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By Sana Atef*, Mehsa Elham*, and Freshta Ghani for Zan Times
Humaira*, a single mother of three, just wants to do her job as a midwife in a hospital in Kandahar province. Each time the Taliban adds another layer of rules and edicts directed at working women, she has to figure out a way to continue her job of helping other women during the dangers of childbirth in a country with the highest maternal mortality rates in Asia. And her experience is being echoed across Afghanistan as female medical personnel struggle to do their jobs under increasingly draconian rules directed at them because of their gender.
In December 2022, when the Taliban banned women from working in non-governmental organizations (NGOs), Humaira’s only way of feeding her family was suddenly at risk. That’s because her salary came from an NGO that works in the health sector. After a visit by UN humanitarian relief chief Martin Griffiths in January 2023, the UN said that “the Taliban have made exceptions for women’s participation in the health and education sectors.”
The exemption meant that women, such as Humaria, could still work but it didn’t mean they were exempt from the general edicts directed at women based on their gender. The hospital where Humaira works, demanded that all female staff had to be accompanied by a mahram (a close male relative) when on duty.
For Humaira, 38, this rule makes it nearly impossible for her to continue her job. She doesn’t have such a male relative. She divorced her husband before the Taliban took over, when he asked her to put her father’s property in his name. Now, living with her three children and paralyzed father, she can’t comply with the order.
To see how Taliban restrictions have affected women health workers, Zan Times interviewed 23 female health workers in 10 provinces of Afghanistan: Kabul, Kapisa, Sar-e-pul, Uruzgan, Herat, Bamyan, Samangan, Ghor, Jawzjan and Kandahar. They all say that their ability to serve their patients is becoming increasingly difficult.
In particular, they tell Zan Times that they are facing the same problem that has plagued Humaira’s life: needing to have a mahram with them while working. Several female doctors say they are being forced to leave their jobs because they did not have an appropriate mahram. Others are facing forced dismissal, because they can’t always have a close male relative with them while they work.
And this is happening in a country that is facing the world’s largest humanitarian crisis in 2023, has the highest maternity rate in Asia, and suffers from a shortage of female doctors and health workers. The situation is expected to worsen as the Taliban have banned almost all areas of public life to women.
In February 2023, Doctors Without Borders/Médecins Sans Frontières (MSF) published a report on how access to healthcare has changed under the Taliban. For this report, MSF spoke with 200 patients and caretakers as well as MSF and Ministry of Public Health staff in Kabul, Kandahar, Khost, Helmand, and Herat provinces between May and August 2022. “A broken healthcare system, widespread poverty, and increased restrictions placed on women are fueling the current humanitarian crisis in Afghanistan,” MSF said in February 6, announcing the finding of the research. “It is already difficult in some of our projects to fill the necessary positions, including gynaecologists,” said Filipe Ribeiro, MSF’s representative in Afghanistan. “If women are not allowed to study, where will the next generation of doctors, midwives, and nurses come from?
For now, some governmental hospitals fill the gap by hiring inexperienced junior female doctors or medical students, several women health workers tell Zan Times. Their lack of experience or specialized skills have caused problems for the women who need their help. A health worker in Aibak city, Samangan province, says there are women who haven’t even graduated from grade 12 working as midwives in the village clinics.
With such inexperienced workers on duty, it’s easy for something to go wrong. In mid-September 2022, Habiba* went to a government hospital in Kandahar city to give birth to her fourth child. During her delivery, the midwife on duty sped up the delivery by using devices that pulled on the baby’s head. Habiba instantly knew something was wrong when she looked at her newborn daughter. “When I touched my daughter’s head, it was very soft, as if I were touching a bag full of water,” she says. “She would not breastfeed and vomited constantly. When we went to the specialist doctor, the doctor said that my baby’s head was badly damaged during the delivery.” Her daughter is now eight months old and under treatment but her mother doesn’t yet know if her condition will improve.
To help women like Habiba and to feed her children, Humaira, the midwife working in a Kandahar hospital, needed to get around the Taliban’s mahram rule. She hired the son of a relative who would accompany her to work in the guise of her brother. In exchange, Humaira paid him 500 afghani, almost half of what she was earning. The solution didn’t last long.
In March 2023, Taliban officials in Kandahar ordered that female employees and their mahrams verify their relationship with each other by bringing their tazkiras (national identity cards) to the hospitals. Only after these verifications would the mahrams be allowed to accompany female employees while the women were on duty. In addition, the female workers and their mahram have to sign attendance records daily and carry their identification cards.
On top of that, the women have to cover all costs related to their mahram’s travel and stay. A source working with the Taliban health directorate told Zan Times that Taliban policies require the women to pay for the travel costs and other expenses of their mahrams. While mahrams can sometimes sleep in empty beds at the government hospital, that option isn’t available at private hospitals, which charge their employees a fee when their mahrams use the waiting room.
Even those who obey the Taliban rules on identity cards and mahram can still end up in trouble. For five years, Nabila Javid* has worked as a gynaecologist and obstetrician in a hospital in Trinkut, the capital of Uruzgan province. Even though her brother accompanies her, she still faces harassment by the Taliban, she tells Zan Times. In late March 2023, she was riding home with her brother on his motorcycle after completing a shift at the hospital when they were stopped by the Taliban. Though Javid and her brother showed their identification cards and said they were siblings, the Taliban still took them to the station for further investigation. “Taliban are not literate enough to read documents, or they say that you forged them and made fake tazkiras,” she says. “I wanted to call my father so that he would come, and mediate, but they took away my cell phones and did not allow any contact with my father or any other member of my family.” Because of Taliban harassment, she refuses to accept work at nights, meaning that less experienced midwives have to work those shifts.
The Taliban identity inspections meant that Humaira had to stop taking her fake mahram to work in Kandahar for fear that the Taliban would find out he wasn’t a close male relative and that she is divorced. She worries that if the hospital and the Taliban discover her situation, they would fire her and probably pressure her to marry. “I wear a hijab and a burqa, but now I cry at night because, if I don’t have a mahram, I will be fired,” she explains.
The stress of living as a woman without a Mahram, the need to feed her family and support patients who need her medical help, has taken its toll. Humaira suffered a stroke, which left one of her legs partially paralyzed.
Some health workers found the Taliban restrictions so onerous that they were forced to leave the country. Dil Afroz* was an internal medicine doctor who worked for a decade in government hospitals in Kabul. The mother of two children used to go to work alone because her husband had travelled to Iran for work. Then, after Taliban vice and virtue officials visited her hospital in October 2022, the rules changed: all female employees without mahram had to resign. Dil Afroz was one of the first to resign, eventually emigrating to Pakistan. But life is still difficult. “We are in uncertainty in Pakistan,” she tells Zan Times. “My husband works in Iran and, with difficulty, sends some money for our food. I don’t know what the future holds for us.”
Those working in the healthcare field in Afghanistan say that women are disproportionately affected by lack of access to health care. The MSF report found that 88 percent of respondents “delayed, suspended, or decided not to seek medical care” in 2022 due to barriers such as cost, and nearly two-thirds say women face worse obstacles than men. MSF’s teams in Afghanistan are also reporting more complicated pregnancy cases compared with 2021 as women are forced to travel long distances to obtain care. Particularly worrisome is that the Taliban are strictly enforcing the “mahram requirement,” on both women health workers and women needing health services, making it impossible for most women-led households to access medical care.
The result is a shockingly high death rate for the women in Afghanistan. Even before the Taliban seized power and imposed its harsh restrictions on women, the World Health Organization (WHO) reported that 8,700 women died in childbirth in Afghanistan in 2020, making it one of the most dangerous places on earth to give birth. The report, published in February 2023, pegged Afghanistan’s maternal mortality rate at 620 per 100,000 live births in 2020.
Health care workers see a bleak future for women in Afghanistan. “With the daily decrease of female doctors, a great disaster will happen to female patients in the villages,” says Humaira, “and the Taliban will be responsible for it.”
*Names have been changed to protect the identity of the journalists and interviewees.
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