Afghan women: Let’s talk about it.
- Afghanistan has a maternal mortality rate of 1,400 per 100,000 live births, compared to 320 regionally and 280 globally (WHO, 2011).
- The probability of Afghan women dying during childbearing period is 1 in 11; the proportion is 1 in 30,000 for developed countries.
- Afghanistan is the worst place to be a woman.
- A national research by Mayhew and his colleagues in 2008 found that only 13 percent of women who gave birth 2 years preceding the study were assisted by a skilled birth attendant. At the same time, access to basic health care (within a 2h walk) was estimated to be nearly 85 percent.
- Literacy rate for Afghan women is 12.6 per cent compared to 43 per cent for men (AMS, 2011).
- Lack of education or the ability to read and write leads to lower rates of health care seeking, and higher rate of adolescent marriage and pregnancy, complications of pregnancy, life-long disability, and maternal death.
- In capital Kabul, the mean age of marriage for girls was 17.2 years with 16 per cent getting married at the age of 14 or younger (Egmond et al, 2004). In western Herat, 47 percent of women became pregnant before the age of 16 (Ahmed et al, 2004).
- In the same studies, 93 percent of women participants needed authorisation from their husband or a male relative to seek professional health-care.
- Both studies revealed that around half of the women (45 and 56 percent respectively) responded that it was the right of a husband to beat his wife when and if she disobeys him (Amowitz et al, 2002; Egmond et al, 2004).
- Early marriage for girls, women’s right to having sex, husband’s right to physically abuse woman, and woman’s need to receive permission for accessing health care influence women’s health at a large scale (Hirose et al, 2011).
Almost every literature on maternal health in Afghanistan points to the lack of women’s decision-making ability regarding their marriage, family planning and birth spacing, and seeking health care. They are all linked to lower education level of women, the patriarchal traditions, and weak social infrastructure and services in the country.
Education for women has shown a significant association with health care utilisation, lower fertility rate, and family planning, and thus better health. Better education is significantly associated with decrease in unhealthy social practices such as early child marriage and physical abuse.
In 1972 Margarete V. Silberberg was frustrated during her nursing experience for women at a Kabul hospital. In 2009 and 2010, Dr Candy Wilson visited nine villages, around 300 to 500 women and children in each. Comparing her experience with Silberberg’s, she writes,
“When reading how Silberberg (1972) described her experience and her multiple frustrations, I cannot say my level of frustration was much different… As I reflect on Silberberg’s experience in comparison to my own, it appears there has been minimal progress in health care or improving the socioeconomic status of women and children in this war-torn nation, but perhaps progress will be measured in centuries and not decades.” (Wilson, 2011, p.261)
The statistics are the evidence of the influence of social determinants of health on maternal health in Afghanistan. Evidences suggest that relying only on health care system to reduce maternal mortality to improve maternal health is unrealistic. Other social determinants such as education, sociocultural practices surrounding maternal health, and social infrastructure have significant impact on maternal health. There is a need for visible and committed involvement of other government sectors alongside health care for the long-term solution to the maternal health problem in Afghanistan. In particular, national and international organizations’ long-term commitment to social investment such as women’s education and social infrastructure is a must.
Afghanistan Mortality Survey. (2011). Afghanistan Mortality Survey 2010. Available online at http://usaid.gov/locations/afghanistanpakistan/countries/afghanistan/ams2010.html Accessed on 15 December 2011.
Ahmed, A., Edward, A., and Burnham, G. (2004). Health indicators for mothers and children in rural Herat. Pre-hospital and Disaster Medicine, 19(3).
Amowitz, L., Ris, C., and Iacopino, V. (2002). Maternal mortality in Herat province, Afghanistan, in 2002: an indicator of women’s human rights. JAMA 288, 1284–91.
Egmond, K., Bosmans, M., Naeem, A., Claeys, P., Verstraelen, H. and Temmerman, M. (2004). Reproductive Health in Afghanistan: Results of a Knowledge, Attitudes and Practices Survey among Afghan Women in Kabul. Disaster 28(3). 269-282.
Hadi, A., Mujaddidi, M., Rahman, T., and Ahmed, J. (2007). The inaccessibility and Utilization of Antenatal Health-Care Services in Balkh Province of Afghanistan. Asia-Pacific Population Journal 22(1).
Hirose, A., Borchert, M., Niksear, H., Alkozai, A.S., Cox, J., Gardiner, J., Osmani, K.R. and Flippi, V. (2011). Difficulties leaving home: a cross-sectional study of delays in seeking emergency obstetric care in Herat, Afghanistan. Social Sciences & Medicine, 73(7), 1003-13.
Mayhew, M., Hansen, P.M., Peters, D.H., Edward, A., Singh, L.P., Dwivedi, V., Mashkoor, A., and Burnham, G. (2008). Determinants of Skilled Birth Attendant Utilization in Afghanistan: A Cross-Sectional Study. American Journal of Public Health, 98(10): 1849 – 1856.
Silberberg, M. V. (1972). In the land of Ghengis KhancBelow the Khypher Pass: Experiences of a peace corps volunteer in Afghanistan. Journal of Obstetric, Gynecological, & Neonatal Nursing, 1; 49 – 51.
Wilson, C. (2011). A “boots on the ground” perspective of caring for the women and children in Afghanistan. Journal of Obstetrics, Gynaecology, and Neonatal Nursing 40(3): 255 – 261.
World Health Organization. (2011). Afghanistan: Health Profile. Available at http://www.who.int/gho/countries/afg.pdf. Accessed on 8 Dec 2011.