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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."