Afghanistan’s Appalling Pregnancy Deaths

December 30, 2010

Every 30 minutes, a pregnant woman dies in Afghanistan. Gayle Tzemach Lemmon reports from Kabul on a courageous young woman determined to change that.

When Feroza Mushtari was barely a teenager, she draped a blanket over her shoulders, donned her father’s woolen hat over her high forehead, and disguised herself as a boy to rush a neighbor suffering from agonizing labor pains to the hospital.

Though her mother cried and pleaded with her not to risk the journey, Mushtari told her she had no choice: Without a mahram, or male chaperone, the Taliban would never allow the women to travel from their Kabul neighborhood to the Malalai Hospital. And if they didn’t get help quickly, both the pregnant woman and her baby would die.

Mushtari’s heartbeat thudded in her ears as the women’s taxi cleared one and then another checkpoint in the dark winter night. If Mushtari’s disguise was uncovered, the women would be sent back home—or worse. Sitting in the front seat like a proper mahram, the girl silently practiced speaking Pashto in a boy’s voice in case the Taliban stopped them. In the back of the car, her neighbor shouted and writhed in pain.

War had made gathering statistics impossible, but after years of conflict and destruction, Afghanistan was known to be among the world’s deadliest places to be an expectant mother. The country counted fewer than 500 midwives nationwide, with no national standards to guide their training, and very few women had access to skilled birth attendants. The lucky few mothers-to-be who lived near city centers rushed to dilapidated hospitals to which they had to bring their own medicine and supplies. But most women simply delivered at home, on their own.

That night, after their car reached the hospital without attracting unwanted notice and a midwife had helped Mushtari’s neighbor deliver a healthy baby, Mushtari vowed to dedicate herself to helping women give birth safely.

“I decided to become a midwife,” says Mushtari, now 26 years old and one of the country’s leading maternal health advocates. “At least if women could not go out and get help, they could have care inside the home, inside their community, inside their family.”

It would take a few more years before the Taliban retreated from power, and Mushtari was free to pursue her dream. In 2002, she joined the country’s first formal midwifery training program, becoming a clinical preceptor and later a clinical supervisor at the Institute of Health Sciences at Malalai Hospital, the same hospital to which she had whisked her neighbors under very different circumstances years earlier. She serves in three critical health positions, all devoted to saving the lives of pregnant women: She is the Midwifery and Nursing Manager for the international health organization Jhpiego, an affiliate of Johns Hopkins University; a member of Afghanistan’s National Midwifery Education and Accreditation Board, and – in her most public role – the Acting Head of the 1,600-plus member Afghan Midwives Association.

And in the eight years she has trained and worked as a midwife, she has seen the country’s maternal health improve, albeit slowly. Today, with a new, nationally accredited midwifery program funded by the U.S. Agency for International Development and the European Commission, among others, the country counts more than 30 midwifery schools and more than 2,000 trained midwives, with hundreds more graduating each year.

Although the maternal mortality rate has fallen to 1,400 per 100,000 live births according to the Afghan government, the statistics remain among the world’s worst. Putting the numbers in perspective, earlier this year the acting Public Health Minister Suraya Dalil said, “Every 30 minutes one woman in Afghanistan dies from causes related to pregnancy and childbirth.”
Mushtari’s mentors say they could not be prouder to see the progress she and other young ladies of her generation are making on behalf of their countrywomen. In their view, these able twentysomethings are not simply midwives working on behalf of mothers and their families, but fearless trailblazers representing the nation’s best hope for a future of peace and stability.
“Feroza has the knowledge, she has the commitment and dedication,” says Pashtoon Azfar, the former head of the Afghan Midwives Association and Afghanistan’s Institute of Health Services now serving as the Asian Regional Adviser for the Confederation of International Midwives. “This young group, they have played a critical role in all the changes and the establishment of the midwifery system—they have proved themselves.”

Unusually for a young Afghan woman, Mushtari travels around the country with female colleagues for as much as a third of the month, visiting midwifery programs and clinics throughout the country.

“When you have a feeling in your heart, no one can stop you,” she says, sitting in the Kabul offices of Jhpiego, a petite and youthful figure speaking in the slow and measured tones of someone far older. She wears a smart black and white paisley blouse under a black blazer and matching black head scarf with white piping. What drives her, she says, is the desire to reverse the statistic that shows that one in 11 Afghan women may lose her life as a consequence of pregnancy.

“It is every woman’s right to have a skilled provider during her pregnancy and childbirth,” she says, pushing back a small silver ring on her index finger and speaking in a tone which shows neither hesitation nor doubt. “My profession is one of the main elements of this woman’s right.”
Mushtari herself has not married—in part because her father wanted to protect her, and allow her to focus on her dream. In fact, during the Taliban years, when Mushtari was barely 13, he moved his 10 children from Kandahar at the time to Kabul rather than run the risk that a man he had heard wanted his daughter’s hand would show up at their home unannounced and make it impossible for him to refuse an offer of matrimony.

Investing in Mushtari’s dream, though, has benefited the entire family. Today, her jobs help pay for her siblings’ school fees as well as medical and other household expenses for her family. “I wanted to help women and I still want to help mothers and their families; my father knows that.”

In Mushtari’s view, the work she and her contemporaries are doing each day to save women’s lives is part of the solution to the conflict, poverty and instability plaguing Afghanistan, all of which she knows intimately.

“I was born in wartime, I grew up in wartime, and I am still living in war; sometimes it is really difficult for me to think about a bright future for Afghanistan from a political point of view,” she says. Then, brightening, she pauses and adds, “Still, I am sure if we continue our efforts, we will have a very bright future…we will lead the next generation.”

Gayle Tzemach Lemmon is the Deputy Director of the Women and Foreign Policy Program at the Council on Foreign Relations. She has spent the last five years reporting on women entrepreneurs in conflict and post-conflict regions, including Afghanistan, Rwanda and Bosnia. Her upcoming book, The Dressmaker of Khair Khana, tells the story of a young Afghan entrepreneur whose business created jobs and hope for women in her neighborhood during the Taliban years. The Dressmaker of Khair Khana will be published by HarperCollins in March 2011.