Eighty-Two Percent Can Walk to the Clinic. That Was the Easy Half.

More than 450 family health houses put a midwife within walking distance for 82 percent of the women around them. The 1994 paper everyone quotes by its title says distance was only one delay of three.

Manawara was forty years old and in her thirty-eighth week when the bleeding started. She lives in a village in northwestern Afghanistan, in the kind of place aid agencies file under "hard to reach," and a generation ago the next few hours would have been decided by how fast somebody could find a vehicle. Instead she got herself to the family health house near her home. The midwife on duty found the baby in breech position, gave her medication, worked through the emergency protocol she had been trained on, and got her stable. Mother and baby both lived.

There are now more than 450 of these clinics in Afghanistan. They are called family health houses — Ashiana-e-Sehi in Dari — and the United Nations Population Fund started the programme in 2009, long before the current government and for reasons that had nothing to do with it. Each one stands on land the community itself gave up. Each serves somewhere between 1,500 and 4,000 people. Each is staffed by a midwife recruited from the village she works in, equipped by UNFPA with basic instruments and a standard list of thirty-five items. Najeebullah Afghan, a health and nutrition specialist at UNFPA, says most of them sit in what the programme calls white areas: at least ten kilometres, or a three-hour walk, from the nearest basic health facility.

The obvious way to tell this is as a story about distance. It is the wrong way, and the programme's own numbers say so.

The paper everyone cites by its title

In 1994 two researchers at Columbia, Sereen Thaddeus and Deborah Maine, published a review in Social Science & Medicine that has been shaping maternal health policy ever since. It is called "Too Far to Walk." Almost everybody who quotes it quotes the title.

The argument underneath is that distance is one delay out of three. A woman dies, Thaddeus and Maine wrote, in the interval between a complication starting and someone treating it, and that interval has parts. There is the time it takes for her and her family to decide she needs care. There is the time it takes her to reach a facility. There is the time that facility takes to give her something useful once she is inside it. The title names the middle one. The paper spends most of its length on the other two.

Family health houses are close to a perfect instrument against the middle delay. An assessment by the International Planned Parenthood Federation across six provinces found that nearly three-quarters of the women surveyed lived within a kilometre of their local FHH, and 82 percent could walk to it. Some 88.7 percent called it "very important" for reaching maternal and reproductive care. That delay is solved.

Then read what the midwives actually describe.

The distance that is not measured in kilometres

Under current rules a woman cannot leave her house without a mahram, a male relative acting as escort. That applies to the patient. It also applies to the midwife, which is the part that tends to get lost. A clinic ten minutes away is not ten minutes away if nobody is free to walk you there.

What UNFPA did about this is the most interesting design decision in the programme, and it is not a medical one. Family health houses give midwives accommodation on site, so a midwife is physically present around the clock and does not have to travel in order to be available. Where they can, the programme employs the midwives' own mahrams as drivers or cleaners — the escort goes on the payroll. Nobody argued a rule away. They built around it.

The harder half of that first delay is not a rule at all. "The older women, especially mothers-in-law, say, 'We gave birth at home, why should the daughter-in-law go to hospital now?'" says Monika Rahmati, the midwife at the Masyam FHH in Herat province. Her patients' nearest emergency care is roughly 130 kilometres away over mountain roads. She and Laila Amini, who runs the Arkalik FHH in the north, say the same thing in different words: however close the clinic is, the household decides.

What happens once she is inside

The third delay belongs to the facility, and here the picture thins out. Arkalik was built to handle 300 patients a month. Amini sees up to 70 in a day. Midwives in the IPPF assessment described caseloads of 20 to 60 clients daily, the same assessment recorded periodic shortages of medicines, and 55.7 percent of respondents asked for services the FHHs do not currently provide, such as vaccination, laboratory testing and treatment for ordinary illness.

Training is the acute problem. In December 2024 the Taliban's supreme leader banned women from studying midwifery, nursing, dental prosthetics and laboratory science — the last fields of study that had remained open to them after secondary schools and universities closed. Human Rights Watch recorded institute heads being told on 2 and 3 December. Classes stopped the next morning. Najeebullah says digital learning became the only viable option left.

The tool is the Safe Delivery App, built by UNFPA with the Danish Maternity Foundation and released in Dari in 2023, with a Pashto version still in development. It runs through power cuts and without an internet connection, and it walks a midwife step by step through postpartum haemorrhage, neonatal resuscitation, infection prevention and kangaroo mother care. It has been downloaded 5,127 times inside Afghanistan in 2026, and UNFPA says it has supported around 1,200 midwives. Nasima Niazi, at UNFPA's local partner the Agency for Assistance and Development of Afghanistan, has trained 171 of them on it herself, and has one complaint: not enough of the content exists in Dari and Pashto.

Does an app on a phone change what happens at a delivery? There is one properly designed trial. Between 2013 and 2014, 70 health facilities in West Wollega, Ethiopia, were randomised to receive the app or not, and 176 birth attendants were assessed at baseline, at six months and at twelve. Baseline skills were poor in both arms, a median score of 12 out of 100. At six months the intervention group's skill scores had roughly doubled — an adjusted mean difference of 29.6 points against 1.8 in the control group — and the gap was still open a year in.

That is a real result, and it is worth reading slowly. It measured skills in a structured role-play, not outcomes in a delivery room. It ran in Ethiopia a decade ago, not in Afghanistan now. Of the 176 attendants enrolled, 130 were still being assessed at twelve months. What it establishes is that this teaching method works when teaching is the thing missing. In Afghanistan, teaching is not the only thing missing.

Numbers nobody in the story disputes

Afghanistan's maternal mortality ratio was 521 deaths per 100,000 live births in 2023 on the UN's modelled estimate. The world average that year was 197. Sweden's was 4. A 2024 study found that fewer than one in three Afghans can reach health care at all.

Against that, 450 clinics. The programme is funded by the European Union, Japan and other donors following the USAID cuts, which is to say it is funded by decisions taken annually in other countries. Afghanistan's National Health Policy for 2025 to 2030 puts primary and community-level care at the centre of its plan for universal coverage without naming family health houses anywhere in it; Najeebullah is hoping it counts.

One more caution, and it attaches to the best line in the story. Amini says there has not been a single pregnancy-related death in her village in seven years. That is the sentence that will travel, and it is a midwife's account of her own catchment area rather than an audited figure. It deserves repeating with that attached.

"Every time I'm able to deliver a healthy infant, it makes me happy," Rahmati says. "Even though things are difficult right now, a new, healthy life always brings hope and joy."

The same idea, bringing care to a place people already visit, is behind a pilot in north-east India where post offices test eyes and hand out reading glasses: Old People in Assam Couldn't Read the Deposit Form. So the Post Office Started Testing Eyes.

Sources

• Geetanjali Krishna, "How Afghan Women Are Rebuilding Reproductive Health Care", Reasons to be Cheerful, 15 September 2026 — https://reasonstobecheerful.world/how-afghan-women-are-rebuilding-reproductive-health-care/
• S. Thaddeus, D. Maine, "Too far to walk: maternal mortality in context", Social Science & Medicine 38(8), 1994 — https://pubmed.ncbi.nlm.nih.gov/8042057/
• Lund et al., "The impact of the Safe Delivery Application on knowledge and skills managing postpartum haemorrhage in a low resource setting: a cluster randomized controlled trial in West Wollega region, Ethiopia", Reproductive Health, 2023 — https://pmc.ncbi.nlm.nih.gov/articles/PMC10273743/
• "Afghanistan's Taliban Ban Medical Training for Women", Human Rights Watch, 3 December 2024 — https://www.hrw.org/news/2024/12/03/afghanistans-taliban-ban-medical-training-women
• "The devastating impact of the Taliban's ban on midwifery and nursing schools", The Lancet Global Health, 2025 — https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(25)00063-4/fulltext
• Maternal mortality ratio, modelled estimate, World Bank / UN MMEIG — https://data.worldbank.org/indicator/SH.STA.MMRT?locations=AF
• Safe Delivery App, Maternity Foundation — https://www.maternity.dk/safe-delivery-app/