Where giving birth is a forecast of death: Maternal mortality in four districts of Afghanistan, 1999-2002

Background: Maternal mortality in Afghanistan is uniformly identified as an issue of primary public-health importance. To guide the implementation of reproductive-health services, we examined the numbers, causes, and preventable factors for maternal deaths among women in four districts. Methods: We did a retrospective cohort study of women of reproductive age (15-49 years) who died between March 21, 1999, and March 21, 2002, in four selected districts in four provinces: Kabul city, Kabul province (urban); Alisheng district, Laghman province (semirural); Maywand, Kandahar province (rural); and Ragh, Badakshan province (rural, most remote). Deaths among women of reproductive age were identified through a survey of all households in randomly selected villages and investigated through verbal-autopsy interviews of family members. Findings: In a population of 90 816, 357 women of reproductive age died; 154 deaths were related to complications during pregnancy, childbirth, or the puerperal period. Most maternal deaths were caused by ante-partum haemorrhage, except in Ragh, where a greater proportion of women died of obstructed labour. All measures of maternal risk were high, especially in the more remote areas; the maternal mortality ratio (per 100 000 livebirths) was 418 (235-602) in Kabul, 774 (433-1115) in Alisheng, 2182 (1451-2913) in Maywand, and 6507 (5026-7988) in Ragh. In the two rural sites, no woman who died was assisted by a skilled birth attendant. Interpretation: Maternal mortality in Afghanistan is high and becomes significantly greater with increasing remoteness. Deaths could be averted if complications were prevented through optimisation of general health status and if complications that occurred were treated to reduce their severity - efforts that require a multisectoral approach to increase availability and accessibility of health care.