Lying on a sagging mattress and wincing slightly, Anna Lado laughs at the idea that she should have been afraid of giving birth to her first child, now lying in a crib near her in a hospital in south Sudan. "It's natural," she smiles.
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But in fact, she received a life-saving caesarean in the capital Juba's teaching hospital: a relatively rare operation in south Sudan where one in 50 women die in childbirth, the world's highest maternal mortality rate.
In this vast expanse of dusty scrubland where around 10 million people live, the return of peace after Africa's longest civil war has exposed the dire state of the healthcare system.
A 2005 peace deal ended two decades of conflict between the south and the north that claimed around 2 million lives and was fought over ethnicity, religion and oil. The conflict is separate from the continuing violence in Darfur in the west.
2 030 out of 100 000 babies die a year
Under the deal, the semi-autonomous south will have a chance to vote for independence in 2011. Meanwhile, authorities must try to rebuild a devastated land that has few paved roads, chaotic laws; rudimentary services, but large oil fields.
Last June, the United Nations Population Fund (UNFPA) said south Sudan had the highest rate of pregnancy-related deaths in the world, at 2 030 per 100 000 births. That compares to a rate of 509 deaths per 100 000 births in the north.
UN officials say at the last count there were nine fully trained midwives in south Sudan, seven of those in the capital. The UNFPA says only around five percent of women in south Sudan deliver in an institution.
At the Juba teaching hospital, wide-eyed babies are weighed in a harness and then passed through a jostling sea of mothers. "It's shocking because most of those women just represent those who get to facilities, how many more did not reach them?" said Magda Armah, who works for UNFPA.
Rural areas are even worse
Festo Juma, the hospital's chief administrator and only obstetrician, looks exhausted as he describes his caseload. He is between operations and is wearing white Wellington boots and green scrubs, with a facemask dangling around his neck. "In the rural areas, the situation is very much worse. The main cause (of the high death rate) is the complete absence of obstetric services in three-quarters of the south," he said.
South Sudan is by no means unique in Africa, but the severity of its situation stands out: Until recently, there was only one delivery bed in Juba hospital. A new theatre with four delivery beds, a blood bank and beds for 150 patients, plus a nursery, are about to open.
In April, a new report by the UN children's agency UNICEF said African countries had made the least progress among developing nations towards a UN goal of cutting infant and maternal mortality by two-thirds by 2015.
The White Ribbon Alliance - an international organisation to promote safe motherhood with members in 91 countries - says African women have a 1 in 16 chance of dying from a pregnancy, compared with 1 in 1 400 in Europe.
"These are needless and preventable deaths. This is not a strange illness that requires science to find a cure. We know what to do but the political will to put resources into this and to prioritize it is missing," said Brigid McConville, the director of White Ribbon Alliance in London.
Funds needed to train and get skilled workers
Armah agrees on the need for investment. "There needs to be a massive injection of funds into the training of skilled birth attendants and we need the infrastructure," she said. UNFPA is working with the Juba hospital to open a blood bank and mini-lab.
UNFPA also plans to inform women about pregnancy care. "People don't know that women have a right to reproductive healthcare," Armah said.
Thousands of miles to the south of Sudan, in the sliver-like country of Malawi, the importance of grassroots education to fight maternal mortality has been recognised.
UNFPA says that nearly two percent of live births in Malawi result in the death of the mother: that's 16 deaths a day from pregnancy or childbirth complications.
Fines for mothers who chance delivering at home
But a community in Dedza district, just outside the capital Lilongwe, is trying to change that. In less than two years, Chitowo community, working with UNFPA, has reduced maternal deaths to seven, from 33.
"This has been possible because as a village we formed committees to encourage pregnant mothers to go for antenatal (care), monitor newborns, distribute bed nets and set up rules to follow on hygiene," said village chief Adamson Mwangwazu. "We also fine those who deliver at home instead of in a health centre ... We no longer lose a child or a mother like we used to."
This example is being copied in other communities in what is being dubbed Malawi's health revolution - albeit a revolution that is limited in scope because of the stranglehold that HIV/Aids has on the country.
Through its local partners in Malawi, White Ribbon Alliance has enlisted the police's help in picking up pregnant women who are walking long distances to try to get to a clinic.
Cutting maternal mortality rate vital
The group is also working with the ministry of health to find ways of retaining health staff in rural communities, by providing housing, power, schools and security.
McConville says cutting the maternal mortality rate will benefit everyone, and not only because women hold communities together and, in many places, do much of the farming work.
"If you get it right for mothers, you've got the health staff in place in the community, you've got the referral system to the next level, you've got the operating theatre, the anaesthetist, the electricity and communications. All of this will benefit a man with a broken leg or a child with a respiratory illness."
In south Sudan, Festo Juma's biggest immediate problem is lack of supplies and staff. He says he has been unable to persuade southern doctors working in Khartoum to return.
"Even here (in Juba), three quarters of the midwives are village midwives, with no proper sense of emergency or knowledge of how to deal with problems," he said.
'The young are dying'
In the hospital, about 40 women die in labour each year, mostly because they arrive in a perilous state. The babies who survive face their own battles: 135 out of 1 000 children in south Sudan die before they reach five years old, according to a government and UN survey.
And early marriage and pregnancy means teenagers are among those dying in childbirth. "Of every 1 000 pregnancies, 200 are adolescents," Armah said. "The young are dying." – (Reuters Health)
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