**Author's note - This article was written in 2011. I'll be posting more on this topic in the near future**
Delivering safe childbirth in Afghanistan
An Afghan midwife talks with a family after a successful hospital delivery.
Photograph: Olivia Arthur/Magnum Photos
First published on Friday 6 May 2011 02.00 EDT
Roya, a midwife in Guldara, north of Kabul, is on the frontline of what may no longer be a war zone, but is still a killing field for women. Afghanistan has the highest proportion of women who die in childbirth of any country in the world.
"It is very common that women give birth at home and either the mother or the child dies," Roya says. "Mothers at home mostly deliver in a sitting position, which can cause the baby's body to end up in the wrong position during delivery. Because the mother doesn't have enough milk in the first three days after delivery, they give butter to the child. Often when they deliver the baby, they don't cut the umbilical cord properly with a clean instrument, which means it gets infected and the child dies."
According to figures from the Institute of Health Metrics in Seattle published last year, 1,575 women died for every 100,000 births in Afghanistan in 2008 – the equivalent figure for the UK is eight. Unicef says 52 babies out of every 1,000 die within two weeks of birth and 134 before their first birthday. A third of the deaths are caused by obstructed labour, in which years of heavy toil, having too many children too young, and possibly vitamin D deficiency as a result of purdah (which forces women to stay indoors), may all play a part.
The vast majority of women – around 87% – deliver with no skilled help, partly because of the paucity of health centres and midwives, partly because of the harsh terrain, and partly because male honour still demands women stay in their homes.
Just before 9/11, Brigid McConville of the White Ribbon Alliance for safe motherhood visited Kandahar province to see how women gave birth there. She visited a compound full of women, girls and babies who, from the age of 11, were not permitted to leave without a male family member as escort. "Giving birth was within that compound, with a neighbour or relative to help," she says. "They gave birth on a cloth over a dung heap, which absorbs the blood. The source of water was the stream running down the hillside behind. The toilets were also on that hillside. Women could only go there under cover of darkness. The stream was polluted. No wonder so many babies die."
The hunt for Osama bin Laden, which recently came to a bloody end, brought soldiers but also unprecedented aid to Afghanistan. The country's tragic record on childbirth triggered international support for a government initiative to train new midwives in remote rural areas. World Health Organisation estimates suggest Afghanistan needs 4,546 midwives to cover 90% of pregnancies – although USAid says it needs 8,000. In 2002, it had just 467.
Save the Children, which runs a college in Jawzjan province, says 2,400 midwives have been trained since the government launched these 18-month community courses and there are 31 schools instead of the six that existed in the cities before 2002. Linda Doull, Merlin's director of health and policy, talks of the sheer physical difficulty in Afghanistan's mountainous regions of accessing any sort of healthcare. "Some women travel three days by donkey over mountain ridges," she says. The need is to get care closer to them. "We choose women to train as midwives from the remote rural villages so that they go back there," she says.
Lima, 25, has delivered more than 600 live babies at the Uruzgan provincial hospital since qualifying in 2007. Women travel many miles, she says, and sometimes are robbed or punished for making the trip by people she calls "militants". "One of the sad cases happened last month," she says. "I received a woman who had delivered at home. When she came to the hospital she was bleeding and had lost a lot of blood. My colleague and I couldn't save her and she died. She left eight children behind her."
According to Save the Children, which published a major report, Missing Midwives, this year, there are just 13 midwives in Uruzgan province where 12,000 women deliver every year and 300 die. Afghanistan has now trained between half and a third of the midwives it needs – although there are still major issues around getting pregnant women to the clinics where they are based. But the worry now is that, as the pull-out of troops accelerates, the funding for training will dry up.
It appears to be happening already. A midwifery college in Kunar, in the heart of the mountainous, violent northeast of the country bordering Pakistan's tribal areas, has just closed. It was being funded by Gavi, the Global Alliance for Vaccines and Immunisations, but once one tranche of students had graduated, the money stopped and no other donors have come forward.
Those in the field say they are aware of a "rethink" towards funding. USAid, which has supported training, is looking at how best the money should be used. Funding for one of the Merlin schools, in Kunduz, ended in April because the midwife quota set for that region has been fulfilled. It is supposed to start again in two years.
It's a sensitive issue. Nobody wants to criticise donors over decisions concerning Afghanistan, but Unicef's deputy country representative, Gopal Sharma, says the job of training midwives is far from done. "There is a big gap in funding which needs to be filled."
Provision is dire in Afghanistan, but no country has enough midwives, according to campaigners such as the White Ribbon Alliance for Safe Motherhood, which estimates that at least 350,000 more are needed worldwide. In some countries they have been trained but the government-run health service cannot afford to employ them. Some blame the International Monetary Fund for its past edicts on public-sector employment. Some just point to the poverty of developing countries and the low priority of health in the government budget.
The dreadful conditions in Afghanistan are a far cry from hygienic NHS labour wards, although the UK is just 23rd in the global league table. Yet Professor Cathy Warwick, general secretary of the Royal College of Midwives, argues that even the UK is 4,500 midwives short. Current numbers failed to anticipate the rising birth-rate of the past 10 years, nor the increasing complexities of cases, as older women and those with other health problems such as obesity go into labour – nor the need for post-birth care over breastfeeding and the risk of infection, for example.
Campaigners say more midwives are critical if the world is to get anywhere near to meeting the two most failing UN millennium development goals of reducing maternal mortality by three-quarters and child deaths by two-thirds. Every day, 1,000 women and 2,000 babies die of infections and other complications of childbirth, according to childbirth campaigners. Trained midwives can identify potential problems in pregnancy and attempt to ensure women give birth in clinics where they have a chance. But one in three women (35%) still gives birth alone or with only friends or relatives on hand.
At the UN summit on the development goals in New York last September, government, private and charitable donors pledged $40bn (£23bn) to improve maternal and child health. "Now we have to make sure the promises are kept," says McConville, "and money goes on training midwives."
