A dearth of maternity care


Afghanistan: Doctors from a Hopkins-affiliated group help train women as midwives to battle an extremely high death rate during childbirth.

July 29, 2002|By Stephen Kiehl | Stephen Kiehl,SUN STAFF

It's not the bombs falling from U.S. warplanes or the years of drought or the shortage of doctors and medicine to treat disease that is killing the women in Afghanistan.

They are courting death by giving life.

Childbirth is the leading cause of death for Afghan women, many of whom have not seen the inside of a school or a hospital for years and who have a life expectancy of just 46 years.

About 90 percent of women have their babies at home on their own. It can take days to reach a hospital, which is often not worth the trip. The staffs are unskilled. The instruments are dirty. And the delivery rooms are packed - up to seven women at a time.

In the United States, mothers die at a rate of 7 or 8 for every 100,000 births. In Afghanistan, 1,700 mothers die for every 100,000 births. Only war-ravaged Sierra Leone has a higher maternal mortality rate.

"Death is a part of life in Afghanistan, and there's an acceptance that women die in childbirth," said obstetrician Jeffrey M. Smith, 38, part of a team of Johns Hopkins physicians who returned from Afghanistan this month. "If you don't value women and women are not an important part of your society, then if a woman dies in childbirth, the impact of that death is not felt."

Two major surveys of women's health that are under way in Afghanistan confirm the fears of medical specialists there. One survey, conducted by UNICEF and the U.S. Centers for Disease Control and Prevention, will show - when it is released in September - that childbirth is the leading cause of death for women of reproductive age, 15 to 49. Childbirth accounts for 44 percent of the deaths of women in that group, according to the survey's preliminary results.

Another survey, by Dr. Lynn Amowitz of the Harvard Medical School, polled 4,486 women in western Afghanistan. It found that more than 50 percent of women thought their husbands had the right to beat them and that it was a wife's duty to have sex with her husband even if she didn't want to. A summary report of that survey, to be released today, details the cultural obstacles to improving maternal care.

In the report, a midwife named Tamar, who works in a clinic three hours from the nearest hospital in Herat, says, "The biggest problem is that women do not know when they should come for help, and neither do the husbands, so women die at home or on a donkey on the way to Herat."

Since April, doctors from the Johns Hopkins-affiliated international aid group JHPIEGO have made two trips to Afghanistan to improve the training and facilities of health care providers. They plan to spend many more months there over the next few years.

JHPIEGO's 300 employees worldwide specialize in low-cost, low-tech solutions to the health problems of women and children in developing countries. They will not provide incubators for newborns, for instance, because incubators break and no one can fix them. Instead, aid workers teach the "skin-to-skin" method of keeping babies warm by cuddling them.

For similar reasons, the group's doctors won't provide autoclaves to sterilize instruments. Instead, they teach how to use bleach available in local markets to mix a disinfecting solution. Rice cookers work well, too.

"Our whole approach is to be almost as invisible as possible," the group's president, Dr. Noel McIntosh, said at its headquarters in Fells Point last week, "because we have to transfer basic skills to Afghan physicians and midwives, and we've got to do that very rapidly." (JHPIEGO once stood for Johns Hopkins Program for International Education in Gynecology and Obstetrics, but the acronym now stands alone.)

McIntosh, who has worked in developing countries for 30 years, described the state of women's health in Afghanistan as "ground zero." It doesn't get much worse.

Girls get pregnant very young - at 14 or 15 years old - and often. The average woman has seven children, and not all survive. The infant mortality rate is 220 per 1,000 live births.

The Taliban forbade women to receive maternal care from men and also banned them from education for the last six years of its rule. The supply of female doctors is critically low.

"There's an incredible, incredible shortage of trained female health workers," Smith said. "They're going to run out of women."

The Taliban put money into war instead of wellness, observers say. Hospitals deteriorated, as did the roads that led to them. Women in some regions of the country are a 15-hour car ride from the nearest hospital, said Mark Fritzler, a JHPIEGO senior program adviser who helped with the group's assessment of Afghan maternal health needs.

"That's if they can get to a car," Fritzler said. "For many of them, it's quite common to have a day's walk or donkey ride [to a hospital], and if a woman is in serious trouble, the ride will kill her, if they even decide to go."

In the country's male-dominated, strict religious culture, that decision is almost always up to a woman's husband or father.

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