Maternal mortality in Herat Province, Afghanistan, in 2002: An indicator of women's human rights

Context: Maternal mortality rates in Afghanistan are estimated to be high. Objective: To assess maternal mortality and human rights issues in Herat, Afghanistan. Design and Setting: Cross-sectional survey of 4886 Afghan women living in 7 districts in Afghanistan's Herat Province, which included 34 urban and rural villages/ towns. Using structured interviews/questionnaires, these women also provided maternal mortality information on 14085 sisters in March 2002. A survey of health facilities in the 7 districts was also conducted. Participants: Mean (SE) age of the respondents was 31 (0.23) years (range, 15-49 years). The majority had received 0.35 (0.11) years of formal education and 4233 (88%) were married (mean [SE] age at marriage, 15 [0.3] years; range, 5-39 years). The mean (SE) number of pregnancies was 5.0 (0.08) and live births was 4.6 (0.2). Results: There were 276 maternal deaths among 14085 sisters of the survey respondents (593 maternal deaths/100000 live births per year; 95% confidence interval [Cl], 557-630). Of the 276 deaths, 254 (92%) were reported from rural areas. The respondents reported the following primary problems: lack of food (41%), shelter (18%), and clean water (14%). Of 4721 respondents, 4008 (85%) wanted to get married at the time of their wedding, but 957 (20%) felt family pressure. Of 4703 women, 4117 (87%) had to obtain permission from their husband or male relative to seek health care; only 1% (54/3946) reported not being permitted to obtain prenatal care. Of 4881 women, 597 (12%) used birth control, but 23% (1013/4294) wanted to use birth control. Of 4306 women, 3189 (74%) reported that decisions about the number and spacing of children were made by husband and wife equally. Of 4637 respondents, 519 (11%) reported receiving prenatal care. Of 4624 women, 40 (0.9%) reported a trained health care worker was present at birth; 97% (4475/4612) had untrained traditional birth attendants. Only 17 of 27 listed health facilities were functional and only 5 provided essential obstetric care. Only 35 physicians served a population of 793 214. Conclusions: Women in most of Herat Province, Afghanistan, have a high risk of maternal mortality. Human rights factors may contribute to preventable maternal deaths in the region.