When Afghanistan’s first midwife-led birth center opened in the poor district of Dasht-e-Barchi in western Kabul this year, it was a symbol of hope and defiance.
It began receiving expectant mothers in June, just over a year after a devastating attack by gunmen on the maternity ward at the local hospital left 24 people dead, including 16 mothers, a midwife and two young children.
For Zahra Mirzaei, its launch – along with another birth center in the eastern part of the capital – marked the culmination of a decade advocating for women’s birth rights.
As president of the Afghan Midwives Association (AMA), Mirzaei was instrumental in establishing the midwife-led units that fostered an ethos of respectful, tailored care away from over-medical settings.
“In our country, this approach to pregnant women is groundbreaking, and there was a great sense of hope when we opened our doors,” she says.
“Women who had previously experienced unworthy, low-quality care in poorly staffed hospitals were pleasantly surprised to discover that there is another way of doing things.”
The units in Dasht-e-Barchi and Arzan Qimat were established with technical support and training from the Europe-based Midwifery Unit Network (MUNet) and funding from two NGOs, which we can not name for security reasons.
In the first weeks, the centers, staffed with a total of 75 midwives, each received 10 to 13 newborns a day. But as the word spread, an increasing number arrived, and this quickly increased to 25 to 30.
By the end of July, Mirzaei was preoccupied with how to handle the increase in cases. But her work was overshadowed by a growing awareness of the Taliban’s military offensive, which had gained unexpected momentum.
The news of the Afghan government’s impending collapse in the midst of the withdrawal of US troops was, for Mirzaei, personally and professionally shocking.
“Suddenly, everything I had worked tirelessly for was threatened,” she says. As a Hazara Shia and a longtime advocate for women’s rights, the 33-year-old knew she and her three children were in danger.
“Former Taliban governments have killed thousands of Hazara people for no reason. I also knew that my feminist work and belief in women’s equality would never be accepted by the Taliban regime,” said Mirzaei, who in 2020 was named one of 100 outstanding female nurses, midwives and managers providing health care in difficult times by Women in Global Health.
While the United States and its coalition partners struggled to air thousands of people from the country, warnings filtered through from Mirzaei’s hometown that she was a potential Taliban target.
The day Kabul fell and threw the country into turmoil, she left her office for the last time and fled in such a hurry that she was unable to gather her shoes. “We did not expect the situation to escalate so quickly,” she says.
Later that night, she was awakened by the sound of her eight-year-old daughter sobbing: “I went up to her and she said, ‘Mom, I’m afraid the Taliban, when I’m 12, will come and take me married and I will not be able to go to school. ‘ It was so painful to hear that I promised every now and then to get us out. ”
After calling any contact she could think of, she heard from a friend in the United States who could help. Mirzaei left home with her family at 01.00 on 23 August, still wearing the flimsy slippers in which she had fled from her office.
They spent a shocking 12 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.
Mirzaei speaks from the Spanish naval base in Rota and explains how leaving Afghanistan also meant, unfortunately, resigning as president of the AMA.
While crushed on giving up the role, she remains a member of the advisory committee and works externally to support the organization, including her successor – a woman from another ethnic group who is more likely to be accepted by the regime.
ONEAs the eighth girl 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 made me sad that girls were not allowed to reach their full potential in our society.”
When 16-year-old Mirzaei grew up in Sar-e Pol province, where poverty was widespread and literacy was poor, educational opportunities were limited.
A meeting at the local hospital set her on the path to becoming a midwife. In the waiting room, she saw a woman desperately looking for a midwife only to be abused by a health worker.
“This incident really affected me – the way they treated her was shameful. When I saw the doctor, I asked her what a midwife was and why it was so important.
“I liked the sound of midwifery – it spoke to the feminist in me. The friendly doctor changed my life by explaining how I could enroll in a community midwifery education. “
A year later, Mirzaei graduated with a diploma after already joining the AMA as a student. “I was inspired by its plans to improve the subject. For me, the most important thing was that women received evidence-based, respectful maternity care. “
But she started as a hospital midwife in 2006 and was worried about what she saw.
“There would be 150 births a day in a hospital with only four or five midwives. Women would be left to give birth in the corner or on the toilet. “The most painful thing was to see how exhausted the midwives were – they could not support pregnant women emotionally, and there was even physical abuse.”
While women in remote areas typically give birth without medical attention, or sometimes with a midwife, childbirth in urban urban environments is heavily medicated.
“These facilities are staffed by doctors who do not seem to know their job description because they are overrun when dealing with straight births,” says Mirzaei. “Treatment is dehumanized, and the use of hormone drops and episiotomies is routine practice.”
Afghanistan has one of the highest maternal mortality rates in the world, although the number of women dying during childbirth has dropped from 1,450 per year. 100,000 live births in 2000 to 638 in 2017, according to UN data.
In 2012, Mirzaei became the provincial director of the AMA and later moved to Kabul to coordinate a midwives’ mentoring program for the organization.
She joined a small but growing cohort to obtain a BA in midwifery education after graduating from the Zawul Institute of Higher Education in 2016. Two years later, she was elected president of the AMA and made it her mission to establish midwifery-led units. .
The model would move away from medical interventions toward a focus on active birth, skin-to-skin contact, and early breastfeeding.
In 2003, there were only 467 midwives operating in Afghanistan – the serious shortage caused by the Taliban’s ban on educating girls and women in previous years. This number has since grown to 6,376 currently in clinical practice.
A 2018 health survey from Afghanistan showed that only one-fifth of pregnant women had received the recommended four antenatal care visits, and fewer than 60% of births were supervised by a skilled health professional.
There were 119 attacks by terrorist groups on health facilities in Afghanistan in 2019, according to the World Health Organization. Then in May 2020 came the massacre in the maternity ward at Dasht-e-Barchi hospital.
Among the dead was a midwife colleague of Mirzaei, Maryam Noorzad. ‘She was killed because she refused to leave a woman alone in childbirth. The baby was on its way, and after it was born, an armed man came in and killed all three of them. “
Not only was the attack a horrific crime against pregnant women, babies and hospital staff – it was also a devastating attack on decades of work to reduce maternal and neonatal mortality in Afghanistan.
Despite fears for safety, the AMA wanted to establish one of the midwife-led units in the same district to close the gap after the attack on the hospital, where 16,000 babies were born in 2019. Many of the midwives who survived the 2020 attack were among the highly trained staff hired by the AMA to operate the new centers.
The success of the centers depends on one-on-one care and requires that the number be kept at a manageable level. To meet the demand, it was Mirzaei’s ambition to open more units across Kabul and beyond.
But so far, her dream has been put on hold at best. The centers closed after the Taliban took power, and while one has recently reopened, many staff are still too scared to go to work. Some midwives have already been questioned by the Taliban for moving around without an escort.
The United Nations Population Fund (UNFPA) has estimated that without immediate support, there could be 51,000 more maternal deaths between now and 2025.
In Spain, Mirzaei is preparing to fly to the United States to start the next chapter of his life. Her immediate future is uncertain, but she has accepted an offer to study global maternal health at the City, University of London, which she has had to postpone until she can arrange a visa.
“Every day I open my phone and look at pictures taken at our maternity home. It gives me hope. Their immediate success rests on the broader political situation, but we will not stop our efforts to do everything we can for girls and women in Afghanistan. “
Many midwives who have fought for women’s rights in Afghanistan are now being hit by the Taliban and have been forced into hiding, while others are in danger because of their ethnicity. The Association of Radical Midwives is raising money to help those seeking to settle in the UK. Visit this crowdfunding site to donate.
The title of this article was changed on October 26, 2021, because an earlier version said the Taliban killed a midwife in an attack on a maternity hospital. While the Afghan authorities blamed the Taliban for the attack on Dasht-e-Barchi Hospital in May 2020, the group denied responsibility. An investigation by Médecins Sans Frontières in May 2021 was unable to establish with certainty the identity of the perpetrators of the attack and their motives.