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The birth of hope

Afghan midwives teach expectant mothers to replace superstition with sanitation.

By Ilene R. PrusherStaff writer of the Christian Science Monitor / March 17, 2004


It's not clear who will be first, but one thing is certain. Three women in the Sakhi family are due to give birth in the next month, and Nasima Kuchi, a midwife, wants to make sure they know what to do - and what not to do.

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The birthing bed should be covered with a clean towel and plastic, she explains to a rapt audience of women in the family's front room, usually reserved for male visitors.

To Westerners, the need for sanitary conditions at a birth may be obvious. But not necessarily in Afghanistan. In one old tradition, women would spread a layer of earth in the place where the woman was to give birth as a way to protect the house.

Perhaps it should come as no surprise that Afghanistan has the second-highest maternal mortality rate in the world. Only Sierra Leone's is higher.

Of every 100,000 women who go into labor in Afghanistan, about 1,900 die, according to Dr. Tessa Wardlaw, a senior program officer for UNICEF, the United Nations Children's Fund. In the US and Japan, by comparison, the number is 8 in every 100,000 women. Afghanistan's infant mortality rate, at 165 per 1,000 live births, is also among the world's highest.

But Mrs. Kuchi is trying to change those grim statistics. She and others are part of a new breed of midwives who go house to house, teaching Afghan women about sanitation, childbirth, and infant care. A Swedish charity pays for the cost of the midwives' training and services.

Still, Kuchi and her handful of colleagues know they have their work cut out for them. Although midwives have been around for many years, few have had much training. The vast majority of Afghan women give birth at home, helped along by other family members following customs passed down from generation to generation. Much of their information entails more myth than methodology.

Replacing old ways with new

Thus Kuchi spends a great deal of time explaining the basics, specifically what they should not do. For example: After the baby is born, don't put lipstick on its navel, where the umbilical cord has just been cut.

"Some people put lipstick on the navel because they think that it will help the baby's lips turn red," says Kuchi, a fair-skinned woman with a patrician air and elegantly applied makeup.

"Don't put anything on the navel," she advises the women. Another important point: If the mother must give birth by Caesarean section, do not follow the conventional wisdom, which holds that she should not be fed for three days afterward.

Although it may sound like common sense, much of Kuchi's information is a revelation to these women.

Many still follow the popular practice that a woman should not eat when she is getting close to her due date - and subsequently gets weaker when she needs her strength.

Others believe that a newborn baby should be kept from the mother for at least a day, and should not be fed anything other than tea and sugar in the first days of its life.

Nearly half of Afghan women of childbearing age who die each year do so as a result of complications in pregnancy or childbirth. A motherless newborn has only a 1 in 4 four chance of survival. Only 7 percent of women who die during or after labor gave birth with the help of a skilled attendant, according to a joint study last year by UNICEF and the US Centers for Disease Control and Prevention in Atlanta.

Most of the deaths, the study found, were preventable.

The numbers add up to this: Motherhood, society's most important job for more than half of the population of Afghanistan, is also its most perilous.

Two years after the fall of the Taliban, which ordered women to stay home - and made it almost impossible for Kuchi to get out to do her work - improving training for midwives is considered by international health advocates to be part of Afghanistan's reconstruction plan.

Heathcare often inaccessible

But many problems remain. Poor, unpaved roads make it difficult for people to get access to healthcare, including the services of midwives. The result of more than two decades of war and a fundamentalist regime mean many families still forbid women to see a male care provider - making the role of midwives like Kuchi all the more crucial.

This morning, on a typical day in the life of an Afghan midwife, Kuchi is visiting Kabul's poorest neighborhoods. With her is a list of houses where pregnant women live. When she comes into the Sakhi home, they behave as if a great dignitary has arrived, and then a crowd gathers around to watch her go to work.