Giving birth is a life or death struggle for women in Afghanistan, where roughly one mother is believed to die every two hours from preventable pregnancy and childbirth complications.
Even mothers who survive face the stark reality that their newborns may not, with the Taliban's Health Ministry estimating 22 children die for every 1,000 live births.
"Why would a woman need to go to the hospital?" 31-year-old Zia Gul, a resident of the northern Parwan Province, recalled her husband saying during her difficult pregnancies. "There are only men at the hospital; there are no female doctors."
Gul told RFE/RL's Radio Azadi that her husband's refusal to let her see a doctor contributed to the loss of two of her newborn children.
Gul's experience is in line with those of many Afghan women, particularly in conservative rural areas, who are bound by the Islamic custom of mahram. The practice prohibits women from leaving their home without a male relative, bars them from being treated by male doctors, and gives them little say in their own health decisions.
Nurses deliver a baby in the maternity ward of a hospital in Mazar-e Sharif.
But the traditional customs enforced by Gul's in-laws, who allowed no discussion on the matter, are just one of the many factors that contribute to high maternal mortality in Afghanistan's deeply patriarchal society.
Years of political upheaval, economic woes, the exodus of medical professionals, low literacy and public awareness on health issues, poor infrastructure, and the lack of access to medical care in remote areas all add up to astonishingly high maternal mortality rates.
Among The World's Worst
According to statistics compiled by the World Bank, the United Nations Population Fund (UNPFA), and other UN agencies, 1,450 mothers were dying for every 100,000 live births by 2000, shortly before the Taliban was ousted from power.
Over the course of the next 20 years, due to increased funding and attention paid to maternal health care and awareness by the UNPFA, international aid agencies such as Doctors Without Borders (MSF), and the Afghan government, that number was cut by more than half to 620 deaths by 2020.
The Taliban's seizure of power in August 2021 raised fears that the extremist group would reimpose the draconian policies of its first stint in power from 1996-2001, including the banning of female education and employment as it enforced mahram.
Many of those fears have been realized. Girls above the sixth grade have been barred from attending school, women are banned from pursuing university education, and women are no longer allowed to work for international aid agencies. Marham is also more prevalent, with women officially required to wear the all-encompassing burqa and remain at home unless accompanied by a male relative.
Once again, according to Aleksandar Sasha Bodiroza, the UNFPA's representative in Afghanistan, women's ability to freely access health facilities to seek maternal and newborn care has been restricted.
No outside nationwide statistics have been made available since 2020, but the Afghan Association of Obstetricians and Gynecologists, citing recent figures from the Taliban-led government's Health Ministry, told Radio Azadi that the maternal mortality ratio has risen only slightly under Taliban rule.
While the figure, 638 maternal deaths per 100,000 live births, is the same number recorded by the international community in 2017, it is still high enough to rank Afghanistan among the world's 10 worst in terms of maternal mortality.
That the situation has remained relatively stable is also difficult to fathom, considering the vast numbers of doctors who fled the country as the Taliban regained power, the country's dire economic situation and multiple humanitarian crises, and the increased pressures on aid workers and on Afghan women.
The state health-care system, propped up by foreign aid for two decades, has also suffered from a dramatic drop in international funding since the Taliban takeover.
Health workers and outside agencies say the damage done to the health sector is undeniable.
"The system has changed in our country. Naturally, it had an impact on the country's economy and the services that the government provides to the people," Hamid Jabari, an Afghan physician who was expelled from the country by the Taliban, told Radio Azadi. "The negative effects are being felt, including the lack of professionals in government, especially the health sector."
A newborn baby is cared for at the Ataturk Children's Hospital a day after being rescued from a deadly attack on another maternity hospital, in Kabul on May 13, 2020.
Some of the losses are offset by the continued involvement of outside organizations, including private hospitals, the UNFPA, and MSF, which have been able to continue to employ women despite the Taliban's ban on women aid workers due to an exemption for health workers.
But tremendous obstacles remain. Bodiroza said in written comments that "despite the exemption of the health sector from the ban on female humanitarian workers, the sector is also suffering from the ban as there are NGOs that indirectly support efficient delivery of health services -- not as frontline health workers but as back office staff, for example."
Afghan women health-care workers, in turn, told Radio Azadi they are being prevented from carrying out their work or expanding their expertise, even as the contributing factors to maternal mortality become more severe. The result is that newborns or pregnant women are now at greater risk of preventable deaths during pregnancy, childbirth, and in the first few weeks after childbirth.
"Many pregnant women can't access antenatal or postnatal care, and the health system struggles to treat women who experience complications in pregnancy," Tomas Bendl, field communications manager for MSF in Afghanistan, told RFE/RL in written comments. "A shortage of qualified female health-care staff also affects access to health care, as maternity and sometimes pediatric wards are women-only spaces."
Dangers At Home
Hussain Sayer, a doctor from Parwan Province, told Radio Azadi that childbirth should ideally take place at a maternity hospital under the care of an obstetrician.
He said it was a "bad custom" for women to be denied access to health facilities during their pregnancies and warned that the only available option for many women -- home birth -- carries great risk.
In the event of births taking place at home, he said, they should be supervised by a trained midwife.
But while great emphasis was made over the past two decades to increase the number of professional midwives in Afghanistan capable of providing medical assistance during pregnancies, deliveries, and postnatal care, many Afghan women who entered the profession say they are unable to help.
Nadia, a midwife who spoke to Radio Azadi on condition that only her first name be used, said many of her colleagues who specialized in gynecology and obstetrics are "unemployed and stay at home" since the Taliban takeover.
Another midwife, who declined to give her name due to security concerns, said fear prevents many of her colleagues from working.
"Midwives don't go from place to place to assist with births -- that's why the problems have increased," she told Radio Azadi. "Every midwife is afraid for her life."
Restrictions on women's mobility have had a harmful effect on efforts to educate communities on women's health in remote areas of the country, according to the UNFPA's Bodiroza.
Even when male family members do allow women to visit health-care facilities, the difficulties in reaching them in rural areas limits the number of visits and can mean help is often administered too late.
Newborn babies at the Ataturk Children's Hospital in Kabul.
"I took my wife to the clinic by motorcycle," Abdul Samad, a resident of the southeastern Ghazni Province told Radio Azadi, explaining he lived far from the nearest village with maternity facilities.
While Samad managed to get his wife to a doctor, shortly after he left to retrieve her mother, he received bad news. "Half an hour later, I received a call saying my wife was in agony," he said. "When I returned, I saw they were right" -- both his wife and their newborn child had died.
Continuing Efforts
It is difficult to assess where Afghanistan truly stands in terms of maternal mortality, but the benefits of continued outreach efforts and on-the-ground medical aid are obvious.
Bendl said MSF operates two projects in Afghanistan that focus on maternal health care, among other things, and employ more than 1,700 medical professionals in Afghanistan, of whom more than half are women.
Last year, MSF assisted in more than 42,700 deliveries, more than 8,000 of which were marked by obstetric complications. In Lashkar Gah, capital of the southern Helmand Province, MSF's support for a hospital resulted in an average maternal mortality rate of 0.1 percent. In the southeastern Khost Province, where MSF operates a maternity hospital, the mortality rate was 0.02 percent.
Bodiroza of the UNFPA said the agency continues "to deliver a full range of maternal health services in Afghanistan" and supports facilities and delivers essential reproductive health supplies in 32 out of the country's 34 provinces.
Despite the positives, those involved in providing health services in Afghanistan say much more needs to be done.
A newborn is seen in an incubator at the intensive-care unit of a hospital in Herat.
Bodiroza said the UNFPA estimates that without immediate and sustained support for reproductive health services, the situation could lead to an additional 51,000 maternal deaths by 2025.
Adding that "reproductive health services are therefore more critical than ever," Bodiroza said the UN agency is aiming to reach 10.6 million people -- including 6.8 million women and girls -- in remote areas with reproductive health support.
Bendl said that "there is no doubt that a dysfunctional health system, widespread poverty, and increased restrictions placed on women are at the heart of the current humanitarian crisis."
"If we want the situation to improve," he said, "policymakers, donors, and local authorities must urgently focus on strengthening primary medical care." And women, he said, "must be allowed to pursue further education and employment opportunities, to raise income for their families and to ensure there are sufficient female health workers in the country to meet the needs."