'Women and babies are dying from entirely preventable causes': Afghan midwives in desperate struggle between life and death

Since the Taliban's takeover a year ago, midwives at the Provincial Hospital in the Zabul province of Afghanistan have said they fear there will be a devastating increase in the maternal mortality rate over the next three years if funding to the country is not urgently increased.

The high maternal mortality rate is not new to Afghanistan. In 2002, the country had the highest ever recorded maternal mortality ratio – estimated at 1,600 deaths per 100,000 live births.

However, over the past 20 years, Afghanistan has managed to massively improve services and the rate has dropped by 60 percent to 638 deaths per 100,000 births.

"Without increased funding to get these health facilities fully functional again, we will tragically see many women die from entirely preventable causes"

This progress is feared to be reversed if funding to the health system is not reinstated and further expanded.

“Afghanistan’s health system is under an immense amount of pressure,” warned Nasr Muflahi, Country Director for INTEROS in Afghanistan.

“Already, hospitals are overstretched, and we are hearing worrying reports that this is becoming increasingly evident in the maternity units. Even before August, it was difficult for women to access health care when they needed it – now it is becoming even harder for them to do so. Without increased funding to get these health facilities fully functional again, we will tragically see many women die from entirely preventable causes.”

Rana* is one of the primary breadwinners for her large family in Afghanistan as her father can no longer work. The 25-year-old has delivered over a thousand babies in both hospitals and clinics all over the country.

During her years as a midwife, Rana has encountered challenges as she seeks to help mothers safely deliver their babies.

“A big problem is that women have very low status in their families here,” described Rana. “Sometimes women come to me and I see that their delivery is going to be complicated, so I tell them that I need to refer them to the hospital. They ask for my support to help explain to their elders why it is that they need to go.

"If they ask by themselves, they will not be allowed to go. Even when I do explain, the grandmother or mother-in-law will always say that it’s not necessary. Their attitude is that their mother and they themselves all delivered their children at home, so why should their daughter-in-law need special treatment? Then I have to explain that not only could their daughter-in-law lose her life but so could her baby. And it is only when I mention that the baby’s life is at risk, that they will start to listen. They only care about their sons and the children of their sons.”

When Rana sees patients who are severely anaemic, she questions them about their diets. “They tell me that they sometimes just eat dust to try and fill themselves up,” she said.

“And when I tell the elders that they need to bring some apples and meat for the pregnant women, they always resist – until I put the focus on the fact that it will mean that she can bring them a healthy and beautiful grandson. Only then do they become happy to do something to help them.”

"Without action to prevent the current situation from deteriorating further, it is predicted maternal mortality rates will rise by over 50% to 963 deaths per 100,000 births by 2025"

Over the last few months, Rana has seen conditions worsen for mothers and babies in clinics and hospitals. “When I first started working as a midwife in 2016, if any mother needed a caesarean section, surgeons were in the hospitals to do these operations.

"If a mother had a postpartum haemorrhage – which is the leading cause of death for women giving birth in Afghanistan – we had surgeons who could perform hysterectomies. But now, if I refer complicated cases from our rural clinic to the District Hospital, there are very few surgeons left there anymore," Rana explains.

"The funding has run out, so they haven’t been paid for months and they’ve left to look for work elsewhere. The lack of funding also means that hospitals don’t have enough equipment, and they don’t have enough medicines. I am very worried that we will see the maternal mortality rate increase by even more than 50 percent if these issues are not addressed.”

 The increasingly precarious situation Afghan midwives find themselves in has led Rana to doubt her future in midwifery.

“I feel like all the knowledge I have gained, the education I have got, and all the difficulties I’ve faced to build my career, have been for nothing,” she said. “Everything is going back to zero, to the starting point. To dust. At times I have felt completely hopeless.”

Immediately following the Taliban takeover in August 2021, the INTERSOS mobile health teams were prevented from visiting villages. Instead, people outside of cities had to attend static health facilities, leaving thousands of people without access to health care for months. By April 2022, the Mobile Health Teams were back in action and flooded with patients who had been desperately waiting for care.

Mantaha* is one of the midwives working with a Mobile Health Team in and around Kandahar. She and her team reach around 6,000 people in villages far away from healthcare facilities.

“All of the women want to give birth in a health facility,” said Mantaha. “But it is hard for them because there are no health facilities nearby. For some people, the nearest health facility is over a two-hour walk away, and they don’t have money to pay for the transport to get there.

"The economic situation has become a lot worse since the government changed, and when we go to the villages and to the remote areas, people are saying that for 5 or 6 days they couldn’t find anything to eat. They face a lot of problems. So our mobile clinic is a lifeline for them.”

For health clinics and mobile health teams to give adequate care to women and babies, they need international funding to kick back in.

“Although NGOs are stepping in and scaling up their work, they cannot fill the gap that has been left by the withdrawal of international funding,” explained Muflabi. “Ultimately, the continued freezing of aid will cause additional harm to women and girls – the very people that all those with an interest in the future of Afghanistan wish to protect.”

In addition to the lack of international funding, the repressive Taliban policies not allowing women and girls could impact future maternal death rates.

Jamila has been a midwife in Afghanistan for 23 years. As a child, she was discouraged by her family to get an education, but against all odds, she started a midwifery course and now works to help mothers and babies.

“The best bit about my job is how happy it makes the new mothers,” Jamila said. “The delivery process is very hard, but when I hand their baby to them, they hug and kiss me and say, ‘Alhamdullilah, how can I thank you for doing this for me?’

"She’ll kiss my hand and say that she would even kiss my foot because she’s so thankful that I helped her. It’s such a lovely feeling to see how much I’ve helped someone and how happy they are that their child has been born.”

Jamila worries that by not allowing girls and women to get a form of higher education, healthcare for women in Afghanistan will suffer in future years.

A new report from the charity Save the Children found 46 percent of girls are not attending school in Afghanistan. Girls interviewed by the charity expressed disappointment and anger over the fact they can no longer attend school and said they felt hopeless about their futures.

“It’s vitally important for girls to be able to study and go to school and university. Not only is it part of our religion, but we also need educated women in our society,” Jamila said.

“If we have female patients, we need female doctors. In our culture, women can’t see a male doctor, so if there’s no female doctor, where will women go? I can’t stress enough how important it is to have educated women. It is a desperate situation.”

Without action to prevent the current situation from deteriorating further, it is predicted maternal mortality rates will rise by over 50 percent to 963 deaths per 100,000 births by 2025.

“It is imperative that the international community and the governing authorities act now,” said Muflahi. “It will not only save lives, but it will also make it possible for us to continue building on the gains that have been made over the past 20 years so that Afghanistan can reduce its maternal mortality rate even further.”

Lauren Crosby Medlicott is a freelance features writer specialising in social justice issues.

Follow her on Twitter: @LaurenMedlicott