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.
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."
Fleeing the Fighting
A year ago, Ahmed Abdallah, 21, married Fadna Abdulla Rhaman, a pretty woman of 25. They lived in a compound of huts about 37 miles east of Nyala, the capital of South Darfur.
Rhaman quickly learned she was with child. Her new husband and their families celebrated. They slaughtered a cow and held the customary feast of celebration for a first pregnancy. But when Rhaman was eight months pregnant, her belly swelling with life, their village was attacked -- either by African rebels or Arab militiamen, allegedly armed by the government to stop the uprising.
"People came on horses at 4 in the morning, rebels or government, we aren't sure," said Khadija Ishak Hamad, Rhaman's mother, who sat in a dank shelter patched together from leaves, rags and sticks in a sweltering camp for those who fled. "My daughter was not well enough to run. I knew she was in pain."
In the late stages of her pregnancy, Rhaman spent her days resting, as most pregnant women do around the world. So when the family had to flee, Rhaman found it almost impossible to keep up. They had little water and had to walk for two days in the sun, with sand whipping up behind them.
"The biggest problem was that we were in the bush and lacked food," Hamad said. "At one point, we had to run to the mountains when we heard more gunfire. I carried her for a while."
During the journey, the family was worried Rhaman might give birth, because she was bleeding and kept passing out. But after several days, they made it to a crowded camp in Nyala where more than 80,000 people were living after being displaced by fighting. Rhaman gave birth soon after, helped along by women without formal training.
Afterward, she held her baby girl, wrapped in a torn pink blanket and named Abdallia, or "Servant of God" in Arabic.
"My wife was so happy," her husband recalled. "We thought everything would be fine. We thought she might need a better meal of meat. But we had nothing."
Rhaman knew she was weak because she couldn't breast-feed and felt dizzy. But her sister, who gave birth last year, fed the baby and the entire family squeezed into one hut, cuddling her. The men came by to praise the miracle. Her husband held the child. Another neighbor came over to offer a small bowl of dates and porridge.
But during the night, Rhaman began bleeding heavily. The next morning, her husband took her to a clinic in the camp. The lines were long. They waited all day. They were told to come back the next day. By then, she had died.
Attempts at Education
"You only see tiny babies here," said Sisa, the Kenyan nurse, looking over the ward crowded with women and newborns at Rumbek Hospital. "So many are in their 10th or 11th pregnancies. No wonder so many women and their babies are dying."
Lately, the nurses in Rumbek have been feeling frustrated by the high number of deaths. Last year, 3,000 village midwives were trained and 1,100 students were recruited for training across the country, with the support of the government and the rebel group that controls southern Sudan.
"We desperately need help," Sisa said. "During the war, you knew why there were so many maternal and infant deaths. But now, we can't have this many people dying."
Recently, she started making lists of health tips to hand out to pregnant women who visit. But she has had to read them aloud in most cases, because few of the mothers can read.
Sisa also wants the hospital to create mobile clinics to educate the population in remote villages about family planning and hygiene. In Africa, large families are seen as prestigious. But Sisa noted that in Kenya, birthrates have slowed among educated women. In Sudan, she insisted, the numbers have to come down.
"I know you are suffering after the war and want large families," Sisa told a group of nurses in training at the hospital. "But you can't build a big nation if the women are dead. You can't have women bearing this many children. It's not healthy."
"Maybe try and stop at six," she said with a laugh, trying to gauge the reaction. Some women seemed to take her seriously, while others appeared to shrug her off.
Sisa has taken a particular interest in Akok's case. She warned Akok last year not to keep getting pregnant, but now she said she wishes she had visited Akok's village to speak with her husband and the other men.
But there was another problem with Akok's delivery. Near the end of the long walk to the hospital, she thought she was about to give birth, so her aunt started washing her with dirty water and using sticks to try to prod the babies out. She got an infection, which caused her boy's death before delivery.
"Never use unhygienic tools," Sisa reminded the group of apprentice nurses. "It's like shooting the mother and baby."
Back in the ward with Akok, Sisa clapped with happiness when she saw that Akok's heart was still beating. She was still losing blood, but there was more color in her face, and she stayed awake a few minutes before passing back into sleep.
During one of Akok's waking moments, Sisa leaned toward her and said: "No more babies. Really."