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Afghanistan :: traditional birth attendant program opens "There is no electricity here, no water, no roads," says Aida, a midwife who recently moved to Tibir, located in the poor, remote, north-western province of Sar-i-Pul. Until June of this year, there was also no clinic in Tibir it was more like a small health post. When a Médecins Sans Frontières team first entered one of the consultation rooms, they stopped a staff member who was just about to inject a syringe into a baby's tender scalp. It turns out this acting "nurse" was in fact the security guard.
Afghanistan has one of the highest maternal mortality rates in the world. One out of every 9 women between the ages of 15 and 49 dies during pregnancy or delivery. Women also face diseases such as anemia, linked to numerous and closely-spaced pregnancies. Due to malnutrition they often give birth to tiny, low-weight babies (under 2.5 kilograms) who have little chance of surviving. Meanwhile many healthy infants and children become the fatal victims of basic, curable diseases. A Médecins Sans Frontières study found that, in this province, the daily mortality rate of children under five is as high as 3.5 per 10,000 (the emergency threshold is 2). Morbidity and mortality rates remain very high in Afghanistan despite the current absence of any major epidemic outbreak or any other natural or man-made catastrophes. This illustrates how poor access to health care and education is and how how deep the cultural, ethnic and religious constraints are. Only in life-saving situations can a female doctor operate on a male patient, or a male doctor on a female patient - for example to perform a Caesarian section. Because male doctors never carry out gynaecological examinations, preventable complications may arise if a midwife or female doctor is not around. A majority of the women living in rural areas deliver at home with the help of a "Traditional Birth Attendant" (TBA) - called a daya. Dayas typically work part-time in their village of origin, assisting mainly members of their enlarged families. Uneducated and illiterate, they have learned what they know from female relatives and from other, experienced dayas. Useful knowledge and skills have been passed on from generation to generation along with harmful tips, traditional beliefs and cultural taboos.
Placenta retention leading to hemorrhage is the number one cause of maternal mortality in Afghanistan, yet it can often be easily prevented. Simply allowing the baby to breast-feed immediately after birth will cause contractions of the uterus that help expulse the placenta. However in Afghanistan, colustrum, rich in antibodies, is considered to be "dirty" and "bad" milk because of its watery consistency, and the mothers are told (by dayas as well as mullahs, religious leaders) to discard it. Dr. Karima spoke to a daya in a remote village about a newborn baby that was not breathing. "The placenta was still attached to the baby and the daya placed the placenta in a pot and on a stove to burn it. It is a traditional belief that this will save the baby". Other dayas told Dr. Karima they had "dealt" with the problem of placenta retention by "making smoke in the room" to ward off spirits which provoke diseases. The first two or three days of their lives, babies are usually given tea with sugar. Then they receive breast-milk until they are about two years old, but no other food. In addition, mothers often stop breast-feeding overnight when they get pregnant because they believe their milk becomes "poisonous". Such brutal weaning can trigger malnutrition in children. One of the achievements in Faryab province that Dr. Karima most eagerly shares is the spread of awareness about oxytocin. In Western countries this potent drug is only administered intravenously in very small, diluted doses and under close supervision. In Faryab bazaar pharmacists were selling oxytocin like candy and dayas were giving it to women in labor via intra-muscular injections to provoke uterus contractions and accelerate deliveries. Women were dying from the high dosages, which cause internal bleeding by rupturing the uterus. Dr. Karima helped rally local medical authorities and push for regulations on the drug. "Today, compared to three years ago," she says, "the sale of oxytocin without a prescription from a certified doctor has decreased by more than 60% in Faryab province".
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