The delivery room feels like a bathroom after a hot shower. There's no fan. And the funk of cheap disinfectant and stale sweat hangs in the air. The midwives and interns sit bored and cross-legged on a bed next to a pile of purses in the delivery room, idly playing with their cell phones. In front of them on a table lies Florence, a 20-year-old in the throes of labor. She looses off an impressive shriek.
Nobody seems to care.
Florence's day had started out badly. The ambulance, a late-model minivan that a soccer mom might drive, was late picking her up from the health center. The two stone-faced policemen sitting in the middle seat had stopped the van at a roadblock and demanded a lift. The driver protested. There's a pregnant woman in labor, he told them. You won't go anywhere, they said, if you don't take us.
When Florence finally climbs into the ambulance, she gingerly sits down. A flimsy piece of plastic has been placed on the seat to prevent the musty interior from getting soiled if the baby decides to come en route.
It was slow going. Here in Uvira, a town in eastern Democratic Republic of the Congo, rush-hour traffic and hoards of pedestrians inch down the middle of the street. The siren on the ambulance was broken, and blasting on the horn didn't do much good. People on bicycles turned and casually veered to the side. When the policemen arrived at their street, they slowly got out and walked off. The driver smashed the gas pedal, trying to make up for lost time.
As we bounce down the road, Florence's mom holds her daughter's stomach under her arm, like a boy holding a basketball on his way to the park. Florence rests her head on her mom's shoulder and never lets go of a handful of her dress, pulling down hard over every rut and bump. French music from the 1980s fills the van, drowning out Florence's moans.
When she gets to the hospital, an orderly eases Florence into a wheelchair and pushes her to the maternity ward. Her mom stays outside. In Congo, family members aren't allowed in the delivery room.
Florence paces the room. Théophile Bangana, a former delivery room nurse who now works with Catholic Relief Services, preps the midwives on what they should do during the delivery.
"We've observed that when women die in childbirth, 80 percent of the time it's from hemorrhaging," Théophile says. This number can easily be reduced if the proper steps are taken.
"After the baby has come out, give the woman a shot of oxytocin; it prevents hemorrhaging," Théophile tells the midwives, who listen arms folded, staring at him like students at a lecture.
Congo's Dangerous Deliveries
Many women in rural Congo don't have the means to go to a hospital like Florence did. They give birth on their own beds in mud huts. Their only help: a poorly trained village midwife or a female relative who hovers over them. Others go to health centers, which are usually staffed by a lone nurse.
When problems arise, they are referred to a hospital—often many miles away. Hospitals charge fees (usually around a few dollars to give birth) that are beyond the price range of rural families. When it comes time to pay the bill, some women offer fruit, chickens or goats instead of cash.
It's not just the money that's a problem. So is getting to the hospital. Estimates vary, but only about 1,400 miles of the country's roads are paved. The national highway in eastern Congo is a dirt road, and parts of it are almost impassable during the rainy season. Women in labor are sometimes pushed on bicycles. Those with money hire motorcycles. Most simply walk.
"The big problem we have here is capacity," says Théophile Bangana.
Many midwives here have had only rudimentary training, says Théophile, and they often don't properly care for the pregnant woman in the hours leading up to delivery or the hours after it. He says it's difficult to properly care for a pregnant woman when basic equipment is missing, such as refrigerators. And refrigerators aren't much use when most remote health centers don't have electricity. Oxytocin, for example, which helps prevent hemorrhaging, requires refrigeration. It quickly spoils in Congo's heat.
"Another problem we have: Are the personnel interested and engaged in [helping women in labor]?" says Théophile. He says many nurses and staff at health centers are paid poorly and neglect women in labor. Virtually all nurses and health center staff in eastern Congo are paid through patient fees, which have to cover not only salaries but running the health center or hospital and stocking the pharmacy. Midwives are paid between $10 and $30 a month. With salaries like this, Théophile says, motivation is often a problem.
"If a sick person comes or a woman in labor comes and they don't have money, they are neglected, and those who have [money] are favored," he says.
Théophile works on CRS' Newborn project, which trains midwives and nurses on how to care for women in labor and how to help them and their newborns in the crucial hours after birth.
Thousands of women die during and just after labor in Congo every year. Because of poor health conditions, poorly trained medical staff and a lack of equipment, hundreds of thousands of newborns die in the days and weeks following birth. Many die, Théophile says, because of the poor care they received in the hours after delivery.
Théophile continues questioning the midwives.
"If the child can't breathe, what are you going to use?" he asks.
Silence. The women stare at him.
"A syringe," one midwife whispers, as she opens a metal container holding three syringes floating in an inch of water.
"Yes. Okay. Um," says Théophile. "But what did we say about the syringes? They shouldn't be stored together. If you use the same syringe for all babies, you risk infecting the newborns."
Empathy for Mom
Monitoring of midwives in action is desperately needed. While CRS has distributed digital thermometers and stethoscopes, and trained midwives on how to properly tie a newborn's umbilical cord, Théophile says that being there to witness how they work is crucial.
But convincing them how to treat women in labor is another matter. Théophile says midwives often yell at—and at times slap—the woman in labor.
In a heartfelt plea, Théophile asks the midwives to put themselves in Florence's place.
"Think about it: A woman who has been pregnant for nine months, who's been carrying a baby that's always moving, that weighs 7 pounds—with all the joy that she's been building up—her baby dies because you and me were not able to take care of her," he tells them. "Think about it."
Florence is lucky. The midwives here aren't mean, just a little cold. They rarely smile. Except for Emma. She's had five children and treats Florence like a daughter.
The hours drag by. Florence is pacing. One minute she is on her side on the delivery table. Then she slides off; she wants to move. Emma rushes over to her. "I want to walk around," she pleads. With a hand on her shoulder, Emma gently explains to her why she shouldn't be walking around. Emma calmly talks her back on the delivery table, helps her get settled, then gives her a kiss on the cheek.
Florence hasn't eaten in two days. She has no energy. "I'm tired," she moans. "I'm never having a baby again." Florence sticks to the table like Scotch tape. The humidity seems to rise.
As the night progresses and the contractions intensify, Florence's screams carry out the window and wash over the pregnant women waiting outside in the breezeway. Conversations stop. But inside, nobody moves. Not even Emma.
Mother and Child
Her biggest problem: She doesn't have the strength to push. Nurses give her a shot of dextrose in hopes that it will give her some energy. But it doesn't help much. So Emma climbs up on the delivery table and starts pushing on Florence's abdomen.
Théophile assures me that in Congo—and other African countries—this is done. He says Emma knows what she's doing.
While Emma pushes and Evaline, the other midwife, pulls, Théophile is right there in the middle of the group. In his calm voice, he continues to coach. Even when the midwives do something wrong, he is never condescending.
Florence musters up everything she has. The midwives yell at her. Push, they scream. Come on, push, says Emma, who's doing just that on top of her.
Evaline sees the head.
"Push!" they yell.
Everyone in the room seems to be pushing with Florence.
Then the room is quiet except for the squeaky cry of a 7-pound baby boy.
Florence is spent. But Théophile is just hitting his stride. He continues his steady stream of advice.
"The baby needs to take advantage of the warmth of the mother," he tells them. "Put him on his mother's chest."
Evaline delicately places the baby, cocooned in a soft green blanket, on Florence's chest.
Florence wraps her arms around him, laces her fingers together, and gently rocks him.
The room is silent except for Florence, humming to her little boy.
Lane Hartill is the West Africa regional information officer for Catholic Relief Services. He is based in Dakar, Senegal.