Afghanistan: A Life for a Life

Maimona is a woman of indeterminate age, her face and body battered by a brutal life. A resident of Kabul, she has given birth 16 times, and she faced each labour alone.

“I would never allow another person to be present during birth,” she said, defiantly. “This is a big shame in our society. Each time I have wrapped my baby in swaddling clothes by myself.”

Maimona is not alone. In Afghanistan, according to a recent study by the United Nations Children’s Fund, UNICEF, up to 90 per cent of all women give birth unattended by medical professionals.

Still, she has been more fortunate than many. Afghanistan has one of the worst maternal mortality rates in the world, with an average of 1,600 deaths per 100,000 births. This is still far lower than the northeast, mountainous province of Badakhshan, which has seen the highest levels ever recorded globally: up to 6,500 deaths per 100,000 births.

In the more developed world, death during childbirth is relatively rare: in the United States, the average is 12 deaths per 100,000 births, while in Sweden the figure is just three.

There are multiple factors that contribute to Afghanistan’s shocking statistics.

Decades of war, a ruined economy, lack of roads and health facilities all play their part. But, as in Maimona’s case, one of the most powerful influences is tradition. In Afghanistan’s male-dominated society, women are often kept out of sight, restricted in their movements outside the home.

Many are ashamed to seek medical help for pregnancy and birth, and their husbands are reluctant to have their wives seen by outsiders, especially men.

Haji Gul Mohammad, a resident of the western province of Herat, has brought his wife to the hospital in Herat city for delivery. He is looking for a female doctor to attend her.

“If I cannot find a woman doctor I will take her home,” he said. “It would be very bad for my wife to give birth in the presence of a man.”

The unwritten prohibition against women being treated by male doctors means that most women go without medical assistance of any kind. Given the ban on women’s education during the Taleban years, the number of female doctors is woefully inadequate to deal with the problem.

Bamian province, in Afghanistan’s central highlands, comes a close second to Badakhshan in maternal mortality. Dr Ihsanullah Shahir, the province’s health director, told IWPR that his hospital, which served the entire province of some 300,000, had ten doctors – only two of them female. The 38 medical centres scattered throughout the more remote areas of the province are staffed with five women and 35 male doctors.

“Maternal mortality is our highest priority,” said Dr Shahir, “but the biggest problem we face is attitude. People think ‘God gives life, and God takes it away’, so they do not seek help until it is too late.”

As in much of the rest of the country, geography plays a large part in Bamian’s maternal mortality figures. Even when a family is willing to seek medical assistance, the lack of roads and the mountainous terrain make finding help almost impossible.

Most medical professionals agree that the major immediate cause of maternal mortality is unchecked bleeding during childbirth. If this occurs in a hospital setting, where doctors and medicines are available, it can be dealt with. But if a woman begins to haemorrhage in a remote location, chances are she will die long before she can travel the long distances - frequently by donkey - along rough terrain to the nearest clinic. In remote and mountainous places like Badakhshan, the situation is truly catastrophic.

As Abdul Momen Jaleel, chief of the public health department in Badakhshan, put it, “The condition of women’s health in Badakhshan will shock you.”

Dr Hafiza Omarkhil, deputy chief of Kabul’s Malalai Maternity Hospital, says social problems, such as poverty, play a large role in maternal deaths. Lack of nourishment during pregnancy increases the risk, as does the practice of marrying girls off at very young ages, she adds.

According to Dr Linda Bartlett, Maternal and Child Health officer with UNICEF, underage marriage is one of the primary causes of maternal mortality.

“In Afghanistan a girl cannot choose the date of her marriage and the number of her children, therefore many young women die because they are married prematurely,” she told IWPR.

There are steps being taken, she added. UNICEF, the United Nations Development Fund for Women, UNIFEM, and the World Health Organisation, WHO, are working together on a programme that will increase the range of services offered to women during pregnancy. Clinics are being established in many provinces and women are being trained in midwifery throughout the country.

But it is an uphill struggle.

With much of the country illiterate - up to 98 per cent of women in some provinces - basic education is difficult. Women are dying because they and their families lack even the most rudimentary information about health matters.

“Women are an underclass in Afghanistan,” said Dr Adelah Mubasher, head of the Women and Children's Health department for WHO. “Little more than two per cent are educated. They do not have access to health care, and they have no information about health.”

The desperate state of the economy also comes in for a large share of the blame.

“The major reason for women dying during childbirth is the economic situation of their families,” said Dr Fakhria Hassin, director of the mother and child department in the public health ministry. With no money for doctors or medicine, she added, many women die unnecessarily. In addition, undernourishment during childhood increases a girl’s risk of developing problems later on.

The efforts of the government and of international organisations to provide more care will help. But still, say Afghan women, real social change must come first.

“In our province there is no clinic for women,” said Karima, a resident of Ghor, in west-central Afghanistan. “But even if there were, my husband would not allow me to go there.”

Salima Ghafari is an IWPR staff reporter in Kabul. Mari Nabard is a freelance IWPR contributor. This story was produced as part of IWPR’s Women’s Perspectives programme.