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MASISI, Democratic Republic of Congo — Mariam Rizik crossed a grassy clearing, walking toward the clinic for her five-month prenatal appointment. Once there, her best green wax print outfit blended into the rainbow of dresses worn by the women who gathered, bellies bulging, for their checkups.
Rizik lives in Lukweti, a village in the Congo rain forest, the second-largest tropical forest in the world. Lukweti is also one of the centers of the diffuse, protracted war in eastern Congo. Four of the mountains that ring the clinic were claimed at different points by one of the armed groups, making Rizik’s previous five pregnancies terrifying.
The clinic walls were water stained, the door to the maternity ward broken and patched with cardboard. The pharmacy consisted of two shelves of folic acid and malaria medicine. This, the only functional health center serving the 6,514 people in this administrative zone, suffered from more than neglect; the Congolese army had pillaged the government-run clinic in March.
The conflict, which has afflicted eastern Congo since the 1990s, has severely weakened the health system, with clinics ransacked, medical workers evacuated and others refusing to work in hot zones. Pregnant women are one of the vulnerable groups swept up in the tumult, and Congo has one of the highest maternal death rates in the world, with 846 per 100,000 live births. (In the U.S., there are 18.5 per 100,000.)
The clashes between armed groups often take place in remote, rural villages like Lukweti, receiving attention from the international media only when they migrate into larger towns or when massacres add dozens to the death toll. Otherwise, the toll climbs quietly and steadily as people die in smaller clashes and from secondary causes such as maternal mortality, malnutrition and treatable diseases. An estimated 5.4 million people have died since 1998 in the conflict; most were civilians.
Overall the DRC has about half the necessary health workforce to effectively manage its birthrate, according to the U.N. Population Fund. And while Congo nearly tripled its health budget from 2001 to 2011, it still allocated only 10.8 percent of government funds to health, below the 15 percent agreed to under the Abuja Declaration in 2001. “The budget for the health sector is insufficient, it augments the suffering,” said Jonas Tshiombela Kabiena, founder of the New Congolese Civil Society in Kinshasa.
When women in the DRC suffer complications in labor, they rarely reach decent services. Health centers here are few and far between; those that still stand often lack supplies or staff. “There’s not a realistic presence of state programs at the provincial level,” said Immaculée Birhaheka, president of the group Promotion and Support of Women’s Initiatives.
Expanding state services is one of the goals of the stabilization programs of the Congolese government and the United Nations, which has its largest peacekeeping force in the DRC. But while the country is often referred to as postconflict by policymakers, the clashes in Lukweti show the fighting is far from over. “The stabilization is in post-conflict zones. Can we have a beginning of life again? Can we put in a hospital, a school?” said Chantal Regenera Kambibi, head of the Program of Stabilization and Reconstruction of Armed Conflict Zones in North Kivu province. But she pointed to the challenges of “restoring state authority and justice” in the midst of “precarious peace.”
To fill the gaps in government services, nongovernmental organizations, or NGOs, have proliferated in the Kivus, the two eastern provinces central to the conflict. Goma, the capital of North Kivu, is littered with signs advertising NGO activities; four-wheel drive vehicles in every hue with flags and stencils of international charities rumble across the potholed streets. But projects tend to be short term and constantly change based on the priorities of donors, serving only as Band-Aids for the gaping holes in the health system.
Rizik visited the clinic that July day to meet with doctors, midwives and nurses from Doctors Without Borders — MSF by its French acronym. Once a week, a convoy of workers from the medical NGO makes the four-hour journey to the clinic from their base in the central town of Masisi.
They run four mobile health clinics in the area, setting out on motorcycles to hot spots around Masisi where the health system has been devastated by conflict. In some areas health workers have fled the violence, and clinics are often gutted by armed groups as the one in Lukweti was.
MSF chooses its locations based on need. The organization is the first to admit that that leaves the second-worst places abandoned. “You have to weigh between dark and dark,” said Bertrand Perrochet, country director of MSF Belgium. The mobile clinic is temporary; the organization relocates as the situation on the ground evolves.
Lukweti was squarely in the worst category. The village had been the stronghold of the Alliance of Patriots for a Sovereign and Free Congo rebel group. Run by the Bible-thumping “General” Janvier Buingo Karairi, APCLS self-identifies as a protective force for the Hunde community, of which Rizik is a part. Janvier is notorious for racist and xenophobic commentary, often lumping Congolese Tutsis with Rwandans, calling them all foreigners who should leave Congo. Lukweti is 74 miles from the Rwandan border, but the conflict here has been shaped by the Rwandan genocide 20 years ago, when thousands fled across the border, adding that country’s social fissures to those already extant in Congo.
On her walk to the clinic Rizik skirted abandoned homes, roofless, cracked and growing weeds from the mud walls. She averted her eyes from Congolese army soldiers drunk on banana liquor, loitering in front of homes they had commandeered when they chased out the APCLS rebels. The army’s springtime sweep was so brutal that the U.N. sent in a brigade of Indian peacekeepers, part of the Force Intervention Brigade, the world’s first peacekeeping mission with a mandate to use force.
“When they first came they looked at us like animals,” Rizik said of the Congolese soldiers. While Rizik did not personally attest to rape, Andre Bakenga Tshimanga, assistant field coordinator for MSF said. “There was so much sexual violence and abuse of the population by the [Congolese army]. Now it’s a little better, just isolated cases.” Abortion is illegal in DRC and while data is scarce, there are numerous testimonies of women who are socially ostracized after giving birth to a child conceived through assault.
The army also targeted men, according to Tshimanga, conflating all the villagers with the rebels. “There are many families without husbands here now. Some husbands have died, some have fled,” Rizik said.
In the face of all this, Rizik had spent her early pregnant months on the run with her husband and five children. She was haunted by memories of her first childbirth nine years before: “Enemies were coming from one side. We had to cross the river.” That time she went through labor in the forest, helped only by a fellow displaced villager, a traditional birth attendant, who knew birth techniques from assisting in countless births, though she had no formal training.
After the UN came in and the fighting quieted, the family returned to Lukweti, moving into a home vacated by a fellow denizen who was unconvinced the village was safe or back to normal. Rizik was relieved to be back in a house, and her husband quickly tried to resume farming, but most of their property had been stolen. Her belongings now were limited to a basin she kept filled with a few household items, and two outfits, the fresher of which was the green wax print she donned to visit the clinic.
Like Rizik, many of the expectant mothers waiting to see the midwife had recently returned to the village after months camped out in the bush. Some had walked miles to get there. “When anyone comes we have to welcome them because next time we might be the victims,” Rizik said, “We are always running.” Sometimes they run for days or weeks. Other times her community camps out for months waiting for the violence to die down.
Displacement is itself a major cause of the high levels of maternal mortality. Giving birth without proper tools can lead to deadly infections; malaria is endemic in North Kivu and in pregnant women can cause anemia or a stillbirth. Many women bleed out with postpartum hemorrhages, and a high number of pregnancies can strain women’s nutritional reserves, leaving them vulnerable to complications. Globally, 15 percent of women experience complications during delivery, almost all of which are treatable if the health infrastructure is in place. But in eastern Congo complications are often left unaddressed and women die.
The MSF midwife was formally schooled. She listened to Rizik’s fetal heartbeat, checked blood pressure, distributed prenatal vitamins and screened for danger signs and complications.
When the midwife encounters women at high risk for complications, she recommends that they go to the main hospital in Masisi Center and stay in a village d’acceuil, a pregnancy lodge of sorts where women live communally for the weeks leading up to delivery. Then they give birth at the hospital, the best in the area, with access to surgery if needed. The facility is owned by the government, but MSF has been based there since 2007, funding additional staff and keeping supplies stocked.
“If you have to go to Masisi, to the village d’acceuil, that means your pregnancy is complicated, so you need to go there,” Anastasie Nyirabari, a health promoter with MSF, explained to the gathered women. “You need to stop the incorrect thinking that if you go to Masisi you will die. It’s just to help you.”
It can be hard for women to negotiate leaving their children behind. But it’s much better than trying to deal with a complicated delivery in the village. “We have to say, ‘Imagine if you have the delivery at home and die. It would be 10 times worse,’” said Steven Van Den Broucke, then–medical director of MSF in Masisi.
Binwa Mongolare was among roughly 60 women at the village d’acceuil in Masisi. She was in the last weeks of her 10th pregnancy. Eight of her children were living; she had lost one at 3 months old. She was suffering from malaria and low blood pressure, so staff from a UNICEF program she had visited near her village in Walikale, a neighboring territory, convinced her to go to the hospital.
At the Masisi hospital, 40 percent of births end in Cesareans and one or two women die each month, according to Van Den Broucke. But the high rates reflect the severity of cases referred there. Mongolare worried more about her kids at home under the care of her husband and female relatives — with no cell network in her village, she couldn’t even speak to them on the phone — than herself. “Here we are just getting help. We are just women here, together,” she said. “Men are the source of the problem, women don’t go fight. We don’t go make war.”
Mongolare said she had gone to a clinic for several of her earlier births, but two had happened alone, while she was on the run. “The births were fine,” she said. “There was fighting. What else could I do? That was the only option.”
While 90 percent of women in North Kivu give birth in medical facilities, in Lukweti that figure is less than 25 percent. On the six days each week that MSF personnel are not in the village, Augustin Kamundu Muhima, the nurse on call, tries to handle deliveries and other health emergencies. But he is handicapped by the lack of staff and equipment. There is no doctor or midwife, and while MSF draws a crowd of patients overflowing into the grass clearing in front of the clinic, carrying umbrellas and draping shawls over their faces to shield the relentless sun, the rest of the week most stay away. The building serves mostly as a referral center, and a severely handicapped one at that.
In the clearing, a post stands in the ground with a ledge carved at the top to prop up a cell phone. The village is so remote and the network so spotty that locals say this is the one place where calls can be made. When there are emergencies, Muhima drafts a text to MSF requesting an ambulance, hits send and hopes the network passes along the message.
Even if the communication gets through, which is rare, MSF has a policy of only driving in the daytime, and its workers cannot pass when there are active conflicts on the road.
Not long ago, one woman in Lukweti had a ruptured uterus, but a firefight kept the ambulance grounded at the referral center in Nyabiondo. “We knew she would die in eight hours and we couldn’t get there,” recalled MSF doctor Adolphe Batundi.
The midwife told Rizik that her pregnancy was progressing fine, but she still had four months to go and everything could change — clashes could reignite or MSF could move its mobile clinic to another village with fresh needs. If there is an unexpected complication during delivery, evacuation is a gamble — part of why maternal death rates are so high.
Congolese activists bemoan the status quo here. Annie Matundu-Mbambi, chair of the DRC office of the nonprofit Women’s International League for Peace and Freedom, remembered attending a global women’s health conference. “I was scandalized when they spoke of DRC. It was all bad. DRC had no stats, no health structures,” she said. “I was so embarrassed that I turned my badge around.”
The war has also undermined any accountability for, or accounting of, the deaths. Those who die in childbirth are part of the ever-mounting tally — based mostly on estimates — of secondary victims of the war.
Muhima said he had seen no maternal deaths at the clinic in his four years working there. When pressed about the uterine-rupture case, he said, “The mother left the center living. How would I count that as my maternal death? She died at home.
“There were shots around the clinic,” he said, “so she left.”
Allyn Gaestel and Allison Shelley reported from the Democratic Republic of Congo with support from the International Women's Media Foundation.