Improving maternal mortality in rural Afghanistan, as in many parts of the world, means facing multiple challenges:
- roads blocked by snow or flooding in winter and spring make it very difficult for women to access clinics and for village outreach health teams to reach women
- lack of educated women in villages to train as midwives/community health workers
- deeply held cultural beliefs about women’s health that are harmful.
Overcoming these challenges requires a long term approach that matches improvements by the government in infrastructure such as roads and clinics, with improvements in women’s education and in communities’ awareness of issues to do with women.
Training and advocacy
International Assistance Mission’s community development approach uses a combination of training and advocacy. Literacy and BLiSS (Basic Life Saving Skills) lessons are offered, and where possible the training is done by local trainers. An example of advocacy would be asking clinics to provide tetanus immunisation.
The BLiSS course was developed for Afghanistan by Operation Mercy to empower uneducated men and women to know what they can do to help each other in pregnancy, during childbirth and afterwards. It focuses on the importance of accessing medical help in a timely manner, and through participatory learning and role plays addresses many of the cultural beliefs that are harmful, such as:
- childbirth is dirty and shameful and should occur in the dirtiest room, usually the cowshed
- colostrum (the milk produced in the first three days) is dirty and should not be given to babies
- if a woman faints from lack of blood, she should be stood up and a gun fired next to her head.
The 17 lessons of the BLiSS course encourage women to speak about their birthing traditions and ideas and look carefully at their underpinning cultural beliefs.
The women show a great dependence on faith, the supernatural and home-based remedies, but they are also starting to rely on the local clinic. The aim is to give worth to women’s ideas (and therefore to women) by listening, teaching and then together trying to find best practice by combining healthy traditional beliefs with healthy midwifery skills. The harmful beliefs and practices are gently challenged through role plays, picture cards and guided discussions that show why, for example, hygienic measures, early breastfeeding and lying a bleeding woman down and raising her legs are all things that women can do to help each other.
What to do about traditional beliefs:
If it’s helpful… use it.
If it has no effect… ignore it.
If it’s harmful… educate against it
Communicating with men
An important part of the approach is to involve men. Operation Mercy offers training for male facilitators as well as women in separate courses. For Afghan male facilitators from conservative areas, the male BLiSS training course may be the first time in their lives that they have used vocabulary to do with childbirth!
After training, male facilitators need to adapt what they have learnt on the course to their cultural setting – sometimes the hardest issue of all. For example, role plays where men play women during childbirth are possible in Kabul, but in conservative areas the workers would be thrown out of the village! Short stories are often an acceptable alternative.
In conservative areas, influential men such as mullahs and elders must give permission for women’s groups to meet. If these men change their behaviour following the men’s BLiSS course – for example, they take their wives to the clinic – other men will follow.
Effective ways to communicate with men include:
- USING RELIGIOUS REFERENCES God values all life, so birth spacing that improves women’s and children’s health is permissible within Islam, as it is within other faiths.
- FINANCIAL INCENTIVES Compare the cost of a funeral and remarriage if their wife dies in childbirth with the cost of seeing a doctor.
There can be no message more powerful about the value of community education than when the life of a woman and her child are saved through the collective knowledge and action of men and women.
The writer of this article works with International Assistance Mission (IAM) in Afghanistan.
Picture cards are useful in community training meetings. Home Based Life Saving Skills Large Picture Cards are available for US $25 from store.hesperian.org (search for ‘picture cards’). Hundreds of cards illustrate common medical issues in pregnancy and birth.
Zulaikha was married about 10 years ago, aged 15, and soon after had a daughter, but following that she had several pregnancies that ended with stillborn babies.
She was pregnant yet again when she heard that a BLiSS course was starting in the village to help women improve their chances of surviving pregnancy and childbirth and giving birth to healthy babies. Understandably, she was really interested and made sure she could come to the course. Because of knowledge gained on the course, she and her neighbours decided she might be physically unable to give birth to live children. She went to the local clinic to see the midwife who confirmed that it was the likely cause of her problems.
Her family agreed that when she started going into labour she should be taken to the provincial hospital immediately (about two hours by car or six to eight hours by donkey). She was taken there safely, and her son was delivered by caesarean section. If it had not been for the BLiSS course and the conversations after it, which led to questions being answered, and greater knowledge and awareness among her neighbours and family, this would not have happened.
Zulaikha is one of several women who have been helped or saved from death by their community since the course took place.
For information about caesarean section, see here.