Mak­ing a dif­fer­ence

Tack­ling the high ma­ter­nity mor­tal­ity rate among Afghan women.

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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

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