Dr Costeira reports on the gaps in access to paediatric care in northern Afghanistan

When I left Portugal in late September this to work as a paediatrician on an assignment in Médecins Sans Frontières' (MSF) newest project in Afghanistan, I was concerned about the environment – wondering how life was in this mountainous country in the Heart of Asia. 

Having previously worked with MSF in South Sudan and Yemen, I had witnessed first-hand the transformative impact of the organisation’s activities. Yet, the tales and experiences awaiting me in Afghanistan reignited the passion within my heart, reminding me of the profound joy and purpose I found as a paediatrician at MSF. 

Resilience and strength of families and children

At the Mazar-i-Sharif Regional Hospital in the Balkh Province in northern Afghanistan, I have witnessed the incredible strength and resilience of the families and children who come through our doors. One inspiring story is that of 22-year-old *Shekiba and her daughter, *Atoosa. 

Shekiba, a proud mother from Chimtal District – situated about an hour's drive from Mazar-i-Sharif – who embarked on a challenging journey when she gave birth to her precious daughter, Atoosa, prematurely at just 28 weeks at Mazar-i-Sharif Hospital’s maternity ward, run by the Ministry of Public Health. Atoosa's arrival at a mere 1.2 kilograms marked the beginning of a long and arduous battle for survival. Due to her very low birth weight and physical condition, she was referred for admission at the Neonatal Intensive Care Unit (NICU), which MSF supports at the hospital.

Premature newborns must undergo long periods of hospitalisation that can be extremely disruptive for their families. In Mazar-i-Sharif, being a regional hospital, we receive premature and sick newborns from various districts and towns across northern Afghanistan. Many mothers remain alone with their baby in hospital for long weeks, far from their families and homes. At the Mazar-i-Sharif Hospital, we admit newborns delivered inside the maternity ward of the facility as well as those referred from other health facilities in the northern provinces of Afghanistan.

What drew me to Shekiba was that she was among the first whose babies we admitted to the NICU, yet they spent a long time at the hospital, giving us a lot of time to build a bond. For two months, she spent every waking moment looking at her baby, sometimes finding it hard to sleep. The agony of seeing your baby on life support and not knowing whether they would pull through can really weigh someone down, and Shekiba would sometimes feel dejected, breaking down into tears. But in those moments of despair, fellow mothers, the nurses and doctors gave her emotional support.

With the help of a medical translator who supports me at work, I tried to speak to her during my breaks and got to know her better. She told me her joy and struggles, and how life was for her growing up with nine siblings at the home in Chimtal. It was also here that she met her husband and decided to have a family. We formed a bond that strengthened as she stayed longer in the hospital. She would ask me how soon her daughter would be discharged from her incubator that she had now shared with another baby for weeks, but more often than not I didn’t have the news she wanted to hear.

The Neonatal Intensive Care Unit (NICU)

The NICU is a dedicated area equipped with specialised medical equipment and medical staff trained to provide care to very sick and premature babies in need of intensive care. The care provided in the NICU is tailored to the unique needs of newborns, often including support for preterm babies, those with low birthweight, perinatal problems or congenital abnormalities.

The NICU supported by MSF at the Mazar-i-Sharif Regional Hospital has consistently had more patients than bed capacity since its doors reopened to patients on the first day of October 2023, following extensive enhancements. We now have more than 60 children in the NICU, yet we only have space for 27. Because of this, many babies have had to share beds. This is not an ideal situation, but one we sometimes face in contexts where the needs are exceptionally high. In Mazar-i-Shariff, we admit about 540 infants in the NICU each month. 

Positive news for mother Shekiba

The day I gave the news to Shekiba that her baby was stable enough to be moved from the NICU to the prematurity ward, she couldn’t hide her joy. This was after staying in the NICU for a month. She whipped out her phone to make a call to her husband’s. The translator told me Shekiba announced “we will be leaving the hospital soon!”

She told me that whenever she gets sad, she holds her baby and feels better. She draws her strength from the love she holds for her daughter and the promise of a future filled with precious moments and cherished memories: “I can’t wait to comb her hair, make long braids, taking her to school and talking for hours.” 

Shekiba grew demonstrably stronger during her stay and took the time to provide support and solace to other mothers facing similar challenges she did, instilling hope in them.

Shekiba left the hospital to go home, having only known the walls of the hospital for two months. Baby Atoosa has reached significant milestones and is getting discharged, weighing 2.0 kilograms. We shed some tears. We send her home, hoping not to see her in the hospital soon, except for routine well-baby clinics. 

The importance of medical care for premature newborns

Prematurity is one of the main causes of morbidity and mortality in newborns in Afghanistan, as in other low-income countries. I am constantly reminded of the critical importance of comprehensive medical care for premature newborns. These vulnerable infants require meticulous attention and specialised treatment, making our work in Mazar-i-Sharif vital in saving young lives. 

The work we do in this hospital is not just a duty; it is enveloped in compassion and dedication. It is a commitment to providing the best possible care for every child, regardless of their background or circumstances. 

It's a privilege to witness people’s determination to thrive, despite the odds stacked against them. The resilience of these children and their families amidst turmoil is a testament to the unbreakable human spirit.

Afghanistan healthcare context

For more than two decades, Afghanistan's healthcare system has faced longstanding issues of understaffing, underfunding, and inadequate response to population needs within the health system. The situation deteriorated further when the Islamic Emirate of Afghanistan (known as the Taliban) assumed power in August 2021 and funding was reduced, adding strain to an already fragile system.

In August 2023, Médecins Sans Frontières (MSF) launched services at the Mazar-i-Sharif Regional Hospital in Balkh Province, Afghanistan, in collaboration with the Ministry of Public Health, aiming to reduce paediatric and neonatal mortality rates in the northern provinces. MSF runs a paediatric emergency room (ER) for children up to the age of 15, supported by a triage system to ensure the most critical patients are admitted and given the care they need. MSF also supports a neonatal intensive care unit (NICU) providing care to premature and sick newborns.

MSF medical teams at Mazar-i-Sharif Regional Hospital admit an average of 3,000 critically ill children in the paediatric ER and an average of 546 newborns to the NICU each month. The average bed occupancy rate has consistently been higher than 140 percent since MSF started activities in the NICU. MSF has had to put in place additional resources to ensure that staff can continue to provide personalised care and attention to each infant and reduce the risk of burnout despite the capacity needs and limited space.

*The names used in this article have been changed to protect patients identity.