Diary of Nabila - a midwife in Afghanistan

International Day of the Midwife 2013 is on Sunday May 5. Take a glimpse into the life of Nabila Gul. She's made her childhood dream of becoming a midwife a reality. Every day she is saving lives and preventing deaths in her village and beyond. 

There is no such thing as a normal day in my line of work. Pregnancies don’t always go to plan - babies turn up when they want and often without warning.

In Afghanistan, many girls start having babies almost annually when they are little older than children themselves. All too often they don’t have easy access to health services. These added risks mean that there is often heartbreak even though a new baby should bring only joy.

Usually, I start work at 8am. I generally see anywhere between 20 to 30 patients in a day, sometimes more.

Kunduz Province is located in northeast Afghanistan. I work in a remote village, separated by 60 km of rough terrain and no road from the nearest hospital. Merlin has a health centre here which provides providing vital healthcare to over 16,000 people.

I am lucky to live and work in the village where I was born. I trained at the Merlin managed Community Midwifery School in Kunduz in 2008 and graduated two years later. The school trains girls and women from rural areas which have few health facilities. Girls like me then go back to their hometown and use their skills in their community.

I wanted to join the medical field ever since I was a child, having grown up in a village with no midwife or doctor.  My family and neighbours always had to travel long distances for healthcare. Now, at the age of 19, I am proud to be the first midwife in my village and to be present 24 hours of the day to serve people who need my assistance.

27 March 2013

Today was a busy day. In total I saw 20 pregnant women for antenatal care, three women for postnatal care and five for family planning. Hours can be very long on days like this as a thorough consultation takes about 20 to 30 minutes per patient.

However long the hours are, antenatal care is vital for women like Bibi Miriam. She has a headache, high blood pressure and most seriously a history of eclampsia. She lost her last baby in childbirth and is extremely anxious to have a safe delivery this time. I tell her that she needs to come back every week so that we can check her blood pressure. This is a challenge for women in remote, mountainous areas. Yet without proper medical care throughout pregnancy she is at serious risk of going through eclampsia – which is life threatening – again.

Mashala is another woman with a high risk pregnancy. She is 45 years old and highly anemic. Her hemoglobin count is 6 – very low. This makes it important for her to have her baby in a hospital or clinic, but she and her husband are very poor. In the past it would have been extremely unlikely that she would have been able to afford the transport costs but Merlin pays these for the most needy families. I gave her 300 Afghanis (£4) for her travel.

28 March 2013

I meet women on a daily basis who have heartbreaking stories. One of the patients I saw today was Gulzada, 22. She was married at the age of seven to a 20-year-old. She has been pregnant six times but only one of her children survived.

Gulzada is now 16 weeks pregnant, and mildly anemic. I am confident that with the right medical attention she will be able to safely have a second child but unfortunately the level of care she needs is only available at a regional hospital in Kunduz – 120 km away. I refer Gulzada for an examination with a gynecologist in the hope that this will make the difference that will enable her next child to survive.

In remote villages like the one that I work in, persuading women to travel long distances takes a lot of hard work. The sheer physical difficulty cannot be understated – especially for a pregnant woman – and many do not leave their homes alone.

Afghanistan desperately needs more midwives to look after countless women like Gulzada. The major hurdle is illiteracy. Partially because of culture, with female teachers in short supply, and partially because of conflict and insecurity, families don’t allow their daughters to go to school. This has huge knock-on consequences for health as it shrinks up the number of women who are qualified to train to be midwives.

31 March 2013

I arrived today to find a woman ready to deliver.  At 11am she gave birth to a baby girl. Shortly afterwards, however, she began to bleed heavily and her blood pressure dropped to 90/60. I was able to stop it but had she been at home, away from skilled medical help this would have been impossible – severe bleeding is another common cause of maternal death in this country. She was discharged early in the afternoon.

When there is an emergency I have to give it all of my attention and deal with only the most critical needs. Sometimes this means women who are here for post natal care or family planning waiting for hours until I am free. Today is was 2 pm by the time I was able to turn my attention to my other patients who had been waiting all morning.

1 April 2013

Today was a particularly busy day with 32 patients, including a delivery. The others were 19 antenatal care, 6 family planning and 6 post natal care cases.

Among of them was a 44 year old woman with post miscarriage hemorrhage. We saw her 22 days after her miscarriage which is too late. She had a history of 15 pregnancies, of which only five children survived.

I gave her medicine and advised her to start using family planning. Women in this part of the world all too often have no say or control over their own bodies. They have very limited access to clinics where they can receive advice about modern methods of family planning, even though this would undoubtedly lead to huge drops in maternal and child mortality.

4 April 2013

I started work at 7:30am today to help a woman in labour. It was thankfully a very normal delivery, with a baby girl arriving at 9am. The clinic was particularly busy today, with 41 patients, but having done this job for two years I am prepared for it. Health education was provided to all of them. Postnatal care and vaccinations were provided where necessary.

6 April 2013

There were 28 patients waiting for me this morning – three suffering from heavy bleeding, five needing family planning, three for postnatal care and 17 antenatal care.

Occasionally, I have to deal with emergencies even when I am not at work. At 7pm a man came to my home saying that his wife had gone into labour but that he did not have a vehicle to bring her to the clinic. He begged me to come with him to his home 5 km away.

By the time I reached their home, she was bleeding and had become highly anemic. Her blood pressure was 80/40 and she was due to deliver in 10 minutes.

Her condition was critical and I wanted to take her to a proper health facility but there was no time. I resolved to do the best that I could and phoned a colleague at the Merlin office in Kunduz. She gave me instructions and talked me through what I needed to do. In a few minutes the patient delivered a baby boy. Soon the baby’s breathing became normal.

Soon afterwards, however, her uterus went into relaxation. Still alone and knowing that this can cause post-partum haemorrhage I tried desperately to stop bleeding by injecting IV fluid and administering Misoprosol. After five minutes she went into shock. Increasingly worried, I gave her another injection of IV fluid and finally she regained consciousness and stopped bleeding at around 11 pm.

Post-partum haemorrhage is extremely dangerous – the world’s leading cause of maternal death. As I went home I could not bear to think about what might have happened had this patient been alone.

Thankfully when I saw her the next day she was making a recovery. Cases like this show how important it is to train midwives to work in remote areas so that no woman is left without skilled medical assistance during pregnancy.