul received prenatal care and had their babies delivered by a skilled attendant. The proportion of women with access to health care was substantially lower in the other three provinces. For example, no women in either Kandahar or Badakshan were attended by a skilled attendant during childbirth.

7. Consistent with global reports, the most frequent cause of maternal death was hemorrhage. The second leading cause was obstructed labor, which means that most of these women died undelivered. However, notably, in Badakshan, more women died of obstructed labor than from hemorrhage. Consistent with our finding of no access to health care, most of these deaths could have been prevented by operative delivery.

8. Only 5 per cent of women on our study could read or write and only 36 per cent of the families interviewed owned a radio.

Conclusions

Maternal mortality in Afghanistan is the leading cause of death among women of reproductive age and varies greatly by region. Levels found in Afghanistan overall are among the highest in the world, and in Badakshan, is the highest ever documented. Most women did not access a doctor or physician to help with the birth, an important way to prevent maternal deaths. In addition, the poor survival rate of the newborns of the women who died shows the impact of a maternal death on these families, already living in a war-torn and stressful environment. Many of the deaths are preventable with basic health care services, yet most women were reported to have encountered barriers to health care at all three levels, indicating the need for comprehensive program development. Public health resources and capacity building in Afghanistan must highly prioritize maternal and child care in order to promote family health and, ultimately, the development of a healthy society.

Recommendations include increasing access to skilled prenatal care to teach women about healthy pregnancies and deliveries; screening for preventable causes of maternal complications, such as pre-eclampsia, anemia, and malaria; and increasing access to skilled birth attendants (physicians and midwives), while improving general health services. Education programs to teach families about healthy pregnancies and other basic health messages such as clean food and water will need to be creatively distributed because of the low literacy levels and small number of families with radios.

The survival of mothers is an issue of extreme health importance in Afghanistan and improving survival is a great challenge, particularly in rural areas where almost no health system exists. However, motivation is very strong in this family-oriented culture, which will be a tremendous resource to the humanitarian aid community and to governments and other organizations as they mobilize to address the complex, long-term issues involved in assuring quality health to all Afghan families.

The names of individuals mentioned above have been changed to respect their privacy.