When Afghanistan’s first midwife-led birth centre opened in the impoverished district of Dasht-e-Barchi in western Kabul this year it was a symbol of hope and defiance.
It began receiving expectant mothers in June, just over a year after a devastating attack by gunmen on the maternity wing at the local hospital left 24 people dead, including 16 mothers, a midwife and two young children.
For Zahra Mirzaei, its launch – along with a second birth centre in the east of the capital – marked the culmination of a decade advocating for women’s birth rights.
As president of the Afghan Midwives Association (AMA), Mirzaei was instrumental in establishing the midwife-led units promoting an ethos of respectful, bespoke care away from an over-medicalised setting.
“In our country this approach to pregnant women is groundbreaking and there was a great feeling of hope when we opened our doors,” she says.
“Women who had previously experienced undignified, low quality care in poorly staffed hospitals were pleasantly surprised to discover there is another way of doing things.”
The units in Dasht-e-Barchi and Arzan Qimat were established with technical support and training from the Europe-based Midwifery Unit Network (MUNet) and funding from two NGOs which we cannot name for security reasons.
In the initial weeks the centres, staffed with a total of 75 midwives, were each welcoming 10 to 13 newborns a day. But as word spread, increasing numbers arrived and this soon climbed to 25 to 30.
By late July, Mirzaei was preoccupied with how to manage the rise in cases. But her work was overshadowed by a growing awareness of the Taliban’s military offensive, which had gathered unexpected pace.
News of the Afghan government’s imminent collapse amid the withdrawal of US troops was, to Mirzaei, personally and professionally shattering.
“Suddenly everything I had worked tirelessly for was under threat,” she says. As a Hazara Shia and a longstanding campaigner for women’s rights, the 33-year-old knew she and her three children were at risk.
“Previous Taliban governments have killed thousands of Hazara people without any reason. Also I knew my feminist work and belief in women’s equality would never be accepted by the Taliban regime,” says Mirzaei, who in 2020 was named one of 100 outstanding female nurses, midwives and leaders providing health services in difficult times by Women in Global Health.
As the US and its coalition partners scrambled to airlift thousands of people from the country, warnings were filtering through from Mirzaei’s home town that she was a potential Taliban target.
On the day Kabul fell, plunging the country into turmoil, she left her office for the last time, fleeing in such a hurry she was unable to collect her shoes. “We didn’t expect the situation to escalate so fast,” she says.
Later that night she was woken by the sound of her eight-year-old daughter sobbing: “I went to her and she said: ‘Mummy, I’m scared that when I’m 12 the Taliban will come and take me to get married and I won’t be able to go to school.’ That was so painful to hear that I promised there and then to get us out.”
After calling every contact she could think of, she heard from a friend in the US who could help. Mirzaei left home with her family at 1am on 23 August, still wearing the flimsy slippers in which she’d fled her office.
They spent a harrowing 12 hours waiting in a sewer near the airport before being rescued by US troops and airlifted to Qatar. From there they were transferred to a refugee camp in southern Spain.
Speaking from the Spanish naval base in Rota, Mirzaei explains how leaving Afghanistan also meant, regrettably, stepping down as president of the AMA.
While she was heartbroken to give up the role, she remains a member of the advisory board and is working remotely to support the organisation including her successor – a woman from a different ethnic group who is more likely to be accepted by the regime.
As the eighth girl of 10 siblings, Mirzaei understood from a young age that boys and girls were not seen as equal. “I had two brothers but my father wanted more boys and it made me sad girls were not allowed to reach their full potential in our community.”
Growing up in the province of Sar-e Pol, where poverty was widespread and literacy rates were poor, 16-year-old Mirzaei found education opportunities were limited.
An encounter at the local hospital set her on the path to becoming a midwife. In the waiting room she witnessed a woman desperately searching for a midwife only to be abused by a health worker.
“This incident really affected me – the way they treated her was shameful. When I saw the doctor I asked her what a midwife was and why it was so important.
“I liked the sound of midwifery – it spoke to the feminist in me. That kind doctor changed my life by explaining how I could enrol on a community education midwife programme.”
A year later Mirzaei graduated with a diploma having already joined the AMA as a student. “I was inspired by its plans for improving the profession. For me the most important thing was for women to receive evidence-based, respectful maternity care.”
But starting out as a hospital midwife in 2006 she was concerned by what she saw.
“There would be 150 deliveries a day in a hospital with only four or five midwives. Women would be left to give birth in the corner or in the toilet. The most painful thing was seeing how exhausted the midwives were – they couldn’t support pregnant women emotionally and there was even physical abuse.”
While women in remote areas typically give birth without medical assistance, or sometimes with a midwife, childbirth in urban hospital settings is highly medicalised.
“These facilities are staffed by doctors who don’t seem to know their job description because they are overrun dealing with straightforward births,” says Mirzaei. “The care is dehumanised and the use of hormone drips and episiotomies is routine practice.”
Afghanistan has one of the highest maternal mortality rates in the world, although the number of women dying in childbirth has slowed from 1,450 per 100,000 live births in 2000 to 638 in 2017, according to UN data.
In 2012 Mirzaei became a provincial director for the AMA and later moved to Kabul to coordinate a midwives’ mentorship programme for the organisation.
She joined a small but growing cohort to achieve a BA in midwifery after graduating from Zawul Institute of Higher Education in 2016. Two years later she was elected president of the AMA and made it her mission to establish midwife-led units.
The model would move away from medical interventions towards a focus on active birth, skin-to-skin contact and early breastfeeding.
In 2003 there were just 467 midwives operating in Afghanistan – the severe shortage brought about by the Taliban’s ban on educating girls and women during the preceding years. This figure has since grown to 6,376 currently in clinical practice.
A 2018 Afghanistan Health Survey found just a fifth of pregnant women had received the recommended four antenatal care visits and fewer than 60% of births were overseen by a skilled healthcare professional.
There were 119 attacks by terrorist groups on healthcare facilities in Afghanistan in 2019, according to the World Health Organization. Then in May 2020 came the massacre at the maternity ward of the Dasht-e-Barchi hospital.
Among the dead was a midwife colleague of Mirzaei, Maryam Noorzad. “She was killed because she refused to leave a woman alone in labour. The baby was coming and after it was born a gunman entered and killed all three of them.”
Not only was the attack a horrific crime against pregnant women, babies and hospital staff – it was also a devastating assault on decades of work to reduce maternal and newborn mortality in Afghanistan.
Despite the security fears, the AMA wanted to establish one of the midwife-led units in the same district to plug the gap left by the attack on the hospital, where there had been 16,000 babies born in 2019. Many of the midwives who survived the 2020 attack were among the highly trained staff taken on by the AMA to run the new centres.
The success of the centres relies on one-to-one care and requires numbers to be kept at a manageable level. To meet the demand it was Mirzaei’s ambition to open more units across Kabul and beyond.
But for now, at best, her dream is on hold. The centres closed after the Taliban takeover and while one has recently reopened many staff remain too fearful to go to work. Some midwives have already been interrogated by the Taliban for moving around without a chaperone.
The UN Population Fund (UNFPA) has estimated that without immediate support there could be 51,000 additional maternal deaths between now and 2025.
In Spain, Mirzaei is preparing to fly to the US to start the next chapter of her life. Her immediate future is uncertain but she has accepted an offer to study global maternal health at City, University of London, which she’s had to defer until she can arrange a visa.
“Every day I open my phone and look at photos that were taken at our birth centres. It gives me hope. Their immediate success rests on the wider political situation but we will not cease our efforts to do everything we can for girls and women in Afghanistan.”