Background: Estimated at 3.6 million, Afghans are the largest population of refugees in the world. Information on the magnitude, causes, and preventable factors of maternal deaths among Afghan refugees may yield valuable information for prevention. Methods: Deaths were recorded between Jan 20, 1999, and Aug 31, 2000, during a census carried out in 12 Afghan refugee settlements in Pakistan. Deaths among women of reproductive age (15-49 years) were further investigated by verbal autopsy interviews to determine their cause, risk factors, and preventability, and to ascertain the barriers faced to obtaining health care. Findings: The census identified 13 4406 Afghan refugees and 1197 deaths; a crude mortality rate of 5.5 (95% CI 5.2-5.8) per thousand population. Among the 66 deaths among women of reproductive age, deaths due to maternal causes (n=27) exceeded any other cause (41% [95% CI 29-53]). 16 liveborn and nine stillborn infants were born to women who died of maternal causes; six of the liveborn infants died after birth. Therefore, 60% (15 of 24) of infants born to these women were either born dead or died after birth. Compared with women who died of non-maternal causes, women who died of maternal causes had a greater number of barriers to health care (p=0.001), and their deaths were more likely to be preventable (p<0.05). Interpretation: Maternal deaths account for a substantial burden of mortality among Afghan refugee women of reproductive age in Pakistan. The high prevalence of barriers to health care access indicates opportunities for reducing maternal deaths in refugee women and their children.
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