On the morning of the attack, Aquila was running late.
“It was around 9AM, maybe 9:30,” the former midwife trainer said. “That's when I heard some shooting behind me.”
Médecins Sans Frontières (MSF), which ran the maternity ward in western Kabul, had devised an emergency whistle system, but for some reason, Aquila heard no such whistle that day.
“Maybe the guard did not blow the whistle, maybe I couldn't hear it over the shooting... but also, this is Kabul – sometimes you hear shooting – so I thought maybe something happened in front of the hospital. But I realised that I had started walking faster back to the office because [the shooting] seemed really close. I saw some of my colleagues and I asked, ‘Do you know where the shooting is?’”
Only then did the hospital alarm start ringing, Aquila – who like others in this article are referred to only by their first name for their protection – recalled. So she and her colleagues started moving toward the main building, where a safe room is located.
“It was then that I saw everyone running… and they were shouting, ‘Go to the safe room!’”
On May 12, 2020, militants attacked the maternity ward at Dasht-e-Barchi Hospital in the Afghan capital, killing 24 people, including 16 mothers, two newborns, and one midwife. No one has claimed responsibility for the attack, which left more than 20 people, including babies, injured. The attack lasted four hours.
MSF reported that more than 90 people were able to take refuge in safe rooms located on the second floor of the hospital.
“There were about 37 of us in one safe room for five hours. International and national staff,” Aquila said. “We could hear the shooting outside, and I was thinking, ‘What’s happening to the hospital? And how are my colleagues? And how is the patient? And how are the small babies? They cannot move or defend themselves. What’s happening to them?’ With every shot I heard, I was thinking that someone was killed.”
“I had one newborn baby with me, and we just hid there behind the bags of rubbish.”
Fawzia, who was a midwife at the hospital at the time, was already in the ward when the shooting started. “There were seven mothers in the ward and I helped them all escape, and then I ran to the safe room, but it was already locked, so I ran outside and I saw a group of men jumping over the wall into the courtyard of the guest house next door. I tried, but I couldn’t climb over the wall. So I hid behind a rubbish bin,” she said. “I had one newborn baby with me, and we just hid there behind the bags of rubbish.”
Fawzia, too, worried about her patients and colleagues, but she started fearing the worst. “I was thinking maybe I cannot see my family anymore, maybe this is the last day in my life and I am here with a baby who is in the first day of her life and I am not even her family.”
Masooma, also a midwife at the hospital since 2017, was in the COVID department delivering a baby when the gunmen entered the hospital. “I was holding the baby when I heard the shooting. I put the baby on the mother’s belly, and I ran to the toilet. One of my colleagues, Fatima, was also there, and we lay down on the ground covering our heads.”
While she was lying on the floor of the bathroom, Masooma wondered whether she should try to go back to her patient. “Maybe if the attackers saw that we were helping the mother, they would not hurt us,” she remembers thinking. “And so, we went back to the mother and I cut the umbilical cord of the baby.”
“I remember the mother. She was so afraid. I dried the baby and wrapped him in a blanket, and I gave him to her and explained that something had happened to the hospital. ‘I cannot do anything for you. You can take the decision: You can stay or you can go, if you want to go,’ I told her. ‘This is up to you, Doctor,’ she said.” Masooma decided to leave with a colleague, and on her way out, she came across a gunman, who miraculously did not see her.
It was only after she got out that reality sank in.
“It was the most difficult thing for me. Until now, I cannot manage myself and my mind. I am thinking every day, ‘Why did I leave my patient?’ This makes me so sad. I am filled with such guilt,” Masooma said, unable to hold back tears.
“I don’t know what happened to her, but in the news, I read [that] one midwife, one nurse and one patient also escaped the attack. Maybe it was my patient – sometimes I tell myself this. It makes me feel a little better.”
Watch Vice News’ report Afghanistan’s Maternity Ward Massacre
Ten women at the ward that day managed to find shelter, but none of the 16 mothers who were left in the open was spared. Three of these young mothers were killed in the delivery room. Six MSF staff, one newborn, and one caretaker were also wounded in the attack. Another baby was shot in the leg several times. Her mother did not survive the attack.
A week after the attack, Aquila and the other midwives were summoned to the hospital. They were told that MSF was leaving.
The organization had operated the maternity ward since 2014, providing care to over 1,200 women a month, but the attack made them decide to cease operations and completely withdraw from the 100-bed hospital – leaving women in the area without vital emergency obstetric care, and the midwives with an uncertain future.
An MSF representative said they "made the difficult decision to leave Dasht-e-Barchi in the aftermath of the attack because while we still don’t know who was responsible, we know enough to realise that the maternity [ward] was targeted.”
Concerned that similar attacks could happen, the representative told VICE World News, “We no longer maintain any physical presence there as we wouldn’t be able to prevent or even reasonably minimise the risk of being targeted again.”
Dasht-e-Barchi is a rapidly growing area of more than a million people in the western part of Kabul. Many of its residents come from other provinces and poor backgrounds. The vast majority of the Dasht-e-Barchi population are Hazara, a marginalized ethnic group that has long suffered from prejudice and violence.
MSF ran the labour and delivery rooms, an operating theatre for caesarean sections and other complicated deliveries, a recovery room, a 30-bed maternity unit, a 20-bed neonatal unit, and a five-bed kangaroo mother care unit. In addition, MSF offered vaccinations and psychosocial counselling for mothers and caretakers, and it operated the laboratory, blood bank, and sterilisation units.
Because of MSF, the maternity ward was able to serve patients for free. It also provided basic necessities like food, medicine and even diapers – all of which few Afghan women could afford.
Many rural Afghan women have no access to basic health clinics, and two-thirds of births in the country happen at home. For decades, Afghanistan battled one of the highest infant and maternal mortality rates in the world, particularly in rural areas, where as few as 3 percent of deliveries are attended by a skilled professional. Postpartum hemorrhaging remains the leading cause of maternal death.
Midwives, then, are some of Afghanistan’s most vital front-line healthcare workers, fighting daily to ensure that women and babies survive childbirth even in the most remote rural areas. With their help, Afghanistan’s maternal mortality rate has dropped from 1,600 deaths per 100,000 live births in 2002 to 638 deaths per 100,000 births in 2017, according to the World Health Organisation. By other estimates, the mortality rate in that period declined further to 400 deaths per 100,000 births.
Support from international aid groups like MSF made training for midwives possible, and built facilities where they could work and mothers could give birth safely.
“As an Afghan woman, I want to help other Afghan women. I want to support women and be effective in our society and in my community, and MSF gave me a good opportunity as a midwife trainer to share my experience with other women,” Aquila said.
“I really begged MSF to stay. The Dasht-e-Barchi community begged them to stay – women, children who had been our patients crowded outside the gate, including a family who lost a baby in the attack, and brought flowers for them,” Atiqullah, the hospital director said. “People were crying, ‘Please don’t leave us. We all need this hospital. We need you,’ they were pleading.”
Instead, former President Ashraf Ghani visited the hospital. He had the bullet-riddled windows and plaster walls replaced. He did not, however, offer to assist with meeting the hospital's urgent need for medical supplies and medicines, Atiqullah said, and neither did the Ministry of Public Health (MOPH).
The maternity ward reopened on June 25, 2020, over a month after the attack, financed by the Afghan government. The difference was stark.
“The other day, a woman gave birth and asked for a diaper, and I couldn’t even give her that. She couldn't even afford a diaper, and there was nothing I could do,” Aquila said.
She said there were previously 100 staff working on the maternity ward, including 70 MSF-supported midwives and 16 midwives from MOPH. After the attack, the maternity ward reopened with just eight midwives, four gynecologists and one supervisor.
Unable to support their own families, most of the midwives returned to their home provinces, where they continued their work, some as volunteers, to provide much-needed obstetric services to their communities.
“The other day, a woman gave birth and asked for a diaper, and I couldn’t even give her that. She couldn't even afford a diaper, and there was nothing I could do.”
Those who could afford to stay were given subcontracts with MOPH until November last year and had their salaries cut by more than half. Understaffed, the hospital had to shut down the operating theatre and blood laboratory for several months, and the neonatal unit remains closed.
Incubators are still stacked against a wall, gathering dust. The hospital lacks the equipment, medicines, and expertise to handle complicated deliveries or treat patients who need special care and has no pediatrician on staff to assist newborns.
“When you give a baby to the mother after a very difficult delivery, and the mother is smiling and comfortable – I miss seeing that.” Aquila said. “First, we had to deal with the attack. But the second attack was MSF leaving. On one hand, we lost our jobs; on the other hand, we lost the hospital. And then, we lost the MSF. And then the patients lost us.”
The MSF representative told VICE World News that they donated drugs and medical equipment in July last year, and that it should have lasted the hospital six months. They said they also facilitated training for MOPH staff before the official handover.
But the representative also acknowledged that “despite billions invested by the international community since the early 2000s, the healthcare system in Afghanistan is deeply dysfunctional and entirely aid-dependent.”
MSF started working in Afghanistan in 1980. The organization currently runs five projects in five provinces of the country and retains a coordination team in Kabul. But at one point, it was running as many as 20 projects.
While MSF has not categorically said when or if they will reopen in Dasht-e-Barchi, the representative said MSF is continuing talks regarding their other programmes in the country, with the Islamic Emirate of Afghanistan (also known as the Taliban), who have told them they would like MSF to continue working as before.
“The reassurances we receive will be continuously assessed," the representative added.
Until then, the midwives will have to do with the few resources they have.
“We are really feeling the gap that MSF left. It’s been really difficult for us to explain to our patients why we can no longer provide like we did when MSF was here, and I'm worried about the future now – we all are. We have to think about the staff, medicine and the equipment, but also I'm thinking about the people in Dasht-e-Barchi,” Sharifa, a doctor who’s been at the hospital for six years, said. ”They are very poor. What will happen to them?”
The added pressure weighs heavily on the remaining medical staff, who themselves are still coping with their own trauma from the attack.
After MSF left, Fawzia was made supervisor of the maternity ward at the hospital.
“When we came back to the hospital after the attack, we were really scared of everything, any movement, any sound… We were six women alone during the night. I remember one of us would think we heard a voice, and we would all start to panic and run to the safe room and just cry,” she said.
“We had only one guard for the whole hospital, and so we would lock the doors after us, wherever we went,” Fawzia added. “I couldn’t sleep well, and if I could sleep, they attacked us again in my dreams.”
The tragedy weighs heavily even on Sakina, a midwife who was not at the hospital during the attack because she was scheduled for the night shift that day. After hearing of the shootings, she came immediately to provide primary care for the wounded who escaped, but she insists it wasn’t enough.
"I wanted to be a midwife and help women,” she said. “Every day, I think about how, on a day they needed me most, I was not there.”
The survivors are also haunted by the memories of those they lost.
MSF midwife Maryam Noorzad was killed on the day of the attack. She stayed with three patients and helped one patient give birth while gunmen attacked the maternity ward.
“That day, we were on the same shift and I wanted to see my child, so she said she would take my patient so I could go home,” Laila, a midwife at Dasht-e-Barchi, told VICE World News. “That’s what I always think about now. If I hadn’t given my patient to her, I would have saved her.”
Aquila also thinks of Maryam’s children who have been left behind. “One of them is just a small baby. But, you know, Maryam was so strong, and that was just how she was. She chose to stay with the patient, and to support the patient.”
At warp speed, the Taliban took over the country, officially overthrowing the U.S.-backed government on August 15. Amid the U.S. military drawdown, donors began pulling more support out of Afghanistan. One of the first hospitals to lose its international funding was Dasht-e-Barchi.
Today, just over two months since the takeover, the situation is dire.
The United Nations Office for the Coordination of Humanitarian Affairs reported this month that as of the middle of the year, nearly half of the population, or 18.4 million people, were already in need of humanitarian and protection assistance. The country is heavily donor-dependent, with 75% of the total public health expenditure coming from external aid. But after the Taliban seized power, the World Bank and other international donors froze $600 million in healthcare aid. This month U.N. spokesman Stéphane Dujarric appealed to donors for $606 million to pay for humanitarian programs through the end of the year. So far, that appeal is only 22 percent funded.
Meanwhile, the World Health Organization warned that two-thirds of the roughly 2,300 healthcare facilities it supports have run out of essential medicines. Only about 400 are now functioning, and according to the MSF representative some medical professionals have been working without pay for up to five months.
Despite progress made since 2001, when the first Taliban regime ended, childbirth remains the most serious problem Afghan women face, and maternal mortality is still the leading cause of death in the country. According to the most recent U.N. data, one out of 52 women die from pregnancy-related causes.
Before starting work with MSF nine years ago, Laila was living in Iran and working as a teacher. “I remember hearing about mothers and children in very poor health conditions and I thought, ‘Afghanistan is my country; I should go back.’ And so, I studied a midwifery course in Iran, and then I came to Afghanistan with the promise to myself to help the women and decrease the maternal mortality in the country,” she said.
Laila earned 29,000 Afghanis ($329) a month while working for MSF, of which 20,000 came from MSF and 9,000 came from the MOPH, she said.
“Now, under the Taliban, none of us are receiving our salaries.”
She said it has been more than three months since the hospital staff in Dasht-e-Barchi received their salary, and no one knows who controls the MOPH now or who would fund it.
The midwives had always known that if the Taliban came back to power, things would only get worse, especially for women. Now, even their most basic medical needs are not being met.
As for the hospital staff, they risk their safety by coming to work, while many patients are too afraid to leave their homes.
“Now, the Taliban have taken our country and we don’t feel safe here anymore. Of course, if you are at home, you also don’t feel safe. If I’m at home and my children are in school and my husband is going somewhere, I’m worried about them,” Laila said. “My husband thinks the same about me, especially when I am coming [to the hospital] for work.”
“But we cannot stop our work. If we stop, how can our families survive, and how will our community survive?”
The Taliban have moved into the hospital, to keep watch. “Two representatives on behalf of the new government have come and reserved a room here. So the Taliban are here, all the time, at the hospital, to control things, and they are checking everything and monitoring us,” said one healthcare worker who chose to be anonymous for her protection.
Some of the midwives have now left the country, and Aquila and Masooma stopped working at the Dasht-e-Barchi hospital.
Unpaid and burdened with uncertainty, Laila and the others still at the hospital soldier on. “We will not stay at home in fear. We will continue our work.”
“I am jobless now. I am not able to find any work, and I don’t feel like myself anymore. I don’t feel secure because everyone in the community knows us and [knows] that we work with women in the hospital. Everything has changed,” Masooma said. “Now, when I go out, I wear long clothes. I’m really struggling to manage. I have lots of stress.”
For those still at Dasht-e-Barchi, the future is uncertain. For now, the Taliban have allowed them to continue their work. “But any day, they could come and tell us all to leave,” said Laila. “I’m most scared about security. And because we are not secure, psychologically we are struggling. Every day, we are working at the hospital and we are scared.”
Unpaid and burdened with uncertainty, Laila and the others still at the hospital soldier on. “We will not stay at home in fear. We will continue our work.”
Outside the maternity ward, no security guards stand at the gate to the hospital. The courtyard is deserted and the hallways are silent except for the gentle swish of a mop as a cleaner dips it into a bucket. And then a cry – the only birth this morning. The first child for a mother who had travelled from neighbouring Laghman province.
The midwives are still here, still working, for now.