Afghanistan is among the worst countries in the world for deaths in childbirth, with one woman dying every two hours.

An estimated 40 percent of Afghan women give birth at home, but that figure increases to 80 percent in remote areas, where they go through the process often with the help of their mother-in-law or a local matriarch, but sometimes alone. [Kobra Akbari/AFP]

Zubaida travelled from the rural outskirts of Khost in eastern Afghanistan to give birth at a maternity hospital specialising in complicated cases, fearing a fate all too common among pregnant Afghan women – either her death or that of her child.

She lay dazed, surrounded by the unfamiliar bustle of the hospital run by international medical charity Doctors Without Borders, known by its French initials MSF. She was exhausted from the delivery the day before, but also relieved.

Her still-weak newborn slept nearby in an iron crib with peeling paint, the child’s eyes lined with kohl to ward off evil.

“If I had given birth at home, there could have been complications for the baby and for me,” said Zubaida, who doesn’t know her age.

Not all women who make it to the hospital are so lucky.

“Sometimes we receive patients who come too late to save their lives” after delivering at home, said Therese Tuyisabingere, the head of midwifery at MSF in Khost, the capital of the eastern province of Khost.

The facility delivers 20,000 babies a year, nearly half of those born in the province, and it only takes on high-risk and complicated pregnancies, many involving mothers who haven’t had any check-ups.

“This is a big challenge for us to save lives,” said Tuyisabingere.

She and the some 100 midwives at the clinic are on the front lines of a battle to reduce the maternal mortality rate in Afghanistan, where every birth carries major risks and with the odds against women mounting.

Afghanistan is among the worst countries in the world for deaths during childbirth, “with one woman dying every two hours”, said Stephane Dujarric, the spokesperson of United Nations Secretary-General Antonio Guterres, this month.

The Afghan Ministry of Public Health did not respond to requests for comment.

According to the latest World Health Organization (WHO) figures, from 2017, 638 women died in Afghanistan for every 100,000 viable births, compared with 19 in the United States.

That figure conceals the huge disparities between rural and urban areas.

Terje Watterdal, country director for the non-profit Norwegian Afghanistan Committee (NAC), said they saw 5,000 maternal deaths per 100,000 births in remote parts of the country.

“Men carry the women over their shoulders, and the women die over the mountain trying to reach a hospital,” he said.

Before the return to power of the Taliban in August 2021, women would sometimes have to brave the front lines to reach help, but now there are new challenges – including a ‘brain drain’ of expertise. [Kobra Akbari/AFP]

‘A lot of gynaecologists have left the country,’ said Terje Watterdal, country director for the non-profit Norwegian Afghanistan Committee (NAC). Taliban authorities also want to get rid of the mobile medical teams visiting women because ‘they cannot control the health messages they were giving’, he added. [Kobra Akbari/AFP]

Under the Taliban government, women have been squeezed out of public life and their access to education has been severely restricted, threatening the future of the medical field in a country where many families avoid sending women to male doctors. [Kobra Akbari/AFP]

‘Access to antenatal and postnatal care for a woman was [always] extremely complicated. It’s even more complicated today,’ said Filipe Ribeiro, MSF director in Afghanistan. [Kobra Akbari/AFP]

The financial strain on families amid the country’s economic crisis increases the risks, said Noor Khanum Ahmadzai, health coordinator for nongovernmental organisation Terre des Hommes in Kabul. Despite the risks, ‘women who used to go to the public sector now prefer to deliver at home, because they don’t have money’, said Ahmadzai. [Kobra Akbari/AFP]

In a public hospital, where the midwives are overworked and poorly paid, women have to bring their own medicine. A delivery costs about 2,000 Afghanis ($29) – a significant sum for many families. [Kobra Akbari/AFP]

Islam Bibi, pregnant with triplets, went to the MSF facility in Khost in pain, and empty-handed. ‘I was sick, my husband didn’t have any money. I was told, ‘Go to this hospital, they do everything for free’,’ said the 38-year-old, one of hundreds of thousands of Afghans who fled Pakistan in recent months, fearing deportation. [Kobra Akbari/AFP]

Multiple births like Islam Bibi’s are common, said Tania Allekotte, an MSF gynaecologist from Argentina. ‘It is valued here to have many children and many women take a treatment to stimulate their fecundity. We often have twins here,’ she said. [Kobra Akbari/AFP]

Women, on average, have six children in Afghanistan, but multiple pregnancies, repeated caesarean sections or miscarriages increase the risk of death. [Kobra Akbari/AFP]

Women in neighbouring Paktia province may have fewer risks now, thanks to a first-of-its-kind maternity centre opened recently by NAC in the small provincial capital Gardez – a clinic run by women for women. [Kobra Akbari/AFP]

‘This type of clinic doesn’t exist in the majority of provinces,’ Khair Mohammad Mansoor, the Taliban-appointed provincial health director, told an all-male audience. ‘We have created a system for them in which sharia law and all medical principles will be observed.’ [Kobra Akbari/AFP]

The NAC facility aims to help ‘many of our sisters who live in isolated areas’, manager Nasrin Oryakhil said, with similar clinics planned for four other provinces in the coming months. [Kobra Akbari/AFP]