- The Washington Times - Saturday, December 27, 2008

FAIZABAD, Afghanistan | When Azada went into labor high in the Hindu Kush mountains, it started an odyssey that lasted 72 hours and covered 60 miles of forbidding terrain.

The journey for the 20-year-old mother of two, who like many Afghans uses only one name, included a trek atop a mule and a bone-crushing drive in a battered rental car over winding paths, through deep gorges and around craggy peaks.

Stops at a clinic near her home and at another poorly equipped health facility offered insufficient help, forcing Azada and her family to trudge on to Faizabad, a provincial capital in Afghanistan’s remote northeast corner.

Azada’s ordeal ended in a hospital. After three days of intense labor, her child was stillborn, she suffered a ruptured uterus and underwent a hysterectomy.

Yet she was fortunate for an Afghan woman: She survived her pregnancy.

“We see patients like this all the time,” said Dr. Waquili Kareem, a physician at the Faizabad hospital. “Many die on the way here.”

Afghanistan’s struggle to provide basic human services underscores the fragility of a government also facing terrorism, drug trafficking and insurgency.

Afghanistan has the second-highest maternal mortality rate in the world, after Sierra Leone, according to the United Nations Children’s Fund (UNICEF). For about every 62 infants born here, one mother dies during pregnancy, in labor or during the postpartum period. The resulting rate of 1,600 maternal deaths per 100,000 live births is five times higher than in neighboring India and 123 times the rate in the United States.

The province of Badakhshan where Azada lives is one of the worst areas.

The province’s Ragh district had the highest rate of maternal mortality recorded, according to a 2002 U.N. survey, with a staggering 6,500 maternal deaths per 100,000 live births.

Medical professionals point to several reasons, notably the lack of facilities, impassable roads that can isolate pockets of the population for months and the dearth of medical professionals to treat and educate citizens.

“They don’t recognize the danger signs and there are no doctors where they live to help,” said Dr. Hajera Zia Bahrastan, 53, chief of the maternity ward at the Faizabad hospital.

“Many of those women who know they are in trouble either can’t afford to travel to a hospital in a city or are unable to reach one because the roads are closed,” she said.

Further complicating matters, the Islamist values of many prohibit male doctors and health workers from examining women or assisting during childbirth. To deal with this complication, all six physicians in the maternity ward of the Faizabad hospital are women.

“Women would never come to this hospital if there were no female doctors,” Dr. Bahrastan said. “They will die before they see a male doctor.”

In an effort to address these problems, the Afghan health ministry is training midwives in far-flung areas of this nation of 32 million people.

In recent years, 2,000 women have trained to assist in childbirth across Afghanistan, according to the health ministry, and the government plans to instruct 8,000 more in the next five years.

In Badakhshan, 38 women have completed an 18-month education program, with 120 others to receive training in the next three years.

The program’s clinical coordinator, Rona Azamyar, said women are recruited where there are few or no health services and then return to their communities.

Because most towns and villages in Badakhshan offer no high school-level classes for girls, prospective students for the midwife services require only an elementary school education. The new midwives can earn up to $350 monthly - a premium salary in this impoverished country.

Momina Hanifa, one of 26 women enrolled in the program, said she was motivated by the pay and the chance to help her community.

“We have a very high rate of maternal mortality where I live and I saw a chance to help,” said Mrs. Hanifa, a 20-year-old mother of one from Ragh district.

The new midwives are having an impact.

Homa Samadiya, 26, said she has assisted in 84 deliveries without a death during her first seven months in the town of Dharaim, a three-hour drive from Faizabad.

However, five women who couldn’t reach her clinic died giving birth at home.

“We encourage the women to come to the clinic four times for prenatal examinations during their pregnancy, but many live too far away,” Mrs. Samadiya said.

Along with midwives, the number of health facilities in the province also is slowly rising.

In 2002, only 14 clinics and one hospital were available in Badakhshan. Today, there are 52 clinics and two hospitals, according to Dr. Zahir Fazil, a physician who directs UNICEF’s Faizabad office.

During the past 10 years, the number of women delivering in Faizabad’s hospital has jumped from about 100 to 3,100, Dr. Bahrastan said.

Still, the maternity ward is filled with women injured by pregnancy and birth.

Near Azada is a woman named Minna.

She is 22 and suffered severe tearing during the delivery of a stillborn, despite help from a midwife. She had no alternative but to travel 10 hours to Faizabad to have her wound repaired.

When asked whether she planned to expand her family in the future, Minna replied immediately and emphatically.

“No! No!” she said, closing her eyes and wincing, as if experiencing the pain of her last delivery again. “I’m not having any more children.”

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