Concord Times (Freetown)
14 October 2008
Fatmata Jalloh's body lay on a rusting metal gurney in a damp hospital ward, a scrap of paper with her name and "R.I.P." 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 like a sleeping teenager. Dead just 15 minutes, the 18-year-old's face was round and serene, with freckles around her closed eyes and her full lips frozen in a sad pucker.
Her bare feet stuck out from the colorful cloths in which she had been wrapped by the maternity nurses who had tried to save her life. 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, Jalloh delivered her first child: a healthy baby boy. Her official cause of death was postpartum hemorrhaging. She bled to death giving birth in a part of the world where every pregnancy is a gamble.
More than 500,000 women a year -- about one every minute -- die in childbirth across the globe, 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 that 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.
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 A. Obaid, executive director of the U.N. Population Fund.
The women die from bleeding, infection, obstructed labor 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 to reduce deaths in childbirth. "But there is not that sense of demand that this is unacceptable, so it continues to happen."
Saidu Jalloh said he and Fatmata had been excited about their first baby.
Saidu, 27, a Freetown grocery vendor, said that after marrying a year ago, the couple rented a room in a house in the city's Brima Lane neighborhood. Fatmata had grown up nearby, in a cluster of small shacks shared by more than 25 relatives. Like many African men, her father is a polygamist, with three wives. Fatmata was the eldest child of her mother and the fourth-oldest of her father's 16 children.
Fatmata, who never attended school, was popular, a lighthearted presence with hair worn in tight cornrows and a bright sense of humor. "She was a very jovial person," Saidu recalled. "She never quarreled with anyone."
About 8 p.m. on a recent Thursday, Fatmata started complaining of back pain. Her sister, Batuli Jalloh, knew the baby was due any day, but the two women weren't sure if the pains were the first signs of labor or just aches from a recent fall Fatmata had taken.
Batuli said they decided to be safe and get it checked out. They thought about going to the Wellington Health Center, a large government-run clinic where Fatmata was registered for prenatal care.
But the clinic was about a 30-minute walk away, tough for a nine-month pregnant woman. And taxis are almost impossible to find after dark in their neighborhood, a muddy collection of shacks on a hill overlooking downtown.
A neighbor suggested they go instead to see Elizabeth Cole, a neighborhood nurse who lived just down the road. Batuli said going to her house seemed easier than walking all the way to the clinic.
The sisters walked in the darkness down the street, which, like much of the capital, is lighted at night by a few oil lamps casting an orange glow in darkened doorways. They passed dirt-floor tin shacks where, during the day, people sell cellphone cards, peppers and tomatoes, and meat crawling with flies.
About 10:30 p.m., they arrived at the muddy alley to Cole's one-story, concrete house. Cole led Fatmata into her birthing room, a tiny cubicle with a sagging cot covered with yellow, heavy plastic sheeting.
Fatmata lay down next to a white wall filthy from age and dirt, in a stuffy and hot room where Cole said she has delivered at least 300 babies. The house has no running water. By Cole's account, Fatmata was far into labor when she arrived: "She almost delivered on her way in the door."
There was no time or transportation to take Fatmata to the clinic or to the larger Princess Christian Maternity Hospital, Cole said later. So she delivered the baby herself, and Fatmata's son was born, without apparent problems, at 11:35.
Fatmata's husband, Saidu, was summoned, and he had a cup of tea with his wife while they held their new baby. Then he went home, and Fatmata fell asleep on the birthing cot, with her sister Batuli sleeping nearby.
At 4 a.m., Batuli said, Fatmata woke with severe abdominal pains and was bleeding heavily. Cole said she tried to stop the flow, but she had no medication or equipment to stanch the hemorrhaging. She gave Fatmata a cup of tea.
"I don't do complications here," Cole said.
They sent for Saidu, who ran frantically around the neighborhood, 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 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 at 6:06 a.m. Nurses wheeled an old iron gurney down to the car and lifted Fatmata onto 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 hospital is a sprawling, low structure that sits between one of the city's busiest market streets and a slum astride the Atlantic shorefront. It has no air conditioning, a broken light in the operating room, bathrooms with an overpowering stench and virtually no medical supplies.
It is the country's best maternity hospital, handling 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 Ibrahim D. Thorlie, one of only two specialists in obstetrics and gynecology 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. Sidique, the other obstetrician on staff, said he had spent almost $250 out of his own pocket this month for sutures, because the hospital has none.
Before a Caesarean section or other surgeries can start, 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.
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