Amid increasing focus on the fraught question of what will happen in Afghanistan after the withdrawal of NATO combat forces, a recent survey released by the country's health ministry indicates a significant leap forward for Afghanistan's women.
Save the Children listed Afghanistan in May as the worst country in which to be a mother. But Afghanistan has recently seen a marked improvement in maternal mortality rates. Previously, 1 in 11 mothers died in childbirth. The new survey indicates that the number has dropped to 1 in 50. The number of children who died before the age of 5 also dropped from 1 in 5 to about 1 in 10.
Ending maternal mortality has been a priority among international organizations because a mother's health is seen as a building block for the rest of the family: If a mother is healthy, a family is healthy, the thinking goes.
Considerable time has been spent drawing attention and funding to awareness campaigns and better training for midwives and nurses.
While the numbers show that the effort is having an effect on women in Afghanistan, life for Afghan women has not radically changed. Experts remain cautious in their assessment.
"Now pregnant women have more information about health," says Sima Ayubi, a maternity doctor in Kabul who advocates hospital births. "This mortality rate is still a problem. There's just a decrease. The problem is not completely eliminated or under control."
The survey also found that complications during pregnancy and childbirth were responsible for the deaths of 40 percent of women between ages 15 and 49.
Additionally, women continue to face considerable gender violence and have limited legal protections. In one recent rape case, the victim was sentenced to 12 years in prison for adultery. She was pardoned by President Hamid Karzai only after she was featured in a documentary by the European Union. Despite the pardon, she still faces pressure to marry her assailant.
Compared with the statistics of other nations, the latest maternal mortality survey may not seem encouraging, but with such daunting challenges facing women in Afghanistan, even small gains are critical.
Miriam, a mother of seven who, like many Afghans, only uses one name, says that she's seen drastic changes in care for pregnant mothers over the past decade.
"I've seen many mothers die during birth and many children die," she says. Miriam gave birth to all her children before 2001, but now she helps many young mothers through their pregnancies.
"In the years before Karzai's government, whenever we used to go to these hospitals ... the patients would cry in the wards and no one would help," she recalls. "Now after what I saw in the clinic, I don't believe people are going to continue dying anymore," says Miriam, who recently visited the hospital.
One of the biggest challenges facing Afghanistan is getting medical care to people living in rural areas – about three-quarters of the population.
In many places residents simply do not have access to medical facilities, let alone roads. According to a recent Asia Foundation survey, only 57 percent of Afghans say they have good or very good access to clinics or hospitals.
As a result, tremendous effort has gone into training midwives who can help women through the birthing process absent a full medical facility.
Since 2002, the number of schools for midwives in Afghanistan jumped from six to 31, according to a report by Save the Children. Afghanistan now has more than 3,000 midwives (up from just 500 in 2003) with an additional 300 to 400 trained each year.
The report indicates that the efforts were successful early on with the number of births in rural areas attended by skilled medical professionals jumping from 6 percent to 19 percent between 2003 and 2006.
Even when hospitals are available, women tend to prefer to give birth in their own homes, without trained attendants. Thus, say health officials, a big part in combating maternal mortality is simply raising awareness so that women will choose to give birth at a clinic if possible.
"All the achievements we've made in Badakhshan Province are thanks to efforts to raise awareness among the people here," says Abdul Momen Jalali, the head of health services for Badakhshan, which has been hit particularly hard by maternal mortality. Even so, he adds, "We still have a lot of problems with remote areas where we don't have roads to access these areas." Notably, Badakhshan was the location of a major attack on foreign charity doctors in 2010.
No matter how much the country's health-care system improves, doctors say there is only so much that can be done in the midst of Afghanistan's ongoing war. Violence often inhibits doctors' travels or stops patients from reaching the nearest hospitals.
"The midwives and doctors cannot go to very risky areas. Even though the doctors do not know any borders, they're still killed, kidnapped, and threatened. I think the mortality [rate] that is happening right now still looks very high. It's coming from those areas where there is not any doctor or security," says Jalil Hassan, a professor of medicine at Kabul University.