Introduction

In the year 2000, 149 representatives gathered together at the Millennium Summit held
in New York to implement an action plan based on the Millennium Declaration known as
the Millennium Development Goals (MDGs). The MDGs were conceived to target the
most prominent issues that are affecting people globally, and eight goals were
identified. The committee of the MDGs projected a resolution to these goals by 2015.
Some of the highlighted areas include promoting gender equality, eradicating diseases
and poverty, promoting education among children, and improving child and maternal
health (United Nations, 2014).

MDG 5, which focuses on improving maternal health (United Nations, 2014), aims to
reduce maternal mortality ration by 3/4 and achieve global access to reproductive
health. Maternal health refers to the health of women throughout the period of
pregnancy, the birthing of the child, and the postpartum period (World Health
Organization, 2012). However, particularly in developing countries, complications to
maternal health can arise when a woman lacks adequate access to appropriate
resources. A report from the World Health Organization (2012) stated that
approximately 800 women die from pregnancy and childbirth, and more often than not,
the causes that led to death could be prevented. It is crucial to take care of women in
the community because women are able to contribute to the economic development via
work, and women can help to ensure the continuity of generations by producing
children.

Thus, this paper will focus on maternal health in Afghanistan, and how it poses as a
health issue.

Maternal Health Status in Afghanistan

According to the World Health Organization (WHO; 2014), the United Nations Children’s
Fund (UNICEF) provided statistics in 2002 that the maternal mortality rate in
Afghanistan was 1600 women for every 100,000 live births per year, averaging to an
estimated four deaths per day. In Afghanistan, it has determined that poor maternal
health is an ongoing challenge as it is ranked as one of the countries with the highest
maternal mortality rate in the world (World Health Organization, 2014). In 2002,
Afghanistan adopted the MDGs, thus pledging a thirteen-year effort to reduce maternal
mortality rates by half (United Nations Development Programme, 2003).

Historical Factors

Afghanistan has had a long history of being dominated by many conquerors from the
11th century till present. In 1921, Afghanistan became an independent nation after the
British were defeated in the 3rd British-Afghan war which lasted for 3 years. Being ruled
by kings who believed in monarchies, Afghanistan was controlled by parties such as
Afghan Communist Party and People’s Democratic Party of Afghanistan. Due to
disagreements of the country being backed by Soviet Union, guerilla movements were
formed to oppose these. Several guerilla movements identified were Al-Qaida,
Mujahadeen and the Taliban. The Taliban took over Afghanistan in 1995 with the
promise of maintaining peace. However, The United States of America refused to
recognize their authority, and tensions grew when Al-Qaida was suspected of bombing
2 American embassies. When the demands for surrendering Osama bin Laden were not
met, The United States of America imposed sanctions on trade and economic
development by restricting Afghanistan trade activity with the world. In 2001, The United
States of America went to war against the Taliban by bombing areas and bases
supposedly belonging to the Al-Qaida network. The United States of America believed
that Osama bin Laden was the mastermind behind the September 11 th attack in 2001.
By December 7, 2001, the Afghan Islamic Press declared that the Taliban ruling on
Afghanistan has ended. Hamid Karzai was then elected as president in the country’s 1st
parliamentary elections after more than 30 years. Therefore, it could be seen that the
political struggles of the nation, accompanied by the declaration of embargo and war by
the United States of America, has led to a diminished focus and priority in maternal
health (PBS Newshour, 2014).
Structural Factors

Afghanistan is currently ruled under the Karzai administration, with Hamid Karzai as
their president. Recently, Afghanistan had undergone a presidential election, but results
of the voting have yet to be announced (Election Guide, 2014). The government had
aims to focus on the reconciliation and reintegration of economic stability and
development, improve relations between their country’s trading and political partners,
and increase the security capability of the Afghan forces. They also aimed to implement
various plans to support the civil society, to counter terrorism, to counter narcotics-use,
to aid in the advancement of women and girls, and to provide humanitarian relief when
needed (U.S. Department of State, 2013).

Of the total population of approximately 32 million people, Afghanistan houses a

diversity of ethnic groups, which comprise of the Pashtun, Tajik, Hazara, Uzbek, Aimak,
Turkmen, Baluch, and others. 80% of the population are Sunni Muslims, with 19%
belonging to the Shia Muslim category and 1% belonging to others (Central Intelligence
Agency, 2009). The Hazaras are considered as outsiders in the Afghan community as
they are the only Shia Muslims, whereas the vast majority are Sunnis. Due to historical
evidence that the Hazaras are descendants of Gengkhis Khan, a Mongolian conqueror
who once ruled over Afghanistan, they were forced to live in the mountainous areas
known as Hazarajat (National Geographic, 2008). Afghan Persian and Pashto hail as
the main spoken language in the country. There is no evidence of any social caste
system as Afghans appear to be of a fixed culture (Central Intelligence Agency, 2009).

There is an equal ratio of men and women in each age category, from young to old.
However, women have suffered greatly during the ruling of the Taliban as they were not
allowed to enter into the workforce, neither were they given passes to travel unless in
the company of a male family member. It was compulsory for women to wear burqas
(veils) no matter where they went, and all-girls schools were also shut down during the
regime (Oxfam, 2011). However, gender equality improved after the end of Taliban
ruling. 85% of the voted population stood for equal rights regardless of gender, 85% of
the voted population supported the idea of equal provision of education for women and
79% of the voted population supported the idea of women being allowed to stand up for
their rights. However, only 62% of the population were in agreement for women to work
outside their homes (The Asia Foundation, 2011).

In Afghanistan, an estimate of 35% percent of the population remains unemployed, with

36% of the population living in poverty. Main categories of work are divided into three
groups; agriculture at 78.6%, industrial manufacturing at 5.7% and service-providence
at 15.7% (Central Intelligence Agency, 2009). Despite agriculture and construction
being responsible for averaging the country’s gross domestic product (GDP) by almost
10% over the past 5 years, opium trafficking is heavily depended upon for the country’s
finance. Majority of the improvements to health and education were largely supported
by foreign aids (The Heritage Foundation, 2014).

39% of children over the age of 15 are able to read and write in Afghanistan. The
country has been equipped with 12,740 schools catering to Grade 1 to 12 education,
and a total of 7.3 million children have achieved primary and secondary education. After
the fall of Taliban, more children are able to gain access to both formal and non-formal
education from ongoing efforts to re-open schools in areas where education has been
intimidated by violence. Afghanistan was also enrolled to be the 44th member of the
Global Partnership for Education (GPE), where the enhancement on the quality of
education systems were implemented (UNICEF, 2011). An investigation elucidated that
at least 26% of Afghan children are forced into child labored to support their families
and pay off any debts incurred by the family (UNICEF, 2011). The report mentioned that
children are noted to be working from home, or in industries such as brick kilns, where
the environment is not conducive for children (International Labour Organization, 2012).

Kabul is the capital of Afghanistan, and 23.5% of the total population has been noted to
live in urban areas. Most people travel via the roads and highways, making up the total
length of 42,150km across the state. All forms of broadcast media is state owned by the
Radio Television Afghanistan (RTA), which operates an estimated 150 private radio
stations, 50 TV stations, and 12 international broadcasting studios (Central Intelligence
Agency, 2009).
The World Health Organization (2014) reported that an estimated 6 million people in
Afghanistan either have insufficient or no access to basic healthcare. Only 48% of the
total population have access to safe drinking water, and 37% have access to safe
sanitation (UNICEF, 2011). The physician-citizen ratio stands at 0.19 per 1000 citizens,
and the hospital-citizen ratio stands at 0.4 per 1000 (Central Intelligence Agency, 2009).
The government’s providence to the healthcare system has been weak, as an estimated
57% of the population are required to walk at least an hour from their residence to a
medical center which provides only a basic health package (World Health Organization,
2013).

Cultural Factors

It has been reported that in Afghanistan, 92% of the women are married before the age
of 25. 53% of the women were married by the time they are 18 years old, and 21% are
married before they are 15 years old (USAID, 2010). Although the legal age for married
has been pegged at 16 years old, Afghanistan women can be wedded off at an earlier
age with the permission of their fathers or a judge. This would often lead to early
pregnancy for these women, and health risks would include the development of fistulas
or obstruction during labor due to the underdevelopment of the pelvis. Untreated fistulas
can lead to severe complications and eventually, death. Of every 1000 married women,
at least 4 develop fistulas, and 75% of the 4 women come from impoverish families
(Human Rights Watch, 2009).

The fertility rate in Afghanistan is 6.6 children per woman (United Nations Population
Fund, 2011). It has been reported by the United Nations (2011), that only 18.6% of
women use contraceptives. Research has shown that although the Afghanistan women
welcome healthcare aid, only 24% of the births are attended to by trained and skill
personnel. The remaining population would often seek assistance of traditional birth
attendants known as “dai” (Prata, Passano, Rowen, Bell, Walsh, & Potts, 2011), often
due to cultural influence. A report by the United Nations Population Fund (2011)
indicated that there are only 2231 midwives to cater to the total female population in
Afghanistan, and an additional 254 individuals were equipped with midwifery
competencies. This report also noted that there are only a total of 44 institutions that
teach midwifery in the country (United Nations Population Fund, 2011).

A structural factor that coincides with the restricted healthcare access is the unspoken
rule that an Afghan woman is not allowed to go anywhere without the permission of her
husband. Based on Islamic principles, females are only allowed to be attended to by
female healthcare attendants. An Afghan woman also faces societal pressures as for
every son borne by the woman, a day can be deducted from the traditional 40-day
mourning period during the passing of her husband. This is a form of indication and
measure of the husband’s merit and social standing (Women News Network, 2012).

Critical Analysis

Reports by the United Nations Development Programme (2013) indicated that

Afghanistan was able to reduce maternal deaths to 327 per 100,000 live births. It was
also reported that over 40% of the child births are now attended to by trained personnel.
The usage of contraceptives has increased to 21% as of 2012, and fertility rates have
reduced from 6.6 to 5.1 children per woman. Thus, it could be seen that Afghanistan will
continue to improve conditions related to maternal health, where progress will be
charted and consolidated at years 2015 and 2020 (United Nations Development
Programme, 2013).

Conclusion

Based on the findings presented by the United Nations, Afghanistan is currently on track
with achieving their targeted goals in improving maternal health. However, the rates of
maternal death have yet to be reduced by the targeted 50%. As of year 2012 to 2013,
Afghanistan has received US$62 billion worth of aid and more can be achieved if the
government is able to utilize the funds received to expand the coverage of healthcare
services to both urban and rural areas in the country, instead of channeling majority of
the funds to military operations (Global Humanitarian Assistance, 2010).
References

Central Intelligence Agency. (2009). The world factbook. Retrieved on April, 14, 2014
from https://www.cia.gov/library/publications/the-world-factbook/geos/af.html

Election Guide: Democracy Assistance & Election News (2014). Islamic Republic of
Afghnistan. Retrieved on April, 14, 2014 from
http://www.electionguide.org/countries/id/2/

Global Humanitarian Assistance. (2010). Tracking major resource flows 2002-2010.

Retrieved on April, 15, 2014 from
http://www.globalhumanitarianassistance.org/wp-content/uploads/2011/02/gha-
Afghanistan-2011-major-resource-flows.pdf

Human Rights Watch. (2009). Afghanistan: Ending child marriage and domestic
violence. Retrieved on April, 15, 2014 from
http://www.hrw.org/sites/default/files/related_material/Afghanistan_brochure_091
3_09032013.pdf

International Labour Organization. (2012). Child & bonded labour in Afghanistan’s brick
kilns: New survey highlights obstacles to ending practice. Retrieved on April, 14,
2014 from http://www.ilo.org/global/about-the-
ilo/newsroom/news/WCMS_172721/lang--en/index.htm

Larson, M., & Hazelton, L. (2008). Hazara people. National Geographic. Retrieved on
April, 14, 2014 from
http://ngm.nationalgeographic.com/geopedia/Hazara_People

Mojumdar, A. (2012). Afghanistan: Large families encouraged by culture as well as

religion. Women News Network. Retrieved on April, 15, 2014 from
http://womennewsnetwork.net/2012/05/29/afghanistan-large-families/
Oxfam. (2011). A place at the table: safeguarding women’s rights in Afghanistan.
Retrieved on April, 14, 2014 from
http://www.oxfam.org/sites/www.oxfam.org/files/bp153-womens-rights-
afghanistan-03102011-en.pdf

PBS Newshour. (2014). A historical timeline of Afghanistan. Retrieved on April, 14,

2014 from http://www.pbs.org/newshour/updates/asia-jan-june11-timeline-
afghanistan/

Prata, N., Passano, P., Rowen, T., Bell, S., Walsh, J., & Potts, M. (2011) Where there
are few skilled attendants. Journal of health, population and nutrition, 29(2), 81-
91. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3126980/

The Asia Foundation. (2011). Afghanistan in 2011: A survey of the Afghan people.
Retrieved on April, 14, 2014 from
http://asiafoundation.org/resources/pdfs/TAF2011AGSurvey.pdf

The Heritage Foundation. (2014). 2014 index of economic freedom. Retrieved on April
14, 2014, from http://www.heritage.org/index/country/afghanistan

UNICEF. (2011). Education in Afghanistan. [Factsheet]. Retrieved on April 14, 2014

from http://www.unicef.org/infobycountry/files/ACO_Education_Factsheet_-
_November_2011_.pdf

UNICEF. (2011). Child protection in Afghanistan. [Factsheet]. Retrieved on April 14,

2014 from
http://www.unicef.org/infobycountry/files/ACO_Child_Protection_Factsheet_-
_November_2011.pdf

UNICEF. (2011). WASH in Afghanistan. [Factsheet]. Retrieved on April 14, 2014 from
http://www.unicef.org/infobycountry/files/ACO_WASH_Factsheet_-
_November_2011.pdf
United Nations Development Programme. (2003). Millennium development goals status
in Afghanistan. Retrieved on April 14, 2014 from
http://www.undp.org.af/MDGs/MDGstatus07.htm

United Nations Development Programme. (2013). Improve maternal health: Where are
we? Retrieved on April 15, 2014 from
http://www.af.undp.org/content/afghanistan/en/home/mdgoverview/overview/md
g5/

United Nations. (2011). World contraceptive use 2011. [Factsheet]. Retrieved on April
15, 2014 from
http://www.un.org/esa/population/publications/contraceptive2011/wallchart_front.
pdf

United Nations Population Fund. (2011). Afghanistan. Retrieved on April 15, 2014 from
http://www.unfpa.org/sowmy/resources/docs/country_info/profile/en_Afghanistan
_SoWMy_Profile.pdf

United Nations. (2014). Millennium summit (6-8 September 2000). Retrieved on April
14, 2014, from
http://www.un.org/en/events/pastevents/millennium_summit.shtml

United Nations. (2014). Goal 5: Improve maternal health. Retrieved on April 14, 2014,
from http://www.un.org/millenniumgoals/maternal.shtml

U.S. Department of State: Diplomacy in Action. (2013). U.S. relations with Afghanistan.
[Factsheet]. Retrieved on April 14, 2014, from
http://www.state.gov/r/pa/ei/bgn/5380.htm

USAID. (2010). Afghanistan Mortality Survey 2010. Retrieved on April 15, 2014, from
http://www.usaid.gov/sites/default/files/documents/1871/Afghanistan%20Mortalit
y%20Survey%20Key%20Findings.pdf

World Health Organization. (2012). Maternal health. Retrieved on April 14, 2014, from
http://www.who.int/topics/maternal_health/en/
World Health Organization. (2012). Maternal mortality. [Factsheet]. Retrieved on April
14, 2014, from http://www.who.int/mediacentre/factsheets/fs348/en/

World Health Organization. (2013). Country cooperation strategy at a glance:

Afghanistan. [Factsheet]. Retrieved on April 14, 2014, from
http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_afg_en.pdf

World Health Organization. (2014). Main public health issues and concerns. Retrieved
on April 14, 2014, from http://www.who.int/hac/donorinfo/afg/en/index1.html

World Health Organization. (2014). Afghanistan: The facts about health. Retrieved on
April 14, 2014, from www.who.int/disasters/repo/7543.doc