Enabling Environment, Model of Practice

Improving the Quality of Health Services in Afghanistan: a guest blog by Samrina Siddiqui

24 May 2022

Blog contributed by Bibi Samrina Siddiqui-Foshanji. Bibi Samrina Siddiqui-Foshanji is a member of ICM’s Member Association, the Afghan Association of Midwives, and is a Senior Technical Advisor for Midwifery based in Kabul, Afghanistan.

I am a midwife by profession, a mother of three, a women activist, and a member of the Afghan Midwives Association. Since 2007, I have been involved in strengthening the three pillars of the Midwifery profession in Afghanistan including Midwifery Education as an instructor and preceptor, in Regulation as a Midwifery registrar, and the Association as an executive board member. I provide capacity-building support for the Midwives working in the health care system on quality improvement tools and high-impact health interventions. I also lead the activities with the Afghan Midwives Association, to collaborate on the capacity building of midwives, advocacy for the rights of midwives, and standardization of the midwifery profession through revision of educational curricula and standards. Alongside the American College of Nurse-Midwives, I work on capacity-building activities for targeted midwives in different provinces.

Under a different regime, this year has been very different in Afghanistan. In the past years, we celebrated International Women’s Day on the 8th of March, as a day to reflect and advocate for equality, women’s rights, better education, access to quality healthcare services, and access to respectful maternity care. This year, very few organizations celebrated Women’s Day. The new regime in Afghanistan considers this occasion to be a Western concept, not authentic to the region. They believe that, in Islam, women are given defined rights in the Qur’an, Sunnah, and other religious books, therefore we don’t need to celebrate it on a certain day. Though in reality, they do not practice any of those given rights that benefit women.

I am a Muslim and I know that the acquisition of knowledge and the use of this knowledge for the betterment of humanity are said as blessed duties for Muslims. In Islam, the duty of seeking knowledge and learning is obligatory for every Muslim. Islam affirms the right to education for all without gender discrimination. The words from Quran: “My Lord, increase me in knowledge.” (Surat Ta-Ha 20:114) and the Prophet Muhammad (P.B.U.H) encouraged education as a religious duty for both man and woman, “Seeking knowledge is an obligation upon every Muslim”. (Sunan Ibn Majah 224). Despite all the mentioned proof, since the takeover of the new regime – since August 15, 2021 – the schools for young girls are still closed in the country.

Another consequence of the remaining girls’ schools closing is the families who have concerned about the security and future of their daughters, for their safety forced their young daughters into family arranged marriages to protect them. We have several examples in our family that unfortunately about 3 girls under the age of 16 were forced to marry their cousins. Since my sister lives in the United States, fortunately, she was able to invite one of our relative’s daughters under the age of 16 to the United States to avoid this family marriage.

However, we marked International Women’s Day at our workplace and at the Midwifery Association in Kabul and in other provincial offices, by coming together as colleagues. In our office, we had a question-and-answer session, where the women were asked questions of the men, and the men were answering the questions. It was really a joyful event, and both male and female colleagues enjoyed it, and we learned a lot from each other as well.

In addition to the above assignments, I track activities at the provincial level and travel to provinces. I recently visited 6 Provinces for a monitoring visit to oversee the quality of maternal and neonatal health services. I visited the targeted health facilities to observe the quality of services and the quality improvement programs.

Still, there are security threats and concerns in the country, especially for women. One of the biggest issues is that, under the new regime, a woman cannot travel without a Maharam, which is a male companion. I didn’t have a male companion to accompany me in traveling to the provinces, so I took my aunt with me. But, since we were two women traveling together without a male companion, the hotel would not give us accommodation to stay at night. Thankfully, in each province our colleagues at the provincial level, allowed us to stay in their homes while we visited the province.

While I was thankful for their hospitality, I still felt unsafe and fearful. My colleagues’ first questions were always: “Who came with you? Who will stay with you? Have you come alone from Kabul?” This made me feel really scared. Other colleagues asked me, “Why didn’t you wear a burka?” I hadn’t taken a burka with me; I had just a hijab—a long dress—and a big veil, but not a burka. I also had a mask to cover my face. But my colleagues in the provincial office were still concerned and said, “We are using the burka so that no one can recognize who we are. Why didn’t you bring a burka with you? This is dangerous!” These frightening new conditions for women have made my job very difficult.

Not only are changes happening at the personal level for women, but also within the structure of our government. Previously, women were working in the Ministry of Justice, Ministry of Finance, Ministry of Education, and other ministries. But right now, women are only allowed to be represented in the Ministry of Public Health. Women no longer have a role at the policy level, or at the decision-making level. They are only allowed to work in the lower levels of the Ministry of Public Health.

In the Ministry of Public Health, the offices for male and female staff have been separated. In coordination meetings, men and women are not allowed to sit together. This is affecting the work, including at the health facility level. For example, during my recent visits to the district hospitals in Kabul and Balkh, and to the comprehensive health center in Kandahar and Nangarhar, the midwives and female doctors were conducting their own morning reports, weekly reports, and monthly reports; while the head of the health facility, along with the male staff, were conducting separate meetings. There was no collaboration between male and female staff at the health facility. Another example is a midwife who is working in a health facility needs to contact a vaccinator. She might need to coordinate with the laboratory, or with the pharmacy department or may need to have contact with the blood bank. Some of these departments have only male staff and no female staff. The female doctors or midwives are unable to provide quality services when they cannot collaborate with the interrelated departments with male staffing at the health facility.

In addition, based on my recent observation from the provinces in Northern and Southern Afghanistan, the number of antenatal and postnatal visits, and institutional deliveries are getting lower than the actual targets, as the women are not allowed to travel without a male companion. As Afghanistan is a male dominant country and with cultural barriers, a male family member (especially the husband) doesn’t like to accompany the woman or refuse to take her to the clinic. Based on the interview with the woman, they have mentioned that her husband is busy, and he is not able to take his pregnant wife for antenatal, intra-natal, or postnatal care to the health facility. As healthcare providers, we all know that lack of or limited antenatal and postnatal care visits and home birth in the absence of a skilled birth attendant can increase maternal and neonatal mortality and morbidity.

We are working on quality improvement for health, and these are the challenges that we are facing right now. I fear that these policies of segregation will have a negative impact on health—especially the health of women and children—and the health care system. Beyond this, I have heard that in other ministries, women are experiencing depression and mental illness due to feeling helpless in the face of these restrictions upon them.

We are trying to be brave, trying to be driven. We are trying to work to help our communities and help women, which is our priority. But we are struggling and the world is watching us without any serious action.