Maternal Mortality in Afghanistan: Where Women Die of Giving Birth

By Jean Chung May, 2007

Afghanistan has seen thousands of civilian deaths due to decades of war and conflict including the fights with the Taliban insurgency in recent years. However, it also suffers from unnecessary deaths of women in childbirth. Afghanistan is the country with the second highest maternal mortality rate in the world only after Sierra Leone. An astonishing number of 25,000 women die from obstetric causes per year, or 1 woman dies every 27 minutes.

A UN report released in 2000 indicates that the national Maternal Mortality Ratio (MMR) in Afghanistan was 1,900 per 100,000 live births, whereas it was 17 in the United States. Sierra Leone’s maternal death ratio was 2,000.

According to the study conducted in May to July 2002 by the team of Dr. Linda Bartlett from Centers for Disease Control and Prevention in the US, of the 90,816 population they have surveyed in four districts in Afghanistan, 357 women of reproductive age (15-49) died, and 154 died of complications during pregnancy, childbirth or the puerperal period. The MMR in those four districts was 418 in Kabul, 774 in Alisheng, 2182 in Maywand, and 6507 in Ragh.

Ragh district in Badakshan province showed the highest mortality risk ever recorded in human history, with 64% - more than half of the women of reproductive age - died during 1999 and 2002.

The causes of deaths were analyzed mainly in two parts: direct and indirect. Direct causes include haemorrhage, obstructed labour, cardiomyopathy, sepsis, obstetric embolism, and pregrancy-induced hypertension; and the indirect causes were tuberculosis, malaria, and obstetric tetanus. According to the survey of Afghan women who died port-partum by Dr. Bartlett in 2002, 94% died within 42 days. 56% of these women died in the first 24 hours.

Other socio-economic, geographic and cultural factors contributed to the high mortality ratio. In 2002, which was shortly after the fall of the former Taliban regime, 60% of Afghans had no access to basic health services. Even though 40% of Basic Package of Health Services (BPHS) offer basic emergency obstetric care in Afghan provinces, only 7% have the capacities to provide comprehensive emergency obstetric cases according to the Ministry of Health in 2006. Most of the professional ante-and postnatal cares are used by only 20% of all pregnant women.

This data is also caused by lack of awareness and transportation. Especially in mountainous districts in Badakshan province, where most people travel by foot or donkey, have limited access to Basic Health Care Centers in district capitals. Jurm district’s basic health center had two minivans that functioned as ambulances, and it took about three to four hours depending on the roads or weather conditions to haul the patient(s) to the provincial hospital in Faizabad, the provincial capital. Inaccessibility to the advanced health care is one of the main barriers for pregnant women. When I was traveling to districts such as Zybak and Ishkashim in mid-May, the effort was thwarted by natural disasters such as floods and avalanches, thus failed to reach the districts. There was no doubt that any emergency patients who needed the advanced care beyond the basic health care level from those effected areas could not travel to Faizabad.

The mortality rate in Badakshan would not improve unless the availability, accessibility and awareness of Afghan people improve. Many mortalities on both mothers and children occur during home births. Home births are widespread especially in rural areas where roads are tough and people are more conservative. Some of the women I have interviewed in the hospitals have told me that the fact that the male members of the family such as husbands and fathers refuse to send their wives or daughters (in-laws as well) to health facilities because of cultural and religious reasons create difficulties in serving people. In Badakshan, most women are not allowed to travel on their own, and if they have to, they need to be accompanied by maharam, a male member of the family. Even if women do want to go to the local health facilities, if husbands or fathers – patriarch of the family – does not allow, they would not be able to see doctors or skilled midwives. As Dr. Bartlett’s report points out, inability to leave the home without the permission or escort of a male relative is a big barrier for women to access proper health care in bigger towns. Chronic poverty and limits on education are also important factors in high maternal mortality rate in Afghanistan.

My photo reportage on Afghan’s maternal mortality tells a story of a woman who died of port-partum complications due to tuberculosis, the disease widely known as the product of poverty. Her death could have been prevented if proper family planning and prenatal healthcare were provided. The story follows her from the hospital when she was recovering from her delivery to the funeral in her village. Through the journey of following this woman, I documented the process of how a woman could lose her life from such unbelievable causes.

When I first met Qamar, a very thin, fragile looking 26-year-old Afghan woman from a remote village at the recovery room at Faizabad Provincial Hospital in Badakshan, she was lying on her bed next to her 75 year-old mother-in-law, Khalisa, and her unnamed son. It was five days after the cesarean section, and although she did not seem to have the energy to move, she rose slowly as I walked in. The nurse explained to me that she had tuberculosis. Her thinness was from the disease. She looked sick, but not too much ill. The baby son was the second child as her first child died in childbirth a few years ago.

Two days later, she began to suffer from fever. Doctors and nurses injected medicine and provided oxygen even though the oxygen machine went occasionally out of power due to lack of electricity. One of the doctors said, “I am very worried about this patient. I need some more blood for her, but there’s no more blood in the blood bank. The family cannot afford to buy the blood.”

After one week, she was transferred to the general patients ward from the maternity ward in the same hospital. It turns out she has been suffering from deadly complications after the delivery: meningitis, hypothermia, and toxoplasmosis. She was barely conscious in a room filled with other female patients and visitors. The family could not get the blood, but one pack of blood did not seem to have been the remedy. Her conditions have deteriorated, and she constantly moaned in agony of her pains. Nurses were injecting painkillers so much, she had a string of injection marks on her left arm. She kept groaning, and the baby was crying. Khalisa, the mother-in-law, was rocking the baby. She said, “We don’t even have money to buy milk. My son is jobless. What can we do?”

Later in the afternoon, the doctor decided to move her to another room and put the oxygen mask on her. However, by that point, doctors were skeptical about her conditions. “The condition is very poor. I think she will die,” one of them said. The mother-in-law did not say too much. She seemed like she had to accept the destiny or too tired to tend the bed. The husband, Azibullah, dropped in the room and called her name. “Qamar, hey Qamar.” He swayed Qamar’s face left and right a bit, then covered his face with hands. He walked outside.

The oxygen and the pulse level were dwindling over time. By 8:30 p.m., Qamar stopped breathing. Azibullah and hospital staff were absent. Khalisa, who was sitting on the bed next to Qamar with her grandson, slowly rose and approached to her. She was already dead. “Qamar, Qamar.” Khalisa called Qamar’s name a couple times, tapped her both cheeks a bit, then confirmed her death. She closed her eyes and called the caretaker. The hospital staff came. One doctor said, “This is the problem of Afghanistan. There was no way we could cure her.” The caretaker tied Qamar’s face and toes with white linen straps, and moved her on the stretcher. There was no morgue or freezer for dead bodies in the hospital. Her corpse was kept in an empty patients’ room.

The next day, Khalisa, Azibullah, and a couple of relatives decided to carry the body back to their village. They knew that the roads were closed from the city called Baharak, about three hours from Faizabad, due to floods. They went to the point in which cars could no drive any longer, then decided to walk to the village for two hours: which was common for Afghans in rural areas. A couple of workers from a nearby bridge construction came to assist them. After crossing landslides and tough roads, they reached the house. They slowly laid the stretcher down in the living room. Azibullah began to cry as relatives and workers laid down. The voices saying “Allah” reverberated in the room as women grieved. Other women began to come to the house and cried for her. After washing the body, men carried the body and buried it in the graveyard. There was silence after the funeral.

The next morning, family members including Khalisa and Azibullah began their normal day. Qamar’s baby was in the hands of Khalisa as she put a pacifier on his mouth. Women baked bread and prepared tea. They seemed to accept death and life and moved on pretty quickly. After all, Qamar is not the only mother who dies in childbirth in Afghanistan. Thousands of other families suffer from the same consequences. It was a part of their life.

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