Mother of all neglect

Fatmata Jalloh's body lay on a rusting metal gurney in a damp hospital ward at Freetown in Sierra Leone, a scrap of paper with her name and “RIP'' taped to her stomach. In the soft light of a single candle — the power was out again in one of Africa's poorest cities — Jalloh looked as if she was only sleeping. The 18-year-old's face was serene, with freckles around her closed eyes and her full lips frozen in a sad pucker.

Her bare feet stuck out from under the colourful cloths in which she had been wrapped by the maternity nurses who had tried to save her. Her toenails bore the chipped remnants of cheery red polish.

In the dark hallway, her sisters and friends hugged and wailed “Fatmata! Fatmata!'' in a tearful song of grief.
Eight hours earlier, Fatmata was delivered of her first child: a healthy baby boy.

The official cause of her death was post-partum haemorrhaging. She bled to death giving birth in a part of the world where every pregnancy is a gamble.

Every year, more than 500,000 women around the world die in childbirth; that is about one death every minute.

The deaths are almost exclusively in the developing world and almost always from causes preventable with basic medical care.

The planet's worst rates are in this startlingly poor nation on West Africa's Atlantic coast, where a decade of civil war, which ended in 2002, deepened chronic deprivation.

According to the United Nations, a woman's chance of dying in childbirth in the United States is 1 in 4,800. In Ireland, which has the best rate in the world, it is 1 in 48,000. In Sierra Leone, it is 1 in 8.

Fatmata's husband, Saidu Jalloh, said he and Fatmata had been excited about their first baby.

Saidu, 27, a grocer in Freetown, said that after marrying a year ago, the couple rented a room in a house in the city's Brima Lane neighbourhood. Fatmata had grown up nearby, in a cluster of shacks shared by more than 25 relatives. Fatmata was the eldest child of her mother and the fourth-eldest of her father's 16 children.

“She was a very jovial person,'' Saidu recalled. “She never quarrelled with anyone.''

About 8pm on a recent Thursday, Fatmata started complaining of back pain.

Her sister, Batuli Jalloh, knew the baby was due any day but wasn't sure if the pains were the first signs of labour or just aches from a recent fall Fatmata had taken.

Batuli said they decided to get it checked up anyway. They thought about going to the Wellington Health Centre, a large government-run clinic where Fatmata was registered for prenatal care.

But the clinic was a 30-minute walk, tough for a woman nine-months pregnant. And taxis were almost impossible to find after dark in their neighbourhood.

A neighbour suggested they go instead to see Elizabeth Cole, a neighbourhood nurse who lived just down the road. Batuli said going to Cole's house seemed easier than walking all the way to the clinic.

The sisters walked in darkness down the street, which, like most of Freetown, was lighted by only a few oil lamps casting an orange glow from darkened doorways at night.

They passed dirt-floor tin shacks where, during the day, people sold mobile phone cards, peppers and tomatoes — and meat crawling with flies.

Unhealthy surroundings

About 10.30pm, they arrived at the muddy alley to Cole's one-storey concrete house. Cole led Fatmata into the birthing room, a tiny cubicle with a sagging cot covered with yellow plastic sheeting.

Fatmata lay next to a white wall filthy with age and dirt in the stuffy room where Cole said, she had assisted in the delivery of at least 300 babies.

The house had no running water. By Cole's account, Fatmata was far into labour when she arrived: “She almost delivered on her way in.''

There was no time or transportation to take Fatmata to the clinic or to the larger Princess Christian Maternity Hospital, Cole later said. So she delivered the baby herself without any apparent problems, at 11.35pm.

Saidu was summoned and he had a cup of tea with his wife while they held their newborn son. Then he went home and Fatmata fell asleep on the birthing cot, with her sister Batuli sleeping nearby.

At 4am, Batuli said, Fatmata woke with severe abdominal pains and was bleeding heavily. Cole tried to stop the flow but, according to her, she had no medication or equipment to stanch the haemorrhaging. She gave Fatmata a cup of tea. “I don't do complications here,'' Cole said.

They sent for Saidu, who ran frantically around the neighbourhood, trying to wake up someone with a car. He found a driver and Fatmata walked herself out of the room, across the muddy courtyard in the rain and into the car.

They sped off on the 20-minute dash to the Princess Christian Maternity hospital. Fatmata was talking in the taxi, complaining that she felt dizzy and weak and saying over and over: “I think I'm going to die.''

They arrived about 6am. Nurses wheeled an old iron gurney down to the car and lifted Fatmata on to it.

They pushed her quickly up a long ramp to the hospital's main maternity ward on the second floor, where four nurses went to work on her.

Although she had been talking a few minutes earlier, Fatmata was now unconscious and gasping weakly for air. She had no pulse or blood pressure.

The Princess Christian Maternity Hospital is a sprawling, low structure that sits between one of the city's busiest market streets and a slum astride the Atlantic seafront.

It has no air conditioning, the lighting in the operating room is broken, bathrooms stink and there is virtually no medical supplies. It is the country's best maternity hospital, which handles emergencies and complicated cases referred to it from all over the country.

“We are the last resort; if we fail, there is nowhere else,'' said Ebrahim Thorlie, one of only two specialists in obstetrics and gynaecology and director of the 130-bed hospital. He carries a battery-powered desk lamp with him into surgery in case of power failures.

S.K. Siddique, the other obstetrician on staff, said he had spent almost $250 out of his own pocket that month on sutures, because the hospital had none. Before a Caesarean section or other surgeries can be performed, the patient's family must hurry out and buy medications, intravenous fluids and bags, catheters, blood for transfusions and surgical gloves for the doctors and nurses.

“Everything you see here, the patient has to buy,'' said Siddique, who had to delay a Caesarian section for 15 minutes one recent day while the patient's husband ran out to buy the gloves.

Because the hospital handles the most difficult cases, its mortality rate is dismal. Last year, there were about 1,230 births at the hospital and the mother died in 141 of the cases.
During one recent 48-hour period at the hospital, six women died and five babies were stillborn.

Two of the women bled to death and the others died from high blood pressure, infection, complications from HIV and a botched illegal abortion. All the women whose infants were stillborn had first gone to local nurses or semiskilled “traditional birth attendants'' for care, then came to the hospital when they developed complications.

The nurses trying to save Fatmata's life realised she was severely anaemic and had lost too much blood. Saidu told them she had not been taking her prenatal vitamins and that she had also been fasting during the day for three weeks in observance of Ramadan.

The nurses sent Saidu down to the hospital's one-fridge blood bank. Since the fridge was empty as usual, blood bank workers bought a pint of type O-positive from a blackmarketeer on the street.

They quickly screened it for HIV and other diseases, then sold it to Saidu.

Because the hospital has so few supplies, patients are required to pay for all their medications and blood — and surgery. That can add up to $200 to $300, which is several months' wages for many. Local nurses with limited qualifications charge much less.

Heart stopped pumping

The maternity ward nurses hung the blood bag and pushed an IV needle into Fatmata's wrist. Head nurse Hawa Fofanah recalled that the blood dripped into the plastic tube but Fatmata's body didn't absorb it; her heart had stopped pumping.

By candlelight, with slashing rain dripping in the open window, Fofanah tried chest compressions to revive the dying teenager.

But at 7.14am, Fofanah pronounced Fatmata dead. The head nurse, who had been working all night, shook her head in weary frustration.

“If she had come here sooner, she would have lived,'' she said.

An hour after Fatmata died, nurses wrapped her in brightly coloured cloths. They had been her clothes when she arrived; now they were her shroud.

They transferred her body on to a stretcher and a group of men carried it to the parking lot. No women were allowed at the burial, as is common in many Muslim communities.

So the silent men walked slowly down an overgrown path, six of them carrying Fatmata's body, which they placed in a freshly dug hole in the rich, red soil.

Ten hours after she had taken her last breath, her sad-eyed husband tossed the first shovel full of dirt.

Ill-equipped to save lives

The Princess Christian Maternity Hospital's main maternity ward is a small beige room with half a dozen small examining rooms behind floral curtains.

The examining tables are tattered and stained and insects fly in through the open windows. The windows also don't keep out the rain.

One recent day, the corpses of three stillborn babies, wrapped in their mothers' clothes, lay on a table for hours waiting to be buried.

An overhead fan pushed the hot air around weakly, carrying whiffs of urine and the unmistakable odour of death, which leaves a bitter taste in the back of the throat.

“Do you see what we are facing here?'' asks S.K. Siddique, the obstetrician on staff at the hospital. “For us, this is something normal.''

Issue of neglect

Maternal mortality rarely gets attention from international donors, who are far more focused on global health threats such as malaria, tuberculosis and HIV-Aids. “Maternal death is an almost invisible death,'' said Thoraya Obaid, executive director of the UN Population Fund.

The women die from bleeding, infection, obstructed labour and preeclampsia or pregnancy-induced high blood pressure.

But often the underlying cause is simply life in poor countries: Governments don't provide enough decent hospitals or doctors; families can't afford medications.

A lack of education and horrible roads cause women to make unwise health choices, so that they often prefer the dirt floor of home to deliveries at the hands of a qualified stranger at a distant hospital.

Women die in childbirth every day, according to people who study the issue, because of cultures and traditions that place more worth on the lives of men. “It really reflects the way women are not valued in many societies,'' said Betsy McCallon of the White Ribbon Alliance for Safe Motherhood, one of the few groups that advocates reduction of deaths in childbirth.

“But there is not that sense of demand that this is unacceptable, so it continues to happen.''