A or Phrase Definition Maternal Mortality (MM) (per 100,000

Critical Examination of Maternal MortalityP1 
in Afghanistan

Word or Phrase

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Mortality (MM) (per 100,000 live births)

Maternal death is the death of a woman while
pregnant or within 42 days of termination of pregnancy, irrespective of the
duration and site of theP2  pregnancy, from any cause related to or aggravated by the
pregnancy or its management but not from accidental or incidental causes. (WHO
Online 2017a)


IntroductionP3 :

over 30 years, the people of Afghanistan have experienced civil and international
conflicts, drought, famine, and epidemics (Bartlett et.al 2005; Askeer et.al
2016). ‘Few countries in the
world have been at the epicentre of conflict, of population displacement, and
of misery for as long as Afghanistan’ (Askeer et.al 2016 p.396). Conflict
has been incessant since 1979; worsening in 1996, when Taliban insurgents
gained control. Such devastations led to the destruction of vital social
infrastructure and severely limited access to basic resources such as
healthcare (Frost et.al 2016; Askeer et.al 2016).

‘By 2002, Afghanistan had some of the
poorest health indicators of any country in the world’ (Frost et.al 2016, p.1). At this time, the
national MM ratio was estimated between 1600 and 2200 per 100,000 live births
(Bartlett et.al 2005). ‘Other
health indicators were also concerning; only 4.6% of Afghan women received
antenatal care and 6% delivered with a skilled provider. The contraceptive
prevalence rate was 2% and the total fertility rate was 6.3.’ (Turkmani et.al 2013 p.1167)

addition to direct impacts of conflict on accessibility to healthcare, repressive
socio-cultural attitudes towards women have exacerbated the problem (Turkmani
et.al 2013; Askeer et.al 2015;). ‘The education of girls was forbidden during the Taliban regime,
resulting in the deterioration of the female skilled health care workforce. In
a country where sociocultural practices restrict women from receiving health servicesP5 
from male providers, these circumstances severely hampered women’s access to
health services’ (Turkmani
et.al 2013, p.1167).

Although the country still
faces issues of inaccessibility and insecurity, the last 15 years have seen
several political interventions aimed at improving access to healthcare for women.

However, a lack of planning, a
dependency of foreign aid, and socio-culturalP6 
attitudes, has meant results are unevenly distributed across the country. Often
neglecting and further intensifying issues for vulnerable populations such as
women in rural areas (Bartlett et.al 2017).

As a member state of the United
Nations (UN) since 1946, theP7 
UN has a responsibility to protect the human rights of women in Afghanistan who
are unnecessarily suffering. As well as a duty to promote sustainable
development for the country. FutureP8 
planning should incorporate policies and initiatives which aim to evenly
distribute sustainable healthcare to women in all provinces, and seek to
collect more reliable and representative data.

Maternal Mortality in Afghanistan


MM Ratio, Per 100,000 Live Births

Proportion of Maternal Deaths Among
Deaths of Female Reproductive AGE (PM%)









48P9 .2










(Table.1 – A Table showing MM and
Proportion of Deaths of Female Reproductive Age between 1990-2015, Source: WHO Online





Reducing MM and
improving maternal health is vital to a country’s development and economic
growth. Providing benefits, including (WB 2006):

Improving labour supply and productive capacity in
women of reproductive age, resulting in improved household income and economic
well-being of families and communities.

Reducing the number of orphans, who may have lower educational
attainment and drastically diminished prospects of leading productive lives.

Reducing new-born mortality, thereby improving
child survival, ensuring a strong labour force for the next generation of

Affirms the value of women in society, leading to
more equitable opportunities for all.

Providing opportunities to integrate HIV
prevention, treatment, and care activities in maternal and child health (MCH)
and family planning (FP) programs to curb the HIV epidemic and mother to child
transmission of HIV/AIDS.

Strengthening the capacity of the health system. Improving
human resources, upgrading infrastructure, strengthening logistics systems for
supplies and equipment, etc. will benefit other health service components.

have been several policies
implemented to reduce MM in line with the United Nations Millennium (WHO Online
2017c) and Sustainable DevelopmentP10  Goals (UN Online 2017a):

Development Goal – Target 5.A

 Reduce by three quarters, between 1990 and
2015, the MM ratio

Development Goal – Target 5.B

Achieve, by 2015,
universal access to reproductive health


Development Goal 3 –

Ensure healthy lives and promote well-being for all at
all ages.


2030, reduce the global MM ratio to less than 70 per 100,000 live births.


By 2030, ensure universal
access to sexual and reproductive health-care services, including for family
planning, information and education, and the integration of reproductive
health into national strategies and programmes.


Examples of Previous Implementations


Basic Package of Health
Services (BPHS) – In 2003, the Ministry of
Public Health (MOPH) contracted with non-governmental organisations (NGOs) to
implement its BPHS, which aims to provide community health-oriented primary
care, delivered to all Afghans, regardless of where they live, ethnicity, or
gender. The BPHS remains the foundation of healthcare service delivery in
Afghanistan (Turkmani et.al 2013).

Increased number of midwives and/or skilled
attendants present at births –

have developed a comprehensive National Reproductive Health Strategy for
lowering MM. ‘The strategy
seeks effective antenatal care for all by focusing on improved availability of
skilled attendants (community-based midwives) at birth and the coverage, use,
and quality of emergency obstetric care, particularly in rural areas. Training
of providers has been initiated, standards of care adopted and distributed,
five centres of obstetric excellence developed, and the number and quality of
health facilities improved’ (Bartlett et.al 2005 p.869, Turkmani et.al



The efforts to revive and
strengthen the healthcare system since 2002, in particular midwifery, have been
critical to reducing MM to 396 deaths per 100,000 live births in 2015 (WHO
2015). A national survey in 2010 found skilled providers attended 34% of all
births, of which midwives provided 20% of the care (WHO Online 2017d).

According to UN (WHO 2015)
estimates, Afghanistan has witnessed more than a 70% reduction in maternal deaths between 1990 and 2015.


Despite these achievements, MM
remains among the highest in the Region. Pregnancy-related causes remain the
leading risk of death for women in their childbearing years (41%). (WHO 2017d),
Figure.1 shows the estimated
breakdown of causes of MM:


(Figure.1, Source: WHO 2017d)










Furthermore, in 2012, only 23% of
the need for maternal and reproductive health services was met. If Afghanistan maintains
its current graduation rate, and follows predicted population growth trends,
only 8% of estimated need will be met in 2030 (UNFPA Online 2015)

However, such statistical data
on MM is ambiguous and contesting (Askeer et.al 2016); ‘One reason for the discrepancy in the figures is a
lack of reliable data. Collecting such information in Afghanistan is
notoriously difficult. Worsening security prevents even officials from the
ministry of public health’ collecting data (The Guardian Online, 2017).

Potential Reasons for Inefficiency and Unsustainability, and
Future Recommendations:

A large body of literature (Askeer et.al 2016,
Bartlett et.al 2017) suggests MM is a largely rural issue (see Figure.2). Bartlett’s et.al (2017)
research used comparable data from both urban Kabul and rural Ragh and
highlighted huge variations in the access and quality of healthcare between
provinces. The greatest disparities were seen in access to improved water and
sanitation, antenatal care visits, and skilled birth attendant coverage
(Askeer etP11 .al 2016).

a map showing percentage change in skilled birth attendance between 2003 and
2010, Source: Askeer et.al 12016 p.403).



In May 2015, the Government of
Afghanistan and health partners unanimously agreed and committed to reduce the
MM ratio to 250 deaths per 100,000 live births 

by 2020 (WHO Online 2017d).


Recommendations to
reach this target:

Collect more reliable and
representative data

In a country where reliable data is so elusive,
a stronger focus and investment on monitoring progress is desperately needed,
or the benefits of the large amount of aid going into healthcare will remain
unclear, and the extent of the issue with not be fully understood (The Guardian
Online, 2017).

for measuring and reporting mortality need to be institutionalized in the
country to generate better data for planning and policy-making. Strengthening
expert review of these estimates and investing in studies on mortality-related
reporting practices in countries with data limitations may result in more
robust estimates’ (Viswanathan
et.al 2010 p.unknown).

Ensure new programmes
are cost effective and have sustainable long term visions –

access to health care remains a challenge and present delivery models have high
transactional costs, affecting sustainability… Future strategies in Afghanistan
will need to focus on investments improving social determinants of health and
targeted cost-effective interventions to address major causes of maternal… mortality’
et. Al 2016 p.395). This will include targeting the more vulnerable areas with
limited access to healthcare, starting with improving infrastructure and
accessibility to healthcare resources for all people in all provinces; then
tackling varying levels of quality.

policies have not considered long term sustainability, for example:

efforts from multiple actors … revitalised a non-functional midwifery
education system that launched 32 midwifery schools in 34 provinces and
graduated 2954 midwives through November 2010, and is now reported at more than
3000. Despite these remarkable achievements, the number of schools has now
dropped to 22 due to un-sustained funding’ (Turkmani et.al 2013 p.1170)

Understand the
healthcare problems as a socioP12 -cultural and political
issue –

Bartlett’s paper showed the impacts political conflict have varying
direct, and indirect impacts across the country:

for areas not directly experienceing conflict, the risk of MM was likely
increased indirectly, through ‘the
destruction or decay of the healthcare, education, and transport systems;
emigration of health professionals; and decreased opportunity for employment
increasing poverty and hindering development. To overcome these substantial
challenges will require well-informed planning within and beyond the health
sector’ (Bartlett et.al 2005 p.869 – emphasis added)

Bartlett et.al suggests that after years of
centralised policy (2017 p,544.): ‘Now is the time to change to a locally led, decentralised bottomup
mode of strategic planningP13  to
address differing implementation needs in different geographic, cultural, and
security conditions and provide quality maternity services for all women’.

The most significant changes in MM will arise when engrained
repressive attitudes towards women, are challenged; and when intrinsic value is
placed on the lives of girls and women (Viswanathan
et.al 2010)

Structure the healthcare
system: Divide Maternity care into Primary and Secondary Prevention. Ensuring healthcare
providers and patients understand the importance and difference between both –

Primary Prevention optimises general health to
prevent complications. ‘Primary
prevention during preconceptional and prenatal care could: decrease the number
of pregnancies and increase birth spacing in higher-risk women; improve
nutritional status; reduce infectious diseases through access to immunisation,
education on hygiene, safe water, and programmes to prevent malaria and
tuberculosis; educate women and their families about warning signs during
pregnancy and delivery; and ensure preparedness for birth’ (Bartlett
et.al 2005, p.869).

Secondary and tertiary prevention, look at ways
to treat and reduce the severity of illness. ‘Secondary prevention services (e.g., screening) and
tertiary prevention (e.g., treatment of life-threatening childbirth
complications) should be provided during antenatal, peri-partum, or
postpartum care’ (Bartlett et.al 2005 p.869)

Increase the emphasises
on family planning, contraception, and education, to reduce the fertility rate,
and allow greater autonomy for females –

Although the use of any method of
contraception has increased, overallP14  coverage remains very low (Askeer et.al
2016 p.401).  The World Bank (Online 2006) provides
suggestions of cost-effective and feasible interventions to reduce the number
of pregnancies in Afghanistan (see Table.2):



Core Interventions

Target Groups


early pregnancies

delayed marriage; set a minimum legal age of marriage of at least
18 for girls.
community participation


at marriage
at first birth
at onset of sexual activity

unplanned and poorly-timed pregnancies 

Expand family planning services through
community-based workers, social marketing, and health facilities
Promote birth intervals of at least 24

Men and women of reproductive
age, with special attention to adolescents, poor rural and urban

Total fertility rate
Contraceptive prevalence rate
Unmet need for spacing and limiting births
(DHS data)
Age at first birth

– a table showing suggestions to reduce to the number of pregnancies in