As the U.S. begins withdrawing from Afghanistan, ordinary Afghans are wondering whether this is the beginning of the end of serious American engagement.
After spending almost $1 trillion and suffering close to 4,000 American deaths, will Washington cut and run? Or will it seek a “responsible end” to the war, as President Barack Obama has claimed?
The answer will depend in large part on how the U.S. continues to support the Afghan government and people. Americans are understandably tired of financing big, expensive initiatives that are riddled with corruption and can't be maintained by Afghans themselves. As incoming Ambassador Ryan Crocker said, the objective must be to invest in projects that meet the goal of “sustainable stability.”
In a worrying sign, Washington is on the verge of eviscerating one of its most successful and cost-effective programs: improving maternal health.
After the fall of the Taliban in late 2001, modern health care in Afghanistan was almost nonexistent. The situation was particularly dire for expectant mothers: 1 out of 7 women in Afghanistan died from pregnancy-related complications, and roughly two-thirds of the country lacked even basic maternal and child-health services, with the majority of women giving birth at home without a skilled attendant. Even if a woman could get to a hospital, there was little incentive to do so. Hospitals had almost no life-saving equipment or medicines and few skilled staff members. A cesarean section in an Afghan hospital was a risk few were willing to take.
Danger From Birth
Although Afghanistan is still among the most dangerous places in the world to give birth, the U.S. has helped lay the groundwork for significant improvement. The Afghan Safe Birth Project, funded by the Department of Health and Human Services, has implemented quality-assurance programs to improve emergency obstetric care in areas where doctors and hospitals are scarce. In Kabul's Rabia Balkhi Hospital, which houses the nation's second-largest maternity facility, the program has reduced deaths due to system errors during c-sections by more than 80 percent in only two years.
In the rural regions where most Afghans live, the Community Midwife Education program, supported by the U.S. Agency for International Development, has trained thousands of women to work as midwives, even in zones where the anti-government insurgency is strongest. There are now 32 midwife schools nationwide serving all 34 provinces of Afghanistan.
New studies indicate that midwives are responsible for significant maternal mortality declines in rural areas, too.
This success is now in jeopardy -- not because of security threats, but because of a fiscal one. In a classic example of short-term thinking that undermines long-term goals, the U.S. government recently eliminated the Afghan Safe Birth Project's budget of $5.8 million. As a result, the initiative has stopped funding emergency obstetric and neonatal pharmaceuticals and supplies. According to Dr. Brian McCarthy, the Afghan Safe Birth Project's senior technical adviser, this could lead to an epidemic of maternal and newborn mortality at Rabia Balkhi Hospital, which delivers as many as 16,000 babies a year.
Health care is one of the few touch points that average Afghans have with their government. Whether in urban hospitals or rural clinics, they receive tangible benefits that improve lives. Maternal health is arguably the most important marker of a government's ability to deliver health care to its people. The processes, infrastructure and skills that need to be in place to reduce maternal mortality form the backbone of a modern health- care system. They also strengthen ties to the government, bolster stability and foster economic growth.
Moreover, investments in maternal health strengthen the position of women, which is critical for Afghanistan during this tenuous transition. Midwife programs in particular have been a huge success in providing skills training and employment for thousands of women in rural areas who have now become role models in their communities.
A few years ago it was hard to get village leaders to approve women's participation in local midwife training programs, but today there are long waiting lists. Families line up to enroll their sisters and daughters in the two-year training program. In midwife service areas, women report that support for girls' education and women's economic and physical mobility has improved as midwives move around their communities sharing valuable information and delivering healthy babies.
The proof is in the numbers: Women who live in provinces that have midwife schools were 40 percent more likely to access skilled birth attendants and 17 percent more likely to access prenatal care than women in provinces without midwife schools.
Although progress has been achieved, the gains are fragile. Estimates indicate that it will take about seven years to train the thousands of additional midwives needed to cover the entire country and drive down Afghanistan's daunting infant and maternal mortality rates.
If the U.S. is serious about its commitment to increase stability and promote development in Afghanistan as it draws down troops, it should continue to support and promote maternal- health programs. Few investments provide the same lasting social, economic and even security returns -- and few programs have proved as popular. Today the U.S. provides more development assistance to Afghanistan than to any country in the world. This assistance will inevitably decline, given current budget constraints, which makes smart use of limited aid dollars all the more important. Maternal health should lead the list of those projects that meet the “sustainable stability” standard.
(Isobel Coleman, author of “Paradise Beneath Her Feet,” and Gayle Tzemach Lemmon, author of “The Dressmaker of KhairKhana,” are fellows at the Council on Foreign Relations. The opinions expressed are their own.)
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