Teaching woman: to care for themselves in Afghanistan

By Sakena Yacoobi

"I am illiterate and I work as a local Daya (traditional birth attendant) in my village. One night people came and picked me up to deliver a baby in their home. The woman had very serious bleeding and I could not control it because I did not know how, so they brought a midwife. It was midnight and the case was very serious, but the delivery happened safely. Since I have received training from the Afghan Institute of Learning (AIL), I now understand many things. I can practice all the things that I learned from this workshop, and with this knowledge, I can help the women of my village better", according to Seema. Like millions of other Afghan women, she knows too well the dangers of pregnancy and delivery.

Afghan women have one of the world's highest maternal mortality rates. They face many obstacles when it comes to accessing health care: most are rural and do not live close to or cannot access medical facilities, if the need arises. The few existing facilities do not necessarily specialize in obstetric and gynaecological care and cannot always offer quality care. Many Afghan families do not recognize signs of complication during pregnancy and delivery, and may not seek medical attention soon enough to save the lives of mothers and babies. Also ongoing insecurity and cultural norms in the country often keep women from leaving the house to seek urgently needed medical care. Because of cultural pressures, families are reluctant to present women to male doctors, and few female doctors are trained to meet the overwhelming medical needs of women; these conditions constitute a death sentence for thousands of women each year.

It is estimated that about 25 per cent of Afghan children die before their fifth birthday from mostly preventable illnesses. The World Health Organization reports that children in Afghanistan are particularly at risk of dying from diarrhoeal diseases that, according to surveys, result in 20 to 40 per cent of all deaths of children under five-an estimated 85,000 children per year. Diarrhoea is also a significant cause of malnutrition, which is a major contributing factor in children's death from other diseases.

With the support of the United Nations Population Fund (UNFPA), AIL is responding to the health crisis of women and children in Afghanistan. In 2002, it created the Women's Learning Centers (WLCs) as a mechanism for reaching isolated women with health education and health care services. The Centres are small-service sites at community-selected locations close to the women's homes, inspiring confidence for their safety. Cultural preferences are also respected when establishing the centres; for example, no men are allowed inside unless authorized by the community. The Centers have been so successful in reaching out to women with urgently needed health care and education that they have been replicated in refugee camps in Afghanistan and Pakistan by AIL, international non-governmental organizations and the Afghan Government. The Afghan Ministry of Women's Affairs is working to establish Centers in every province of the country.

UNFPA and AIL share the belief that women who are empowered with basic education are more prepared to make choices that protect the health of their families and their own. They are providing health care and health education each year through WLCs to tens of thousands of women and children in Afghanistan, as well as training women health professionals to continue providing services.

The Institute supports three basic health clinics in the rural areas of the country, each operating a mobile unit. Because there is no hospital nearby, the clinics often act as mini-hospitals, providing a wide range of health services to meet the needs of about 6,600 patients each month. They provide medical exams, medicines, injury care, dental care, midwifery, vaccination, first aid, laboratory analysis, minor surgery, health education, family planning and natal care. The AIL Mir Bacha Kot clinic provides intensive nutrition services for malnourished and undernourished children, as well as nutrition education to mothers. All AIL clinics emphasize reproductive health services for women and provide family planning, pre- and post-natal care and other health care services to over 1,500 women each month.

The Institute promotes positive health practices, with health education messages integrated into the curriculum of every WLCs class and AIL school. Students learn how to protect their health through good hygiene, sanitizing water, getting vaccinations and using medication properly. Similarly, every AIL patient receives health education, and classes are organized to provide an in-depth education about specific diseases like diarrhoea and other health topics. Over 40 per cent of health education lessons at the clinics relate to women's reproductive health and on topics such as family planning, nutrition, vaccination and breastfeeding.

Health education is essential to reversing the tide of maternal, infant and child mortality in Afghanistan. Many rely on superstitions or traditional wisdom when making health decisions, sometimes with disastrous consequences for women's and children's health. For example, some women do not breastfeed because they believe their milk is not clean and will make their baby ill. Since many parents are not aware of the benefits, they do not provide their children vitamin-rich food and do not bring them for vaccination when they are sick.

The AIL health education programme has demons-trated success in improving health practices. With UNFPA support, AIL developed an intensive five-day reproductive health workshop in 2004 to educate women about pregnancy and childbirth. It has been offered to some 500 women, including teachers and health workers who will disseminate this important information through their jobs. Participants have been very appreciative of the workshop, because they learn so much about safe childbirth, breastfeeding and family planning. "I have been scared of pregnancy", one participant said, "but after this workshop I am not scared anymore. I can practice the messages I have learned from this. I pray for the Afghan Institute of Learning and its trainers who worked hard to improve our awareness."

Women in Afghanistan need the health services and education to prevent future problems. In addition, they also need trained female health professionals who can continue to provide vital health services and education for generations to come. The AIL post-secondary nurse/midwife/health educator (NHE) training course is build-ing a base of trained female health professionals to serve thousands of patients each year, while increasing women's access to health care. During the intensive nine-month course, NHE students learn over 100 medical subjects, from first aid to physiology, and perform practical lessons in local hospitals and clinics. To date, 55 women have graduated from the NHE course and some have enrolled in medical school at Kabul University and were exempted from numerous courses because of their AIL training.

UNFPA is supportive of the Institute's comprehensive approach to improving the health and well-being of women and girls by increasing their access to health education and health-care services. Those who receive the needed health care during their lifespan will be healthier during critical times like pregnancy and childbirth. They will be empowered to make the best choices concerning the health of their families and their own.

Through culturally acceptable education programmes based on Afghan values, AIL has expanded women's access to education and built trust among women, their families and communities. Because of that, it is able to offer education and services like family planning without the conservative backlash that other similar organizations have encountered. However, AIL will only start a new programme if a community has requested it and gets involved. Communities have contributed resources, such as land, space, security assistance and in-kind donations, to AIL centres and clinics to ensure the success of the programme. Community leaders and the women themselves provide input as to the kind of classes and services they would like and how to best offer them.

The UNFPA support is making it possible for the Afghan Institute of Learning to respond with urgently needed, culturally appropriate care that helps women deliver healthy babies safely and raise them to be responsible citizens. It has also provided life-saving medical care and health education to tens of thousands, saved countless lives and developed a model for reaching women with urgently needed reproductive health services in spite of cultural barriers.