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Cablegate: Usg-Trained Midwives Help Combat Afghanistan's Appalling


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1. (U) Summary: In a country with high birth rates and sparse
medical assistance, one in eight Afghan women dies in childbirth.
Afghanistan's maternal and infant health statistics are the second
worst in the world, and it is one of few countries in which women
have a lower life expectancy than men. Doctors are rare in rural
areas and most children are delivered at home. USAID's Community
Midwifery Education Program, in cooperation with the Ministry of
Public Health (MoPH), is working to change these horrible
statistics, training more than 2,000 rural women in maternal health,
childbirth assistance and basic public health and providing
graduates the critical skills they need to save women's and
children's lives in their own remote villages. Selected by their
communities in conjunction with the MoPH, the midwives are the face
of the delivery of critical life-saving services by the Afghan
Government. End summary.

Afghan Women: Early Marriage, Many Children, Early Death
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2. (U) Afghan women are 600 times more likely to die in childbirth
than their North American counterparts - one Afghan mother dies for
every 55 children born. Fifty-seven percent of Afghan women marry
before the legal age of 16, and the average Afghan woman has 6.75
children in her lifetime before dying at age 44. Most will never
receive treatment from a medical doctor - in rural areas, where most
Afghans live, mullahs are the sole medical providers. Mullahs
generally rely on advice passed down through generations, and they
do not deliver children or conduct ob/gyn exams or treatments.
Local midwives often assist births, but they too have no formal

Community Midwifery Education Program
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3. (U) Through the MoPH, USAID's Community Midwifery Education
Program has trained more than 2,000 competent midwives through 12 in
basic obstetrics and gynecology, as well as pre- and antenatal care.
The women are often the most educated person in their rural
districts. All three women who spoke with EconOff September 29 at a
program graduation ceremony in Bamiyan had completed the 12th grade.
Since the program began in 2002, all but one of the two hundred
graduates from the Bamiyan school has returned to her village to
practice. Participants in the Bamiyan program come from several
surrounding provinces. The 18 month program costs $16,000 per year,
per student for trainers, room and board, transportation, child
care, medical tools and follow up to make sure they have the proper
working environment.

4. (U) Most participants in the training program are married, and
their families clearly support their ambition. Each woman
interviewed had her own personal story of maternal mortality - from
lost mothers, sisters, and neighbors, the tragedy was universal. As
participants are in their 20s, many have their own infants who they
can bring with them to the central training location and enroll in
on-site childcare. One graduate said her husband, a mullah,
encouraged her to apply for the program, and added she hopes they
can work together to promote maternal health in their community.

Training Is Just One Challenge
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5. (U) While the training program has tremendous potential to save
the lives of mothers and children, the challenges new midwives face
when they return to their communities are great. Depending on their
location, some graduates work in clinics or local sub-centers of the
Ministry of Health, but few are assigned to hospitals. Several said
the nearest hospital is more than a day's walk from their village,
leaving them on their own in case of emergency. Under Afghan law,
midwives cannot perform cesarean sections.

6. (U) Hemorrhage is the leading cause of maternal death in
Afghanistan. JPAIGO, a USAID implementing partner affiliated with
Johns Hopkins University, conducted a study in which midwives and
health workers provided expectant mothers with misoprostol, a drug
that prevents hemorrhaging if taken immediately after delivery. The
Afghan Government is cautious about using the drug, since it can
also be used to induce abortion, which is illegal in Afghanistan.
However, the study found 45 percent of births result in
hemorrhaging, and that misoprostol dramatically improves chances of
maternal survival.

7. (U) Concern about improper drug use is not unfounded. One
midwife graduate said that when she worked as a health educator in
her village, an expectant mother came to the clinic with
preeclampsia (the third leading cause of death for Afghan mothers
behind obstructed labor). The untrained midwife in the clinic gave
the woman a high dose of labor-inducting drug oxytocin, killing the

baby and almost killing the mother. The graduate said she is glad
she knows more about proper use of drugs after her training.

Saving Lives and Promoting COIN
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8. (SBU) Trained midwives provide a local face to the delivery of
critical governmental services. Due to cultural considerations,
most women do not travel outside of their community for childbirth -
especially to see a male medical professional. In addition to
medical care, the program provides tangible evidence of Afghan
Government support to its citizens. In a country where every woman
knows she is at risk of dying in childbirth, Afghans are more likely
to support a government that helps fight an all-too-personal cause
of death.

9. (SBU) At the September 29 graduation ceremony, both the Bamiyan
Governor Habiba Sorabi and Deputy Minister of Health Faizullah Kakar
thanked the USG for supporting one of the most important programs in
Afghanistan and helping the Afghan Government meet the needs of its
citizens. As several recent polls indicate, Afghans list healthcare
as one of the services they most demand from their government.

10. (SBU) Comment: Midwife education is a low-cost, high-impact
program for Afghanistan's vulnerable rural population. The program
enables motivated women to further their education and support their
families through their profession, creating jobs and opportunities
in extremely poor communities. The program also delivers
much-needed life saving services through the MoPH - thus
demonstrating the Afghan Government's ability to help its citizens.
While Afghans may not see the link between healthcare and
counterinsurgency, they definitely understand the importance of
governmental provision of basic services. The program's importance
should not be overlooked. End comment.


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