Every 30 minutes, an Afghan woman dies in childbirth, yet husbands decide how many children they should have. Paul Cullen visits a country where motherhood is misery.
Compared with the bustle of Kabul street life outside its gates, the dank corridors of Rabia Balkhi hospital stand strangely silent. This is a place for women, a small oasis in an ocean of male domination. But the only sound here is that of suffering silently borne by women old beyond their years.
In the delivery ward, Gul has just given birth to her eighth child, a small boy still swaddled in her shawl. Two other pregnancies miscarried. She is 30 but looks old enough to claim a pension. Yes, she wants more children, but how many? "More and more," she replies, but without enthusiasm.
The mothers in the pre-delivery ward clasp their stomachs and bear their pains stoically; there are no induced deliveries here. Laila is 35, but she looks over 50. She has five children, and lost another two, one to illness and another to a rocket attack last year. The eldest is 17 and when I ask what he will do after school, she replies: "His father will decide."
This is the story of women in Afghanistan, where poverty and war and an oppressive cultural code have made of motherhood a misery. One woman is on her 16th pregnancy, but has lost eight children. In a refugee camp in Pakistan, an Afghan woman begs me for medicine for her sick child. Her first three children have died; now, her precious surviving boy is convulsive and the doctor says he will not live. In another camp, a mother cradles her newborn child. The boy is healthy but the mother has liver cancer and will die soon, though she does not know it.
Incredibly, these are the privileged ones. They at least have some access to healthcare. Most Afghans do not.
Ninety-eight per cent of women give birth at home, unattended by any expert help. Every 30 minutes, a woman dies in childbirth in this, the country with the highest rate of maternal mortality in the world after Sierre Leone. One woman in 15 is destined to suffer this fate unless conditions improve.
"It's a big unknown, what's happening out there. There is no monitoring and no proper ante-natal care, so the problems are not diagnosed on time. The result for many women is that they bleed to death in childbirth," says Dr Olivier Brasseur, region head of the United Nations Population Fund (UNFPA).
But in a country with no social security, children are seen as the best old age pension. And in a place where one quarter of all children die before the age of five, having lots of children is the best way to ensure that you have some left at the end of it all. Not that the women have much of a say; even before the fundamentalists arrived, only 2 per cent used contraception. In virtually every family, the man makes the decision to have a child.
Women have always drawn the short straw in this country. Long before the Taliban banished them from public view, they were the helpless victims of war and domestic violence. Even this Kabul hospital recalls the legacy; it is named after a beautiful, doomed medieval poetess long celebrated in Afghanistan. Rabia Balkhi was the first woman of her time to write love poetry in Persian, but she died tragically after her brother slashed her wrists as punishment for sleeping with a slave lover. She wrote her last poem in her blood as she lay dying.
In the 20th century, war destroyed the social structure that had provided women with some status. Their children died in the crossfire, their conquerors raped them and even the end of conflict brought oppression. The Taliban ended all education for women, banished them behind the head-to-toe burqa and even forbade women from making noise.
"Women, you should not step outside your residence. If you go outside the house you should not be like women who used to go with fashionable clothes wearing much cosmetics and appearing in front of every man before the coming of Islam," read one of their edicts from 1996. The religious police handed out beatings for offences like showing your ankles, and stoned women accused of adultery.
Women are still invisible on the streets of downtown Kabul. Men trade goods, do the shopping and talk politics, while their wives remain hidden at home or behind the sky-blue pleats of the burqa.
The burqa has proved a fixation for the West; even now, few women visitors to Kabul can resist trying on this suffocating garment with its tiny face grille. Ironically, though, Afghan women told me it provided them with some protection and a zone of independence, albeit hidden. They could dare to wear make-up and jewellery, so long as it remained cloaked. They learned to sew, wean a child and even smoke behind a burqa. And in the refugee camps, they could go to the toilet at night with less fear of being raped.
For Dr Brasseur, war is the single greatest factor in the problems faced by Afghan women. "War makes men no longer interested in their families. They only care about fighting, power and the continuation of conflict. There are men here approaching 30 who only know fighting." Islam itself is not the problem, he says. "The problem is the interpretation given to Islam by certain groups, and this is linked to ignorance and superstition and a desire to maintain power."
The Taliban removed women from all jobs, except in medicine. Rabia Balkhi hospital stayed opened through these dark days, but men were forbidden to enter, all medical training was stopped and the indefatigable director, Dr Rahima Staneczai, was banned from entering the ministry of health.
Dr Staneczai secretly educated students in an abandoned hospital and examined them in her house. "Things are better now, and we pray they stay that way," she says.
The West, having won the war, now has to win the peace. But if its intervention in Afghanistan is to mean anything, it should surely improve the lot of ordinary Afghans, and especially its women.
Some progress is being made. Boys and girls are back in school together for the first time in years; at present, only 4 per cent of women are literate. About 10 million children have been immunised against polio. Almost 600,000 children in Kabul have been immunised against measles this year, six times the coverage achieved in the whole of 2001. UNFPA is helping to rebuild maternity hospitals.
Yet there are obstacles along the way. Will there be sufficient resources? The hospital, for example, has no generator, no incinerator and only a bare minimum of drugs and equipment. Dr Staneczai could earn $400 a month working for a Western aid agency; here, she is paid $20 a month, less than a policeman. To supplement this meagre income, she teaches and runs a private clinic; emigration is not an option. "I don't want to leave here. There is no better place than my country. If everybody leaves, who will help it?" Help is at hand, though, with UNFPA sending operating tables, incubators, ultrasounds and other equipment to this and other hospitals in Kabul. Training for midwives and nurses is being organised nationwide.
Changing the practices enforced by the Taliban won't be easy. "It is difficult to get women to come to health clinics. It is not customary for them even to leave their homes," Dr Brasseur says.
You get a glimpse of what might be achieved in Khorasan refugee camp, across the border in Pakistan. Amid the rows of mud houses and dirt lanes, a small women's learning project is flourishing. Classes in tailoring and cooking are filled to overflowing. Practical skills provide the women with the opportunity to generate income, rather than being totally dependent on their husbands.
In a small, windowless room, the "psycho-social training" group sits cross-legged on the floor and talk about men and relationships. At first, they are closely veiled in the presence of a man, but as the discussion becomes animated the veils drop and the atmosphere grows lighter.
One girl relates how she was married off to "a 90-year-old man" for a dowry of 45,000 rupees (about €800). Unable to keep him happy, she fled back to her family after a few weeks. Now, she can't get a divorce.
Another woman tells how her husband wants another child; they already have five. The facilitator suggests she talk to her mother-in-law, who may discourage the husband.
Over at the health centre, the charts show that some women are using contraceptives, particularly injectable ones that are easy to administer. "But it is difficult to convince women to use family planning. They will not go against the will of their husbands," Dr Shaida Ramana concedes. The absence of men from these education initiatives poses a major obstacle to change.
Ironically, the staunchest opposition to these kinds of interventions by UNFPA comes not in the Muslim world but back at headquarters in the US. Population politics is a vexed issue, but most particularly with conservative Christian groups. The first thing George Bush did on becoming president was to slash UNFPA's funding after conservative church groups claimed it was supporting China's forced abortion policy. The organisation repeatedly denies that it has anything to do with coercive family planning, but finds itself forever on the back foot and starved of funds because of the allegations.
"The case made against UNFPA is disgusting, unfair and untrue. We do not promote abortion in any way. And in those countries where abortion is legal, we do not advocate its use as a method of contraception. Abortion marks the failure of a contraceptive program," says Dr Brasseur.
Because of these skirmishes, UNFPA this month invited Mary Banotti MEP and a group of journalists to examine its work in Afghanistan. Banotti, a former nurse who acts as a goodwill ambassador for the organisation, says the needs of Afghan women there are enormous.
"Reproductive health is about giving women control over their own lives, and when they choose to have children. Afghan women have massive gynaecological problems, and they deserve our help," says Banotti. She is critical of the "silence and misinformation" surrounding the debate in the Republic and the US.
In Afghanistan, these debates are pretty academic. Some of the women in the hospitals I visited will undoubtedly die, their doctors say, if they have more children.
During the Taliban era, the UN tried to appease the fundamentalists by proclaiming its "high respect" for local customs and cultures, even as women were being turned into baby factories and driven from every part of public life. While no-one wants it to go to the other extreme, it can hardly afford to make the same mistake twice.
But change won't happen immediately, as Dr Brasseur admits. "The major difficulty is that we have to deal with a multitude of problems at the same time. You can't deal with poverty without dealing with population growth. And that requires education.
Finally, there are economic factors that have to be addressed. "Twenty-five years of war has destroyed Afghanistan's infrastructure and ruined its health system. But it has also destroyed human beings and their souls. And you can't fix that overnight."