Expectant women across the world are concerned about how their births will go. But the women of Badakshan, a rugged province in northeastern Afghanistan, have reasons to be genuinely afraid. Jackie Dent reports.
It is a sunny afternoon in Dehkalan, a remote village which clings to the side of a steep hill. Children chase goats across the roofs of buchi or mud houses that overlook a brown river.
Around 20 women, clad in colourful translucent veils and thick strands of pearls, sit huddled under a small veranda, gazing at a blackboard.
"In the name of Allah, most Beneficent, most Mercifu, l Afghanistan is an Islamic country. Afghanistan is located on the Asian continent," is chalked across the board.
The students are aged between 15 and 35 but they look much older, worn from the endless quest to find food, as well as the effects of chronic diseases like malaria and tuberculosis.
Surat, who doesn't know her age, is a widow who looks after her eight children. Karmagal, 25, has five children and spends her days milking cows and cooking bread.
These women have come to learn to read and write, as well as basic health and nutrition skills.
"Vaccinate your newborn baby. The best food for children between four and six months old is mother's milk. Keep your nails clean."
Tragically, these students are a blueprint for many poor women in Afghanistan: illiterate, diseased, married at a young age with many children, their lives limited by patriarchal practices embedded within the culture.
But the women of Badakshan province carry an extra burden: they are more likely to die in childbirth than anywhere else in the world.
Badakshan, in mountainous northeastern Afghanistan, has the feel of another age.
The main roads that weave into Faizabad, the main centre, are often clogged with shepherds herding their flocks of sheep. There are few electricity poles. Donkeys and walking are the main modes of transport.
Young children sit by the side of the road with little to do but gaze out at the landscape, which despite its beauty enforces a difficult life upon its inhabitants - 93 percent are illiterate, life expectancy is around 42 years of age and only one in five communities has safe drinking water.
It is only June but, in Dehkalan, 15 women have already died in labour this year, through loss of blood and obstructed labour. It is unsurprising.
Local birth attendants have limited skills and no equipment. The nearest hospital is in Faizabad, which is at least a four-hour walk away.
Nobody in the village owns a vehicle, and travel by donkey for a sick, pregnant woman along bumpy, mountainous roads is nearly impossible. In winter, the village gets snowed in.
Often, the only option is to call the local mullah and pray for the pain to go away.
Badakshan health facilities for its 725,000 inhabitants 98 percent of whom live in rural areas, are dismal.
According to the Afghanistan Ministry of Health, there is one hospital in Faizabad and 30 clinics spread throughout the rest of the province. In Argo, where there is a population of 100,000, there is only one doctor permanently living in the area.
Dr Najlah Zarifi works in Faizabad hospital, the only facility in the province that can deal with emergencies, such as a caesarean.
Zarifi was so concerned about the lack of care for women that she left paediatrics two years ago and shifted to obstetrics.
She says there are few experienced doctors in Badakshan health centres and overcrowding is a problem.
"Sometimes we run out of space, so we ask the patients to sleep on the ground in the corridors. We know it's not proper, but we have no choice, we have to," she told WFP.
"People cannot reach health centres because they live in remote areas, and health personnel can not reach them either," she said.
"For example, from the Darwaz area in Badakshan, people travel for three days by animals, either donkey or horse, and an additional three days by car to reach Faizabad. There are many cases of mother and child dying on the way."
Plans are underway with Afghanistan 's Ministry of Health, UN agencies, USAID and a handful of NGO's to improve the dire situation, particularly for emergency deliveries.
The World Health Organisation (WHO) is actively involved in training community midwives, and also supports Faizabad hospital with drugs and equipment such as forceps.
WFP supports classes such as the one in Dehkalan. To encourage attendance at these classes, WFP gives the women a monthly ration of wheat, oil and pulses.
Without these incentives, the majority of these housebound women would not be permitted by their husbands, fathers or brothers to attend.
The alarming maternal death rate in Badakshan - the highest ever recorded - was only identified in 2002.
A team of researchers led by Dr Linda Bartlett conducted a nationwide study and discovered Afghanistan had the highest level of maternal mortality in the world.
Almost half of all deaths among women aged 15 to 49 were a result of pregnancy and childbirth.
In the United States, 17 in 100,000 women die from childbirth. In Afghanistan the figure jumps to 1,900. But for Badakshan the statistics are 6,500 per 100,000.
Bartlett's report, published in The Lancet in March 2005, showed that 78 per cent of deaths could have been prevented.
While globally women tend to die in childbirth from haemorrhage, in Badakshan, the leading cause was obstructed labour.
The high number of obstructions has been attributed to a raft of reasons, including a lack of exposure to sunlight, giving rise to growth stunting, poor literacy and having babies at too young an age.
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