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Social Determinants of Maternal 
Health in Afghanistan: A Review 
 

Said Ahmad Maisam Najafizada1, Ivy 
Lynn Bourgeault2, Ronald Labonté3 

 
1Division of Community Health and 
Humanities, Faculty of Medicine, Memorial 
University of Newfoundland, Canada; 
2Telfer School of Management, University of 
Ottawa, Canada;  

3School of Epidemiology, Public Health and 
Preventive Medicine, University of Ottawa, 
Canada 
 

Vol. 6, No. 1 (2017)   |   ISSN 2166-7403 (online)  

DOI 10.5195/cajgh.2017.240 |   http://cajgh.pitt.edu 

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Abstract 

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. 

Keywords: Maternal health, Afghanistan, healthcare utilization, review  

Social Determinants of Maternal 
Health in Afghanistan: A Review 
 

Said Ahmad Maisam Najafizada1, Ivy 
Lynn Bourgeault2, Ronald Labonté3 
 
1Division of Community Health and 
Humanities, Faculty of Medicine, Memorial 
University of Newfoundland, Canada; 
2Telfer School of Management, University of 
Ottawa, Canada; 
3School of Epidemiology, Public Health and 
Preventive Medicine, University of Ottawa, 
Canada 

Research 

Afghanistan has a high maternal mortality 
of 400 per 100,000 live births, compared to 
320 regionally and 280 globally.1 While the 
maternal mortality rate has decreased 
dramatically since 20002, there is still a 
significant  burden of maternal morbidity and 
mortality in Afghanistan mainly attributed to 
hemorrhage, obstructed labor, infection, high 
blood pressure, and unsafe abortions3.  

Marmot describes the high burden of 
disease responsible for premature loss of life 
arising primarily from the conditions in which 
people are born, grow, live, work, and age.4 

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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.4,5  

Afghanistan is struggling to build an 
efficient, self-reliant, and sustainable health 
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, 
and care for the newborn.6 However, 
utilization of these services is variable and 
inconsistent among Afghan women7.  

In general, health care systems are 
focused on treating and preventing population-
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 

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order to inform policy and programs that target 
maternal health in Afghanistan.  
 
Methods 
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.8 Based 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”. 
 
Data sources 

A 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. 

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.  

 

 
Figure 1: Flow chart of the review 
 
Inclusion and exclusion criteria 

The following inclusion criteria were 
used: articles and reports on maternal health in 
Afghanistan, articles discussing social 
determinants of maternal health, reports 
published between 2000 and 2016, articles and 
reports written in English, and quantitative and 

125 potentially relavant articles extracted 
from Medline, Social Abstract, CABI  

Global health, Nursing and Allied Health 
databases 

51 articles retrieved for further 
assessment 

15 articles excluded on the 
basis of full text review 

38 articles included in the 
review 

2 articles identified from 
references of the reviewed 

article 

74 articles excluded on the 
basis of relevance of title and 

abstract  

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qualitative studies. Articles were excluded 
according to the following criteria: articles and  
reports with main focus other than 
Afghanistan, articles and reports with main 
focus other than maternal health in 
Afghanistan, articles focused on refugees,  

articles published before 2000 or after 2016, 
and articles not in English. 
 
Results 

Articles reviewed in this study included: 
cross-sectional studies, cluster surveys, 

Study design Number of 
Articles 

Observational Study Household Survey (Retrospective Cohort Study, 
Multiple Indicator Cluster Survey) 

8 

Cross-sectional Survey 3 
Administrative data base study (labour and 
delivery logbook, Operating Room logbook) 

2 

Case Study 3 
Descriptive Survey, 1 
Needs assessment survey 1 
Questionnaire/Interview/Observation 1 
Baseline and endline Survey 1 

 Subtotal 20 
Experimental Study Nonrandomized Experimental Control Design 2 

Community based intervention 1 
Knowledge-Attitude-Practice Survey 1 

 Subtotal  4 
Others Perspective and Observation 6 

Editorial 4 
World Report 2 
Literature review 1 
Conference proceeding 1 

 Subtotal 14 
 Total 38 
Table 1: Designs of studies and reports 
 

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facility-based surveillance systems, 
nonrandomized experimental control designs, 
and observational and qualitative studies 
(Tables 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. 
Accessibility, lack of healthcare professionals, 
and variability in the utilization of health care 
services were major problems for Afghan 
women. In a study of maternal mortality 
conducted in western Afghanistan before the 
start of the BPHS program, Amowitz et al. 
found that only 63% of the health facilities 
listed by WHO as functional were in 
operation.9 All health facilities with 
Emergency Obstetric Centers were located in 
one district, which was not accessible by 
women in any of the rural districts. In a 
reproductive-health knowledge, attitudes, and 
practices (KAP) survey in the capital Kabul, 
Egmond et al. found that 18.2% of the 
population thought the health facility was too 
far away and 14.2% reported that  
transportation to the medical facility was a 
problem.10 The situation was even worse for 
women residing in the rural areas. In 2002, 

Amowitz et al. found that seven districts of 
Herat Province namely Adraskan, Pashtun 
Zarghon, Zendajan, Enjil, Karokh, Herat, and 
Guzarah had only one or two physicians.9 
Later 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 Lack 
of human and technical resources were the 
major reported reasons associated with adverse 
maternal and infant health outcomes in the 
poor-resource setting of Afghanistan.14–16 The 
findings of the studies conducted between 
2001 and 2011 that there is a need to improve 
health facilities, and to increase the number of 
professionals in both urban and rural areas in 
order to improve maternal health.17–26  

Published research suggests that the 
provision of expanded health services alone 
would not lead to the increased utilization of  

 
 
 

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Articles  
 

Design Social Determinants  

1. Ahmed, Edward, & 
Burnham, 2004 

*Obs: Multiple indicator 
cluster survey 

Education; sanitation (water and 
latrine); health care; sociocultural 
practices 

2. Amowtiz & Iacopino, 2000 Perspective Health care; sociocultural 
practices 

3. Amowitz, Ris, & Iacopino, 
2002 

Obs: Cross-sectional survey Food; housing; sanitation (lack of 
clean water); sociocultural 
practices 

4. Ayotte, 2002 Perspective Sociocultural practices 
5. Bartlett et al., 2005 Obs: Household survey Health care; education; housing; 

food 
6. Bick, 2007 Editorial Health care 
7. Bristol, 2006 World Report Health care 
8. Brown, 2010 Perspective Health care 
9. Currie, Azfar & Fowler, 
2007 

Case study Health care (Human Resources 
for Health: midwives) 

10. del Valle, 2004 Perspective Sociocultural practices 
11. Stephenson, 2004  Editorial Health care (HRH) 
12. Egmond et al., 2004 **Exp: KAP Health care; Education 
13. Garwood, 2006 Perspective Health care; Transport 
14. Guidotti et al., 2009 Obs: Administrative 

database 
Health care 

15. Gupta et al., 2011 Obs: Multiple Indicator 
Survey 

Health care; Education; Food 

16. Hadi et al., 2007 Obs: Cross-sectional 
approach 

Education; Income/employment; 
Health care 

17. Hadi et al., 2007 Obs: Descriptive survey Health care 
18.  Huber, Saeedi & Samadi, 
2010 

Exp: Community-based 
intervention 

Health care; sociocultural 
practices 

19. Hussein et al., 2009 Obs: Cross-sectional  Health care; sociocultural 

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practices 
20. Kaartinen & Diwan, 2002 Obs: Needs assessment 

survey 
Health care; sociocultural 
practices 

21. Kandasamy et al., 2009 Obs: Administrative 
logbooks  

Health care 

22. Khorrami et al., 2008 Obs: Needs assessment 
survey 

Health care; transport; income 

23. Mayhew, 2009 Perspective Health care 
24. Mayhew et al., 2008 Obs: Cross-sectional  Health care; education; income; 

transport 
25. Sanghvi et al., 2010 Exp: Nonrandomized 

Experimental Control 
Design 

Health care 

26. Smith & Burnham, 2005 Perspective Health care; sociocultural 
practices 

27. Smith et al., 2008 Obs: Case study Health care; education 
28. Walraven et al., 2009 Perspective Health care 
29. Walsh, 2007  Perspective Health care 
30. Williams & McCarthy, 
2003 

Perspective Health care 

31. Wilson, 2011 Perspective Health care; sociocultural 
practices 

32. Rahmani et al., 2015 Exp: Multiple indicator 
regression 

Health care; sociocultural 
practices 

33. Akseer et al., 2016 Exp: Household survey 
analysis 

Health care; sociocultural 
practices; education 

34. Rasooly et al., 2014 Exp: Household survey 
analysis 

Health care; sociocultural 
practices, education; income 

35. Shahram et al., 2015 Exp: Household survey 
analysis 

Health care; sociocultural 
practices; education; income 

36. Newcomer, 2014 Perspective Sociocultural practices; 
education; income 

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37. Tappis et al., 2016 Exp: Cross-sectional 
analysis 

Health care; income 

38. Speakman et al., 2014 Case study Health care; education 

*Obs = Observational   

**Exp = Experimental 

Table 2 Design of articles and social determinants discussed in the papers 
 

antenatal care,19,27 as some women were more 
likely to use services than others, depending 
on their education, family income, social 
status, and beliefs. A national cross-sectional 
study by Mayhew et al. in 2008 found that 
only 13% of women who gave birth two years 
prior to the study had a skilled birth attendant 
at the time of delivery.16 At the same time, 
access to basic health care (within a two-hour 
walk) was estimated to be nearly 85%.28 This 
demonstrates that despite availability of 
services, utilization of these services remains 
low, possibly due to low level of 
education.29,30 In northern Afghanistan, (Balkh 
province), Hadi et al. found that utilization of 
antenatal care remained low, mainly due to 
significant accessibility-related problems.29 
Their 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. Our review of the 
literature found that education level has been 
associated with improved health care 
utilization, increased birth spacing, and 
empowered women. 3,10,31–33 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. 31 Egmond 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.10 A study by 
Khorrami and his colleagues found that higher 
levels of education were associated with lower 
rates of hemorrhagic complications during 
pregnancy.34 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 

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spacing, family planning, and their overall 
health.10,16,29,34,35   
 Studies found that educated women 
recognize emergency obstetric complications 
and seek medical care immediately34, receive 
antenatal care, use skilled birth attendants, use 
contraceptives10,16,35, and have lower rates of 
adolescent pregnancies.10 Women’s education, 
irrespective of other socioeconomic factors, 
had positive contribution to improved 
reproductive health.10  
 
Sociocultural practices 
 Patriarchal societal practices such as 
early marriage, rights surrounding sexual 
practices, and need to obtain husband’s 
permission to receive health care, all have 
large impact on women’s health in 
Afghanistan.15,27,32,36–39 One study in the 
capital city revealed the mean age at marriage 
was 17.2 years with 16% married at age 14 or 
younger.10 Another study in rural western 
Afghanistan found that 47% of women became 
pregnant before the age of sixteen.31 Two 
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.9,10 In the same study, 93% of women said 
that they needed authorization from their 
husband or a male relative to seek professional 
health care.10 In 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 These 
factors are strongly linked to the traditional 
attitudes that prevail in Afghan society, where 
reproduction remains the predominant role for 
women. 10,40–42  
 
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.10  Qualified 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.10 
 Various studies found a positive 
association between household income/wealth 
and women’s health care utilization.10,16,29 
Egmond et al. suggsted that the high cost of 

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birth in a health care facility was a reason for 
women not using health care services.10 
Mayhew et al. found that wealth was the 
strongest determinant of skilled birth attendant 
use.16 Women 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.16 While 
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.29 The 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 non-
economically active women. 29 The 
relationship is the opposite in the urban areas, 
where economically active women are slightly 
more likely to access antenatal care services.29 
It 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.29 Also, 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. 9,10,16,31,43 In a 
study in western Afghanistan in 2002, 
protected water sources and appropriate 
control of feces were lacking in districts under 
investigation.9 Latrines were used by 85.1% of 
households in Karokh and 28.4% in Chesht-e-
Sharif.31 The 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.31 In a survey, women participants 
identified their primary problems such as lack 

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Figure 2. Pathways through which determinants influence maternal health 

of food (41%), shelter (18%), and clean water 
(14%).9 Lack of food (malnutrition with 
subsequent anemia) contributes to the 
increased risk of complications among 
pregnant women.9 Though some improvement 
has been made in the first decade of 21st 
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, 
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 
Carton found that education was the most 
important predictor of women’s institutional 
delivery.45 Education was linked with better 
maternal health in other rural settings of low-
income countries such as Pakistan, India, 
Laos, and Malawi.45–48 Women’s education 
levels demonstrated a significant association 

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NAJAFIZADA 
 

 
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Figure 3. Factors negatively (left side) and positively (right side) influencing maternal 
health in Afghanistan 

with health care utilization, lower fertility rate, 
family planning, and improved maternal 
health. In general, better education decreases 
unhealthy social practices such as early 
childhood marriage and adolescent pregnancy. 
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.9,10,16 There are buildings for clinics, 
but no doctors or midwives; there are 
ambulances, but no fuel; there is high-
technology equipment, but not the skills to 
operate them.49 Mayhew argues that there is a 
need for large-scale implementation of low-
technology, simple solutions in rural areas 
where the majority of people live. “Defining 
reality and maintaining simplicity are too often 

Maternal 
health 

Health care 
• Health care access 
• Health care utilisation 
• Health care quality 

Sociocultural practices 
• Early marriage & Adolescent 

pregnancy 
• Absence of women's right to 

(reproductive) health 
• Husband's physical abuse 
• Women's internalisation of 

patriarchal values 

Education 
• Low  women's education  level      
•  low men's education level 

Income/employment 
• Low household income/wealth 
• Illiterate women's economic 

activity 

Water/Food/Sanitation 
• Lack of clean water 
• Unbalanced diet (Anaemia 

during pregnancy & 
Complication of pregnancy 

•  Poor sanitation   

Education 
• Mandatory secondary education 

(until 12th grade) 
• Health related education 
• Woman’s right related 

education 

Sociocultural practices 
• Criminalisation of marriage 

below 18 
• Promoting women’s rights 

through mass communication 
campaigns s 

Social Services 
• Improved health care access 

and quality 
• Provision of clean water and 

sanitation 
•  Creating job opportunities  

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forgotten prerequisites for success in such a 
challenging environment”. 50  

The notion that social determinants 
impact maternal health is well established in 
the literature.51 Studies 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. 9,10,13,27,30,52,53 Studies 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.10,32,38,52 
Undesirable social conditions such as lack of 
proper shelter, lack of potable water, and poor 
waste management definitely impacts maternal 
health.9,10,29,31  

Women’s education, on the other hand, 
improves the social status of women in the 
family and alters the undesirable and health-
deteriorating sociocultural practices, and thus 
improves maternal health.3,29–31,34 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.10,30 

Employment, income, and wealth also 
influence health through access to the health 
care and through the intersection with 
education.10,30,54  

Studies 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.55 However, 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 
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 non-
governmental 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 

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attendant, 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 
among women proved to be effective in secure 
areas.7 Recruiting more female teachers in the 
schools resulted in higher attendance by 
female students.56 Najafizada 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.57 
However, 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. 

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 well-
recognized 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 in-
depth analyses of each individual health 
determinant important for maternal health. 
 
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	Social Determinants of Maternal Health in Afghanistan: A Review
	Abstract
	Keywords: Maternal health, Afghanistan, healthcare utilization, review
	Social Determinants of Maternal Health in Afghanistan: A Review
	Research
	Figure 3. Factors negatively (left side) and positively (right side) influencing maternal health in Afghanistan

