GHANI KHEL, Afghanistan — A year ago, Wahida watched her aunt suffer in labor for 18 hours before dying. Her isolated village of 1,000 people in eastern Nuristan province had no clinic, no doctor, no roads to get help.
"We couldn't take her anywhere," said Wahida, 18, who like many Afghans has no second name. "No one knew what to do."
So this year, Wahida joined a program teaching young women to become midwives in an attempt to cut Afghanistan's maternal mortality rate, the second-highest in the world.
As the U.S. focuses more on fighting militants in Afghanistan, the situation with women and childbirth is one of the biggest health problems facing the country, a life-and-death matter made worse by war, the impossibly difficult terrain and insurgent antipathy toward government health workers.
Almost every 26 minutes here, a woman dies giving birth. Only Sierra Leone's rate is worse. In her lifetime, an Afghan woman has a 1 in 8 chance of dying in labor. Almost half of all deaths among Afghan women of reproductive age are due to pregnancy and childbirth.
For cultural and religious reasons, only female doctors and midwives are allowed to deliver babies, and many mothers have no prenatal care. Skilled health workers assist in only 14 of 100 births. Sometimes, in a complicated birth, a spiritual woman is called, who recites Koran verses and tells the pregnant woman to repent her sins, which may be why her birth is so difficult.
"The problem is that Afghanistan is still a traditional country," said midwife Meena, 21, who teaches new midwives and did not want to give her last name because it could embarrass her father. "Men do not allow a woman to deliver in the hospital because they think there might be men in the delivery area. And the women are embarrassed because they don't want anyone to hear them scream."
The midwife program recruits young women from remote areas, trains them in 18 months and sends them back home. There, they work in clinics, educate their villages about the importance of safe delivery and deliver babies in women's homes.
Shortly after the Taliban fell in late 2001, a Dutch relief agency set up the midwife program in Ghani Khel. It has since spread to 18 other provinces. Through it and other programs, more than 5,000 new midwives and nurses have been trained. There are now 1,400 clinics and hospitals, up from 900 in 2001.
Next year, the government hopes to survey hospitals, clinics and midwives to see if the maternal mortality rate has been reduced. "We have evidence there is a decrease," said Abdullah Fahim, the Ministry of Public Health spokesman.
But in a country where government employees are attacked constantly by Taliban-led insurgents, being a midwife is a risky political statement.
The Ghani Khel program is supposed to train students from neighboring Kunar province, a militant haven, but no students from Kunar are enrolled. A clinic that opened in the dangerous Pech Valley of Kunar has almost no patients because it is close to a U.S. base, and Afghans there do not want to associate — or be seen associating — with Americans. That clinic is being moved.
"People didn't want to send their women there because it was near the Americans," said Toorpekay Nawab, 51, the midwife who runs the Ghani Khel school. "The war affects everything. Of course, it hurts our program."
But Nawab said the Ghani Khel elders protect the women, who live in the same building where they study.
On a recent day, 17 students sat in a classroom and raised their hands at every question.
Later, they wore white lab coats and green hairnets and masks as they practiced delivering dolls from plastic pelvises next to fake patients who yelled in pretend pain.
The deliveries were not easy. Pushing the fake babies through the fake birthing canals required shoving and yanking.
But the women persevered, pretending to use iodine to prevent infections and consoling the fake patients screaming in agony.
Nadia, 19, from Khogiani district of Nangarhar, a militant stronghold, helped in a simulated delivery, but at seven months pregnant, she was a bit unnerved by the screaming. "I'm afraid it's going to hurt," she said.
Nawab, 51, the program director and mother of 10, laughed and told Nadia what she had to look forward to.
"It's very painful," she said cheerfully. But in Nadia's case at least, surrounded by medical help, it would probably no longer be as deadly.