Every day, Zargul arrives at the Haidarabad subhealth centre in Bamyan Province before eight o'clock to start her midwifery shift. “We set up the workspace and prepare the essential drugs, equipment and registers for the day, and then we have a morning conference where we share problems and solutions. We conduct health education sessions for clients before beginning our usual antenatal, postnatal, delivery and birth spacing services for 15 to 20 women. After that, we track absent patients and mothers close to their delivery date and prepare for the next day.”

Zargul is one of nearly 550 midwives working with AKDN across five provinces in Afghanistan. Her community health centre operates within AKDN’s internationally-accredited healthcare system, which reaches remote areas of Badakhshan, Baghlan, Bamyan, Kabul and Takhar and serves over 1.6 million patients per year.

How did Zargul choose this profession?

“When I was in school, there were really poor families in our neighbourhood. In one household, there was a pregnant woman who died due to childbirth complications, and her children were helpless and experienced numerous challenges. I made a decision for myself at that moment: ‘In the future, my goal is to become a midwife so that I may assist mothers during childbirth and, if possible, reduce maternal mortality so that their children do not grow up without a mother.’”

Zargul recalls an occasion when she achieved this goal. “Because Bamyan is mountainous and the roads are difficult to pass, especially during the winter season, the women I see have less access to services. There is still a shortage of ambulances in some health centres for the transportation of maternity patients.

“Once, when the weather was very cold and all the roads were closed, a community leader’s wife had given birth at home. She had placenta retention, was bleeding very severely and was in shock. Using the skills I had learned in the midwifery course, I was able to save the mother's life.”

Pregnant women in Afghanistan face many challenges. They often encounter cultural, geographic and economic barriers to seeking care during pregnancy. If they make it to a health centre, funding restrictions due to the economic downturn and reduced funding from international donors may impact the care services that are available. According to a 2022 United Nations Population Fund report, Afghanistan has the highest maternal mortality ratios in the Asia-Pacific region, with 638 deaths for every 100,000 live births.

Observing these high mortality rates for both mothers and newborns herself, Mehrvash, like Zargul, felt compelled to train as a midwife. She works at the AKDN-managed Faizabad Provincial Hospital in Badakhshan, and typically meets 30 patients a day, many of whom have travelled long distances to reach the hospital.

When asked about the challenges of her job, Mehrvash notes delays in patients seeking help, low awareness of health services and birth spacing amongst women, and a high demand for her services. “Through counselling, we can reduce the misperceptions [women may have] and get their trust and acceptance,” she says. She would also like to see families given health education, and the improvement of basic healthcare services to remote areas.

Nazia is a critical care nurse with a decade of experience, as well as being a cardiac nursing specialist and a midwife instructor. She works at the French Medical Institute for Mothers and Children (FMIC), a tertiary-level hospital managed by AKDN. The hospital is a partnership between the Governments of Afghanistan and France, the French NGO La Chaîne de l’Espoir and AKDN.

“When I was in school, my neighbour was a midwife, supporting childbearing women and their babies in the antenatal, intrapartum and postpartum periods. She was a role model for me and at that time I decided to become a midwife. I also wanted to become a nurse. My family is very happy about my decision because I am playing a vital role in my family and society despite many challenges for girls and women. My elder sister is also a midwife and my younger sister is a nurse.”

Between 2012 and 2019, Nazia spent most of her time studying. She began with three years at the Aga Khan University (AKU) School of Nursing and Midwifery to learn nursing. Next, she specialised in cardiology before training as a midwife. After this she took a BSc in Nursing at AKU, followed by a BA from Karachi University. “During my studies I faced lots of challenges because I belonged to a lower-income family and had studied in a very small school. Initially it was very difficult for me and then I began to cope with my studies.” She is now a member of the Afghanistan Midwives and Nurses Associations, helping develop learning material, standards and policies. She hopes to gain a Masters degree in nursing from AKU.

“When I was working as a midwife I used to see 40 to 50 patients per day in the DK-German Medical Center in Kabul. We were teaching them about birth spacing, antenatal and postnatal care and also treating infertility cases. The most interesting part of my job was listening to the stories of the women about their experience of pregnancy and health practices.

“The social norm in Afghanistan is that people put their family’s interests before their own, especially when it comes to girls and women. This means that family responsibilities tend to hold a greater importance than the personal needs or health of a woman, leading to child marriage, exchange marriage [where two families exchange daughters for marriage] and early pregnancy. It directly affects the health of a woman.

“Some families do not allow the women to go to the doctor for antenatal care because they do not allow their women to expose their body parts for the examination.

“Many also believe that feeding the neonate with dates and honey is good.”

While developing their expertise and earning an income, the midwives are visibly fulfilling their aspirations for others too. In a country where surviving childbirth cannot be taken for granted, these women are making a vast difference for their patients.

The names of the women featured in this story have been changed to protect their identity.

Read more about AKDN's work in Afghanistan.