From a young age, Zahra Mirzaei, 32, decided to become a midwife after she encountered a kind doctor who encouraged her to pursue studies in the field. Observing the role that midwives played in her country — Afghanistan — while challenged by extremely limited educational opportunities for women and girls, Mirzaei said: “It spoke to the feminist in me. A woman for women!”
Now a midwifery and nursing team leader in Kabul for Jhpiego, an international nonprofit health organization affiliated with Johns Hopkins University, she has transitioned from working as a skilled birth attendant to providing technical support for midwives in schools and hospitals. As the president of the Afghan Midwives Association, Mirzaei has 14 years’ experience working in the field.
The country’s maternal death spiral has significantly slowed, according to the United Nations. In 2017, there were 638 deaths for every 100,000 live births, down from a high of 1,450 in 2000; at the same time, the number of practicing midwives has increased and the quality of their training and education has improved.
Yet overwhelming challenges persist in this country long at war: the World Health Organization reported 119 attacks on health care facilities in Afghanistan in 2019, many committed by the Taliban and the Islamic State. In May, a hospital housing a maternity clinic supported by Médecins Sans Frontières (MSF, or Doctors Without Borders) was attacked in the Dasht-e-Barchi neighborhood of Kabul, killing at least 16 people, including a midwife who refused to leave a mother who was in labor.
Mirzaei, who is married and has three children, was interviewed in October about the life of a midwife; her responses, communicated from Kabul via Skype and email, have been condensed and edited for clarity and style.
PassBlue: How and why did you decide to become a midwife?
Mirzaei: I was born into a traditional family of 10 children and, because of the war in Afghanistan, we had to immigrate to Iran. My father wanted more boys to assist him with the family income in bad economic times. I was the eighth girl born into this family; we had two brothers as well. When I was only 4 or 5, I came to understand there is a difference between girls and boys in our family and our community, and it made me really sad. I was 11 when I started advocating for women’s and girls’ rights in my family and with my relatives. Sometimes I debated with my mother and elder brother about why girls can’t be permitted to reach their full potential as boys do.
In 2005, when I was 16 years old, we returned to Afghanistan and settled in Sarepul Province, where poverty and illiteracy were deep and pervasive. Continuing my education seemed impossible for me at that time. One day, I became sick. My mother and I went to the district hospital. While waiting for the doctor, a lady in a white uniform came into the corridor. A woman with old, torn clothes reached out to the lady, a health facility worker, and touched her uniform, saying: “Could you please tell me where the midwife is? I need a midwife, please.” The health worker pulled the woman’s hand away from her uniform and shouted, “It is not my job to guide everyone in this hospital.”
Watching this incident really affected me. I did not believe that one woman could treat another woman like this. Her attitude and behavior were shameful. Lots of thoughts popped into my mind: who is a midwife? Why is a midwife important? How I can help the woman who needs a midwife? On that day, I helped the woman to find the midwives’ room and then I visited the doctor.
This doctor — her name was Farida — changed my life. She treated me very kindly. She explained what a midwife is and how a midwife helps women and mothers. That sounded amazing to me: a job by women to help women! She asked me, “Do you want to become a midwife?” I replied happily: “Yes, I would. But how? My family won’t allow me to leave my province for education and there is not a university in Sarepul.” Then she told me about the [Jhpiego-supported] Community Midwifery Education program and helped me to enroll. I liked midwifery; it spoke to the feminist in me. A woman for women!
PassBlue: Where and when did you obtain your training as a midwife? What is the minimum training needed to be a skilled/certified midwife, and where do other midwives go for training?
Mirzaei: I graduated from Sarepul Province’s Community Midwifery Education [CME] program as a diploma midwife in August 2006; in June 2014, after many years working as a hospital midwife, CME trainer and CME program coordinator, I joined the Afghan Midwives Association as a mentorship national program coordinator based in Kabul, which gave me the opportunity to continue my education. In 2016, I graduated from Zawul Institute of Higher Education with a bachelor of science degree in midwifery and an average score of 94.30 percent. Diploma level [at least 10 years of secondary education] is the minimum necessary to work as a midwife in Afghanistan. After completing high school, girls can study midwifery at a governmental midwifery school, which are the Institute of Health Science in the big cities and CME in provinces, remote areas and small cities. There is only one governmental university and five private universities that train midwives for a bachelor’s degree, and they are all in Kabul.
PassBlue: How do you personally keep going in your country with all the unrelenting threats and barriers to midwives’ work?
Mirzaei: In one word, I could say, love. Love and passion about what we want to do, about our job and all the activities we do in our community and society. Midwives serve the most vulnerable part of society, which are mothers and children. When I travel to an unsecure area, I know what kind of risk is waiting for me, but it is important to me to make sure about the quality of health services for mothers in unsecure areas as well as near cities, so how can I ignore their need?
PassBlue: What does it feel like when you midwife a baby?
Mirzaei: I can’t forget the first time I helped a mother give birth in the Sarepul provincial hospital, when I was only a student and my teacher encouraged me to take responsibility of that woman; she already had five stillbirths due to toxoplasmosis [a parasitic infection]. This one was alive and a very lovely and healthy baby. I was the first one to touch him, even before his mother. Then the mother kissed me and hugged me with lots of happiness and thanks for this beautiful baby. I felt so happy and proud.
But there were some bad stories as well. During my night duty, a mother with bleeding after birth came to us. Unfortunately, she came very late and she was in shock. I called for help, as I was only a student and then started [treatment] for shock management, but I understood that she was already dead. She had four more children at home waiting for their mother to come back with the baby. I was very young and couldn’t control my emotions. My teacher, the same Dr. Farida, came to me and asked, “Why you are crying?” I said: “I don’t want to become a midwife anymore. Because we can’t help women always. I can’t do anything for this woman.” She replied: “Just look at your hands and see what changes you can bring by these hands. You should not give it up. You should be ready to prevent such kind of a sad story after graduation from midwifery school.” So for the second time, she motivated me to be a midwife — a woman changing the life of other women.
PassBlue: Besides the coronavirus right now, with the country confirming 42,000 cases and 1,558 deaths, what are some of the most pressing challenges for midwives in Afghanistan? I know the political situation is constantly evolving as the United States tries to broker a peace deal, but that appears to have stalled recently as violence rises.
Mirzaei: In my conversations with midwives and members of the Afghan Midwives Association, here are the issues they raise: Gender-related barriers, as 100 percent of midwives are female; unsupportive working environments, including exhausting work schedules — some midwives work 36 hours without a break — lack of job security, targeted attacks, low salary, lack of continuing education and mentorship support, especially in remote areas; lack of higher education opportunities [limited bachelor degree programs and no master’s degree offered]; lack of leadership and mismanagement of midwifery human resources; and lack of research knowledge among midwives.
PassBlue: What is the average salary of a midwife, and is it enough to live on?
Mirzaei: There is a different level of salary for midwives, dependent on nongovernmental organizations’ support. Overall, in a big city like Kabul and in public health facilities, it is between $100 to 150 a month and sometimes difficult to cover life expenses without an extra job or another supporter like an employed husband. For me, $150 only covers my housing rent per month.
PassBlue: How did the horrific attack on the Kabul hospital’s maternity ward last May affect the practice of giving birth in the area since then? Is there enough protection for midwives and other medical professionals to ensure the war stays out of the birthing arena now?
Mirzaei: Unfortunately, there is not any protection for health care providers. The attack at the Dasht-e-Barchi maternity hospital in Kabul is just one example. There was an attack in the Kunduz hospital; a midwife in Samangan Province was gang raped during a night shift in a health facility; and there are other terrible incidents. These all are our concerns. Dasht-e-Barchi maternity hospital closed and MSF [Médecins Sans Frontières] no longer supports the hospital due to security concerns. But pregnant women still need maternal and newborn health services and midwifery support.
PassBlue: Since the Dasht-e-Barchi maternity hospital has closed, where do women in Kabul give birth now?
Mirzaei: Women go to private health facilities and other public ones that are far from their home or they stay home without seeking health care. But midwives are ready to go back to the hospital and continue their job. The surviving midwives [from that attack] said to the Afghan Midwives Association that they don’t fear gunmen and attacks and nothing can stop them from serving mothers and children. They are ready to sacrifice themselves, like the midwife Maryam [Noorzad, who refused to abandon a birthing mother and was killed by a gunman in the Dasht-e-Barchi delivery room].
PassBlue: How has the practice of midwifery changed since the outbreak of the coronavirus in Afghanistan? Does the country have enough personal protective gear, or PPE, for health care workers and does it adhere to the best practices for prevention and spread of the virus?
Mirzaei: This has been a stated need of many midwives, especially those who live in areas far from Kabul and other cities. But this is a global problem; does any country have sufficient personal protective equipment? Working with our partners in the Afghan Midwives Association, Jhpiego has delivered $700 worth of PPE to the association for distribution to their members and we hope to do more.
PassBlue: What role do you think midwives in Afghanistan can play toward reaching the 2030 UN Sustainable Development Goals on reducing maternal mortality — fewer than 70 deaths per 100,000 live births? Obviously, the latest figures in Afghanistan [at 638] are still too high. Do you know what percentage of mothers receive proper prenatal care and use a skilled birth attendant?
Mirzaei: Midwifery is an ancient profession all over the world, and it is widely understood that well-educated, regulated, well-resourced and supported midwives have a crucial part to play in providing skilled birth attendance, enhancing reproductive health and protecting the health of newborns and families for all women, and thus in reducing maternal and newborn mortality. Data show that increasing the number of midwives results in increased institutional deliveries and decreased maternal mortality rates. But yes, the maternal mortality rate here is too high. I think in 2002, we were in a situation of urgent need for more midwives as we only had 467 midwives in the country. But now we have more than 20,000.
Afghanistan needs to work more on two things: First is quality of midwifery services, which means more investment in building the skills and confidence of midwives and providing higher education for them. Second is the distribution of the midwifery workforce and good management of the workforce in Afghanistan. I am referring to the density of midwives within the population. It is now 1.3/10,000. Only 20.9 percent of pregnant women receive the recommended four antenatal care visits, and 58.8 percent use a skilled birth attendant, according to the Afghanistan Health Survey 2018. So once again, the midwifery profession in Afghanistan needs lots of support in leadership, management, higher education and research skills for evidence-based interventions and advocacy.
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