By Farida and Dr Mohammad Naseem in Kabul (ARR No. 45, 24-Jan-03)
Afghanistan's remote Badakhshan province currently holds a grim world record that no other place on earth will be keen to challenge. Last year, 6,500 women died giving birth in the region - a mortality rate of 64 per cent.
After 23 years of bitter war, Afghanistan is one of the poorest countries in the world. Its midwives are untrained, facilities are poor, and there is a shortage or complete absence of beds in maternity hospitals.
The startling statistic from Badakhshan - and other less dramatic but still disturbing ones from other parts of the country - have prompted international and local health organisations to work together on a crash training course for midwives who can step in where there are no proper medical facilities available.
Shairose Mawji, a representative of the United Nations International Children's Fund, UNICEF, in Kabul, told IWPR that - in addition to the Badakhshan statistics - 2,200 pregnant women died last year in Nangarhar province, and 800 each in Laghman province and Kabul.
"We estimate that half of the pregnant women die due to lack of facilities. In Kabul, where there is one maternity hospital, the mortality rate was 16 percent. However, in Badakhshan, where there is very limited access to medical facilities, it was 64 percent. That is the highest rate in the world."
With such a shortage of facilities and trained staff, the death of a mother in childbirth means that the chances of the child surviving are slim.
"If a mother of a new-born baby dies, the chances of its survival are 25 percent," said Linda Barteh of the United States Centre for Disease Control and Prevention.
"Most of them die in the first month of their life because they have no access to their mother's milk."
She added that haemorraghing was the most common cause of death during childbirth.
According to health workers, conservative traditions in many families - which prevent a woman from being treated by a male doctor - also play a crucial role. The same customs also prevent women from seeking an education and becoming medics themselves. The handful of female physicians working in the relatively liberated capital are seldom willing to do so in the provinces.
Mina Sherzoy, who recently returned from two decades living in the United States to found a local women's group called the World Organisation for Mutual Afghan Network, WOMAN, said poverty was one of the major causes of mortality among mothers and babies.
"Our people are so poor that they are unable to provide proper food for expectant mothers - and if they don't eat properly, their child may die in the womb or soon after birth," she told IWPR.
The main problem in Khost province, which lies south-east of Kabul and borders on Pakistan, is a lack of maternity beds.
"There is not one maternity hospital in the province - and Khost Hospital has only two beds for pregnant women," Dr Sayed Anwar Yusofzai, head of Khost's Public Health Department, told IWPR.
Khost resident Hamed told IWPR that his daughter, now aged three, was born a deaf-mute. "Doctors said this happened because she was delivered at home," he said.
Gul Makai said she had complications while giving birth at home, and after two days went to Khost hospital. There, doctors told her that her baby had died in the womb, which had then become infected. She had to have a hysterectomy as a result. "It was my first child. Now I will never be able to have any," she said.
In many rural areas where there are no hospitals or doctors, midwives are helping women give birth in their homes. But many of these lack even the most rudimentary medical training - a large proportion are illiterate - and work with traditional methods handed down through generations.
A local health worker said it is common practice for some midwives to rattle something if a baby fails to cry after birth, "If the baby wakes up, it is alive. If it doesn't, they assume the child is dead. It is likely that dozens of babies have been buried alive after being wrongly diagnosed like this."
Recognising these problems, a number of groups including the International Medical Corp, IMC, have set up five training centres in the provinces. Around 20 trainers at each base give midwives enough basic instructions to enable them to help in normal births - and to recognise emergency cases where the woman needs to be taken to hospital.
"Trained local midwives have a valuable role in reducing the number of deaths of newborn babies and their mothers," IMC's local medical coordinator Dr Jamaluddin Javed told IWPR.
"We give them a basic course lasting 15 days, and they undergo regular five-day refresher courses after that. At the end they are given medical equipment, and certificates so that women know they are qualified."
One local midwife, who had just finished the course, told IWPR, "To tell you the truth I didn't have any proper training before, and was helping women give birth using advice from elders of my region.
"Some mothers and babies died as I was trying to help them, but I comforted myself by telling myself they were in poor condition and would have died anyway."
Farida is a radio journalist working in Kabul. Dr Mohammad Nassem is a doctor working in Kabul.