KABUL // Afghanistan had little reason to join the other countries that celebrated motherhood yesterday after a new report named it the world's worst place to be a mother.
From its craggy mountains, where roads are few, to the desert badlands of the Taliban south, Afghan women live tragically short lives, with an average life expectancy of just 45 and with a one in 11 chance they will die during childbirth, said the survey of maternal and child health in 164 countries conducted by the international non-profit group Save the Children.
Azima Yalda Jalil, an Afghan mother of two who lives in Kabul, said: "There is no hope for pregnant women in Afghanistan."
Although educated and living in the comparatively modern Afghan capital, Ms Jalil gave birth two years ago to a starving, premature baby girl after her in-laws forced her to continue working at her job as an editor and maintain a heavy load of household responsibilities during her pregnancy.
Ms Jalil said she was deprived of the nutritious food she required during pregnancy by her husband's family, causing her to slip into a coma when she was seven months pregnant with her daughter.
Doctors in Kabul were forced to perform an emergency caesarean section, and her daughter now has developmental problems, she said.
Just under half of Afghanistan's 28 million people are women, but every Afghan mother, Save the Children says, "is likely to suffer the loss of a child".
At least one in every five children will die before reaching their fifth birthday in Afghanistan, from preventable diseases such as pneumonia and diarrhoea.
This child-mortality rate is due to a lack of sanitary conditions, insufficient health services, and malnourishment, the report said.
In Norway, by contrast, where maternal health services attained the survey's number one slot, only one in 175 women will lose a child under the age of five.
Even in Afghanistan's neighbouring Tajikistan, a woman's life expectancy is 70, and just one in 430 die giving birth.
Dr Ghulam Sakhi, the spokesman for the Afghan Ministry of Public Health, said: "We don't have the resources to address the problem the way we would like to, the way that we need to, People are poor, they can't access our health centres, and it is a traditional society. Men won't send their wives to male doctors."
Indeed, severe poverty, a lack of access to health facilities in remote and violent areas, low education levels, and conservative norms that keep women at home or from seeing male doctors all translate into abysmal conditions for both pregnant women and new mothers in Afghanistan. Many women are forced to travel by donkey or even on foot to reach health services. Poor nutrition, from which many Afghan women suffer, weakens bone formation and can ultimately prove fatal for both the mother and child during labour.
"When a woman is pregnant, she can't go out without the permission of others. Most times, the family does not know how to feed a pregnant woman properly," Feroza Mushtari, president of the Afghan Midwives Association, said.
A woman who loses a child at birth but survives herself faces stigma, Afghans say.
"When she loses the child, everyone blames the mother for this and she becomes depressed," Mrs Mushtari said.
In Afghanistan, women will give birth to five or six children in back-to-back pregnancies, aid workers here say. At 6.4 children per woman, they maintain the highest birthrate in Asia, the United Nations Population Fund says. In comparison, the birthrate in Iran is 1.88 children per woman and 3.17 children per woman in Pakistan.
But not all of it is bad news. With the help of the United States Agency for International Development (USAID), Afghanistan's Ministry of Public Health says it has managed to reduce the rate of maternal deaths during live births by 22 per cent in the last eight years.
In 2003, an estimated 1,600 women per 100,000 live births died during labour. Now, that number is down to 1,400.
Health officials credit the drop largely to a push by USAID to recruit, train and support female Afghan midwives. Once schooled in modern medicine, the midwives can more easily penetrate Afghanistan's more remote and conservative areas, where female health workers are scarce.
According to USAID, there are now 2,500 midwives trained across Afghanistan in 32 of the country's 34 provinces. The Afghan Midwives Association, based in Kabul, says it has 1,600 members, up from 80 in 2005.
Still, at least 30 per cent of the country's health facilities lack either midwives or female health workers, the public health ministry says.
"If there are health centres with female workers, people will be happy to send their women there," said Abdul Matin a tribal elder from Oruzgan, one of Afghanistan's more under-developed and insecure provinces. "But no one will send their wife to a male doctor."
Dr Sakhi says the Ministry of Public Health is joining forces with the Ministry of Hajj to implement a joint health awareness campaign titled "Health & Islam". Part of the campaign will focus on using mosques to educate Afghan men on the importance of maternal health, and allowing their wives and daughters to access health professionals.
"In the rural areas, men and women, we all die because of war," Mr Matin said. "But we also die because there are no hospitals."