The First 28 Days of Essential Care

In northwestern Afghanistan, 35-year-old Fatima traveled to the Injil town health center in the middle of the COVID-19 pandemic. She was pregnant with her seventh child and new to the area after being forced to flee her home in the Farah province due to conflict. When she arrived at the health center, Fatima was greeted by the friendly face of Muzhda Rasooli, a midwife suited up in protective gear from head-to-toe. Despite the ongoing pandemic, Muzhda was equipped with the knowledge and skills to deliver quality care.

Over the past two decades, the global community has made great strides in child survival, investing in basic, evidence-based interventions to prevent children under 5 from dying from preventable diseases, such as diarrhea, malaria, and pneumonia. Tragically, improvements in the prevention of newborn deaths have significantly lagged behind improvements in child health, with newborn deaths making up nearly half of all deaths of children under 5.

The three main causes of newborn death (prematurity, intrapartum and birth complications, and neonatal infections) are mostly preventable through high coverage of cost-effective, low-tech maternal and newborn health interventions. The COVID-19 pandemic threatens to derail progress made for mothers and newborns, especially regarding facility-based deliveries with skilled birth attendants, essential newborn care, early and exclusive breastfeeding, and care during the most vulnerable period in a child’s life — the first 28 days.

“There is no doubt that COVID-19 makes the situation more stressful for everyone,” Muzhda said of the labor and delivery services provided at the Injil Comprehensive Health Center (CHC) in Herat province where she works. “But I keep motivating everyone to work without any delay and provide the services to mothers and newborns.”

Muzhda and the three other midwives with whom she works received training and mentorship from USAID’s Helping Mothers and Children Thrive (HEMAYAT), a program that has prepared them to remain resilient, resourceful, and capable of boldly meeting new challenges. Since October 2017, HEMAYAT has focused on reducing maternal and newborn mortality across five hubs — Balkh, Herat, Kabul, Kandahar, and Nangarhar — that account for approximately 40 percent of the country’s population and contain the country’s major urban centers.

Since the start of the coronavirus outbreak, more women have been coming to the Injil Comprehensive Health Center to give birth because of its location in the highly-populated area of Herat. Government mandates to stay home, transportation challenges, and continuing security concerns limit their ability to travel to health facilities further away. The midwives at Injil CHC are supporting three to four births a day, and continuing to promote simple, high-impact behaviors like skin-to-skin contact between mother and baby, and early and exclusive breastfeeding for newborns.

All new moms and families are made aware of the health center’s infection prevention and control measures before receiving care. Families are provided with proper handwashing instructions, directives to wear masks, safe cough practices, social distancing requirements, and most importantly, reminders to stay home and not leave unnecessarily.

“Once the mothers enter the CHC, they stand in the open area of CHC and keep the social distance about two meters from one another and we reach out to them individually,” Muzhda explained.

Despite significant progress over the last few decades, maternal and child mortality rates in Afghanistan remain dangerously high; in 2019 there were approximately 31.1 neonatal deaths per 1,000 live births, 57.4 under-5 deaths per 1,000 live births, and 552 maternal deaths per 100,000 live births.

Skilled birth attendants, including trained nurse-midwives, or “kabilaha” as they are called in Afghanistan, play an instrumental role in preventing these deaths — which is why USAID and its partners are working to establish trained midwifery as a profession worthy of support and respect. Since 2012, USAID has invested $667 million in preventing child and maternal deaths in Afghanistan. These investments provide support to health facilities experiencing high volumes of births and deaths, elevate the role of midwives through mentorship focused on health system resilience, and bolster new partnerships and data collection for improved cooperation and analysis of results.

Many of the existing programs for both the midwives and the mothers in their care have been adapted to function remotely to reduce the risk of coronavirus transmission. For example, messages from group prenatal care sessions are provided over the phone to mothers who can no longer attend the socially distant meetings in-person. Thoughtful changes like these have helped enhance women’s experiences and quality of prenatal care to create stronger, more trusting, and mutually respectful relationships between women and midwives, thereby improving care seeking by pregnant women.

HEMAYAT has prepared more than 665 members of the Afghan Midwives Association to provide care during COVID-19 and to mitigate its potential impact on pregnant women, mothers, and newborns. Through the association, HEMAYAT provided tailored resources for members focused on infection prevention and control, including virtual training, learning materials, and a WhatsApp group.

Recognizing the vulnerability of preterm babies during the pandemic, HEMAYAT programming this year also included technical forums and learning sessions focused on essential care for small babies, partnerships to increase data collection around preterm births, and efforts to help health centers better calculate the gestational age of mothers during prenatal care and labor.

Muzhda is just one of many dedicated midwives continuing on the frontlines.

“I am grateful to the HEMAYAT program for the learning sessions, for improving our knowledge and skills. Now, I am more confident to save the lives of mothers and babies,” she says.

In the middle of a pandemic, confidence and lifesaving skills can make all the difference. For Fatima, Midwife Muzhda’s courage and care meant she was able to deliver a healthy baby during the most uncertain of times.

Led by Jhpiego, HEMAYAT is implemented with partners FHI360, Palladium, and the Afghan Social Marketing Organization in collaboration with the Ministry of Public Health.

About the Author

Led by Jhpiego, HEMAYAT is implemented with partners FHI360, Palladium, and the Afghan Social Marketing Organization in collaboration with the Ministry of Public Health. Rahmat Nahbi, Communications Advisor, Jhpiego Afghanistan office, developed this story. Zahra Mirzaei, Midwifery and Nursing Team Leader, Jhpiego Afghanistan office, contributed to the story.