The call startled me; I jumped up searching for the handheld radio. “Balay?” (Yes) I quickly switched into the local language. The nurse's static reply came over the radio. She told me there was a woman, 9 months pregnant, who had come to the hospital with a prolapsed umbilical cord. My heart sank. At this time of night she had most likely walked or come on a donkey several hours to reach this remote hospital.
I hurriedly radioed the visiting midwife. I had traveled to the highlands of Central Asia to work in a small 21-bed hospital for 3 weeks for a short-term assignment. My husband and I had lived and worked for the last 3 years as international aid workers in another part of Afghanistan.
In the northern city in which we lived, I volunteered twice weekly at the local hospital and nursing school, helping student nurses get better hands-on clinical experiences. The government-run hospital had problems with staffing, low supplies, and corruption. Despite these issues it was extremely worthwhile to invest in the country's future nurses. For the moment though, it was a pleasure working at this mission hospital where I could always find gloves, the medicines were current, and there were places to wash your hands. Until the urgent phone call, I had been thoroughly enjoying my experience.
During my 3 weeks at the mission hospital, I happily worked almost day and night. As an RN, I taught continuing-education courses with the local Afghan nurses, basic first aid and care plan development to student nurses, assisted at the clinic and the hospital, and acted as a translator and staff nurse for a visiting midwife who didn't speak the local language. The last role led me to the unsettling phone call.
The call came around 10 p.m. The stars shone brightly that cold, crisp, March night as Grace* met me and we started our short journey to the hospital. In this more remote area light pollution was nonexistent. I've found that the stars always have a profound effect on me. That night they seemed to whisper, “Remember you are not alone, the One who created you is with you in all circumstances.” I sensed God guiding me in the dark. Grace, the midwife, and I briskly walked about 10 minutes, keeping our eyes open for stray dogs and holes in the ground. I silently prayed God would give me the strength to deal with what seemed inevitably, a bad situation.
At the time, I was 5 months pregnant and I didn't know if I could deal with seeing a full-term stillborn baby. I had been dreading this exact situation since I had arrived and received my assignments. I knew these women lived hard lives and home births were common. Women typically only came to the hospital when things had gone wrong and it was too late for a good outcome.
We arrived at the hospital, quickly removed our coats, washed our hands, put on gloves, and entered the woman's room. As I opened the door the heat of the room hit me. My eyes locked with a young girl who was no older than 18. Her eyes reflected fear, bewilderment, and pain. Two older women, probably relatives, huddled in the corner hiding behind their headscarves. They seemed afraid to touch the young woman. I felt certain these older women were no strangers to tragic births. Though the statistics have improved greatly within the last 10 years with the initiation of a basic package of health, the Afghanistan infant and maternal mortality rates are far from normal.
MATERNAL INFANT MORTALITY
The 2010 Afghanistan Mortality Survey (AMS, 2010) found that from 2003 to 2010 the percentage of women using antenatal care rose from 48% to 58% across the country. Those using a trained birth attendant or midwife in rural areas during the antenatal period rose from 8% in the early 2000s to 54% (AMS, 2010). Afghanistan is a mountainous country where infrastructure has been developed over the past 10 years, but the challenge to get midwives into remote locations and facilities to serve rural populations remains a difficult endeavor. Many midwifes don't want to leave their families and live in a remote area, and many of the rural areas don't have educational facilities through 12th grade, making it difficult to train women to serve their own communities.
In addition, education and training needs to be available at the community level for pregnant women to understand the importance of seeing a midwife or physician during their antenatal period. In the AMS survey, lack of money and distance to a birthing center or clinic were two of the greatest barriers identified for why women did not receive care during their last pregnancy. In addition, 4 out of 10 women surveyed who did not receive any antenatal care with their last pregnancy, cited that they thought care was unnecessary (AMS, 2010).
It is estimated that for every 1,000 live births between 3 and 5 women are still dying in childbirth (AMS, 2010). The AMS also estimated that the lifetime risk of pregnancy related death is five times higher in rural areas than in urban areas (AMS, 2010). The World Health Organization's (WHO) 2008 statistic rated the infant mortality rate to be 73 per 1,000 live births (WHO, 2008). Unfortunately, given the statistics, the situation facing this young woman during delivery is not uncommon.
The midwife quickly asked questions as I translated, took the woman's blood pressure, and gathered the necessary equipment. We could see that the baby's head was already crowning so there was nothing to do but have her continue to push as our eyes fell on the umbilical cord, blue and lifeless.
A beautiful stillborn boy was born minutes later. We tried to resuscitate him, but nothing could be done. This was her first child. The two older women who accompanied the young mother made a motion to grab the baby Grace had carefully wrapped in a white cloth. The women wanted to whisk the baby away before the mom could see him.
Tension mounted. The young mother was reaching out for her child, begging to see him, to hold him. I didn't want this girl to wonder for the rest of her life what her child had looked like. She had carried him for 9 months, loving and thinking about being a mother. Though this wasn't how it was supposed to be, she deserved to hold her child.
God gave me strength to say, “No, she must see her baby!” As I handed the young mother her baby boy tears came, then her whole body rocked with the force of her sobs. She sobbed and sobbed, clutching her child to her breast. I could only pray while rubbing her back, asking God to begin healing as she saw and held her stillborn son. Time passed and finally her sobs quieted as she lovingly stroked his tiny face. Then she was able to release him to her relatives.
Here there would be no funeral for a child who had never lived. Within the day, he would be slipped into an unmarked grave, just as this woman would slip out of my life, back to her village. I prayed that time would heal her pain, and that our gracious God would comfort her and someday bless her with another child. There was no medical reason why she wouldn't be able to deliver a healthy baby in the future. A prolapsed cord is one of those tragic accidents that can happen during the birthing process. An immediate Cesarean section would have been performed if she had been in the hospital during delivery, saving the life of her son.
Later, the young woman fell into an exhausted sleep. The next morning she was ready to be discharged and return to her village. The midwife and I discussed with her what had gone wrong with her birth and why the baby had died. We were able to help her identify the closest clinic with a community health worker that she could visit for follow-up in the coming weeks and monthly check-ups during her next pregnancy. We emphasized the need to deliver at a facility with a trained health worker for her next birth.
MAKING A DIFFERENCE
This incident has made a lasting impression. For a brief moment my life intertwined with a grieving mother from the highlands of Central Asia, where I believe that the God who lives inside of me chose me to be an instrument of his love. The profession of nursing, partnered with our faith, provides many opportunities to reach out and extend healing and hope.
As nurses, we are aware of global health needs and the tragedy that befalls women worldwide. Certainly we should not overlook the need to be advocates for women's and infant health in our communities. But as Christ-followers we are called to look beyond our own communities. Worldwide, during the 20th century pregnancy and childbirth killed more than tuberculosis, suicide, traffic accidents, and AIDS combined (WHO, 2012). Half of all women in developing countries don't have a skilled birth attendant present during delivery, which contributes greatly to maternal infant mortality (WHO, 2012). What can nurses do to make a difference?
Many Christian denominations have global outreach programs addressing maternal, infant, and child health. These programs address things like antenatal care, nutrition, oral rehydration, growth monitoring, and immunizations for women, infants, and children. Christian nurses can support and promote these outreach programs, as well as consider donating personal time and expertise.
The Daring, Caring, and Sharing Nightingale Initiative for Global Health (NIGH) is a grass roots organization raising awareness of this problem based on the United Nations millennium development goals. NIGH's mission is to inform and empower nurses and other healthcare workers and educators to become “21st Century Nightingales” working in local, national, and global communities to make health a top priority through mobilizing public opinion and building a healthy world. Another initiative focusing on women's health is, Save the Mothers, an international organization that equips healthcare professionals in developing countries to improve the health of mothers and babies and work to overcome preventable maternal death.
Being aware and having an open heart to impact the world are the first steps toward lasting and lifesaving changes. My hope and prayer is that women worldwide will not have to experience what this young mother experienced that cold night in Afghanistan.
Afghan Public Health Institute, Ministry of Public Health (APHI/MoPH) [Afghanistan
], Central Statistics Organization (CSO) [Afghanistan
], ICF Macro, Indian Institute of Health Management Research (IIHMR) [India], & World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO) [Egypt]. (2011). Afghanistan Mortality Survey 2010
. Calverton, MD: APHI/MoPH, CSO, ICF Macro, IIHMR and WHO/EMRO. Retrieved from http://www.measuredhs.com/pubs/pdf/FR248/FR248.pdf
* Name changed to protect anonymity.
Keywords:© 2014 by InterVarsity Christian Fellowship
Afghanistan; global health; infant mortality; nursing; pregnancy; prenatal care