Further to the information on Afghan midwives that I posted yesterday, a blog post from someone on the web alerted me to the fact that there was someone who practiced midwifery in Affy who has just been profiled in the NYT.

For those who are interested, here is the article:

By DENISE GRADY
Published: July 27, 2009
Everybody wants Pashtoon Azfar. Her government, American aid groups and her own colleagues, the midwives of Afghanistan, all want her to work for them, lead them, help them rebuild a health system from the rubble of war.

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Chris Maddaloni for The New York Times
Pashtoon Azfar, president of the Afghan Midwives Association.
Ms. Azfar, 51, is trying to oblige. By day she directs Afghanistan’s Institute of Health Sciences, by night she works for a nonprofit group from Johns Hopkins University that focuses on women and children’s health, and somehow she also manages to serve as president of the Afghan Midwives Association.

Visiting from Kabul recently, she was the star at a Capitol Hill briefing titled “Maternal Health in Afghanistan: How Can We Save Women’s Lives?” Her audience included members of the Congressional caucus for women’s issues.

Afghanistan has the world’s second-highest death rate in women during pregnancy and childbirth (only Sierra Leone’s is worse). For every 100,000 births, 1,600 mothers die; in wealthy countries the rates range from 1 to 12. In one remote northeastern province, Badakhshan, 6,507 mothers die for every 100,000 births, according to a 2005 report in the medical journal Lancet. In all, 26,000 Afghan women a year die while pregnant or giving birth.

The main causes of these deaths are hemorrhage and obstructed labor, which can be fatal if a woman cannot obtain a Caesarean section. Even if the mother survives, obstructed labor without a Caesarean usually kills the baby. Most of the maternal deaths — 78 percent, according to the Lancet report — could be prevented. Against this bleak history, Ms. Azfar told her Washington audience, “I would like to share some successes with you.”

An intense woman with short, graying hair, Ms. Azfar rarely smiles. She ran through statistics showing notable increases recently in the country’s number of midwives, their education and the percentage of women who give birth with the help of a “skilled attendant,” usually a midwife. The United States, the World Bank, the European Commission, Unicef, the Hopkins group (known as Jhpiego) and other donors have all helped Afghanistan’s Ministry of Public Health to make improvements.

But there is a long way to go. Most women in Afghanistan, as many as 80 percent, still give birth without skilled help, and only a third receive any medical care at all during pregnancy.

Afghanistan’s problems mirror those of many other poor countries: shortages of personnel, supplies and transportation to clinics or hospitals, especially in remote regions and mountainous areas that are snowbound half the year. The deeper problems are cultural, rooted in the low status of women and the misperception that deaths in childbirth are inevitable — part of the natural order, women’s lot in life.

During her talk in Washington Ms. Azfar quoted Dr. Mahmoud Fathalla, an Egyptian physician and advocate for women’s health: “Women are not dying of diseases we can’t treat. ...They are dying because societies have yet to make the decision that their lives are worth saving.”

Ms. Azfar works 12 hours a day, seven days a week. She has irked relatives by missing weddings and other family events because of work.

“My children are not happy,” she said in an interview after her speech.

Ms. Azfar grew up in a village about an hour from Kabul.

“Everywhere then, girls went to school,” she said. “Women’s rights before the Taliban were the same as in Western countries. Women had the right to vote.”

Her mother had 10 children, 2 of whom died. She always gave birth alone, behind a closed door. When Ms. Azfar was 9, she began to help, by waiting outside the door to receive the newborn baby and wash and swaddle it, while her mother then delivered her own placenta.

Ms. Azfar never actually saw a birth until she began studying midwifery at age 16, and only then, she said, did she realize how brave her mother had been. She finished the rigorous three-year program at the top of her class in 1976.

“It was a very well-respected profession in my country,” she said.

But decades of war destroyed midwifery and much of health care, she said. Professionals fled the country, and many never went back.

“One day, 100 rockets came into Kabul,” she said. She and her husband, a physician, took their four children and moved to Pakistan, living there from 1992 to 2003. She had a fifth child there.

By the time she returned to Afghanistan, she said, midwifery was in a shambles. Spots in professional schools of all kinds were being filled by people with political connections instead of those with good grades. The midwives who had stayed behind had not received any continuing education. Their skills were outdated, and their attitudes were even worse.

“A culture of war was going on,” Ms. Azfar said. “If a mother came for delivery they didn’t treat her as she deserved or needed to be treated. There was no emotional support.”

Attitude counts in midwifery: if midwives and other health workers seem indifferent or disrespectful, women start to avoid the clinics, and they miss out on the help they urgently need.

Ms. Azfar acknowledged that it was hard to change attitudes, but she insisted that it could be done, by making “interpersonal skills” part of the training and the tests that students must pass to be allowed to practice. In Afghanistan, these things became part of the midwifery curriculum in 2004.

“Does she greet the mother properly?” she asked. “Offer her a chair? A drink of water? Introduce herself? Let the mother ask questions? They are trained. They have to do it.”

She has seen signs of progress, of hope.

“Just five years ago we started the reconstruction of this profession,” Ms. Azfar said. “These midwives, they are champions. Oh, I love them. They are my heart.”