“Even on a mountain, there is still a road.” Pashto proverb
Why are women just over the border of a small 60 foot river, in Tajikistan, about fifty times less likely to die in childbirth as compared to women in Afghanistan?
Words have been spilled generously attempting to describe the difficult terrain (both topological and political) of Afghanistan. Less has been devoted to the deep-boned stubbornness, a defiance, which living in this gnarly terrain has forged in its people. It is stubbornness to outside rulers (whether Alexander the Great or the Soviets), stubbornness with traditions, and stubbornness in both friendships and enmities. Wars have laid waste to a land that was once a geo-economic fixture on the Silk Road and a central post of the Mughal Empire, but stubbornness has allowed a people to survive.
Conflict is an eternal presence. Within this patchwork nation of tribal allegiances of Pashtuns, Tajiks, Uzbeks, and Hazaras. Out of this unending clashes emerged a truly horrifying state of affairs for women, especially under Taliban rule. Today, abuses and subjugation are regular features of nearly every woman’s life. The threat of violence is an everyday reality for those who dare to advocate for the rights of women. 87% experience domestic violence, women earn 25 cents to every man’s dollar, and the life expectancy for women is under 50 years old.
It’s without doubt the worst country on earth for women.
Maternal mortality rates (1 in 11 mothers die of pregnancy-related causes) and child mortality rates (1 in 10 will die before their fifth birthday) are astronomical. Fatal landmines across Afghanistan’s provinces are not just hidden in fields, but also in the delivery room and in the vaccine-less clinics.
This was the state of maternal child health that Kylea Liese, a medical anthropologist and certified midwife, encountered in the Badakhshan province of Afghanistan (around 2008). Traditional birth attendants abound and have been known to “sever the umbilical cord with broken glass or the edge of a shoe.”
Kylea Liese found that Badakshan was even worse than the rest of Afghanistan. The risk of dying during childbirth was at near flipping-a-coin levels: 1 in 3. But while Liese (at the time a post-doctoral fellow at Stanford) was troubled by the abominable death rates, she was intrigued by the contrast that a small trip across the Panj River into Tajikistan where the lifetime risk of dying was at 1 in 115.
What accounted for this difference? The simplest explanation would be access to advanced obstetric care, like the kind we do in the United States. However, the reality on the ground denied that claim. In Tajikistan, maternal mortality was dramatically lower, despite substandard obstetric care.
Liese found that “socially stratified risk” explained far more: the visibility of women in the public sphere alone tracked better with lowered risk for obstetric complications. She found that in Tajikistan, more attention to reproductive health and girls' education laid a lifelong trajectory of resilience for women, Whereas the lack of these factors in Afghanistan put women at tremendous risk during childbirth.
These “local moral worlds” were ones that she saw through ethnographies of community midwifery programs in the Kunduz, Takar, and Badakshan provinces. They were products of international forces disrupting and creating local histories of violence. War had weaved its way into mortality during childbirth. We will explore more of Liese's important findings in the next blog. Stay tuned.
Photo credit: February 16, 2010, by "Afghanistan Matters." Creative Commons.
Jean M. Bouquet, DO, is an Assistant Professor of Family Medicine and Co-Director of the Urban Underserved Track at the Rocky Vista University College of Osteopathic Medicine. He is the founder of the Bouquet Speculum, an innovative and FDA-cleared medical device that helps to screen women for cervical cancer. Dr. Bouquet also started the Cure Cervical Cancer nonprofit. The following blog post was written by Dr. Bouquet about his journey to creating the Bouquet Speculum.
Dr. Daniel Kimani is a trained and licensed medical officer in Kenya, holding a Bachelor of Medicine & Surgery, and a post-graduate certificate on basic oncology training. Dr. Kimani is the founder of the Global Cancer Care and Research Institute, and is an expert in clinical colposcopy — a procedure to examine the cervix, vagina, and vulva.