More than a number: maternal mortality in Afghanistan
There is much more to maternal mortality in Afghanistan than the appalling statistics as Mahri Zohra Haider explains
Statistics on maternal mortality in Afghanistan are among the worst in the world, second only to Sierra Leone. There are 1,800 maternal deaths per 100,000 live births (or one maternal death for every 55 births) and Afghan women have a one in eight lifetime risk of maternal death. (1) The average birth rate is 6.75 children per woman and every pregnancy is associated with a risk of death that is 600 times greater than that of a woman who is pregnant in North America. (2) Although the problem of maternal deaths in Afghanistan is clear in the numbers, the solutions lie in the details beyond the numbers. However, all too often the majority of effort is spent on dissecting the problem, with merely an afterthought to what can actually be done. One study designed to verify the above statistics concluded that “deaths could be averted if complications were prevented through improvement of general health status” and if “complications that occurred were treated to reduce their severity.” (3) These recommendations are vague and fail to draw attention to the specific challenges of addressing maternal mortality in Afghanistan.
While determining statistics on maternal mortality is difficult, developing programs to address it is arguably more complex. This article uses Afghanistan as an example to explore some of the considerations when trying to create a program to address high maternal mortality. A well designed program must define indicators, choose interventions, and then navigate implementation. Each of these phases should be considered within that countries unique context.
Defining the indicator
The maternal mortality ratio or MMR is just that: a ratio. It is one of the most frequently quoted indicators when discussing maternal death because it indicates the risk that a woman undertakes during delivery. It is expressed as the number of maternal deaths, due to pregnancy related causes, per 100,000 live births. A rate on the other hand would be number of maternal deaths per some unit of time. This semantic is important because how you choose your indicator can determine how you design your program or determine its impact. Interventions aimed at decreasing the MMR largely involve labor and delivery, and improving prenatal care. In Afghanistan, where infrastructure is poor and terrain limits access to health facilities for many populations, particularly during the winter, it is very challenging to train the necessary obstetrics specialists and build the facilities required for these types of interventions. Although there are current efforts using innovative approaches, such as community midwifery education, it will take time and some semblance of security in order to fully implement a complete package of high level obstetric care.
Choosing an intervention
In the meantime, there are situations where the MMR stays about the same, or decreases slightly, but the absolute number of women dying due to pregnancy related causes decreases significantly. (4) One way to prevent the risk of pregnancy is by preventing the pregnancy itself. Increasing access to family planning and contraception services has the potential to decrease the absolute number of women who die from pregnancy related causes. It is particularly tragic when a woman dies due to pregnancy related causes during a pregnancy that she would have avoided given access and education about contraception. Contraception provides a relatively inexpensive and quick way to address the risk of pregnancy and can be delivered by community health workers. Rather than directly addressing the risk of pregnancy, it aims to decrease maternal deaths by increasing the time between pregnancies and the total number of pregnancies in a woman’s lifetime. Although there is some information to suggest that increasing contraceptive prevalence also decreases the MMR, this indicates that an element of selectivity must be involved where women who may otherwise have risky pregnancies are choosing contraception at a greater rate. (5)
Navigating implementation
Family planning is a notoriously sensitive subject in many cultural contexts. In Afghanistan the notion of a western program designed to decrease or limit the population may be taken as un-Islamic or a form of population control. Of course everyone will not make this assumption, but it is important to note that in the Islamic context the notion of birth spacing is more accepted than family planning. The Koran directly supports the idea of birth spacing by promoting two years of breastfeeding for babies. In a recent Reuter’s article the UN undersecretary general, Thoraya Ahmed Obaid, emphasized the benefits of birth spacing for both maternal and child health, stating that it ensures adequate time for a women’s body to recover between pregnancies while also allowing for adequate nutrition for the baby. (6) If programs are introduced with the ultimate objective of improving maternal health by spacing births then it may be more likely to be accepted by local communities. While the evidence in Afghanistan is primarily anecdotal, qualitative studies have been conducted in Pakistan and Jordan documenting a preference towards birth spacing. (7) Noting the intricate relationship between family planning and Islam, involving mullahs and other community leaders can also be an important aspect of a birth spacing program. (8)
Complex problem, complex approach
The complexity of addressing maternal mortality is one of the great challenges in achieving progress towards the millennium development goals. Afghanistan provides a particular challenge due to its high maternal mortality, cultural factors, and concurrent insecurity. However, sensitively increasing contraceptive use with local community participation and feedback may provide a relatively rapid and inexpensive way to decrease the number of maternal deaths. Given the lack of data showing the relationship between contraceptive prevalence and declining maternal deaths, it also presents an opportunity to potentially correlate the uptake of contraceptives with a subsequent decline in fertility rate and also number of maternal deaths.
Mahri Zohra Haider
4th year Medical Student
University of Washington Medical School
and
MPH student
Harvard School of Public Health
mazoha@gmail.com
(1) WHO, Maternal Mortality in 2005: estimates developed by WHO, UNICEF and UNFPA. Available at: http://www.who.int.offcampus.lib.washington.edu/reproductive-health/publications/maternal_mortality_2005/mme_2005.pdf (Accessed Oct 20, 2007).
(2) Leidl, P. Dying to Give Life: Maternal Mortality in Afghanistan. UNFPA. July 7, 2006. Available at: http://www.unfpa.org/news/news.cfm?ID=822 (Accessed Oct 29, 2007).
(3) Bartlett LA, Mawji S, Whitehead S, Crouse C, Dalil S, Ionete D, Salama P. Afghan Maternal Mortality Study Team. Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999-2002. The Lancet. March 5-11 2005; 365(9462): 864-70.
(4) Fortney JA. The Importance of Family Planning in Reducing Maternal Mortality. Studies in Family Planning. March 1987; 18(2): 109-114.
(5) Bulatao RA, Ross JA. Which health services reduce maternal mortality? Evidence from ratings of maternal health services. Tropical Medicine & International Health. August 2003; 8(8): 710-721.
(6) Family Planning Key to Afghan Maternal Deaths- U.N. Reuters. April 23, 2007. Available at: http://uk.reuters.com/article/healthNews/idUKISL1210620070423?pageNumber=1 (Accessed October 25, 2007).
(7) Farsoun M, Khoury N, and Underwood C. In Their Own Words: A Qualitative Study of Family Planning in Jordan. IEC Field Report Number 6, Johns Hopkins Center for Communication Programs, Baltimore, Maryland, October 1996. Available at: http://www.jhuccp.org/pubs/fr/6/6.pdf (Accessed Feb 2, 2008).
(8) Hasna F. Islam, Social Traditions and Family Planning. Social Policy & Administration. 2003; 37 (2), 181-197. Available at: http://www.blackwell-synergy.com/doi/abs/10.1111/1467-9515.00333 (Accessed Feb 4, 2008).