Two women: One, an American, born in 1881; one, an Afghan born 80 years later in Ghorban, Parwan province, Afghanistan, both tied together by one common goal. The first rode on horseback to help women giving birth in isolated areas of the Appalachian mountains in eastern Kentucky; the second delivered babies of Afghan refugees and braved the rough terrain of northern Afghanistan to train others to do the same. Kentucky's Mary Breckinridge and Afghanistan's Pashtoon Azfar never met, but both devoted their lives to establishing midwifery as a trained profession—and as a calling worthy of support and respect.

Breckinridge, the first to bring nurse-midwifery to the United States, founded the Frontier Nursing Service (FNS), the forerunner of the Kentucky State Association of Midwives, which became the American Association of Nurse-Midwives in 1929. Like Breckinridge, who worked to battle the alarming rates of maternal and child mortality in the US, Pashtoon Azfar is also a pioneer, not in the US, but in modern day Afghanistan. As the Midwifery Education Manager for the REACH Safe Motherhood Unit, Pashtoon also serves as Chairperson of the newly formed Afghan Midwives Association (AMA).

Afghanistan's maternal and child mortality rate is among the highest in the world. From 1996 to 2001 the Taliban-controlled government did not permit training of new nurse-midwives. As a result, Pashtoon is one of only 537 skilled, trained Afghan nurse-midwives (kabilaha) serving a population of around 28 million.

Therefore, Pashtoon is working with the USAID-funded Rural Expansion of Afghanistan's Community-based Healthcare REACH Project, implemented by MSH, to triple that number. This $3 million REACH grant, awarded in April 2004, is supporting midwifery training in Afghanistan's four most populated provinces, conducted through the Afghan Institutes of Health Science, while also supporting six Community Midwife Education Programs. The programs will graduate a total of 720 skilled midwives by the end of March 2006.

Before joining the REACH Safe Motherhood Unit in April 2004, Pashtoon spent seven years heading Save the Children's US Clinic for Primary Health Care and Reproductive Health in an Afghan refugee camp in Peshawar, Pakistan. She returned to Afghanistan in August 2003 to train midwives and community health workers as part of the International Medical Corps' Rabia Balkhi Hospital Project in Kabul.

Rebuilding and revitalizing Afghanistan's midwifery training programs after years of neglect requires unflagging energy and determination. Pashtoon is actively providing REACH technical assistance to the Institutes of Health Science in both Kabul and the provinces as they rehabilitate their Schools of Midwifery and implement REACH Safe Motherhood objectives. Along with colleagues from the Safe Motherhood Unit, she also conducts clinical and training skill courses for REACH NGO trainers, who are responsible for preparing others involved in competency-based midwifery education. Pashtoon is also involved in the implementation of standardized national midwifery and community midwife curricula, which will educate Afghan midwives into the future.

However, knowledge and desire alone can't always produce change. In March 2004, at a workshop on Reproductive Health sponsored by REACH and the Afghan Ministry of Health (now the Afghan Ministry of Public Health),, Dr. Mehr Afzoon, MOH Reproductive Health Director, publicly expressed her belief that Afghanistan's kabilaha must not continue to work without strength and moral support, the opportunity for professional growth, and the heightened status that combining their numbers in an Afghan Midwives Association could bring. At last, Pashtoon heard her own dream being voiced, and she soon found herself talking to others about the possibilities. Soon after, with the encouragement of her colleagues, Pashtoon accepted the task of being Chairperson at the first AMA meeting on June 6, 2004.

Aided by REACH Midwifery Education Advisor, Sheena Currie, Pashtoon is tackling an ambitious agenda. At a recent AMA meeting held at Rabia Balkhi Hospital in Kabul, 25 nurse midwives, all practicing in clinics, health centers, and hospitals in Kabul, gathered to discuss ways to increase membership. “Nurse-midwives in every Afghan province must learn of and be represented in the Association,” says Pashtoon. “The greater our number, the greater good we can do for women, mothers, and families in this country.“ Razia, one of eleven nurse-midwives attending an AMA meeting for the first time, echoed Pashtoon's view: “All of us need the support an organization like this can provide. Until now, we've had to work alone.”

Before the meeting ended, the group had discussed drafting a constitution, producing and distributing a newsletter, and finding funds for a national conference of midwives timed to celebrate International Midwives Day in Kabul in the spring of 2005.

Within a cultural context that has long excluded women from educational and professional opportunities, under Pashtoon's leadership, and with the support of the MOH and REACH, the Afghan Midwives Association is working to expand its membership and taking the steps necessary to qualify for membership in the International Association of Midwives. “Afghanistan faces many problems,” says Pashtoon. “The path will not be easy, but if we travel it together, giving strength to one another, we can do so much more to help solve them.”

In a letter seeking the International body's support and guidance, REACH's Sheena Currie wrote, “The history of midwifery in Afghanistan has yet to be recorded ….” When it is, Pashtoon Afzar will have a proud and prominent place in its annals.

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