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March 16, 2006 March 23, 2006

Posted by Linda Barnes in Afghanistan, Midwifery.
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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, 2006

Posted 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.Dist7-2.jpg

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.

Taliban stories Excerpted from conversation with four midwives at Rabia Balkhi March 23, 2006

Posted by Linda Barnes in Afghanistan, Midwifery.
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“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.”

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“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, 2006

Posted by Linda Barnes in Afghanistan, Midwifery.
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WinterinKabul.jpgReturning 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. 

Summer 2004 March 23, 2006

Posted by Linda Barnes in Afghanistan, Midwifery.
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Kabul appears as a city-that-once-was. The Russian occupation, which began in 1979, ended in their defeat and subsequent retreat from Afghan soil. Many believe that the defeat of the Russian Army in 1989 contributed to the end of “Communist Russia,” yet the security vacuum following the Russian withdrawal plunged the country into a decade of civil war and subsequent control by the Taliban. Millions of Afghan people died as a direct result of the conflict and over six million took refuge in Pakistan, Iran, or elsewhere in the world.

3.jpgThe blue burka, still prominent in the streets of Kabul, is a universal symbol of the repression and vulnerability of women. At the Rabia Balkhi Hospital for Women, where I am working, many of the female doctors–who wear professional attire throughout the workday–still put on the burka to leave the hospital.

 

Afghanistan currently has the highest maternal mortality rate in the world, averaging 1600 maternal deaths per 100,000 live births (compared to Western Europe and Japan where the average maternal mortality rate is less than eight per 100,000 live births). Half of all deaths among women of child-bearing age in Afghanistan are a result of preventable complications during pregnancy or childbirth. One in four children dies before the age of five. In most of the country prenatal care is inaccessible and, in the wake of two decades of war and the fundamentalist regime, barriers to health care for women still prevent most pregnant women from receiving basic care.

Folic acid deficiency in the maternal diet contributes to the high rate of neurologically damaged newborns. Several babies with neural tube defects are commonly seen at Rabia Balkhi Hospital every week. Tragically, because of no prenatal care, many of the anomalies are unanticipated. As with most buildings in Kabul, Rabia Balkhi Hospital was severely damaged in the years following the 1989 retreat of the Russians. The hospital, named after a famous Sufi poet and women’s advocate, is exclusively for women. Located in the city center, the hospital is surrounded by markets and a teeming free-for-all of human and vehicular traffic.

RBHLunch1.jpgThe conditions inside the hospital are bleak by American standards. Often, especially at night, electricity and essential supplies such as disinfectant, medications and sterilized instruments are routinely unavailable. The hospital kitchen has been renovated and a meal of rice and meat is served at noon each day; still, many of the wards double as small kitchens and temporary living quarters for female family members of patients. Sometimes sorting patients from extended family members can be difficult and, if one is not careful, it is easy to trip over pots of food or tea being cooked under beds with a plethora of extension cords snaking across the floor to one outlet.

Everyone on staff at Rabia Balkhi Hospital has a base salary of $40 a month and most of the medical staff have outside jobs. Often the hospital feels deserted after 2 pm as many professional staff go to their private clinics in other parts of the city. In their absence, obstetric emergencies are handled by a few junior residents, nurses and midwives.DeliveryRoom.jpg

In the delivery room where I spend part of my day, only female residents and nurse-midwives are available. The atmosphere is often hectic with as many as 50 deliveries a day. Since most women inpatients have had no previous care and the diagnostic technology is poor, multiple gestations and atypical presentations are often discovered at labor. Six small exam tables are covered with vinyl sheets that are washed down between deliveries. At times, multiparous women must deliver on a plastic mattress on the floor since women who have not previously given birth are given priority for the delivery tables.

Women bring in all their inpatient maternity requirements and arrive in the delivery room with plastic bags containing an assortment of rags, towels and wrappings for their newborn. The hospital now has a limited supply of medications, sutures and dressings for emergency surgical deliveries, but patients must purchase supplies and medications from the bazaar for anticipated cesarean sections.

Since the summer of 2004, the Ministry of Public Health has approved a three-year midwifery curriculum in English and Dari (one of the languages spoken in Afghanistan) with a Pashtu (another Afghan language) translation in progress. Standards of midwifery practice are being established as well as standards for teachers of midwifery and the teaching facilities. A great effort is being made to bring this curriculum to all the provinces of Afghanistan. The newly formed Afghanistan Midwife Association meets regularly and will be represented at the 2005 International Confederation of Midwives meeting in Australia. These midwives have clearly demonstrated their intent to assume a central position in women’s health care in Afghanistan; it is an honor to be in their presence.

Days at Rabia Balkhi Hospital can be frustrating. I envisage a better hospital with better care for patients and abiding the daily reality is difficult. Improvements occur in very small increments; a sense of tentativeness is felt at every juncture. Afghans sense a paper-thin margin between recovery and being plunged back into the darkness of war

Afghanistan March 23, 2006

Posted by Linda Barnes in Afghanistan, Midwifery.
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There are hundreds of organizations participating in the reconstruction effort in Afghanistan. It is a complicated situation; stemming the loss of mothers and infants (currently the highest rate in the world) is fraught with many social, economic and political barriers. Both government and non-government aid agencies are territorial and proprietary in their offerings of assistance and reconstruction; political factors between these organizations and the local authorities often impede change or give mixed messages about process and outcome.

Afghanistan, another "failed state" as described by a number of authors, notably Amalendu Misra, was cobbled together by the then-more-powerful nations in the world. Afghanistan is but one of many such "failed states" facing the formidable challenge of building national identity and infrastructure amidst cultural and political multiplicty and historical enmity between ethnic/tribal groups. The obstacles to improving the social, political, and economic infrastructure, especially following years of conflict (over 25 in the case of Afghanistan) is daunting. Women and children who exist on the soft underbelly of society are caught in the actual and figurative cross-fire of the resulting chaos.

The following are some of my ruminations beginning in the summer of 2004 and onward. Some of you may have already seen these ruminations (the initial piece is excerpted from an article in Midwifery Today, Autumn 2005,No. 75)… fast forward knowing it is my intention to stir up interest and dialogue around my experience and observations.

There is a Dari adage that captures the spirit of bring change to the health structures in Afghanistan: "qatra qatra darya mesha" …"drop by drop a river is made."