Overcoming Barriers to Safe Maternity Care in Afghanistan

by Annie Clark, CNM, MPH

The majority of women in Afghanistan are constricted by traditional customs forbidding them to travel without a male companion.

Last month, NPR’s Morning Edition posted a story about midwifery in Afghanistan with Renee Montagne reporting from the remote region of Badakshan along Afghanistan’s northern border. The story provides a snapshot of the situation in Afghanistan where the maternal/infant health statistics are among the worst in the world. According to UNICEF, the estimated infant mortality rate is 165 per 1000 live births, and under-five mortality is as high as 257 per 1000. (You can also watch an excellent video summarizing the situation in Afghanistan here.)

A recent study undertaken in four Afghan provinces indicates that the country still has one of the highest maternal mortality rates in the world—estimated at 1600 deaths per 100,000 live births. Montagne reports on a USAID initiative to address these appalling statistics by recruiting and training midwives in rural areas. She personalizes the account with an illustrative example of midwife Farangis Sultani, who was chosen by her Village Health Council to participate in an 18-month community midwife training program and then return to serve her community and receive a salary.

In just six years, midwife training programs have increased the number of midwives in Afghanistan from 467 in 2002 to nearly 1700 in 2008 (2300 was the total number of midwives reported to me when I was in Afghanistan earlier this month). The objective is to train a total of 5000 midwives. This has not been an easy undertaking for a number of reasons, including the fact that up to 86% of Afghan women are illiterate, making it difficult to find candidates who meet the required prerequisites for midwifery training. The majority of women in Afghanistan are also constricted by traditional customs forbidding them to travel without a male companion. Consequently, few women in rural villages manage to deliver outside their own home. There was opposition to the concept of a midwife traveling alone to the home of a laboring woman, let alone staffing a clinic at night.

The NPR story highlighted the efforts of Jhpiego, an affiliate of Johns Hopkins University, which has been implementing a USAID-funded project to train community midwives. Jhpiego helped combat cultural barriers to training by promoting the establishment of Village Health Councils. When confronted with the problem and the possible solution, Village Health Councils independently selected young women candidates for midwife training and agreed to some flexing of cultural norms.

There are many additional donors and NGOs who are involved in efforts to address the high maternal and child mortality and morbidity rates in Afghanistan, including UNICEF, the World Health Organization (WHO), Merlin, Aga Khan, and University Research Company/Health Care Improvement Project.

Did you know that ACNM, as a partner with Jhpiego on the USAID-funded ACCESS project, helped launch the Afghan Midwives Association in May 2005? Find out more about the grant-funded ACNM Department of Global Outreach at www.midwife.org/global.cfm.