Extreme childbirth

It’s 10am on a stiflingly hot Monday morning and I am in a delivery room with one of the unluckiest mothers on the planet. She is Dahara Laouali, and at the moment she is lying on a narrow, dusty hospital trolley pushing her baby into the world. Although the birth is imminent, Dahara is making no noise at all. This is Niger, where the tradition is that mothers labour in silence. It is hard keeping quiet in the throes of childbirth: but almost everything is hard for mothers in Niger.

Dahara pushes, pain creasing her sweating face, and then pushes again — and suddenly, between her legs, there is a little boy with the walnut features of newborns everywhere and a mop of damp, dark hair. Insa gives a delighted squeal, but Dahara is still silent: as her baby is wrapped in a cloth, she turns her face to the wall and sobs quietly. Maybe she is tired after the labour. Maybe she wants to be alone. Maybe she is not ready quite yet to welcome the baby into her heart. But maybe, too, she is remembering other births, and other babies. Because this boy is the fifth child Dahara has pushed into the world and, of the others, only one is still alive.

This, then, is Dahara’s misfortune: and it is not just a personal tragedy, but one she shares with every other mother in her country. Niger is officially the most dangerous place on Earth to have a baby. In May, a Save the Children report found that, of the 125 nations it surveyed, Niger was where childbirth was most likely to end badly.

Statistically Dahara (26) has a one-in-seven chance of dying during her reproductive years as a result of a pregnancy-related complication or infection, or childbirth injury. Her son, lying here on the table, has a 15% chance of not reaching his first birthday and a one-in-six chance of not making it to the age of five. And Dahara is fortunate to have had the skills of a midwife such as the cheerful Insa; across the country, only 16% of deliveries are attended by anyone with any training at all.

Dahara lives in a village called Bande, about two hours’ drive from Zinder, the rundown former French colonial capital. To call the birth centre here basic is an understatement. Inside are two small, grubby rooms: the delivery room, with its trolley and rickety desk, and the recovery room, which boasts a mattress-less bed and a greying cot.

Here Dahara and her new son — whose name is to be Mohammed — will stay for a couple of hours. Then, Dahara will tie Mohammed to her back and walk the kilometre or so to her village.

There is no aftercare, no midwife will check up on mother or baby, so Dahara will have to use her judgement if there are any post-natal problems and seek help if and where she can. Dahara’s husband has not been involved in the birth and is unlikely to play a big role in the early weeks with the baby. In Niger, birth is considered to be women’s work and fathers keep their distance.

The only piece of medical equipment in evidence in the entire centre is a plastic bowl into which Dahara has delivered the placenta.

Ten days later, I am in another maternity unit. This one is in the University Hospital at Uppsala, north of Stockholm. In almost every way, giving birth in Sweden is light years away from giving birth in Niger.

The mother and baby I meet in Uppsala are Carmen Helwig and her new daughter. Carmen paints a strikingly different picture of new motherhood. She is older (38), but Tess is her first baby. She was born by Caesarean section because of worries over a uterine scar, the result of previous surgery. It might have been fine, the doctors told her, but there was a risk it might rupture.

“Why take that risk?” says Carmen, smiling. Tess was born three weeks early and is slightly underweight, but she is being carefully monitored at Uppsala and Carmen knows she will soon be taking her daughter home. Until then, she, her partner Tommy Svedberg (41) — who was at the birth and is now taking paternity leave to be involved in his daughter’s first weeks — and Tess are staying at the hospital in a large, hotel-like double room. “Once I’m home, I’ll be able to phone the hospital with any worries and the midwives will come out to see me every day if I need them,” she says.

Carmen is Dahara’s mirror-image, one of the luckiest mothers in the world. The Save the Children report found that, while risk can never be entirely removed from the business of becoming a parent, the dangers for Swedish women are minuscule in comparison with the risks for mothers in Niger.

Carmen’s chance of dying as a result of childbirth over her lifetime is one in 29 800 (as opposed to Dahara’s one in seven). The risk of Tess dying in her first year is one in 333. In Sweden, 100% of births are attended by a skilled, trained midwife. Overall, it is the safest place in the world to become a mother.

More than 99% of births in Sweden take place in hospital, but it would be a vast oversimplification to attribute the gulf between the two countries’ statistics to this fact alone. Layer upon layer of disadvantage and deprivation, and advantage and blessing, have meshed together to create the circumstances that divide Dahara and Mohammed from Carmen and Tess.

Niger is rated the world’s poorest country by the United Nations. About 14% of its under-fives are significantly malnourished (and in the aftermath of last year’s crop shortage and in the face of another shortfall this year, that figure could soon be much worse). Less than half its population has access to safe water.

In Niger, women are more than materially disadvantaged, they are educationally and physically disadvantaged too. Fewer than one in 10 is literate. Most girls marry early and have many children: the fertility rate, at 7,5, is among the highest in the world. Most of the mothers I talked to had had their first baby at 15 or 16 — one had had 11 babies before she was 25. Only 4% use modern contraception, and not for cultural or religious reasons. Many of the women I asked said they would welcome advice on spacing their children.

Sweden, by contrast, is one of the wealthiest economies on Earth. Its people are healthy and well fed, its shops well stocked, its communications excellent and its women well educated, with virtually 100% female literacy. More than 72% use modern contraception and the average age for a first birth is 29. The fertility rate is 1,7. It is, in every way, a happier and healthier place to be a woman.

More shocking still is the fact that, unlike Sweden, where excellent maternity care comes free of charge, Niger’s women have to pay for the privilege of their inadequate services (while healthcare fees have been abolished in principle, they are still enforced in practice). And, although the sums are paltry by Western standards — an antenatal check-up is 1 000 CFA francs (£1), a new-baby check-up is 5 000 CFA francs (£5) and a Caesarean is 17 000 CFA francs (£17) — the amounts are impossibly large for impoverished families in a country where the average per capita income is 127 000 CFA francs (£127) a year.

In the village of Yawouri, outside Zinder, nurse Abdulaye Hachiou explains that women often fail to seek help in labour because they, or their husbands, fear the expense. “You get husbands who say their wives can’t be brought to the clinic because they don’t want to pay the bill. And then the wife gets worse and they say, well, there’s no point in taking her now, she’s going to die anyway.”

Removing healthcare fees, says Save the Children, would save women and babies’ lives in Niger. But that is far from the whole solution. The country needs more trained midwives, well-equipped antenatal clinics (the one I visited shared its only blood pressure monitor with the district nurse — if she was using it, the blood pressure of mothers-to-be went unchecked), more obstetricians and a modern maternity unit in every town. In a perfect world, Niger would also have a vigilant system of post-natal care and beyond that, but equally important, clean water, a decent standard of living and good healthcare.

But that would be in a perfect world. So must childbirth continue to kill women and babies, on the sort of scale it did 200 years ago in the West, for many more decades to come? Not necessarily, says Save the Children.

Anne Tinker, the Washington-based author of the report, says she believes seven out of 10 of the lives being lost could be saved if a few low-cost measures were put in place. Education, she says, is key. “If we could raise awareness of some of the health issues, we could save many lives,” she says. “Women need to know about the danger signs in pregnancy. They need to know when to seek medical help. They need to know how important it is to get help in labour if things aren’t progressing,

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