KABUL, Afghanistan: Over the many trips that I have made to Afghanistan and Pakistan over the past two decades, the question I often ask women is, “What is most important to you and how can we help?”
You would think that a woman would say she wants prosperity or a good husband or list some desired material or luxury goods.
But in Afghanistan, women consistently tell me three things, “We want peace, we want education, and we don’t want our babies to die.” More recently, I’ve learned that they desperately fear dying in childbirth and being unable to take care of their babies.
Although there has not been peace in this war-torn country since 1979, I’ve witnessed two dramatic and inspiring changes since my first trip to Afghanistan 13 years ago: a surge in school enrollment, and a substantial decrease in maternal mortality rates.
The number of students in school, according to the Afghan Ministry of Education, has increased from around 800,000 before 9/11, to more than 10 million today, which makes it one of the greatest increases in school enrollment in any country in modern history.
But the decline in maternal mortality rates is simply a miracle. Just a decade ago, the Afghan Ministry of Public Health states, 1,600 of every 100,000 births ended with the death of the mother. In 2013, “only” 327 of every 100,000 women died while giving birth.
NOTE: School enrollment figures vary from 8 million to over 10 million, depending on the source (Afghan government, United Nations, World Bank, USAID), and the situation in a given area (security, displacement, and funding are all contributing factors). Maternal mortality rates also vary and it is difficult to ascertain the number of women in remote rural villages who die during childbirth with no trained provider to help them.
Maternal Health Organizations
The Afghan Midwives Association (AWA) attributes the reduction in maternal mortality to the introduction of about 3,500 trained midwives who often provide critical services in remote areas where there is little or no health care. Other factors are increased literacy, and improved roads, cellphone, and public health awareness. However, Afghanistan still needs and hopes to at least double the number of midwives to 7,000 in by 2020, and then up to 20,000 later.
“When we lost my aunt during delivery, it really motivated me to pay more attention to the rural areas, where women have no resources or hospital or even trained midwives to help,” Victoria Parsa, AMA executive director and a midwife since 2004, said at a recent AMA conference.
Parsa has worked relentlessly to get more midwives in Afghanistan, especially in the rural areas, and more recently has been advocating for increased awareness of and treatment for debilitating fistulas, which are often the result of child-brides having babies at very young ages.
Remote Badakhshan province, home to about half of CAI’s Afghan schools and projects, previously had one of the highest maternal mortality rates in the world at 6,000 deaths per 100,000 live births. But that figure, too, has dropped dramatically, to an estimated 1,000 deaths/100,000 births.
“Now that we are starting to have the first wave of literate and educated girls in high school and beyond, we are prepared to get as many local educated women as possible into maternal healthcare training,” said Pariwash Gouhari, CAI’s manager in the Badakhshan’s Wakhan Corridor and one of the region’s first educated females. “But the problem is that there are few programs like that in Afghanistan.”
In the isolated and remote Wakhan, CAI has helped train and supports two maternal healthcare providers. These two brave women, Bano and Parveen, have essentially reduced the maternal mortality in their villages from several women per year to zero or one. Bano and Parveen’s villages have no phone, electricity, Internet, or potable water.
Last fall Parveen said to me in her village of Wargeant, “It’s not just about the delivery. What really makes a difference is what we do every day to educate the mothers and children about hygiene, nutrition, and sanitation. Also, since nearly all the pregnant women are anemic and suffer from malnutrition, we get angry at their husbands who don’t want to share meat, eggs or protein with their wives – sometimes I carry a big stick with me to make that happen”.
Improving Maternal Mortality
Dr. Suraya Dalil, Afghanistan minister of Public Health, is also a fierce advocate for midwives. She recently received the Global Leaders Council for Reproductive Health’s Resolve Award for leadership in expanding health service access.
Ironically, the maternal mortality rate in the United States maternal mortality rate in the United States has simultaneously risen sharply, from 7.2 deaths/100,000 live births in 1987 to 18.5 deaths/100,000 live births in 2013, according to a University of Washington study. The US maternal mortality rate is double that of Saudi Arabia and Canada.
Women’s literacy also helps reduce maternal mortality, as literate women are more aware of their own and their children’s health, can read educational materials and medical directions, and more. CAI has established women’s literacy centers – some in formal settings in buildings and others in teachers’ homes. Some of the women are afraid to tell their husbands that they are learning to read and write for fear they will be beaten or shunned. However Nasima, a women in a CAI literacy center near Kabul, said her illiterate husband quickly changed his mind when Nasima was able to help him enter names and numbers on his cell phone.
Rahima, a widow who teaches a CAI woman’s literacy course in a rural house courtyard packed with women, also teaches her students about infant and maternal mortality. Last week Rahima told me, “None of my women had literate mothers, many have lost their babies at an early age, and nearly all of them had someone in their extended family die in childbirth. That is my fight, not only for peace through education, but to prevent unnecessary death.”
As a former nurse and advocate of home births and midwifery, being in the presence of confident midwives in Afghanistan or Pakistan easily ranks among the most moving experiences I’ve had over the past 21 years of working in these regions.
When I visit most CAI schools in rural Afghanistan, about 80 percent of the girls say they want to become doctors. Another 10-15 percent want to be teachers (not desired due to low pay), and the others police, lawyers, engineers, businesswomen, journalists, farmers, and even pilots.
Few of the girls have ever heard of midwives, so I have encouraged some of these high school girls who want to be doctors to consider becoming midwives, especially in villages without health care. In the months and years ahead, we plan to encourage our teachers to motivate female students about midwifery and have midwives visit some of our schools to talk to students about careers in this noble profession, so that the miracle of life and fulfillment of one of the women’s main wishes continues.
QUOTE: Only mothers can think of the future – because they give birth to it in their children. – Maxim Gorky
– Greg Mortenson, CAI co-founder