When I visited Gulpari,* I found her sitting in the corner of a room. Given the hot summer weather outside, the room was surprisingly dark and damp. On the other side of the room, her 18-month old daughter lies asleep on the floor, covered with flies, with only a thin sheet separating them from her small face and body. Her two older daughters run around semi-naked in the small courtyard outside. Next to Gulpari, a tightly swaddled newborn baby girl lies quietly in a crudely made cradle. In a country where boys are prized, having another girl does not bode well for this Afghan mother. Gulpari once gave birth to a baby boy. She recalls how his head got stuck after his body was born and when his head finally came out hours later, he was stillborn.
Since then, Gulpari and a few of her local friends have attended a safe childbirth course. The course gives poor, uneducated women some basic self-help measures for pregnancy, birth and the postnatal period and trigger points for referral to hospital. Gulpari’s youngest baby was born at home, too quickly to make it to hospital. The basic skills she and her friends learned, such as how to prepare for a hygienic birth at home and how to tie and cut the umbilical cord, equipped her and the baby for a safe birth.
More than 30 years of war has left Afghanistan with a damaged health care system, a lack of midwives and some of the highest maternal and newborn mortality rates in the world. Poverty and instability in the country continue to hamper efforts to strengthen the health care system and in 2011, Afghanistan was ranked the worst place to be a mother.
“…in Afghanistan, a typical woman has fewer than five years of education and will not live to be 45. Less than 16 percent of women are using modern contraception, and 1 child in 5 dies before reaching age 5. At this rate, every mother in Afghanistan is likely to suffer the loss of a child.” (State of the World’s Mothers, 2011)
Other factors contributing to women dying from pregnancy or childbirth related causes include:
- A tradition of child marriage, resulting in early first pregnancy which is associated with more complications.
- A lack of family planning means that women often have one pregnancy after another. Having more than four pregnancies can put a mother at higher risk of complications during pregnancy and birth.
- The physical geography of Afghanistan ( in parts very mountainous), high proportion of the population living in rural areas and lack of transport infrastructure, can make travel to a health care facility to see a midwife costly and lengthy.
- Among more conservative communities, women may not able to leave the house to access maternity care without a male chaperone.
However, during my time living and working in Afghanistan, I have seen glimmers of hope that things are changing for mothers and babies. Some of the changes include:
- A dramatic scale-up of an 18-month midwifery programme leading to greater numbers of skilled midwives.
- The formation of the Afghan Midwives Association, building capacity and supporting midwives.
- The training of large numbers of community health workers who play a pivotal role in educating families on matters relating to maternal and newborn health.
- Greater numbers of health care facilities.
- Community health programmes, such as the course that Gulpari attended, have also played a vital role in encouraging communities to seek out maternity care as well as providing self-help measures.
According to a national mortality survey conducted in 2010, it seems that this is starting to pay off, with a reported drop in maternal mortality rate from 1,600 per 100,000 births in 2000 to 327 in 2010. In the 2014 State of the World’s Mothers report, Afghanistan had moved up 33 places from the bottom of the ‘Mother’s Index’ – an impressive leap for such a fragile nation.
I saw Gulpari about a month ago and could not help but notice her swollen abdomen – she confirmed that she is four months pregnant. This will be her sixth birth and she is not yet 30. Maybe she is hoping for a boy this time. She may believe that by having many children, she will be seen as a good woman. Gulpari may not have access to essential family planning services.
There is clearly still a long way to go in improving maternal, newborn and reproductive health in Afghanistan. But let’s hold onto the glimmers of hope.
*Her name has been changed to protect her identity