• Saving mothers in Afghanistan: Progress, challenges & the road ahead

Saving mothers in Afghanistan: Progress, challenges & the road ahead

12 May 2014

by Vanessa Thevathasan

Independent consultant Vanessa highlights the progress & obstacles for Afghan maternal health

Afghanistan has once again been labelled one of the worst places in the world to be a mother. According to UNICEF, across Afghanistan a woman dies every two hours due to complications during pregnancy. The main causes of maternal deaths are hemorrhaging, eclampsia and prolonged or obstructed labour, which are all preventable with effective and efficient treatment. Progress has been made, but with Afghanistan stalling at the bottom of global health rankings, the sustainable improvement of maternal wellbeing remains a serious and complex challenge in Afghanistan.

The provision and delivery of basic health services has been essential to ensure the general health and wellbeing of pregnant women and mothers. The Afghanistan Ministry of Public Health (MOPH) created the ‘Basic Package of Health Services’ to promote equity in primary care services, especially in rural areas. The package promotes good health practices through immunisation and the supply of prenatal supplements such as folic acid and iron.  The MOPH has additionally set up the Rural Expansion of Afghanistan's Community-based Healthcare (REACH) programme to rectify the shortage of skilled care workers and insufficient health facilities. Together these programmes have resulted in an impressive rise in the population’s access to basic health services (measured as a maximum two hours walk to a facility) from 9 percent in 2001 to almost 85 percent today. However, Stewart Britten of Healthprom notes that community health workers are not sufficiently trained as birth attendants or to deliver maternal health care.

The success story here is one that has been supported and financially backed by USAID, EU and the World Bank. They are contracted by the MOPH to implement its policies and partner with organisations including Jhpiego, Save the Children and Futures Group International.  These policies are now being implemented by Afghan NGOs.   Three core programmes have been created.  

Firstly, the Health Services Support Project has helped train thousands of midwives each year. Secondly, Community Midwife Education Programme trains community midwives for deployment in rural areas to ensure deliverance of clinic-based reproductive healthcare.  Thirdly, Maternity Waiting Homes admit pregnant women within four weeks of their expected due date. This ensures they receive comprehensive prenatal and postnatal services and care.  Expectant mothers are counseled on warning signs during pregnancy as well as the importance of breastfeeding, hygiene, immunisation and family planning. Being staffed by female community midwives has helped build greater community acceptance and utilisation of this service. There has also been a push to train girls in rural areas to become Skilled Birth Attendants. This helps with the continuation of care and referrals to health centres when midwives are not present in particular localities. Results so far have indicated gains in preventing postpartum haemorrhaging and the delivery of postpartum family planning services.

Despite such progress, uptake of care remains significantly low, especially in rural areas where a majority of births take place at home without a trained carer or birth attendant.  Priorities remain, including promoting greater usage of maternal services, the presence of community midwives in rural areas and improving the quality of care in provincial hospitals. New technology should be sufficiently taught to midwives and birth attendants. 

The challenges faced in Afghanistan’s maternal health discourse are tied irrevocably to the principle of gender equality in health care. Seeing women’s health care as a human rights issue ensures that governments are accountable for their legal commitments to provide and ensure access to reproductive health services without discrimination or prejudice. The Afghan government has ratified CEDAW and the National Action Plan for the Women of Afghanistan, and is therefore legally committed to protecting and promoting women’s rights. Additionally, the Afghan Midwives Association is a platform for community midwives to lobby for policy change towards health care. Integrating gender equity into health services also requires addressing violence against women. CBMs have encouraged male heads of families to take a more active role in the health of their families. Additionally, collaboration between religious leaders, politicians and health officials is essential for disseminating accurate health information whilst simultaneously addressing the cultural and religious misconceptions around healthcare. Clearly, men of all sections of society will continue to be vital in creating safer environments for mothers in Afghanistan.

Despite these numerous improvements in maternal health care, Christopher Stokes, Medecin Sans Frontier's general director, argues for a “reality check" by the international community on Afghanistan’s health system.  Investment in the last decade has been towards political and security objectives as opposed to the daily needs of Afghans. Furthermore, progress so far has been dependent on extensive foreign investment. As such, the withdrawal of foreign forces within the year and cuts to international investment in Afghanistan threaten the sustainability of gains made in the past decade.

In addition, high corruption in Afghanistan and pressure to meet targets on reducing maternal deaths has raised questions on the credibility of the latest statistics.  The Afghan Mortality Survey 2010 found 327 deaths per 100,000 live births per year. This would mean a dramatic drop from 1,600 deaths per 100,000 live births in 2001 and the fulfillment of obligations under Millennium Goal five years early. This has been argued as simply too unrealistic. If such statistics are inflated, the concern is that this will result in reduced focus and incentive to prioritise issues on maternal mortality.  This will do little to help Afghan women and girls.

The fact that more women are surviving childbirth is a testament to the headway made by community midwives. Afghanistan has proposed to increase their numbers and ensure that at least 80 percent of women have access to emergency obstetric care by 2020. The coming year for Afghanistan will be crucial to realising such ambitious goals. The international community must remain committed to providing financial investment for integrated and sustainable maternal care development. While gains remain fragile, women and men have demonstrated a clear commitment to change during the elections last month.  All women have the basic human right to survive childbirth and experience a future as a mother. There is no greater time to make good on these promises in Afghanistan.