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 • 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 • 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 • 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 • 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 • UNICEF. At a glance: Afghanistan statistics. Available at: http://www.unicef.org/infobycountry/afghanistan_statistics.html.
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.
HOW DID THIS SITUATION HAPPEN? Culture & Conflict
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 • 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 • 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 Examples of culturally-appropriate programming…
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 • 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