The birth of hope
Afghan midwives teach expectant mothers to replace superstition with sanitation.
KABUL, AFGHANISTAN — 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.
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.
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.
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.
Kuchi, who has six children of her own, asks the three women who are due next month to approach her. Each is a wife of one of the family's eight sons; a new wife usually moves in with her husband's family. Kuchi moves her hands over each rounded belly, listening with a rudimentary stethoscope for a baby's heartbeat.
Then Kuchi and her midwife partner, Gul Ghuta Musleh, lead an informal class in how to deliver a baby.
Assembled on the carpet are all the women of the extended family, as well as girls from the age of 10, some of whom can expect to be mothers in the next four to five years.
Most of the women will bear their children here, in this cement room where a chilly draft wafts through windows that sit askew.
Hajira is on her sixth birth, although she's already lost two infants along the way. A baby-faced woman in a dark-blue scarf, she looks too young to have been through so much. But at 20, she's already been married for six years, and had one pregnancy a year.
"We didn't know what to do, really," says Hajira. "Now we know more, because [the midwives] come to visit and they keep coming back.
"She's always reminding us what to do," the young woman says of Kuchi, "because it's good to hear it more than once. Sometimes we forget."
Next, the midwives hand out sealed bags, free kits from the United Nations that come with the bare essentials - a clean sheet and plastic, plus a string and a razor for cutting the umbilical cord.
Using a doll - which looks more like a gingerbread man with a tube coming from its stomach - Kuchi demonstrates how to treat the newborn. She carefully shows the women how to make two knots in the umbilical cord, a distance apart, and then cut in between.
While the procedure looks simple enough, thousands of Afghan infants die each year of tetanus acquired from cutting the cord.
If pregnant women don't have one of these ready-made kits, Kuchi says, they need to make one. Boil the string. Wash the cloth and plastic and hang them out to dry. No one who hasn't just washed her hands should be allowed to touch it. In a pop quiz, Kuchi asks a few women to reenact what they just learned.
"If the time comes and we're away, then you can help each other," Kuchi tells them. When in doubt, she says, send for her.
Many families, however, will not - or won't have the option. Some are afraid of having to pay costs they assume are associated with employing a midwife. Kuchi and Musleh, however, do not take any fees. Their visits are paid for by Terre des Hommes, a Swedish aid organization.
"Most of our patients want to have the child at home," says Kuchi. "This way, they can rest there and they don't have to travel and pay for the transportation."
In more remote, rural areas of Afghanistan, where the mortality rate is the highest, there are very few trained midwives, and the lack of transportation makes getting help almost impossible; some villages are accessible only by donkey.
Moreover, many families are unable to recognize an emergency when it occurs. Training by the midwives gives them a better sense of when to know it's time to ask for help.
Toward the end of Kuchi's visit, the women have more questions. One wants to know why she can't conceive - and many others want to know how they can stop.
Birth control, says one of the wives, Mektup, a mother of seven, is a controversial issue: "In Islam, they say it is a sin to take birth control pills, but what should I do? I already have seven children. I pray to God that all my children live, but I don't want any more. All of our husbands are poor, and we cannot afford to have more children."
Kuchi doesn't answer. She bids farewell and heads off to another Kabul home at the end of a rocky, dirt road. Here, a woman named Nuriya gave birth to Suriya, now 6 weeks old, and Kuchi is visiting them for the first time since the delivery.
Wrapped up and sitting in Nuriya's lap, Suriya has eyes that jump out like those of a model in a fashion magazine. The upper and lower lids are rimmed with black kohl, which the family believes will protect her from harm.
"We put the 'black stone' on her eyes so she looks beautiful - so her eyes will be healthy and her eyesight will be good," says Nuriya, a young mother of three whose husband is unemployed. "We put black on her eyes now so she'll be able to see at night when she gets older."
Nuriya's mother, Nafes Gul, nods approvingly.
Now that she knows Suriya is doing well, Kuchi gives Nuriya tips on what to feed the baby. This is, after all, a country with no equivalent of books like "What to Expect in the First Year," and no Baby Gerber jars on the shelves.
After six months, she says, you can feed the baby spinach, but don't add oil or salt. Protein isn't a bad idea, either.
"Before," explains Kuchi, "women thought that you shouldn't give an egg to a baby because then the child would be [stupid]."
The proud grandmother, Nafes Gul, is glad for the help. She had six boys and two daughters, but also lost four other children in childbirth. When she had her babies, there were no professional midwives; other women in the family simply pitched in to help. She already has 16 grandchildren, she says.
"No, let's count them," says Nuriya, ticking off her siblings' children. "Eighteen."
"Yes, 18," Nafes Gul confirms with a laugh. And then she thanks Kuchi with a blessing: "May you live long."
Kuchi's final stop of the day is at a far poorer home, an adobe-style hut of packed mud. Inside, a young woman is pregnant for the first time - and nervous.
"How old are you?" Kuchi asks.
"Hmm. Maybe 20?" comes the answer in a whisper.
Kuchi takes out one of the information cards she uses to keep track of her patients. She leaves a copy behind, trying to encourage women to chart their own progress, insisting they keep it with them like an identity card.
Fatima is from the Hazara ethnic group, and her face is an exotic mix of East and West - Asian features with fair skin and freckles. Next to Kuchi's urban clothing, Fatima's tribal garb is bright and colorful. But her mood is not - she isn't feeling well, and is worried she will have a difficult pregnancy.
Her mother-in-law, who sits next to her spinning wool, considers her daughter-in-law to be getting a late start.
Kuchi gives Fatima advice on what to eat - less meat and more vegetables, of which there are few in the Afghan diet. Then she tells her to get more rest and do less heavy work, glancing at Fatima's husband sitting in the corner.
As she leaves, she passes a collection of burqas, hanging on nails jutting out of the mud wall. Outside in the sunlight, Kuchi says she's glad she no longer has to dress in the all-encompassing women's wear that made Afghanistan famous.
"Without it, I feel young again," she says with a smile. "And every time I wore it, I had a headache - it sits so tight around your head."
The fact that most of her patients still wear burqas reminds her of how much Afghanistan has changed since she was young.
In the early 1970s, during Afghanistan's modernizing heyday, women were wearing short skirts. In those days, she wanted to be a flight attendant on Afghanistan's national airline - or a policewoman. Her father insisted she learn to be a midwife instead.
"I resented him then, but now I love it," she says, closing up her kit for the day. Plumes of powdery dust from the alleyway kick up under her heels and swirl around the midwives' long, dark coats.
Tomorrow, Kuchi and her colleague will visit more houses. They will go to several more the next day, and the day after that.
But even with their many rounds, they know they will reach just a small percentage of Kabul's expectant mothers.
Still, this is a big improvement over what life used to be. Under the Taliban, nearly all aid workers came under the suspicion of Afghanistan's leaders, which made it more difficult to address the crisis in maternal fatality rates.
Now, in a freer postwar era, the United Nations and independent aid groups have been able to invest more in training programs for midwives. But their efforts are like a few scattered raindrops on badly parched soil. Many rural provinces still have no medical/health facilities at all - and are not being served by the new programs.
The largest training course is at Kabul's Malalai Women's Hospital, which offers five weeks of classes for midwives.
Many of the students there are women who had already been working as midwives, but had never received any formal instruction.
"If someone becomes known as a midwife, everyone in the village trusts her and looks up to her," says Ziba Kamal, chief of obstetrics at the hospital, during a break in her course for midwives, some of whom have traveled several hours to come to the course.
"Usually she has watched a few others, one or two, and then she becomes a midwife."
It's difficult to know how much of an impact the additional trained midwives are having in reversing the grim statistics surrounding birth in Afghanistan.
But Dr. Kamal and midwives such as Kuchi and Musleh are doing all they can to turn things around.
As Kuchi knows from experience, mothers who have had the help of a midwife are tremendously grateful - and relieved.
The presence of a calm, knowledgeable midwife does more than alleviate fear. It can be the difference between celebration and grief.