The number of midwives delivering skilled health care to women in Afghanistan has more than tripled under programs supported by Jhpiego and partners, leading to significantly more women surviving childbirth.
Jhpiego, an international health non-profit and affiliate of Johns Hopkins University, has been at the forefront of efforts to prevent childbirth-related deaths in Afghanistan since 2002. In partnership with the Afghan government and funded by the U.S. Agency for International Development, Jhpiego helped revitalize the Afghan midwifery workforce by developing a national education system to train midwives to provide competent skilled care to women during childbirth.
At the time the USAID-funded work began in 2003, Afghanistan’s maternal death rate was the second highest in the world. There were only 467 midwives in a country of 20 million, less than 8 percent of pregnant women gave birth with a skilled provider at her side, and only one province offered midwifery education.
Today, as a result of the USAID-funded Health Services Support Project (HSSP) and prior programs, the state of midwifery in Afghanistan is vastly improved:
• More than 3,000 new midwives have graduated from a network of government-accredited schools whose curriculums and competency-based training were developed by Jhpiego in collaboration with the Afghan Ministry of Public Health and other partners;
• The percentage of women giving birth in a health facility has increased from 19 percent in 2005 to 32.4 percent in 2011;
• Midwifery programs have increased from 1 in 2002 to 30 today;
• 86 percent of graduates of community midwifery schools received jobs;
• A professional organization of midwives was organized and supported with the help of USAID; the association has more than 2,000 members across 33 out of 34 provinces;
The Afghanistan Mortality Study (AMS), which was released last year by the government, showed a significant reduction in women dying in childbirth. The study found that 327 Afghan women die for every 100,000 births. That compares to the World Health Organization rate of 1,400 for 100,000 births in 2008.
Dr. Leslie Mancuso, Jhpiego President and Chief Executive Officer, said Jhpiego’s innovative strategies to build the capacity of Afghan midwives and strengthen health facilities throughout the country have resulted in improved health services for women.
“The fact that more Afghan women are surviving childbirth is a testament to the newly-educated midwives who are working in their communities to prevent the needless deaths of women and families,” said Dr. Mancuso. “Jhpiego’s focus on skilled care and innovative strategies to prevent the deaths of women shows that continued investment in strengthening the Afghan health system will save lives.”
While working at a local hospital in mountainous Faryab Province in northern Afghanistan, Masoma, a midwife, encountered the case of a 13-year-old girl who had been repeatedly sexually assaulted by her 26-year-old husband.
Masoma had treated teenaged brides before—arranged marriages are common in culturally conservative Afghanistan and many Afghan girls are married off before they reach the legal age of 18. Marriage at such a young age, when girls are neither physically nor emotionally ready, make the wives vulnerable to sexual assault and violence. In the case of this young woman, because of her age, the girl’s father and the husband had agreed that although they were married, she would live at her parents’ house until she was 18. Although the girl’s husband and mother in-law initially agreed to this arrangement, soon after the wedding her husband took her against her will and sexually assaulted her.
When this 13-year-old’s situation became known to Masoma, the midwife was ready to act. She is among 227 health care providers who participated in a gender-based violence training course sponsored by the Jhpiego-led Health Services Support Project (HSSP) with Futures Group as a partner. Through the training, funded by the U.S. Agency for International Development, Masoma learned how to address such situations and how best to advocate for the safety of women and girls.
“Based on what I learned from the training, and with the support of the hospital staff, I was able to convince her parents to take their daughter back to their home,” said Masoma. “I also spoke to her in-laws about the health consequence of this case. Fortunately, both families agreed to allow the daughter to live away from her husband until the age 18.”
“By participating in the HSSP gender-based training,” the midwife continues, “I learned how to advocate for women’s safety and am committed to sharing this knowledge with my community.“
In Afghanistan, as in many developing countries, women don’t always have the opportunity to access resources to protect their health. Because of cultural barriers, poor literacy and limited education, women are at a disadvantage in their ability to make informed decisions about their own health and well-being. The focus of the HSSP gender-based violence training is to raise awareness among health service providers in Afghanistan about the effects of violence on women’s health and the health of their families, and to encourage providers to be a voice of support on their behalf.
Gender-based violence is among the hardest topics to talk about in Afghanistan because the majority of victims are not willing to disclose their situation to health care providers or law enforcement authorities. They worry that their families will be dishonored if they report incidents of domestic abuse or sexual violence. In addition, providers who lack awareness about gender-based violence can end up judging patients rather than treating them.
To address these various barriers, HSSP has taken a systematic approach to integrate gender awareness into the delivery of basic health services as described by the government. The ultimate goal of addressing gender issues is to ensure that these interventions and services improve women’s access to and use of health services. HSSP interventions that integrate gender within service delivery include:
Masoma is clear on the benefits and continued need for gender-based violence training: “I hope this program expands to the rest of Afghanistan,” she says, “so that public awareness about gender and gender-based violence increases.”
Kabul, Afghanistan – Midwife Naseema Qochi is easily recognized when she walks into the small, spare health clinic nestled beside a rose garden in the dusty warrens of Qlia Bakhtyar. The health officer greets her warmly, Salaam alaikum (Peace). Qochi has helped three generations of women in this community give birth. “Naseema is the doctor,” a visiting midwife says in explaining Naseema’s primary role here and the respect she commands.
In conservative areas of Afghanistan, families are often reluctant to have their women give birth in a health facility, where birth complications can be handled by skilled providers and lives can be saved. It’s a reality that Naseema deals with daily, even as the number of educated and skilled midwives has increased across Afghanistan through the work of Jhpiego.
“I encourage them to go to the clinic. I talk to their husbands. I tell them about the risk of pregnancy…but they refuse,” says the veteran midwife and member of the Jhpiego-supported Afghan Midwives Association. “In one case, a lady fell down from the top of the roof; even in that case they didn’t bring her to the health clinic.”
So Naseema goes to the women. She educates them on nutrition, breastfeeding, the danger signs of pregnancy and how to care for a newborn. She also provides skilled care in the months before birth.
In her visits to women’s homes, Naseema carries a leather case filled with the tools of their profession: blood pressure cuff, fetoscope, iron pills to prevent anemia, syringes, scissors, clamp, chlorine, clean cords, emergency drugs and other supplies.
On this particular day, Naseema meets with a married teenager who lives with her mother, younger brother and husband in a spare room of a neighbor’s house. The girl is seven months pregnant and this is Naseema’s third visit to the family. In addition to examining her, she will explain to the teenager’s mother what to do in case the baby comes unexpectedly or the mother-to-be can’t get to a health facility in time.
With deliberation, Naseema unfolds a gray plastic sheet and places it on the floor. She ties a clean white scarf around her head and prepares to show the mother how to properly wash her hands, lathering soap between her fingers and scrubbing up to her elbows. She opens her black bag and pulls out several props: a baby doll and small box covered in material that resembles a split curtain. Talking to the mother, Naseema begins a simulation of birth, proper cord clamping, care of the newborn and delivery of the placenta.
“If you are facing challenges, if there is no midwife or the baby comes in the middle of the night, you have to know [how to do this],” she says to the pregnant wife’s mother.
In the district she covers, Naseema may have as many as 500 pregnant women and new mothers as clients. For a woman whose baby is in the breech position, Naseema will pay for a car to take her to the nearest hospital to give birth. After a birth, Naseema will return to check on the mother and child.
In her 30 years as a midwife, Naseema says has delivered as many as 50,000 babies. But since the fall of the Taliban in 2001, she has seen more women choose to give birth in a hospital or health clinic, a shift she attributes to education and the growing number of midwives who have received training through programs supported by the U.S. Agency for International Development and Jhpiego. That shift is important because research has shown that a skilled health provider at birth is key to reducing maternal deaths.
“Before, I had 60 deliveries a month. Now I have 20 deliveries at home. That’s a big difference,” she says.
And yet the pregnant girl’s mother insists she will call Naseema when her grandchild is ready to be born. The 57-year-old midwife smiles, knowing what she will say, “I will encourage her to go to the hospital for delivery. This is my responsibility.”
Kabul, Afghanistan – At age 40, Zaghrona Sabet is embarking on a career.
She has decided to become a midwife, not a small thing in this conservative society where a mother of four is expected to be at home. Zaghrona will spend the next 18 months in a classroom, learning about maternal and newborn health and acquiring the clinical skills to save lives.
Zaghrona’s career choice has as much to do with personal experience as her desire to become one of the “white coats.” During Afghanistan’s civil war, Sabet and her husband moved to Pakistan, where they began their family. Although she had access to skilled care, unlike many women during those troubled times, Zaghrona says her birth experience in a local hospital was a confusing whirlwind. “No one explained the procedure for normal delivery. I was given an injection and no one explained to me what I was getting.”
Since her return to Kabul, Zaghrona says she has wanted to become a midwife so she can ensure women in Afghanistan have the skilled care they deserve. And there’s a more personal reason for her career choice: “In Afghanistan, all people respect the doctors and midwives who wear the white coat.”
Zaghrona is among a group of 52 women, many right out of high school, who are attending the Asia Medical Institute, a midwifery school recently established at the private Kabul International Hospital, a 50-bed facility under new management and with ambitions to provide 21st century care. The school reflects the increasing popularity of midwifery as a profession for young women in Afghanistan.
Although the Asia Medical Institute has yet to receive accreditation, the class is full. The curriculum is based on national midwifery standards and the school’s two teachers are graduates of government-run midwifery schools.
On a recent day, the students are learning how to take a physical history and the components of prenatal care. A visitor asks why they wanted to become midwives. A show of hands appears and several of the students speak up:
As you know, the maternal mortality rate in Afghanistan is very high. We are training to be expert medical midwives.
I remember my mother was pregnant. There was no good care in Takhar [a province in northeast Afghanistan]. There was no transport for her. We lost the baby.
My mother wanted to be a midwife. One of her wishes is for me to finish this midwifery class.
I am disabled. My mother says I got this problem during delivery. I want to be able to take care of all mothers and their babies.
Kabul, Afghanistan – Her older sister died while giving birth to her niece, and now Sedeqa Khavari feared her pregnant, younger sister, Masoma, would suffer the same fate.
Masoma had become seriously ill from hypertension, and a visit to the hospital offered no relief. After returning home, the expectant mother suffered convulsions and fell unconscious. The family rushed Masoma back to the hospital, where her premature baby was delivered by cesarean section and the young mother survived.
The experience left a lasting impression on Sedeqa and set her on a new path.
“I will never forget [that night],” says Sedeqa. “My sister was near death. I decided I have to learn more about midwifery and this way I can help all mothers in Afghanistan.”
Sedeqa followed through on her decision. In 2007, she graduated from a government-sponsored midwifery school in Bamyan Province, one of 13 across Afghanistan supported by the Jhpiego-led Health Services Support Project (HSSP). Since 2002, when Jhpiego helped develop and rebuild a national midwifery education system in Afghanistan, more than 3,000 new midwives have graduated from accredited schools, many of them returning to their communities to care for women and their families.
Sedeqa worked for two years as a community midwife and then left her home province of Bamyan in north central Afghanistan to work in Kabul at the Cure Hospital, a private health facility that employs several graduates of the HSSP-supported schools.
Working as a midwife, this 28-year-old, single mother is able to provide for her son and contribute to the improved health of mothers and newborns in her country. She says Afghanistan needs more midwives like her. “We should think about increasing the number of midwives, especially in remote areas,” says Sedeqa, after talking about her older sister, who lived and died in mountainous Ghor Province, where transportation to adequate health care is difficult. “If we continue our training and get new training, health care services would be better for mothers.”
Sitting in a small office outside the maternity ward at Cure Hospital, Midwife Supervisor Fahima Naziri is awaiting lab results for a 35-year-old woman in labor. The woman, who is carrying a big baby in a breech position, may well be suffering from pre-eclampsia, a high blood pressure disorder that can rapidly escalate into the more dangerous eclampsia.
Based on her training, Fahima predicts her patient will need a cesarean section, but the woman’s husband is opposed. “We are checking the baby’s fetal heart rate and the contractions,’’ says the 26-year-old midwife. “We are also checking the blood pressure. When the lab results return, we will decide whether to give her magnesium sulfate [the prescribed treatment for pre-eclampsia].”
In an effort to get the woman the care she needs, Fahima seeks the assistance of a colleague, a male doctor who meets with the husband and explains the situation: Do you want your wife to live?
The husband reluctantly agrees to the operation, recognizing that without his wife there will be no more children. Despite seven pregnancies, the couple has only two children. The nurse-in-charge, Jennifer Housand, explains that in the maternity ward, “Unfortunately, the woman has no say. The husband decides.”
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