Ted Richardson
When Fawzia went into labor with her fifth child, she knew something was wrong. She felt like her insides were being ripped apart by knives. She bled so much that her clothes were soaked. "I did not want to die," recalls Fawzia, 25, who, like many rural Afghans, only uses one name. "I prayed and hoped the pain would go away. But when it didn't, I asked to go to a hospital."
Fawzia, an ethnic Hazara from Jaghori district in the volatile center-east province of Ghazni, had never been to a hospital, and says she had no idea where to find one. She had given birth to her other children at home, and the closest clinic is a two-hour drive away. When she got there, the staff said they couldn't help her. Go to Kabul, they said. It took another 10 hours to drive to Rabia Balkhi, a women's hospital in central Kabul that offers free services to impoverished women.
By then, Fawzia had lost so much blood that doctors were worried she wouldn't make it. Dr. Taiba Motaqi, 30, a resident in obstetrics, knew right away that the young woman had a ruptured uterus. The complication is rare among pregnant women in the developed world, but it kills many Afghan women each year. Fawzia underwent an emergency C-section, a common procedure at Rabia Balkhi Hospital. "Women come here with problems like this at the very last minute," Dr. Motaqi says. "We have to work quickly to save them."
When Fawzia got married 10 years ago, the Taliban were still running Afghanistan, and women's rights were at a nadir. Most women gave birth at home, and the few who managed to venture to hospitals often discovered that the facilities were understaffed and lacked equipment and medicine. In late 2001, the U.S.-led military campaign pushed the Taliban out of power, and since then, millions of dollars in U.S. and foreign aid have gone to help build clinics and hospitals and train health workers. It was supposed to be a new beginning for Afghan women marginalized by the Taliban's brutal and theocratic rule. But a decade later, Afghanistan still ranks as the worst country in the world to be a mother.
About 18,000 Afghan women die during childbirth every year, says the Afghan Health Ministry. According to a recent report by the NGO Save the Children, Afghanistan ranked as the worst place to give birth, followed by Niger and Chad. In these countries, 60% of all births are not attended to by skilled health professionals. On average, about 1 in 23 mothers are expected to die from pregnancy-related causes. Children also die young and suffer from malnutrition, and education for girls is poor.
Often the challenge is just getting women to hospitals. Rural Afghans, even in relatively progressive provinces like Bamiyan in central Afghanistan, are suspicious or dismissive of doctors. In the town of Bamiyan, the main hospital has a new maternity ward. But head midwife Sediqa Hosseini says many of the 25 beds in the ward are often empty. On a recent summer afternoon, Hosseini, a tiny, serious woman in a baby blue headscarf, greets the 12 women who have checked in. One is Fatima, a 25-year-old farmer's wife. "When Fatima arrived, her baby was coming out shoulder first," Hosseini says. "She had to have a C-section. Without help, both of them would have died."
Fatima says her husband took her to the hospital when her labor became so painful that she was doubled over. Hosseini says few husbands would have done the same. Many rural men prefer to pray with a mullah to cure illnesses, she says. "They believe this is more reliable than medicine." As she breast-feeds her newborn daughter, Fatima says she wouldn't have gone if it had not been for a community-health worker who told her hospitals are safe and free.
Adding to the problem is that rural Afghan women are also conservative, and some are ashamed of being pregnant because it's a public acknowledgement of sex with their spouses, says Gulpari, a midwife in Bamiyan's remote Sayghan district. Sayghan is a dusty, wind-lashed stretch of bare mountains, cratered dirt roads and some 60-odd villages of compact mud huts. Gulpari lives in the village of Khudadadkhel, where she works at the small, understaffed Sayghan clinic that mostly treats stomach ailments and lung diseases.
Most of Sayghan district's residents are Tajiks who are Sunni and far more conservative than Bamiyan's main ethnic group, the Shi'ite Hazara. Hazara women were liberated enough to take up arms against the Taliban in the 1990s. The Tajik women rarely leave their homes, Gulpari says, but she's managed to convince some of them to let her help them when they give birth at home. "In 15 years, I've never lost a mother," she says.
Gulpari says she decided to do this work when she was a girl and watched a relative who was a midwife help a scared young woman give birth to her first child. She began apprenticing while the Taliban was running Afghanistan, and many men threatened her for doing what they deemed "dirty work." Now she says even conservative men in her village accept the value of what she does. The Community Midwife Education Program, financed by the U.S. Agency for International Development, has trained thousands of rural Afghan women to work as midwives, according to a recent report by the Council of Foreign Relations think tank.
But in many rural areas, there is still a shortage of midwives — Gulpari says she's only one of four midwives for at least 40,000 people in the area. "I'm not fooling myself," she says. "There are so many women, probably thousands, that I don't see. That I will never see. Some live in ravines deep in the mountains that take days to get to because you can only go by foot or donkey. I'll never know what happens to them."
Even women like Fawzia, the young mother from Ghazni, who are determined enough to get to urban hospitals, face other problems. Many hospitals don't have the money to stock medicine and instead send patients to street markets to buy drugs that are often fake or mislabeled, says Dr. Faizullah Kakar, an epidemiologist and special adviser on health to Afghan President Hamid Karzai. "Even if they are the right drugs, it wastes time to go out and buy them," says the doctor, who has worked with U.S. doctors who trained staff at Kabul's Rabia Balkhi Hospital. The Afghan Safe Birth Project, funded by the U.S. Department of Health and Human Services, has helped reduce deaths during C-sections at the hospital by 80% between 2008 and '10 by providing medicines as well as good training, says Dr. Kakar. The project at Rabia Balkhi was supposed to be a model for other Afghan women's hospitals to follow. But in April, the U.S. government cut the program's $5.8 million annual funding, and Dr. Kakar says the Afghan government doesn't have the money to keep it going. By October, the hospital will no longer be able to buy medicine. "I'm worried we will once again have an epidemic of mothers dying here," he says.
The doctor is also worried about what the budget cuts will mean for Afghan infants. In 2008, UNICEF reported that 52 out of every 1,000 Afghan infants died within the first two weeks of birth. That's a rate 10 times higher than in the U.S.
More than 22,000 babies are born in Rabia Balkhi Hospital every year. Dr Motaqi, the resident in obstetrics, isn't married and doesn't have children of her own, but the shy, intense doctor often visits the hospital's neonatal unit, which smells like rubbing alcohol and powder. There are healthy babies there, but on a recent afternoon she stops near a boy who is tiny and almost still. His skin is tinged blue, and he flutters his eyelids, which are crusty with dried tears. Dr. Motaqi clasps his miniature hand between her thumb and forefinger. "He was born too soon, and he came out the wrong way," she sighs. "He's going to die."
The doctor walks back to Fawzia, the mother from Ghazni province, who lost her son on the drive to the hospital. "I felt him stop moving," Fawzia says, curled up in her hospital bed. She's sleepy from the anesthesia. Dr. Motaqi sits on the edge of Fawzia's bed and tries to manage a smile.
— With reporting by Karim Sharifi / Kabul; Moneer Nyazi / Bamiyan
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