February 2007 – Kabul District: Women in Distress February 17, 2007Posted by Linda Barnes in Afghanistan, Maternal Mortality Afghanistan, MCH in Community, Midwifery, Rabia Balkhi Hospital, Terres des Hommes.
In this ever-expanding urban sprawl in Kabul women are disadvantaged. No dependable supply of potable water, shallow or non-existent latrines, no public transport, poorly staff and distant basic health facilities, and dangerous neighborhoods all contribute to abject vulnerability. Family affairs are tightly regulated by custom and ultra-conservative law. Women are exposed to additional cruelties: forced teen marriages, squalid households dominated by female relatives-by-marriage, virtual imprisonment and physical/sexual abuse.
My current work in Afghanistan has again put me in contact with a cadre of community midwives working for Terres des Hommes (TDH), a Swiss non-government organization with a wide range of activities in Afghanistan. These midwives have been working in Kabul District communities since 1997. They are professionally trained midwives, many of whom started their career in one of the two major maternity hospitals in Kabul, Rabia Balkhi Hospital and Malalai Hospital. Some moved back to the community during the Taliban years when leaving home was dangerous; others were drawn back to their communities to provide basic care to pregnant women and newborns. These are unusual women who, for reasons of practicality and/or compassion, are dedicated to the unrelenting plight of women who live on the soft underbelly of this society.
With a small grant from the Gates Foundation a pilot intervention in two of the poorest districts in Kabul is being started; it will provide additional support to households with low birth weight newborns (newborns weighing less than 2,500 gms at birth). There is scant data in Kabul regarding low birth weight in the ever-expanding urban sprawl, however the contributory factors associated with low birth weight are endemic. Last week a midwife from District 7 in Kabul reported delivering both twins and triplets within 36 hours…all five newborns were premature. In both cases the mother had no antenatal care or diagnosis of multiple pregnancy; in both households the women were forbade from going to a clinic. The midwife had been summonsed to the births in the middle of the night because she is known in the community.
It is estimated that only 20% of births in Afghanistan are attended by “skilled” midwives. Additionally only a fraction of births occur in a health care facility. Most babies born in the major maternity facilities in Kabul are discharged within 2-3 hours of birth and therefore are at high risk from the onset of their fragile existence. It has been reported that between 18 and 25 percent of infants die before their first birthday. All these appalling figures only illustrate the vulnerability of children in Afghanistan.
When the midwives arrived at this household the two wives and mother-in-law were the only occupants of the family space, a room about 12 x 12 feet and shared by first of the two wives, the husband and six children. By the time the midwives began the visit another 20 women and children had crowded into the room; they are eager for information and contact with the midwives. Despite their lack of control over matters of reproduction they are keen to participate in the communal antenatal visit and the midwives’ demonstration of how to help a woman deliver at home. Each client of the TDH midwives keeps her own copy of the home-based maternal record and the women scrupulously observe all the information the midwives enter in it even though they cannot read. The home-based maternal record is an empowerment tool.
Women being in charge of information; insignificant it may seem, but in this setting the home-based medical record is a symbol of support for these vulnerable women of remarkable resilience.
“Motherhood Afghanistan” was recently aired by PBS. The film graphically illustrates the plight of women and infants in Afghanistan and exposes the duplicity of the US government response since 2001.
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Summer 2006 in
All summer there seems to be a constant trickle of depressing news about Afghanistan: Taliban resurgence, poppy lords controlling the eco/political scene, maternal mortality not being reduced despite millions being poured into the health system. The numbers of Internally Displaced Persons steadily increase according to UNHCR; most IDPs end up in the emergent urban sprawl around Kabul. Basic needs are not being met…potable water, electricity, health care…let alone the amenities of education, transportation, and accessible commodities.
The new NATO commander recently suggested the country close to anarchy. The revival of the “Department for the Promotion of Virtue and Prevention of Vice,” infamous during the Taliban, elicits fear and outrage among Afghan women.
So, what to think about my time in Afghanistan, along with others like myself who have lived and worked in
Afghanistan? What difference will it make in the long haul? Some say, with historical credibility, that Afghanistan is a “failed state”…never should have been carved up the way it was…destined to revert back to tribal territories.
As America’s focus turns toward other “hot spots” Afghanistan is being weaned off American reconstruction funding, but Afghanistan remains 100% dependent on those funds. The withdrawal of funds is acutely felt in efforts to increase services to pregnant women and newborns.
Before I left in early August I had the opportunity to visit one of the Kabul districts where midwives with the NGO “Terre des Hommes” (TDH) provide a wide range of services for women and children who have little access to basic health care. TDH is of Swiss origin and has worked in Kabul District since 1997. There is currently a cadre of 28 midwives who visit homes in pairs providing a full scope of midwifery services ranging from antenatal care, intrapartum assistance and family spacing. Most women in these communities have little hope of delivering their baby at a hospital and are dependent on relatives or neighbors to assist them in birth. TDH midwives provide education, support and simple birthing kits for the often inevitable unassisted birth. They are dedicated to women whose lives are at risk every time they become pregnant.
Mid-May in Kabul June 1, 2006Posted by Linda Barnes in Afghanistan, MCH in Community, Midwifery.
Thursday to District 7 where I met with 20 of the Community Birth Educators who had just completed a course in “community mapping” sponsored by USAID. The CBEs are very proud of their community maps. I visited two households, traipsing after one of the CBEs in her burka as we made our way through narrow alley-ways bisected by a trough of fetid water and debris. In one home a mother-in-law and a daughter-in-law, two of the four reproductive-age women in the household, had given birth on the same day about a month ago. The mother-in-law had a healthy looking baby happily breast-feeding in her lap. The daughter-in-law’s baby had died of “hepatitis” 10 days prior; the mother recounted that the baby was very yellow and it died in the hospital. A few questions prompted information that her blood was “bad”…with a few more questions she produced a piece of paper the an Rh Neg. lab result. She then reported she had lost a pregnancy at 7 months the previous year. Finally when all the bits and pieces were teased out of the young girl we discussed her need for Rhogam with her next pregnancy. Rhogam costs $50-$60 in Kabul; it is unlikely this woman, with no prenatal care and no contact with the health system other than the CBE, will get Rhogam. The CBE is aware of the danger to future pregnancies, but who knows if the dots will ever be connected for this mother.
I ponder this dire condition of Afghan women sitting in Dubai awaiting a flight to London…traveling between the fragility and fundamentalism of South Asia to the bravado and fundamentalism of my homeland. Dubai, a strange “paradise” having escaped the ravages of war and conquest, sits two hours from Kabul with verdant landscaping sharply outlined against the indigenous desert, flashy SUVs, and towering glass shopping malls; its opulence is disquieting. I unabashedly give myself over to the reprieve from Kabul…happily suspended for 18 hours in this sumptuous vacuum halfway between two worlds separated by two hours…on the same planet.
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On May 1st and 2nd over 200 midwives from across Afghanistan assembled in Kabul for two days of meetings and education. I sensed the excitement of renewing friendships just as I remember from midwife gatherings in the US. Wherever midwives gather the privilege and responsibility of being midwives, being “with women,” is celebrated.
The strides made by the AMA are remarkable. I recall just 2 years ago the early meetings at RBH when Pashtoon Azfar guided a small group of midwives through the initial forging of a “statement of purpose” and Sheena Currie led discussions about the goals of a professional organization.
Now there are 650 local members and a handful of international midwife members from across the US, UK and Europe. The AMA was represented at the 2005 American College of Nurse-Midwives (ACNM) 50th Convention and was recently accepted into full membership in the International Confederation of Midwives (ICM).
As the AMA weans itself from financial and technical assistance of international NGOs the organization must begin to secure its own funding base and expand its organizational structure. Continuing interest and membership from international professional colleagues will represent the global vision and connectedness. It will also provide part of the needed financing for continued growth and development.
Currently in Afghanistan one woman dies of pregnancy-related complications every 30 minutes, 30% of these deaths from post partum hemorrhage. Of 1.1 million births in Afghanistan yearly, only 12% are attended by a “skilled provider” and 92% of births still occur in the home. There are many initiatives being piloted in Afghanistan designed to address the extraordinary rate of maternal and newborn deaths. Midwives with knowledge and skill are the backbone of saving women’s lives.
It is estimated that Afghanistan needs 10,000 midwives; most of these midwives will be posted in remote locations with little assistance. The AMA is dedicated to increasing quality education and professional standards as well as to provide support and the connection with midwives around the globe.
Visit the International Health booth at the ACNM Convention in Salt Lake City; you will find photos from the recent AMA Congress and an opportunity to support the Afghan Midwives Association.
Independence Day April 28, 2006Posted by Linda Barnes in Afghanistan.
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Every morning at around 6:00 a bevy of helicopters, thrashing against the early morning quiet, flap over our residence…there are about 8 of them…it is a chilling noise. I have become quite accustom to their arrival and watched as they slowly glide into a distant two-by-two formation and veer off to some destination north of Kabul.
Yesterday morning was Independence Day in Afghanistan so the usual flap of helicopter blades was accompanied by the thunder of cannons and other miscellaneous weaponry. I wondered, having read some Afghanistan history, exactly what Afghans were becoming “independent” from. They have been continuously trodden over by foreign powers for almost as long as history has been recorded, but colonized…not. One of my Afghan colleagues said Independence Day has been celebrated for about a dozen or more years (her memory of it anyway). This coincides with the Afghans finally forcing the Russians out after their 20 odd years of misadventure in Afghanistan through the 1980 and 90s.
Otherwise the weather has turned very warm and my nasturtiums have awakened to life in Kabul (I have never seen any nasturtiums here). The “green fuzz” referred to in my earlier rumination has now leafed out. I realize now that there is actually green throughout the summer in Kabul…it just gets covered with increasingly thick layers of dust giving the overall impression of Kabul being a dull green/grey terrain.
I have been very hospital/office bound this trip and am looking forward to connecting with midwives this week at the Afghan Midwives Association Congress. I have been promised a trip outside Kabul to visit one of the Community Midwife Education (CME) programs. I will be leaving mid-May to return in July-August.
I wonder why “independence days” seem always to be about guns and military posturing. It was a pleasure yesterday afternoon, after all the cannons and marching before dignitaries had ceased, to see the flutter of kites filling the Kabul sky….”Kite Day”…. wouldn’t that be a novel national holiday..
Springtime in Kabul – April 2006 April 13, 2006Posted by Linda Barnes in Uncategorized.
Back in Kabul delighting in this brief seasonal interlude between the searing winter and the equally searing summer weather. There is a peach-fuzz-like shimmer of green over the usually dusty brown terrain. I am amazed at the Afghan capacity to nurture flowers (and food) from terrain that is essentially rubble and dust. The usually dry Kabul River is lined with saplings and potted plants for sale. The river itself has some water in it, but a far cry from old photos in which it is a beautiful and flowing river; the river appears to be a lake of plastic bottles and bags and looks pretty toxic. The surrounding mountains are gradually losing the shimmer of snow. I planted my nasturtium and morning glory seeds at our compound; the gardener, delighted with new seeds, assured me he will watch them closely.
So, what’s new on the hospital front. Every time I return there is perceptible change. The hallways and wards are cleaner than before; the new paint (not just white wash, but a thick smelly permanent, washable oil base) offers bright whiteness and convey a sense of a higher standard of care. Case reports follow a sensible format in the morning meetings of the consultant staff and patient management is improving. I am always delighted to see the staff; they are always so welcoming. The hospital has at least a dozen new midwives freshly graduated from the midwifery training at the Institute of Health Science in Kabul. Both the nursing staff and the midwife staff have bright blue scrubs under their white coats.
In Kabul there is intense interest in the parliamentary proceedings confirming and challenging the ministerial appointees. There is obvious pride in this process…a sense of “democracy” with local ownership.
I am gratified the “Christian” was escorted to Italy. I follow the proceedings of the Afghan teenager, Khadr, who allegedly at the age of 15 hurled a grenade that killed an American. The conditions of his incarceration at Guantanamo are at issue. I hope this case will stay under the general “demonstration radar” as demonstrations inevitably disrupt our travel to and from work.
The Afghanistan Midwives Association congress is set for early May and there will be a general celebration on International Midwives Day on May 4th. With the new membership dues and sponsorships from the US there are 10 new international members and money to sponsor 30 Afghan midwives for annual membership in the association.
This past week we had a govt. holiday and a dozen of us (including guards, cleaners, drivers) took off for a Afghan picnic and beheld the true beauty of Afghanistan where, despite 25 years of war and 12 years of severe drought, the land, as the people, come back!
March 16, 2006 March 23, 2006Posted by Linda Barnes in Afghanistan, Midwifery.
I write comfortably from Durango, CO; I am preparing to return to Kabul next week for six weeks. News of Avian Flu is a little scary; the security situation continues to teeter on some kind of edge.
I am gratified that midwife colleagues have sent their $25 annual membership/sponsorship for the Afghanistan Midwives Association (AMA); these fees will be a great boon to this nascent professional group in Afghanistan. Just before I left Kabul the AMA was officially welcomed as a full member of the International Confederation of Midwives (ICM). Midwives have a long and arduous path ahead in Afghanistan. Those of you who are midwives can imagine the challenges these midwives face in Afghanistan where women feel safest looking through the grill of a burka.
January-February 2006 March 23, 2006Posted by Linda Barnes in Afghanistan, Birthing, Midwifery.
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Yesterday I had the opportunity to visit the "field" as part of a regionalization strategy to begin to try to serve the forgotten areas of Kabul Province. Our objectives are to try to begin put structure on the referral system and help women get prenatal care, of which there is virtually none right now in Afghanistan. Midwives are the backbone of a referral system but it will be a long and arduous journey from where we are now and actually getting care to the desperate women in the outlying areas.
Our small group traveled to one of the further reaches of District 7 that is primarily made up of people of the Hazara ethnic group, many of whom have migrated into Kabul seeking work. In most of the five households we visited the men, primarily construction workers, were unemployed during the winter months and households were with very limited funds and food. The typical diet, asked of several women, was tea and bread, augmented by beans when they could afford it; most compounds had several chickens, but no mention was made of eggs. Most of the houses were either unheated or in the middle of the "sitting room" was a metal stove with coals and a large blanket over it where we could sit on the floor and put our feet under the blanket for warmth…usually there were one or two kids also sleeping under the blanket. One woman baked bread and sold it to supplement income. There were no meat or vegetable shops that I saw in the area.
We walked along open streams of water, open pits that were obviously used for refuse. There was one pump in the middle of the area for water and we were told that it was a shallow well and the water tasted salty so many people took drinking water from the various streams that ran through the area. Clearly this was not potable water.
In the five households visited we met five women who said they were, and appeared to be, 8-9 months pregnant; one was seven months pregnant. One of the women was in early labor. Their ages ranged from 17 to 38 and gravity ranged from 2 to 13. Most of the women had lost children within 1 month to 1 year and when asked the cause of death one woman described her baby as dying of "fear" but then went on to describe that the baby had turned blue. One would speculate anything from tetanus to measles? When asked about tetanus vaccine for herself, one woman said she had the tetanus vaccine, but "got pregnant anyway."
The Community Birth Educator (CBE) accompanying us covered topics including nutrition, money for transportation, breast feeding and delivery kit. We asked the woman in early labor to show us her "delivery kit" and she produced several bundles of rags, one of which was obviously the baby's packet as it included a blanket and a swaddling cord. I asked to see her packet to take care of the umbilical cord and she had wrapped in a piece of cotton a new razor in its envelope and a small spool of thread. This woman's plight was typical of those we visited. She had virtually no money. It would take at least 1 1/2 hours to reach even a Basic Health Clinic and there was no transportation in the area even if she had time and money in the event of an obstetric emergency. Her husband was "away" seeking work and her probable birth attendant would be her 12 year old daughter. Another barrier to care that several women mentioned was the lack of anyone to take care of their other children if they were to go to a hospital for delivery. Another woman who has had five spontaneous abortions prior to the current full term pregnancy wanted to go to Rabia Balkhi Hospital (RBH) for the delivery; her husband said she could not go because he had no money, and could not pay for the "medicine" at RBH. She was hoping a sister-in-law could be found when she went into labor. There are a few traditional birth attendants around, but they are unsupported and officially unrecognized by the government.
The overall impression in this Bala-Koh was of extreme poverty, poor nutritional status, unhygienic living conditions and many economic and social barriers to health care. These mothers are pretty much left to fend for themselves on the outskirts of Kabul Province. It is not difficult to imagine that there is a significant morbidity and mortality rate amongst these women and a commensurately high rate of infant death.
CBEs seem to do an excellent job of keeping track of these women and families and they provide support and basic education/advice which is obviously received well by the women in the community. CBEs are well-positioned to provide some basic adjuncts such as a birth kit, vitamins and iron, and nutritional supplements. These items are low-cost, but would be of great benefit in these remote reaches of Kabul Province where the referral system appears to consist solely of CBEs. It continues to amaze me that with all the "inputs" in Afghanistan, we still find it impossible to supply CBE's with vitamins and iron; the bureaucracy is mind-boggling!
At some future date, when there is an established referral system, a mobile clinic in areas like Bala-Koh would be of very great benefit to the overall health and well-being of these women. It is likely that CBE's with their inroads in the community would be able to find an accommodation for a mobile clinic such that providers could come periodically with their own basic assessment equipment, some nutritional supplements and vitamins and iron. This would be a beginning.
“While the Taliban was in control women had a very hard time coming to Rabia Balkhi, especially at night. There were no medications and no electricity was available and we had to take care of women using candles. One night a woman came who had preeclampsia. We had no medicine and had to watch the mother while she had an eclamptic seizure and both the mother and the baby died right in front of me.”
“I was living in Jalalabad during the Taliban time and I was living in the town. Most women had their babies at home and sometimes I was called by one of the relatives of a mother if her birth was difficult. One night I was taken to a house where a mother was having twins. The first baby came okay, but the second baby was breech and also had a meningocele (sometimes seen as Spina Bifida) that prevented the baby from being born. I had to cut the meningocele open and the baby died.”
“One night one of our midwives (H.) came to the hospital very sick. She came alone because her husband and two children had been killed. She lay in the courtyard outside the hospital because she was very poor and the Taliban would not let her in the hospital unless she paid them money. She needed blood and had no one to give blood to the blood bank so she could not get a transfusion. We midwives each donated blood so that she could get transfusions and she lived and is here with us today.”
“During the Taliban the midwives were the only ones in the hospital, especially at night, as most doctors left Kabul City and were hiding in their homes in the country or had left the country. We had no pay for five months but we came to work every night. Now that the doctors are back they don’t respect us for what we did while they were hiding. Now they think we should not attend deliveries and that we should just clean instruments and the floors. When the Americans bombed Kabul and drove the Taliban out we were all very afraid for our children who we had to leave at home when we came to the hospital. One of my children was killed in the bombing and I didn’t know about it until two days later because I couldn’t leave the hospital. I still have three children.”
January March 23, 2006Posted by Linda Barnes in Afghanistan, Midwifery.
Returning to Kabul in January is like stepping into an old black and white photograph; the city is a study in shades of grey. Kabul–a city without snow for the past 12 years–is suddenly deluged with eight inches. Vehicles are piled up by the side of the road, unable to negotiate the ice and snow. Children grab onto the backs of busses and are pulled along the slick roads. Bicycles and motorcycles pile up at the traffic circles. Policemen are hopelessly waving round painted signs with the command: “SOTP POLISE.” (sic)
I have arrived two days before Eid-al-Adah (the Islamic celebration of the sacrifice of Isaac) and the usual marketplace chaos is thickened by shoppers rushing to purchase food and sweets prior to the four-day holiday.
The muted colors inside Rabia Balkhi Hospital match the Kabul winter colors: dark and cold with an occasional oasis of warmth where someone has found an electric outlet for a space heater or has a small wood-burning fire flickering. The hospital is still a microcosm of the general disarray in Afghanistan and the dark and cold winter penetrates the wards and hallways. The Rabia Balkhi Hospital staff warmly welcome me back with many traditional hugs and ask about my family, my trip, my self; I feel truly “back.” There are now 46 midwives and, unlike the weather, the welcome back is warm and generous. I find it hard to fathom how these women, after suffering unimaginable personal losses and continuing to work throughout the torturous years of war and the Taliban, can still demonstrate such a resilient spirit. They are smiling and appear to be delighted that a midwife trainer is back to work with them.