RUMBEK, Sudan -- The slender, exhausted woman in bed No. 6 was struggling for her life. A nurse had warned Bang Akok last year, and the year before that, to stop getting pregnant. But the pressure to have another child was just too great.
Even at age 23, even after eight other pregnancies, even after she almost died from hemorrhaging during her previous delivery, Akok could not resist the overwhelming demands from her family and her society -- trying to rebuild after 21 years of civil war -- to help replace those lost during fighting.
Bang Akok at Rumbek Hospital with her baby girl and her aunt, Agoen Matheu. The baby's twin died before delivery.
(Emily Wax -- The Washington Post)
_____Crisis in Sudan_____
Q&A: Darfur A brief explanation of the issues and current humanitarian situation in Western Sudan.
Photos: Continuing Crisis
Photos: Sudan's Rebels
A Former Rebel's Search for Sudanese Identity (The Washington Post, Feb 11, 2005)
Sudan Offers War Crimes Trials (The Washington Post, Feb 9, 2005)
Lack of Access Muddies Death Toll in Darfur (The Washington Post, Feb 8, 2005)
Girls From Sudan's War Now Fight to Learn (The Washington Post, Feb 4, 2005)
U.N. Report on Sudan Draws Mixed Reaction (The Washington Post, Feb 2, 2005)
Now, hours after giving birth again, Akok was dehydrated and suffering from internal bleeding. This time, she had been pregnant with twins. One of her babies -- a boy -- died before he could be delivered and had to be cut from her womb. His sister survived and was napping by her mother's side, with a head full of brown hair.
"Her body was too tired," said Akok's soft-spoken aunt, Agoen Matheu, 50, as she held the young woman's hand in a hospital ward in this town in southern Sudan. "We knew she shouldn't make another baby. But she did."
In a continent with some of the world's highest rates of infant and maternal mortality, southern Sudan is a pocket of especially harsh suffering and poor survival odds for pregnant women and their newborns. Here at Rumbek Hospital's maternity ward -- the only one for hundreds of miles -- less than half of the pregnancies and births result in both a living mother and baby.
Across sub-Saharan Africa, women face a 1 in 16 chance of dying from pregnancy and childbirth, which have outpaced AIDS-related diseases as the leading causes of death for women, according to the World Health Organization. In the developed world, less than 1 in 2,800 pregnant women face the same fate. Babies also die at extremely high rates in this part of the world, with more than 100 deaths per 1,000 live births, compared with 34 in East Asia, 30 in Latin America and 6 in industrialized countries.
In Sudan, 590 women die in childbirth for every 100,000 live births. It is a brighter picture than in countries such as Sierra Leone and Afghanistan, where the number is more than three times as high, according to WHO. But the ravages of civil war, the lack of skilled health workers and the remoteness of many settlements have made Sudan an especially precarious place to give birth.
"To come up with a live baby and a live mother at the end of a pregnancy is a huge, huge challenge," said Terry Sisa, a Kenyan nurse who works at Rumbek Hospital, where a small team of midwives toils without electricity, running water, blood supplies or pain medication. Each month, they assist with 35 healthy births. But each month, 50 infants or mothers die before, during or after delivery.
When it comes to maternal health, Sisa said tiredly, Sudan is "a century behind the rest of the world."
In Sudanese society, having many children is considered a wife's principal function and measure of worth. After years of war, women face added pressure to replenish the populace. In the rural south, girls often marry as young as 14 and are expected to produce nine or 10 children; as a result, fertility rates are among the highest in the world.
Yet, conditions surrounding most births remain primitive. Half of all babies in Sudan are delivered without the help of a skilled attendant, according to a 2004 study by the U.N. Population Fund. Poverty and underdevelopment compound the problem, with patients enduring long treks in the pounding sun to reach the nearest clinic. Akok walked for a week before reaching Rumbek Hospital in January.
A peace deal signed Jan. 9 between the Islamic, Arab government and the Sudan People's Liberation Army, a largely Christian and animist African rebel group, has eased tensions in southern Sudan and allowed health professionals to survey the extent of problems facing women and children.
But in the western region of Darfur, a separate ongoing conflict between the government and rebel groups is an additional obstacle to normal pregnancies, births and child care. Tens of thousands of families have been displaced by fighting, and their health is deteriorating because of instability and poor nutrition.
"Giving birth is hard enough," Taban Paramena, a health officer with UNICEF, said during a recent visit to Rumbek. "Pregnancy is not easy even under the best circumstances. But try it in Sudan."