Midwifery 'more than just a profession'
It was the early 2000s when Sabera Turkmani, a recent medical sciences graduate in Iran, considered returning to Afghanistan, the troubled homeland she and her family had escaped when she was a toddler. Despite residing in Iran for most of her life and doing all of her schooling there, Sabera was still considered a foreigner and therefore had limited opportunities for employment.
“I thought to myself, ‘Well, I have all these skills and I have a country which has been absolutely demolished through three decades of war, so the best thing for me is to go back to Afghanistan’,” she says.
Her decision to return to the war-ravaged nation followed the collapse of the Taliban regime, sparking renewed optimism for a period of relative safety and stability.
“As you can imagine, I entered with lots of hope for my country,” Sabera recalls. “Instead I found wrecked buildings, a deeply flawed health system, and the situation of women was terrible. I kept thinking, ‘What can be done to make this situation better?’”
Sabera’s first step was to take on a job with the International Medical Corps, a non-government organisation that was seeking a healthcare professional to develop midwifery in one of Kabul’s biggest maternity hospitals. It was a baptism of fire for the young graduate, who quickly discovered how under-resourced the hospital was.
“I remember every night seeing the dead bodies of women passing my eyes in the maternity ward,” says Sabera, who had studied maternal health as part of her bachelor’s degree. “I was so young and it really overwhelming. As I watched, I would think, ‘We need to fix this’.”
At the time, due largely to the Taliban policy to prohibit the education of females, many hospital staff lacked adequate training to handle complications in maternity care. Despite Sabera’s limited clinical experience, her strategic expertise enabled her to implement effective quality improvement programs that addressed these gaps in skill and knowledge, significantly reducing the rates of maternal and newborn mortality at the hospital.
“Once we started the midwifery training program, within six months the maternal deaths in the hospital were down to one per night, and the newborn deaths were also reduced massively,” she says. “There was still room for improvement, but it was clear that we had made progress.”
Sabera was soon approached by USAID, an international development agency that tasked her with spearheading a nationwide program to establish community midwifery education and address the burden of maternal and newborn mortality.
“We started recruiting women in a very remote areas, training them as midwives and deploying them back to the villages where there are no roads, no transport, no health facilities and limited access to other essential resources,” says Sabera, who recalls the many challenges of working in regions that were still under Taliban control.
“It wasn’t always completely safe and I remember having to travel with a bullet-proof vest, but there was a real need to work with the Taliban, to convince them that what we were doing was for the best of the community, for the best of women, and for the best of the future of the country.”
Freedom and empowerment
When Sabera first arrived in Afghanistan, there were fewer than 400 midwives in the country, many only partially-trained. By the time she left 12 years later, the programs she had helped to implement saw midwife numbers swell to some 9500. In the same period, the maternity mortality rate dropped from 1600 per 100,000 live births, to about 450.
Through her work with USAID, she oversaw the establishment of 34 midwifery schools and clinical sites, including in the furthest corners of the landlocked nation.
These initiatives transformed the lives of the women benefitting from improved treatment, and they also empowered the women who had gained new skills and knowledge, seeing them become role models in their respective communities.
“We had a situation where these women were working as midwives and earning a salary, and this financial independence gave them a sense of freedom and empowerment,” says Sabera, who adds that midwifery offered women a voice in decision-making, enabling them to foster strategies to improve health and education and contribute to the growth of the nation.
“[It] gave them a voice they never had before, and then those women would help other women and empower them and give them advice and guidance, which was just amazing to witness and be part of.”
Eventually, however, the personal risks became too much to bear. With the resurgence of the Taliban in more parts of the country, its forces began to make threats against Sabera and her family. After a dozen years in her homeland, she was forced to flee once again and seek asylum in Australia.
“I left Afghanistan not by choice, but by force,” she says. “You can imagine how a woman-led organisation and a woman-led profession would be suppressed by a patriarchal society where women are deprived of social, political and financial freedom. There was much more work to be done, but for the safety of my family, and for the safety of myself, I had to leave.”
On arrival to Australia in 2013, Sabera immediately set out in a new direction, adding research skills to her extensive experience in the field by pursuing a career in academia.
Over the following decade, she conducted research on diverse topics aimed at vulnerable female populations, including several projects with the Centre for Midwifery, Child and Family Health, culminating in the completion of her PhD in 2019 at the University of Technology Sydney.
Her work has explored the experiences of migrant women affected by female genital mutilation, investigated the state of midwifery in small island-nations in the Pacific, and examined lessons from Afghanistan to guide the expansion of midwifery in challenging settings.
Dr Turkmani speaking in Afghanistan.
At present, Dr Turkmani works with the Burnet Institute, conducting global research with a focus on marginalised populations. She endeavours to share her findings with like-minded organisations and researchers, in a coordinated effort to drive meaningful change.
“I’ve been able to see how evidence can make a change in this world, because you can’t go into a hospital and alter things unless what you’re doing is reinforced and backed by a strong evidence base,” she says.
“Nowadays, we possess a wealth of knowledge about what is beneficial for mothers during breastfeeding and the optimal practices for childbirth. However, it is important to recognise that this knowledge has been acquired through the diligent efforts of researchers who have worked tirelessly behind the scenes to uncover these best practices and generate new insights.”
Being ‘with woman’
Despite her impressive resumé in the fields of public health and maternal health, Dr Turkmani is not technically qualified to work as a midwife in Australia.
Seeking to remedy this, she took the decision to return to study, enrolling in a Bachelor of Midwifery at ACU’s Blacktown Campus in early 2023. By bridging the gap between research, policy and practice, she aims to contribute to the development of evidence-based practices and advocate for change to positively impact clinical outcomes for women, families and communities.
“The clinical aspect of maternal health is an area I’ve been missing since I moved into research, and I’m sure it will be a transformative experience for me because I’ve never worked in a hospital setting in a country like Australia,” says Dr Turkmani, who has secured her first work placement alongside midwives at the Royal Prince Alfred Hospital.
“In the long run, this will be a skill that will improve my research, allowing for an in-depth analysis of the gaps in quality of care for women in Australia and beyond. But it will also allow me to practice midwifery, something I intend to do for the rest of my life.”
Mindful of the themes of feminism and gender equality that are intertwined with this line of work, Dr Turkmani sees midwifery as “more than just a profession”. She feels a strong connection with a central tenet of midwifery philosophy and practice: being ‘with woman’.
“‘Being with women’ is just two or three words, but there is so much more behind that statement,” she says. “It means centring women, advocating for their rights … it means empowerment, it means supporting, sharing and building a relationship of mutual trust and respect … that’s the beauty of midwifery for me, and I feel so fortunate to be here on this path, working with women and for women in a field that I love.”
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