The long days of Afghanistan’s midwives

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The country’s midwives fight daily to help the women and children of the nation

“I was initially interested in tribal midwifery in Afghanistan,” Lynzy Billing explains. Billing is an investigative journalist and photographer, working between Afghanistan and Iraq. And her latest project follows Afghan midwives and explores the challenges they face. “In the provinces, many people still don’t have access to basic health clinics, nevermind well-equipped hospitals or health facilities,” she continues. “So they have a village elder or an older woman who assists with the births, and sometimes a midwife will travel out to them. I was really interested in the role of midwives working in hospitals and villages across Afghanistan.”

“In regard to documenting healthcare in the country, I feel that we most often see stories about the surgeons and doctors treating war wounds, which is a common role for doctors in Afghanistan, and of course, a vitally important one, but I wanted to also highlight the work of the country’s dedicated midwives who work around the clock to ensure the safety of women and babies, ” Billing continues. Only a small per cent of the photojournalists working in the country are women, and so access to maternity wards is not possible for most. 

Billing travelled to six health facilities across Afghanistan over the past two years. The images, featured below, document the ICRC-supported maternity ward at Mirwais Hospital in Kandahar city, southern Afghanistan. This is the busiest maternity ward in the country, delivering as many as 90 babies a day. “I was told by hospital staff and NGOs working in the area that the midwives wouldn’t talk to me because they are very conservative in Kandahar,” Billing explains. However, she was able to collaborate with the entire ward, spending days and nights interviewing midwives and patients, and documenting them at work.

© Lynzy Billing.

Amid the Covid-19 pandemic and America’s military drawdown, Afghanistan risks becoming a distant memory on the international agenda. Since 2001, international donor funding has led to crucial improvements in health access in Afghanistan. However, the amount of funding pledged by donors at the Afghanistan Conference in Geneva in November 2020 fell by three billion dollars compared to the previous four years. The drop could mean reduced funding for NGO-run hospitals and health programmes on the ground in an already overstretched healthcare system.

“It’s a pretty bleak future, particularly for hospitals and health facilities that are in rural areas, because all of their support comes from international donors,” Billing explains.

© Lynzy Billing.

With reduced support from NGOs and international medical professionals, Afghan midwives and hospitals stand to suffer a further lack in equipment, medicine and financial support, while facing escalating violence and security concerns, with insurgent attacks targeting health facilities, maternity wards and midwives. On May 12, for instance, militants attacked a maternity ward at Dasht-e-Barchi Hospital in Kabul and killed 24 people, including 16 mothers, two newborns, and one midwife. More than 20 people, including babies, were injured. In the wake of the attack, Médecins Sans Frontières, which ran the maternity ward, decided to cease operations and withdraw from the hospital—leaving women in the area without emergency obstetric care. “International staff can leave the country, but Afghan midwives still feel that they have to go to work the next day because life goes on, this is their home and this is their job,” says Billing.

“I want people to know that these women are facing battles on so many fronts in Afghanistan from a lack of resources and equipment to a lack of security and now a pandemic. But they continue their work for their people. And they really want people outside of Afghanistan to know that they’re still working despite the difficulties of their situations, and they don’t want the international community to take their eyes off Afghanistan.”

The future of Afghanistan’s maternal healthcare is at the heart of Billing’s project. “If Afghan women can’t reach hospitals, then they will go back to giving birth at home. The danger of this is huge. For decades, the country has battled one of the highest infant and maternal mortality rates in the world, particularly in rural areas. The country has only just managed to bring this number down by the increasing presence of midwives, and improving a mother’s and baby’s chance of survival with more women giving birth in a hospital,” Billing continues. 

“Every midwife I spoke with feels very strongly that they must continue their work supporting Afghan women. Their patients need them and they are committed to helping their community because if they don’t, no one else will.”

Sitara Habibi, 35

Portrait of 35 year old Satara from Kandaharr has been working as a midwife in Mirwais hospital in Kandahar, Afghanistan for seven years.

“It was my choice to be a midwife, and my family wanted me to [be one] as well. According to them, it’s the best profession to serve the women of my community.

“It’s completely different in Afghanistan in comparison to other countries, things don’t go according to the standards here. One midwife has to attend four or five deliveries at a time, but in other countries, there is sometimes one midwife for one mother. I wish I could have that, to give more attention to each mother. But here we can’t apply those rules because there are so many patients and there is such a lack of space and time.

“Over the past five years, the number of patients has increased, and their expectations have also. Women from across Kandahar heard that we have a delivery ward, and now they all come here. Some travel for days and spend all the money they have to come. When they come, their whole family comes too, each with their own health problems. They want the midwife to treat each family member, but there is only so much that we can do with so few staff.

“The men also need to be aware of family planning. Talking to them directly about it wouldn’t be appropriate for them or for us. If there is something specific that we can’t say here, like telling her to avoid sleeping with her husband for a certain period of time, we tell the woman discreetly and then advise the patient to convey it to her husband later. In this way, we often need to go through the women to educate the men.”

Mazia Azimi, 30

© Lynzy Billing.

“I studied at the only government institute in Kandahar teaching midwifery. I decided to be a midwife because in the place we were living, there was no doctor to check up on women.

“There have been a lot of changes in these last eight years, we have a lot more patients now in the delivery ward than before. We used to have 50 to 70 patients, but now in 24 hours, we have 200 to 250 patients. Right now in our hospital, every 24 hours, mothers deliver 80 to 90 babies.

“Some women still give birth at home because the hospital is far away and there is no transportation. But, with home deliveries, complications like haemorrhaging are common, and many women and babies die. These complications could be easily addressed if these women were giving birth here at the hospital.

“When I was a student and I would leave my house, people in the village would talk about me behind my back, saying ‘look at her, always going out’. They weren’t aware where I was going, but when they came to the hospital and saw that I was helping their wife for delivery, their perceptions changed.

“Our country is very different compared to other countries. Last year a woman had anaemia and was pregnant for three months and bleeding. The doctors wanted to treat the patient but even though her husband and her family also agreed, the patient herself did not agree to do this. The husband took her out of the hospital. After two years they came back and they did the treatment, and she was transfused one unit of blood and the patient was cured. For us [midwives], we have to have their permission before we can perform any procedure. Even if it takes two years before they agree. Unfortunately, this is the way things are here.”

Isaac Huxtable

Isaac Huxtable joined the British Journal of Photography in October 2020, where he is currently the Editorial Assistant. Prior to this, he studied a BA in History of Art at the Courtauld Instititue of Art, London.