Women vote in the presidential election in Kandahar, Afghanistan, in August 2009 (AFP/Getty Images)

For decades, Afghanistan has ranked with the very poorest African countries as one of the hardest places for infants and small children to survive. Conflict, poverty, poor health services and low levels of female education and rights combined to produce extremely high mortality rates for Afghan newborns, older infants and very young children. But finally, after 15 years of Western-backed civilian rule, their chances of survival are improving dramatically.

In 2000, after four years under an extremist Taliban regime that kept women secluded at home, nearly 100 of every 1,000 Afghan babies died before their first birthday, according to the annual United Nations World Population survey. That rate was topped only by a handful of African nations, led by Sierra Leone with 149 infant deaths and followed by Angola with 138 and Liberia with 129. In the United States, the rate was six.

But today, with health services for Afghan women more widely available, the death rate for their babies has fallen sharply, even though most mothers still have very little or no education and many still give birth at home. In a few isolated provinces the mortality rate is still high, but a recent Afghan government survey found that between 2001 and 2015, the nationwide mortality rate for all infants had fallen from 66 to 45 deaths per 1,000 live births, and from 87 to 55 deaths per 1,000 for all children under 5 years old.

Those findings, published in a report funded by the U.S. Agency for International Development, were based on interviews with 29,000 married women across the country. The results differ significantly from annual population surveys by the U.N. and the CIA. The U.N. found that Afghanistan's infant mortality rate for the past five years was 71 per 1,000, considerably higher than the Afghan report. The CIA World Fact Book put the number at 115, making it the highest in the world.


Trends in child mortality from 2001 to 2015. (Demographic and Health Survey)

One key to the greater survival rate has been an intensive effort to recruit, train and deploy thousands of community midwives to rural areas where there are no hospitals or doctors within reach, according to Ferozuddin Feroz, the Afghan minister of public health. In 2002, there were only 400 such midwives. Today, there are more than 5,000.

"We still need more," Feroz said Wednesday in an interview during a visit to Washington. "To provide safe deliveries across the country, we need at least 11,000 midwives." Feroz said the midwives do much more than deliver babies, also providing lessons in hygiene, infant care and broader health education to women who have no other way to obtain them. According to the report, 84 percent of about 29,000 married women surveyed in 2015 said they had never attended school. Only 8 percent had completed primary school, and another 9 percent had been to high school or college.

Afghanistan also has one of the highest fertility rates in the world, with an average of 5.3 children born per woman. Only 23 percent of married women reported using any method of contraception, the report said. But in urban areas, more and more of them are delivering their babies in hospitals and receiving skilled prenatal and postnatal care. In 2015, more than 75 percent of mothers gave birth in a health facility and were assisted by a skilled provider. Women in three major urban areas — Kabul, Herat and Mazar-i-Sharif — have higher education levels and greater access to professional maternity care.

But access to safe deliveries and baby care, and the resulting survival rate, are both much lower in rural areas. In Nooristan Province in eastern Afghanistan, the discrepancy is especially shocking. According to the survey, only 1 percent of births in Nooristan took place in a health facility, only 11 percent of pregnant women received prenatal care, less than 2 percent were delivered by a skilled provider such as a formally trained midwife, and less than 1 percent had an immediate postnatal checkup. Similarly, 74 percent of babies there received no vaccinations, while nationwide 74 percent were inoculated against measles and diphtheria and 79 percent against polio.

"There are three factors that can work against us: insecurity, geography and economic problems. Nooristan has all three," Feroz said. He said that both the government and private aid groups operate health clinics there but that the constant danger of insurgent violence had made it difficult to find female staff members to work in them, a problem that has added to traditional family reluctance to allow women to visit those clinics.

Feroz, 50, is a medical doctor who was appointed to his post by President Ashraf Ghani, the former World Bank official who took office last year vowing to increase efficiency and root out corruption in government. Feroz said that public health services have suffered from various forms of corruption and double-dipping, including illegal resales of medicine, side practices by doctors to supplement low public salaries and bribes to health inspectors. With Ghani's encouragement, he said, he asked a newly formed anti-corruption agency to review and evaluate public health administration and delivery.

"They found a lot of leakage," he said, referring to theft. "There is also a lot of nepotism and misuse of power."

One especially vexing problem, he added, is that many Afghans go abroad for special medical treatment, which drains funds from the public health service and makes it hard to attract qualified doctors. Feroz said an estimated $300 million per year leaves the country when Afghans seek treatment in Dubai, Iran or Pakistan. The improvements in health care have come with substantial financial aid from the U.S. and other Western governments, which are gradually tapering off. Officials are now looking at sales taxes and other ways to increase revenue to find health care and other public services.

"We can't change the culture, but we have laid the foundation," Feroz said. "Now we have to find a way to sustain it."