Prague, 25 February 2005 (RFE/RL) -- In a cold, dark, mud house in the border town of Ishkashim in Afghanistan’s remote northeastern Badakhshan Province, Gulnama tries to calm her screaming six-month-old son.
In two months, 22-year-old Gulnama is due to give birth to her second child, and she could die from doing so. The nearest hospital is about 100 kilometers away, four to five days by donkey, the most common form of transport in rural Afghanistan.
Despite the risk she faces, Gulnama told Reuters Television that she is not too worried. "I will give birth and their destiny belongs to God," Gulnama said. "God will save them. We know we have problems -- no heating, no food."
"Some patients come with prematurely ruptured membrane, with amniotitis [or infection of the amniotic sac], fever [and they are in a] very bad state. We need antibiotics, we need serum, we need a lot of anesthetics."
Afghanistan's first National Human Development Report, launched earlier this week by the United Nations Development Program, reveals that a woman dies in war-ravaged Afghanistan every 30 minutes as a result of complications from pregnancy. Maternal mortality rates are 60 times higher than in industrial countries.
The reasons why are evident. Badakhshan's only maternity hospital, located in the capital Faizabad, is inaccessible to most of the province's women of childbearing age. And, for those who make it, the ill-equipped 20-bed hospital has little to offer.
Gynecologist Hajera Zia Baharestani and her overworked team must carry out complex surgical procedures using emergency lights powered by a faltering generator: "Some patients come with prematurely ruptured membrane, with amniotitis [or infection of the amniotic sac], fever [and they are in a] very bad state," Baharestani said. "We need antibiotics, we need serum, we need a lot of anesthetics."
Baharestani said she hopes President Hamid Karzai's government will make good on its promise to build roads and clinics and provide better salaries to attract skilled staff.
Johns Hopkins University affiliate USAID/REACH, one of many foreign aid organizations involved in women's health in Badakhshan, has recently opened a mid-wife school in Faizabad to train women who will go back to their villages to help pregnant women with complicated deliveries.
But Jeffrey Smith, who works for the organization in Kabul, warned it could be decades before Afghan mothers get the proper care. "It's the kind of thing that we can't change overnight," Smith said. "The issue of maternal mortality is an issue of infrastructure. We have to develop the right personnel, we have to deploy those personnel -- midwives, doctors -- to health centers in the rural areas. Just serving the urban centers is not going to reduce maternal mortality or address the problem."
North of Afghanistan, Central Asian women of reproductive age are suffering from the region's painful transition from controlled markets to market economies after independence nearly 15 years ago. Health care that was provided free for all in the controlled society has often seen a decline in the free-market economy as governments provide less support.
Gunta Lazdane is the Denmark-based adviser on reproductive health and research for the World Health Organization's (WHO) office for Europe, which also deals with the former Soviet Union. She told RFE/RL that the Central Asian republics have the highest numbers of maternal deaths per 100,000 live births. "In Kyrgyzstan it's around 50 [per 100,000 live births]. In Kazakhstan, [Turkmenistan,] and Tajikistan it's around 40 per 100,000 life births," Lazdane said. "The average in the European region, [including] the Commonwealth of Independent States, is 16 per 100,000. So it's three times higher. These are the reported figures but most probably they are underestimates."
Poor access to health care forces many women to deliver their children at home without a qualified birth attendant or doctor, increasing the risk of both infant and maternal mortality.
Shamsuddin Qurbonov, who heads the Mother and Child Health Care Center in the Tajik capital, Dushanbe, said such circumstances are increasing in the country, which went through a five-year civil war in the 1990s. "While in many regions of Tajikistan up to 70 or 80 percent of births take place at home," Qurbonov said, "I am sure there are many unreported and unregistered cases of child and mother mortality nationwide."
WHO recommends that pregnant women should have at least four prenatal checkups. According to official statistics, however, 20 percent of pregnant women in Tajikistan have not had any prenatal care.
(Farangiz Najibullah, from RFE/RL's Tajik Service, contributed to this report.)