KABUL, Afghanistan - Fereshta, 28, repositions herself slowly in her bed at Malalai Hospital, on the western outskirts of Kabul. It is just a day after she has received surgery to repair an obstetric fistula, a childbirth injury that left her incontinent after her first delivery ten years ago, when still just a teenager herself. 

During the decade she lived with obstetric fistula, Fereshta gave birth to another six children. Only one survived -- her daughter, now six years old.

Though crying moments earlier, as she recounted the years of isolation her injury caused, Fereshta stops instantly when a doctor returns to check on her. But her reaction is one neither of relief nor celebration. Instead, Fereshta stiffens, and with urgency in her voice asks when she will be able to go back home to Jalalabad. "I don't want to lose my daughter, I need to see her."

Today, Fereshta has only one immediate concern. Her husband wishes to take another wife and have more children - and he plans to exchange Fereshta's daughter to pay for his new bride.

Fereshta had not sought medical treatment for her fistula until now, though she knew the treatment existed. Her husband desired children, and a common misconception among many in this region is that the surgery causes infertility.

Giving birth too young, too often and with too little time between pregnancies

Women's subordinate status in the household remains as much of an obstacle to reducing maternal death and injury in Afghanistan as geographic and conflict-related factors. Under pressure from the patriarchal society, and without access to education and health care, women and girls like Fereshta and her daughter continue to give birth too young, too often or with too little time between pregnancies. And when complications in pregnancy do arise, cultural factors are among the reason they delay or are unable to seek care.

Afghan culture does not allow women to be treated by male doctors. During her first pregnancy, Fereshta went to her mother's house to deliver. Traditionally, Afghan women are also expected to conceal labour pain to their families. When the pain became unbearable for Fereshta, and it was clear that she was not facing a normal delivery, her family finally decided to bring her to the hospital. But by that time, it was too late - Fereshta delivered in the car.

The child, which was in the difficult breech position, died before they reached hospital. Fereshta developed a vesico vaginal fistula, a hole between the uterine wall and the bladder.

The challenges facing the Afghan health system are many - decades of conflict, cultural restrictions, poverty, poor health education, gender inequity and a shortage of women health workers trained in midwifery all prevent women from accessing health care. Just 14 to 24 per cent of all births are attended by skilled health personnel (the different figures are from UN and government assessments, respectively).

It is no surprise, then, that women in Afghanistan face shocking rates of maternal death and injury. The maternal mortality ratio is 1,400 deaths per 100,000 live births - more than four times the threshold of 300 per 100,000 live births that is generally considered ‘high'. The survival of newborns is equally tenuous: 5 out of every 100 babies die during the first 28 days after birth.

Women, communities and policymakers forge consensus on the need to save more lives

Recently, however, there has been growing consensus in Afghanistan about the need to reduce maternal and neonatal deaths. President Karzai included maternal, newborn and child health in his July 2010 address to the Kabul Conference, which brought regional, international and national stakeholders in Afghanistan's development together to outline a roadmap forward. In September 2010, the Government of Afghanistan made strong commitments to the Global Strategy for Women's and Children's Health including to:

• Increase per capita health spending from $10.92 to $15 by 2020
• Nearly double the midwifery workforce to increase skilled birth attendance to 75 per cent
• Expand the proportion of women with access to emergency obstetric care, to 80 per cent
• Strengthen health service outreach to communities
• Increase the contraceptive prevalence rate from 15 per cent to 60 per cent
• Expand immunization programs to cover 95 per cent of children
• Mainstream international protocols for integrated management of childhood illness.

Since 2010, UNFPA and the International Confederation of Midwives have supported a midwifery training programme in Afghanistan. In a society dominated by men and by a male doctor health system, the role of these midwives is crucial for patient and care provider alike. The State of the World's Midwifery 2011, report released by UNFPA and partners in June 2011, found that Afghanistan needs almost 4,000 additional midwives to attain 95 per cent skilled birth attendance by 2015.

Since January 2011, the Nursing and Midwifery Department of Ministry of Public Health has received technical and financial support from UNFPA to develop the first National Policy and Strategy for Nursing and Midwifery Services. The plan, approved in August, gives nurses and midwives a clear roadmap to achieve a healthier Afghanistan for women and newborns. That same month, UNFPA's Executive Director, Dr. Babatunde Osotimehin, visited Afghanistan and announced additional support to raise funds for the development Afghanistan's health system.

Female midwives can enter doors that are closed to male doctors

Saleha Hamnawzada, 35, graduated from the Balkh Institute of Health Sciences in Afghanistan and is now the Executive Director of the Afghanistan Midwifery Association (AMA). "In a country like Afghanistan where women, especially in remote areas, can't really access medical facilities because [they lack] women heath workers, a midwife can save a woman's life," Saleha explains. "The midwife is the only one who can really enter the family. She can talk with the husband and she can influence the family's decisions."

A mother of four children, Saleha faced her own uphill struggle to reach her current position. She practiced midwifery for ten years in mobile health clinics in remote areas of Afghanistan, and later managed a programme to train community midwives in Bamyan Province. Working in these areas, it became clear to Saleha that cultural and gender norms are among the biggest challenges for Afghanistan today.

But she has seen examples of where this has been transformed to benefit pregnant women, mothers and babies. She credits not only to the establishment of fully-equipped delivery rooms in remote areas, but also a change in the general perception of a midwife in society.

Dreaming of, and working toward, a better future

"Today a midwife [who] graduates from a [community midwifery education] programme is a woman well respected by the community," Saleha says. "She can earn her own salary, and she represents a role model for the future generation. A midwife is not only saving women and children's lives, she is also bringing a huge contribute to a more equal Afghanistan."

Saleha Hamnawzada's hope for the future of Afghanistan is to see a midwife leading the Ministry of Public Health.

As for Fereshta, she hopes to have a healthy family and to keep her six-year-old daughter at home. It was her husband's decision to take another wife that finally pushed her to seek treatment for her fistula at the Malalai Hospital Fistula Centre, supported by UNFPA. "Being able to have more children is my dream for the future. After years of loneliness, I hope that this operation will help me to be part of the family again.

-- Gaia Chiti Strigelli