KABUL—For a woman in the last few weeks of her pregnancy, 24-year-old Sohaila walks surprisingly quickly as she invites us into the first-floor guest room of her traditional Afghan house in the outskirts of Kabul in October.
The large yet delicately decorated room will serve as her makeshift maternity ward when she is scheduled to go into labor in three weeks. Sohaila, who requested her name be changed, goes over her plans as she, her grandmother, the translator, and I take seats on the many toushaks (long traditional cushions used for seating) that will be used as her bed during the delivery. “We will cover everything with a clean cloth,” Nooriya, Sohaila’s 62-year-old grandmother whose name has also been changed, explains. “Two women from the family will assist me with her delivery.” Although never formally trained, the senior woman has been a midwife for most of her life, having learned the skill from her mother and aunts over the years.
In a rather worrying trend, an increasing number of women like Sohaila are turning back to traditional methods of home birth in Afghanistan, over the fear of both renewed Taliban violence and catching the coronavirus in a clinic or hospital.
“Aside from the damage caused by the disease itself, COVID-19 negatively affected all the health services in Afghanistan,” Akmal Samsor, a spokesperson of the Afghan Ministry of Public Health, said in an October interview. “We admit that our initial communications around the pandemic created more fears,” he said. “As a result, people were afraid to utilize essential services. Our OPD [outpatient department] dropped by 30 percent, and our IPC [inpatient care] was down by 50 percent in the first four months of the pandemic.” The hospital beds, he said, “were empty.”
The same goes for maternity wards. Shafiqa Babak, a doctor who is chief of quality assurance at the Rabia Balkhi Hospital for women in Kabul and who also runs a private clinic, observed a significant drop in patient numbers. The hospital even created a special ward for pregnant women who were infected by the virus, well equipped with all medical support devices, many donated by international organizations and donor countries. But it failed to attract many expectant mothers. Babak, who had to close her private clinic during the worst months of the pandemic, observed many cases where women opted for home births instead.
In the last two months, people have started to return to Rabia Balkhi Hospital. There were seven live births during a visit on Oct. 7. But one of the doctors on staff says that this is still far fewer than the average number of daily deliveries in pre-coronavirus days. “Earlier we used to have over 60 deliveries and C-sections in a day, but now we have far fewer than 50,” one of the young doctors shared on the condition of anonymity.
“With risk of coronavirus, it has been hard for me to go to the hospitals for even checkups. I would not want to deliver there at all,” said another expecting mother who identified herself as Zarmina. The 28-year-old, from the northern Baghlan province, has four other children. Three were born in the hospital. She’s decided to return to traditional birthing methods for the latest baby. “My mother-in-law and a relative will help with the delivery; they’ve done this before, and I trust them,” she affirmed.
The health ministry has already registered over 9,000 home deliveries in the first half of this year, and it is counting on more. (In years past, the health ministry said, that figure was far lower.) This year’s official count is likely far under the real total, too. Officials have noted that in cases where babies are delivered by a family member, they very likely are not registered in the official figures, both because registration rates for home births were already low and because families now fear going to government registrars.
Even in the best of circumstances, this would be a worrying development, since delivering at home in Afghanistan can be dangerous to mothers and their newborns. Already, the country leads the region in maternal mortality rates—638 per 100,000 live births, according to data from the World Health Organization (WHO). The comparable figure in the United States is 19.
“Every birth that is happening at home is at a risk,” Babak warned.
“The most common cause of death among new mothers in Afghanistan is postpartum hemorrhage. Many Afghan women suffer from anemia, in which case even a little bleeding can be concerning,” she said, adding that hemorrhages are extremely common in home births where there is no skilled medical personnel to help.
The risks are doubled during the COVID-19 pandemic, the doctor added: “There are higher chances of complication and infection.” Women frequently need to be taken to the hospital and receive treatment in a matter of minutes, “which is not possible at home,” she said, adding that many women die on their way to the emergency room.
Since the fall of the Taliban two decades ago, the Afghan health sector has grown and changed in many ways. However, its overall infrastructure remains underdeveloped, which undermines its reputation among the Afghan public, especially in times of crisis such as the pandemic. When Afghans avoid hospitals, though, it leads to greater health problems, which the health sector struggles to manage.
Beyond that, in the last two years, several health facilities have come under insurgent fire. The most recent attack, in May this year, targeted a maternity hospital in Kabul, resulting in 24 deaths including newborn babies, mothers, and medical staff. “Security is not good in Kabul, even the maternity ward is not safe,” Sohaila said. “Your child could be born normal and healthy, but then an attack can destroys all lives.
Zarmina echoed similar concerns. “Nowhere is safe these days,” she said. “You carry your baby in the belly for nine months, and then a stranger walks into a hospital and kills you and your baby. Who knows when the insurgents will target another hospital?” That is a reasonable assessment, but with women avoiding hospitals, maternal mortality could climb even higher.
Until the country’s security situation improves and the pandemic wanes, the answer may be more midwives. Over the years, Afghanistan’s health ministry, along with international organizations, have trained thousands of midwives. As of 2020, there are 3,998 working directly with the health ministry. Another 20,000 certified professionals are registered with the Afghan Midwives Association across the country.
That is progress from the Taliban years, when restrictions on women’s education and work resulted in a dramatic shortage of qualified midwives. To overcome this gap, in 2003, the ministry reduced the training period for midwives from 4 years to 18 months with the hopes of graduating larger numbers of trained professions. (There are still only around 3.2 per 10,000 people, according to WHO, but this represents a sharp increase.) Training modules were made concise and focused on the most common issues faced by Afghan women during childbirth that will help reduce maternal and infant mortality rates. Students of these courses are taught skills to tackle serious issues such as hemorrhage, eclampsia, preeclampsia, and management of the third stage of labor (when the placenta is delivered), which those like Nooriya may not be equipped to handle.
Sohaila and her grandmother, however, dismiss such concerns. When asked how they will prevent infections or complications at home, Nooriya replies with the confidence of a seasoned caregiver, “We will give her warm water that has been blessed by passing under the Quran to help her.” For Sohaila, who had considered a hospital birth prior to the pandemic, her fears of being infected by the coronavirus are greater. “Hospitals are crowded, and the risk of infection is higher,” she says. Besides, she adds, there will be chai and naan available here while they wait for the baby to arrive.
