Sarah Boseley Friday 8 May 2009 16.42 BST www.guardian.co.uk
The other day I watched a woman die. A small crowd of nursing staff, orderlies and onlookers clustered round the bed in the treatment room where she had been taken after collapsing on the grass outside. It seemed like an intrusion to join them,but, in truth, one more made no difference. She was motionless, legs bent below her red dress and head to one side. With the horror of a westerner used to ambulance sirens, I counted the seconds ticking away while nothing was done. No drip, no oxygen mask, no injections, no resuscitation. They had seen it too often before. They knew there was nothing they could do.
It happens in Uganda all the time. The previous day there had been nothing wrong with Florence Ayupo. She was fit and healthy, cooking for her husband and four children, sweeping the yard. Then in the early hours of her last ever morning, she went into labour.
"She woke me up about 3am," said her husband, Joseph Etoku, outside the health centre. He seemed to want to talk. I didn't realise until later that he had not been told his wife was dead. "I had to hurry on a bicycle to get the TBA [traditional birth attendant]. She delivered about 6am. We realised there was a problem."
Exactly what the problem was, nobody will ever know. They don't do autopsies on women who die in childbirth in Katine, north-east Uganda. The nearest obstetrician who might have had an expert view was in Soroti town, 20 miles away. The nearest doctor of any sort, in fact, was in the same town. And that's why she died.
Certainly she haemorrhaged. But she could still have been saved if she had got to a hospital in time. But it all happened like one of those nightmares where you try to run, but your feet are stuck to the ground. Her husband hired a motorbike from a neighbour and took her to a local health centre. But it was a clinic with only low-grade nursing staff. She was bleeding heavily, they told Etoku. She must go to the district hospital in Soroti.
They set off, and the vehicle ran out of fuel. Nobody can afford a full tank here. Etoku had to flag down a car. They got a bit further, but it broke down. Eventually a Land Rover stopped, but the driver took one look and said she needed urgent medical help. It would take half an hour to get to Soroti. He drove the short distance to Tiriri health centre, a level 4 facility that is supposed to have a doctor, but doesn't because the doctor left for better pay elsewhere. It has an operating theatre, but nobody qualified to do surgery, and hardly any drugs, let alone a blood bank.
And so Ayupo was carried inside and laid on a sloping bed in the treatment room. And people gathered around, perhaps for some sort of moral support. Because everybody knew she was going to die. And she did.
Outside, a girl sat silently on the grass in the shade of an out-building with a still bundle wrapped in a blue and white checked blanket across her knees. The life of Ayupo's last baby, a girl, is now at risk too, with no mother to feed her. Unsterilised baby bottles and formula made with dodgy water could kill her too. And the life chances of the other four children have also suddenly been severely compromised. It is mothers in Africa who care for them, feed them, protect them and get them educated.
What is to be done about this tragic cull of young women? It's a huge problem. More than half a million women die every year across the world in, or as a result of, pregnancy and childbirth. Their children's chance of dying before the age of 10 rises as a result - two million of the children who die every year have no mothers.
There has been a flurry of activity this week in the UK, with reports from the Foreign Policy Centre thinktank, the all-party group on population, development and reproductive health, the charity Women and Children First and the medical aid agency, Merlin, all timed around the International Day of the Midwife. Sarah Brown, wife of the prime minister, and former spice girl turned UNFPA goodwill ambassador Geri Halliwell spoke at events.
But for all the current concern, reducing the death toll from childbirth is a huge task. It is the Millennium Development Goal on which we have made least progress. That's because what are really needed are more trained midwives, more ambulances and other forms of transport and clinics equipped for surgery with doctors or specially trained medical staff who can carry out caesareans. In other words, some countries' entire health systems need to be upgraded.
It needs to be done. Progress in reducing mothers' deaths is now being seen as the marker of good healthcare. Governments in developing countries have begun to accept that and prioritise it. But the very real danger, at this point in time, is that, as donor nations cut back on their spending in the face of recession, the money will run out. Women like Ayupo and her friends are voiceless. They must not be forgotten.
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