GABU, Guinea-Bissau — Fatumata Djau gave birth to her fourth daughter alone, at home, in the dark. She arrived at the hospital at 3 a.m. with the newborn still attached, and the midwife cut the cord in the parking lot.
Hours later, the 32-year-old mother lies listless on her side as sweat beads trickle down her back. She has lost a lot of blood, and the maternity ward is stifling, with no electricity to whirl the rusty ceiling fans to life.
Across the courtyard, first-time mother Aissato Sanha is following doctor's orders — she is spending the final three weeks of a high-risk pregnancy in a bed literally a dash from the delivery room. But she is young, maybe too young, in her teens, and she has high blood pressure.
Both women are up against the same challenge: Guinea-Bissau is one of the deadliest places in the world to give birth.
Despite some progress, childbirth is still a perilous endeavor across sub-Saharan Africa, and Guinea-Bissau stands out for its dire statistics. A woman has a 1 in 19 chance of maternal death in this tiny country, compared to about 1 in 2,100 in the United States.
Experts say women are increasingly heading to medical centers when things go awry. Lives here, though, come down to whether cell phone networks are working, whether tides will allow boats to set sail. How quickly women can get to hospitals on muddy, rutted paths lit only by the moon, and whether their families can buy the right medicine.
Even then, it can sometimes be too late.
Amid the maze of packed beds at the Gabu Regional Hospital, Djau's distraught relatives cluster around her bed in the tiny ward. The room reeks of iodine and bed pans. The howls of labor pain form a chorus with the cries of newborns swaddled in rusty bassinets.
"Give life without dying," reads the poster taped above the chairs where women deliver their babies. It is apt — Guinea-Bissau's maternal mortality rate is the fourth-highest in the world, after Afghanistan, Somalia and Chad. But few can read the sign anyway, because 60 percent of women here are illiterate.
Most women still prefer to have babies in their villages, where they sit in a stew of warm water and banana leaves as matrons coax labor along. However, if anything goes wrong, they are often far from a hospital.
As in many parts of western Africa, Guinea-Bissau's hospitals are few and far between. A journey of just 11 miles can take three hours by foot, or cost up to 10,000 francs ($20) for a car, should one happen to be available.
Entrenched cultural practices can make the fight to save mothers' lives harder. Here, 13-year-old brides have children before their bodies are ready — about 7 percent of girls under 15 are already married, according to UNICEF.
Nearly all women in the Gabu region have undergone female genital mutilation. More than 20 percent had the most extreme form, which involves stitching a woman's vagina shut so that only a small hole remains — a serious health risk during labor and delivery.
Even if a mother gets to a hospital, families must purchase anesthesia drugs before emergency operations can take place. While Djau is hooked up to an IV, a brother is sent out to buy medicine to stop the blood loss.
He comes back with a plastic bag of drugs from the pharmacy, but the midwife tells him he's been given the wrong one. He sets off again, as their sister paces tearfully in the courtyard.
Medics explain that Djau is hemorrhaging badly because she didn't deliver the placenta after giving birth at home. Around 4 p.m., she suddenly begins to convulse in her bed.
The midwife is summoned and attempts CPR, in front of an open room full of other new mothers. A cleaning woman furiously guards the door, as other family members rush to see Djau.
The efforts to save her show no signs of working. Her distraught female relatives begin pouring out into the courtyard. It takes the strength of several women to keep her mother from collapsing to the ground.
Their cries of grief echo through the ward indoors, where her husband wipes tears from his face as the midwife checks for a pulse one last time. Her eyes remain open to the ceiling, her lips parted weakly. The midwife covers her body and face with the same orange, brown and blue wax print fabric she had been wearing around her waist.
Djau's family lifts her lifeless body into the back of a bush taxi. Relatives on motorcycles follow the makeshift hearse in a slow procession back to her home.
Not long after Djau's death, Aissato Sanha shuffles over to the maternity ward with her mother by her side. She's given her age as 18, but the midwife believes she's as young as 15.
It is a triumph for health workers that Aissato is here at all.
The hospital has a House of Mothers, a building just a few minutes' walk away from a delivery room, where women count down the anxious days to birth under close medical supervision.
Outreach teams from a program operated by Caritas and Catholic Relief Services now regularly head into remote villages to identify high-risk pregnant mothers and relocate some closer to medical services. The teams also train traditional birthing matrons, helping them to determine when it's time to get women to the hospital.
Such efforts have made inroads in sub-Saharan Africa: The United Nations reported recently that the number of women dying from pregnancy and childbirth has nearly halved over the last two decades.
But even now, and even at the hospital, it is touch-and-go. Generators only hum to life when a surgery is being performed. There is no power for refrigeration to store blood donations, and no electricity to run incubators for babies who have come too soon.
A typed list pinned to the bulletin board in the hallway shows the grim statistics at Gabu hospital alone: Four mothers died here in January, seven in February and three in March. There were no totals kept for April, when a military junta seized power, or for the chaotic month of May that followed.
As the sun falls, the head midwife at the hospital works with only a flashlight tucked under her chin and sometimes the glow of a candle on a nearby countertop to guide her.
The night wears on, and Aissato tosses restlessly in the one-room ward lit only by candles. At one point, she catches a glimpse of another woman's baby coming out legs first, as the staff scream at her to push or the baby will die.
Tears stream down Aissato's bewildered face as her water breaks on the floor near the nurse's station. It puddles around the stools where they are logging each stillborn, each close call.
But by 10:30 a.m. the next day, her baby is no closer to birth. The hospital's director is called, opinions are shared. Aissato must have a Cesarean section, an expensive but lifesaving procedure for both her and her child.
"You must buy these drugs now or the baby will die," the surgeon tells her mother firmly as she sets off briskly to the neighborhood pharmacy.
Once the supplies arrive in a coral plastic shopping bag, Aissato, her mother, the doctor and the nurses walk over to the operation room.
After the surgery, as Aissato's mother tends to her in a hallway, staff workers approach her father to see the baby. When shown the little boy who had struggled for so many hours to enter the world, the grandfather recoils with horror on his face.
The baby is missing part of a leg and waves around hands that have fingers webbed together. One eye socket is completely obscured by a cleft palate that stretches across a head far too large for his little body.
Aissato most likely took some kind of medicine in the early weeks of her pregnancy that caused the severe malformities, medical officials said. It was not discovered in an ultrasound because she never had one.
The decision is made not to show Aissato or her mother the little boy, who instead snores on a table in the corner of the delivery ward.
The midwives don't know whether Aissato's family will take the baby home. Some families don't, others do but only to neglect the disabled child.
As staff arrive for the start of a new shift in the maternity ward, news spreads of Djau's death from the day before. Why didn't her initial blood tests show how sick she really was? Why did it take so long for her to get there from the outskirts of town? Why did her husband wake up only when the baby started to cry?
"It was her fourth child — how did she not know she was in labor? Why did she choose to give birth at home all alone?" head midwife Maria Antoneta Cabral Barbosa says, shaking her head as she looks over her medical chart. "It stuns me."
At a tidy cottage on the outskirts of Gabu with donkeys tied out front, mourners gather to comfort her 74-year-old widower, who is now left with four motherless girls.
The women crowd tearfully inside the windowless, dark entry room, while the men sit on floor mats in the family's backyard as chickens and children scamper past. Djau's 5-year-old, Halimato, smiles and clings playfully to her father, oblivious to the mourning all around her. Her 13-year-old sister, Roqui, sits on the sidelines, all too aware of how their lives have changed.
"She was a great confidante," Djae Embalo said of his wife of 14 years. "I was sick for six years and she took care of me. Then when she was ill I could do nothing to save her. Now I am alone."
Female relatives bring out Djau's motherless newborn, who is swaddled in a scrap of bright orange and blue cloth, her head a mess of thick curly hair. What to feed her? her father wonders aloud. He's heard of formula but is not sure how it works or how he will afford it.
And what to call her? Her mother died before they had chosen a name.
In the end, the little girl is called Mama Saliu Embalo. It is a boy's name in the Fula language, after a tradition designed to protect children whose mothers have died during childbirth. This way, the mother cannot find the child and reclaim it — a belief that underlines just how high infant mortality is after a mother dies.
In the meantime, Aissato's little boy is taken to an orphanage in the capital.
Aissato did not choose a name for him.