The maternal mortality rate in Afghanistan is among the highest in the world, and is largely attributable to a lack of access to medical care. Amowitz L, Reis C, Iacopino V. Maternal mortality in Herat Province, Afghanistan, in 2002.  JAMA 2002; 288: 1284-91. [PubMed] In rural areas, in particular, there is an acute shortage of qualified medical staff to provide care in the health centres that are functioning--symptomatic of a deteriorating healthcare system suffering the effects of decades of war and lack of funding. Current estimates state that Afghanistan has only one doctor for about every 15,000 persons.Transitional Islamic Government of Afghanistan Ministry of Health. Afghanistan National Health Resources Assessment, December 2002.

Médecins Sans Frontières (MSF) opened a basic emergency obstetric unit in the Dashte Barchi clinic in Kabul, Afghanistan, in March, 2003. The unit serves women who wish to deliver in a clean and safe environment and for women who deliver at home and have acute, life-threatening complications. Midwives deal with most delivery complications on the spot, whereas the most severe and surgical cases are referred to the Mallalai hospital. From April to December, 2003, the unit assisted in 1,726 deliveries, 491 emergency consultations, and transferred 282 emergency patients. Haemorrhage, premature or prelabour rupture of membranes, pre-eclampsia, and obstructed labour, were the main reasons for transfers.

Since opening in March, 2003, the clinic has experienced a steady increase in patients, and deliveries have more than doubled. Similarly, figures from December, 2003, have shown a large and consistent increase in consultations for prenatal and postnatal care, gynaecological services, and family planning services, requiring MSF to double the number of midwives. The increase is attributed to the clinic having gained a reputation as a trusted health facility where qualified and culturally acceptable (female only) staff are available 24 hours a day, and all care is free of charge.

The trend seen at Dashte Barchi clinic is illustrative of the demand for qualified obstetric care in Afghanistan. The clinic is fortunate, in that it is easily accessible and a referral hospital is at hand for emergencies. Unfortunately, in most of Afghanistan, transport difficulties, lack of facilities, and lack of female medical staff make obstetric care inaccessible. Complications during delivery continue to be an important cause of otherwise preventable maternal deaths. Hospitals and clinics without international support lack basic materials and have extremely low salaries (a doctor earns about US$32 per month). Clinics or hospitals without support usually have inadequate supplies of fuel and other basic needs, and patients have to buy their own drugs.

Insecurity continues to take a toll on maternal health. Although rehabilitation and training will take time, in a large part of the country the process is slowed by armed conflict. Continued fighting, including the targeting of aid workers, is hindering reconstruction of the health sector and blocking much of the needed humanitarian assistance.

Efforts to reduce maternal mortality must support the training of more medical professionals, ranging from midwives to obstetric specialists, particularly women. Allocation of qualifed female health-care workers, with special attention to underserved areas, will be a priority in providing lifesaving obstetric care that is acceptable and accessible. Referral systems appropriate to the Afghan setting will also be instrumental in accessing prompt and effective care for obstetric complications.