KABUL Afghanistan has the worst rate of maternal mortality in the world, the latest World Health Organization data shows, with a toxic mix of inaccessibility, poverty and cultural barriers to women's healthcare conspiring against expectant mothers.
One Afghan woman in 11 will die of causes related to pregnancy and birth during her childbearing years, the WHO says. In neighboring Tajikistan, that figure is one in 430, while in Austria, it is one in 14,300.
WHY DO SO MANY WOMEN DIE IN PREGNANCY AND BIRTH?
A tradition for early marriages and a lack of effective family planning mean women often have babies very young and very frequently, which can increase the risk of health complications such as eclampsia -- fits caused by high blood pressure.
Girls who give birth before age 15 are five times more likely to die in childbirth than women in their 20s, United Nations figures show. A 2010 UN report said some studies showed half of all Afghan girls were married before that age.
A weak economy and decades of conflict have hit public health provision, so clinics and hospitals, while state-funded, are few and often limited to urban areas. There is also a lack of trained midwives, although this is slowly being addressed.
The geography of Afghanistan and poor infrastructure mean it can be physically difficult to get women from home to the hospitals that do exist. With car ownership still low, women are transported by motorbike, donkey or even wheelbarrow to clinics.
WHY AREN'T THEY BEING HELPED?
Women in deeply conservative Afghanistan face daunting cultural barriers to accessing maternal healthcare. Many are unable to leave the house without a male relative to accompany them. If one is not available, they must give birth at home.
Treatment by male doctors remains taboo, and blocks to women's education under the Taliban regime severely restricted the numbers of female doctors and midwives.
Barriers persist unofficially in some conservative areas, which either lack girls' schools or have leaders who still object to their education.
Medical intervention in birth is still regarded with some suspicion. A liking for big families means some women prefer not to undergo procedures like caesarian sections, which can limit them to just three or four babies -- a small family by Afghan standards, where the average is just over five.
Women's families often favor taking them to village elders or traditional birth assistants for help. Among them, even basic healthcare skills can be lacking.
Villagers say traditional birth assistants often don't wash their hands before deliveries, and have been known to sever the umbilical cord with broken glass or the edge of a shoe.
ARE THINGS GETTING BETTER?
Data from the WHO shows that the rate of maternal mortality had declined since the Taliban were ousted from government, to 1,400 per 100,000 live births in 2008 from 1,800 per 100,000 lives births in 2000.
The Afghan government also flags up improvement.
A recent survey it carried out of 22,000 families suggested the maternal mortality rate had dropped to 327 per 100,000 live births, although it admitted its results were skewed to more secure areas, and some under-reporting remained.
Presenting the survey, Afghanistan's acting minister of public heath, Suraya Dalil, said the department recognized there was still a long way to go to improve maternal health.
A survey carried out by the charity Save the Children in 2010 found that only 14 percent of births are attended in Afghanistan, and that only 16 percent of women were using modern contraception.
(Compiled by Jan Harvey; Editing by Sanjeev Miglani and Paul Tait)