AFGHANISTAN – The crisis of maternal and child health

by Nancy Glass, Rabia Jalalzai, Paul Spiegel, Leonard Rubenstein

BMC Conflict and Health 2023;17(28)

Background — When the Taliban first seized power in 1996, Afghanistan’s healthcare system had already suffered from decades of war and limited investment by past governments. The country had some of the highest rates of maternal, infant and child mortality in the world. During Taliban rule, morbidity, and mortality for women, infant and children worsened. The regime’s prohibition on women working outside the home or attending school, including female health care professionals, severely affected women’s lives, and undermined the health of the nation’s women and families. After the Taliban regime fell in 2001, the Ministry of Public Health (MOPH) inherited a healthcare system characterized by a shortage of human resources, particularly women, an infrastructure in ruins, and no sound data on the population’s health. In response, the European Union (EU), United States Agency for International Development (USAID), and the World Bank provided sustained funding of hundreds of millions of US dollars for health services and partnered with the MOPH in creating an effective system of primary and secondary health care, training a new generation of healthcare professionals, including women.

…From 2013 to 2018, the System Enhancement for Health Action Transition (Sehatmandi) project supported a basic package of health services and essential package of hospital services under one umbrella through the Afghanistan Reconstruction Trust Fund platform. It was administered by the Ministry of Public Health, which contracted with NGOs to provide services. As a result of significant investment in health, including recruitment and training of midwives, and Afghan leadership, despite an ongoing war that included violence inflicted on health personnel and facilities, Afghanistan reduced maternal mortality from approximately 1,450 deaths per 100,000 live births in 2000 to 638 deaths per 100,000 live births in 2017; infant mortality from 88 deaths per 1,000 live births in 2001 to 45 deaths per 1000 live births in 2020 and under 5 years mortality reduced from 125 death per 1,000 in 2001 to 58 deaths per 1000 in 2020. Access to health care improved dramatically for the whole society with more than 2,000 functioning healthcare facilities, including primary health centers, district hospitals, provincial hospitals, and specialized hospitals.

The Taliban takeover in August 2021 brought global economic sanctions, economic collapse, and draconian restrictions on women’s freedom of movement, work, political participation, and education. This study examined Afghan health workers’ experiences and perceptions of availability and quality of maternal and child health care since then.

Methods — We conducted a survey, using a convenience sample, of health workers from urban, semi-rural, and rural public and private clinics and hospitals across the 34 provinces, covering changes in working conditions, safety, health care access and quality, maternal and infant mortality as well as perceptions about the future of maternal and child health and health care. Interviews were conducted with a subsample of health workers to further explore their perceptions of changes in working conditions, quality of care, and health outcomes since the Taliban takeover.

Results — 131 Afghan practicing health care workers completed the survey. The majority were women (80%) working in facilities located in urban areas. Most female health workers (73.3%) reported that they have not always been safe when going to and from work; 81% because of harassment by the Taliban when they did not have male accompaniment. Almost half of the respondents (42.9%) reported a decrease in availability of maternal and child care and 43.8% stated that conditions for providing care were “worse” or “much worse” than before. Almost one-third (30.2%) indicated that changed working conditions negatively impacted their ability to provide quality care, and 26.2% reported an increase in obstetric and newborn complications. Health workers also reported (38.1% )an increase in sick child needs and an increase in child malnutrition (57.1%0. 57.1% reported decreases in work attendance and 78.6% a decrease in morale and motivation. Qualitative interviews (n = 10) of a subsample of survey participants expanded on these findings.

Conclusion — The combination of economic collapse, lack of sustained donor support for health care and Taliban interference with human rights has severely compromised access and quality of maternal and child health care. Strong and concerted international pressure on the Taliban to respect women and children’s rights to essential health service is critical for the future of the Afghan population.

SOURCE: Inter-Agency Working Group (IAWG) on Reproductive Health in Crises. E-mail: 3 July 2023

PHOTO: NPR, by Wakil Kohsar/AFP via Getty Images. Nurses feed newborn babies rescued and brought to Ataturk National Children’s Hospital in Kabul on 15 May 2020, after their mothers were killed in an attack on a maternity ward operated by Doctors Without Borders.