Bamako — It's a typical weekday morning at the Luxembourg Mother-Child hospital in the capital, Bamako. Around 20 patients are there for appointments - shy teenagers sit alongside more confident, older women. Most clutch health cards, documenting past visits and carrying details of tests, previous illnesses and vaccinations.
The woman they are waiting to see is senior gynecologist Dr. Safiatou Kallé, born in Mali and trained in Italy. For much of the year, Kallé works at a hospital in Rome, but she makes sure she spends several months practicing medicine in the country of her birth.
"When I first saw medical conditions in Mali, I wanted to break down and cry," she says. "I was just asking myself: how can you be a doctor in these conditions? But it is getting better."
Kallé is quick to acknowledge that Mali faces massive struggles in meeting its goal of providing access to free health care in a country the United Nations ranks among the bottom five in terms of human development indicators.
Events this year will likely worsen that situation. The eruption of a rebellion in Mali's north in mid-January triggered huge population movements, with thousands of refugees fleeing to neighbouring Niger and Burkina Faso. The uprising further strained already stretched medical facilities. Two months later, a coup rocked what had been seen as a promising democracy.
With Mali seemingly locked into a worsening internal crisis, health issues affecting women have slipped downwards on the policy agenda. That means less attention focused on maternal health, family planning and the associated risks of their neglect.
Spacing births has a dramatic impact in reducing both maternal and child deaths, and raising the age of childbearing also helps. But contraceptive use is low in the country. The U.S.-based Population Services International (PSI) rates Mali as being "among the countries with the lowest contraceptive prevalence rates", with less than seven percent of the population covered.
The UN Population Fund, UNFPA, says 19 per cent of women in Mali between 15 and 19 are already mothers. According to Unicef, the UN children's fund, the rate of maternal mortality in 2008 (the latest date for which figures are available) was 830 deaths for every 100,000 live births.
Health experts warn that the situation may be even worse than those numbers indicate. Accurate statistics are hard to compile, particularly in outlying areas with poor record keeping.
Kallé notes that there is one trained midwife for every 24,000 women in Mali. Seventy-five percent of qualified gynecologists are based in the capital, Bamako. The city's health system is overloaded, but it provides far greater care and support than can be found in the country's vast interior.
Nevertheless, Kallé is confident that improvements are being made in her own field, and that common sense and good practice count, even when financial means are lacking.
"You have to do the very best with what you have," she says. "I hope we are learning to do that."
Getting the Word Out
A number of factors contribute to Mali's high rate of maternal mortality: the lack of sanitary conditions and qualified personnel, particularly in remote areas; the prevalence of early marriage and the dangers for teenage brides whose bodies are not ready for childbirth; the lack of proper family planning, with very little use of contraception and little effort to space births; the continuing practice of female genital mutilation (FGM), with associated risks of infection; the high rates of female illiteracy and the lack of access to potentially life-saving information.
Malian women's organizations, backed by PSI and other international partners, have taken a high profile role, running information campaigns on contraception while lobbying religious leaders on the need to speak out against FGM and for acceptance of contraception. But the overall climate remains challenging.
In the long-term, Kallé says, simple communication can make an enormous difference. So she was relieved rather than exasperated to see the lines of women waiting for examination at the Luxembourg hospital.
"It proves the message is getting through," she says. "One of the biggest problems we had here was women's reluctance to seek help or come for a check-up unless there was a real emergency. It's all about getting treatment, not thinking about prevention, leaving everything to the last minute - and that can be extremely dangerous for pregnant women."
In the past, most of Kallé's patients would arrive "when something was clearly wrong", and they were suffering from high fever, vomiting, contractions and other complications. She had to coax them into coming in for check-ups, although she understood the reluctance.
"Acknowledging pregnancy is difficult for women," she says. "They often try to hide it in the first few months. You have to explain that it's a natural thing, not an illness."
There is also the question of basic costs.
"I would fix up appointments with a woman and then find she had not showed up. I would remonstrate with her, but she would explain: 'I hadn't got money for transport, I was worried about the consultation fees, the prescription charges, my husband didn't want me to come.'"
Kallé says it is vital to educate men as well as women about the importance of both pre-natal and post-natal care. But she admits it is often difficult for women to follow advice, such as getting sufficient rest.
"The day-to-day life of a woman here is tough," she says. "You prepare breakfast for the children, you have to get food from the market, you have to get water, prepare the evening meal, and have to respond to your husband's sexual needs."
Kallé warns that women and their partners must watch for signs of stress and hypertension and always seek help when a problem arises. She says health cards, or carnets de suivi, are vital, allowing women to keep track of their condition as their pregnancy progresses.
According to midwife Dianka Doumbouya, about 40 women a month give birth at the Luxembourg hospital. Deaths in labor are rare, as a doctor, a midwife and a minimum of one nurse are typically on hand when a woman gives birth.
This is by no means the norm in Mali. Dr. Alassane Traoré is now based in Bamako, but spent seven years as a gynecologist in Gao, a major provincial centre 600 miles to the northeast. It is an area now under the control of rebel forces.
"The most dangerous thing is women giving birth at home," Traoré says.
He understands the reasons women make this choice: pressure from relatives, particularly from the head of the family; a feeling of security from being close to friends and neighbors; and the cost, inconvenience and real danger associated with visits to medical facilities. But Traoré argues that home births should be outlawed. And he pointed to the dangers of the birth process being entrusted to unqualified traditional birth attendants, or accoucheuses traditionelles.
"With 85 percent of births, everything will be alright," he said. "It's the 15 percent where something goes wrong that worries me."
Regardless of how many babies birth attendants have delivered, they are untrained and unequipped to deal with critical problems, such as postpartum hemorrhage, he says.
"There are so many things to watch out for: the mother may be experiencing severe headaches, or the delivery may be going on much longer than usual, indicating that the baby can't get out. If these problems are not dealt with..." Traoré echoes his colleagues at Luxembourg hospital in pleading for better training for midwives.
Mali's health system is designed as a pyramid structure. At the bottom are community health centres, available at village level, or in districts of towns and cities. They are modestly stocked and staffed but offer a minimal service that can cope with routine problems. More difficult cases should be transferred up to the referral health centres, which in turn send patients on to district hospitals.
But Traoré acknowledges there are major gaps in the referral system, particularly at community centres, where inexperienced staff are often slow to recognize problems.
There are also massive logistical headaches. Despite substantial investment in the principal highways, Mali's road system remains basic. Large parts of the interior are connected by little more than dirt tracks. With few ambulances available, women have to use any means at hand to reach clinics or hospitals: bus, taxi, motorbike or donkey.
Like Kallé at Luxembourg hospital, Traoré says communication is crucial for tackling maternal mortality. That means everything from persuading people to give blood to meeting with religious and community leaders, to running radio programs about childbirth.
"But changing behavior is a long process," Traoré admits. "None of this is for tomorrow."