Posted on 18-3-2004

The Birth Of Hope .

Afghan midwives teach expectant mothers to replace superstition with
sanitation. By Ilene R. Prusher, Christian Science Monitor

KABUL, AFGHANISTAN ? It's not clear who will be first, but one thing is
certain. Three women in the Sakhi family are due to give birth in the next
month, and Nasima Kuchi, a midwife, wants to make sure they know what to
do - and what not to do.

The birthing bed should be covered with a clean towel and plastic, she
explains to a rapt audience of women in the family's front room, usually
reserved for male visitors.

To Westerners, the need for sanitary conditions at a birth may be obvious.
But not necessarily in Afghanistan. In one old tradition, women would
spread a layer of earth in the place where the woman was to give birth as
a way to protect the house.

Perhaps it should come as no surprise that Afghanistan has the
second-highest maternal mortality rate in the world. Only Sierra Leone's
is higher.

Of every 100,000 women who go into labor in Afghanistan, about 1,900 die,
according to Dr. Tessa Wardlaw, a senior program officer for UNICEF, the
United Nations Children's Fund. In the US and Japan, by comparison, the
number is 8 in every 100,000 women. Afghanistan's infant mortality rate,
at 165 per 1,000 live births, is also among the world's highest.

But Mrs. Kuchi is trying to change those grim statistics. She and others
are part of a new breed of midwives who go house to house, teaching Afghan
women about sanitation, childbirth, and infant care. A Swedish charity
pays for the cost of the midwives' training and services.

Still, Kuchi and her handful of colleagues know they have their work cut
out for them. Although midwives have been around for many years, few have
had much training. The vast majority of Afghan women give birth at home,
helped along by other family members following customs passed down from
generation to generation. Much of their information entails more myth than
methodology.

Replacing old ways with new

Thus Kuchi spends a great deal of time explaining the basics, specifically
what they should not do. For example: After the baby is born, don't put
lipstick on its navel, where the umbilical cord has just been cut.

"Some people put lipstick on the navel because they think that it will
help the baby's lips turn red," says Kuchi, a fair-skinned woman with a
patrician air and elegantly applied makeup.

"Don't put anything on the navel," she advises the women. Another
important point: If the mother must give birth by Caesarean section, do
not follow the conventional wisdom, which holds that she should not be fed
for three days afterward.

Although it may sound like common sense, much of Kuchi's information is a
revelation to these women.

Many still follow the popular practice that a woman should not eat when
she is getting close to her due date - and subsequently gets weaker when
she needs her strength.

Others believe that a newborn baby should be kept from the mother for at
least a day, and should not be fed anything other than tea and sugar in
the first days of its life.

Nearly half of Afghan women of childbearing age who die each year do so as
a result of complications in pregnancy or childbirth. A motherless newborn
has only a 1 in 4 four chance of survival. Only 7 percent of women who die
during or after labor gave birth with the help of a skilled attendant,
according to a joint study last year by UNICEF and the US Centers for
Disease Control and Prevention in Atlanta.

Most of the deaths, the study found, were preventable.

The numbers add up to this: Motherhood, society's most important job for
more than half of the population of Afghanistan, is also its most
perilous.

Two years after the fall of the Taliban, which ordered women to stay home
- and made it almost impossible for Kuchi to get out to do her work -
improving training for midwives is considered by international health
advocates to be part of Afghanistan's reconstruction plan.

Heathcare often inaccessible

But many problems remain. Poor, unpaved roads make it difficult for people
to get access to healthcare, including the services of midwives. The
result of more than two decades of war and a fundamentalist regime mean
many families still forbid women to see a male care provider - making the
role of midwives like Kuchi all the more crucial.

This morning, on a typical day in the life of an Afghan midwife, Kuchi is
visiting Kabul's poorest neighborhoods. With her is a list of houses where
pregnant women live. When she comes into the Sakhi home, they behave as if
a great dignitary has arrived, and then a crowd gathers around to watch
her go to work.

Kuchi, who has six children of her own, asks the three women who are due
next month to approach her. Each is a wife of one of the family's eight
sons; a new wife usually moves in with her husband's family. Kuchi moves
her hands over each rounded belly, listening with a rudimentary
stethoscope for a baby's heartbeat.

Then Kuchi and her midwife partner, Gul Ghuta Musleh, lead an informal
class in how to deliver a baby.

Assembled on the carpet are all the women of the extended family, as well
as girls from the age of 10, some of whom can expect to be mothers in the
next four to five years.

Most of the women will bear their children here, in this cement room where
a chilly draft wafts through windows that sit askew.

Hajira is on her sixth birth, although she's already lost two infants
along the way. A baby-faced woman in a dark-blue scarf, she looks too
young to have been through so much. But at 20, she's already been married
for six years, and had one pregnancy a year.

"We didn't know what to do, really," says Hajira. "Now we know more,
because [the midwives] come to visit and they keep coming back.

"She's always reminding us what to do," the young woman says of Kuchi,
"because it's good to hear it more than once. Sometimes we forget."

Next, the midwives hand out sealed bags, free kits from the United Nations
that come with the bare essentials - a clean sheet and plastic, plus a
string and a razor for cutting the umbilical cord.

Using a doll - which looks more like a gingerbread man with a tube coming
from its stomach - Kuchi demonstrates how to treat the newborn. She
carefully shows the women how to make two knots in the umbilical cord, a
distance apart, and then cut in between.

While the procedure looks simple enough, thousands of Afghan infants die
each year of tetanus acquired from cutting the cord.

If pregnant women don't have one of these ready-made kits, Kuchi says,
they need to make one. Boil the string. Wash the cloth and plastic and
hang them out to dry. No one who hasn't just washed her hands should be
allowed to touch it. In a pop quiz, Kuchi asks a few women to reenact what
they just learned.

"If the time comes and we're away, then you can help each other," Kuchi
tells them. When in doubt, she says, send for her.

Many families, however, will not - or won't have the option. Some are
afraid of having to pay costs they assume are associated with employing a
midwife. Kuchi and Musleh, however, do not take any fees. Their visits are
paid for by Terre des Hommes, a Swedish aid organization.

"Most of our patients want to have the child at home," says Kuchi. "This
way, they can rest there and they don't have to travel and pay for the
transportation."

In more remote, rural areas of Afghanistan, where the mortality rate is
the highest, there are very few trained midwives, and the lack of
transportation makes getting help almost impossible; some villages are
accessible only by donkey.

Moreover, many families are unable to recognize an emergency when it
occurs. Training by the midwives gives them a better sense of when to know
it's time to ask for help.

Toward the end of Kuchi's visit, the women have more questions. One wants
to know why she can't conceive - and many others want to know how they can
stop.

Birth control, says one of the wives, Mektup, a mother of seven, is a
controversial issue: "In Islam, they say it is a sin to take birth control
pills, but what should I do? I already have seven children. I pray to God
that all my children live, but I don't want any more. All of our husbands
are poor, and we cannot afford to have more children."

Kuchi doesn't answer. She bids farewell and heads off to another Kabul
home at the end of a rocky, dirt road. Here, a woman named Nuriya gave
birth to Suriya, now 6 weeks old, and Kuchi is visiting them for the first
time since the delivery.

Wrapped up and sitting in Nuriya's lap, Suriya has eyes that jump out like
those of a model in a fashion magazine. The upper and lower lids are
rimmed with black kohl, which the family believes will protect her from
harm.

"We put the 'black stone' on her eyes so she looks beautiful - so her eyes
will be healthy and her eyesight will be good," says Nuriya, a young
mother of three whose husband is unemployed. "We put black on her eyes now
so she'll be able to see at night when she gets older."

Nuriya's mother, Nafes Gul, nods approvingly.

Now that she knows Suriya is doing well, Kuchi gives Nuriya tips on what
to feed the baby. This is, after all, a country with no equivalent of
books like "What to Expect in the First Year," and no Baby Gerber jars on
the shelves.

After six months, she says, you can feed the baby spinach, but don't add
oil or salt. Protein isn't a bad idea, either.

"Before," explains Kuchi, "women thought that you shouldn't give an egg to
a baby because then the child would be [stupid]."

The proud grandmother, Nafes Gul, is glad for the help. She had six boys
and two daughters, but also lost four other children in childbirth. When
she had her babies, there were no professional midwives; other women in
the family simply pitched in to help. She already has 16 grandchildren,
she says.

"No, let's count them," says Nuriya, ticking off her siblings' children.
"Eighteen."

"Yes, 18," Nafes Gul confirms with a laugh. And then she thanks Kuchi with
a blessing: "May you live long."

Kuchi's final stop of the day is at a far poorer home, an adobe-style hut
of packed mud. Inside, a young woman is pregnant for the first time - and
nervous.

"How old are you?" Kuchi asks.

"Hmm. Maybe 20?" comes the answer in a whisper.

"Name?"

"Fatima."

Kuchi takes out one of the information cards she uses to keep track of her
patients. She leaves a copy behind, trying to encourage women to chart
their own progress, insisting they keep it with them like an identity
card.

Fatima is from the Hazara ethnic group, and her face is an exotic mix of
East and West - Asian features with fair skin and freckles. Next to
Kuchi's urban clothing, Fatima's tribal garb is bright and colorful. But
her mood is not - she isn't feeling well, and is worried she will have a
difficult pregnancy.

Her mother-in-law, who sits next to her spinning wool, considers her
daughter-in-law to be getting a late start.

Kuchi gives Fatima advice on what to eat - less meat and more vegetables,
of which there are few in the Afghan diet. Then she tells her to get more
rest and do less heavy work, glancing at Fatima's husband sitting in the
corner.

As she leaves, she passes a collection of burqas, hanging on nails jutting
out of the mud wall. Outside in the sunlight, Kuchi says she's glad she no
longer has to dress in the all-encompassing women's wear that made
Afghanistan famous.

"Without it, I feel young again," she says with a smile. "And every time I
wore it, I had a headache - it sits so tight around your head."

The fact that most of her patients still wear burqas reminds her of how
much Afghanistan has changed since she was young.

In the early 1970s, during Afghanistan's modernizing heyday, women were
wearing short skirts. In those days, she wanted to be a flight attendant
on Afghanistan's national airline - or a policewoman. Her father insisted
she learn to be a midwife instead.

"I resented him then, but now I love it," she says, closing up her kit for
the day. Plumes of powdery dust from the alleyway kick up under her heels
and swirl around the midwives' long, dark coats.

Tomorrow, Kuchi and her colleague will visit more houses. They will go to
several more the next day, and the day after that.

But even with their many rounds, they know they will reach just a small
percentage of Kabul's expectant mothers.

Still, this is a big improvement over what life used to be. Under the
Taliban, nearly all aid workers came under the suspicion of Afghanistan's
leaders, which made it more difficult to address the crisis in maternal
fatality rates.

Now, in a freer postwar era, the United Nations and independent aid groups
have been able to invest more in training programs for midwives. But their
efforts are like a few scattered raindrops on badly parched soil. Many
rural provinces still have no medical/health facilities at all - and are
not being served by the new programs.

The largest training course is at Kabul's Malalai Women's Hospital, which
offers five weeks of classes for midwives.

Many of the students there are women who had already been working as
midwives, but had never received any formal instruction.

"If someone becomes known as a midwife, everyone in the village trusts her
and looks up to her," says Ziba Kamal, chief of obstetrics at the
hospital, during a break in her course for midwives, some of whom have
traveled several hours to come to the course.

"Usually she has watched a few others, one or two, and then she becomes a
midwife."

It's difficult to know how much of an impact the additional trained
midwives are having in reversing the grim statistics surrounding birth in
Afghanistan.

But Dr. Kamal and midwives such as Kuchi and Musleh are doing all they can
to turn things around.

As Kuchi knows from experience, mothers who have had the help of a midwife
are tremendously grateful - and relieved.

The presence of a calm, knowledgeable midwife does more than alleviate
fear. It can be the difference between celebration and grief.