In a hospital ward in Freetown, the capital of Sierra Leone, Fatmata Conteh, 26, lay on a bed, having just given birth to her second child. She had started bleeding from a tear in her cervix, the blood forming a pool on the floor below. Two doctors ran in and stitched her up, relatives found blood supplies, and nurses struggled to connect a generator to the oxygen tank. One nurse jammed an intravenous needle into Conteh's arm, while another hooked a bag of blood to a rusted stand, and a third slapped an oxygen mask over her face. In the corner of the room, a tiny baby--3 hours old--lay on a bed, wailing, swaddled in bright-colored African fabric. "Listen! You must feel happy to hear your baby cry," said a nurse, pleading with Conteh to find strength. Three visiting members of a neighborhood church began chanting over Conteh: "Jesus, put blood into this woman! Thank you, Lord!" But as their chants grew louder, the nurses stepped back from the bed. Conteh was dead.
Some version of that scene is repeated around the world about once a minute. Death in childbirth is not just something you find in a Victorian novel. Every year, about 536,000 women die giving birth. In some poor nations, dying in childbirth is so common that almost everyone has known a victim. Take Sierra Leone, a West African nation with just 6.3 million people: women there have a 1 in 8 chance of dying in childbirth during their lifetime. The same miserable odds apply in Afghanistan. In the U.S., by contrast, the lifetime chance that a woman will die in childbirth is about 1 in 4,800; in Britain, 1 in 8,200; and in Sweden, 1 in 17,400. Deaths are heavily weighted to the poorest and most isolated in each country, which means that many politicians remain largely ignorant of the scale of the tragedy. "Often the people in the cities do not know what is happening in their own rural areas," says Sarah Brown, wife of British Prime Minister Gordon Brown and patron of the White Ribbon Alliance, a global advocacy organization that works with governments to lower maternal mortality rates. Brown--who lost a baby 10 days after giving birth in 2001--says that when she tells heads of state and their spouses how many women die in childbirth, "they are aghast."
The Gains Not Made
They have reason to be. For here is the truly ghastly reality of maternal mortality: in 20 years--two decades that have seen spectacular medical breakthroughs--the ratio of maternal deaths to babies born has barely budged in poor countries. To be sure, maternal health has seen advances, with new drugs to treat deadly postpartum bleeding and pregnancy-related anemia. But in many places, such gains are dwarfed by a multitude of problems: scattershot care, low pay for health workers and a scarcity of midwives and doctors. In Mozambique, where women have a 1 in 45 lifetime chance of dying in childbirth, there are just 3 doctors per 100,000 people; in all of Sierra Leone, there are 64 government doctors, only five of whom are gynecologists. Millions of families have never seen a doctor or nurse and give birth at home with traditional birthing helpers, while those who make it to a clinic--some being carried on bicycles or in hammocks--often find patchy electricity, dirty water and few drugs or nurses. Explaining the task of reducing maternal deaths, Sierra Leone's Minister of Health, Saccoh Alex Kabia, who returned home last year after decades of working as a surgeon in Atlanta, says, "The whole health sector is in a shambles."
Many hope that maternal death rates in poor nations will naturally fall over time, as they did in much of the world in the 20th century. They well might. But international officials say governments often lack the political will--as well as the money--to tackle the issue, perhaps because there are too few women politicians to push it. Monir Islam, director of the maternal-health program of the World Health Organization in Geneva, calls governments' low level of investment in reducing deaths in childbirth a "sinful neglect."
In an attempt to jolt officials into action, governments at the U.N. General Assembly in 2000 chose to make a drastic reduction in maternal mortality one of the eight Millennium Development Goals (MDGS)--a series of targets in a program that channels aid to key issues, including education and clean water--to be met by 2015. The MDGS hold people "to a golden standard for progress," says Jamie Drummond, executive director of the antipoverty organization DATA. When world leaders gather in New York City this month to take stock of the MDGS, their speeches are likely to tout the many achievements since 2000: millions more African children now attend school and sleep under mosquito nets; thousands of new water wells have been dug. Yet though maternal health care underpins many other development goals (healthy mothers are more likely to ensure that their children are well fed and educated), the total number of women dying in childbirth has remained virtually unchanged in eight years.
Why? Health officials are clear in their answers. Aside from lack of money and political will, they also face entrenched traditions and fatalistic attitudes to maternal mortality, especially in very poor communities. "People think that dying in childbirth is not preventable," says Nadira Hayat, Afghanistan's Deputy Minister of Health. "They say it is up to God."
So it seemed before dawn one Sunday in August in Kora Olia, a remote village in Afghanistan's northeastern province of Badakhshan, where maternal mortality is about four times the country's already high rate. Nine months pregnant, Harakatmo, 19, began bleeding heavily. Her husband and mother-in-law were concerned, but the local doctor was far away, and expensive, so they waited. When Harakatmo was still bleeding the next morning, they sent a horseman to fetch a village health worker, but Harakatmo's bleeding continued. Panicked, her husband strapped her to a makeshift stretcher and carried her down the steep track from their home until he found a police truck to take them to a clinic several miles away. The doctor there urged the family to rush Harakatmo to Badakhshan's only hospital, in Faizabad, the provincial capital. Harakatmo's husband hired a ramshackle minivan for the journey--a five-hour ride along rutted dirt roads. On the way, they stopped while Harakatmo's mother-in-law delivered the baby. It was already dead; the tiny corpse was wrapped in a cloth and placed next to Harakatmo. Lying in the hospital that evening, she said she considered herself lucky. "When I left my house this morning, I thought I would die."