Hariane hadn't heard the expression "Life is about the journey, not the destination." To this modest young mother living in rural Zambia, her life, and that of her newborn daughter, was very much about the destination. "When I was due for delivery, I came to the clinic but there were no nurses or staff there," Hariane says. We're sitting in a one-bed labor ward in Zambia's Southern Province, just out of the earshot of a dozen mothers and newborns waiting for immunizations. "As I walked back to the village, the baby's head was already coming out. I didn't know what to do." So Hariane gave birth to her daughter, Violet, under a tree next to a narrow dirt road about an hour's walk from her village. In other words, her childbirth happened on the journey because her destination was out of reach.
When it comes to giving birth in Zambia, the journey to an adequate destination is often a long one. The country is roughly the size of France, but has a quarter of the population and less than one percent of the paved roads. Most women live at least a three-mile walk from a facility that offers any kind of childbirth care; the vast majority are more than 15 miles from basic emergency services if they suffer a complication like excessive bleeding or high blood pressure.
Fortunately, Hariane delivered safely. Her friend walked to their village and phoned a traditional birth attendant nearby, who met Hariane on the road just in time for her to give birth. "It was not a good experience," she says. "I had to use a blanket to cover myself and the whole time I was worried an animal would come and take my baby. But it was too late to worry—I was already in the middle of labor."
No one would ever classify Hariane as lucky, but compared to the thousands of Zambian women who die or nearly die during childbirth every year, she admitted she felt that way. Like many countries in its region, Zambia sees far too many of its women suffer maternal deaths: Its maternal mortality rate is 30 times higher than France and 10 times higher than the United States. Women in rural communities are twice as likely to die than those in urban areas, which have far more health providers and facilities.
While global health experts attribute maternal deaths to the "three delays"—delays in seeking, getting to, and ultimately receiving childbirth care—Zambia is particularly prone to challenges related to distance and travel.
Pregnant women rarely have access to a car or an ambulance (there's just one ambulance for Hariane's whole district, and it's out of use), so they'll often walk long distances for care. Others rely on community members to carry them or transport them on the back of a bicycle. During rainy season, when the roads are typically washed away, more women give birth at home, miles away from help.
With this reality in mind, Zambia has taken steps to mitigate the challenges pregnant women face in getting to a hospital or clinic. Through an initiative called Saving Mothers, Giving Life—funded in large part by the US government—the Zambian Ministry of Health and local partners are training community health workers to link women to care, creating more transportation options in remote villages and constructing small residences near hospitals where women can stay before they give birth.
"One approach we're hopeful about is maternity waiting homes," said Jelita Chinyonga, the provincial medical officer for Southern Province. "The closer women are to a health facility with the staff, medicines, supplies, and equipment to care for them, the lower their risk of suffering a life-threatening emergency that goes untreated."
So far, these efforts to connect rural women to care have helped Saving Mothers produce impressive results: More women are delivering in hospitals and clinics, and as a result, maternal deaths have gone down. In fact, mortality rates in target facilities have declined by more than half since the initiative started.
Still, though, the distance challenge persists. Many waiting homes are in poor condition—the one near Hariane's clinic has a half-open roof and nowhere to sleep—dissuading women from using them. Likewise, rural transport remains unreliable at best, particularly since the rains started earlier this month. This places added importance on having a "birth plan."
"We're trying to sensitize women to these issues and help prepare them to deliver," says Beaut, a health worker in Hariane's district. "Now more [women] are making it to the clinic in time."
Although Hariane wasn't one of them, she feels confident in the health system's ability to care for her in the future. "Even after that nasty experience, I will still come to the facility. Delivering here is more helpful than at home."
To most people in the West, dying during childbirth because healthcare is out of reach is a foreign concept. But to Hariane and the millions of expecting mothers like her, it's a looming reality. To these young women, life may be about the journey, but giving life is increasingly about the destination.