Stories from Afghanistan

I am frequently asked what my favorite country to work in has been, so far. When I am on mission, that place is usually my favorite place. I become immersed in every aspect of the work, country, and community. For me, the only way to get through months in a difficult context is just immerse and move in. I must embrace every aspect of the experience from the weather, food, living conditions, language and security, to the communication issues, workload, and of course, the tragedies; it is the only way I mange to get through some days. Some contexts are far more difficult than others, that is for certain. Still, when I am asked about my favorite place, I am usually between missions back home. Without hesitation, I respond, “Afghanistan”. People’s eyebrows shoot up, heads tilt, they respond in astonishment, “really?”, almost without fail.

Yes, really. I love Afghanistan. It is a brutal place, which is what most people imagine when they envision Afghanistan. But it is also ancient and beautiful, an ethereal beauty that almost escapes words. My only experience of the country itself, aside from what was outside my bedroom window, was the trip from Kabul to the mission and from the mission back to Kabul to go home. So, all I know of it, I know from a moving vehicle and my bedroom window. I fell in love, nonetheless.

Afghanistan is an Islamic Republic, which means that just prior to landing in Kabul, I had to get out my hijab and cover my head, it is the law. I was already wearing clothes which covered my arms and legs, also required. Kabul is, I suppose, what most people think of when they envision Afghanistan. And indeed, Kabul is a loud, over crowded city with helicopters whirling overhead like enormous dragon flies and the occasional explosion heard in the distance. Brutal. The traffic is awful, like any other large city. But its one redeeming quality is the beautiful Hindu Kush, jutting majestically out from the horizon. The Hindu Kush is a 500 mile stretch of mountains that run through Afghanistan, Pakistan and into Tajikistan.

Once out of Kabul, the terrain opens to a vast expanse of rocky topography and qal’ahs, the traditional mud houses that litter the countryside. The houses blend into their surroundings and look like part of the mountainside which makes for quite a remarkable effect.

I loved looking out my bedroom window or sitting out on the rooftop porch at our house and looking around at the seemingly endless expanse of mountains. I would never mistake these for mountains anywhere else, they have there own unique essence. And one must not be fooled by their rugged, bare terrain, they hide a secret. Emeralds. It delighted me to look at those mountains and know I was surrounded by a vast fortune in gems.

We were not allowed to post on social media for security reasons, so I never wrote a blog or posted about my experiences like I do now. As mentioned before, we were not allowed to go anywhere outside the compound other than next door to the hospital and we were accompanied there and back.

Here is an excerpt of what I wrote to a friend at about 2 months in: I am tired most of the time. My head hurts most of the time. It may be altitude, it may be stress. We attend 600 to 700 births a month. Everything and anything. Name a complication. Name a disorder or a malformation or birth defect. They have it all many times over. Meconium and hemorrhage, every day. Breech and twins many times a week. Last month about 26 breeches and 10 sets of twins. We don’t count the breeches that are with the twin births in our breech tally. Breeches come every which way and by now I have done and seen it all!

Here is what I remember: Cord prolapse, cord presentations, molar pregnancies, uterine rupture, uterine inversion, placenta previa, acreta, percreta, bicornuate uterus, polyhydramnios, oligohydramnios, chorioamnionitis, preterm, PROM, PPROM, retained placenta, abrupted placentas, obstructed labor, severe shoulder dystocia, breech extractions, interlocking twins, cervical head entrapment. Gestational hypertension, gestational diabetes, gestational trophoblastic disease, choriocarcinoma. Diabetes, fatty liver disease of pregnancy, HELLP, pre-eclampsia, eclampsia. Anencephally, hydrocephally, dwarfism, spina bifida, limb malformations, IUGR, LGA, severe post-term, and 20 week babies born that live for over an hour outside the uterus. Ectopic pregnancies, early and late miscarriages, missed abortions with hemorrhage, grand parity over 8, 10, 12, severe anemia that need transfusions. Then the babies that just fall out, cry, followed by their placentas and no bleeding. Dozens of those per week. I am only called for the high risk.

The Afghan women are simply stunning. I wish it had been appropriate to take their photos. The combination of dark skin and green eyes make it difficult to look away. If you have seen the photo of the 12 year old Afghan orphan, Sharbat Gula on the 1985 National Geographic cover, you know what I am referring to. I realized then that she was not at all unique. There were a host of people with the piercing green eyes all over South Asia and many of them came through our maternity.

In Afghanistan, as in many Muslim majority countries, women cannot make healthcare decision for themselves. They cannot really make any decisions for themselves. This means, we cannot treat a patient that comes in if we do not first have the permission of a male family member. Usually this is the husband but in his absence, it can be the father, brother, uncle or even sometimes a son – even a son who is still a minor can give authorization but a woman cannot. Even if the woman’s life is in immediate danger, staff has to run around looking for a male relative to put a thumb print on the paper authorizing us to treat.

The maternity is staffed with 6 to 8 national staff midwives during the day. A little less at night. It was these midwives that I supervised. The majority of them were in their early to mid 20’s. Most had attended thousands of births. They had excellent clinical skills and were always eager to learn more.

My Afghanistan assignment has been the only time as a midwife where I could see a baby being born almost any time I wanted because we had such a high volume of patients. I would arrive at the maternity at 7:30 each morning and start my day by going into the area with the birth rooms. Usually there was someone giving birth and sometimes even more than one. I would stand quietly by and watch, just to see new life at the beginning of the day, knowing that the rest of the day could well bring anything with it and not necessarily good things. I would congratulate the mother and then join the rest of the team on rounds.

A non-pregnant woman came in one day and it was very apparent she was quite ill, close to death actually. She was pale, weak and severely underweight and we admitted her into the ICU after an initial evaluation which showed a hemoglobin of 2 (we would expect it to be more like 12). We started a blood transfusion immediately.

A full patient history was taken and a story emerged. The patient was in her early 30’s and had been married over a decade and had no children. After a few years of infertility, her husband took another wife (it is common to have multiple wives in Afghanistan) and that wife produced children. Infertility is a shame upon the family of the woman, because they were paid a lot of money by the husbands family, so it is seen as a kind of reneging. Another wife was taken a few years later and more children came along. In the meantime, the patient was relegated to the role of a servant. She did the chores, cooked, took care of children with the other wives but she was also not fed adequately. Food scarcity is fairly widespread in many parts of Afghanistan. When there is food, the men always eat first, then the children, then the women. This woman was the very last in the pecking order. She was unable to produce offspring and in Afghan culture, if you cannot bear children, you have no value. They ignored her suffering for a long time and so it wasn’t until she was very close to death that they brought her for medical care. Keep in mind, the care is FREE. They were not trying to get out of paying for treatment, they just didn’t care.

Eventually she began to feel better after several units of blood. We kept her for a few days while she gained some strength back and then she was discharged. I often wonder what has become of her since her situation is not likely to change.

It was not uncommon for us to see girls as young as 12 come into the maternity hospital. Families will marry off their daughters if they are in need of money and find someone willing to pay the bride price. As you can imagine, these girls are terrified and barely understand what is happening to them. They have all suffered trauma just by virtue of the fact they were married off at such a young age, some to much older men. We also saw cases of extreme sexual violence of girls and women brought in within a day of their wedding. Most often the violence was caused by the mother-in-law of the bride, making an incision, basically an episiotomy, to make sure the marriage was consummated. Most of the damage was severe enough that it required general anesthesia for the surgical repair. It was the humane thing to do.

We had many multiples born each month. They came in every presentation imaginable and most of them were vaginal births because we did not do Caesarean’s routinely. Presentation of the twins was not a deciding factor as to whether the birth would be vaginal or not. If there was a failure to progress or an arrest of descent and it was clear these babies were not going to be born vaginally, then we would refer for a c-section just as with a vertex presentation. So when we had a breech/vertex presenting set of twins, we proceeded as usual although many providers would risk that combination out. I experienced 3 such sets during my time there. It is one of the more uncommon twin presentations. All 3 sets were term. Two proceeded without any issue and the third I determined was likely to have an issue because the babies were facing each other. Those babies did become locked as the first one descended but I was able to manage and I will write about that birth in a separate post.

Afghanistan is a multiethnic and mostly tribal society. Dari and Pashto are the official languages and are fairly widely spoken but there are other languages and dialects in different regions of the country that are spoken by different tribes. There were times in maternity when the staff didn’t understand the patient because they didn’t speak a language familiar to anyone on staff. So sometimes, if there was a younger family member available, we would bring them in to interpret because they usually spoke Dari or Farsi. This happen mostly with the Kuchi people. They are nomads but there are many different tribes. Kuchi actually means nomad.

The Kuchi women were incredible. They would come in in these incredible clothes, layers of skirts, headdress, cloth and blouses adorned with elaborate beadwork, sequins and ornate embroidery. Their jewelry was equally impressive with a multitude of necklaces, heavy dangling earrings, nose jewels, rings and exquisite glass bracelets. They made noise when they moved due to all the adornments. They have marks on their faces called khals. The women have been doing pin and ink tattoos like this for centuries. It is believe to be pre-Islamic. They are rites of passage. All the women looked like they had just walked off of a movie set. I marveled each and every time one came in and the staff found this amusing.

Because of their nomadic lifestyle, they are very hearty. The woman are stoic and strong. They make not a peep during labor or birth. The Italian obstetrician on staff who had been there for 11 years said, “you will never see a Kochi woman have a c-section unless it is for something like an abrupted placenta, an emergency. But never for obstructed labor or failure to progress or CPD. Never.” And she was correct, no Kuchi woman ever had a c-section during my tenure there.

I remember vividly an older woman coming in with preterm labor. Her baby was about 20 weeks from what I recall. She had several children already and would birth this tiny preterm baby with no difficulty. We did not know why she went into preterm labor but I did know the baby was still alive, just not viable. Whenever we had someone who was going to birth a preterm, non-viable baby and I was on shift, I always asked to do it. The midwives were perfectly capable of managing but I knew they would be more matter of fact and less compassionate because that is just their way. It is a very busy maternity. There was always a staff midwife with me because we worked in pairs and they were there to learn.

I noticed when they attended preterm births of non-viable babies or stillbirths, they severed the umbilical cord and put the baby to the side for the cleaner to wrap in muslin and take to the morgue and later give to the family for burial. Then they would turn their attention to the mother and the placenta. And that was that. I asked them if they asked the mother if she wanted to hold her baby. They dismissed that notion. They always said the mother didn’t want to. But I then I would say, “the question was, did you ask her? No, they had not. So I explained to them that they should not just assume the mother doesn’t want to hold the baby, they need to ask because even if most do not want to hold their baby, some will, don’t assume. Sure enough, when they asked, some of the mothers did indeed want to hold their stillborn babies briefly.

Some of these non-viable preterm babies actually came out alive and the midwives treated them the same as a stillbirth – they wrapped them up as though they were already dead and put them off to the side to be taken away by the cleaner to the morgue. Horrified and indignant, I explained to them they couldn’t do that! This was a living, breathing human being and although his time here with us would be short, he deserved to be treated with kindness and compassion, not be shoved off in a corner to die alone. The midwives would nod their heads, not really understanding this kind of reasoning but if I was on the unit, they would listen to me.

So it came to pass that when I was working, I held many a non-viable preterm baby, wrapped in a blanket, close to my heart so that they did not have to die alone. So they knew they were safe during those first minutes and last minutes of their lives. I don’t know how many times I did this, but it was a lot. No one should die alone.

When the older woman in preterm labor gave birth, her baby moved, made little crying sounds and fought valiantly to try to stay as long as possible with us. At 20 weeks, it would not be long. I asked the midwife to ask the mother if she would like to hold him. I told them to explain to her there was no possible way he was going to survive for long but he was alive right now. She wanted her baby. I wrapped his tiny little perfect body up in a much too large for him blanket and handed him to her. She cooed at him all while we removed her placenta and cleaned her up. Then it was time to go to postpartum. But women who lost babies were put in the general medical/post-op room so they didn’t need to be with all the mother with babies, adding insult to injury.

We moved her and her tiny little boy whom she cradled closely, seeming to not see anyone else in the world during that time. She cooed over and over, “joon, joon”, at him. Joon can mean ‘life’ or ‘dear’ in Farsi. Over and over I could hear her as I moved through the ward. I kept going back every few minutes to put a finger on his chest to check for a heartbeat and every time, there it was. I was astonished. I could not believe how long this baby was able to survive with nothing supporting him at all, except the love of his mother.

The OB residents came into the ward to check on someone else and asked what was going on. I explained about the 22 week baby, his birth and that his mother wanted to hold him. The one resident smiled at me in a mocking way thinking this was the most ridiculous thing she had ever heard. She didn’t believe the baby was even still alive. She peered into the blanket and felt the heartbeat and then rolled her eyes. She told me the baby was not going to live. I told her I knew that and the mother knew that but that he was alive now and she wanted to hold him and so she was! Finally the resident took her judgement and moved on.

I stayed by that mother so that no one could disturb her or her little joon. I stayed until at last I felt no heartbeat and I told the mother. She abruptly handed him to me then and I took him away as she wept quietly in the ward. I prepared his tiny body which consisted of wrapping him in white muslin and tying it all up like a package. He would then be given to waiting family to take home for burial, which would happen very quickly. He had lived an entire hour!

My months in Afghanistan had a profound impact on my work and life. It was difficult, heartbreaking and beautiful. I am forever changed by it in ways I cannot even begin to articulate. I have enough stories from that time to fill a book, but I have decided it is better to space them out in multiple posts over a few weeks. It is a lot for me to dig up and process and I find it somewhat overwhelming. Still, I would go back in a heartbeat. Afghanistan challenged me to my very core and I have immense gratitude for that experience.