Last year, 1500 civilians were killed as a result of fighting between pro-government and anti-government elements in Afghanistan, the highest number since 2001. But there is another reason why Afghanistan is an unsafe country, a problem that takes some 24,000 civilian lives a year. Their deaths are less newsy; they make no banner headlines, lead to no talk shows, and generate little shock. These 24,000 were young Afghan mothers, all of whom died as a result of pregnancy and childbirth.
The maternal-mortality ratio in Afghanistan is around 1600 per 100,000 live births. In the remoter parts of the country it is several times this figure, reaching 6500 in the largely inaccessible northeastern province of Badakshan. Despite concerted attempts, and granted same success in certain areas, the underlying causes of the high maternal-mortality ratio (MMR) have not shown much change over the last seven years, since the fall of the Taliban and the influx of international aid. Afghanistan has the second-highest MMR in the world and the highest in the Asia-Pacific region. Further, the figure of 1600 is actually the lower estimate in a range of 1600-2200 – the upper estimate of which surpasses that of Sierra Leone, with an MMR of 2000 per 100,000 live births, officially the highest in the world.
In Afghanistan today, a woman giving birth is estimated to die every 29 minutes. According to the Kabul government, this extremely high MMR is due to a "tragic combination of poverty, conflict and cultural tradition". Each factor exacerbates the impact of the other, and the overall ratio is slow to change. Explaining the individual causes, Dr Malalai Ahmadzai, a specialist in maternal health with UNICEF in the country, says the barriers are extremely straightforward: the non-recognition of a medical problem due to lack of awareness, the insufficient training of birth attendants, or the complete absence of health facilities. "People here see birth as a natural phenomenon, a private matter," she says. "And so it complicates the decision of when to call for medical help."
Gender dynamics play a tragic role. Even where a problem may be recognised by the pregnant woman or other female members of the family, the decision to seek medical help rests with the male head of the household. That individual, meanwhile, may or may not recognise or accept the gravity of the situation. Furthermore, even when the condition is recognised and medical help is sought, there may simply be no medical help to access, either due to the remoteness, the difficulty of travel or the expense involved. "There are great disparities in health care because of the geography of our country," says Dr Ahmadzai. The absence of roads in much of rural Afghanistan can mean a journey lasting hours if not days, with some areas completely cut off during the winter. "Even after reaching the facility, the required medical care may not be available, even when the family can afford to pay."