Elsevier

The Lancet

Volume 365, Issue 9462, 5–11 March 2005, Pages 864-870
The Lancet

Articles
Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999–2002

https://doi.org/10.1016/S0140-6736(05)71044-8Get rights and content

Summary

Background

Maternal mortality in Afghanistan is uniformly identified as an issue of primary public-health importance. To guide the implementation of reproductive-health services, we examined the numbers, causes, and preventable factors for maternal deaths among women in four districts.

Methods

We did a retrospective cohort study of women of reproductive age (15–49 years) who died between March 21, 1999, and March 21, 2002, in four selected districts in four provinces: Kabul city, Kabul province (urban); Alisheng district, Laghman province (semirural); Maywand, Kandahar province (rural); and Ragh, Badakshan province (rural, most remote). Deaths among women of reproductive age were identified through a survey of all households in randomly selected villages and investigated through verbal-autopsy interviews of family members.

Findings

In a population of 90 816, 357 women of reproductive age died; 154 deaths were related to complications during pregnancy, childbirth, or the puerperal period. Most maternal deaths were caused by ante-partum haemorrhage, except in Ragh, where a greater proportion of women died of obstructed labour. All measures of maternal risk were high, especially in the more remote areas; the maternal mortality ratio (per 100 000 livebirths) was 418 (235–602) in Kabul, 774 (433–1115) in Alisheng, 2182 (1451–2913) in Maywand, and 6507 (5026–7988) in Ragh. In the two rural sites, no woman who died was assisted by a skilled birth attendant.

Interpretation

Maternal mortality in Afghanistan is high and becomes significantly greater with increasing remoteness. Deaths could be averted if complications were prevented through optimisation of general health status and if complications that occurred were treated to reduce their severity—efforts that require a multisectoral approach to increase availability and accessibility of health care.

Introduction

For longer than 20 years, the people of Afghanistan have faced international and civil conflicts, drought, famine, and epidemics. Much of the country's infrastructure has been destroyed.1 In 2002, 60% of Afghans had no access to basic health services.2 Services for women are particularly scarce; in 2002, two-thirds of Afghanistan's districts lacked maternal and child health services and only 10% of hospitals were adequately equipped for caesarean deliveries.2 To guide development of reproductive health services in the post-Taliban era, we assessed the numbers of maternal deaths during 1999–2002 in four districts in Afghanistan and identified their causes, risk factors, and preventability, as well as barriers to care.

Section snippets

Study design and setting

We undertook a two-stage, retrospective cohort study of women of reproductive age, defined as 15–49 years, who died between March 21, 1999, and March 21, 2002, in four districts in diverse settings (urban to rural). The first stage, death identification, consisted of finding households (individuals sharing a cooking area) in which a woman of reproductive age had died during the study period. First-stage data were collected between March 22 and April 30, 2002; interviews were carried out at

Results

Among the 13 848 households in the four districts (total population 90 816), 2560 deaths were reported during the study period (table 1). 357 deaths were among women of reproductive age. 294 (82%) were investigated by verbal autopsy to assess their relation to pregnancy or childbirth; there was no verbal autopsy for 63 women because of insecurity or relocation. Of 154 maternal deaths identified by families, 133 were investigated by verbal autopsy. 109 (82%) were found to be direct maternal

Discussion

Maternal mortality among Afghan women was high, and risk increased with greater remoteness. Numbers of deaths from maternal complications exceeded those from all other causes among women in the three semirural or rural sites. As in many other less developed countries, ante-partum haemorrhage was the most common maternal cause in three sites, but in Ragh, where maternal mortality was higher than any rate reported anywhere else in the world, more women died from obstructed labour. Overall, in all

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