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Reproductive Health Research in Afghanistan: Elements in Action PowerPoint PPT Presentation

Reproductive Health Research in Afghanistan: Elements in Action Catherine S. Todd, M.D., MPH Assistant Professor, Department of Obstetrics & Gynecology, College of Physicians and Surgeons, and Heilbrunn Department of Population and Family Health. OBJECTIVES

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Reproductive Health Research in Afghanistan: Elements in Action

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Reproductive Health Research in Afghanistan: Elements in Action

Catherine S. Todd, M.D., MPH

Assistant Professor, Department of Obstetrics & Gynecology, College

of Physicians and Surgeons, and Heilbrunn Department of Population and

Family Health.


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OBJECTIVES

  • Describe overall reproductive health situation in Afghanistan.

  • Identify physical and cultural barriers impeding care.

  • Describe impact of conflict on existing barriers.

  • Discuss human rights considerations that must be incorporated into programming.


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AFGHANISTAN: GENERAL PICTURE

  • Lack of infrastructure for last 30 years.

  • Lack of tax base & regional interference.

  • Multiple ethnic groups vying for power.

  • Active foreign military occupation.

  • Destabilizing effects of narcotics trade and politically-motivated insurgency.

  • Return of refugees with continued internal displacement due to drought and insecurity.


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AFGHANISTAN: SPECIFIC ISSUES

  • Literacy rate: male 51%, female 21%.1

  • 4 different languages spoken

  • Unemployment rate: 40% nationally

  • Discrimination against certain ethnic groups

  • Low status of women culturally, further diminished by the Taliban regime.

    1.At a glance: Afghanistan statistics. Available at: http://www.unicef.org/infobycountry/afghanistan_statistics.html.


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AFGHAN HEALTH INDICATORS 1990 vs. 2004

  • Statistics come with caveat that data is sparse and largely based on village leader report.1

  • Lack of gender disparity:

    • Contributing factor is 1 in 8 lifetime risk of maternal mortality.4

  • Waldman R, Hanif H. The Public Health System in Afghanistan: Current Issues. Afghan Research & Evaluation Unit 2002.

  • UNICEF. At a glance: Afghanistan statistics. Available at: http://www.unicef.org/infobycountry/afghanistan_statistics.html

  • U.S. State Dept. Central and South Asian Statistics. Available at: http://www.state.gov/r/pa/ei/bgn/5380.htm

  • Bartlett LA, et al. Afghan Maternal Mortality Study Team. Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999-2002. Lancet. 2005;365:864-70.


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DECADE COMPARISON OF HEALTH INDICATORS

  • UNICEF. At a glance: Afghanistan statistics. Available at: http://www.unicef.org/infobycountry/afghanistan_statistics.html.


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WOMEN & CHILDREN AFFECTED MOST:

  • Maternal mortality ratio is 1900/ 100,000 births; 2nd highest globally.1

  • Some rural areas reveal highest maternal mortality ratios ever recorded; 6507 deaths/ 100,000 live births.2

  • Child mortality rate (5 and under): 257/ 1000; 4th highest globally.3

  • Contraceptive prevalence rate is 15.4% for rural areas, 35.2% for the Kabul metropolitan area in 2006; nationally, had been estimated at 10%.3,4

  • Fact Sheet: Reproductive Health Indicators in Afghanistan. UNFPA. Available at: http://www.unfpa.org/ emergencies/ afghanistan/factsheet.html.

  • Bartlett LA, et al. Afghan Maternal Mortality Study Team. Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999-2002. Lancet. 2005;365:864-70.

  • At a glance: Afghanistan statistics. Available at: http: //www.unicef.org/infobycountry/afghanistan_statistics.html.

  • MoPH/JHU/IIHMR. Afghanistan Household Survey, 2006. Kabul, Afghanistan.


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HOW DID THIS SITUATION HAPPEN?

Culture & Conflict


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CULTURAL CONTRIBUTIONS TO REPRODUCTIVE HEALTH SITUATION

  • Purdah & family honor

  • Prioritization of male education

  • Arranged marriage & familial displacement

  • Sanctioned polygamy


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CONFLICT CAN ENHANCE OR REDUCE CULTURAL EFFECTS

  • Enhancing features:

    • Fear of violence increases drive to isolate women in homes.

    • Educational & health systems disrupted.

    • Displacement to other areas or other countries may introduce critical shortages in basic living necessities.

    • Family income diminished/ diverted to supporting most pressing issues, which may no longer be health of most dependent members.

    • Death of combatants & collateral damage creates widows with little social standing or means of survival.

    • Forced early marriage/human trade to survive.

  • Diminishing features:

    • Receipt of better services as refugee in other countries.

    • Loss of sons may promote interest in educating daughters.


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HUMAN RIGHTS CONSIDERATIONS

  • Western concepts of autonomy & personal responsibility not comprehensible/tolerated in this setting.

  • Gender discrimination culturally ingrained, with religion used as legitimizing tool.

  • Gender-based violence tolerated & expected to be meted out by family in situation where group survival is threatened.

  • Cultural code of honor (pashtoonwali) is de facto legal code.


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KEY TO SUCCESSFUL PROGRAMMING: INCORPORATION & RESPECT OF CULTURAL NORMS

Examples of culturally-appropriate programming…


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REPRODUCTIVE HEALTH

  • Community midwifery program in 24 provinces.1

  • Maternity waiting home project.

  • Accelerating Contraceptive Use in Afghanistan2

    References:

    1.Huber D, et al. Accelerating Contraceptive Use Project report. Management Science in Health. Kabul, Afghanistan, 2006.


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ACKNOWLEDGEMENTS

  • Mentors:

    UCSD: Steffanie Strathdee

    MoPH: Syed A. S. Ghazanfar

    Columbia: James Phillips

    David Vlahov

  • Donors:

    • Fogarty International Center of the United States National Institutes of Health (1K01TW007408-01),

    • The Doris Duke Charitable Foundation,

    • USAID,

    • UNFPA,

    • The Global Fund to Prevent TB, HIV, and Malaria, and

    • Henry M. Jackson Foundation.

  • Colleagues at the Ministry of Public Health, particularly the directors of the Kabul maternity hospitals: Drs. Najia Tariq, Najeeba Seeamak, Nafisa Nassiry, and Hafiza Amarkhail and their staff

  • All study participants for their time and trust


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