The New York Times
By CARLOTTA GALL

Afghan Motherhood in a Fight for Survival
May 25, 2003

Maleka, a birdlike woman of 30 with a wizened face, lay on the floor on a flat cushion, wrapped in a woolen shawl. Hours earlier, she had given birth to her sixth child, who, like three others before him, had not survived.

Afghanistan has among the world's highest rates of both infant mortality and maternal death because of difficulties during pregnancy or during childbirth. In this poor farming village in the Panjshir Valley northeast of the capital, Kabul, the death of Maleka's son was not unusual. That was clear from the relatives sitting with Maleka. Her aunt said she had lost 6 of the 10 children she had borne. Her mother-in-law had lost one of her six children, another relative had lost four. Maleka's sister-in-law was nursing a fragile infant girl, born prematurely just two weeks earlier.

Millions of women across rural Afghanistan live in a constant cycle of pregnancy and birth through most of their adult lives with little or no medical care. It is not uncommon to meet mothers of 10 or 15 children, and they seem old before their time from the physical strain. The combination of poor health and nutrition, lack of skilled medical care, the remoteness of their villages and the cultural traditions that forbid women from seeing male doctors all take a toll on women and their children.

The maternal mortality rate in Afghanistan is the highest in the world, according to Dr. Peter Salama, director of Unicef in Afghanistan. Final results of a study conducted last year by Unicef and the Atlanta-based Centers for Disease Control and Prevention are to be released in coming weeks and are expected to show a national ratio of more than 2,000 maternal deaths per 100,000 live births. Afghanistan also has the fourth highest rate of infant mortality and deaths of children under 5, ranking behind only Sierra Leone, Angola and Niger, according to Unicef. Babies whose mothers die in childbirth have only a one in four chance of surviving to their first birthday, Dr. Salama said.

Almost half of the deaths of Afghan women from 15 to 49 are caused by complications during pregnancy, or by childbirth itself, the study found. The researchers state that 87 percent of the maternal deaths they investigated could have been prevented with better medical care. It is not known how many children die during childbirth or its complications, but nearly a quarter of the maternal deaths investigated in the survey resulted from obstructed labor, which means that in most cases the baby died with its mother before delivery

Death rates vary significantly between Afghanistan's urban and rural populations, with the rural areas, where there are few skilled medical professionals and no comprehensive medical care, far worse off. Only 6 of Afghanistan's 32 provinces have hospitals that can perform blood transfusions and Caesarean sections. Foreign health experts working in Afghanistan foresee no quick solution to the alarming mortality rates of mothers and young children.

The entire life cycle of women here is to blame, Dr. Salama said. In addition to inadequate medical care, he cited poor nutrition; stunted growth, which causes difficulties giving birth; a lack of education; teenage marriages and women's low social status.

Overcoming these obstacles will take years. None of the women in Maleka's extended family, for example, has ever made the six-hour journey to Kabul, which has the closest maternity hospital, to give birth. All delivered their children at home, with just the help of female relatives and, in the last few years, of Bibi Gul, a village woman with some rudimentary training in assisting at births. An illiterate mother of five, Mrs. Gul has been working for 30 months at an outpatient clinic for mothers and children here in Safed Cheher. She arrived just before Maleka gave birth, but was unable to help.

Although Safed Cheher is fortunate in being one of the few villages to have such a clinic, only a small percentage of the women living in the surrounding area visit it, according to Myriam Modrin, a French midwife working with Aide Medicale Internationale, or A.M.I., a French agency that runs the clinic. "If they live far away from the clinic, they have to walk, so they do not come," she said.

In a society in which women rarely leave their family compound and never show their face to a male other than their husbands or blood relatives, Afghan village women rarely see a doctor at all. The few doctors who work in rural areas are invariably male. Female doctors and other health workers tend to work in the cities, given the cultural restrictions on women's movements in villages.

Most village women, for their part, are illiterate and cannot qualify for any medical work beyond that of assistant midwife, said Zakia Kohistani, an Afghan midwife who trains women through A.M.I. Mrs. Gul said that when she first began working for the French agency two and a half years ago, she spent months visiting women in their homes with a French midwife, trying unsuccessfully to persuade them to visit the clinic. "The husbands did not want to send their wives to the clinic," she said. "When a woman dies or is sick it is no problem for the husband. They do not bring them to the clinic."

Sometimes the men's desire to preserve the family honor runs stronger than their concern for the women, said Ms. Kohistani, 25, who worked for three years in an A.M.I. hospital in eastern Afghanistan. More than once, she said, husbands refused to allow a male surgeon to operate on their wives, even when they were in mortal danger. She described anesthetizing one woman who had a ruptured cervix, and secretly bringing in the surgeon in order to save the woman. "We saved her life," she said. "No one in the family ever knew she had been attended to by a male surgeon." Illiterate village women can also suffer through the ignorance of poorly trained health workers, or by heeding superstitious traditions or even harmful if well-intended advice from the local mullah.

One patient from the village of Khenj, a few miles downriver, who recently visited the clinic here had lost 10 of her 15 children, Ms. Modrin said. All 10 had died within two months of birth, probably from malnutrition because their mother, on instructions from the local mullah, had tried to give them cow's milk instead of breast- feeding them. "I would like to meet the mullah of Khenj," Ms. Modrin said.

During four days of consultations in Safed Cheher, Ms. Modrin found herself constantly reassuring women that breast-feeding was beneficial for their babies. Ms. Modrin said another of her patients had been in labor for hours with her first baby until her family finally took her to a hospital that delivered it by Caesarean section. Even after that experience, she tried to deliver the second baby at home. That baby was also malpositioned and died, while the mother's uterus was so badly ruptured that she will never have any more children.

"There is no idea of preventative care," Ms. Modrin said. Women, she said, "usually come to the clinic only when they have pain," not for regular examinations during pregnancy. Most of her 30-odd patients on one day were not pregnant, but desperate to become so. Such is the pressure on Afghan women to have large families, particularly sons, that women had been medicating themselves with fertility drugs and having too many pregnancies too close together, she said. A 19-year-old came in with powerful drugs purchased in Kabul to stimulate ovulation, and she was asking how and when she should take them. Another 20-year-old, already the mother of two, was worried that she had not become pregnant since her last baby, who was 2 years old.

"It is a huge problem here for women who have not had children, or who cannot," Ms. Modrin said. "It is a catastrophe." The older women, among them a mother of 12, said they were weary of constant childbearing, but hesitated to take any advice about family planning because they said their husbands would oppose it. As for Maleka, who has only two children after the death of four others, there was no question whether she would try for more children. "Of course she will," one of the older women answered for her.