PHR Library

September 10, 2002

FOR IMMEDIATE RELEASE

Physicians for Human Rights Finds High Maternal Mortality Ratio in Herat Province, Afghanistan

First Data-Driven Survey Details Health Crisis for Afghan Mothers / More Funds Needed for Health Infrastructure

Afghan women are dying in childbirth at an extraordinarily high rate, according to a new study by Physicians for Human Rights (PHR) released today. The PHR study, Maternal Mortality in Herat Province: The Need to Protect Women's Rights, is the first data-driven survey to compute the maternal mortality ratio in Afghanistan in over ten years. The group called on the international community to provide urgently required funds into the Afghan health sector to stem the shockingly high number of fatalities in childbirth.

The study found that 593 maternal deaths occur for every 100,000 live births and the majority of the maternal deaths (92%) were reported from rural areas. This figure ranks the province of Herat, Afghanistan with the highest rate of maternal mortality outside the African continent. The maternal mortality ratio for Herat Province also exceeds that of all six countries bordering Afghanistan: Pakistan (200/100,000), Iran (60/100,000), Turkmenistan (65/100,000), China (60/100,000), and Tajikistan (120/100,000). In contrast, the United States has an estimated ratio of 12/100,000. Excerpts from the study were published by the Journal of the American Medical Association in its September 11 issue, also released this week.

The PHR study revealed that of 4,637 respondents, 519 (11 percent) reported receiving prenatal care. Of 4,624 women, 40 (0.9 percent) reported a trained health care worker was present at birth; 97 percent had untrained birth attendants. Only 17 of 27 known health facilities in Afghanistan were functional and only 5 provided essential obstetric care. Only 35 physicians served a population of 793,214.

The study also identifies factors that may contribute to preventable maternal deaths in the region. These include inadequate basic facilities to care for normal and complicated deliveries, inadequate supplies of medication and equipment for complicated pregnancies and births, the requirements of traditional society that women deliver at home, and lack of transportation to hospitals in urban centers and poor roads in rural areas. Women often cannot afford to pay for health care services even when they know they are in danger of having a problematic delivery. Other possible factors include the denial of individual freedoms such as freely entering into marriage, access to birth control methods, and possibly control over the number and spacing of one's children.

"The rate of maternal mortality in a society is a critical indicator of the health and human rights status of women in a community," said Dr. Lynn Amowitz, Senior Medical Researcher at PHR and well-known expert on women's health in Afghanistan. "What appears to be simply a public health catastrophe in Herat Province also speaks to the many years of denial and deprivation of women's rights in Afghanistan. Promoting rights such as access to adequate health care, food, shelter, and clean water will directly improve their health."

"When a woman dies in childbirth in Afghanistan, the entire family suffers because of her death," stated Dr. Amowitz. "The urgent response of the international community to maternal mortality will save the lives of countless children, in addition to those of their mothers."

PHR documented the tremendous suffering of families upon the loss of the mother. This story told by a 60-year old widower in a village in Zendajan illustrates the effects of such losses on Afghan families and the importance of effective access to medical assistance.

The Dauya (traditional birth attendant) did not know what to do so she [my wife] died in a pool of blood without holding or feeding her babies. I am trying to remember if I was by her side, but the years have removed many memories. There was no doctor to help. Even if there was one, I had no money to pay a doctor or a clinic. If I had money, I was going to take her [my wife] to a clinic in the city. The baby twins needed to be cared for so I brought them to a village woman who had milk in her breasts. One died after three months and the other at six months. I think she did not take good care of them.

URGENT RECOMMENDATIONS TO INTERNATIONAL DONOR COMMUNITY

Notwithstanding generous promises to the people of Afghanistan, the international community has not kept faith with its commitments. Contributions from donors have failed to meet Afghanistan's desperate need, including urgently required funds for the health sector. While donors continue to provide emergency assistance, including food aid and other relief to Afghanistan, contributions for the development of infrastructure have been limited. Afghanistan's Economic Affairs Director, Adib Farhadi, reported on September 4 that Afghanistan had received $750 million for humanitarian aid and overhead costs, but only $150 million for reconstruction projects. He appealed to the international community to contribute $1.8 billion this year for reconstruction in Afghanistan. According to UNICEF, they have received only $28 million of the $58.3 million they requested for their health and nutrition program this year.

PHR issues the following urgent recommendations intended to alleviate the most severe and immediate factors affecting the health of Afghan women before, during and after childbirth (long-term recommendations are included in the full report).

1.   The donor community should quickly provide the basic equipment needed for normal and complicated births to local clinics and regional health centers. Almost none of these facilities have rudimentary supplies such as intravenous medications to control seizures, bleeding or infection; clean water; or vacuum extractors. This basic package of materials and equipment at every facility, combined with the proper training, could save the lives of tens of thousands of women and children every year. On an urgent basis, recruitment and deployment of trained health professionals to every Essential Obstetric Care (EOC) Facility is necessary.

At the present time, there does not appear to be a coordinated donor strategy to assure the development of such facilities. Rather, individual humanitarian groups have taken responsibility for some of them.

2.   The donor community and the Afghan government must recognize that even when services are available and reachable, user fees may preclude life-saving care for many women. The donor community and the Afghan government should develop access for women to life saving treatment in emergencies, including obstetric emergencies and prenatal care at no cost.

3.   Training programs for traditional birth attendants (TBAs), as well as other health professionals, in rural areas should be considered by the donor community. As documented in this study, TBAs are overwhelmingly (97%) the only ones to accompany an Afghan mother in labor. Currently, they lack basic skills such as knowledge of how to massage the uterus to expel the placenta or prevent hemorrhage-a frequent cause of death that could be prevented.

The United States Congress provided an additional $134 million for humanitarian assistance to Afghanistan when it passed the "emergency supplemental" appropriation in July, but President Bush vetoed $500 million of the emergency supplemental, including the additional assistance for Afghanistan, on the grounds that he had not requested them. When President Bush sent forward his own budget amendment to Congress this week restoring some of the programs he had previously vetoed, humanitarian aid to Afghanistan was not included. PHR urges the US Congress to insist upon an increase when it reconsiders the measure in the context of the fiscal year 2003 foreign aid appropriations bill.

5,014 households were sampled for this survey, 4886 females between the ages of 15 and 45 participated (97.5% response rate). Dr. Amowitz of PHR conducted the survey with the assistance of local data collectors.

Physicians for Human Rights (PHR) mobilizes the health professions to advance the health and dignity of all people by protecting human rights. As a founding member of the International Campaign to Ban Landmines, PHR shared the 1997 Nobel Peace Prize.