When Afghanistan’s first midwife-run birthing center opened this year in the impoverished Dasht-e-Barchi district of western Kabul, it was a symbol of hope and challenge.
It began receiving pregnant women in June, just over a year after a devastating attack by gunmen on the maternity wing of the local hospital left 24 dead, including 16 mothers, a midwife and two young children.
For Zahra Mirzaei, its launch, along with a second birthing center in the east of the capital, marked the culmination of a decade of defending women’s birth rights.
As president of the Afghan Midwives Association (AMA), Mirzaei was instrumental in establishing midwife-led units that promote a spirit of respectful and personalized care away from an over-medicated environment.
“In our country, this approach to pregnant women is innovative and there was a great sense of hope when we opened our doors,” she says.
“Women who had previously received unworthy and low-quality care in understaffed hospitals were pleasantly surprised to find that there is another way of doing things.”
The units at Dasht-e-Barchi and Arzan Qimat were established with technical support and training from the Midwifery Units Network (MUNet) and funding from two NGOs that we cannot name for security reasons.
In the first weeks, the centers, which had a total of 75 midwives, each received 10 to 13 newborns a day. But as word spread, a growing number came in and soon rose from 25 to 30.
In late July, Mirzaei was concerned about how to handle the surge in cases. But his work was overshadowed by a growing awareness of the Taliban’s military offensive, which had picked up an unexpected pace.
The news of the impending collapse of the Afghan government amid the withdrawal of US troops was, for Mirzaei, personally and professionally devastating.
“Suddenly, everything I had worked tirelessly for was under threat,” he says. As a longtime Shiite Hazara and women’s rights advocate, the 33-year-old knew that she and her three children were in danger.
“Previous Taliban governments have killed thousands of Hazara for no reason. I also knew that my feminist work and my belief in women’s equality would never be accepted by the Taliban regime, ”says Mirzaei, who in 2020 was named one of the 100 outstanding nurses, midwives and leaders providing health services in difficult times through Women in global health.
As the United States and its coalition partners scrambled to airlift thousands of the country’s people, warnings leaked from Mirzaei’s hometown that she was a potential target of the Taliban.
On the day Kabul fell, plunging the country into chaos, he left his office for the last time, fleeing in such a hurry that he couldn’t pick up his shoes. “We didn’t expect the situation to get worse so fast,” he says.
Later that night, she was awakened by the sound of her eight-year-old daughter sobbing: “I went to her and she said, ‘Mom, I’m afraid that when I’m 12 the Taliban will come and take me married and I won’t be able to go to school. . It was so painful to hear that I promised to get us out there. “
After calling all the contacts he could think of, he heard from a friend in the United States that he could help. Mirzaei left home with her family at 1 a.m. on August 23, still wearing the flimsy slippers with which she had fled her office.
They spent 12 harrowing hours waiting in a sewer near the airport before being rescued by US troops and flown to Qatar. From there they were transferred to a refugee camp in southern Spain.
Speaking from the Spanish naval base in Rota, Mirzaei explains how leaving Afghanistan also sadly meant resigning as WADA president.
While heartbroken to leave office, she remains a member of the advisory board and works remotely to support the organization, including its successor, a woman from a different ethnic group who is more likely to be accepted by the regime.
TOAs the eighth child of 10 siblings, Mirzaei understood from a young age that boys and girls were not seen as equals. “I had two brothers, but my father wanted more boys and it saddened me that girls were not allowed to reach their full potential in our community.”
Growing up in the Sar-e Pol province, where poverty was widespread and literacy rates were low, 16-year-old Mirzaei found that educational opportunities were limited.
An encounter at the local hospital led her to become a midwife. In the waiting room, she saw a woman desperately looking for a midwife, but was abused by a health worker.
“This incident really affected me, the way they treated her was shameful. When I saw the doctor I asked him what a midwife was and why she was so important.
“I liked the sound of midwifery, it spoke to the feminist in me. That kind doctor changed my life by explaining to me how I could enroll in a community education program for midwives. “
A year later, Mirzaei graduated with a diploma and had already joined the AMA as a student. “I was inspired by his plans to improve the profession. For me, the most important thing was that women received respectful and evidence-based maternity care. “
But starting as a midwife in a hospital in 2006, she was concerned about what she saw.
“There would be 150 deliveries a day in a hospital with only four or five midwives. Women were allowed to give birth in the corner or in the bathroom. The most painful thing was seeing how exhausted the midwives were, they could not emotionally support the pregnant women and there was even physical abuse ”.
While women in remote areas often give birth without medical assistance or sometimes with a midwife, delivery in urban hospital settings is highly medicalized.
“These facilities are staffed by doctors who seem not to know their job description because they are overwhelmed by dealing with simple deliveries,” says Mirzaei. “Attention is dehumanized and the use of hormonal drips and episiotomies is a routine practice.”
Afghanistan has one of the highest maternal mortality rates in the world, although the number of women dying in childbirth has dropped from 1,450 per 100,000 live births in 2000 to 638 in 2017, according to A DATE.
In 2012, Mirzaei became the provincial director of the AMA and later moved to Kabul to coordinate a midwife mentoring program for the organization.
She joined a small but growing cohort to earn a bachelor’s degree in midwifery after graduating from the Zawul Institute of Higher Education in 2016. Two years later, she was elected president of the AMA and set out to establish midwifery-led units.
The model would move away from medical interventions and focus on active labor, skin-to-skin contact, and early breastfeeding.
In 2003 there were only 467 midwives operating in Afghanistan – the severe shortage caused by the Taliban’s ban on educating girls and women in previous years. Since then, this number has risen to 6,376 currently in clinical practice.
To 2018 Afghanistan Health Survey found that only a fifth of pregnant women had received the four recommended prenatal care visits and fewer than 60% of deliveries were supervised by a trained health professional.
There was 119 attacks by terrorist groups against health facilities in Afghanistan in 2019, according to the World Health Organization. Then, in May 2020, the massacre took place in the maternity ward of the Dasht-e-Barchi hospital.
Among the dead was a fellow Mirzaei midwife, Maryam Noorzad. “They killed her because she refused to leave a woman alone in labor. The baby was coming and after he was born a gunman came in and killed all three of them. “
The attack was not only a horrific crime against pregnant women, infants and hospital staff, it was also a devastating assault on decades of work to reduce maternal and newborn mortality in Afghanistan.
Despite security fears, WADA wanted to establish one of the midwife-led units in the same district to fill the void left by the attack on the hospital, where there had been 16,000 babies born in 2019. Many of the midwives who survived the 2020 attack were among the highly trained staff hired by WADA to run the new centers.
The success of the centers depends on personalized attention and requires that the numbers be kept at a manageable level. To meet demand, Mirzaei’s ambition was to open more units in Kabul and beyond.
But for now, at best, his dream is on hold. The centers closed after the Taliban took office and, although one has recently reopened, many staff remain fearful to go to work. The Taliban have already questioned some midwives for moving unaccompanied.
The United Nations Population Fund (UNFPA) has estimated that without immediate support there could be 51,000 additional maternal deaths between now and 2025.
In Spain, Mirzaei prepares to fly to the United States to begin the next chapter of his life. Her immediate future is uncertain, but she accepted an offer to study global maternal health at the City, University of London, which she had to postpone until she can apply for a visa.
“Every day I open my phone and look at photos that were taken in our birthing centers. It gives me hope. Its immediate success is based on the broader political situation, but we will not cease in our efforts to do everything we can for girls and women in Afghanistan. “
Many midwives who have campaigned for women’s rights in Afghanistan are now targeted by the Taliban and forced into hiding. while others are at risk due to their ethnicity. The Radical Midwives Association is raising funds to help those seeking to settle in the UK. To donate, visit this crowdfunding page.
George is Digismak’s reported cum editor with 13 years of experience in Journalism