Social Determinants of Maternal Health in Afghanistan : A Review

Introduction
Afghanistan has a high maternal mortality rate of 400 per 100,000 live births. Although direct causes of maternal morbidity and mortality in Afghanistan include hemorrhage, obstructed labor, infection, high blood pressure, and unsafe abortion, the high burden of diseases responsible for maternal mortality arises in large part due to social determinants of health. The focus of this literature review is to examine the impact of various social determinants of health on maternal health in Afghanistan, filling an important gap in the existing literature.


Methods
This narrative review was conducted using Arksey and O'Malley's framework of (1) defining the question, (2) searching the literature, (3) assessing the studies, (4) synthesizing selected evidence in context, and (5) summarizing potential programmatic implication of the context. We searched Medline, CABI global health database, and Google Scholar for relevant publications.


Results
A total of 38 articles/reports were included in this review. We found that social determinants such as maternal education, sociocultural practices, and social infrastructure have a significant impact on maternal health. Health care may be the immediate determinant, but it is influenced by other determinants that must be addressed in order to alleviate the burden on health care, as well as to achieve long-term reduction in maternal mortality.


Conclusion
Because of the importance of social factors for maternal health outcomes, committed involvement of multiple government sectors (i.e. education, labor and social affairs, information and culture, transport and rural development among others, alongside health care) is the long-term solution to the maternal health problems in Afghanistan. National and international organizations' long-term commitment to social investment such as education, local economy, cultural change, and social infrastructure is recommended for Afghanstan and globally.

The social determinants of health refer to the societal factors and the unequal distribution of these factors that contribute to the overall health of the population and health inequalities.There is compelling evidence that social injustice, including inequity in social conditions, distrubition of resources, power, and opportunities, takes a massive toll on health of the population of this region, especially for women. 4,5fghanistan is struggling to build an efficient, self-reliant, and sustainable health and care for the newborn. 6However, utilization of these services is variable and inconsistent among Afghan women 7 .
In general, health care systems are focused on treating and preventing population-

Review process
This review was conducted using Arksey and O'Malley's framework of (1) defining the question, (2) searching the literature, (3)   assessing the studies, (4) synthesizing selected evidence in context, and (5) summarizing potential programmatic implication of the context. 8Based on a preliminary literature search of maternal health in Afghanistan and social determinants of health, the reviewers developed and then refined the research question.Keywords utilized in this research included "maternal health", "maternal health services", "maternal mortality", "women's health", "Pregnancy", "Pregnancy complications", "Afghanistan", "health care", "social determinants of health", "sociocultural", "social and cultural factors", and "socioeconomic factors".Google Scholar was also searched for published articles.After a process of identification and screening of citations identified, 38 article/reports met the inclusion criteria and were included in the review (Figure 1).All of the articles were published in academic journals and 32 articles had abstracts.

Inclusion and exclusion criteria
The following inclusion criteria were used: articles and reports on maternal health in   1 and 2).The most important social determinants identified in this research included health care, education, employment and income, sociocultural practices, food and sanitation.

Health care
Healthcare factors were identified as the major determinant in the reviewed studies.Guzarah had only one or two physicians. 9ter studies found that the Caesarean section (CS) rate was 10% in Kabul Maternity Hospital, and 3.5% in general hospitals, 11,12 demonstrating wide variation in the utilization of this life-saving operation.In 2010, in a nonrandomized experimental control study to test the safety, acceptability, feasibility, and effectiveness of community-based education and distribution of misoprostol for prevention of postpartum hemorrhage at home birth, only 16% of women in the intervention group and 21% of women in the comparison group received prenatal care from a midwife. 13[19][20][21][22][23][24][25][26] Published research suggests that the provision of expanded health services alone would not lead to the increased utilization of prior to the study had a skilled birth attendant at the time of delivery. 16At the same time, access to basic health care (within a two-hour walk) was estimated to be nearly 85%. 28This demonstrates that despite availability of services, utilization of these services remains low, possibly due to low level of education. 29,30In northern Afghanistan, (Balkh province), Hadi et al. found that utilization of antenatal care remained low, mainly due to significant accessibility-related problems. 29eir study concluded that inaccessibility, illiteracy, poverty, and involvement of pregnant women in economic activities (farm work) were major barriers to the use of antenatal care.Haidi et al. concluded that the health status of the population could not be improved further without fundamental changes in education, income, and quality of life. 29

Education
Education was another major determinant of maternal health in Afghanistan identified in this review.2][33]  Bartlett et al.   found that 93% of women who died due to maternity-related causes were illiterate. 3

Ahmed et al. reported that in western
Afghanistan less than 5% of pregnant women had ever attended school. 31Egmond et al.
found that in the capital city of Kabul that 64% of the women participating in the reproductive health survey never attended a regular school, and 62% were illiterate. 10A study by Khorrami and his colleagues found that higher levels of education were associated with lower rates of hemorrhagic complications during pregnancy. 34 spacing, family planning, and their overall health. 10,16,29,34,35udies found that educated women recognize emergency obstetric complications and seek medical care immediately 34 , receive antenatal care, use skilled birth attendants, use contraceptives 10,16,35 , and have lower rates of adolescent pregnancies. 10Women's education, irrespective of other socioeconomic factors, had positive contribution to improved reproductive health. 10

Sociocultural practices
7][38][39] One study in the capital city revealed the mean age at marriage was 17.2 years with 16% married at age 14 or younger. 10Another study in rural western Afghanistan found that 47% of women became pregnant before the age of sixteen. 31Two studies revealed that 83% and 75% of women respectively, expressed the view that it was a wife's duty/obligation to have sex with her husband even when she did not want to have sex. 9,10In the same study, 93% of women said that they needed authorization from their husband or a male relative to seek professional health care. 10In addition, published studies reported that that around half of the female respondents (45% and 56% respectively) reported that it was the right of a husband to beat his wife when she disobeys. 9,10[42]

Employment and Income
There is no published evidence about the link between women's formal employment and their health status, which may be related to the low employment level among women in Afghanistan.Published evidence suggests a correlation between the husband's employment, household income, the woman's economic activity, and the woman's health.
Egmond et al. found a significant association between the husband's "qualified regular job" and use of family planning, antenatal care, and the woman's delivery at a health care institution in Kabul. 10Qualified regular job was defined as employment in a government or non-government organization for men with post-secondary education.However, they did not find any association between the husbands' general employment and the woman's health. 10rious studies found a positive association between household income/wealth and women's health care utilization.birth in a health care facility was a reason for women not using health care services. 10yhew et al. found that wealth was the strongest determinant of skilled birth attendant use. 16Women in the poorest quantile had lower odds of skilled birth attendant use compared to women in each of the other quintiles; the strength of the association increased with each wealth quintile. 16While the health system is designed to accomodate the low income population, even a small fee for health care or drugs can prevent the low income population segment from accessing health care specialists.
A study by Hadi et al., which was carried out in rural areas, showed the association between women's economic activity and their health. 29The study conducted in northern Balkh province indicated that in rural areas, economically active women are much less likely to access antenatal care services compared to noneconomically active women. 29The relationship is the opposite in the urban areas, where economically active women are slightly more likely to access antenatal care services. 29 probably implies that women participating in farming, agriculture, or cattle-raising do not have control over the income generated from these activities.
Education played an important role in health care utilization among economically active women.Hadi et al. found that in rural areas, among women with at least six years of schooling, those who were economically active were more likely to use antenatal care services. 29Also, among women with little or no education, economic activity was an impediment to the use of antenatal care services.Therefore, the combination of low education, rural residence, and the need to work outside the home meant that these women were much less likely to use antenatal care services than were those who were not economically active. 29

Sanitation and Food
Lack of food, clean water, and latrines were identified as primary problems for the population in various studies. 9,10,16,31,43In a study in western Afghanistan in 2002, protected water sources and appropriate control of feces were lacking in districts under investigation. 9Latrines were used by 85.1% of households in Karokh and 28.4% in Chesht-e-Sharif. 31The most common type of latrine was the open-back latrine from which night soil is removed for fertilization of crops.The main alternative to this type of latrine was using an open field. 31In a survey, women participants identified their primary problems such as lack  of food (41%), shelter (18%), and clean water (14%). 9Lack of food (malnutrition with subsequent anemia) contributes to the increased risk of complications among pregnant women. 9Though some improvement has been made in the first decade of 21 st century, 63% of the population have no access to improved toilet facilities in 2010 and 50% were without improved water sources. 44

Discussion
The literature on maternal health in Afghanistan reveals that health care, Carton found that education was the most important predictor of women's institutional delivery. 456][47][48] Women's education levels demonstrated a significant association In addition to education, access to primary health care has also been a significant determinant, but the ability to access primary care does not help to address the underlying problems.Quantitative and qualitative studies have established that health care services, although increased in numbers, lack quality. 9,10,16There are buildings for clinics, but no doctors or midwives; there are ambulances, but no fuel; there is hightechnology equipment, but not the skills to operate them. 49  forgotten prerequisites for success in such a challenging environment". 50e notion that social determinants impact maternal health is well established in the literature. 51Studies included in this review suggest that health determinants in Afghanistan have either direct impact on maternal health or are mediated by other determinants (Figures 2 and 3).Health care services including health promotion, disease preventon, treatment facilities, and presence of skilled health personnel have a direct impact on maternal health. 9,10,13,27,30,52,53Studies also documented the direct health effects of local sociocultural practices such as childhood marriage and pregnancy, unwanted sexual activity, physical abuse, and the need to obtain permission to access health services. 10,32,38,52desirable social conditions such as lack of proper shelter, lack of potable water, and poor waste management definitely impacts maternal health. 9,10,29,3131]34 Improved transportation systems such as paved roads and availability of emergency vehicles, for example, provide access to health services, improves health service utilization, and subsequently improves maternal health. 10,30ployment, income, and wealth also influence health through access to the health care and through the intersection with education. 10,30,54udies in other developing countries support our findings that social determinants such as education, economic status, sociocultural practices, and weak infrastructure are strongly associated with maternal health. 55However, we attempted to explain the pathways by which these individual determinants intersect and impact maternal health.We believe that individual determinants cannot explain the complexity of maternal health; therefore, a web of correlations between the determinants makes the impact greater compared to the sum of all of the determinants.Thus, we suggest that among women proved to be effective in secure areas. 7Recruiting more female teachers in the schools resulted in higher attendance by female students. 56Najafizada found that the presence of female physicians on television health shows leads to an increased number of female callers responding to the show, ultimately resulting in an increased coverage time for topics related to women's health. 57wever, involvement of men in promoting women's rights is also necessary, as true empowerment takes place only when both men and women believe in the capacities of women as equitable to those of men.
care system.International organizations such as USAID, World Bank, and the European Commission are the main donors contributing to the health care system development, with national and international non-governmental organizations providing health care services.Other organizations, such as Canadian International Development Agency (CIDA), the UK's Department for International Development (DFID), German Department for International Cooperation (GIZ) and other international development agencies help to strengthen the health care system.The Afghan Ministry of Public Health plays a stewardship role and is the only organization that most people consider to be responsible for maintaining the general health of the population.The primary health care services provided for the Afghan population are delivered through the Basic Package of Health Services (BPHS).The primary health care is linked to the tertiary services also known as the Essential Package of Hospital Services (EPHS).The BPHS is designed to focus on maternal and newborn health, child health and immunization, public nutrition, communicable diseases, mental health and disability, and the supply of essential drugs.Maternal care provided in this package includes antenatal, delivery and postpartum care, family planning, based diseases; however, the comprehensive population health approach intervention takes into account social determinants of health, such as education, income, gender, housing, socioeconomic status, etc. Availability of health care services often does not guarantee their utilization.Improvement in socioeconomic factors, sociocultural beliefs, and education level has a great poteintal to improve utilization of health services.The level and the pathway of impact of the social determinants of health also differ depending on geographical and geopolitical regions.The aim of this literature review is to examine the impact of various social determinants of health on maternal health in Afghanistan, filling an important gap in the existing literature, and to identify the social determinants that influence maternal health, in This work is licensed under a Creative Commons Attribution 4.0 United States License.This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press.Central Asian Journal of Global Health Volume 6, No. 1 (2017) | ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2017.240|http://cajgh.pitt.eduorder to inform policy and programs that target maternal health in Afghanistan.
primary search of the Medline database identified 78 relevant citation titles, sociological abstract database identified 8 articles, CABI global health database identified 30 articles, and Nursing and Allied Health database identified 9. Overall, 125 citations were reviewed for this research.
This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press.Central Asian Journal of Global Health Volume 6, No. 1 (2017) | ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2017.240|http://cajgh.pitt.edufacility-based surveillance systems, nonrandomized experimental control designs, and observational and qualitative studies (Tables On the other hand, studies have found that years of schooling had a significant positive influence on the level of health services a woman would receive, birth This work is licensed under a Creative Commons Attribution 4.0 United States License.This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press.Central Asian Journal of Global Health Volume 6, No. 1 (2017) | ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2017.240|http://cajgh.pitt.edu Egmond et al. suggsted that the high cost of CENTRAL ASIAN JOURNAL OF GLOBAL HEALTH This work is licensed under a Creative Commons Attribution 4.0 United States License.This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press.Central Asian Journal of Global Health Volume 6, No. 1 (2017) | ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2017.240|http://cajgh.pitt.edu This work is licensed under a Creative Commons Attribution 4.0 United States License.This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press.Central Asian Journal of Global Health Volume 6, No. 1 (2017) | ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2017.240|http://cajgh.pitt.edu

Figure 2 .
Figure 2. Pathways through which determinants influence maternal health education, sociocultural practices, employment, income, food, and sanitation are important determinants for maternal health.Almost every article focusing on maternal health in Afghanistan points to the lack of women's decision-making ability in regards to their marriage, contraceptive use, family planning, birth spacing, and seeking health care.They are all linked to lower levels of education for women, patriarchal traditions, and weak social infrastructure and services in the country.A study in Pakistan by Agha and

Figure 3 .
Figure 3. Factors negatively (left side) and positively (right side) influencing maternal health in Afghanistan This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press.Central Asian Journal of Global Health Volume 6, No. 1 (2017) | ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2017.240|http://cajgh.pitt.edu interventions that are targeted to improve maternal health should be comprehensive.Improving maternal health is such a complex task that the Ministry of Public Health alone cannot handle it.Other governmental and nongovernmental sectors (educational organizations, labor and social services, cultural organizations, and mass media organizations) need to recognize their vital role in improving maternal health, and take appropriate policy level actions to address it.Aside from programmed approaches to address immediate maternal health challenges (such as obstetric care, access to skilled birth This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press.Central Asian Journal of Global Health Volume 6, No. 1 (2017) | ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2017.240|http://cajgh.pitt.eduattendant, antenatal and post-natal care) in the health sector, we propose three other recommendations.First, women's education should become a cornerstone of maternal health.The literature review suggested that higher level of schooling increases the age of marriage, improves woman's control over her reproductive health, health care utilization, and overall health.At the policy level, the Ministry of Education and Higher Education should recognize the significance of education and work collaboratively with the Ministry of Public Health to encourage eduation of women and girls.Second, gender specific initiatives have proven to be very useful in improving women's health.The Afghan Ministry of Public Health's strategy of deploying female health workers to remote areas to help increase acceptance and utilization of health care

Finally, without improved
social infrastructure such as provision of clean water and sanitation and work opportunities for women, further improvements in maternal health will be difficult to achieveremain a dream.Weak social infrastructure is a wellrecognized barrier to health protection and promotion for the entire population in Afghanistan.One of the limitations of this review was its inability to include all relevant studies due to limited database selection, exclusion of grey literature, and exclusion of articles published in languages other than English.The goal of this review was to capture the breadth of the available literature, thus allowing for the inclusion of multi-and cross-discliplinary articles.Using these findings as a starting point, future studies can focus on more indepth analyses of each individual health determinant important for maternal health.

Table 2 Design of articles and social determinants discussed in the papers
This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press.Central Asian Journal of Global Health Volume 6, No. 1 (2017) | ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2017.240|http://cajgh.pitt.edu This work is licensed under a Creative Commons Attribution 4.0 United States License.