About the author of this post: Bart de Bruijn (PhD) is a demographer and development sociologist. As a consultant in population and development he provides technical assistance in the field of household surveys and population censuses to UN agencies and governments in developing countries and countries in transition. Since 2009 he is involved as Chief Analyst/Editor in the Afghanistan Living Conditions Survey (ALCS, formerly known as NRVA). For feedback or questions you can contact him via email b.j.debruijn@online.nl.

Compared with other health indicators, maternal mortality presents some of the largest disparities between developing and developed countries. Global estimates by the Maternal Mortality Estimation Inter-agency Group indicate that developing countries accounted for 99 percent of the 287 thousand maternal deaths in 2010 worldwide. Accordingly, the Maternal Mortality Ratio (MMR) in developing countries was 240 per 100,000 live births, compared to only 16 per 100,000 live births in developed countries; and the life-time risk of dying of maternal causes was one in 150 for women in the former group of countries and 3,800 in the latter. The cynical paradox of dying while trying to give life is aggravated by the fact that such deaths are almost entirely preventable.

The picture of maternal mortality in Afghanistan is especially bleak. The Afghanistan Mortality Survey 2010 estimated an MMR of 372 per 100,000 live births in the seven years preceding the survey. This implies that in this period around one in 50 women died during pregnancy, childbirth or in the two months after delivery. The Inter-agency Group estimates are even higher, with an MMR of 460 and a life-time risk of maternal death of one in 32.

Surprisingly, these grim figures for Afghanistan do contain elements of hope when viewed from the perspective of less than a decade earlier. A mortality study conducted in 2002 estimated an MMR in a range between 1,600 and 2,200 per 100,000 live births, which corresponds to the UN estimate of 1,900 for the year 2000. The mortality study covered maternal deaths in the last years of the Taliban regime in the country and the first months after its fall in November 2001. In this period, the health system in Afghanistan had collapsed after decades of war that had destroyed the health infrastructure and caused large numbers of skilled health workers to flee the country. A similarly devastated education system was largely unable to produce new qualified staff. Moreover, the Taliban regime suppressed women’s opportunities to work or follow education outside their homes, or to seek health care when in need of medical assistance and counselling, especially if no female health workers were available. This resulted in a situation in which pregnant women were trapped: hardly allowed to leave the house; and even if allowed to do so, with very few health facilities to visit; and even if these were available, no female staff to assist them.

The estimated rate for the year 2000 of around 1,900 maternal deaths per 100,000 live births would imply a total of 20,000 maternal deaths in the country in that year. This figure for Afghanistan alone equals the total estimated number of maternal deaths in the same year for Central America and the Caribbean, North America, Europe, the former Soviet Union, Australia, New Zealand, Japan and China combined. Although the Afghanistan figure is based on data that are far from reliable, there can be no doubt that maternal mortality was exceptionally high around that time, and higher than any country has experienced in recent years. Similarly, there can be no doubt that the situation – although still extremely poor – has improved substantially.

Support for strongly decreasing maternal mortality can be found in a series of multi-purpose surveys that have been conducted in Afghanistan. The National Risk and Vulnerability Assessments (NRVA) were carried out in 2005, 2007-08 and 2011-12, and provide information about key indicators like percentages of women receiving ante-natal care and skilled birth attendance, and giving birth in health facilities. Other surveys provide similar information for intermittent years. Although survey methods are not fully comparable, the resulting trend is sufficiently robust to suggest that Afghanistan’s health system is recovering and that women have increasing access to maternal health services (Figure 1).

Figure 1: Percentage of women with a birth in the five years before the survey using maternal health services, 2003 to 2011-12 (Source: Central Statistics Organization 2014)

In the eight-year period between 2003 and 2011, the proportion of women who gave birth with the assistance of skilled health personnel increased by a factor of 2.7. There was an even greater increase in the proportion of women who received any ante-natal care and in the proportion who gave birth in health facilities: both increased by a factor of 3.2. Preliminary figures of the 2014 NRVA round (now renamed the Afghanistan Living Conditions Survey, ALCS) that is currently being implemented in the field indicate a continued increase of institutional births. Closely related to this, child mortality indicators showed comparable improvements. Thus, the under-5 mortality rate decreased from 172 per 1,000 live births in the MICS 2003 to 91 per 1,000 in the NRVA 2011-12.

These results indicate that the massive donor support and a somewhat more woman-friendly government in Afghanistan have enabled the country to achieve significant improvements in health sector performance, and that fewer than 460 maternal deaths per 100,000 births is a plausible figure. To the extent that the estimated MMR estimates are correct, they would imply that in the space of eight years, Afghanistan has already almost achieved its Millennium Development Goals target of 75 percent reduction in maternal mortality that was set for the year 2020.