Musuna is not strong; she is anaemic and needed a blood transfusion the previous evening. How will she cope, I asked midwife trainer Victoria Parsa? She shrugs: “I don’t know. She already has three children, but only one boy – she will want another.”
But other lost lives go unremarked and unreported; the lives of Afghan women and girls. They die for a number of unforgiveable reasons ranging from murder to neglect. The country’s maternal mortality rate is the highest in the world. A woman dies of pregnancy-related causes every 27 minutes. Few use contraception and childbirth represents a bigger threat to life than bullets, air-strikes or suicide bombings.
In distant Helmand province, at Bost Hospital, a program is underway to train female midwives who will take their skills back to their villages and save lives. We visit it with 32-year-old Royal Navy Lt Rebecca Parnell who is on her second tour of duty in Afghanistan, based at Lashkar Gash.
“Women are more forward looking than men,” explains Rebecca. “They see the importance of creating a better future for their children. They acknowledge that they need ISAF support and see us as a less patriarchal society.”
At Bost we meet the hospital’s director, Dr Enaytullah Gafar, an articulate and dedicated man. He says: “This hospital is for men and women, with 150 beds for all kinds of patients. There are 10-15 for emergency obstetric cases. In this province we have a shortage of female doctors and midwives; when the 24 midwives in training complete their 18-month course and graduate it will solve a small part of the problem.”
There are 48 clinics in Helmand, of varying capability. “All complicated cases come here” says Dr Enaytullah, “and also to two district hospitals, in Garmsir and Goreshk. One was damaged and had to close for a while but has started up again. After surgery patients go back to their own homes or areas to convalesce.”
The reality is that until stability is restored to Helmand, and there is freedom of movement, travel for patients and staff alike is fraught with danger.
Some of the women on the Bost midwife training course travel hundreds of kilometres to attend. “We select students who are married,” says Dr Eyanatullah. “It is important for stability. There is a dormitory for them here and their husbands can come to visit at weekends. There is also a nursery because many of these students have young children who no-one else can look after. But the main problem is security; it is has a big impact on delivery of healthcare. Some of these women come from very dangerous areas.”
The hunger for peace, security and education is immense and nowhere more evident than among Helmand’s women. Gentle, gracious, playful, hospitable and as generous with their time as their possessions, they illustrate more compellingly than any political argument why stability is important. Each has a personal story of tragedy, hope, ambition or sorrow. All realise that Afghanistan’s children and young people hold the keys to its future.
In the midwifery students classroom the modestly dressed women sit in a horseshoe arrangement around a flip chart. Their teacher, Bibi Shahan, and her colleagues use drawings to illustrate foetal positioning – simple, but effective. What they learn, and take back to their villages, will save lives.
At first the women are bashful, reluctant to talk about their lives or be identified, but they are delighted that someone is taking an interest in them. Gradually curiosity overcomes reluctance and they start to tell their stories.
Nasaneen, at 15, is the youngest student. A shy but curious girl she has recently married a provincial councillor in Helmand who has another wife and eight children. Other classmates are older with considerably more life experience than Nasaneen; some have been refugees, others are pregnant or have children of their own, many have lost loved ones over the years of fighting and instability.
Parween Naswiri’s story is typical. She tells me: “My dad died in mosque explosion. He was an engineer and a good man. I miss him so much. He encouraged me. Now I don’t know what will happen to us.”
Aged 29 she speaks good English and is already qualified as a teacher. She enrolled on the midwife training course to learn about maternal health, but her real ambition is to be a doctor. As we speak I realise I have already met her sister Yasmine, 22, translating for the British Justice Advisor at Lashkar Gah Women’s Centre. Their youngest sister Muzda, 18, is a founder member of the newly formed Women’s Justice Group. The sisters ache for life opportunities that are never going to materialise until the conflict in Helmand is resolved.
Zainab, 20, grew up in exile. Her family lived in Iran for 25 years and returned only after the election of President Kharzai. She has been married for five months. She says: “Life here is very hard. My mother is here, but my dad is in Kabul – it is too far away; we are so sad. Please help us. We’re so afraid. We hate this fighting. Our teacher says we will all find work here in our province. I hope so.”
Shaheen is 30, the wife of a finance officer in Lashkar Gah and pregnant with her first child. She has been on the course for four months. She wants a boy. Sharin is from Pakistan; she wants to talk to me but has no English and our interpreter (who was born at Bost Hospital ) is tied up elsewhere. Hand signals and smiles say “thank you for coming here.”
Lunchtime provides an opportunity to socialise and ask questions – largely to do with husbands and numbers of children. Our armed bodyguards lurk at a discreet distance while we join the students for their mid-day meal of kofta in spicy gravy, beans in delicious tomato sauce, pitta, yoghourt, cucumber and fiery chillies that make our eyes water – and the ladies laugh! It is laid out on an oilcloth in a room adjacent to the classroom.
The children join us; little Bilal, a beautiful child with learning difficulties, is curious about the newcomers. It’s easy to forget that danger lurks everywhere in Helmand. We have come to Bost with heavy security. Rebecca, who routinely deals with requests for aid, confesses that she has never had the opportunity to dine cross-legged on the floor of an Afghan home. When the students hear this they heap more food on her plate and prepare a ‘doggy bag’ for her as we rise to leave.
The women’s day starts at 8am and finishes at 4pm. After class those who board are reunited with their children. Those from Lashkar Gah are collected by family members to walk or be driven home. All wear burqas. “I don’t feel safe on the streets,” says Parween.
Bost is an oasis of hope in a troubled area; the wider issues of maternal care in Afghanistan need addressing centrally by rigorous training and robust enforcement of protocols that cut through cultural taboos.
Ironically one of the places that advice on planned parenthood can be easily accessed is in jail. Zaraf Shan is a career policewoman, mother of six and the senior female officer at Kabul’s new Women’s Prison. At 42 she is slim, attractive and well groomed. Zaraf is responsible for 15 staff managing security, patrolling, looking after administrative issues and “ways to make things better”. Four doctors are attached to the prison and the women have access to advice on birth control, female health, STDs and hygiene training.
But in the remote provinces it’s a very different story life is cheap for women. Afghanistan is a land of savage beauty, its unforgiving terrain scarred by decades of conflict. In spite of the fragile democracy that was established by parliamentary elections in September 2005, it is still male dominated.
In some areas, girls as young as eight are married to men old enough to be their grandfathers, forced to give birth before their immature bodies are ready. Many husbands would let their pregnant wives die rather than allow them be treated by a male doctor.
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Legislation has formally addressed the issues; but education, investment and major cultural changes are needed to give it teeth.
Limitations on mobility and negative perceptions of female behaviour will only change through the advocacy of men who can link it to the well-being of their children, sisters, wives and mothers.
The former Medical Director of the Cure International Hospital, Dr Jacqui Hill, recalls the case of a
36-year-old mother of three, nine months pregnant with twins. “ She’d had no ante-natal care and the day before admission had gone to a doctor with headache and abdominal pain. No one had examined her properly or picked up on the fact that she was suffering from pre-eclampsia.
“During the night this poor woman had a seizure. By the time she reached us she was unconscious and both babies were dead. The duty team did everything they could for her but it was too late and she died too. Cases like these are all too frequent due to lack of knowledge, both of patients and of medical staff. This is why the training of the Afghan medical staff is SO important. ”
And it’s a story with several sub-texts. Simplistically maternal care is about provision of services – midwives, doctors, clinics, hospitals, medication, and equipment. But even at this level there are ‘issues’ – like the cheap (but adulterated) pharmaceutical products that flood the market; the clinics that open, only to close later due to intimidation or lack of funding.