As a second wave of the Covid-19 pandemic threatens medical infrastructure across Afghanistan, many couples in the conservative country, where family planning is largely considered a taboo, have begun opting for contraceptive services out of fear of a risk to their health.
Masouma Sarwar, a 28-year-old university professor and a mother of three children, is part of a small but increasing number of Afghan women who are seeking contraceptive services to take control of their reproductive health.
Having had Covid-19 earlier this year and still feeling the consequences, such as brain fog, forgetfulness and physical weakness, she and her husband have decided that it would be best not have another child until the pandemic is over.
“The risks of having a baby during these times in Afghanistan are too high,” she said while waiting for her sister-in-law in the courtyard of the Malalai Maternity Hospital in central Kabul. She had just given birth via Caesarean at the hospital, braving a pregnancy with many challenges brought on by coronavirus.
“Nearly everyone in our family has had Covid, and we had to make sure [my sister-in-law] remained safe. We isolated her and took all the precautions we could. We were very afraid of losing her,” she said.
Like many other Afghan families, her brother and his wife considered a home birth to limit the risk of contracting infections from the hospital, but complications in the pregnancy meant that couldn't happen.
In a deeply conservative and patriarchal society like Afghanistan, families are traditionally large, with every new child seen as sign of prosperity and virility. There is no official census data available, but it is estimated that nearly one million children are born in Afghanistan every year.
The subject of family planning and use of contraceptives is considered to run counter to religious beliefs, making those like Ms Sarwar social outliers.
However, health concerns surrounding pregnant women and coronavirus have prompted the Ministry of Public Health to issue advisories encouraging Afghans to consider it.
"Studies have shown that pregnant women have a lower immune response to most infections,” said spokesman Dr Akhmal Samsor.
“There is a release of a lot of oestrogen and progesterone, hormones that suppress the immune response in pregnant women. That means disease is about five times more severe."
The ministry launched an awareness campaign in the early months of the pandemic advising Afghan women to space their pregnancies, or wait till after the end of the global crisis to have their next child.
“There was a fear that the number of pregnancies could increase during lockdown, since family planning is not popular in Afghanistan," he said, adding that it was too early to know if the campaign had any positive impact.
The campaign falls short, however, in a patriarchal society where few women have a say over the number of children they conceive.
Dr Khatol Hamidi, who manages a small family planning centre in Rabia Balkhi Hospital in Kabul, said the decision is usually made by a husband or mother-in-law.
“It would help if Afghan laws were designed to protect women from physical, mental and sexual abuse,” she said.
One woman who discreetly acquired a contraceptive implant from their clinic, without the knowledge of the husband, was dragged her back to have it removed when her husband found out.
The worsening security situation in the country, and its slow economy, have also contributed to concern among young couples.
“Afghanistan’s economy is not that strong to support more people. There are not enough services available for everyone, which is why we are seeking family planning services,” said Arzoo, a 25-year-old schoolteacher waiting for an implant at Dr Hamidi’s clinic, who did not want to give her full name for fear of repercussions.
“The government needs to highlight how planning children can help families economically and the health benefits for women," she said.