Independent Appeal: Afghanistan... the most dangerous place in the world to have a baby

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The Independent Online

Manija Hojipour's decision to join a midwifery course did not meet with universal approval at her home village of Durayi. Her mother was reduced to tears by claims that the 20-year-old will be corrupted by mixing with unbelievers and become a pariah in her own community.

Among those voicing hostile sentiments were some daiyas, the traditional midwives, mostly elderly women, of rural Afghan-istan. "They were angry because they thought I was going to take their jobs," Ms Hojipour said. "They said I was immoral and I was abandoning my religion."

It is, in fact, the sheer deadliness of the old ways which has made modern midwifery training so imperative for Afghanistan. Five years after the liberation from the Taliban, with all the attendant benefits that was supposed to bring, the country, along with Sierra Leone, has the worst maternal death rate in the world.

The mortality rate during childbirth is 1,600 out of 100,000, which means one in six women between 15 and 49 dies during delivery. The British figures are 13 deaths for every 100,000.

Most deaths could be avoided if skilled midwifery care was available. Many of the deaths are due to infections or haemorrhages. There is also the dangerous practice, widespread throughout the country, of administering oxytocin, a hormone that accelerates labour. If given in too high a dose, this can lead to uterine rupture and cause the foetus to die. Often, labour is slow because the pelvises of girls, married in their early teens, are too small.

One of the prime causes of this shockingly high mortality is that more than 80 per cent of Afghan women do not have trained ante-natal care from a doctor or a midwife. The facilities that did exist were dismantled during 25 years of war and the oppression of women under the Taliban.

The continuing lawlessness, with a resurgent Taliban battling Western forces, has made it extremely difficult to establish medical facilities in vast swaths of the country. But the British medical charity Merlin - one of the three charities in this year's Independent Christmas Appeal - has set up the first midwifery programme since the war at Taloqan, in Takhar province, and it has been a significant success.

Addie Koster of Merlin, head of the Taloqan midwifery school, has worked in several Third World countries in Africa, Asia and Latin America. "But I have never come across situations as bad as in Afghan-istan," she said. "We have all the problems of a poor society and, at the same time, the damage that has been caused by war and a history of denying basic rights to women. And we have the violence and political problems as well.

"But the interest in the course has been fantastic, and I think we are managing to convince people we are here to help, not to entice people away from their communities."

The school had to close for a week this year after a rumour was spread in Taloqan bazaar that a bomb was going to be dropped on the site. Taliban supporters warned some students to stay away, and, as in the rest of the country, security is always an issue. In Kunduz, the nearest big town, Nato forces have been attacked several times.

But there was a huge number of applicants for the 18-month course, funded by USaid, with some hopefuls travelling for days to get to the interview.

Ms Hojipour, who is half Iranian, had almost given up hope of a prized place. But her father refused to bow to the community pressure, declaring his daughter would attend the course even if he had to take her there himself.

That is what Abdul Khaliq does now. He has given up his life as a farmer and works as a guard at the clinic so he can bring Ms Hojipour on his motorcycle. "A lot of people, including relations, were saying it was wrong for Manija to work with foreigners," said 40-year-old Mr Khalaq. "My wife just kept crying and saying our daughter's life would be ruined. But I said her life would really be ruined if we stopped her from this opportunity."

Students at the midwife school have to agree to go back to work in their home area for at least five years. In many cases, the community had chosen the candidate to be sent to the school and they want a return for their "investment".

Nuriya Kalili, 27, a student from Baghlan province, said: "People put their trust in us, and we have to repay that. We all have experience of how bad things can be. My uncle's daughter-in-law was given oxytocin by a daiya at the wrong time. There were side-effects, she lost her baby, and she died.

"We also had a neighbour who died because her husband refused to let a male doctor treat her when the pregnancy went wrong and she needed urgent help. These are the kind of things that women suffer from in Afghanistan. There are a lot of problems here."

Khal Mohammed, 40, and his wife had brought their five-month-old daughter, Parwana, to the clinic for vaccination. He had assisted in the birth of each of his six children, but would have been be happy, he said, if a qualified midwife had been present. " Surely Allah will be pleased if we make sure to give our wives medical help," he said.

Such views are not held by everyone. In Kunduz, an hour's drive from the clinic, Safia Ali was being buried. Her delivery had gone wrong but her husband refused permission for her to be taken to hospital because a female doctor could not be guaranteed. A doctor was finally called with Mrs Ali profusely bleeding and the attendant daiya unable to help. But it was too late.

Dr Ahmed Qussim Ali at Kunduz said: "The daiya probably helped cause the deaths, but there is nothing we can do about that. It is such a shame because someone with proper training could have probably saved both lives."

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