Social Determinants of Maternal Health in Afghanistan: A Review

Main Article Content

Said Ahmad Maisam Najafizada
Ivy Lynn Bourgeault
Ronald Labonté


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.

Article Details

How to Cite
Najafizada, S. A. M., Bourgeault, I. L., & Labonté, R. (2017). Social Determinants of Maternal Health in Afghanistan: A Review. Central Asian Journal of Global Health, 6(1).
Author Biography

Said Ahmad Maisam Najafizada, Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, Canada

Assistant Professor

Faculty of Medicine 


WHO. Afghanistan: WHO Statistical Profile.; 2015.

Bartlett L a, Mawji S, Whitehead S, et al. Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999-2002. Lancet. 2005;365(9462):864-870. doi:10.1016/S0140-6736(05)71044-8.

Bartlett LA, Mawji S, Whitehead S, et al. Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999-2002. Afghanistan AMMST, ed. Lancet (British Ed. 2005;365(9462):864-870. doi:10.1016/S0140-6736(05)71044-8.

Marmot M. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Geneva: Commission on Social Determinants of Health; 2008. doi:10.1080/17441692.2010.514617.

Wilkinsn R, Marmot M. Social Determinants Of Health: The Solid Facts. (Europe RO for, Denmark., eds.). World Health Organization; 2003.

Health M of P. Islamic Republic of Afghanistan Ministry of Public Health Islamic Republic of Afghanistan Ministry of Public Health. 2010;(July).

Ameli O, Newbrander W. Contracting for health services: Effects of utilization and quality on the costs of the Basic Package of Health Services in Afghanistan. Bull World Health Organ. 2008;86(12):920-928. doi:10.2471/BLT.08.053108.

Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19-32. doi:10.1017/CBO9781107415324.004.

Amowitz LL, Reis C, Iacopino V. Maternal mortality in Herat Province, Afghanistan, in 2002: an indicator of women’s human rights. JAMA, J Am Med Assoc. 2002;288(10):1284-1291. doi:10.1001/jama.288.10.1284.

Egmond K, Bosmans M, Naeem A, Claeys P, Verstraelen H, Temmerman M. Reproductive Health in Afghanistan: Results of a Knowledge, Attitudes and Practices Survey among Afghan Women in Kabul. . Disaster. 2004;28(3):269-282.

Guidotti RJ, Kandasamy T, Betrán AP, et al. Monitoring perinatal outcomes in hospitals in Kabul, Afghanistan: The first step of a quality assurance process. J Matern Fetal Neonatal Med. 2009;22(4):285-292. doi:10.1080/14767050802464510.

Kandasamy T, Merialdi M, Guidotti RJ, et al. Cesarean delivery surveillance system at a maternity hospital in Kabul, Afghanistan. Int J Gynaecol Obstet. 2009;104(1):14-17. doi:10.1016/j.ijgo.2008.08.024.

Sanghvi H, Ansari N, Prata NJ V, Gibson H, Ehsan AT, Smith JM. Prevention of postpartum hemorrhage at home birth in Afghanistan. Int J Gynaecol Obstet. 2010;108(3):276-281. doi:10.1016/j.ijgo.2009.12.003.

Bick D. The importance of midwifery to maternal and infant health in Afghanistan: midwives making a difference. Midwifery. 2007;23(3):219-220. doi:10.1016/j.midw.2007.07.002.

Huber D, Saeedi N, Samadi AK. Achieving success with family planning in rural Afghanistan. Bull World Health Organ. 2010;88(3):227-231. doi:10.2471/BLT.08.059410.

Mayhew M, Hansen PM, Peters DH, et al. Determinants of skilled birth attendant utilization in Afghanistan: a cross-sectional study. Am J Public Health. 2008;98(10):1849-1856. doi:10.2105/AJPH.2007.123471.

Bristol N. Reconstructing Afghanistan’s health system. Lancet. 2006;366(9503):2075-2076. doi:10.1016/S0140-6736(05)67871-3.

Brown G. A day in the life. J Am Acad Physician Assist. 2010;23(6):15-16.

Tappis H, Koblinsky M, Doocy S, Warren N, Peters DH. Bypassing Primary Care Facilities for Childbirth: Findings from a Multilevel Analysis of Skilled Birth Attendance Determinants in Afghanistan. J Midwifery Women’s Heal. 2016;61(2):185-195. doi:10.1111/jmwh.12359.

Kaartinen L, Diwan V. Mother and child health care in Kabul, Afghanistan with focus on the mother: women’s own perspective. Acta Obstet Gynecol Scand. 2002;81(6):491-501. doi:10.1034/j.1600-0412.2002.810604.x.

Stephenson P. Midwives for Afghanistan. Safe Mother. 2004;31:4.

Williams JL, McCarthy B. Observations from a maternal and infant hospital in Kabul, Afghanistan--2003. J Midwifery Womens Health. 2005;50(4):e31-5. doi:10.1016/j.jmwh.2005.02.009.

Walsh D. Afghanistan’s midwives tackle maternal and infant health. Lancet. 2007;370:1299.

Walraven G, Manaseki-Holland S, Hussain A, Tomaro JB. Improving maternal and child health in difficult environments: the case for “cross-border” health care. PLoS Med. 2009;6(1):e5. doi:10.1371/journal.pmed.1000005.

Faso B, Caisses R. payment to a pre- payment system , whether you use. 2006;84(November):845-847.

Bartlett L a, Dalil S, Salama P, Mawji S, Whitehead S. Conceiving and dying in Afghanistan. Lancet. 2005;365(9476):2006. doi:10.1016/S0140-6736(05)66692-5.

Hirose A, Borchert M, Niksear H, et al. Difficulties leaving home: a cross-sectional study of delays in seeking emergency obstetric care in Herat, Afghanistan. Soc Sci Med. 2011;73(7):1003-1013. doi:10.1016/j.socscimed.2011.07.011.

Acerra JR, Iskyan K, Qureshi ZA, Sharma RK. Rebuilding the health care system in Afghanistan: An overview of primary care and emergency services. Int J Emerg Med. 2009;2(2):77-82. doi:10.1007/s12245-009-0106-y.

Hadi A, Mujaddidi MN, Rahman T, Ahmed J. The Inaccessibility and Utilization of Antenatal Health-Care Services in Balkh Province of Afghanistan. Asia-Pacific Popul J. 2007;22(1):29-42.

Shahram MS, Hamajima N, Reyer JA. Factors affecting maternal healthcare utilization in Afghanistan: secondary analysis of Afghanistan Health Survey 2012. Nagoya J Med Sci. 2015;77(4):595-607.

Ahmed A, Edward A, Burnham G. Health indicators for mothers and children in rural Herat Province, Afghanistan. Prehosp Disaster Med. 2004;19(3):221-225.

Newcomer J. Maternal Mortality in Afghanistan : An Emerging Cultural Complexity Maternal Mortality in Afghanistan : An Emerging Cultural Complexity. J Student Nurs Res. 2014;3(1).

Smith JM, Currie S, Azfar P, Rahmanzai AJ. Establishment of an accreditation system for midwifery education in Afghanistan: maintaining quality during national expansion. Public Health. 2008;122(6):558-567. doi:10.1016/j.puhe.2008.03.009.

Khorrami H, Karzai F, Macri CJ, Amir A, Laube D. Maternal healthcare needs assessment survey at Rabia Balkhi Hospital in Kabul, Afghanistan. Int J Gynecol Obstet. 2008;101(3):259-263. doi:10.1016/j.ijgo.2007.11.022.

Rahmani AM, Wade B, Riley W. Evaluating the impact a proposed family planning model would have on maternal and infant mortality in Afghanistan. Int J Health Plann Manage. 2015;30(1):71-85. doi:10.1002/hpm.2206.

Amowitz L, Iacopino V. Women’s health and human rights needs. Lancet. 2000;356:S65. doi:10.1016/S0140-6736(00)92052-X.

Hussein J, Newlands D, D’Ambruoso L, Thaver I, Talukder R, Besana G. Identifying practices and ideas to improve the implementation of maternal mortality reduction programmes: findings from five South Asian countries. BJOG. 2010;117(3):304-313. doi:10.1111/j.1471-0528.2009.02457.x.

Raj A, Gomez CS, Silverman JG. Multisectorial Afghan perspectives on girl child marriage: foundations for change do exist in Afghanistan. Violence Against Women. 2014;20(12):1489-1505. doi:10.1177/1077801211403288.

Wilson C. A “boots on the ground” perspective of caring for the women and children in Afghanistan. J Obstet Gynecol Neonatal Nurs. 2011;40(3):255-261. doi:10.1111/j.1552-6909.2011.01251.x.

Ayotte B. Women ’ s Health and Human Rights in Afghanistan : Continuing Challenges. J Ambul Care Manage. 2002;25(2):75-77.

Currie S, Azfar P, Fowler RC. A bold new beginning for midwifery in Afghanistan. Midwifery. 2007;23(3):226-234. doi:10.1016/j.midw.2007.07.003.

Hadi A, Rahman T, Khuram D, Ahmed J, Alam A. Raising institutional delivery in war-torn communities: experience of BRAC in Afghanistan. Asia Pac Fam Med. 2007;6(1):51.

Gupta S, Shuaib M, Becker S, Rahman MM, Peters DH. Multiple indicator cluster survey 2003 in Afghanistan: outdated sampling frame and the effect of sampling weights on estimates of maternal and child health coverage. J Heal Popul Nutr. 2011;29(4):388-399. doi:10.3329/jhpn.v29i4.8456.

Requejo J, Bryce J, Victora C. Countdown to 2015: Maternal, Newborn & Child Survival. Building a Future for Women and Children. World Health Organization and UNICEF; 2012.

Agha S, Carton TW. Determinants of institutional delivery in rural Jhang, Pakistan. Int J Equity Health. 2011;10(1):31. doi:10.1186/1475-9276-10-31.

Kitui J, Lewis S, Davey G. Factors influencing place of delivery for women in Kenya: an analysis of the Kenya demographic and health survey, 2008/2009. BMC Pregnancy Childbirth. 2013;13(1):40. doi:10.1186/1471-2393-13-40.

Nair M, Ariana P, Webster P. What influences the decision to undergo institutional delivery by skilled birth attendants? A cohort study in rural Andhra Pradesh, India. Rural Remote Health. 2012;12:2311.

Palamuleni M. Determinants of non-institutional deliveries in Malawi. Malawi Med J. 2011;23(4):104-108.

Tappis H, Koblinsky M, Winch PJ, Turkmani S, Bartlett L. Context matters: successes and challenges of intrapartum care scale-up in four districts of Afghanistan. Glob Public Health. 2016;11(4):387-406. doi:10.1080/17441692.2015.1114657.

Mayhew M. Salon Shame and simplicity in Afghanistan. Can Med Assoc J. 2009;180(8):896.

Marmot M. Social determinants of health inequalities. Lancet. 2005;365:1099-1104.

Hirose A, Borchert M, Niksear H, Alkozai AS, Gardiner J, Filippi V. The role of care-seeking delays in intrauterine fetal deaths among “near-miss” women in Herat, Afghanistan. Paediatr Perinat Epidemiol. 2012;26(5):388-397. doi:10.1111/j.1365-3016.2012.01299.x.

Hirose A, Borchert M, Cox J, Alkozai AS, Filippi V. Determinants of delays in travelling to an emergency obstetric care facility in Herat, Afghanistan: an analysis of cross-sectional survey data and spatial modelling. BMC Pregnancy Childbirth. 2015;15(14):(5 February 2015).

Akseer N, Salehi AS, Hossain SMM, et al. Achieving maternal and child health gains in Afghanistan: a countdown to 2015 country case study. Lancet Glob Heal. 2016;4(6):e395-e413. doi:10.1016/S2214-109X(16)30002-X.

Ahmed S, Creanga AA, Gillespie DG, Tsui AO. Economic status, education and empowerment: Implications for maternal health service utilization in developing countries. PLoS One. 2010;5(6). doi:10.1371/journal.pone.0011190.

Valle H del. Beyond the burqa : addressing the causes of maternal mortality in Afghanistan. FMR.:10-12.

Najafizada SAM. Health content of Afghan Media. Univ Ottawa. 2011;(August).