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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. OBJECTIVES

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reproductive health research in afghanistan elements in action

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
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.
afghanistan general picture
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.
afghanistan specific issues
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.

afghan health indicators 1990 vs 2004
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.
decade comparison of health indicators
DECADE COMPARISON OF HEALTH INDICATORS
  • UNICEF. At a glance: Afghanistan statistics. Available at: http://www.unicef.org/infobycountry/afghanistan_statistics.html.
women children affected most
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.
cultural contributions to reproductive health situation
CULTURAL CONTRIBUTIONS TO REPRODUCTIVE HEALTH SITUATION
  • Purdah & family honor
  • Prioritization of male education
  • Arranged marriage & familial displacement
  • Sanctioned polygamy
conflict can enhance or reduce cultural effects
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.
human rights considerations
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.
key to successful programming incorporation respect of cultural norms

KEY TO SUCCESSFUL PROGRAMMING: INCORPORATION & RESPECT OF CULTURAL NORMS

Examples of culturally-appropriate programming…

reproductive health
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.

acknowledgements
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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