According to Afghan tradition, children are the fruit of heaven. The more each couple produces, the greater the blessing; hence the country has one of the world's highest birthrates. If an infant dies, village tradition says, another will come along soon. If a mother dies giving birth, it is the will of God.
But according to international studies, Afghanistan is also one of the most dangerous places in the world to be born or to deliver a child. In a recent report, the U.S. charity Save the Children found that Afghanistan has the world's second-highest rate of newborn deaths, 60 per 1,000 births, just below Liberia. It also found that one in six Afghan mothers -- 20,000 a year -- die during or after childbirth.
Safia, an illiterate villager of about 30, has survived several pregnancies, but just barely. Last month, she arrived at physician Roshanak Wardak's clinic in this town 50 miles west of the capital carrying a 3-week-old baby.
The child was thin and weak, because Safia could neither produce milk nor afford to buy formula.
Her previous child, a boy, had nearly died at birth. Safia was in labor for two days and nights, she said, with no way to travel from her village. By the time she finally reached a hospital two hours away, she had to have an emergency Caesarean section, and both she and the baby were hospitalized for a week.
"My husband was away working. I couldn't reach him, and no one else would help me," she said. "I was having terrible pains, but the baby would not come. Later the doctors told me it was because I worked so hard during my pregnancy, lifting water buckets and other heavy things. They told me not to have any more children for three years, but now I have this new one."
'As bad as it can get'
Although Afghanistan has had a stable, Western-backed government since late 2001 and foreign donors have since spent tens of millions of dollars to improve health care, conditions still conspire to sabotage the chances of healthy and normal births.
"It's really as bad as it can get and still sustain a population," said Linda Bartlett, a physician and maternal and child health officer for UNICEF in Kabul, the capital.
Many parts of Afghanistan are harsh and remote, with bad roads, few clinics and little ability to attract skilled health workers. Village girls are often married by 15 and urged to produce a child each year. About 85 percent of Afghan infants are born at home, without even a trained midwife in attendance.
If complications arise, families may not recognize the danger signals and end up wasting precious time deciding what to do. The mother, in protracted labor or losing blood, may have to be carried or put on a donkey for several hours to reach a road leading to a hospital. By then, it may be too late to save her or the child.
"The worst problem is lack of skilled staff. In some provinces, there are no female health workers at all," said Nadra Hayat, director of maternal and infant health at the Public Health Ministry in Kabul. Delivering babies is traditionally done in Afghanistan by women, and many families do not want male doctors to treat their wives or daughters.
Even when foreign donors offered to increase the government's monthly salary for doctors from $40 to $1,000 for those willing to work in arid, isolated southern provinces, Hayat said, "the living conditions were so bad that no one wanted to go."
Two-fold problems
According to Bartlett, health care has improved significantly in some provinces, with new clinics built and staffed in large towns. The problem, she said, is at two extremes: remote regions where medical help is dangerously scarce, and urban areas where hospitals can barely keep up with the population boom.
In Kabul, the main maternity hospital, Malalai, is hard-pressed to keep pace with the crush of deliveries resulting from a wave of returning refugees that has tripled the city's population since the U.S.-led invasion in late 2001. The staff delivers 80 to 100 babies every 24 hours, and most new mothers are discharged the same day to keep enough beds open.
Doctors and nurse-midwives said that since the end of Taliban rule and the influx of foreign aid, the hospital has made major improvements. Infection rates have fallen sharply, and new diagnostic equipment has been donated. In the past 15 months, fewer than 10 patients have died.
"Some things are much better. We used to do 10 deliveries with one pair of gloves," said Safia, a nurse-midwife who has worked there for 35 years.
Still, conditions are far from ideal. Basic supplies often run out. Patients may be asked to privately purchase such items as intravenous drips. When patients arrive with severe bleeding, doctors often take up a collection to buy plasma from other hospitals.
With doctors in short supply, Afghan and foreign aid agencies have focused on increasing the quantity and quality of midwives. Until recently, many were unskilled women who did little more than cut the umbilical cord. If the mother started hemorrhaging or the birth was obstructed -- the two leading causes of maternal mortality here -- there was little they could do.
'A real revolution'
In the past three years, a U.S.-funded program has trained hundreds of community midwives, and a national midwives association has been formed. The number of trained midwives has increased from about 500 to 1,500, and many are working in remote regions with high rates of infant and maternal deaths.
"It is a real revolution," said Pashtun Afzer, the association's president. "These women are so committed. They want to be competent. They know the danger signs and the causes of bleeding. Some rural people were afraid to go to strange clinics, but these are women from their own areas, so the people trust them."
Bibi Ashrafi, a midwife in her fifties, has delivered more than 1,000 babies in Wardak province. She said most village families still prefer home births because they don't want to expose their wives or daughters to unfamiliar doctors.
"I only carry a bag with a scalpel, soap, gloves and clean cloths," she said. "I am very careful. I wash my hands eight times before and after the birth, I sterilize my scissors, and I make sure the placenta is not left inside. If the mother is doing well, I feed her a soup of sugar and oil and flour, and then I leave."
In the past, Ashrafi said, many women died giving birth, and their families would say it was "God's decision that her time had come." But three years ago a clinic opened in the area and she received some training. Now, when a mother is bleeding heavily after the birth, she has a place to send them.
"It's great we have a clinic now, but the problem is with the people," she said. "They are so concerned about privacy that they don't call me until a woman has been bleeding for three days. I tell them to space out the births, but they want to have as many children as possible. I tell them that is bad for the mother's health, but they don't want to change."
Transport difficulties
A few miles away, outside Wardak's clinic in Sheikhabad, several dozen women huddled on the ground, their swollen bellies hidden under billowing burqas. All were illiterate. Many had histories of multiple miscarriages, problem deliveries or babies born early and weak.
Wardak said she opened her clinic after the winter of 1996, when 40 women died giving birth in the district. Even now, she said, many pregnant women live so far up in the barren brown hills that they can barely get to her door, let alone endure another two-hour ride to the hospital in Kabul if they have labor complications.
"Some villages are eight or nine hours away, and the cars charge extra because the roads are so bad," she said. "I haven't lost a patient in nine years, but we have women traveling from one district to another with labor pains, trying to find help. Sometimes, on the way, the babies die inside them."