By DAVID LINDSAY/ Global Health Frontline News

Bangui, Central African Republic

The Central African Republic (CAR) is a country in almost constant crisis.

Decades of political instability, military conflict and ongoing skirmishes with rebels have rendered it one of the world’s poorest and least developed nations.

All this has left the CAR’s health sector in tatters.

Facilities are poor, there aren’t enough trained staff, and even for them, wages often don’t come on time, sapping morale and motivation.

The result is that there are many deaths that could have been avoided. Average life expectancy here is just 47 years.

One of the most vulnerable groups is pregnant women.

Therese Zeba, the UN Population Fund’s Country Representative in Bangui, says far too many mothers are dying in childbirth. “It is almost four to five women dying every day in the Central African Republic. This is too much. It is too much.”

One of the reasons for so many maternal deaths in a country with just four-and-a-half million people is that nearly half of all deliveries take place at home without a doctor or trained midwife.

The government is trying to encourage more women to give birth in hospital, but there’s a fee that many people simply can’t afford.

Shiphra Perriere, a new mother at the age of 17, did give birth to her son Japhet in hospital, but only just. “When the contractions started I had to endure the pain for three days as we did not have money to go to the hospital.”

While Shiphra struggled at home, her mother went from house to house, begging relatives and friends for contributions. “In the meantime,” says Shiphra, “I was praying to god to give me the strength to continue to endure it until my mother collected the required amount of money.”

Once the money was in hand, Shiphra was rushed to the public hospital in the capital, Bangui, where luckily she gave birth without complications.

But even though there are rudimentary facilities here, Hortense Gongaye, head of the national midwives association says they need much more. “We have hemorrhages, and we don’t have a blood bank nearby; and having to leave the local hospital to go all the way to the general hospital is the problem. Here we need a blood collection center nearby to save women who are hemorrhaging.”

Even if they get more staff and equipment, the cost issue remains a major hurdle.

The UN Population Fund is trying to mitigate the problem by providing birth kits with gloves, soap and other items that are needed for a delivery.

But Therese Zeba is frustrated that other costs, no matter how small, are still too much for families to pay. “Women are dying for peanuts, you see, nothing really important.”

Zeba says tragedy can strike simply because a family doesn’t have enough money to make a phone call to the doctor. “It is really unacceptable.”

Henrietta Sounba is another 17-year old who has just given birth to her first child. She’s an orphan whose parents died of what the family calls “a sickness” several years ago. She now lives with her grandparents in a small two-room house.

Her grandfather, Andre Kpamanda, says they had to scrimp and save to get enough to pay for their Henrietta’s pre-natal care at a local health center, plus medication, and the cost of the hospital delivery.

Altogether he says it cost 65,000 Central African Francs, or about $140 US dollars, a huge sum for people here.

“I’m retired,” he says. “It’s costing us a lot of money. With the help of the relatives, and with the help of the little sister, we are trying to collect something to face this problem. It’s quite a challenge. It’s not easy.”

Despite the financial strain, Henrietta did receive care from qualified personnel. But many others aren’t as lucky, either because they can’t afford it or, if they live in remote areas, there simply aren’t enough trained staff and facilities.

This, in a country with only six obstetricians, all of whom are in the capital.

In rural areas, a ‘birth attendant’ with little or no training is often the best option for a woman in labor. But if there are complications, the birth often ends in tragedy.

More trained midwives would help, but many aren’t willing to go because it’s too dangerous and conditions are so poor.

“In the rural areas, we need midwives,” says Nurse Hortense. “But really the problem that we have is the care of the midwives who go into the provinces; the distance traveled and the lack of security are issues.”

The government is well aware of the problems and is attempting to train more doctors and nurses and assign them to rural areas. But they often have to train in other countries with better facilities.

Too many of them never return.

David Lindsay is the Managing Editor of Global Health Frontline News. For more, go to www.ghfn.org