Covering Maternal Death in Afghanistan
Living in Afghanistan for almost one year since the summer of 2006, I've been covering various women's-rights issues such as education and politics. However, I did not realize that Afghanistan has the second highest maternal mortality ratio (MMR) in the world, only after Sierra Leone, as of February 2007.
I had visited the Ministry of Public Health to see my friends who work there and to discuss my work on the general health story I'd been working on. As we were talking about various health issues she suggested I look into the maternal mortality issue. I'd heard about it before but was intimidated about doing the story because of the difficulty gaining access to women in Afghanistan and photographing them. This is especially hard when it involves private moments like giving birth. Unlike in the '60s and '70s when women wore miniskirts and listened to The Beatles, Afghan women have lived through hard times before: during the '80s with the communists and the '90s when the Taliban took over. The Taliban regime forbids printed pictures, secular music and watching TV. And, now the war. For five years women could not even show their faces in public, get an education or a job. Those five years had affected the lives of both Afghan men and women, and women are afraid of being photographed even today.
I had to tell the story of maternal death in a very private setting. Though I had photographed a cesarean section in Laos before, Laotians were very generous in accepting photographers. Afghanistan is definitely not like Laos: it is one of the toughest countries in the world to take pictures of women. How should I go about this? Could I tell the story visually without harming anyone's privacy? How would this even be possible?
Many people – especially male NGO workers who had been rejected by local Afghans for photographing their female family members – had told me this project was "mission impossible." I thought so too. Many Afghan patriarchs do not even allow their wives or daughters-in-law to see the gynecologists.
My friend at the health ministry showed me data and recommended I go to Badakshan. It is the only province never taken over by the Taliban. However, my fear of not being able to take pictures did not diminish. One district called Ragh had the highest maternal mortality rate in the world. Not only that but according to the study conducted from May to July 2002 by the team of Dr. Linda Bartlett from the Center for Disease Control and Prevention in the U.S., the Ragh district was credited with the highest mortality risk ever recorded in human history, with 64 percent – more than half of the women of reproductive age – having died during 1999 and 2002.
Without any proper preparation or budget I just decided to head north to Badakshan province last May and I booked my one-way ticket to Badakshan's capital, Faizabad. The Hindu Kush Mountains are in this province bordering Tajikistan. The roads are unpaved and avalanches are frequent during the winter-spring season. May was a good time to go.
After I landed in Faizabad, I hired a female translator who could only work for three days, then headed to the Faizabad Provincial Hospital. In the maternity ward there were female gynecological doctors and surgeons. They allowed me to take pictures inside the ward only when the patients agreed. They also strictly told me not to take pictures during the delivery. I felt really bad bothering them but the doctors helped me greatly. I tried my best to respect their requests. I also stayed in the hospital overnight but later on was advised not to do so because of security reasons.
I didn't mind the restrictions on taking pictures because I respected my subjects and especially the doctors who gave me access. The physicians also worked in extremely adverse conditions caused by a lack of staff and space in the delivery room. There were only four delivery beds and the six female doctors worked around the clock – one of them was even six months pregnant – inside the only provincial hospital in Badakshan.
On May 11, while meeting my subjects inside the delivery and recovery rooms I saw one patient named Qamar among almost 30 patients in the ward. A nurse told me she had tuberculosis and had just delivered her baby son through a cesarean section a few days earlier. I made a few portraits of her, her son and her mother-in-law.
After that day I attempted to visit other districts including Ragh but soon realized I should have obtained permission from each NGO that supervised the local clinics. A doctor who oversaw reproductive health in Ragh district feared that his program might be jeopardized if he allowed a photographer to work there. Other NGOs didn't welcome a photographer knowing that a patriarch would have blocked her from taking pictures in a private house. It really was a "mission impossible." To make matters worse I couldn't travel to the districts I had intended to visit because of floods and avalanches the day before the trip.
I wandered around southern Badakshan for four days. Sub-governors and local police commanders persuaded me to return to Faizabad because of the danger. It was a burden for them to have a foreigner, especially a female journalist, because of the recent string of insurgent kidnappings. There was even an IED explosion next to the police headquarters the day after I left Faizabad. Things had become more precarious.
After failing for four days to find a midwife who worked in private houses, I returned to Faizabad with a second female translator and her uncle who worked as a driver. I felt devastated. I felt like I had wasted my time and money for nothing. I realized that it was much more difficult to photographically document this particular private subject matter than I hoped.
I then revisited Faizabad Hospital. There were many fewer women in the recovery room. The delivery room was quiet. Nurses and doctors were either taking a nap or drinking tea. Nothing really was happening.
Then I looked for Qamar with new my translator. Qamar had been transferred to the regular general ward. When I finally found her, she was in serious condition and suffering from postpartum complications: meningitis, hypothermia and toxoplasmosis.
The mother-in-law accepted my presence in the hospital and her son accepted the fact that a foreign journalist was taking pictures of his wife. When Qamar was again transferred to a different room, which I assume is a modified intensive-care room, the mother-in-law and the baby and I tended the bed. The husband did not stay in the room, probably because of the cultural reason. The room was mostly occupied by women. Qamar grunted in pain as the time went by. The doctors gave her an oxygen mask with a pulse machine attached to it, but the main doctor said that her conditions were too bad. Everyone was skeptical that she would survive. They rather prepared to accept her death.
At around 8:30 p.m. on the same day, her breathing stopped. The mother-in-law, who was tending the baby on the bed next to Qamar, slowly rose and approached to her. She called her name a couple of times, "Qamar, Qamar," then patted her cheeks gently. She confirmed Qamar's death and closed her eyes. She died on May 20 leaving the baby and her husband behind. Then within a minute two caretakers came to the room. They tied up the face and the toes, then moved her to a different room on a stretcher – there was no morgue. It was very quietly done.
The next morning, the family members, including the mother-in-law, the husband and a couple of male relatives traveled to their hometown in a district called Shohada, about three hours from Faizabad. However, after two hours from the provincial capital, the roads were again washed out due to previous floods and landslides. We all decided to walk to Qamar's family home. Several male volunteers joined in the trip and they carried her body on a wooden stretcher. The 75-year-old mother-in-law rode on a donkey and carried the baby.
Our group arrived at the house at around 12:30 p.m. after walking more than 10 kilometers on foot through the landslides. I was worried that family members might not accept me but they did and that was a big relief. The women gathered around Qamar and began weeping. They also washed her body and put a shroud on it. The whole funeral process took about a couple of hours. After the women's job was done the men carried her body to the grave and buried her.
The mullah of the village conducted the funeral. He said that Qamar was going to a better place and prayed for Allah to take care of the remaining members of the family. He also thanked me for being there, going through the tough circumstances with the family.
The next day, the village commander escorted me back to the place where we left the car the day before. Along the way I experienced the fresh air and beautiful countryside. I imagined Qamar washing clothes in the clean river surrounded by the green mountains of Badakshan. She is no longer in this world but her story will be seen by many people. The world will now know the conditions of pregnant women and childbirth in Afghanistan through her story. My best wishes go to her family who accepted me. I may not make a dramatic difference in reducing maternal death but I am so thankful that the story was recognized in the international community and hope there will be better and more tangible help to improve the situation.
© Jean Chung
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