© Vivian Lee/MSF
08 Mar 17
Claire FotheringhamClaire FotheringhamAustralianGynaecologistAfghanistan

Afghanistan: One of the most dangerous places on earth to have a baby

March 8 has always been a special day for me and my family – not only is it International Women’s Day, it’s also my birthday. Throughout my childhood we often celebrated my birthday by attending International Women’s Day events. 

Perhaps that spirit of advocating on behalf of women influenced my career choice as an obstetrician, ensuring that women are able to give birth safely. 

One of the countries where it is most dangerous to give birth is Afghanistan.

There are an estimated 396 maternal deaths for every 100,000 live births in Afghanistan. By comparison, the figure in the UK is nine maternal deaths for every 100,000 births.

Why are Afghani women so much more likely to die during pregnancy and childbirth

During my field placement with Médecins Sans Frontières/Doctors Without Borders (MSF), at their maternity hospital in Khost, Afghanistan, I met many women who shed some light on the complex answers to this question.

When deliveries at home go wrong

In Afghanistan, two out of every three deliveries occur at home, without any skilled birth attendant.

We frequently saw women who had attempted to deliver their babies at home. They came into the hospital with complications resulting from this. 

An MSF obstetrician/gynaecologist speaks with a mother and her daughter in Khost maternity hospital. The daughter is recovering from a post-partum haemorrhage after giving birth at home.
One woman had done this herself, and started bleeding profusely. Because it was the middle of the night she was unable to travel safely to the hospital. 

By the time she arrived to us the next morning she was moribund, completely unresponsive, with a very weak pulse.

Despite us giving her immediate medical attention she sadly passed away. 

Dangerous journeys

In many parts of Afghanistan there’s very little availability of preventive and antenatal healthcare.

As a result, women and their carers don’t always appreciate the danger signs of pregnancy and when they should seek assistance. 

"Women often have to travel long distances [to reach hospitals], and road travel can be extremely dangerous due to chronic conflict in Afghanistan."

Many women now prefer to come to the hospital to deliver, but it can still be very difficult to access. They often have to travel long distances, and road travel can be extremely dangerous due to chronic conflict in the country. 

There was a case not long before I arrived, where a woman had just delivered a baby and was travelling home. 

During the journey a roadside bomb went off, and both mother and child were killed. 

A woman’s voice

A major issue in Afghanistan is that women are not free to make decisions within a family. 

Even if they think they need medical care, in the end it is up to their husband or mother-in-law. They need a male caretaker to accompany them to hospital, to consent to any surgery or family planning.

Afghani women tend to get married and have children early in life, and because they are expected to have a lot of children, they often continue having babies into their 40s.

Services in MSF's Khost maternity hospital include comprehensive emergency obstetric and newborn care, vaccinations, family planning, health promotion, and care for survivors of sexual violence.

Complications often occur at these two extremes of the age spectrum. Our facilities see a lot of women having their first child, and a lot of women who are older, having their ninth or tenth. 

Women are not in control of their own fertility: they often don’t have the capacity to space out their births because they can’t access family planning. 

Pregnancies that are too close together are risky for mother and baby, as the woman’s body may not have had time to recover. They need to replace nutrients such as iron, calcium and folate, which are depleted during pregnancy.

MSF impact

Although the risks are unacceptably high for women giving birth in Afghanistan, MSF is making an impact. 

In places like Khost, where there is such a huge need for maternal services, our facility is well respected for the quality of care it provides. 

Our presence is changing attitudes around where women give birth, and the importance of having a skilled birth attendant.

Aqila is a Midwife Supervisor in Dasht-e-Barchi hospital, Kabul, working in the maternity ward built by MSF. Here she delivered her most recent baby, a boy.

During my placement, we held a jirga, a meeting with community leaders. Here we discussed the idea that to be an honourable man, it’s important to bring your wife to hospital to ensure she has a safe delivery. 

We focus on caring for women with complicated deliveries, who require the high-level care that we can provide. 

In 2016 we strengthened our health promotion activities to improve recognition of complications throughout the community, including through radio messaging. 

We’ve also worked with private clinics to ensure that women with complications are swiftly referred to our hospital. 

Training local women

In all our projects we emphasise the importance of teaching and training local doctors and midwives. 

This is incredibly important because international staff come and go but the local staff stay on. 

A historical lack of education for women in Afghanistan means there are too few female doctors and midwives to look after women in labour. 

Despite this, many families only seek care from a female. 

Training local female staff means that we’re leaving something positive behind.

Hear more from our staff on the MSF blogs.