March 21, 2013

Maternal and Child Health in Badakhshan Afghanistan: Progress and Challenges

Badakhshan -a beautiful province of Afghanistan nestled in the lap of Hindu-Kush Mountains is surrounded by gorgeous snow-caped mountains, splendid green valleys, turbulent rivers and fascinating lakes.

Badakhshan came in the limelight of both national and international media in 2002, when the Ministry of Public Health Afghanistan discovered that Badakhshan had the highest rate of maternal mortality in the world: 6,500 out of every 100,000 women die during child birth. And a woman in Badakhshan faces almost 600 times the risk of dying during child birth than her counterparts living in North America. The survey report not only stunned the whole world but it also sparked my interest in going to Afghanistan to be part of the global effort of reducing maternal deaths in Badakhshan. In July 2004, I got an amazing opportunity to work for Aga Khan Development Network (AKDN) in Badakhshan. At the onset, I was not sure if going to Afghanistan was such a good idea. The western media was filled with horrendous stories about Afghanistan and at such a time, going there would mean putting my own life at risk. However, the rays of insecurity, fear and doubt disappeared behind the beautiful mountains of Badakhshan when I stepped on the beautiful and lush green land of Faizabad - the capital of Badakhshan Province.
My first encounter at the Provincial Health Department struck me as a bolt from the blue. The tumbledown, two-story building validated the poor health status of Badakhshan. It never dawned on me that a Provincial Health Department in Afghanistan could be without basic furniture, stationaries, national guidelines and provincial action plan. The health situation was far worse than what had been reported in the international media. Eleven health facilities in total were providing basic health care services to one million people in twenty eight districts of Badakhshan. In other words, one health facility was for a catchment population of approximately 91,000. Almost all health facilities were without female health professionals, equipment and lifesaving drugs. Laboratory facilities were nonexistent. Except Faizabad Provincial Hospital, all other health centers were entirely at the disposal of non-certified male nurses. Health professionals had never undergone any formal training since they had graduated from medical universities. Immunization coverage and hospital delivery rate were almost zero. The most heart touching story that brought tears to my eyes were of those hundreds of thousands of pregnant women who developed complications during pregnancy and left their home for Faizabad with a hope that they would return alive and rejoin their family but died on the way. The story of 40-year-old Watan Sultan - mother of seven children whom I met in Shughnan district of Badakhshan in September 2011 when she was under treatment at a local hospital touched me to the very core of my soul. She shared with me the most heart-rending story of a family member who died during pregnancy because of unavailability of a midwife. She said,
Fifteen years ago, an immediate relative of mine got pregnant. We were very excited to find out the good news. Everyone was waiting anxiously for the new addition to our family. Anxiety began to pile up when the due date passed but she could not give birth despite of arduous labor pain. We waited a few more days but her condition started deteriorating because of the massive bleeding she had. Finally, we decided to take her to Faizabad Hospital. As there was no road so my husband placed her on a donkey and departed for Faizabad at night. It was almost a 10 days walk. The patient was crying and bleeding continuously but except praying, we could not do anything as we were all helpless. After two days when we were somewhere close to Ghoron village, the patient breathed her last. We started moving back to our village with tears in eyes, pain in heart and prayers on lips. We arrived home with the dead body after two days. It was the most terrible day of my life. I saw a family member dying in front of me and there was nothing we could do to save her. Though, it happened over 15 years ago but the incident is still fresh in my mind
The UN sponsored Bonn Conference in 2001 emerged as a ray of hope for Badakhshan when the people of America pledged to support Afghanistan through United States Agency for International Development (USAID). The Ministry of Public Health Afghanistan in collaboration with renowned international agencies achieved a major milestone by developing "Basic Package of Health Services" (BPHS), "Essential Package of Hospital Services" (EPHS) and reproductive health policies for Afghanistan. Ministry of Public Health and USAID in partnership with international non-governmental organizations (NGOs) like Aga Khan Development network (AKDN), Merlin and Medair established health facilities in twenty eight districts of Badakhshan as per the BPHS guidelines which had placed great emphasis on maternal and child health, family planning, immunization, safe motherhood, availability of basic equipment and essential medicines. The shortage of human resources in health was a major obstacle to the delivery of primary health care. According to available health statistics, Badakhshan had 6-8 female physicians and 5-6 registered community midwives in 2003. Without a sufficient female workforce, the proposed goal of reducing maternal morbidity and mortality in Badakhshan was easier said than done. Due to cultural sensitivity, women prefer to be treated by a female doctor, especially where gynecological issues are concerned. Sadly, Afghan female health professionals from other provinces were also disinclined to work in Badakhshan. To address the shortage of female health professionals, AKDN set forth an idea of bringing female doctors, nurses and midwives from Tajikistan until Afghanistan attained self-sufficiency in health care workforce. The Tajik midwives played a critical role in providing quality health care to people in remote villages of Badakhshan. Almost every health facility in Badakhshan had one community midwife from Tajikistan.
The other exciting and ground breaking steps taken to reduce maternal deaths in Badakhshan was an establishment of "Community Midwifery School" by the Ministry of Public Health Afghanistan in partnership with the Johns Hopkins Program for International Education in Gynecology and Obstetrics (Jhpiego) and Aga Khan Development Network (AKDN). The community midwifery education program started at a time when Badakhshan had an acute shortage of midwives and was known for the highest maternal deaths in the world. In 2005, eighteen young girls selected by village health committees from fifteen remote districts of Badakhshan started their eighteen months training at Faizabad Community Midwifery School. By the end 2012, 109 students successfully graduated from the school and returned to their respective health facilities against which they had been selected. The community midwifery school was the very effective program that not only resolved the acute shortage of midwives but also improved the maternal and child health situation in Badakhshan to an unbelievable extent.
Afghanistan mortality survey 2010 indicates significant gains in maternal and child health. For instance, the maternal mortality ratio (MMR) and under 5 mortality ratio have reduced to 327 deaths per 100,000 live births (from 1600 deaths /100,000 live births in 2002-03) and 97 deaths per 1,000 live births (172 deaths /100,000 live births in 2002-03) respectively. Similarly, the contraceptive prevalence rate, skilled birth attendance, immunization and antenatal coverage have also improved. Today, Badakhshan province has 110 fixed health facilities and mobile health clinics. The Ministry of Public Health Afghanistan and other international agencies need to be sincerely appreciated for all the work and effort that they put in to make this happen despite volatile and insecure conditions in Afghanistan. In contrary to this, some segments of the international media and local Afghan politicians have expressed partial satisfaction over the progress made so far. They argue that the achievements are not compatible with the amount of money pumped into ailing the health sector in Afghanistan since 2001. As a public health professional, I do not deny the fact that a lot more needs to be done to improve maternal and child health in extreme remote districts of Badakhshan. However, there are several key challenges that have not yet sufficiently caught public's eye. Provision of maternal and child health care should not only be the sole responsibility of Ministry of Public Health, rather all other ministries and non-governmental organizations must also play a critical role in addressing these problems to improve the health status of the people of Badakhshan.
Inaccessibility: Badakhshan is a mountainous region and 20 percent of the total population of Badakhshan (living in Darwaz ,Khawhan, Ragh, Shughnan and Wakhan districts) have no road access. In summer, people walk for 18-20 days to get to Faizabad - the Provincial capital where the provincial hospital is located. In winter, the temperature drops below minus twenty two (-22) degrees Fahrenheit and heavy snow cripples life in the valley. These districts are cut off from the rest of province for at least seven months. The Ministry of Public Health has established primary health clinics like sub health center (SHC), basic health center (BHC) and comprehensive health center (CHC) in extreme remote villages where at least one midwife and one male nurse have been deployed. In extreme winter, the pregnant women can neither access these health facilities nor the midwife can go out to perform the outreach activities. Similarly, in case of emergencies, serious patients cannot even be transferred to the Provincial Hospital in Faizabad. Many people lose their lives to avalanches while making efforts to reach health facilities. Unfortunately in the event of emergency, not even a helicopter can land in the deep narrow valleys because of the massive snow and low clouds.
Lack of Human Resources: Badakhshan is facing a dire shortage of female doctors which afflicts the health care delivery process. Even today, a large number of health facilities in the province are without a female doctor. Though, some of the international organizations have brought female physicians from neighboring countries like Tajikistan but it is still a temporary solution to a permanent problem.
Ultra-poverty: A large majority of people in Badakhshan live below the poverty line. The exorbitant travel costs do not permit patients from remote districts to come to the provincial capital and seek the advice and care of specialist doctors.
Early Marriage: The custom of early marriage is prevalent in Badakhshan. Most of the girls get married before the age of 18 and in some districts as early as 12. This leads to several health problems like low birth weight, high fertility rate, malnutrition, increase mental distress. In addition to this, early marriage is also a potential cause of obstructed labor. Studies have shown that the younger women are married, the more likely it is that they will not have fully developed pelvis and therefore will be at risk of obstructed labor (Institute of Development Studies, Brighton UK-1996)
In spite of all these challenges, I strongly believe that today is better than yesterday and tomorrow will be better than today. The international community should continue to support the poor people of Badakhshan until all women have access to care during pregnancy and child birth. No woman should die giving birth and no child should be left an orphan because of unavailability of physicians, equipment and medicines.

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                                     Published in "The Huffington Post" USA on March 21, 2013

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