KABUL, Afghanistan - The pregnant woman was bleeding and in trouble.
So Mullah Abdul, 42, helped load his terrified young cousin into a jitney van and sent her on the six-hour ride from her isolated village to the nearest hospital, in a town called Pul-e-Kumri.
Three hours later, in the midst of the journey across the Hindu Kush mountains, the woman died. So did her child, struggling to be born. The driver turned around and drove them home to be buried.
The young woman might have been saved by medicines that control bleeding and that are available in every delivery room in the United States. But in the woman's Bamyan Province village there was no clinic, no doctor, no one who could help.
"We have a local midwife," Abdul said. "But she has no education."
The pregnant woman died surrounded by snow-swept mountain peaks, yet in a terrible sense she was far from alone: 23,000 Afghan mothers die in childbirth each year, making it the nation's leading cause of death for women.
"It's not a clean death, a clinical death," said Dr. Jeffrey M. Smith of Johns Hopkins' Bayview Medical Center, an adviser on maternal health to Afghanistan's health ministry. "It's death in a pool of blood. It's death in incredible pain. It's death on the top of a mountain."
Biggest cause of death
It's also the single biggest health threat that Afghan women face, claiming the lives of more expectant mothers each year than malnutrition and war. It is a public health catastrophe with few parallels elsewhere in the world.
In the United States, the lifetime risk of death in childbirth is one death out of every 2,500 women - the risks for any individual depending greatly on the number of times she gives birth. In Afghanistan, the figure is one in six.
Giving birth is perilous here partly because of the nation's poverty; the lack of roads, clinics and health workers; and partly because the country's culture has blocked health care advances.
Women here may marry as young as 12 and bear children at 13, long before they are full-grown adults. Those who survive bear an average of seven children - facing grave risks each time they do so.
Dr. Fahima Sekhundari, director of Afghanistan's largest childbirth center, the 270-bed Malali Maternal Hospital in Kabul, routinely sees women near the point of death - and beyond.
"We had a patient Friday, who had been riding in a car for eight hours," she said in a recent interview. "When she arrived, she was already dead."
One pregnant woman arrived at the hospital with a severe case of eclampsia, which can cause dangerously high blood pressure. "Her family took her to lots of religious shrines," Sekhundari said. "Only after that did they take her to the hospital. And by that time, she was in a coma."
Most births at home
Only 8 percent of Afghan births occur outside the home but that figure might soon rise. In interviews, village elders across eastern Afghanistan said that they want their wives, sisters and cousins to go to clinics or hospitals to give birth.
"It is dangerous to have a child at home," said Muhammad Salim, an apple broker from a village about three hours southwest of Kabul in Wardak Province.
One of Salim's neighbors died giving birth to twins in March. Both of the babies died as well. There was no doctor or midwife nearby. No one knew what to do.
So when Salim's wife was ready to deliver, he paid $22 - a small fortune here - for the taxi ride to Malali hospital in Kabul. "We decided it wasn't a good idea to have children at home," he said. "A clinic is the most important thing that we need."
Smith, of Johns Hopkins, says he has seen a change in attitudes in the past two years. "I think there's a growing sense that people should take advantage of Western medicine, that they should not just live or die," he said.
Malali Hospital, a jumble of one- and two-story masonry buildings on a residential Kabul street, would never be mistaken for a modern, Western institution. Despite a 2003 renovation by foreign aid agencies, the institution's wards and snaking corridors are cramped and in need of a coat of paint. But for Afghanistan, it is a state-of-the-art facility.
Taxis arrive in the courtyard every few minutes. Scores of men loiter in the waiting room or under shaded porches. Inside, only women are allowed - and a handful of male hospital staff.
As many as 100 children are born here a day, including the boy born recently to Najilah, a 27-year-old Kabul resident.
Like many Afghans, Najilah uses only one name. She was brought in, Sekhundari said, suffering from uncontrolled bleeding. So doctors performed a procedure used in just 2 percent of births here: a Caesarean section. (About a quarter of all births in the United States are by Caesarean section, making it the most commonly performed surgery in America.)
Shrine or hospital
In the village, Sekhundari said, Najilah "would have gone straight to a shrine" for prayer, instead of a clinic for treatment. And she probably would have died.