Intended for healthcare professionals

Opinion

To sustain maternal and newborn health in Afghanistan under the Taliban regime, midwifery must be prioritised

BMJ 2022; 376 doi: https://doi.org/10.1136/bmj.o653 (Published 11 March 2022) Cite this as: BMJ 2022;376:o653
  1. Esther Sharma, midwife and doctoral researcher1,
  2. Sebera Turkmani, research fellow2, former President3,
  3. Diane Duclos, assistant professor1,
  4. Natasha Howard, associate professor14
  1. 1London School of Hygiene and Tropical Medicine
  2. 2University Technology Sydney School of Nursing and Midwifery
  3. 3Afghan Midwives Association
  4. 4National University of Singapore Saw Swee Hock School of Public Health
  1. Twitter: @maternalmatters; @TurkmaniSabera; @DianeDuclos5; @howardsends

Following the withdrawal of US troops from Afghanistan in August 2021 and the Taliban’s rapid takeover, maternal and newborn health are at risk while the long term impact remains to be seen. During previous Taliban control (1996-2001), maternal and newborn health outcomes were among the worst globally, with maternal mortality ratios estimated at 1600 per 100 000 live births and an infant mortality rate of 90 per 1000 live births in 2000.12 Women faced extreme restrictions, which contributed to high levels of illiteracy and inaccessibility of reproductive, maternal, and newborn health services, including no skilled birth attendants for most women. Deteriorating physical and psychological health of women was reported and maternal mortality was the leading cause of death for women of reproductive age.34

Significant maternal and newborn health gains have been made since the initial defeat of the Taliban following the 2001 US-led invasion. Between 2000 and 2017, Afghanistan was one of the countries to achieve at least a 50% reduction in its maternal mortality ratio and an increase of over 15% of births attended by midwives, nurses, or in health facilities.5 By 2019, the infant mortality rate was 47 per 1000 live births—almost halved from rates observed in 2000.2 Central to these achievements was the scaling up of midwifery in Afghanistan.6 Midwifery education was identified as a key strategy to improving maternal and newborn health, and by 2010 it was expanded to 34 provinces aiming to increase women’s access to trained midwives, particularly in rural and remote areas. The first Afghan Midwives Association was formed in 2005, in partnership with the Afghan government, to lead in advocating necessary reforms in policies and strategies concerning maternal and newborn health and women’s rights.7 Midwives became the backbone of sexual and reproductive health improvements. By 2017, the maternal mortality ratio had dropped to 638 per 100 000 live births—a huge improvement, yet still among the 10 highest maternal mortality ratios globally.8 The situation remained fragile, with the health system reliant on financial and technical support from international donors, increased attacks on health facilities in recent years, and deteriorating security.9 Additionally, the covid-19 pandemic is thought to have led to a 14% decline in perinatal outpatient appointments.10

Thus far, the newly-formed Taliban government appears to be enforcing restrictions on the public life of women and girls. It has indicated that women should not be employed in roles that men can do, or work alongside men, and that women—while still needed in healthcare—cannot work alongside men but instead in female-only hospitals.11 Although the Taliban regime has not banned university education for women, very few girls are able to continue education beyond sixth grade (ages 11-12), albeit with some notable exceptions.12 The Taliban indicated education for this group of girls will resume in March 2022, but many doubt this will occur.13 Even if girls are allowed to return to school, there are obstacles to accessing ongoing education, such as requirements for girls to only leave the house with a close male relative and school classrooms too small to accommodate the segregation of boys and girls the Taliban require. Unless education of girls beyond sixth grade is permitted and made readily accessible, it will not be long before there are insufficient educated girls able to enter university for midwifery training.

Meanwhile, the numbers of midwives and clinicians who have recently left Afghanistan is unknown. International funding to the health system was frozen when the Taliban retook Afghanistan, causing rapid health system deterioration, with health facilities unable to pay staff and major reductions in women health workers.14 On 5 September 2021, the Afghan Midwives Association released a statement calling for the release of funds from The World Bank, USAID, and other major donors. Now, in the face of an unfolding humanitarian catastrophe in Afghanistan, international funding is being released. However, questions remain as to how this will support health systems, how healthcare spending will be prioritised and what mechanisms will ensure transparent and effective expenditure of funds under the Taliban. While this financial relief is widely welcomed, it is a short term response and as yet there are no plans to support health services on a longer term basis. The outlook for maternal and newborn health therefore appears bleak.

Sustaining and supporting midwifery in Afghanistan must be a global commitment regardless of the political environment. It is imperative that midwives continue being paid, funding is provided for maintaining health facilities, and that midwifery education continues scaling up. Reliance and trust in Taliban governance of international aid appears unwise and close monitoring of health funding distribution is needed to prevent corruption and ensure women are able to access quality maternity services, and thus sustain and build upon the huge improvements made in maternal and newborn health in Afghanistan since the end of the previous Taliban regime.

Footnotes

  • Competing interests: none

  • Provenance and peer review: not commissioned, not externally peer reviewed

References