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Ten years ago there was not a single midwife in the Afghan town of Baharak. Today there are four and the number of women dying in childbirth has fallen dramatically.
Care may still be basic by Western standards, but new midwives like Nasira Karimi mean that in 10 years Afghanistan has seen a staggering improvement in maternal health.
Experts warn these gains are precarious and fear progress could be threatened after NATO combat troops withdraw from Afghanistan by the end of 2014, when some predict the country will descend into renewed civil strife.
Karimi, 24, says stories about the horrors of childbirth convinced her to apply for a coveted place on a two-year course training midwifes to go back into their communities.
“I heard so many stories about women who died in these circumstances when I was young… There is even a word in Dari, ‘Sarefarzan’, which means dead in childbirth,” she told AFP in Baharak, north of Kabul in the Hindu Kush mountains.
In 2000, one in 12 women died as a result of pregnancy and childbirth. In 2010, it was one in 32, according to the World Health Organization (WHO), which ranks only 20 other countries, including 18 in Africa, as having a worse rate.
The situation in Badakhshan, Karimi’s home province, was particularly dire.
According to UNICEF, 6,500 out of 100,000 women died as a result of pregnancy, childbirth or post-delivery complications in Badakhshan in 2002, compared to a national average of 1,600.
AFP could not obtain any recent statistics from the province, but Karimi says the situation has improved significantly.
“Today women from Baharak rarely die from pregnancy,” she said.
National child mortality figures are also down. In 2009, one out of five children did not reach their fifth birthday, according to UNICEF, but today it is one in 10, according to the Afghan health ministry.
Tragedies still occur as a result of ignorance or transport problems in a region where villages can be cut off by snow for up to six months a year.
“Two months ago, a woman died after delivering. She had a haemorrhage. We told her brother and her husband that she had to go to hospital in Faizabad. But they refused. We couldn’t do anything for her, so she died,” one of Karimi’s fellow midwives said.
Even if the family had agreed, the woman would still have faced a bone-crunching two-and-a-half hour journey over potholed roads spanning the 45 kilometres (30 miles) to the provincial capital.
Karimi is a product of a programme run by the Agha Khan Foundation, which between 2005 and next spring will have trained more than 100 midwives.
At the provincial training centre in Badakhshan’s capital Faizabad, 30 young women soak up the words of the instructor and do exercises on the blackboard.
“The students, chosen by their community, have to pass an exam before being taken on. Everyone makes a written commitment to working for at least five years in their community,” says Sairam Saadad, the coordinator of the programme.
“In 2010, there were only four midwives in Badakhshan, all based in Faizabad. Now there 28 districts are all covered. It’s a success!” she said.
But as NATO’s 2014 deadline approaches, fears are growing that the gains made since the end of Taliban rule in 2001 could be under threat, and in September insurgents launched an attack in Warduj district, near Baharak.
Doctor Soroush Janbush, who works at the hospital in Baharak, said in the wake of the attack patient numbers fell from 400 a day to 120.
“When people are frightened, they stop coming to the hospital,” he said.
There are also financial issues. In July, the international community committed $16 billion for Afghanistan until 2015, conditional on democratic elections as well as progress on fighting corruption and promoting human rights.
But without this money the government will not be able to maintain health programmes.
“In 2002, the situation was there,” said Janbush, drawing a basic graph on a piece of paper and pointing to the bottom.
“Since 2012, we have progressed, but we can also go back very quickly to the point of departure,” he added, drawing the curve up — and then back down.