HERAT, Afghanistan – Even for a country that generates grim statistics, this one looms large: One in eight women in Afghanistan dies during childbirth.
Even more tragic is that the overwhelming majority of these deaths — 80 percent, according to the United Nations — are easily preventable.
"It's not easy for women to have health care," said Dr. Qudsia El-Yar, a 41-year-old gynecologist who works at the Herat Maternity Hospital in western Afghanistan.
She proceeded to rattle off a list of factors that conspire to give the country the world's second-highest maternal mortality rate (after Sierra Leone). At the top of the list is poverty. Scores of rural communities lack the most basic health facilities. Moreover, many rural villages are so remote that it takes hours, sometimes days, to reach the nearest clinic or doctor's office.
|VIDEO: Teaching Afghan midwives to save lives|
Poverty also means illiteracy and a lack of education. Many people, particularly in the rural areas, don't realize they need health care or don't know how to get it.
A strong tradition of early marriages also compounds the problem. Child marriages lead to young pregnancies, and Dr. Qudsia, as she is known locally, said she regularly sees pregnant girls under 16. At that age, their bodies are not ready for reproduction, and often they die during labor.
Another factor is Afghan society, which is predominantly conservative Muslim. Women, especially in the rural areas, don't have much of a say over their health. "Especially the young women," said Dr. Qudsia. "They are not the decision-maker in the family. The decision-maker is the man, and also the mother-in-law."
Furthermore, women in conservative communities are forbidden from leaving the home without a male companion, even to see a health expert. If they can seek health care, they are only permitted to consult female health practitioners – who are still very rare in the country.
Challenges related to the last factor were particularly acute during the Taliban era. Dr. Qudsia described that time as being extremely repressive for professional women such as herself. "It was very difficult for women, especially for nurses, midwives and female doctors, to come to the hospitals," she said. "We couldn't do our jobs."
So a solution has been to train midwives to help curb the number of deaths due to childbirth – a process considered elsewhere to be among the most natural in the world, but in Afghanistan one of the most dangerous things a woman can do.
'Two lives at stake'
Midwifery training programs have sprouted around major population centers in Afghanistan during the last four to five years; one of the earliest is the Midwifery Education Program (MWEP) run by World Vision, an international relief and development agency.
|Adrienne Mong / NBC News|
|Health experts say poverty, illiteracy, and a conservative society keep many women in Afghanistan from getting direct access to health care.|
The program – under way in Herat and Ghor provinces – is designed to train Afghan women to become qualified midwives within two years.
Wendy Olebeng Tsiane, a registered midwife from Bostwana, arrived in Herat in 2009 to oversee World Vision's midwifery program. She was shocked by the conditions she saw while traveling around the province, notably in the rural villages. "In most cases, we find there are major complications of pregnancy or major complications of delivery, and they end up dying," she said.
And it's not just mothers. Babies die, too. In the first three months of 2009, out of the 421 admissions at Herat Maternity Hospital, 138 wound up with stillborn infants.
Since its inception in 2004, the program has graduated 171 midwives. They have gone on to work at health facilities in Herat City as well as Ghor Province, where in many villages, women's health care never existed.
And although the number of graduates might sound small, Afghanistan, with an estimated population of around 28 million, has just over 2,000 midwives. The U.N. says at least four times that number of midwives are needed to cover the most basic needs across the country. No easy feat given that 86 percent of women here are illiterate, according to UNICEF, let alone able to train for a medical license.
The current MWEP class of 40 young women is midway through the course at the Institute of Health Sciences and at the Herat Maternity Hospital, where on average 1,400 to 1,700 babies a month are delivered in a city of roughly 2 million. The hospital provides the trainees with valuable hands-on experience.
"The midwife is very important, because there are two lives at stake – the mother and the child," said Freshtah Sadat, a 22-year-old trainee in the midwifery program. Sadat, who comes from Herat, saw a cousin and an aunt die in childbirth "because they did not have prenatal care," she said.
It's this kind of experience that motivates young women like Sadat. Another Herati student, 20-year-old Farahnaz Gul Mohammedi, lost an aunt under similar circumstances. And a cousin's first baby died only days after he was born.
Mohammedi's dream is to "to see mothers with their newborn babies, hand in hand and healthy."
On the morning we visited the maternity hospital, Mohammedi was checking the vital signs of three prematurely born babies in the neonatal unit started up by World Vision.
One of the infants, Almeh, was born at 32 weeks. Her mother, Somaia, was trying to breastfeed but to no avail. Small and thin-faced, the 25-year-old woman was still weak from her pregnancy. Almeh was her fifth child.
|Adrienne Mong / NBC News|
|The Herat Maternity Hospital delivers on average 1,500 babies a month.|
"Two of my babies were born in the hospital," said Somaia. "It's better, because everything is available, like medicine and doctors. If I give birth at home, it's not a clean environment. I could lose a lot of blood, and I could die."
Another mother, Soraya, also praised the neonatal unit and its staff. The 31-year-old was already a mother to three boys when she became pregnant with daughter Saetayesh last year, but complications caused her to give birth two months early. The baby weighed only 1.8 pounds.
"They put the baby into a machine to keep her alive. I didn't want to see her because I thought she might not survive," said Soraya. "But she grew slowly day by day." When the midwives finally let her hold Saetayesh, the mother cried. "I couldn't believe it," she said. "I was so happy."
The morning we met Soraya, Saetayesh was a healthy, vibrant little girl who walked confidently and swung from laughter to tears and back, just like any other healthy child.
Having helped to save lives, the midwifery program faces a different challenge now – money. The MWEP has been funded by the U.S. Agency for International Development (USAID), but Tsiane, who runs the program, said there has been no firm financial commitment yet for the next round of trainees.
At stake is the fate of not just future students but also graduates. World Vision has been raising money to help provide salaries for the latter until Afghanistan's Ministry of Public Health has the budget to pay the midwives for working at facilities like the Herat Maternity Hospital.
World Vision is trying to raise $171,700 by early January to provide ongoing support, supplies and training for 20 midwives for one year. So far, it has raised about $35,000.
For the women of the Herat Maternity Hospital, the midwifery program is critical. Dr. Saida Said, chief of the hospital, put it succinctly: "It is important for us to have a healthy mother and a healthy child and in total we have a healthy community in Afghanistan."
For those interested in donating to World Vision, please visit their Web site,
www.worldvision.org, or call 1-888-56-CHILD and say you want to give to World Vision's Maternal & Child Health Project in Western Afghanistan, or Project #192582.