Sunday, December 17, 2006

Afghan women saving mothers' lives

Last night I was having an after dinner drink with some colleagues and visitors from Kabul and we got onto the topic of midwife projects here in Afghanistan. I raised the subject because of a very cool Icelandic woman who is based up in Chegcharan in Ghor who is a development advisor to the PRT and who has been putting lots of energy into getting midwife training happening up there. This story was in the news yesterday. I found it both disturbing and somewhat encouraging. Nothing really seems very encouraging in this country, but here is a little step that might make a big difference to some women and babies. Afghan women saving mothers' lives Dec 17 - (AFP) In a white coat and with a dark scarf covering her hair, newly graduated midwife Fatema, 20, is just months on the job and still a little nervous. But the determined young woman has no doubts about the importance of her work in a small clinic in rural northern Afghanistan, a country with one of the world's highest maternal mortality rates. Fatema's elder sister bled to death in childbirth when she was 16, having been married at 15. Her baby's shoulder became stuck in her small pelvis and two traditional birth attendants broke its neck trying to pull it out. It was a complicated breech delivery, with the child positioned bottom first, and the untrained birth attendants -- who help 80 percent of Afghan women have their babies -- did not know how else to handle the problem. "Look, if someone had known something at that time, we could have referred them to go to hospital," says Fatema, which is not her real name because like many Afghan women interviewed for this story she did not want her name to be used. Lack of knowledge and superstition amongst the rural community in Takhar province spawned rumours afterwards that the dead teenager must have been "bad" to deserve such a fate. When the British medical charity Merlin came to Takhar in 2004 to look for women to train as midwives, Fatema jumped at the chance. In February she and 20 other women became the first graduates from a USAID-funded 18-month course at the Community Midwife Education centre in the provincial capital Taloqan, returning to their districts with internationally recognised diplomas to improve the chances of women surviving birth. War-shattered Afghanistan is behind only Sierra Leone for the highest number of women to die in childbirth. The maternal mortality rate here is around 1,600 out of 100,000 live births, according to a recent UNICEF survey. This means that one in six women between the ages of 15 and 49 die giving birth. This compares with a rate of about 13 out of 100,000 in Britain, where one in 3,800 women die in childbirth, according to 2000 UN statistics. There are many grim stories to illustrate the problem in Afghanistan: of traditional birth attendants, called dayee, cutting a baby's limbs off with a kitchen knife in a desperate attempt to save a woman's life when something went wrong in delivery; of pregnant women bleeding to death on a days-long donkey ride to find help at a far-away health facility; of husbands beating their pregnant wives' bellies because they can't afford another child. "It is the worst I have ever seen," says Addie Koster, who heads the Taloqan centre and has worked in Afghanistan for the past five years after stints in Africa, Asia and Central America. There are many reasons so many women die, says Koster, most linking back to the 25 years of war that destroyed the country's infrastructure and entrenched a social system that denied women basic rights. Often mothers' pelvises are too small for birth, she says. This can be because they are young -- with nearly two-thirds of girls married before age 16, according to statistics cited by the United Nations -- or malnourished as about two-thirds of pregnant Afghan women are. When complications arise, the difficult terrain and lack of infrastructure can mean clinics are days away although some women are too poor to even afford the donkey ride. Dayees sometimes rely on folklorish techniques -- such has biting on hair to dislodge the placenta -- that may appear to work in simple births but are of little use when things go wrong. More dangerously, they make liberal use of oxytocin -- an injectable hormone that can be bought in the smallest bazaar without a prescription -- to induce labour even when the baby just cannot fit through the pelvis. In a custom entrenched during the 1996-2001 rule of the ultra-conservative Taliban who forced women under the all-covering burqa that most still wear, some men still refuse to allow their wives to go to clinics where only a male nurse or doctor is present. Taloqan's Community Midwife Education centre is a key part of a strategy taking on all these problems. One of its main aims is to boost the number of women in the province giving birth with the help of a skilled attendant from the current eight percent. Province-wide clinics are being built -- although in one case staff operated out of tents for two months before being able to move into a newly constructed building. Female staff are being trained and recruited from other provinces, even other countries; community meetings are explaining the benefits of pre- and ante-natal check-up, having a baby with a trained midwife, and breast feeding. Another of the centre's fresh graduates, 22-year-old Lailuma, is installed in a clinic far from the provincial capital. Since arriving in April, she has helped with 15 deliveries -- up from zero before she arrived because women would not see the then male-only staff. "The area where I live is very remote. There were no midwives," the stylish woman says softly, a black scarf framing her face. "I wanted to become a midwife because I wanted to do something for women." Twenty-two new students have been in place since April, learning to suture on chunks of raw meat and delivering the same dummy baby over and over again before getting down to the real thing. They are not shy about describing the difficulties facing Afghan women. "There are no cars, no road, no transport. And security is not good," says one explaining why most rural women give birth at home. "The dayees know nothing. After 20 years of war, no one knows anything. We have been left behind because of the war," says another. "During the Taliban it was worse," adds one more, recalling the government that refused to let women work which meant there were few female doctors for them to see. The situation is improving in provinces like Takhar which see little of the current Taliban insurgency, which is focussed on the south and east of the country. When the hardline regime fell, Takhar had only five female medical staff, says provincial health chief Hakim Aziz. Today the number is well on the way to the goal of putting at least two women into each of its 52 clinics. And whereas a community health clinic once saw on average five deliveries a month, there are now about 25, Aziz says. The new students at Merlin's centre were selected by their communities for the program and are obliged to return after graduation to work for at least five years. They will go a long way towards filling the 32 vacancies for midwives in Takhar, says Nezamuddin Jalil from the Social and Health Development Program. The group runs nine of the province's clinics including Fatema's at Bangi, a community of about 30,000 people 30 kilometres (19 miles) from Taloqan and dotted with green flags marking some of the fiercest battles of the US-led offensive that dislodged the backward-looking Taliban. "We started from zero," the doctor says. "There was no staff, no access. Now we have enough health facilities and enough equipment. But there is a lack of female staff." Despite the challenges, "day by day it will be ok," he says.

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