In Paktia, a province in southeastern Afghanistan, a pregnant woman confided to the visiting midwife that she wanted to give birth at the local health center but her family wouldn’t hear of it. “What should I do?” she asked.
Midwife Sema Saboori was at a loss for words. Her education and experience had taught her that a woman who gives birth in a health facility is more likely to survive complications of childbirth. But the tradition in this province is to give birth at home, and an expectant mother does not have the power to negotiate otherwise. Saboori was well aware of the potential consequences if the mother-to-be defied her family.
In Afghanistan, cultural beliefs and practices are strong, women have few to limited rights and violence in the home is a well-kept secret. Saboori felt helpless, asking herself, who was she to interfere?
“I have graduated from midwifery school. However, as a midwife, I work to help women and children in the clinic. I did not know how to empower women to enable them to be sustainable and self-reliant,” she said.
Saboori’s dilemma is not uncommon in Afghanistan, where social conventions consign many women to subservient roles, access to quality health care is often limited, and domestic violence can be a matter of family honor. Leading the U.S. Agency for International Development’s Health Services Support Project (HSSP), Jhpiego, in collaboration with Futures Group International, has worked diligently to assist the government of Afghanistan in its efforts to integrate issues of gender equality and equity across educational and health programs to ensure quality care in basic health services.
In addition to supporting Afghanistan’s Ministry of Public Health to establish a national strategy to develop and implement gender-sensitive programming on a range of health topics, HSSP has also helped the Ministry make its policies and procedures gender equitable. Through this partnership, Jhpiego is building capacity among midwives, doctors and other health providers on gender equity issues to help deliver quality health care and strengthen the health system.
From the curricula developed for the national midwifery education system, to gender-based violence workshops designed for health providers, the Afghan government’s ultimate goal with support from Jhpiego is to improve the quality of health service delivery, which includes the integration of gender-sensitive care. In many areas of Afghanistan, women don’t get the health care they deserve and need because of gender-based societal barriers.
For example, women can only attend health facilities in the case of emergencies, or they must obtain permission from the head of household, or seek no care at all. Young and newly-married women can only seek health care if escorted by a male family member, also known as a mahram. A shortage of skilled female providers means birth complications are poorly-managed, resulting in more women dying during delivery. Without 24-hour maternal health services, women must either travel long distances to seek medical services or settle for less than optimal circumstances in an emergency.
To address such gender-inequity issues, Jhpiego and the Ministry of Public Health have adopted an innovative cross-cutting approach that includes:
- Incorporating gender in the quality assurance process used to improve the quality of health services; so far, 478 health facilities across 21 provinces are implementing gender standards as a part of this process for a stronger healthy system.
- Strengthening midwifery pre-service education to expand the midwifery workforce. Graduates of the country’s national midwifery schools are providing skilled care to women in their communities, and community support helps create an enabling and empowering environment in which a midwife can work effectively. To date, 966 midwives have been trained with Jhpiego’s support.
- Developing community-based interventions that bring services closer to the community and establish a continuum of care from the facility to the household.
- Including a module on gender-based violence in the national pre-service education program for community health nurses, a new cadre of health care provider in Afghanistan.
- Providing gender training to 227 nongovernmental organization staff and health providers.
Saboori is among the scores of Afghan health providers who have attended a gender-based violence workshop led by Futures Group International. Topics covered in the workshop include the human rights of women, sexual and physical abuse, and circles of influence in a family.
At the workshop, Saboori recognized that as a health provider she had a responsibility to help her pregnant client pursue her desire to give birth in a facility with skilled care. She visited the woman’s family and persuaded them to support her decision by explaining the benefits of giving birth in the presence of skilled health care providers and in a health facility, where the mother-to-be would be carefully monitored, reducing the prospects of potentially-fatal complications. It was a conversation in which Saboori used her clinical and leadership skills.
For some participants, the workshop made a difference not just in their professional lives, but in their personal lives as well.
“Before attending gender-based violence training, I used to punish my little son because he cried very often,” said one male participant. “After the training, I realized that punishment is a kind of violence, and it has had a really bad effect on my son. Last night, when my son was crying, I went near him and I made him quiet in a very good way. My wife was really amazed and asked how I changed so much. I told her it was all because of the good lessons I learned during the training.”