Foreign Policy

The Midwives on the Entrance Traces

KANDAHAR, Afghanistan—The maternity ward at Mirwais Hospital in Kandahar city in southern Afghanistan is one of the country’s busiest. On a crisp February morning, women in pastel-colored burqas crowded the corridors outside the maternity ward clamoring to get in. A woman in labor stretched out on a blanket with her young children beside her, waiting for a free bed. Another woman perched on a stool guarded the doors, unwavering. They flung open, and a new mother pushed through the crowd with a newborn. The halls were filled with the cries of newborn babies.

Sitara Habibi, 35, a bright-eyed, wiry midwife, bustled around the maternity ward. She was at the end of her double shift—24 hours of nonstop births, attending to young mothers from tribes across Kandahar. At one bedside she checked a patient’s dilation, and at another she changed an IV bag—all while answering questions from concerned relatives. Habibi is one of 38 midwives at the government-run Mirwais Hospital, where she has worked for seven years and delivered thousands of babies.

Sitara Habibi attends to a woman in labor, to her left, with the woman’s mother to her right, as other women in labor wait nearby, at Mirwais Hospital on Feb. 18. Lynzy Billing for Foreign Policy

Midwives are some of Afghanistan’s most vital front-line health care workers, fighting to ensure that women and babies survive childbirth in even the most marginalized rural areas. “I wanted to be a midwife and serve the women of my community because this profession is needed so desperately in Afghanistan,” Habibi said.

Afghanistan has seen four decades of war, leaving its health care system overstretched, with limited coverage in conflict-affected areas. Despite the peace deal signed between the United States and the Taliban in February, violence continues unabated. Some of the violence has targeted maternity hospitals and health workers, including at Mirwais Hospital: In 2016, two armed militants dressed as doctors walked through the doors, and one patient was killed in the ensuing gunfight. The World Health Organization reported 119 attacks on health care in Afghanistan in 2019.

A midwife performs an ultrasound on a patient in the admissions department of the maternity ward at Mirwais Hospital on Feb. 17.

Surgeons deliver a baby by cesarean section at Mirwais Hospital on Feb. 17. Lynzy Billing for Foreign Policy

On May 12, militants attacked a maternity ward at Dasht-e-Barchi Hospital in Kabul and killed 24 people, including 16 mothers, two newborns, and one midwife. More than 20 people, including babies, were injured. The attack lasted four hours. Ten women managed to find shelter, but not one of the 16 mothers who remained exposed was spared: Three were killed in the delivery room. In the wake of the attack, Médecins Sans Frontières, which ran the maternity ward, decided to cease operations and withdraw from the hospital—leaving women in the area without emergency obstetric care.

Mothers and relatives visit babies in incubators in the intensive care unit of the pediatric department at Mirwais Hospital on Feb. 17. Lynzy Billing for Foreign Policy

Across the country, the escalating violence has made health facilities harder to reach. Mirwais Hospital serves 6 million people from five provinces, including many from areas where the Taliban are actively fighting government forces. The hospital is southern Afghanistan’s only large-scale surgical facility, and since 1997 it has been supported by the International Committee of the Red Cross, receiving medicine, equipment, and staff training. Its doctors and nurses work at the heart of the continuing Afghan conflict, with war casualties coming through the doors day and night. Mirwais Hospital sees an average of 300 patients and as many as 90 births every day. More than 27,000 babies were born at the hospital in 2019.

Midwives staff the busy delivery ward at Mirwais Hospital in Kandahar, Afghanistan, on Feb. 18. Lynzy Billing for Foreign Policy

Two-thirds of births in Afghanistan still occur at home, and many rural Afghan women have no access to basic health clinics. For decades, the country has battled one of the highest infant and maternal mortality rates in the world—particularly in rural areas, where as few as 3 percent of deliveries are attended by a skilled professional. Postpartum hemorrhaging is the leading cause of maternal death. “Some women still give birth at home because the hospital is far away and there is no transportation. But in a home delivery, complications like hemorrhaging are common, and many women and babies die,” said Mazia Azimi, 30, another midwife at Mirwais Hospital and a mother of three. “These complications could be easily addressed if these women were giving birth here at the hospital.”

Mazia Azimi, left, and Sitara Habibi are longtime midwives at Mirwais Hospital. Lynzy Billing for Foreign Policy

Over the last two decades, the increasing presence of midwives has started to play a role in improving a mother’s and baby’s chance of survival. Afghanistan’s maternal mortality rate has dropped from 1,600 deaths per 100,000 live births in 2002 to 638 deaths per 100,000 births in 2017. (Other estimates put the current figure at 400 per 100,000 births.)

The number of patients at Mirwais Hospital has increased in recent years, along with their expectations. “Women from across Kandahar heard that we have a delivery ward, and now they are all coming here. Some travel for days and spend all the money they have to come to Mirwais,” Habibi said. “There are not enough of us. Every bed is full. On the delivery ward every bed is full, and upstairs surgeons are doing back-to-back cesareans, often two women at a time, and things don’t go according to the standards here. One midwife has to attend to four or five deliveries at a time.”

Azimi talks to a surgeon in the delivery ward at Mirwais Hospital on Feb. 17.Lynzy Billing for Foreign Policy

Mirwais Hospital often takes on patients who have been unable to receive proper treatment from their local clinic—if they have access to a medical professional at all. “The midwives here have saved many women’s lives from very complicated and dangerous situations,” Azimi said. However, some complications are discovered too late. “Some women’s families don’t let them come for checkups, or sometimes the hospital is just far away. In these cases, we are not able to address the complications in time,” she said.

Azimi attends to a newborn baby in the delivery ward at Mirwais Hospital on Feb. 17. The baby was born breech and required oxygen through hand ventilation before being taken to the ICU.

Babies rest in the ICU of the pediatric department at Mirwais Hospital on Feb. 17. Lynzy Billing for Foreign Policy

Beyond the maternity ward, Afghan midwives deliver other reproductive care to women, including disease prevention, breastfeeding guidance, and family planning. In conservative Kandahar, providing such support is also challenging—and sometimes dangerous, with midwives facing threats from the community and even patients’ family members. Not all midwives have the support of their own families. “For some of them, their families don’t allow them to come here, but they insist that this is the work they want to do,” Azimi said. “They know how important it is for the community, and they manage to get the permission somehow, but every day they battle just to come into work.”

Women in labor wait in the corridor outside the maternity ward at Mirwais Hospital on Feb. 19. Lynzy Billing for Foreign Policy

Women walk outside the maternity ward as children wait nearby at Mirwais Hospital on Feb. 19. Lynzy Billing for Foreign Policy

A woman holds her child in the pediatric department at Mirwais Hospital on Feb. 17. This is the third hospitalization for the 2-year-old, who suffers from malnutrition. Lynzy Billing for Foreign Policy

Afghanistan’s conservative social norms and the lack of access to education for women present other unique challenges for the midwives of Mirwais Hospital. The average Afghan household has eight members, and women from conservative families balk at the idea of birth control, Habibi said. Afghanistan remains one of the most dangerous countries in the world for women. Violence against women is still commonplace, as is the expectation that a wife will provide her husband with many children. Husbands and other male family members are often the biggest obstacle to family planning, so the midwives deliver targeted information to husbands and male relatives through screens in the waiting area.

Some subjects are sensitive: Talking directly to the men about birth control would not be appropriate for them or for the midwives, according to Habibi. “If there is something specific that we can’t say—such as advising the women to avoid sleeping with her husband for a certain period of time for health reasons—we tell the woman discreetly and then advise the patient to convey it to her husband later,” Habibi said. “In this way, we often need to go through the women to educate the men.”

Midwife trainees prepare the labor ward for the first patients of the day at Mirwais Hospital on Feb. 18. Lynzy Billing for Foreign Policy

Despite the many challenges and risks, the midwives have no plans to leave their work at the hospital. Their patients need them. As dusk fell on Mirwais Hospital in February, Azimi walked out of the maternity ward with a newborn, and the men and children waiting outside jumped to their feet to get a peek—hoping that she was carrying their newest family member.

A father and son wait outside the maternity ward at Mirwais Hospital on Feb. 17. Lynzy Billing for Foreign Policy

A newborn baby receives his vaccinations in the maternity ward at Mirwais Hospital on Feb. 18. Lynzy Billing for Foreign Policy

A proud grandmother holds a newborn baby boy after he received his vaccinations in the maternity ward at Mirwais Hospital on Feb. 18. Lynzy Billing for Foreign Policy

“It’s not an easy job because the lives of many mothers and children are in our hands,” Azimi said. “Women come from very far away because they know that the hospital provides experienced midwives and legitimate medicine. They trust our hospital, and they trust us.”

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