Some recent examples of maternal deaths in remote villages in four provinces
Dr Harun Najafizada and Alia Rajai
To inform the debate on maternal deaths in Afghanistan we wanted to take some snapshots of some recent deaths in remote villages. Two of us (Harun Najafizada and Alia Rajai) made brief visits to remote districts in four provinces and these stories were told to us almost at random. We had not heard that there had been a death in such and such a village; we just went to the area and found there had been a recent death. Our criteria were a village which is at least two hours walk by donkey to a health centre and relatively safe. All informants gave signed consent to our publishing these stories.
We have been minimally selective. Below are the four stories we were told. They all illustrate that while it is possible to predict some risks, it is never possible to rule out all risk. Two of the three stories are examples of ‘the three delays’, how delay in reaching and receiving skilled care can lead to death. The second case illustrates the first and second of those three delays, finding transport and making the journey. The third case illustrates the third delay, at health facilities.
Our purpose was to bring examples of the actual consequences of giving birth in remote villages to the awareness of all concerned, which is almost everybody, not to make recommendations on the basis of such a brief paper. But we have added some minimal recommendations at the end.
A death due to ignorance
Rafiq comes from Kaar Saeed Village of Yaftal Sufla District in Badakhshan Province. He lives a single man’s life now after losing his wife about four months ago. He used to serve in the Afghan National Army with a minimum monthly salary of about $200, and was mostly away on duty in other provinces of
Afghanistan. While for cultural reasons Rafiq declined to name his wife, he was willing to share the story of her death. Thanks partly to his low income and regular separation, his wife had never visited a midwife for antenatal care during her first or second pregnancies and the births had been at home and normal. Everybody in his village thought that once a woman had given birth normally, the chances of complications during later births were reduced immensely because she has already “passed the test of God”. So this time too, with the help of an old and untrained traditional birth attendant, she delivered at home. A couple of days after the normal delivery both the baby and the mother appeared well, but then suddenly the mother got hot and complained of pain and shivered and the health condition of the mother got worse. Villagers, ignorant of the risks – like infection – that can follow delivery, came up with different advice. The old birth attendant thought she was too weak and needed strong meals; some advised pain killers; a few others said her condition might be caused by fear. Visiting a doctor was way down the list, a measure only of last resort. But eventually, fearing that his wife was dying before his very eyes and unable just to watch her fading away, Rafiq decided to take her to Faizabad, for some length of the way on a hand-made wooden cart, and then by hired car. But soon after setting out he saw that his wife had died on the cart, in the open air. He now takes care of his two small children as best he can, but in hardship as he is jobless and grief has torn him apart. He expects that he will never remarry and that he will have to bring up his children alone.
A death due to lack of transport
Gadai Bibi’s husband “M” is shaking the cradle, but his newborn does not stop screaming. Their three children, who appear smaller than their actual age, are playing in the small yard as women continue to come to express sympathy with the family. They are directed to another room. On 28th August 2016, the mother of the family lost her life during delivery of her fourth baby in Ghor Province, one of the poorest areas where over 95 percent of women give birth at home and maternal mortality is higher than average.
Gadai Bibi’s family lives in Sare-e Ghalmin District of Cheghcheran, some 40 kilometers away from the health centre. There is no Community Health Worker or midwife or ambulance at the site of the village of mud-brick houses. If complications arise during labour, the only hope for people living in districts of Ghor is to try to transport the woman to the centre, Feroz Koh, where some help is provided. Gadai Bibi’s husband says that is what they tried to do when his wife failed to deliver the baby and she started to become weaker. “I started calling fellow villagers, but nobody’s vehicle was available at that short notice” M said. After several hours, they finally secured a flying coach minibus to transport Bibi to Feroz Koh.
Gadai Bibi was sat with her back leaning on the window and her legs resting on the seat. She was trying not to cry out as the vehicle went over bumps on the road. M could hear that his wife’s crying was getting weaker. When she passed into coma and he could not get her to respond, he shouted to the driver to go faster. But when they reached the hospital, the doctors told him Gadai Bibi had died.
A death due to lack of health care
It was a hot dark night on the eve of Nowruz (March 2016) that Zia Gul, 35, resident of Kholm District started the labour pain. Her village is deep inside the isolated Deh Logari area in Kholm District, without electricity, proper sanitation, drinking water and roads. There’s a basic health clinic near the village that offers services to over a thousand people, but their daily duty finishes at 4 pm and there’s no system to cover patients beyond that. As it was about nine pm, Zia Gul’s sister in law (Sharifa) told us that they had to rush the mother to the District Hospital in Kholm to meet the only surgeon. As taxis are not available, a motorcycle turned into a Zaranj carrier was the only available option other than donkeys. As the family is a poor one, whose income is from shepherding and gathering thorn bushes to be sold in the local market for fuel, it took one hour to arrange one. Zia Gul had two experiences of Caesarean sections in the past in the district hospital some three hours’ walk by donkey. This time during the ninth month of pregnancy she had visited the doctor only once when the doctor had told her that her expected date of delivery was only about 16 days away. By the time Zia Gul and her husband arrived at the district hospital, the severe pain was already in its second hour. It was nearly midnight and, to everybody’s surprise and shock, the surgeon was off duty in Mazar-e Sharif. Sharifa says it took another hour until the doctor arrived and by then Zia Gul was already unconscious and probably dead. There was a pool of blood in the waiting room. The doctor took her to the operation room and after a few minutes told the family that he could only rescue the baby boy. Zia Gul and her husband had thought that given the two cases of birth, the third would be easier. This time, unlike in the past, she continued to stay home rather than plan to wait in her mother’s home in Mazar-e Sharif. There was no Community Health Worker in their village to warn her on the potential consequences of the birth. Unawareness of the risks, failure to take precautions and cultural barriers to visiting a male doctor takes life in Afghanistan day in and day out.
After five years of marriage 23 year old Monika was hoping to gain the prestige and respect of her in-laws by giving birth to a baby boy. Three ultrasound images during pregnancy showed that she was indeed carrying a baby boy. Monika had previously given birth normally at the Charikar Hospital, Parwan Province. But the private clinic was nearer and thought to be less crowded. Humaira, her aunt, said that on the night of September 1st 2016, she was rushed to the private clinic in the city of Charikar, with a mixture of fear and hope. Only one midwife was present at the time, and no woman obstetrician. The delivery took longer than in the past. Monika kept pushing as her mother witnessed. But the baby was not coming and the midwife used a vacuum appliance to assist with the delivery as Monika struggled to breathe. After much effort, the baby was pulled out, but the vital signs of the mother dropped. And then there was blood everywhere. The midwife did not know how to stop the bleeding and revive Monika. Her mother was shouting to have her blood transfused to Monika. Her husband then rushed her to the main hospital, but there a doctor pronounced her dead.
- Midwives should educate women, and where possible husbands, on the risks of birth and do birth planning at antenatal care visits. They should also educate women after delivery on risks for future births. For example, both women and their husbands need to know that though the risks of the first birth are higher than the second and third, the risk increases from the fifth birth. Everyone needs to know how rapidly a woman can bleed to death, whether antenatal or postnatal, without any prior warning signs.
Education on risks enables parents to plan for births, especially transport.
- Many, if not most, births in Afghanistan take place at night. It is said that women tend not to take note of labor pains until the day’s work is done. That means that travel to a health facility will often be in the dark. Health facilities need to have 24-hour cover.