Afghanistan's Hebammen wollen es wissen!

Afghanistan's midwives tackle maternal and infant health
Declan Walsh

Decades of conflict have left Afghanistan's maternal health services woefully under equipped and under staffed. But a movement is underway to boost the number of trained midwives in the country, and amid the insecurity there are already signs of success. Declan Walsh reports.
The Afghani people have much to fear this year. Taliban insurgents are on the march, engaging western forces in battle, and the death toll is soaring—over 5000 deaths so far due to suicide bombings, beheadings, airstrikes, and roadside bombs, up 25% on 2006. But for Afghan women, the greatest peril is not bombs or bullets—it is the act of giving birth. On average one Afghan woman dies every 30 minutes from pregnancy-related causes. The national maternal mortality rate is 1600 per 100 000 livebirths, second only to Sierra Leone.
An expectant mother faces colossal problems in seeking professional help. The road to a hospital or clinic may be rutted, snow-filled, or crawling with armed insurgents. Her family might be too poor to afford a car or a taxi fare; a 4 hour donkey ride could be too painful. Male relatives may discourage her from going to hospital, fearing the comments of sneering neighbours. The local mullah may be even sterner.
Hannah Gibson of JHPIEGO, an aid agency affiliated with Johns Hopkins University in Baltimore, remembered one pregnant woman with high blood pressure who had been taken to the local mullah in search of a cure. The mullah beat her to banish the evil spirits inside her. “By the time she got to hospital she had been beaten black and blue and the baby was dead.”
There are stark regional variations in the level of care for women. Hospitals in major towns are often well resourced but swamped with clients. Kabul's Malalai Hospital delivers 18 000 babies a year. In the distant provinces, the situation is more dire. In Badakhshan, a mountainous province on the northern border, some 6500 mothers die for every 100 000 livebirths—the highest ever recorded rate.
Cultural barriers and ingrained superstitions exacerbate the problems. Some Afghans, for example, believe that all running water is clean, or that liquids should be withheld from children with diarrhoea. In some places girls receive little medical care because of the privacy worries of domineering male relatives.
But there is hope. Since 2001, Afghan and western health workers have concentrated their efforts on this gargantuan problem, and progress is being made. A sharp fall in infant mortality is saving the lives of up to 40 000 children every year, according to a recent study by Johns Hopkins researchers. The investigators also note that the number of births assisted by a skilled health worker rose from 50 000 in 2002, to 190 000 in 2006.
A midwife training scheme has been key to that success. The British medical aid agency Merlin has trained 44 new midwives in Takhar, a northern province on the border with Tajikistan, since 2004, as part of a community-based programme. “In the beginning it was not easy”, said country director Paul Sender. “We had just 20 applicants for 20 places. It was considered a strange idea for a woman to go and live in a training compound, away from her family. They were being dissuaded from coming, not through direct intimidation, but in a gossipy way at village level.”
Merlin overcame the suspicion with educational messages on local radio and television stations, and an exhaustive round of consultations with local religious leaders. It worked—in its last intake Merlin had 200 applicants for the same number of places.
Good wages help. A community midwife in a rural area can earn up to US$350 per month, a huge salary by local standards. But the need remains acute. Across the country there are only 2200 midwives against an estimated need of between 6000 and 8000.
“The amount of money you could pour into the health system is limitless”, admits Sender. “But things are changing. We have newly constructed clinics, working midwives, and mothers delivering babies. It is moving in the right direction.”

The Lancet Volume 370, Issue 9595, 13 October 2007-19 October 2007, Page 1299