Making a difference
Tackling the high maternity mortality rate among Afghan women.
Torefah cried out as the car jumped and jarred its way down the rocky Afghan mountain road, every awkward manoeuvre ricocheting pain through her feverish, malnourished frame. Sweat glistened on her forehead as she clung to her dress in a futile attempt to suppress her screams. Her husband Ahmad sat silently in the front seat of the ageing Toyota taxi, knowing his 15-year-old pregnant wife may not make the winding two-hour journey from Jalalabad to the maternity hospital in Kabul. Turning to look at her, he took her hand in his, “Janeam, it’s OK my love,”, he murmured before returning to his weathered prayer beads, rotating the smooth wooden balls between his calloused fingers.
Behind him, as Torefah clung to her own life and that of their unborn child, he knew there was little else to do but pray.
A few hours later Torefah gave birth to a baby boy. She was one of the fortunate mothers in Afghanistan, a country with one of the world’s highest maternal mortality rates at approximately 400 fatalities out of every 100,000 live births. She was assisted through a difficult delivery at the Ahmad Shah Baba Hospital on the outskirts of the Afghan capital, a round-the-clock health care facility funded by Médecins sans Frontières (MSF) that alongside general health care provides free obstetric care to more than 50 women a day.
“Many patients who come here are very young,” explains Laila Zawarim, the hospital’s midwife director. “They are 16 or 17 years old, which is a problem because at that age they are more prone to complications. Young girls have a lot of bleeding because the pelvis is not yet able to deliver normally. In those cases we have to perform a Caesarean but even then
sometimes their babies are born premature and weak.”
Child pregnancy is just one of reasons that in 2011 Save the Children declared Afghanistan “the worst place in the world to be a mother”, and in 2012, the country was second on the list. Today, according to the World Health Organization, one in 11 Afghan women still dies from causes related to pregnancy and childbirth.
Although steep gains have been made in most parts of the country and the maternal health index has improved dramatically – a decade ago, 1,600 of every 100,000 births ended with the death of the mother, in 2013 that was down to 327 – as spokeswoman for the United Nations Population Fund (UNFPA), Dr Annette Sachs Robertson says, “While there has been an almost four-fold decrease in maternal mortality over the past 12 years, every two hours a woman still dies in childbirth or from a pregnancy-related complication.”
She adds, “The decline in maternal mortality rates has been significant and the current UN estimates reflect that. While the figure is still probably amongst the top 15 or 20 countries in the world it’s definitely no longer in the top 10. However, the issue is women can walk for days. If she has a complication like postpartum haemorrhage or she is in labour, trying to reach a health facility by foot is extremely hard.”
Infrastructure in rural areas is by all accounts weak, craggy mountain roads are not covered in tarmac but simply oft-trodden ways littered with rocks and debris from frequent landslides, driveable roads can be few and far between.
With relatively few cars in remote locations, it remains routine practice to transport women to a health clinic by bike, donkey or even a wheelbarrow.
Those who can afford the luxury of a shared taxi take the long, often expensive trips to the urban and more sophisticated health centres.
“The predominant complication we see here is bleeding,” says Laila on the outskirts of Kabul. “We see many women travelling long distances to reach us and they arrive with ruptured uteri. They come from places like Jalalabad because they have no real access there so they have a three or four hour journey by bus or by taxi.”
“Many women don’t have access to comprehensive obstetric care because of the remoteness of their villages,” adds Dr Sachs Robertson. “You have small pockets of populations living in very mountainous areas and in the winter these areas become almost completely inaccessible.”
Often the births in these situations are carried out at home, and according to the latest MICS survey conducted by the United Nations
‘In the winter roads are snowed under. Men and their pregnant women can walk for days’
still ongoing and there are elements that need to be addressed.”
Those elements are not simple to resolve, however, in a conservative country deeply embroiled in years of tradition, patriarchy and geo-socioeconomic barriers.
Apredominate thorn in Afghanistan’s side is its geographical make-up. Breathtakingly beautiful yet remote mountains and magnificent cascading valleys account for 90 per cent of this land, rendering swathes of it inaccessible to modern advances.
In many rural parts life simply stands still for the Afghan people, and access to even the most rudimentary maternal health care is limited. It is a land-locked country where it can take a day to travel on foot from one district to the next. There is a countrywide lack of health facilities.
“In the winter roads are completely snowed under,” says Dr Sachs Robertson. “Men and their pregnant Children’s Fund, 39 per cent of the country’s annual 960,000 births are not assisted by a skilled attendant.
Government funds, although today firmly geared at rapidly improving maternal health, are still insufficient to fund a prevalence of fully fledged medical staff in areas beneficial only to small pockets of people.
“It is tragic,” says Dr Sachs Robertson. “Unfortunately you can’t justify sending a doctor to one tiny community. You have to look at other mechanisms that will ensure women have access to health care because you can lose a woman and child in a very short period of time.”
Part of the solution is to increase the availability of midwives in rural areas. Today development agencies such as UNFPA and MSF alongside the Ministry of Public Health (MoPH) are introducing programmes across the country to ensure remote areas have adequate medical facilities.
Community clinics and Health Houses are becoming established in rural areas, while government-led initiatives are seeing community midwifery upscaled.
Midwifery graduates have increased from 400 in 2001 to 4,000 in 2014 with the aim of achieving 7,000 by 2020. The campaign ensures midwives are in the villages and maintaining strong communication between medical staff and district hospitals so a higher level of care can be accessed if needed.
“Health facilities have been upgraded and built in key locations,” says Dr Sachs Robertson, “and the number of midwives has increased significantly, contributing to an
increase in skilled birth attendance. The MoPH is working on recruitment and retention of female staff, including midwives, to remote areas.”
One of the key areas of focus to save women is to dramatically increase the uptake of family planning. Despite the fact that the vast majority of Afghans have little access to general health care, much less to detailed family-planning information, contraception use in Afghanistan has doubled from 10 per cent in 2003 to 20 per cent in 2012. However that figure remains critically low and much still needs to be done to achieve a government target to increase its prevalence rate to 40 per cent by 2016.
“Unfortunately women are still not using the modern methods of family planning,” says Dr Nasrin Oryakhil, director of Afghanistan’s
‘Women shouldn’t die from a natural process. It’s a basic human right to have a baby and live’
Malalai Maternity Hospital in Kabul. “Currently 90 per cent of women are well aware of contraceptive methods but only 22 per cent are actually using them.”
Understanding why the level of knowledge is high but the level of utilisation within women of reproductive age is limited, is key to bringing about change.
“There are many issues, particularly ethno-cultural ones,” says Dr Sachs Robertson. “However, we need a deeper understanding of the behavioural patterns that lead to women rejecting family planning methods. It could be a desire for bigger families, particularly amongst the less educated and less empowered women, it could be an accessibility issue or it may be down to the fact that decision-making is in the hands of the men, or even misconceptions of side effects.
“When women can exercise the right to plan their families; where every pregnancy is wanted; when they can safely deliver healthy babies; and when they can fulfil their human potential, progress reaches every corner of society.”
Despite considerable achievements in educating Afghans about the importance of maternal health, offering professional advice on gaps between pregnancies and distributing free contraceptives,
This baby in the MSF Maternity Hospital in Khost is one of the lucky ones
While access to maternal health care is improving, poor infrastructure can prevent women like Fereshta from seeking emergency care
Sharifa was treated by Dr Pashtoon Kohistani at the Malalai Maternity Hospital
Aqela, Masooma and Fatima are students at the Community Midwifery School in Kabul
These newborns in the neonatal ward at the MSF Maternity Hospital get the care they need
The neonatal ward at the MSF Maternity Hospital in Khost offers babies a better chance at life