Afghanistan: in the aftermath of conflict: Mary Gibson and Dineke Mol write of their experiences in Afghanistan aiming to re-establish midwifery training, increase skilled attendance at birth and improve outcomes for women.

• Auteur: Gibson, Mary

Suffering characterises the life of women in Afghanistan. All women, urban and rural, live with misery and stress. Education and health services for women have never been adequate, but are particularly limited at present. Pushtoon women living in rural areas have always experienced limited civil rights due to repressive traditions and lack of education. Under Taliban rule, urban women's rights were equally limited.

Although Afghanistan has received worldwide attention over the past year, it existed in relative obscurity over the previous 20 years, which were also fraught with conflict and misery for its people. The country has a rugged mountainous terrain, an arid climate and extreme seasonal temperature fluctuations. The majority of its population lives in rural areas, which are isolated from the rest of the country--and indeed from the world--due to bad roads, no transport (except pack animals) and lack of power and communication systems. In addition to the tyranny of the Taliban over the past five years, the country has suffered from a nationwide drought, which has caused food shortages and widespread malnutrition.

Women's and children's health

In terms of maternal and child health, WHO estimates infant mortality in Afghanistan to be 165 per 1,000 live births, while mortality among under-fives may be as high as 257 per 1,000 (data from UNDP, 1995). The estimated maternal mortality rate throughout Afghanistan is possibly as high as 1,000 per 100,000 and the lifetime risk of maternal death is 1 in 7.

The organisation Physicians for Human Rights conducted a survey, in March 2002, in Herat Province to assess maternal mortality and human rights issues in an attempt to verify estimates that Afghanistan women experience some of the world's worst maternal mortality rates. The results showed a maternal mortality ratio of 593 per 100,000 live births. It is estimated that 92% of those deaths occur in rural areas where the majority of the population lives. Fewer than 11% of women received antenatal care and less than 1% of births were attended by skilled birth attendants. Complications of pregnancy and delivery are the primary killers of women between 15 and 45 years of age, with postpartum haemorrhage being the major cause of maternal mortality. There is little use of contraception in the country due to inadequate knowledge, unavailability and cultural restrictions. Women in the survey ranked their chief problems to be: lack of food, lack of adequate shelter, and lack of clean water.

The low status of women in Afghanistan impacts on their health in a variety of ways. Adolescent girls are expected to enter into arranged marriages at puberty. Of the women surveyed, 86% felt that women should be allowed to choose a husband, as well as deciding the number and spacing of children. In this survey the mean age of marriage was found to be 15 (range 5-39) and the mean number of pregnancies was 5 (range 0-20)...