In the mountains of central Afghanistan, blocked by snow for half the year, temperatures plummet to minus 37C. Nothing's easy in this part of the world – least of all childbirth.
Healthy newborns run the serious risk of hypothermia as some mothers simply don't understand the need to keep their baby warm. There is a host of hidden cultural challenges – for example, many women bleed to death before they can receive permission from their husband or mother-in-law to get medical help.
It's not surprising Afghanistan has the highest rate of maternal deaths in the world. When World Vision arrived in Ghor province in 2007, there wasn't a single skilled midwife in a province of 800,000 people.
Most deaths are preventable. It's down to lack of awareness about basic care, bad diets and women working physically too hard in the fields right up to giving birth. This is coupled with unskilled care and dangerous cultural practices such as cutting the umbilical cord with the edge of a shoe, from a well-meaning villager or mother-in-law.
Now there's hope, in the form of newly-trained midwives like 32-year-old Shukria. A close relative of hers bled to death during childbirth when a traditional birth attendant tried to remove the placenta with her hand, but mistakenly pulled out her womb. This horrific moment has inspired Shukria to help others.
When Shukria started work in Chagcharan, the mullawi (religious scholar) told her she was an "infidel" and wasn't welcome. It wasn't until she helped his wife, who became ill during pregnancy, and he was also satisfied with her answers to some religious questions, that she was allowed to stay.
Our midwives are only allowed to travel with a close male relative, and each now runs clinics to reach many more mothers and children.
I was based in remote Hazarajat in Afghanistan back in 2001 when the US-led invasion occurred. We were told to evacuate, but it took three days to reach the capital, Kabul, on dirt roads, and by the time we got there the airport had been bombed. We managed to get to Pakistan and a local colleague skilfully negotiated our way across the border.
Security is always a concern. A few months ago a small army base, five minutes drive from our team house, came under attack and we were evacuated. A colleague told me not to worry as "the explosions weren't close until the windows rattled".
When the security is poor I need to travel wearing a Herati burqa – a big patterned black sheet that covers you completely except for your face. I find it difficult to handle and often trip over the ends.
This is the fifth time I have worked in Afghanstan since 2001, and I have seen countless changes. The government now has a health system. It has set up many more health centres and trained health workers at all levels.
The story of these midwives, and the personal sacrifices they make, is inspiring. My team has grown from eight people to 38. In the past year, with the help of a local NGO, we have trained nearly 300 people to teach basic healthcare and carry out growth monitoring for more than 20,000 mothers and children each month. More than 90,000 mothers and fathers now attend these groups across five districts.
Working against the odds in such harsh surroundings, these women are changing health practices and attitudes which, in turn, is saving countless lives.
• Dr Sarah Pickworth is public health specialist for aid agency World Vision
The Guardian
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