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February 2007 – Kabul District: Women in Distress February 17, 2007

Posted by Linda Barnes in Afghanistan, Maternal Mortality Afghanistan, MCH in Community, Midwifery, Rabia Balkhi Hospital, Terres des Hommes.

District 10

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. Winter in District 7

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 contributoWeighing a Newbornry 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.

Birth Demonstration

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.


August 24, 2006

Posted by Linda Barnes in Afghanistan, Birthing, Maternal Mortality Afghanistan, MCH in Community, Midwifery.
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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.   

tdh2.jpgBefore 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 healtdh1.jpgth 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, 2006

Posted by Linda Barnes in Afghanistan, MCH in Community, Midwifery.



Dist 7 maps.jpgThursday 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. TheDist 7 3.jpg 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. laCBE Haley 2.jpgb 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.