It's 10am on a stiflingly hot Monday morning and I am in a delivery room with one of the unluckiest mothers on the planet. She is Dahara Laouali, and at the moment she is lying on a narrow, dusty hospital trolley pushing her baby into the world. Although the birth is imminent - Insa, the midwife, says that with the next contraction the head will be out - Dahara is making no noise at all. This is Niger, where the tradition is that mothers labour in silence. It is hard keeping quiet in the throes of childbirth: but almost everything is hard for mothers in Niger.
Dahara pushes, pain creasing her sweating face, and then pushes again - and suddenly between her legs there is a little boy with the walnut features of newborns everywhere, and a mop of damp, dark hair. Insa gives a delighted squeal, but Dahara is still silent: as her baby is wrapped in a cloth, she turns her face to the wall and sobs quietly. Maybe she is tired after the labour. Maybe she wants to be alone. Maybe she is not ready quite yet to welcome the baby into her heart. But maybe, too, she is remembering other births, and other babies. Because this boy is the fifth child Dahara has pushed into the world and of the others, only one is still alive.
This, then, is Dahara's misfortune: and it is not just a personal tragedy, but one she shares with every other mother in her country. Niger is officially the most dangerous place on earth to have a baby: in May, a Save the Children report found that, of the 125 nations it surveyed, Niger was where childbirth was most likely to end badly. Statistically, Dahara, who is 26, has a one-in-seven chance of dying during her reproductive years as a result of a pregnancy-related complication or infection, or childbirth injury. Her baby son, lying here on the table, has a 15% chance of not reaching his first birthday and a one-in-six chance of not making it to the age of five. And Dahara is fortunate to have had the skills of a midwife like the cheerful Insa: across the country, only 16% of deliveries are attended by anyone with any training at all.
Dahara lives in a village called Bande, about two hours' drive from Zinder, the rundown former French colonial capital. To call the birth centre here basic is an understatement: to the western eye, from the outside, it resembles a neglected public lavatory. Inside are two small, grubby rooms: the delivery room, with its trolley and rickety desk, and the recovery room, which boasts a mattress-less bed and a greying cot. Here Dahara and her new son - whose name is to be Mohammed - will stay for a couple of hours. Then, Dahara will tie Mohammed to her back and walk the kilometre or so to her village. There is no aftercare, Insa explains: no midwife will check up on mother or baby, so Dahara will have to use her own judgment if there are any post-natal problems and seek help if and where she can. Dahara's husband has not been involved in the birth and is unlikely to play a big role in the early weeks with the baby: in Niger, birth is considered to be women's work and fathers keep their distance.
The only piece of medical equipment in evidence in the entire centre is a plastic bowl into which Dahara has delivered the placenta.
Ten days later, I am in another maternity unit. This one is in the University Hospital at Uppsala, north of Stockholm. Bande is 3,200 miles away, although I feel as if I have travelled from the middle ages to the middle of the 21st century. In almost every way, giving birth in Sweden is light years away from giving birth in Niger. And yet, of course, it is all ultimately about the same thing: a mother and a baby.
The mother and baby I meet in Uppsala are Carmen Helwig and her new daughter. Carmen paints a strikingly different picture of new motherhood. She is older - 38 - but Tess is her first baby. She was was born by caesarean section because of worries over a uterine scar, the result of previous surgery. It might have been fine, the doctors told her, but there was a risk it might rupture. "Why take that risk?" says Carmen, smiling. Tess was born three weeks early and is slightly underweight, but she is being carefully monitored at Uppsala and Carmen knows she will soon be taking her daughter home. Until then, she, her partner Tommy Svedberg, 41 - who was at the birth and is now taking paternity leave to be involved in his daughter's first weeks - and Tess are staying at the hospital, in a large, hotel-like double room. "Once I'm home, I'll be able to phone the hospital with any worries and the midwives will come out to see me every day if I need them," she says.
Carmen is Dahara's mirror-image, one of the luckiest mothers in the world. The Save the Children report found that, while risk can never be entirely removed from the business of becoming a parent, the dangers for Swedish women are minuscule in comparison with the risks for mothers in Niger. Carmen's chance of dying as a result of childbirth over her lifetime is one in 29,800 (Dahara's, remember, was just one in seven). The risk of Tess dying in her first year is one in 333. In Sweden, 100% of births are attended by a skilled, trained midwife. Overall, it is the safest place in the world to become a mother.
More than 99% of births in Sweden take place in hospital but it would be a vast oversimplification to attribute the gulf between the two countries' statistics to this fact alone. Layer upon layer of disadvantage and deprivation, and advantage and blessing, have meshed together to create the circumstances that divide Dahara and Mohammed from Carmen and Tess. Niger is rated the world's poorest country by the UN. Around 14% of its under-fives are significantly malnourished (and in the aftermath of last year's crop shortage and in the face of another shortfall this year, that figure could soon be much worse). Less than half its population has access to safe water.
In Niger, women are more than materially disadvantaged - they are educationally and physically disadvantaged too. Fewer than one in 10 is literate. Most girls marry early and have many children: the fertility rate, at 7.5, is among the highest in the world. Most of the mothers I talked to had had their first baby at 15 or 16 -one had had 11 babies before she was 25. Only 4% use modern contraception and not for cultural or religious reasons - many of the women I asked said they would welcome advice on spacing their children.
Sweden, by contrast, is one of the wealthiest economies on earth. Its people are healthy and well-fed, its shops well-stocked, its communications excellent and its women well-educated, with virtually 100% female literacy. More than 72% use modern contraception and the average age for a first birth is 29. The fertility rate is 1.7. It is, in every way, a happier and healthier place to be a woman.
And its maternity service is second-to-none. Antenatal care in Sweden is free. Women have a legal right to take time out of the working day to attend appointments and take-up is almost 100%. Mothers in labour are looked after with every hi-tech advantage possible; the foetal monitoring system here is among the most advanced and sensitive in the world. Dr Pia Axemo, the senior obstetrician at Uppsala, explains how pethidine - still used in the UK as a form of pain relief during labour - is deemed obsolete in Sweden. "Around 31% of mothers have epidurals but these are mobile epidurals and they can still walk round," she says. "But we feel strongly about women being supported in labour and we encourage them to try other sorts of pain relief - massage, a shower, acupuncture - before opting for an epidural."
The impression you get as you chat to mothers in Uppsala is that they feel remarkably well looked after, cared for, listened to and supported. It is not just about technology and machines. In a confident, well-developed, successful maternity unit such as this one, there is a generosity of resources that makes the mother-to-be feel individually cared for. It is something Gunilla Hallberg, the doctor who heads the unit, is particularly proud of. "What makes us successful is that we put women at the centre of what we're doing," she says. "We have everything technology can offer but, even more importantly, we treat mothers as individuals."
Individual care isn't a phrase you feel gets bandied about much at the main regional maternity hospital in Zinder - the Maternité Centrale, a blue-and-white painted building in the centre of the city. This is what passes for high-grade care in Niger, but it is pitiful in its privations. Where Uppsala's hospital is white, clean, spacious and calm, Zinder's is dirty, cramped and chaotic. The corridors are crammed with dusty, ancient-looking equipment. There are open bins and swarms of flies in the quadrangle, and cats roam free. The paint is peeling, there is no air conditioning despite temperatures of 40C and more, and everywhere you look there are people. Because, it transpires, when you come into hospital to have a baby in Niger, your relatives come too: they sleep on the floor by your bed, they help look after you and your baby, and they are here, too, to donate blood if you have a postpartum haemorrhage - you only get blood if you bring your own donors.
It is hard to imagine the hell into which Zinder's mothers-to-be descend if they end up giving birth here: but if your imagination isn't up to the job, a tour of the delivery facilities brings sound effects to ram the point home. It may be the tradition in Niger to bite your tongue through contractions, but the women whose complicated labours have forced them to seek help here are clearly past caring about niceties such as protecting their honour. They scream, they shriek, they moan, they writhe: and they do it two to a room because there is no such thing as private delivery space. Nor for the most part is there any such thing as pain relief - a trip round the dispensary reveals empty shelves. Only women who have a caesarean are given anaesthetic.
Mariama Bashir, the general manager of Zinder's maternity hospital, is a strikingly beautiful young woman in traditional African dress who sits behind a desk in a cramped office with a whirling fan. In between a constant stream of interruptions from harassed-looking midwives, she delivers the statistics with an air of weariness. Of 2,600 babies born here last year, around one in six was dead at delivery or died soon afterwards. In addition, a total of 61 mothers lost their lives. This is shocking stuff: in Uppsala, where there are 4,000 births a year, two to three babies will die annually and one woman will die, on average, every seven years.
But there is more to the horrors of Zinder. Many of the women who come here will have travelled long distances, often in agony, to reach the hospital: some, says Bashir, come from villages as far as 50km away. The commonest problems that bring them here are pre-eclampsia, eclampsia itself (which causes fits) and women whose pelvises are too narrow to allow the baby out (especially common in teenage mothers). For the many women who need instrumental deliveries, the hospital has two sets of forceps and one ventouse. "But the ventouse is not in good condition," says Bashir. "We need a new ventouse. But then, we need many things."
More shocking still is the fact that, unlike Sweden where excellent maternity care comes free of charge, Niger's women have to pay for the privilege of their substandard, inadequate services (while healthcare fees have been abolished in principle, they are still enforced in practice). And, although the sums are paltry by western standards - an antenatal check-up is 1,000 CFA, or £1; a new-baby check-up is 5,000 CFA, or £5; a caesarean is 17,000 CSA, or £17 - the amounts are impossibly large for impoverished families in a country where the average per capita income is 127,000 CFA or £127 a year. In the village of Yawouri, outside Zinder, nurse Abdulaye Hachiou explains that women often fail to seek help in labour because they - or their husbands - fear the expense. "You get husbands who say their wives can't be brought to the clinic because they don't want to pay the bill. And then the wife gets worse and they say, well there's no point in taking her now, she's going to die anyway."
Removing healthcare fees, says Save the Children, would save women's and babies' lives in Niger. But that is far from the whole solution. The country needs more trained midwives, well-equipped antenatal clinics (one I visited shared its only blood pressure monitor with the district nurse - if she was using it, the blood pressure of mothers-to-be went unchecked), more obstetricians and a modern maternity unit in every town. In a perfect world, Niger would also have a vigilant system of postnatal care and beyond that, but equally important, clean water, a decent standard of living and good healthcare.
But that would be in a perfect world. So must childbirth continue to kill women and babies, on the sort of scale it did 200 years ago in the west, for many more decades to come? Not necessarily, says Save the Children. Anne Tinker, the Washington-based author of the report, says she believes seven out of 10 of the lives currently lost could be saved if a few low-cost measures were put into place. Education, she says, is key. "If we could raise awareness of some of the health issues, we could save many lives," she says. "Women need to know about the danger signs in pregnancy. They need to know when to seek medical help. They need to know how important it is to get help in labour if things aren't progressing, rather than leaving it too late. And they need to know how to look after their newborns and when to take them to the health centre."
In Zinder, Dr Antoinette Awaya, of Save the Children, is putting some of these measures into practice. She runs a health education programme, running training courses for volunteer health workers. The volunteers learn basic information about healthcare, hygiene and feeding babies, and pass it on to other mothers in their village. "Saving mothers' and babies' lives here needn't be expensive," she says. "There's so much that can be done through education. Breastfeeding, for example, saves many babies: but the tradition here is that mothers don't give colostrum, the first milk, because it looks yellow and they think it's bad. Once you get the message across that this is the best milk, that it can protect their babies from disease, they get on with it and give it: it's not that mothers are resistant to the things that could make a difference, it's that the messages aren't getting through."
Beyond education, there are other ways of using limited funds to the best possible advantage: immunising pregnant women against tetanus, for example, protects both mothers and babies and it is one of the most effective and least expensive vaccines on the planet. Treating pregnant women for malaria, which is endemic in most parts of Niger, can reduce the risk of prematurity and low birthweight by 40%. Providing postnatal support costs about half the amount of providing care during birth itself, but has the potential to reduce newborn mortality by between 20 and 40%. So, while there is much to be done, there are clearly cost-effective priorities. Until now, says Save the Children, child survival programmes in places such as Niger have tended to concentrate on diarrhoea and vaccine-preventable diseases. What is needed now is an emphasis on preventing deaths in babies, especially those in the early days and weeks of life.
On my final day in Zinder I am at a rural health clinic. It is quiet, the nurse is sitting at his desk, the sun is scorching. Suddenly, across the dusty scrubland, there is a flurry of noise and commotion: a woman is running towards us, a baby in her arms. Even from a distance you can see, from the way the head is thrown back, that this is a child in trouble. The mother, meanwhile, is crying out, shouting for help.
The nurse gets up, runs to her, takes the baby, disappears into his stifling, dark little consulting room. He shouts to the mother, a bit roughly, to stay out of the way. She stands at the door moaning, craning her neck, trying to look into the room to see her baby, to find out what the nurse is doing to him, to check he is all right.
But her baby is not all right. The nurse says he is "très grave": his only hope is the Médecins Sans Frontières hospital 20km away. The mother is lucky: because there is a Save the Children car here, she can get a lift to the hospital. She and the child are bundled in, her face contorted in panic, the baby's contorted in pain. This, then, is what infant mortality in Africa looks like when you get close up. This is how it happens. This is how it ends.
And it does end, for this baby, about an hour later. He makes it to the hospital, but dies soon after being admitted. He had an infection. He was just four months old. Not a chance, says the driver from Save the Children later when he returns to break the news. "C'est la vie," he says, sadly. "C'est la vie, ici".
A tale of two pregnancies: from a helicopter to a horse and cart
Sweden
Lisa Klercker is 35, and 30 weeks pregnant with her third child. She lives in a Stockholm suburb. Her other children are Ebba, seven, and Max, four. She has monthly antenatal check-ups at the mothercare centre near her home, and she will give birth in hospital. Lisa says that she is quietly confident that the delivery will go well. "We do have friends whose babies have had problems, so I don't take anything for granted," she says. If there are problems, she knows she will get the best possible care: before Ebba's delivery, the baby's heartbeat dipped suddenly, and she was transferred to hospital by helicopter. "It was quite dramatic but the medical staff were really calm. They made me feel everything would turn out OK and it did," she says. "What I like about being in hospital is that I know everything I need will be there. I feel I'll be in a safe place, with the best possible care available." Lisa expects to go home within hours of the delivery, and will then have visits from a team of postnatal midwives to help with any early problems.
Niger
Salawa Abdou is 20 and expecting her second child in a few weeks' time - she is not sure exactly when. She lives in Fardun Sofo, a village an hour by car from Zinder. Salawa has had no antenatal care. She dreads the delivery because she endured a very difficult, 48-hour labour with her son, Banani, two years ago. "It was very painful and very long," she says. "I was at home and we tried everything, but the baby wouldn't come out. It was terrible. In the end I was lucky, but I worry a lot about what is going to happen this time." Death is a real possibility for women who get into difficulties giving birth in Fardun Sofo: Zeinabou Abdou, the village's traditional birth attendant, has years of experience but no drugs and no equipment except for a packet of razor blades for cutting the umbilical cord. If Salawa needs medical help, she will be put on a cart and pulled by horse to the small maternity unit in Matamy, 15km away. So far this year, two mothers-to-be, out of a population of around 400, have died making the journey.
