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Letter From Herat
September 11, 2002

Maternal Mortality in Herat Province, Afghanistan, in 2002An Indicator of Women's Human Rights

Author Affiliations

Author Affiliations: Physicians for Human Rights, Boston, Mass (Drs Amowitz and Iacopino and Ms Reis); and Brigham and Women's Hospital and Harvard Medical School, Boston, Mass (Dr Amowitz).


Section Editor: Annette Flanagin, RN, MA, Managing Senior Editor.

JAMA. 2002;288(10):1284-1291. doi:10.1001/jama.288.10.1284

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 14 085 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 14 085 sisters of the survey respondents (593 maternal deaths/100 000 live births per year; 95% confidence interval [CI], 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.