Although I was supposed to start my work in Khost, a town on the Afghani-Pakistani border where MSF runs a maternity hospital, the increased security surrounding the national elections delayed my travels.
In the interim, I was given a temporary post about 20 kilometers east of Kabul’s city center at Ahmed Shababa Hospital. With only seven delivery beds, 11 laboring beds (unlike in the US, women here labor in a different room than where they deliver), and one examination table, the hospital still manages to crank out 1000 deliveries a MONTH average. *Insane* numbers – a real live baby factory!
The national (i.e., Afghani) staff at Ahmed Shah Baba are phenomenal; the first day, I initially started shadowing Dr. Nila, who was gracious, hard-working, energetic, somewhat cowboy, and forever polite, and ended with Dr. Saya, who is more thoughtful, patient, and cautious. In the US, certain personalities are stereotypically attracted to certain medical specialties (e.g., the decisive, reflexive ER doc or the patient, approachable family practitioner), and I’ve been amused to notice that, similarly to US ob-gyns [obstetrician-gynaecologists], the Afghani ob-gyns I’ve met personify many of these same stereotypes. Apparently, some medically typecast roles still cross cultures and international borders.
On my first day, I watched in dazed amazement as fully dilated, actively laboring women waited in the delivery room, rocking back and forth and quietly moaning through contractions. A new mom would eventually vacate one of the seven delivery tables, an ever-present cleaner would quickly wipe away the residual blood and amniotic fluid, and the waiting mom would then climb up to deliver her own baby. Midwives efficiently moved between moms and babies, making sure one was not bleeding too heavily and the other was stimulated and breathing well.
Although the labor room was equipped with a few curtains to maintain at least some semblance of privacy, they were rarely used, and in the delivery room, no curtains were to be found at all. Privacy is all but non-existent. Nor is there any kind of pain control for either labor or delivery; the only analgesic available is lidocaine, used to repair post-delivery tears and episiotomies.
I also saw at least four women at various gestational ages who presented with stories of no fetal movement for the past few days; the quick bedside ultrasounds I performed confirmed that the fetal hearts had stopped beating. Although all such stories are tragic, one woman in particular was devastated. She had three daughters at home, and she came to us with a full-term dead son inside her belly.
We induced her labor, which can be more painful (both physically and psychologically) when the baby is dead, and she howled in agony as her cervix slowly dilated and begged us to perform a C-section. Another patient who was in labor with a healthy pregnancy responded to this poor woman’s cries, and tried to ease her pain by rubbing her back and whispering comforting words to her in-between her own contractions. Prior to coming to the hospital, she had been a complete stranger to the other woman, and yet watching them both labor together, one with a live baby, the other with a dead one, they seemed as if they could be family. Maternity wards in developing countries are raw and unforgiving, yet can also demonstrate such universal kindness and communal sympathy.
After the first woman finally delivered her dead son naturally, she grabbed my hand as I walked by, and through one of the midwife interpreters, sincerely thanked me for my care; I was speechless — how could she even think beyond her own unfathomable loss to feel gratitude for anything? I turned away in order to hide the spontaneous tears.
The second day we were greeted with two neonatal deaths; one full term baby inexplicably died in labor, and the other was either a premature or growth restricted baby who had died while delivering in a breech position (with butt delivering first instead of head). I watched as two adult men towered over this delicate, limp blue baby, trying to resuscitate her; the midwives had quickly brought in screens to protect the modesty of the mother from the male physicians’ presence, but she craned to look around the screen to see her baby.
With each loss, both Afghani and expatriate staff recognize that in wealthier, safer, and more stable countries, many of these babies and moms could have likely been saved. Yet in the face of such seemingly overwhelming and sobering odds, they continue to battle on tirelessly each and every day to achieve the safe and successful delivery of pregnant women in a country with one of the highest maternal mortality rates in the world.