Story by Kevin Sullivan
Photos by Carol Guzy
The Washington Post
Sunday, October 12, 2008
FREETOWN, Sierra Leone -- 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-months 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.
"Everything you see here, the patient has to buy," said Sidique, who had to delay a C-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 those 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 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 and rain fly in the open windows.
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 odor of death, which leaves a bitter taste in the back of the throat.
"Do you see what we are facing here?" Sidique said. "For us, this is something that is normal."
The nurses trying to save Fatmata's life realized she was severely anemic and had lost too much blood. Saidu told them she had not been taking her prenatal vitamins, and she had also been fasting during the day for three weeks in observance of the Muslim holy month 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 black marketeer 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 slim qualifications charge much less.
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 a hot, slashing rain dripping in the open window, Fofanah tried chest compressions to revive the dying teenager.
But at 7:14 a.m., Fofanah pronounced Fatmata dead.
Fofanah, who had been working all night, shook her head afterward 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 colored cloths. They had been her clothes when she arrived; now they were her shroud.
They loaded her body onto a black stretcher, and several men carried it to the parking lot.
The hospital's ambulance was broken down, so the family flagged down a small delivery van. They loaded Fatmata's body into the truck's covered bed, pushing aside a spare tire.
Then six of Fatmata's relatives and friends squeezed in with her body, and the truck pulled out into the chaotic morning traffic in the pouring rain, its yellow emergency lights flashing.
Twenty minutes later they arrived at Fatmata's family home, a collection of small shacks around a concrete courtyard. They sat behind the ruined remains of the family's former house, a grander structure that was burned by rebels in the 1990s during the civil war.
A dozen women waited near the rusting iron gate. Over and over they screamed, "Fatmata! Fatmata!" as men carried her body past an ancient truck up on blocks, past the dogs and chickens in the courtyard and into a small bathroom where her body was unwrapped and washed.
Fatmata's father, a tall and regal-looking man in a long blue robe and a white skullcap, sat with his head in his hands, taking fast and shallow breaths. Fatmata's mother was stuck at least eight hours' drive away in the countryside, caring for her own sick mother.
For the next seven hours, at least 100 people flooded into the courtyard. Many women knelt before Fatmata's father and cried as he consoled them with a gentle touch on the head.
Isata Barrie, 32 and heavily pregnant with her fifth child, sat with dozens of other people on plastic chairs. She said the death of another teenager in childbirth was not a surprise: "This is what happens to women here."
Just before 4 p.m., Saidu and several other men lifted Fatmata's body, now wrapped in a gauzy white burial cloth, into a wooden box. The box belongs to the mosque, which lends it out to families to carry bodies to the graveyard.
They placed her body in a small delivery van and drove slowly, with scores of men walking behind, to the cemetery, where many dead mothers had come before.
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 shovelful of dirt.