• The risk of a woman dying as a result of pregnancy or childbirth is about 1 in 26 in Africa – and about 1 in 7,300 in developed regions
• More than 10 million women a year suffer from severe or long-lasting illnesses or disabilities caused by complications relating to pregnancy and childbirth. These range from obstetric fistula to infertility and depression
• The main causes of maternal death are heamorrhage, infections, seizures caused by high blood pressure, obstructed labour and unsafe abortions.

Nothing has gone right for Severino Caballero since his wife died in childbirth two years ago.

Caballero, 55, lives in Quebrada Cañas, a tiny mountain community of the Ngöbe tribe in Panama’s predominantly indigenous Chiriquí province. His wife, Cristobalina Santos, developed complications after giving birth to the couple’s 12th child, squatting according to tribal tradition on the floor in their straw hut. The placenta did not emerge, and that night Cristobalina developed an aggressive infection.

“I tried to get together enough people to carry her to the clinic, but there was no one around,” he said. Cristobalina died at 3 a.m. She was 36 years old.
The loss shattered the family. Severino was devastated and too weak to work. “I felt sad for a long time,” he said. The couple’s surviving seven children suffered too. “They were sad and pale,” he recalled.

The Ngöbe are among Latin America’s poorest and most traditional indigenous people, many of whom are suspicious of modern health services, such as family planning, antenatal care or skilled midwifery at delivery. While Panama’s overall maternal mortality rate is a moderate 70 deaths per 100,000 live births (among the ten best in the region), the rate for some of the country’s indigenous areas is 658, higher even than Haiti’s, the Western Hemisphere’s worst at about 600 deaths per 100,000 live births.

A few months after Cristobalina’s death, a tree fell on him while he was working in the fields, injuring his back. Now he can only do light work, such as cleaning coffee beans and bananas before bringing them to market. As a result, the family is barely surviving, cultivating small amounts of coffee, bananas and a few vegetables, and receiving help from the local church.

Severino has not remarried. He has thought about moving closer to the clinic in Hato Chami, but he has no money to move. Neither is any road likely to come soon through the steep hills and jungle ravines to Quebrada Cañas.
Asked how his family might get better access to health care, he fell silent. Cristobalina, he said at last, “was the one who took care of the house, the children and me.” He shook his head. “She loved me so much.”

In Bolivia, indigenous tradition often means women give birth at home, fully clothed, squatting on the floor, with only family members to help. When Albina Chambe, 15, went into labour in a poor suburb of La Paz, her fiancé Grover, only 18 himself, wanted to take his wife to a hospital. But Albina’s mother had delivered 13 children at home, without skilled assistance, and argued that Albina should follow tradition.

Soon, however, Albina’s pains worsened, so Grover half-carried Albina on a 20-minute uphill climb to the nearest dirt road. He spent more than a day’s pay for a taxi to the hospital. There a medical team safely delivered Luz Belen, the couple’s new baby girl.

Leonora Pocaterrazas, 21, was not so lucky. When she went into labour in the high mountain village of Columpapa Grande, weeks ahead of schedule, her husband wasn’t ready. “She told me she was in pain. I gave her a massage and then I went to ask my sister for help,” he told visitors. “When I got back she had already had the baby.”

The sister couldn’t stop Leonora’s bleeding, and the baby wasn’t breathing. “The baby was too small. He died half an hour later,” the husband said. Leonora died as well, leaving three other children behind.

Marietta Kiden grew up in a desolate refugee camp in Uganda for people displaced by Sudan’s civil war. The camp had no school and no clinic, but she managed to survive without either. She returned to her village in southern Sudan as a young adult and married a boy she loved.

Three years later, after a traditional fertility ceremony, Marietta and her husband conceived the child they had yearned for. But Marietta received no antenatal care, and only an unskilled traditional birth attendant was at her side when she went into labor. The baby’s head was too big for Marietta’s fragile body, and three days of agony tore her apart before she was taken to a distant hospital.

The baby died. The hospital saved Marietta’s life, but the ordeal left her with an obstetric fistula, a devastating opening between her birth canal and her bladder. For the next 25 years, she suffered uncontrollable urine leakage, odor and repeated infections.

An estimated two million women, virtually all in developing countries, live with obstetric fistula, many in hiding and shame. Fistula was once also a devastating problem worldwide – the Waldorf-Astoria Hotel in New York City, for example, sits on the former site of an obstetric fistula hospital – but investments in prenatal care and emergency obstetric surgical facilities and health care personnel have brought caesarean section to save the lives and children of millions of other women who would otherwise have shared Marietta’s fate.

One early surgical repair attempt did help Marietta for awhile, but later she was assaulted while collecting firewood outside her village and her fistula reopened. Her husband, unlike many men whose wives suffer fistula, remained loyal to her and cared for her during this period.

In 2006, Marietta’s sister told her about fistula repair surgery newly available at the Juba Teaching Hospital where the sister worked as a midwife. Supported by UNFPA, the UN Population Fund, the hospital hosted a surgeon who successfully repaired Marietta’s fistula. Her brother slaughtered a goat for the jubilant family’s celebration.
Fully recovered, Marietta has become a public advocate, traveling through southern Sudan as part of a campaign to raise awareness among other women afflicted with fistula that they can regain normal lives as she did. She is also living evidence of the need for investment in antenatal and emergency care that could have averted her needless suffering, and in the surgical training and facilities that finally restored her creativity and energy.

So says Janice Banaag, a new mother at 18, in Manila in the Philippines. She used to counsel her peers about preventing unwanted pregnancy and sexually transmitted infections (STIs). But “accidents happen”, she admits with a laugh, and now Janice is a living lesson in how adolescent sexuality and poverty interact in Tondo, a densely populated district of slums and industry.

Janice, husband Joell and baby Janelle live in a small windowless room lit by a bare suspended bulb. They live on what Joell earns driving a pedicab – about 100 pesos a day, the equivalent of two dollars.

“I only dream of eating three times a day,” Janice says.
While most births in Tondo take place at home without a skilled attendant, Janelle was born at a mother-child clinic run by the Zone One Tondo Organization (ZOTO), an activist group serving the urban poor.

Janice was a singer with a band until accidental motherhood limited her mobility. She says her wish is to have a big house someday and enough money to educate her children.

But Janice doesn’t want to have another child until her family has some savings, so she is queuing up to get contraceptives. She wants an IUD.

Awatif, six months pregnant, is frightened of giving birth after the sun goes down. The Serif camp she has called home for the past four years has no night midwife available because of security concerns.

“I’m afraid,” she said, swathed in a shawl of sunset orange, reds and purples. “I want a midwife to be by me in case something happens.”

Awatif, 27, was married at the age of ten, and this is her second pregnancy in this camp for internally displaced persons outside of Nyala, the capital of South Darfur. The camp midwife helped her give birth to the youngest of her four sons, and she is hoping for a girl this time.

The first time her village was attacked in Darfur’s civil war, she said, “They took all of our cows. The second time, they attacked the people and burned all our houses.” After that she fled here with her family.

In Awatif’s village, the nearest health care centre was a three-hour walk away. Awatif relied for her first three pregnancies on a traditional birth attendant, who in Darfur customarily ties the hands of the expectant mother above her head and then pulls on the rope to elongate the woman’s body through each contraction. It is a difficult and painful process, especially if the woman’s labour continues for hours on end.

In the camp, a nighttime complication will mean Awatif will have to get from the camp to the hospital in Nyala. But donkey carts are the only available transport. “It’s dangerous, and you have to pay a lot of money,” she said.

Maternal mortality is high in Sudan: 509 women die for every 100,000 live births – a ratio that puts Sudan 130th on a World Health Organization ranking of the 181 countries with populations of 1 million or more. A woman’s lifetime risks here are so great that one in every 30 Sudanese women will die of pregnancy-related complications: only 71 percent of pregnant women receive antenatal care, only 57 percent of deliveries have a skilled birth attendant present, and only 13 percent of women receive postpartum care in the first six weeks following delivery.

Most people do not know how to identify complications, and men – who make the decisions about when a woman can seek health care – often do not recognize the importance of referring their wives to emergency care, or they are too poor to seek it.
A green tent houses the camp’s maternal health care clinic. Straw mats cover the floor and the smell of disinfectant wafts through the hot air. A simple sheet separates the ‘operating theater’ from the consultation room, manned by midwife Amina Mohammed. She provides ante- and post-natal care to IDP women, but wives must be accompanied by their husbands to receive contraception.

Fatima’s story illustrates the dire consequences a mother’s death has for her family and her community. She and her husband Ahmed already had nine children and were barely surviving on his salary as a security guard when she became pregnant again. He nearly lost his job taking care of the family during her difficult pregnancy. Then Fatima died giving birth to twin boys in a Kabul hospital. Because Afghanistan’s shattered health care system multiplies their lifetime risks, one in every six Afghan women will die in this way, from complications of pregnancy and childbirth.

Fatima’s hospital expenses put Ahmed deeper into debt, so he took their 13-year-old son out of school to work. The twins had to be fed on goats’ milk and expensive infant formula and they were often ill with diarrhea or acute respiratory infections, the most common killers of infants worldwide. The family’s 11-year-old daughter was taken out of school to care for them. At seven months, the smaller twin died of a respiratory infection.

Ahmed remarried, adding to his debt and poverty, so he married off his oldest daughter when she turned 13. She became pregnant at 15, before her body was ready, and suffered an agonizing obstructed labour. Her baby was born brain-damaged and she was left with an obstetric fistula, an opening between her vagina and bladder that made her incontinent. The resulting wetness and odor caused her acute humiliation. Her husband abandoned her, and she had to return to her father’s home to continue a life of poverty.