ArticlesWhere giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999–2002
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.
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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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Other team members listed at end of the paper