Suraya Dalil

Now at HSPH as a Presidential Scholar, Dalil is studying health care management. She described her experiences at a "Global Chat" talk on April 20, sponsored by the Office for Student Affairs.

Before coming to HSPH, Dalil worked with UNICEF Afghanistan as the Safe Motherhood Project Officer on a national program to reduce maternal mortality. In 2002, she participated in a maternal mortality study conducted by UNICEF, the Afghan Ministry of Public Health, and the Centers for Disease Control and Prevention. The survey, "Maternal Mortality in Afghanistan: Magnitude, Causes, Risk Factors, and Preventability," documented the desperate plight of Afghan women of childbearing age.

"Our study determined that the maternal mortality ratio in Afghanistan is the second-highest globally–1,600 per 100,000 live births," said Dalil. (Sierra Leone is first, with 2,000.) "We estimate that 87 percent of these deaths are preventable with medical services."

She continued, "Maternal mortality is not just a health issue. It is a development issue."

Overlapping problems plague the war-torn country, contributing to the high maternal mortality rate. For example, few medical facilities or skilled birth attendants in the countryside mean that pregnant women who suffer from complications must travel to cities for treatment. Such travel, typically via donkey, is often impossible over the unpaved roads in mountainous terrain. Clean water is a rarity, and even the cities have only spotty electricity. Cities also have inadequate numbers of emergency obstetric care facilities and staff.

The study’s findings helped launch a planning initiative, in which Dalil was also involved, to address the nation’s maternal health obstacles. In 2003, Afghanistan’s Minister of Health collaborated with UN agencies, including UNICEF, and other nongovernmental organizations and donors to establish national reproductive health care priorities.

The health partners in Afghanistan also prepared the "Basic Package of Health Services," which defines the minimum services that must be established. Goals include decentralized emergency obstetric care, particularly in rural areas. The package calls for training to boost the numbers of nurses and midwives, as well as refresher courses for current birth attendants.

"We must train midwives in rural areas especially," said Dalil. "This may, in theory, look easy to implement, but it is not." One reason is a chronically undereducated rural population. Because girls were forbidden to attend school under Taliban rule, most women in rural areas lack literacy skills, making midwifery candidates difficult to find.

Despite this and other challenges, community-based collaboration has helped start rural midwifery training as part of the Ministry of Health’s initial three-year implementation plan. "We met with religious leaders and community elders," Dalil explained, "to obtain their support for women’s midwifery training. We also asked for help in deciding where the training would take place. They were very receptive."

The Ministry has also initiated health center construction in the countryside. In cities, maternity hospitals are being renovated to include emergency obstetric care. When Dalil completes her MPH this June, she will return to Afghanistan and will join UNICEF as a project officer for policy and training, a senior national position. Her new assignment will include advising the Minister of Health and coordinating UNICEF’s involvement in health system development. "I am optimistic that we will reduce maternal mortality in Afghanistan," she said, "but we certainly have a long way to go and much work to do."

--EM