Five women were in the throes of labour at the delivery ward of Rabia Balki Women's Hospital in Kabul. From one corner a woman cried, "Allaiii! Allaiii! Allaiii!" but the rest were quiet. A couple gazed distractedly in my direction.

Not only were all but one silent, they were also completely alone - no sister or mother held their hands and wiped their faces. Even the midwives and nurses weren't touching them.

Allyson Arnold, a midwife trainer with IMC UK (International Medical Corps), later explained that convincing the midwives to touch women in labour has been one of her biggest challenges.

This brings to mind something the president of Afghanistan's midwifery association Pashtoon Azfer told me: "As Afghans lost their buildings and possessions they also lost their compassion," she said.

As a counterpoint to this view, an Afghan obstetrician explained that many women are used to giving birth alone in Afghanistan. Take her mother - every once in a while, she would disappear into the bathroom and emerge after a few hours holding a new brother or sister.

Most Afghan women don't go to hospital when giving birth unless they are very sick or relatively wealthy city dwellers, health workers say. In fact, an estimated 90 percent of deliveries are not attended by any skilled personnel, according to a 2003 study by the London School of Hygiene and Tropical Medicine (up-to-date statistics are very hard to find in this place).

Not surprising then that Afghanistan has among the world's highest maternal and infant mortality rates.

A recent study by the U.S. Centers for Disease Control and Prevention (CDC), the United Nations Children's Fund (UNICEF) and the Afghan Ministry of Public Health, showed that more than 40 percent of deaths among women of child-bearing age are caused by preventable complications in pregnancy.

It can be hard to get reliable statistics in Afghanistan, but the CDC, UNICEF and Ministry of Public Health give the average maternal mortality rate as 1,600 deaths per 100,000 live births - the figure is based on a survey of four provinces.

This compares with reported mortality rates of 37 and 500 per 100,000 in neighbours Iran and Pakistan, respectively, according to UNICEF statistics.

Strides have been made. In 2002, the country had 467 recognised midwives; now there are about 1,500, said Azfer. Clearly there is a very long way to go.

RESCUING ANGELS

The IMC, which trains health workers in Afghanistan (and many other countries), is on the frontline in tackling the high maternal mortality. One thing that particularly struck me was the intense negotiation necessary to get women to participate in the demanding 18-month training programmes offered by IMC and others.

I talked to Dr S. Shahab Ansari, IMC's physicians trainer, at the graduation ceremony for around 50 midwives in Parwan, a province close to Kabul. Beneath modest white robes and demure pink head scarves many of the women wore their wedding outfits - brightly coloured dresses and dangly gold jewellery.

Convincing families to allow their women to enrol in such programmes is a major hurdle. For the class attending the graduation ceremony, Ansari had to make five visits to remote communities beforehand to negotiate with village elders.

The most impressive thing about his efforts was that he managed to persuade some who lived far from provincial capital Charikar to allow women to stay at a boarding house during the course. This is a very big deal in a country where many women still do not step outside their front doors without an escort of some sort.

Speakers at the ceremony included engineer Mohammad Khan, who was celebrating the graduation of one of his six daughters. The village elder from Parwan's Salang district told me he had also convinced five other families to let their wives, daughters and sisters become midwives.

I asked him why this was so important.

"When the Taliban was in power I helped one daughter go to a midwifery course. I, with my wife, and daughter would go to the villages to help women give birth. I saw so many die and realised that one person cannot make a difference - you need many people," he said.

During a speech at the ceremony, he called the graduates "rescuing angels" and exhorted community leaders to help women to carry out their work in remote villages. This is an important point - it is often very hard to convince trained medical workers to live in the harsh conditions in the countryside.

"Even with the offer of exceptionally high salaries, NGOs (non governmental organisations) are experiencing extreme difficulties in recruiting female staff to rural areas," says the School of Tropical Medicine study. This is mainly due to security fears and abysmal infrastructure in the provinces.

It's worrying to note that this study was written before the recent rise in criminality and the renewal of the Taliban insurgency.

Still, Khan is pretty optimistic given what Afghans have been up against before.

"We proved during jihad that we could win the holy war (against the Soviets). And then we resisted the al Qaeda occupation," he said during his speech.

He did issue a note of alarm, though. Five years after the fall of the Taliban many communities still do not have proper equipment or clinics. Without these, much of the effort and money that goes into training midwives will be wasted.

"These midwives are now key players in our country's remote areas," he said. "But when a midwife sees a woman die in labour because of poor equipment, it only discourages the midwife and does not help the dying mother."