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Midwife training programme aims to reduce maternal mortality in Afghanistan

© UNICEF Afghanistan/2008/Rich
Dr. Forough Malalai is the only female maternal health doctor in Panjshir province, a mountainous region in central Afghanistan with 600,000 residents.

This year, UNICEF’s flagship report, ‘The State of the World’s Children’ – to be launched on 15 January – addresses the need to close one of the greatest health divides between industrialized and developing countries: maternal mortality. Here is one in a series of related stories.

PANJSHIR PROVINCE, Afghanistan, 13 January 2009 – Dr. Forough Malalai is the only female maternal health doctor in Panjshir province, a mountainous region in central Afghanistan. With vast valleys and harsh winters, many of Panjshir’s 600,000 residents live in villages that are inaccessible by road and often blocked by floods and avalanches.

“Some women have to walk for hours, even days, to reach the clinic,” says Dr. Malalai. “It is quite difficult to transport emergency cases to the clinic.”

At present, Dr. Malalai can provide her patients with basic services at the clinic, but she hopes that one day the clinic can be replaced by a hospital. For now, she must manage to use the limited resources to provide the region’s women with good obstetrical care.

Traditional customs hinder maternal care

Female doctors are rare in Afghanistan. Maternal deaths, on the other hand, are alarmingly frequent.

With an estimated 1,800 maternal deaths per 100,000 live births, Afghanistan has one of the highest maternal mortality rates in the world. Women from rural populations, like those in the Panjshir Valley, are at an even greater risk of dying during childbirth.

Many of these deaths could be prevented by the presence of a trained birth attendant.  But the majority of women in Afghanistan are constricted by traditional customs that forbid them to travel without a male companion. The result is that few women in rural villages manage to deliver outside of their own home.

Even more problematic is that traditions in the country discourage the treatment of women by male doctors.

Midwife training

Contributing to the difficulty of finding qualified female doctors in Afghanistan is that there is little emphasis on girls’ education in the country. As a result, up to 86 per cent of Afghani women are illiterate.

On average, in rural areas, there are fewer than six doctors, seven nurses and four midwives available for every 100,000 women. In Panjshir province, there are seventeen health centres. Each employs only one female doctor and one midwife to serve 30,000 to 60,000 people.

To help fill the need, UNICEF is supporting an extensive midwife training programme throughout the country. The programme provides a year-long course of study that includes anatomy and physiology classes, as well as delivery simulations using life-sized models.

In Mazar-e Sharif, a 19-year-old woman named Farzana is midway through her course. She is from a small village of 300 that is a full day’s drive to the south.

“They are proud,” she says of her family, who, though conservative, support her decision to leave the village to pursue her studies. “When I go back home I can help the people of my village.” 

In the far east, these programmes are even more controversial. One midwife trainee in Jalalabad, Meena, says that as long as she wears her burqua to class, she does not “get any problems from the men.”

Recently engaged, Meena asserts, “I will keep working in any situation, even after I am married.”

Progress is being made

There are signs that the situation is improving. Four years ago, less than 10 per cent of district hospitals provided caesarean section births. Over the last four years, according to the National Health Service Performance Assessment 2004-2006, the percentage of facilities staffed with at least one female doctor, nurse or midwife has risen from less than 40 per cent to 76 per cent.

In addition, the UNICEF-supported midwifery program attracts young women from the countryside as well as from Afghanistan’s larger cities, ensuring that the communities most in need will be served.

UNICEF is also supporting Dr. Malalai’s Rukha clinic, where in addition to safe deliveries, Dr. Malalai is taking great risks to provide information about family planning and contraception.

But the real progress may only come once the women of Afghanistan begin receiving the same educational opportunities afforded to the country’s men.   

“Ignorance is another factor, which affects the health of mothers and children. The rate of the mortality of children would reduce if mothers are educated,” says UNICEF Heath and Nutrition Specialist Dr. Shahwali Popel.




UNICEF correspondent Elizabeth Kiem reports on midwife training in Afghanistan.
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A young midwife trainee in Mazar-i-Sharif talks about her studies.
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