Safe Childbirth Not Yet One Of Afghan Women's Rights
http://www.washingtonpost.com/wp-dyn/articles/A3150-2002Sep25.html washingtonpost.com
Safe Childbirth Not Yet One Of Afghan Women's Rights
By Pamela Constable
Washington Post Foreign Service
Thursday, September 26, 2002; Page A01
KABUL, Afghanistan -- The midwife frowned at the blood pressure gauge on Afghan Gul's arm. The patient was 35, overweight and nine months pregnant.
Gul's dirt-floor hut on a South Kabul alley was the third stop on the midwife's daily rounds. She had demonstrated how to cut and stitch the plastic umbilical cord on a rag doll, doled out iron pills to anemic expectant mothers and showed them how to clear a newborn's lungs.
This time, she had a different message to deliver.
"Your pressure is too high," she told Gul firmly. "Before you go into labor, you must get to a hospital."
The woman's face fell, and she clutched her stomach protectively.
"My husband won't let me go to a hospital," she murmured. "Please, can't you come here to deliver the baby?"
As Afghanistan begins to rebuild after more than two decades of ruinous conflict including five years of repressive Islamic rule, the new, U.S.-backed government has strongly promoted women's rights, and international aid groups have launched programs across the country to improve health care for pregnant women and children.
But in 2002, Afghanistan remains one of the planet's riskiest places to have a baby. According to UNICEF, more Afghan women die during pregnancy and childbirth -- 1,700 per 100,000 -- than in any other country except Sierra Leone. The infant mortality rate of 165 per 1,000 live births is the third highest in the world, and one in four children die before they reach age 5.
The vast majority of Afghan women receive no prenatal care and deliver their babies with no help except from female relatives and untrained, traditional birth assistants known as dayas. As the country moves slowly toward modernization, entrenched rural poverty -- and the conservative attitudes that accompany it -- have left many pregnant women and infants trapped in helpless isolation.
"Most deliveries still occur at home, and when I ask women why, they say their male family members don't give them permission to go out," said Noor Khanum, a doctor who runs a midwife service in Kabul for a Swiss charity called Terre des Hommes. "The political situation has changed, but the mind of the people has not."
To a certain extent, the blame lies with the Taliban, the ultra-conservative Islamic movement that ruled most of Afghanistan from 1996 until last year. Placing women's "honor" above their health, the Taliban banned women from traveling -- even in emergencies -- unless a male relative accompanied them. Authorities also made it difficult for women to study medicine and shut down hundreds of clinics to prevent men and women from coming into contact.
But the Taliban's rule only compounded problems that have long afflicted Afghan women and remain stubbornly resistant to change. More than 70 percent of women live in rural provinces, where health care has always been scarce and transportation primitive. They marry as teenagers, bear an average of seven children, rarely attend school and live in male-dominated households where women's rights is an unknown, threatening concept.
Many rural women are anemic or malnourished, making them especially susceptible to complications of childbearing. Sometimes, according to doctors here, a husband will prefer that his wife die in childbirth than be exposed to male doctors. And even women with more liberal families often wait until they are seriously ill before trying to reach professional help.
"In most cases, they are already too sick to walk and certainly could not withstand a donkey ride for hours in the hot sun or freezing cold," said Chadija, a female obstetrician at a provincial hospital who was interviewed for a recent study by Physicians for Human Rights. "Once they get here, we have to send their relative to the bazaar to buy the drugs they need, [and] more time goes by."
The study, conducted in the western province of Herat by the Boston-based medical advocacy group, found that 97 percent of women there delivered at home with no skilled help and that maternal health care facilities and providers were "virtually nonexistent." Only 11 percent of women received prenatal care, and 593 died in childbirth for every 100,000 live births.
In Kabul, a teeming city of 2 million, there are a half-dozen public hospitals with maternity wards where health care is theoretically free, as well as 30 community clinics that have reopened since the Taliban was ousted from power last year. But the city has been inundated with impoverished returning refugees in the last nine months, overwhelming medical facilities, and staff members said they lack medicine and essential equipment for safe deliveries.
In the maternity wing of the city's military hospital, the rooms are spotless and cheerfully painted, but doctors said they had virtually no painkillers, plasma or antibiotics on hand. Some patients, recovering last week from the complications of unattended pregnancies or home births, slumped exhausted from their ordeals.
"I was at home when my baby came. I couldn't get to a hospital, and I couldn't leave the other children alone," said Sarwar, 45, a mother of nine who lives in a village one hour's drive from the capital. "It was only God and me in the room. The baby screamed for six nights and then he died. Now they say I need blood, but I can't afford to buy it."
With poverty and prejudice preventing most Afghan women from seeking professional care, the vast majority of babies are delivered by local dayas. Unlike midwives, dayas have no formal training and little knowledge of how to prevent or treat such common -- and potentially fatal -- delivery problems as infection and hemorrhaging.
During the Taliban's rule, the enforced isolation of women increased their reliance on dayas, while many doctors fled the country and training for female nurses was sharply curtailed. Today, in a country of 26 million people, there are still only 7,000 doctors and an equal number of midwives, mostly located in cities or towns.
To bridge the gap, foreign aid organizations including UNICEF, the World Health Organization, the International Medical Corps and HealthNet International have begun a number of maternal health projects across the country, including two that teach dayas basic hygiene and delivery care. Their ultimate goal is to replace them with more skilled providers, but that may take several years of training.
"The dayas are a big problem, because they have no knowledge and they may endanger their patients' lives," said Shukria, 29, a veteran midwife in Kabul who trained dayas during the Taliban era. "There was a need for them at the time, but more clinics are open now and women can travel more easily. When I see dayas, I ask them not to practice, but people still come to them for help."
Agencies such as UNICEF are also trying to increase the number of midwives by funding crash courses for former students who were forced by the Taliban to suspend their studies. At the UNICEF program at Malalai Hospital for Women in Kabul, 25 re-enrolled midwifery students are learning to monitor fetal heartbeats, clamp umbilical cords and administer anti-bleeding drugs during labor.
"If you pull out the placenta too soon, the uterus can be deformed," Layla Shams Mohmand explained to one class, demonstrating with a rubber pelvis. "If the placenta stays in place too long, it can be fatal and the patient must go to a hospital. You must always check the placenta, no matter how tired you are after a delivery."
Meanwhile, Khanum's team of 24 midwives struggles to keep up with the soaring demand for their services. Visiting 120 homes a day in Kabul's poorest neighborhoods, they provide checkups for thousands of mothers and babies, answer questions about family planning, discourage dangerous traditional practices -- such as packing the umbilical stump in mud -- and persuade reluctant husbands to send their seriously ill wives to the hospital.
"Some Afghans think if a woman dies giving birth, it is part of life," said Malalay Nazir, a physician and former director of the program. "Some think hemorrhaging or convulsions are a normal part of delivery. And some say if your wife is dying, don't be sad or spend your money on her; you can always get a new one."
Last week, a team of two midwives knocked at the gate of a primitive urban hut with flour sacks for windows. Their patient, a nearly due woman of 26 named Shahnaz, was waiting eagerly for her second prenatal exam. Her first four babies had been delivered by a daya, and two had died in infancy. She was determined not to lose another.
In one corner of the hut, a wrinkled woman named Reza nodded approvingly as she listened to the midwives' advice. She was Shahnaz's mother-in-law, an illiterate village wife who had borne 14 children of her own, only to see six of them perish.
"When I had my babies, there was no one to help me. I delivered them and they died," Reza said matter-of-factly. She smiled as one midwife bent over Shahnaz with a fetoscope, listened for the baby's heartbeat, and pronounced it normal. "My daughter-in-law is very lucky," she said.
