HERAT, Afghanistan (Reuters) - She was 15 years old, heavily pregnant and had travelled eight days on the back of a donkey to reach hospital.
Suffering from seizures and high blood pressure, she died soon after at the Herat Maternity Hospital in western Afghanistan, one of the thousands of women who die in the country each year from causes linked to pregnancy and birth.
“She came at a late stage and we couldn’t help her,” said Somayeh, a midwife at the hospital and herself just 21. “She was already in a coma.”
Politicians, economists and activists from around the world met in Bonn this month to thrash out their vision for battered and impoverished Afghanistan. In addition to the insurgency and violence, it remains the most dangerous place in the world for a woman to have a baby, the latest World Health Organization data shows.
The figures are distressing, but still a marked improvement on the situation 10 years ago. The latest available WHO data, from 2008, shows the number of women who died giving birth had dipped to 1,400 per 100,000 live births from 1,800 in 2000.
The Ministry of Public Health says it has made maternal health a priority, supporting training schemes that have lifted the number of qualified midwives in the country to 3,000 from just 400, and expanding emergency delivery services.
“We have demonstrated that these strategies can work in Afghanistan. They can bring a change in the lives of women and families,” acting public health minister Suraya Dalil says. “The challenge is to sustain those achievements.”
Charities such as World Vision — which trained Somayeh — and Medecins Sans Frontieres (MSF) also have in-depth programs to help new mothers across Afghanistan.
But they worry that the planned drawdown of Western troops and funds — all foreign combat soldiers will be gone by the end of 2014, and a large chunk of aid budgets is expected to go with them — could jeopardize the modest gains of the last decade.
Without foreign cash to bolster scarce government funds, midwife training will almost certainly drop off, while aid groups may leave if they cannot operate in safety. MSF closed its Afghan operations in 2004 after five team members were killed, although the group has since returned.
“The greatest risk at present is through aid levels dropping off precipitously,” says Sarah Pickworth, a public health specialist who has worked extensively in Afghanistan.
“Without sufficient funding, there is likely to be a significantly slower pace of change. This risks losing the momentum of the tremendous gains made.”
Faced with an appalling death toll among pregnant women and new mothers, communities in rural areas — which have some of the highest mortality rates — have mobilized to help women.
Herat’s Institute of Health Sciences (IHS) has trained 256 midwives in the past seven years through schemes largely supported by charities such as World Vision. Many of its students have been deliberately selected from remote villages.
But if Herat is hit by violence, the families are likely to take their daughters out of school and take them home to safety.
A deterioration in the security situation would likely hit pregnant women as well as midwife training.
Transporting women in labor from rural areas to clinics is already a tough proposition in a country where few can afford cars and roads are scarce and badly maintained. It will become still harder if gunmen have freer rein to target travelers.
The re-emergence in political life of groups like the Taliban, which banned education and the free movement of women, could also have a devastating effect on death rates.
Under their influence, a generation of potential female midwives and doctors has already been lost, midwife trainers say. This is particularly devastating in a country where male doctors treating women is still largely taboo.
But as big a problem for Afghanistan is money. The Afghan government is facing a $7 billion hole in its budget after 2014, which it will need to pay for security and other services. It is relying on foreign help to plug that gap.
The grinding poverty in which many women live means hygiene and nutrition are often poor. A recent survey showed only around half of Afghans have access to clean drinking water, and only a fifth use approved toilet and sanitation facilities.
The IHS’ deputy director, Dr Ehrary, says money is a major stumbling block to completing the five further rounds of midwife training he calculates are needed to provide a base number of healthcare professionals in the region.
“Training is not difficult, but finding funds is difficult,” he says. The institute is struggling to train this year’s government-recommended quota of midwives to the right standard.
“We told the ministry we could not run the class this year because we have only three teachers and we cannot meet their standards,” he added. “They have now been funded. We found another donor, (German humanitarian group) Cap Anamur.”
If meetings like the Bonn conference fail to deliver a plan for action on poverty and some kind of roadmap to stability, the fragile gains in maternal healthcare could easily slip away.
In rural Herat, villagers say they are determined to stop that happening. After decades of upheaval and war, they are tired of death and violence and want a safer future.
“Everybody hopes there will be no more war in Afghanistan,” says one senior shura, or village council, member from rural Herat. “The first thing we want is safety, the second is to improve people’s health. We need doctors — we need midwives.