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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.     



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.