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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.

2nd Annual Afghan Midwives Association (AMA) Congress May 5, 2006

Posted by Linda Barnes in Afghanistan, Midwifery.
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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.AMA2.jpg

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.




March 16, 2006 March 23, 2006

Posted 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, 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.

“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, 2006

Posted by Linda Barnes in Afghanistan, Midwifery.

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."