Nation feels only the pain of childbirth

The House of Mothers project is trying to help women have safe pregnancies where culture and poor facilities drive up maternal mortality rates.

The pregnant mothers walk to the nutritional centre of the hospital to collect food for their lunch. At the House of Mothers high risk mothers can rest during the final months of their pregnancy.

GABU, GUINEA-BISSAU // Fifteen-year-old Miriama Baldi eased herself to the ground and propped her feet up on a pillow. She was within days of giving birth, and her slight frame seemed barely able to carry the weight. A shy smile touched her face as she sat down to eat with 26 other women, all facing high-risk pregnancies. Three weeks earlier, a doctor visited Miriama's village and recommended she come to the House of Mothers, a facility fighting to save women's lives in one of the world's most dangerous places to give birth.

"The doctor said I am too young to have a baby," said Miriama, who was carrying her first child after getting married about a year ago. "He sent me here because of my age." The United Nations ranks Guinea-Bissau 175 out of 177 countries on its human development index, which measures education, income and life expectancy. The country's high maternal mortality rate is one reason for its poor ranking - 1,110 women die for every 100,000 live births (the figure rose from 910 in 2003).

Part of the problem lies with an abysmal healthcare system that covers only 40 per cent of the population, according to the World Health Organization. The United Nations said only three out of 107 existing healthcare structures offer complete quality obstetric care, and only 35 per cent of births are assisted by skilled attendants. Cultural factors also make Guinea-Bissau a dangerous and difficult place to be pregnant.

For example, many women become pregnant when they are very young and their pelvises are too narrow to give birth safely. At a second House of Mothers in the small city of Bafata, 12-year-old Sana Mfande was expecting her first child. She said she is the second wife of her husband, who is 35. Fifteen-year-old Tida Fateh's pregnancy was complicated by a physical disability. She had one leg amputated at the hip as a small child after contracting a disease she could not identify.

Sana sat by herself, staring blankly into space. Tida sat quietly among the other women, her one crutch resting at her side. Neither of them expressed excitement at the prospect of motherhood. But they are actually among the lucky ones, according to Serifo Embalo of Catholic Relief Services, which funds the House of Mothers. As a co-ordinator for the organisation's mothers-at-risk programme, he spends much of his time travelling to remote villages where he often finds women eight months or nine months pregnant who have never seen a doctor.

"This is a very difficult culture, and many women in remote communities give birth alone in their homes," he said, adding that women commonly work right up until the day they give birth. The House of Mothers provides women with a place to rest during the final stage of their pregnancies, as well as medical care and healthy meals - factors that can make a difference between living or dying during childbirth.

But even when Mr Embalo, or other staff, identify women at risk, it can be hard to get them to the facility. He recently met a pregnant woman suffering from severe anaemia in a remote village. The woman's husband was away, and Mr Embalo tried to persuade her father to let her go to the House of Mothers, explaining that her life was in danger if she did not receive immediate medical treatment. The father refused to let her go.

When Mr Embalo returned a couple of weeks later, the woman had died. Even when women do seek medical treatment, the state medical system hardly inspires confidence. The hospital in Gabu, for example, has not had a steady supply of electricity since 1992. Babies are delivered by candlelight. The hospital is incapable of treating the most serious problems, said Gabrielle Menkhelam, the region's only gynaecologist. In severe cases, the patient will be sent to the national hospital in the capital, Bissau, about three hours away.

"Maybe on the way to Bissau the person will die," he said. Dr Menkhelam said women usually do not show up at the hospital until they are seriously ill. Partly to blame is Guinea-Bissau's poor transportation network, which makes it difficult for people in remote areas to travel to hospitals in Gabu and other urban centres. But cultural factors play a role as well, Mr Embalo said. For example, women are expected to bear the pain of pregnancy quietly, and they even try to hide the fact they are pregnant for the first five or six months.

Another tradition that puts women at risk is female genital mutilation. Mr Embalo said the practice is widespread among the Fulani and Mandingo ethnic groups, who mistakenly believe that Islam requires girls to be circumcised. The operation is often performed under unhygienic conditions, creating the risk of infections, and this can lead to scarring, which can result in haemorrhaging during a subsequent delivery.

Despite the dangers posed by female genital mutilation, Mr Embalo said the subject is so taboo that he cannot speak about it directly when talking to tribal elders. It even affects his own family, he said. "I am a Muslim, and I don't want it for my own daughter, and I won't permit it," Mr Embalo said. "But my mother wants it." As a result, he will not let his daughter visit her grandmother unaccompanied for fear that she will force the young girl to undergo the operation.

When Mr Embalo visits rural communities, he approaches such sensitive subjects as female genital mutilation and early marriage very carefully. "You can't just arrive there and tell them it's bad," he said. "That's why it's a long-term project. These conversations only start to change something over a long time." Still, Mr Embalo takes comfort in the fact that the project is saving lives. Since the House of Mothers opened up in Bafata four years ago, he said, the maternal mortality rate for the region has fallen by 75 per cent.