During the summer of 2003, through a grant from the UCLA Bixby Program in Population and Reproductive Health, I had an opportunity to visit Afghanistan. The goal of my trip was to learn about the ongoing programs on reproductive health in Afghanistan and to try to establish links between the School of Public Health at UCLA and the non-government organizations (NGOs) in Afghanistan working on health issues. I visited several NGOs active in Afghanistan and was able to visit hospitals and family planning clinics in and outside of Kabul, the capital city. My familiarity with the culture and the fact that I was able to communicate in the official language of the country enabled me to start my activities and learn about Afghan society very quickly.

War and civil conflict in Afghanistan have deteriorated the infrastructure of the country to a point that even basic services such as electricity, running water and adequate sanitation are not available. These conditions exist in the small towns and rural areas as well as large parts of the capital city. According to WHO reports, access to safe water is about 23% (18% rural, 43% urban) while access to adequate sanitation is only 12 % (28% rural, 6% urban).

The health and educational system in Afghanistan is in a state of almost complete disrepair. Afghanistan has some of the most alarming health statistics in the world. Life expectancy at birth is 45 for men and 47 for women. Maternal mortality is the highest in the world (1900/100,000 live birth/year). Total fertility rate (TFR), the average number of children born to a woman during her lifetime, is 6.0. Less than 15% of deliveries are attended by trained health workers, mostly traditional birth attendants. More than 25% of children die before the age of five. About half of children under 5 years of age are stunted due to chronic malnutrition and up to 10% have acute malnutrition.

Among many fundamental obstacles to the country's development (such as security issues) is the fact that there is a great shortage of professionals, almost at every level. Capacity building in Afghanistan is a major problem for the re-establishment and strengthening of social services.

Shortage of skilled personnel in particular health professionals are contributing to the slow progress and improvement of health status in Afghanistan. According to UNICEF Afghanistan has one of the lowest literacy rates in the world, with men at 46 % and women at 16%, and are part of the many challenges the country faces to train new health personnel.

During the dark years of the Taliban regime intellectuals and professionals including physicians and in particular women health providers were targeted for persecution by the government. Thousands of health care professionals fled the country to escape persecution. Consequently many women died from minor and treatable injuries or illness because there were no female health workers to attend to them and male health providers were forbidden to see, touch or treat women. Despite the recent changes, Afghanistan is still a very conservative Muslim society with strong views on the role and place of women in society. The majority of women wear some type of hair covering. A large number of them still wear the burka (Taliban's mandatory head to toe covering that covers the entire face). Although views on treatment of women by male health personnel have improved, large numbers of women are nevertheless prohibited to seek assistance from male health workers especially for reproductive health services. This situation has had serious consequences for the health of women, highlighting the need for training and educating female health workers.

There is a great-unmet need for reproductive health and family planning education and services in Afghanistan. Many women I talked with in the maternity wards of the hospitals and in health clinics had no or very little knowledge of family planning. During a visit to a hospital most of women (some had given birth 8 or 9 times) in a crowded recovery room stated that they did not want any more children but did not know what to do. Unsafe abortion is also a major problem and a main contributor to maternal mortality in Afghanistan. In one hospital alone there was a room full of women who were seeking medical attention for abortion related complications.

The health system of Afghanistan relies heavily on the foreign assistance. There are over 1100 NGOs involved in development activities. A number of them work on improving reproductive health and address maternal mortality issues. Some of the NGOs active in this field are Management Sciences for Health, International Medical Corp, International Planned Parenthood Federation, and Marie Stopes International. One newly reactivated Afghan NGO, the Afghan Family Guidance Association (AFGA), has started family planning education and services in Kabul. AFGA with the support of International Planned Parenthood Federation and other organizations has opened 4 family health clinics in Kabul. Another Afghan NGO, the Afghan Education and Rehabilitation Organization (AERO), has set up several rural health clinics and is doing valuable work in providing health education training and services outside of Kabul. I visited several of the AFGA and AERO clinics. Despite many basic limitations, I found their personnel enthusiastic and dedicated.

A rural clinic situated in a mud building outside of Kabul was particularly impressive. The newly established clinic provides services to a population of 30,000. On the day of my visit women and children filled the clinic. In a small room an instructor was training local men for the massive polio eradication campaign. In another room upstairs women were receiving health education. The room was so packed by women that it was difficult to walk across the room. They were eager to learn and some women had walked hours to get to the clinic and attend the health education session.

Despite all obstacles, the current situation in Afghanistan does provide an opportunity for advancement of women's health. The health system is influenced by the foreign relief organizations and depends on their expertise and financial support. The new government is experiencing a degree of openness to new health initiatives and programs. The devastating effects of severe maternal mortality is felt by the communities, and women desire to learn and improve their lives. These conditions combined with the fact that as of yet there are no comprehensive or standard health direction or health policy that governs the health programs of the country, presents a window of opportunity to introduce and disseminate family planning education and programs in Afghanistan.

The direct relationship between family planning and reduction of maternal mortality could be highlighted in the current reproductive health programs and pave the way for the expansion of family planning services. Society's eagerness for new knowledge and new ways to join the global community plus the absence of an established policy opposing family planning programs provides a unique opportunity for organizations interested in reproductive health and family planning to step in and become more active in Afghanistan.

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