Canadian Women for Women in is a volunteer not-for-profit organization founded in 1996 with over ten chapters across Canada. The goals are to advance education and educational opportunities for Afghan women and their families; and to increase the understanding of Canadians about human rights in Afghanistan. Maternal Health in Afghanistan: Overcoming a Legacy of Failure

Maternal Health During the Taliban to provide basic needs for their children. In last decade. For instance, the Afghanistan There is a revered saying in Afghanistan that addition, women face structural discrimination Health Survey of 2006 found a 25% paradise lies at the feet of the mother. Yet, throughout the country.” reduction in the mortality rate of children during the Taliban time and immediately - Melissa Dittmann, 2004, p. 34. under five years of age, since 2001 (from after, Afghanistan held the dubious position 257 to 191 deaths of children per 1000 of having the highest maternal mortality Maternal mortality rates are highly indicative live births). Significant improvements were rate in the world. A study by Physicians for of other socio-economic conditions, such also made in reducing the mortality levels Human Rights (PHR) published in 1998 as women’s access to primary health clinics, of children under one year of age (Fatimie found that during the Taliban period, 28% the number of doctors in the population, & Ramin, 2008). A Ministry of Public of women reported “inadequate control , and the status of women in Health was established and goals set for over their own reproduction.” At one point, society. Thus, the dismal state of maternal alleviating some of Afghanistan’s worst there was a single hospital open to women health in Afghanistan at the time was health indicators, including the shockingly in the capital, the Rabia Balkhi Hospital, a window onto the broader challenges high maternal mortality rate, which in 2002 and only one maternity hospital, Maiwand, facing women, and their limited rights was estimated nationally at 1,800/100,000. which typically had eight beds to a room, within the society. Similarly, today the However, as of 2011, Afghanistan is still and in some cases, two women per bed. The persistently poor health conditions facing considered the “worst place in the world Rabia Balkhi Hospital “lacked basic medical pregnant women, mothers and infants to be a mother,” according to a recent supplies and equipment such as X-ray impacts women’s abilities to access other report by Save the Children. Progress has machines, suction and oxygen, running rights, such as the right to education, thus not advanced enough a decade after water, and medications. Women housed and it prevents the realization of many of the fall of the Taliban, every year still there said they had received no medical Afghanistan’s development objectives, such leaving thousands of women vulnerable attention; one had not been attended to for as the alleviation of poverty or improving life to preventable death and illness during ten days,” according to PHR. During that expectancy. pregnancy and childbirth. The prevalence time, 87% of women reported a decrease of child marriage (the average marriage in their access to healthcare and all of the “One woman was losing her child because of age is only 15 for girls) contributes to this reasons cited to PHR were related to the RH incompatibility and no available antigen. vulnerability, as under-age mothers face Taliban’s restrictions against women, such Some of the women interviewed by PHR higher risks in pregnancy and are less likely as having no chaperone available (27%), were experiencing abnormal bleeding during to give birth to healthy babies. restrictions on mobility (36%), the hospital pregnancy. Some were given a prescription but refusing to provide care (21%), no female they had not bought it because they couldn’t doctor available (48%), not owning a burqa afford it; other women had been at the hospital (6%) and economics (61%). for days and had received no treatment at all.” – Physicians for Human Rights (1997), “The more children men have, the better their “The Taliban’s War on Women: A Health and mental health. However, the opposite holds Human Rights Crisis” true for women: the more children they have, the higher their levels of emotional distress. Maternal Health Post-2001 A possible explanation for this, Miller says, Despite the extreme lack of services at might be that because of scarce pediatric and the time of the fall of the Taliban, overall, maternal health care, women are unable access to healthcare is one sector where Afghan midwives training remarkable progress has been made in the Photograph: WHO/Christopher Black

website: www.cw4wafghan.ca P.O.Box 86016, Calgary, AB T2T 6B7 • Tel: 1 403 244-5625 • email: [email protected] sustained. Independent non-governmental Quick Facts: Maternal Health in organizations (NGOs) also remain key Afghanistan players in the provision of healthcare services, where the government has been - As of 2011, maternal mortality is unable to bring services or improvements. estimated at 1,300 per 100,000 Gaps in government health services are births, though may be as high as also increasingly being filled by private 1,600 per 100,000 (by comparison, healthcare, as hospitals for profit-making Italy’s maternal mortality rate purposes are opened, and subject to limited is 3.9/100,000 and Canada’s is The Malalai Maternity Hospital in regulations and scrutiny in the quality of Photo: UNICEF, 2010 12/100,000 care. There remains an urgent need for - Across Afghanistan, a woman dies improvement in the training of healthcare improving children’s health. Overall, the every 30 minutes from a pregnancy personnel employed by state health goals of Afghanistan’s Ministry of Public related problem Health are to “develop the health sector - Save the Children’s 2011 report found institutions, and to raise the quality of service provision carried out by state services. to improve the health of the people that one in every 11 women dies in of Afghanistan, especially women and Afghanistan during childbirth children, through implementing the basic - The primary complications of Quick Facts: Stats on Healthcare Providers package of health services (BPHS) and childbirth that threaten women are the essential package of hospital services bleeding, infection, hypertension, - More than 2,900 midwives are (EPHS) as the standard, agreed-upon and obstructed labour working across Afghanistan, but minimum of health care to be provided - Some 10 years ago, one out of four there is a shortage of at least 3,500 at each level of the ,” as infants died before reaching the age more needed to help curb the current of five, but now one child out of level of maternal mortality well as expand access to higher quality six dies before getting to the age of - In 2002, there was one midwife emergency care and reproductive and five, according Afghanistan’s acting training centre and only 467 children’s healthcare. The implementation Minister of Public Health (2011) midwives in the whole country. of the current policy is expected to reduce - 54% of Afghan children are born However, since then, 32 provincial maternal mortality to 1,264 deaths per stunted, according to the UNDP in midwifery schools, as well as some 100,000 births by 2013, and to 800 by Afghanistan medical institutes, have been set up 2015; and to reduce infant mortality to 105 - The Afghan fertility rate is second in the capital and in other urban per 100,000 and under-five child mortality highest in the world (7.5 births/ areas rate to 180 by 2013. woman) - Overall, 2,000 new general health- - Girls who give birth before age 15 care centers have opened across the “With this situation, it is a long road for are five times more likely to die in country since 2002 Afghanistan to achieve the Millennium childbirth than women in their 20s; - Nationally, 14% of births are Development Goals of reducing maternal and a child born to a girl under 18 attended by a skilled health mortality.” - UNICEF Representative has a 60% greater chance of dying in professional (World Health Catherine Mbengue (2009) the first year of life than one born to Organization, 2011) a 19 year-old, according to Prasanna - Due to the lack of healthcare International donors and UN agencies Gunasekera of the UNFPA services, many women give birth at operating in Afghanistan have committed home, unattended by any medical funds towards the government’s maternal professional healthcare goals. For example, the Rural Thus while important progress has been Expansion of Afghanistan’s Community- made in increasing women’s access to “When I first started there was just one bed for based Healthcare (REACH) is a USAID- basic primary healthcare, in significantly expectant mothers in the entire hospital.” – Dr. funded grants program to expand health raising the number of trained midwives, in Bahrastan, a female doctor who has worked services, distributing over $70 million for reducing infant mortality and in slightly in Faizabad’s main hospital for 14 years the provision of “primary health care to reducing maternal mortality, critical (Badakhshan), in a 2008 interview with the women and children in underserved areas challenges remain. The revenue of the BBC. of the country and training for midwives, Ministry of Public Health is largely reliant doctors and nurses” (Management Sciences on external donor funding, rather than Moving Forward: 2011 and Beyond for Health, 2006). UNICEF also has on a domestic revenue source. Therefore, Afghanistan’s current national health a program on maternal healthcare in without significant international assistance, policy priorities, as part of an overarching Afghanistan that helps support the national it is uncertain whether the current level policy for the period 2005-2015, includes health systems already in place. According of service and the continued restoration reducing maternal and newborn mortality, to David Koch (2009), UNICEF supports of the healthcare system could be as well as reducing child mortality and

website: www.cw4wafghan.ca P.O.Box 86016, Calgary, AB T2T 6B7 • Tel: 1 403 244-5625 • email: [email protected] programs “to expand antenatal care for own health and the health of their children, their children who are Afghanistan’s future pregnant women. They are providing as well as to make good choices in planning generation. increased access to skilled assistance at parenthood. Grassroots health education delivery, breastfeeding education and programs are also needed for men, so that training for hospital staff and community they can support women to make healthy health workers.” UNICEF partners with choices around family planning, pregnancy other NGOs to alleviate the maternal health and the health needs of their children. crisis and to try to build the healthcare Afghanistan’s maternal mortality rate, and system in Afghanistan so that it can the poor access of women to reproductive ultimately become more sustainable. health services and information, will continue to deter poverty alleviation and Desired Results by 2013: development ambitions if it’s not addressed • Percentage of deliveries attended by with urgency in government and donor Specialized Birth Attendants will be planning priorities. Access to health increased to 40% by 2013 and medicine is a human right, but in • Contraceptive prevalence rate will be Afghanistan it’s a right that is being denied increased to 40% by 2013 to too many women, and consequently, to • Maternal mortality rate will be reduced by 21% by 2013 • Total fertility rate will be reduced to 4.5 by 2013 • Access to reproductive HCSs will be 90% of population by 2013 - Afghan Ministry of Public Health

The Afghan Government introduced a Health and Nutrition Sector Strategy in 2008. The strategy for reproductive and maternal health (Strategy 4.1) outlines the following: “Health and Nutrition Sector (HNS) is committed to ensuring that development partners deliver the different components of reproductive health as an integrated package. In maternal health, the HNS is committed to increasing the accessibility of mothers and women of child bearing age to quality reproductive healthcare services, including antenatal care, intrapartum care routine and emergency obstetric care and post partum care, counseling and modern family planning services, through skilled birth attendants working with community and other healthcare workers.” More work must also be done to expand healthcare education programs among rural women and girls to increase basic knowledge of reproductive health. Women and girls need information about their own bodies, reproductive cycles, conception, birth control, pregnancy, childbirth, prenatal care and antenatal care if they are to be empowered to better protect their Worldwide causes of maternal mortality (2005), World Health Organization

website: www.cw4wafghan.ca P.O.Box 86016, Calgary, AB T2T 6B7 • Tel: 1 403 244-5625 • email: [email protected]