As part of "Beginnings," a summerlong series onAll Things Considered , Melissa Block traveled to Mozambique to explore maternal health. This is the first of three reports.
In Mozambique in southeastern Africa, the rates of maternal and infant mortality are among the highest in the world.
In her lifetime, a Mozambican woman has a 1 in 37 chance of dying during pregnancy or within a short time after a pregnancy has ended. One in 10 children won't live past the first year. One in 7 dies before reaching the age of 5.
So NPR wanted to find out what might help improve those outcomes.
Volunteer Health Workers
In the countryside of northern Mozambique, in Nampula province, a large group of women sits on the ground in a small community of mud huts. Just about every woman has a baby on her breast, bundled inside a brightly colored cloth called a capulana.
On average, women in Mozambique have five children. And they start having babies when they're very young — as young as 10.
The women talk about an initiation ritual called okanone, soon after a girl has her first period. It's seen as the end of her childhood. Men know that once a girl has had her okanone, even at age 10 or 11, she's considered old enough to have sex and marry.
Paulina Francisco says the girls learn a "rhythm of initiation" dance that teaches them a lot about sex and about how to please a man. She says that girls are taught when a man comes and wants to sleep with you, "Do this, turn this way, turn that way, grab him this way." Amid much merriment, she wiggles her hips for emphasis.
Francisco is a volunteer health worker in this community, which is named "The 25th of June," after Mozambique's day of independence from Portuguese colonial rule. The group Save the Children, working with Mozambique's Ministry of Health, has trained village workers like Francisco to help with basic medical care. The community volunteers visit people in their homes, since for many it's impossible to make the long haul to a health center.
On a recent day, Francisco visits a young mother named Belita who gave birth to a baby girl in her mud hut just two days before. The mom lies alongside her baby on a low cot on the dirt floor. The hut is tiny — dark and sweltering — and it buzzes with flies.
Francisco rinses her hands, takes the newborn's temperature, then slides her onto a spring scale she has brought to check her weight.
The baby weighs in at nearly 6 pounds — a normal weight.
Francisco warns the mother to look out for danger signs — diarrhea, umbilical infection — and she urges the couple to bring the baby to a hospital soon for vaccines. The father says they'll try to find a bicycle to get to the nearest health center, which is in the city of Monapo. Assuming they do find a bike, it will take them three hours to get there. This community is about 18 miles from the nearest clinic, down rutted red dirt roads.
This family's story is typical of rural Mozambique. In the countryside, more than half the babies born are delivered like Belita's was: not in a health facility, but at home. The women are often attended by a relative or friend, but not by a skilled health worker. The risks are great for both mother and child.
So the government is trying to encourage women to have their babies in maternity units, like the one at the Rural Hospital of Monapo.
Two Newborns, Different Outcomes
This hospital is a grim outpost, old and battered. In the tiny "maternity room," two women with bulging bellies are lying under blue sheets covered with old bloodstains. One woman has an IV drip. She moans softly and grips the metal bed frame. A piece of paper taped to the wall urges, "Bring your baby into the world smiling." It turns out to be a cruel wish.
Minutes later, more quickly than seems possible, both women have quietly given birth — side by side, with no curtain for privacy, and with virtually no assistance. There is no doctor on hand.
A nurse holds up one baby — a boy — by his feet and vigorously slaps his back, drawing his first cry, before bundling him in a cloth and taking him to be weighed. But the other baby — a girl — is silent. She's still, and blue.
The nurses move with no great urgency. They suction the baby's mouth — try to pump air into her lungs, holding a bag mask over her mouth. They try chest compressions. Excruciating minutes go by.
The newborn girl never takes a breath.
The mother, Fatima Florenco, is expressionless. Maybe she's stunned, or maybe she's resigned to this outcome.
Outside the hospital, head nurse Messias Mireche says unfortunately this baby died because the mother delayed getting to the hospital. She had apparently been in labor for two days before coming here.
Maybe she didn't come in time because she didn't have a way to get here, he adds. Or maybe she didn't know how important it is to get to the hospital. But all that said, even once she got there, the bare-bones hospital had no fetal heart monitor. No doctor standing by to perform an emergency cesarean section.
Skilled Nurses
As unforgiving as conditions are at the Monapo rural hospital, some 40 miles away in the city of Nacala, there is a brand-new hospital painted a creamy yellow. It's spotless.
And, there, you might find your best hope in nurse Laura Simbini, who is trained in maternal-child health. And she embodies one of the ways Mozambique is trying to improve outcomes for women and children. Mozambique has one of the worst doctor-patient ratios in the world: just 1 doctor for every 25,000 people, according to the Ministry of Health.
So nurses like Simbini have been trained to perform emergency surgery: She can do C-sections and hysterectomies. She can operate to treat ectopic pregnancies or sepsis. All these things that the U.S. health system would consider the exclusive province of a doctor, she can do as a nurse.
"We do it this way because we have very few specialists," Simbini says. "So we were trained to deal with emergency situations. We have a doctor here, a specialist, but only one."
Simbini can't talk long: She has two C-section patients waiting for her. One is a 15-year-old girl. Big baby, small mother, Simbini explains. And off she goes to operate.
The Ministry of Health has trained 60 nurses like Simbini around the country, providing emergency obstetric care to women who might otherwise have none. The Mozambican government knows the numbers for maternal and infant death are still way too high. But this at least is one way to try to bring those numbers down.
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