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Onward to Afghanistan: Midwifery in A Warzone

 

This is Part Two in a three-part series by the director and co-founder of the International Midwife Association (IMA). Read Part One here.

 

Labor is an altered state. Women have amazing experiences in labor. I had some amazing moments when I was in labor. I liked it a lot. Don't take me wrong, it hurt like crazy at some points. Really it was when I was distracted by someone that the contractions were so extremely painful. But there was a way to get around it, if I wasn't distracted, that made it not really like pain, and very interesting.

There is a mind/body connection in labor that cannot be denied. When a wild animal is in labor in the woods and hears people, her labor will stop. She will get up, move to another quieter place, and then proceed with the birth. It is likely there is some kind of analogy for women. Many of us have our own personal theories about what that is. There's even some science about it. But for sure, how the mother feels can influence her birth.

Outside of all our medical understanding of the physical aspects of birth, there is this other, huge component, if only we will acknowledge it. It looks different for different women, but usually it involves a feeling of safety, warmth, sometimes darkness, sometimes quiet, often some element of the sacred, but almost always it's about being made to feel safe. Sometimes in that environment, in that big wave of energy that accompanies incarnation, the room gets pretty intense.

That intensity sometimes holds information for me. It took me 15 years of attending homebirths to learn to understand what it means when the hair on the back of my neck stands up. I have also had the honor of attending deliveries during which very magical things happened. These births I attend, they belong to the family I am serving. They aren't about me, and any marvelous experience I might have is my great privilege, not something I'd ever feel responsible for. But one time in 2003, I had a most amazing experience at a labor, and very surprisingly to me, it impacted my life profoundly. It's bizarre to me that those moments caused me to change my life so drastically, but they did.

In 2003, homebirth midwifery had been legal and regulated in Colorado for 10 years. We had gotten a regulatory program up and running, written rules and prosecuted un-licensed midwives. We had been back to the legislature for a "sunset" ritual twice. The "Sunset Hearing" is a regular review of a regulatory statute, scheduled first in 1996 (way too early, imposed as a sort of torture by our opponents) and again in 2001. By 2003 I had to admit it was actually working. The rule of law was interacting functionally, imperfectly, but functionally, with midwifery. The dominating quest of my adult life was completed. While it was happening I had thought that the struggle to change the law against midwifery was my "reason for being here." But after it was done, I began to suspect it had all been some sort of preparation for something else.

I really wanted out of homebirth midwifery's business. I had been at the center of so much drama for so long. I wanted out of the loop. I had retreated into horseback riding to burn off the stress of working in the legislature, and wished that I had more time to think about and learn about horses. Also, I was interested in surgery, but liked the idea of surgery on horses instead of people. So many of the things that I wanted to know about horses are part of that education, I thought maybe I should go to vet school.

Did I really want to be a veterinarian? I have never become disenchanted with the actual practice of midwifery. I enjoy working as a midwife. But I was feeling increasingly different, disconnected from trends and some homebirth practices. I felt that the community was sometimes knee-jerk in its dismissal of beliefs that are considered "medical." The hostility toward medicine was something I could not sustain. I see too much scientific illiteracy. There are plenty of completely factual arguments in favor of homebirth and midwifery. I don't believe that we need to demonize anyone or misspeak to promote our choices and ideas. I fancied veterinary medicine as perhaps less polarized than midwifery and obstetrics.

I decided I needed a change. I took a class to get good GRE scores, worked with a vet, did all the things that might help me be accepted. But I was old for vet school, and I worried that I might be too weird. My undergraduate degree and grades were great, but they were long ago, and then I became a political homebirth midwife. My friend Grant had recently graduated from Colorado State University (CSU), where I applied. He said no possible way would I be accepted the first time I applied. He said (accurately) that I would be offered a "non-admit" interview after being declined, and someone would tell me honestly what my prospects were for the next year. On the night of the labor when I had my paranormal experience, I was waiting to hear whether or not I'd been accepted.

I was at a labor that took quite a while. The mother did push her baby out at home, but the baby's head was in a challenging position, and so the birth took longer than it might have. During the labor the couple was playing some music of Buddhist monks chanting. It was very beautiful, and a little loud. We were up in the wee hours, as midwives and laboring women often are. Where we were in the house found me sitting on some stairs, slightly up and out of her vision, so I could hear her but also give them privacy. She was laboring on one of those exercise balls that some women like. I found myself thinking about my own life, that I still hadn't been notified by CSU about the fall and now it was February. I would know soon, although it was a lot to hope that I would get in the first time I applied.

The monks were gonging away and I was away, somehow, in a different place than the homebirth in Boulder, Colorado. It was not like a dream, it was tactile, I found myself in a different place. The monks were loud, making beautiful music. It seemed that what they did in this place, in this most remarkable but somewhat cold building, was make this celestial music. It seemed very holy there. I am not a Buddhist, I have no way to interpret what I saw, but I was touched in a very deep way by their prayerfulness. It seemed that the chanting had some sort of function, some sort of positive effect and purpose in the world. Their lives looked beautiful and straightforward in a most wonderful way.

The monks were all men. I spoke with a few of them about the place and their lives. We walked around the place. I expressed my admiration for their lives and practice. Then I asked, "where are the women? Where are women doing this work, this prayerful dedication to the world?" They laughed very hard at me and I was back on the stairs. It was not like waking up — I've done plenty of that at labors. It was something different. The parents sitting quietly below me had tears running down their faces, as did I. The loud gonging continued. A baby boy was born the next day. I still wonder who he will be. For me it was clear in the warm and sweet laughter that was the monks' answer: I could have a new project, but it included being a midwife.

In the fall of 2003 I started studying Farsi instead of veterinary medicine. Not very many Afghans speak English, and I was going to Afghanistan. I had gotten a call, an actual phone call. It was a client of mine, someone I had helped have a baby some years before. She called because she was involved with a group of women who wanted to organize to send aid directly to Afghanistan. Specifically, they wanted to send US midwives to train Afghan women to be midwives. She thought I could "be the midwife." Laughing, I told her certainly she'd be wanting more than just one midwife. It felt pretty edgy, but I did have a very strong feeling that this was in fact the call. Afghanistan?

It seems that my client, Judy, has a friend who is also named Jennifer. This Jennifer had spent some important years of her life growing up in Afghanistan. After the US expelled the Taliban, she went back to try to help the completely devastated country. She brought seeds and knowledge to teach widows to garden. The seed project was a success, but the experiences she had there filled her with a determination to send more aid. She was blown away by the visible, obvious need of mothers and babies for healthcare. Things were grim — are grim — in Afghanistan. Jennifer had a homebirth before they were fashionable and was convinced that homebirth midwives are well suited to low-resource situations. She wanted to send midwives to Afghanistan right now!

In 2003, as today, Afghanistan was a war zone. I had never been anywhere like it. I was a good midwife, and a good teacher, in English. But I had no depth of experience to say that I was a qualified foreign aid worker. In fact I was not. But Judy and Jennifer were hooked up with a group of Afghan Americans who went to Afghanistan at least once a year on relief missions. They were emphatic that the regular aid agencies and the government weren't doing anything close enough to address the extreme need and suffering occurring all over the country. The Afghan American group wanted us to come along on their spring 2004 trip and DO SOMETHING for the Afghans. They assured us they were well connected and would provide us with a place to stay, translators, and guidance about where to work, if only we would get supplies together and come with them to Kabul. The Boulder ladies were psyched to raise the funds to send us and to provide support. A grant was drafted. I believe they called it the Midwifery and Infant Care Training Program, which is impossible to shorten to an acronym a person can say. We learned that lesson.

We got some more good help together. My friend Jan, from my battles in the Colorado legislature, agreed to come along to Afghanistan. It was a funny thing to ask a friend to do, but I just knew she would, and she agreed the first time I asked. Carmela, another woman I knew from having helped her have a baby, agreed to provide expertise relative to moving about in developing countries, and about development work in general, as that is the domain of her regular job. This is the story of the birth and growth of a charitable organization devoted to mothers and babies. Many people attribute the majority of this organization's growth to work done by me. In fact, none of what we've accomplished would be possible without this amazing Carmela, who brought a skill set that we could not have lived without.

Not everyone I knew was psyched that I was going to Afghanistan. I was busy learning the language and every other thing that might be helpful. I made lots of progress, but various people in my personal life protested quite loudly. I was able to make contact with some midwives who had been working in Afghanistan, and one in particular was very helpful. We made contact with the Ministry of Health to learn about what programs the government was sanctioning. It turned out that a pilot program was being conducted in Jalalabad, a class of community midwifery students was scheduled to graduate in the spring of 2004. But many of my friends seemed to think that I would surely die in Afghanistan. This seemed a little strange to me. I felt really called to go there. I doubted that God was sending me to Afghanistan to be killed. Also, having lived through a couple of rounds of lymphoma has convinced me that we are not in any way in charge of when we die.

But it's dangerous, for sure. More than for me, or Jan or Carmela, or for those Afghan Americans we traveled with that first time, it's dangerous to be an Afghan and live in Afghanistan. It's one of the most dangerous and difficult places you can live in the 21st century. It's a perilous place to have a baby. Being pregnant, anticipating a pregnancy and birth is an altogether different thing for Afghan women than for my clients in lovely Boulder. Not only is there no assumption that there will be a live baby, it is also a very risky business for the mother. The cauldron of suffering that is Afghanistan is unique and terrifying. Maybe the most terrifying thing about it is that it's happening right now, on the same planet where you sit reading this.

It's tough to know what to do, how to feel. What most people do, the people who live relatively comfortably, is they don't look. Here in America we can look away, but right now in Africa, in Afghanistan, in Haiti, in so very many places on this very same planet you and I are sitting on, innocent people are without safe water and a place to sleep at night. Right this very minute, vast numbers of people are displaced by war. They are suffering right now. They are hungry right now. They are hoping that you care enough to try to help them right now.

In Afghanistan, the current string of conflict began in the 1970s with the Soviets. In the wake of their defeat (a very famous story now, involving US Stinger missiles), civil war raged for years and flattened what was left of the country. Mortars rang out daily, and few structures were spared. Into that vacuum, devoid of civility and peace, came the Taliban. With the social order they imposed came repression, tyranny and terror. When I went to Afghanistan the first time, in the spring of 2004, life expectancy there was 42. They were wrapping up a third decade of war and a seventh year of drought. The schools had been closed since the early 1990s, and women were still getting used to leaving their homes. The young people did not read or write. There was widespread hunger, no power, no running water, no paved roads and no rule of law.

Whatever you might believe about the culpability of the Afghans in what happened to their country (because certainly they'll tell you that all the bad actors are from out of town), Afghan women had no say in these wars. They were victims, pure and simple. Perhaps you have read Mr. Hosseini's A Thousand Splendid Suns. Ann Jones's Kabul in Winter offers outstanding insight into Afghan women's lives. The stories are endless, and they can be numbing, but I believe we must struggle against the numbness. Afghan women have suffered and are suffering through desperate and awful circumstances. These women are fundamentally just like all other human women and their pain is huge. We have the opportunity to act on their behalf, those of us who are not living in fear.

It is almost impossible for me to reconcile our experience of struggle against diseases and injustice in America with the fact that one woman is dying every minute of every day, one woman per minute, because of pregnancy or childbirth. These women are dying in the developing world, from preventable causes. A huge number are in Africa. How many friends do you have who died in childbirth? Can you imagine one in seven, as it would be if you lived in northern Afghanistan? What does "reproductive freedom" mean in an environment where mothers are dying in childbirth on a regular basis?

We went to Afghanistan. We worked in a variety of settings. We did some home care, sort of visiting nurse stuff with a community leader in Kabul, where we also did some family planning workshops with women. We worked in two different Kabul hospitals and got a good sense of what the training programs were looking like. We worked for a couple of weeks at a hospital in Kabul that delivered 80 to 100 babies every 24 hours. It had a surreal quality.

We spent two weeks with women from a village an hour north of Kabul. We discussed their troubles with pregnancy and childbirth and did training in safer practices, things they could do simply and on their own. The village was too far from Kabul to go on foot, and no one had a vehicle. There was no clinic.

We traveled to Bamiyan, known for the enormous, now smashed, stone Buddhas. Bamiyan is one of the two poorest provinces in Afghanistan, and it's the home of the Hezara people, Afghanistan's persecuted minority. The Hezara suffered terribly under the Taliban (a Hezara boy is featured in Mr. Hosseini's The Kite Runner. In Bamiyan everything was smashed or burned: the old commercial district, the Buddha statues, the irrigation canals for the fields, everyone's home.

The fields are full of mines. The people are living in caves, at high altitude in the Himalaya. I got frost bite indoors in Bamiyan, and it was in Bamiyan that we met our destiny. A hospital was being raised out of what was left by a departing NGO. Another big agency had come in to do the job. There was also a plan to get one of the new Community Midwife Training Programs up and running. It was an enormous undertaking, and we were extremely impressed by the people who were doing the planning. They became our contacts in Bamiyan, and ultimately our colleagues.

Twenty-two young women had been recruited from villages all over the rural Province of Bamiyan. They were nominated by their village elders. They were supposed to be able to read and write. They agreed to return to their remote homes to practice midwifery after finishing school. Each came with a husband and children, or a brother, a father or an uncle. All those men needed jobs. The children needed daycare. All twenty-two women came to Bamiyan City to go to school, to the Community Midwife Training Program. Big NGOs, plus USAID had put in a great deal of effort to get the school ready to begin, providing everything necessary to make it work.

However, they were having trouble finding teachers. Most of the groups that do this sort of work were asking for one to three year contracts. Not very many US midwives were interested in living in Afghanistan for one to three years. We talked at length about the possibility of our little group supplying a rotating pool of American nurses and midwives, and maybe even an obstetrician, to provide clinical instruction to the midwifery students. By supervising in the outpatient clinic and the maternity ward, the Americans would also provide a level of quality control with regard to patient care at the hospital. And by rotating a small group of Americans in and out of Bamiyan, no one had to go without a shower for more than two months. The plan was for the students to begin school in late 2004, or for sure by the beginning of 2005.

When we got back to the US, the Afghan Americans we traveled with felt that we had completed a big project. We did do a wide variety of things, and certainly we attended quite a lot of births. But we felt we had only just learned enough to begin something, and wanted very much to make available the instructors for the Community Midwife Training Program in Bamiyan. We could not turn away. The pull to try to put together this huge project was strong. We incorporated, we gave ourselves a name that made a decent acronym (International Midwife Assistance is IMA–Hebrew for "mother"); we applied for 501c3 status. We raised more funds, we recruited midwives and nurses to go to Bamiyan (not easy) and found a permanent translator for the program (tougher still). I became the Program Director, and Carmela the Executive Director.

We worked with that school in Bamiyan until the students graduated in the spring of 2006. All twenty-two graduated, and all twenty-two are working as midwives in Bamiyan Province. One began a women's center in her village. They are all amazing midwives and extraordinary women, working as primary health care providers in a land where very few women have any career at all. And these women perform the back-breaking labor of keeping their homes as well as working as midwives. They carry water along with all the women of Afghanistan.

In Afghanistan I saw the most extreme poverty, much more intense than anything in this country. I met women who any one of us would guess were in their 70s and they were never older then 45. I saw thirsty people drink the filthiest water. I saw women suffer their children freezing to death at night. I met women near death for absolutely preventable reasons. I saw so many, far too many, dead infants. I saw so many gruesome images, pain and loss such as we cannot imagine. But it could surely happen to us too. Innocent people find themselves in a war zone and their lives are almost unimaginable to us. I cannot help thinking of the prisoners in all those German camps in World War Two. Surely they were thinking, someone is coming, someone knows and they are coming to help us, any day it could happen. But I met women who feel completely forgotten. They live in hell and they have no belief that there is any relief in sight.

In 2006 it became too dangerous for us to begin another class in Afghanistan. That was terribly sad, and we hope to return one day. We currently have an amazing project in Uganda. We have become an extremely effective organization because we are small. I believe we represent a possibility of another model of delivering aid, where there is a very high degree of accountability and smaller, better projects. We are creating a community of Americans who are coming together to support our work. We have continued to be funded by private donations alone because we provide birth control which is at odds with current US funding policy.

The problems of the world are vast, and the choices we have in this country are also vast. We have the ability to turn away. We have the ability to find water that is safe to drink in public places. We have all kinds of things we don't realize that we have. How far away does a child have to be for us to decide that it's too far away to help? How many people have to live on less than $1 a day before we decide to devote our lives to real justice? Please visit our website at www.midwifeassist.org to see more about the projects, and consider joining our community of supporters. It's hard to know who to trust, where the money will be spent responsibly, whether or not it makes a difference. International Midwife Assistance is here to make a difference.

 

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