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Low contraceptive use, in combination with early age at marriage and closely spaced births – both factors associated with increased risks for maternal and child health and deaths – lead to the estimated fertility level of 6.3 see Sections 3.3.2,
3.4.1 and 8.4.3. This indicates a high reproductive health burden for Afghan women, as each subsequent pregnancy exposes them to the risk of severe bleeding, infections, obstructed labour and eclampsia, most of which can be averted
by effective health services. However, the use of maternal health care is critically low in Afghanistan. Overall, 36 percent of women reported the use of skilled antenatal care services MDG-5.5, which may provide them with medical check-
ups, referrals of pregnancies that could result in complicated deliveries, and information about managing pregnancies and deliveries, immunization, breastfeeding and child spacing. The overall proportion of women delivering with a skilled
birth attendant MDG-5.2 is as low as 24 percent, but the use of frequently life-saving obstetric and newborn care is vastly different for urban 69 percent, rural 15 and Kuchi 8 percent women, as well as for different provinces and
women of different education levels. It can, therefore be concluded that Afghan reproductive health care is grossly inadequate for those who give new life.
NRVA data reveal that generally expenses and distance are the major constraints for women to accessing health services. The availability of a male companion, which is a culturally dictated practice, compounds these constraints, along with
the value attached to women’s health and the discretion of male family members to allow females to be treated by male health practitioners. In addition, the need for a male companion doubles the money needed for travel and may also
contribute to reduction of earnings for those men who are gainfully employed. The common practice that the husband or family may disapprove treatment of a female patient by a male health staff is a real constraint considering that the sector
has an enormous shortage of service providers, and especially among females.
Whereas the NRVA analysis paints a harsh reality on women’s health, it also discovers some hopeful signs of improvement. It finds that for successive younger cohorts the share of women marrying before age 18, and especially
before age 15, declined and that fertility is, slowly, declining. It also suggests that the use of contraceptives is increasing, that use of antenatal care has grown, and the use of skilled birth attendance has substantially increased. The decisive
outcome indicator of maternal mortality is, however, badly needed to establish the true improvement in the field of reproductive health.
10.3.5 Decision-making
The previous section 10.2 on decision making indicated that women’s say in various matters depends on the specific area of decision making, but that is generally is limited or very limited. On specific family affairs, such as family planning,
and marriage and education of the children, women tend to have relatively more influence through joint decision-making with others, but even here far more often their husbands decide alone. In financial matters – taking or paying off debt or
household spending – decision-making is in the large majority of situations the domain of the husband or father of the women. Even for the relatively few women who generate income themselves, only 20 percent decide on spending freely
on their own. In various decision domains, however, women’s empowerment seems to increase with age.
Representation of women’s voices in the community is also poor compared to that of men. In the Community Development Councils, the rate of direct women’s representation is only 60 percent of that of men, and in the traditional Shuras it
is only 35 percent. It can, therefore, be concluded that in both these primary institutions of the household and the community, equity in decision making is far from established.
10.4 Conclusions
In many aspects, Afghan women and girls share the poor life conditions of their male counterparts. However, the NRVA 20078 confirms that a consistent pattern of relative deprivation exists across almost all development sectors.
Moreover, the gender gaps are large. This is the case in decision-making power at community level and the level of the household, where women depend almost invariantly on their husbands, fathers or other families. At least at the level
of communities, the government can augment women’s representation by promoting female and mixed Community Development Councils.
Women’s position on the labour market is also particularly weak. They participate less in economic activities, for fewer hours and predominantly in vulnerable employment. On the other hand, for those women who are currently active, the
unemployment rate is as high as the male unemployment rate, and for the better educated women even twice as high.
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The positive by-product of gender-based barriers to the labour market is that child labour to a lesser extent occurs among girls and less affects their development, for instance in terms of educational deprivation. Among other things,
policy could be directed to facilitate women’s employment in the public sector, especially public administration, health and education.
One precondition of such policy would be educational adequacy of women. In this development sector large gender gaps persist, especially in rural areas and even more among the Kuchi population. Literacy of women is less than
one-third of that of men, which is already extremely low in international perspective. However, comparison of literacy across age groups shows an increase, and even an accelerating increase, of female literacy, which strongly suggest
recent improvements of the educational system. This is supported by the increase of girls’ – and overall – enrolment in primary education, compared to the NRVA 2005. Especially in urban areas the NAPWA target of 70 percent enrolment
of girls is within reach, and girls are closing the gap with boys. Policy should, however, be primarily directed at the rural areas where the large majority of children live and where girls enrolment is around 38 percent. Besides education of
new generations, Afghanistan has an adult population of 9.5 million people who are illiterate – among whom 5.5 million women – who should be provided with an opportunity to learn basic reading and writing skills.
Reproductive health has particular importance for women and girls, as a high – but not exactly determined – price is paid for high fertility, closely spaced births, early pregnancies and poor maternal health care in terms of antenatal and delivery
care. In addition, the health system provides gender-specific barriers to women because of their restricted mobility and unresponsiveness in the sense of providing female health personnel. Policy measures should consider temporary
importation of female health volunteers and intensified campaigns to enroll more women in health professions. The development of paramedics for rural deployment as well as mandatory up-skilling of existing female professionals may
also be considered. In addition, from a women’s and a health perspective, accurate information about maternal mortality is urgently needed for policy making and priority setting in the country. Despite the very low levels of maternal health care
provision, the NRVA surveys suggest significant improvements in the last few years.
Also in terms of age at first marriage – important with respect to pregnancy-related health risks – and spousal age differences – important for, for instance, more gender balance in household decision making – noticeable changes can
be observed. Increasingly smaller proportions of girls marry at young 18 and very young 15 ages, and the average age differences between wives and husbands has significantly declined. An issue that is partly related to large spousal
age gaps is the large number of widows in the country – over half a million. In the context of Afghanistan, these can be classified as vulnerable, along with 70 thousand female heads of households. Sharp focus on these groups of women
and their families is needed in designing and implementing development policies.
In terms of population information, any survey and census undertaking should pay particular attention to adequately capture women and girls in the data collection through targeted training and supervision of fieldworkers.
The general conclusion should be that huge challenges remain with respect to women’s mobility, participation in public life, decision making, health, and access to economic and educational opportunities. The most urgent needs
are found among the rural and Kuchi populations, and in line with that, gender gaps are usually larger among these than in the urban population, with the notable exception of labour force participation and employment. But on the
positive side, significant improvements can be achieved in a relatively short time span, as is suggested for the education and health sectors.
