March 8 has always been a special day for me and my family – not only is it International Women's Day, it's also my birthday. And throughout my childhood we often celebrated my birthday by attending International Women's Day events. Perhaps that spirit of advocating on behalf of women influenced my career choice as an obstetrician, ensuring that women are able to give birth safely. One of the countries where it is most dangerous to give birth is Afghanistan. There are an estimated 396 maternal deaths for every 100,000 live births in Afghanistan. By comparison, the figure in Australia is 6 maternal deaths for every 100,000 births. Why are Afghani women so much more likely to die during pregnancy and childbirth? During my field placement at Médecins Sans Frontières' maternity hospital in Khost, Afghanistan, I met many women who shed some light on the complex answers to this question. In Afghanistan, two out of every three deliveries occur at home, without any skilled birth attendant. In Khost we frequently saw women who had attempted to deliver at home before coming into the hospital with a complication, such as post-partum haemorrhage. I remember one woman who had delivered at home and then started bleeding profusely. She had been able to access a small amount of care at home, but because it was night time she was unable to travel safely to the hospital. By the time she arrived the next morning she was moribund, completely unresponsive, with a very weak pulse. And despite immediate medical attention she unfortunately passed away. Many women now prefer to come to the hospital to deliver, but it can still be very difficult to access. They often have to travel long distances, and road travel can be extremely dangerous. In many parts of Afghanistan there's very little availability of preventive healthcare and antenatal healthcare, so women and their carers don't always appreciate the danger signs of pregnancy and when they should seek assistance. Another issue is that the women themselves are not usually the decision makers. So even if they think they need medical care, in the end that decision is usually made by their husband and mother-in-law. Plus, women may need a male caretaker to accompany them to hospital and to consent to any surgery or family planning method. In obstetrics, we have a mantra for the risk factors for maternal deaths: "too early, too late, too many and too close together". Sadly all these elements apply in Afghanistan. Afghani women tend to get married and have children early in life, and because they are expected to have a lot of children, they often continue having babies into their 40s. Complications often occur at these two extremes of the age spectrum so our facilities see a lot of women having their first child, and a lot of women who are older, having their ninth or tenth child. On top of that, women often don't have the capacity to space out their births because they can't access family planning, and because they are not in control of decisions around their fertility. Pregnancies that are too close together are risky for mother and baby because the woman's body may not have time to recover – for instance to replace nutrients such as iron, calcium and folate – that are depleted during pregnancy. Although the risks are unacceptably high for women giving birth in Afghanistan, Médecins Sans Frontières' work is making an impact. In places like Khost where there is such a huge need for maternal services, our facility is well respected for the quality of care it provides. Our presence is changing attitudes around where women give birth, and the importance of having a skilled birth attendant. During my placement we held a jirga, a meeting with community leaders, where we discussed the idea that to be an honorable man it's important to bring your wife to hospital to ensure she has a safe delivery. We focus on caring for women with complicated deliveries, who require the high-level care that Médecins Sans Frontières can provide. In 2016 we strengthened our health promotion activities to improve recognition of complications throughout the community, including through radio messaging. We've also worked with private clinics to ensure that women with complications are swiftly referred to our hospital. In all our projects we emphasise teaching and training local doctors and midwives, which is incredibly important because international staff come and go but the local staff stay on. Historically, lack of education of women meant there were few female doctors and midwives to look after women in labour, however culturally many families only seek care from a female. Training local female staff means that we're leaving something positive behind. And as well as training within our facilities, we've also trained midwives in local health centers to improve care of normal deliveries. Just the sheer numbers of babies Médecins Sans Frontières delivers in its four maternity services across Afghanistan makes a huge impact. In 2016, more than 66,000 babies were delivered by our teams in Afghanistan, which equates to more than 180 babies every day. In Khost, approximately one out of every three babies born in the province is delivered in our maternity hospital. There are so many women and babies surviving as a result of Médecins Sans Frontières being in Afghanistan. — Dr Claire Fotheringham is Medical Advisor – Obstetrics & Gynaecology within Médecins Sans Frontières' medical department, providing technical advice both remotely and in the field for Médecins Sans Frontières projects in countries such as Pakistan, Uganda and Yemen.
