Shortly after midnight, a soft wailing cry broke through the sweltering Sahelian night.
In a small mud-brick room at Sanam's health clinic, bare except for a small bed, 24-year-old Maimou Issoufou gave birth to her third child - a boy. Peaceful and reflective, the baby lay in the arms of the midwife who had attended the birth. According to local customs, he would not receive his name for a week, when a baptism ceremony would celebrate his entry into the world.
After making sure that all was well with the fragile new life, the midwife turned to hand the baby boy to his mother. And then she realized something was terribly wrong with Maimou.
The young mother had turned over on her side, lapsing in and out of unconsciousness, and was obviously in severe pain and distress. What the midwife hadn't realized until then was there was another baby waiting to be born.
But wracked by chronic malaria and weakened by hunger, Maimou was too exhausted to deliver the twin. For hours the midwife and Sanam's local nurse, Boubacar Harouna, courageously tried everything they could think of to help her deliver her baby. Her contractions weren't strong enough. She went to sleep.
As day broke over the edge of the Sahara, the midwife and doctor decided that Maimou couldn't stay in Sanam.
Sanam's tiny clinic is one of nearly 120 health facilities that Mercy Corps is supporting in Niger, the lowest-ranked country on the United Nations' Human Development Index. The people of Niger, already mired in poverty, continue to suffer from chronic undernutrition: more than ten percent of the country's 12 million people are "acutely malnourished."
For nearly two years, Mercy Corps has been helping village-level health centers identify and treat malnourished children, distribute food supplements and provide basic medical treatment. More than 40,000 children have been treated and their families have also benefited from our programs.
But, despite the determination and energy of Niger's doctors and midwives, village clinics are no match for more severe health problems. Unfortunately, Maimou's worsening condition was too much for Sanam's staff to handle.
I was just waking up from an uneasy outdoor sleep in the health clinic's courtyard when an older woman wearing a colorful head wrap and heart-shaped earrings approached me. She gently held a newborn baby in her arms and was speaking Hausa in an urgent, yet calm manner.
Since I don't speak Hausa, the predominant language of this part of Niger, I waved over one of my Mercy Corps colleagues - a health officer - to come and translate her words.
"She says that a young mother in the clinic is fighting for survival," he explained. "Her second baby is trapped inside of her and she's too exhausted to deliver."
"How can we help her?" I asked.
My colleague had a brief but intense dialogue with the midwife and then turned anxiously to me. The photographer who I was traveling with, Thatcher Cook, joined the conversation.
"The mother needs to be transported to the regional hospital in Filingué," the health officer said, alluding to the regional capital, a city more than four hours away down a potholed, two-track road. "They can't do anything else for her here."
"Can we take her in our car?" Thatcher immediately asked.
"No," the health officer answered. "She needs to lie down the whole way. There's an ambulance here, but the clinic has no money for gasoline.
"The doctor was wondering," he continued cautiously and a bit uncomfortably, "if you would be able to pay for the gasoline to transport her to Filingué."
I exchanged a quick look with Thatcher; there was no time to mull over an answer.
"How much would it be to get her there and back?" I inquired.
"Gas is scarce here," the health officer responded. "It will cost 20,000 francs [about $40] to fill up the ambulance."
Thatcher and I reached for our wallets, took out some bills, counted them and handed the cash to the midwife, who smiled wearily and nodded her head in thanks. Then she said something to the health officer.
"She would like you to come and see the mother," he translated. "It means a lot that you're doing this for the family."
Somewhat reluctantly, we walked a short distance to the room where Maimou was staying. I felt embarrassed about any recognition for what we were doing; I didn't want to intrude during this family's time of sadness and doubt. I didn't want the young mother's suffering to become a spectacle in any way. At the same time, though, I wanted to be polite and acknowledge our nascent connection with a visit.
We entered the room slowly, and solemnly greeted the family members who stood around her bed. She lay on her side facing the wall, and her breathing was shallow.
We stood there for several minutes, not sure of what to do or say. At one point, I closed my eyes and said a silent prayer for Maimou's health and that of her unborn child.
I felt a hand on my shoulder. It was the field officer, letting us know that it was time for us to depart for our scheduled field visits. As we quietly shuffled out of the room, I felt woefully inadequate. Sure, we had just provided money for Maimou's transportation to a hospital that might be able to help her. My own humanitarian values, however, nagged at me that just spending money wasn't enough. What else could I have done, though?
I couldn't push that question from my mind as I packed my bags and got ready for the long day ahead.
A half-hour later, after we had climbed into the car and turned onto the road that would take us out of Sanam, the wail of an ambulance sounded high above the stillness of Sanam. It may have been wishful thinking but, to me, it sounded like hope rather than alarm.
Waiting at the gate
As we traveled to a few village health clinics that day, meeting dozens of young mothers who had brought their underweight children for therapeutic feedings - the central mission of our work in this region of Niger - I couldn't help but wonder what was happening with Maimou and her unborn child.
We'd soon find out. When our scheduled meetings were complete, our team drove the long, difficult road from Sanam back to our quarters in Filingué, following the same route the ambulance had taken just hours before. I cringed every time we hit a deep pothole or swerved off the road to avoid one.
We arrived in Filingué at dusk. There were two men waiting for us at the gate to the Mercy Corps office. They had news about Maimou.
As we pulled into the Mercy Corps office at dusk, two men - relatives of Maimou that we didn't recognize from earlier that day in Sanam - were waiting for us outside. They told us that the ambulance had brought Maimou to the regional hospital that afternoon, but that the medical staff there had been unable to deliver the baby; her contractions were still not strong enough to give birth. The doctors at the hospital also didn't have the facilities or equipment to perform an emergency caesarean section.
The only place that could help Maimou, they told us, was the main hospital in Niger's capital, Niamey - three hours away. They told us that they'd heard we had helped earlier with gasoline for the ambulance. They needed our help again.
Unlike our first decision, this time I hesitated. I didn't know the men. I also didn't want to compromise Mercy Corps' work in any way by handing out cash and giving any reason for others to expect the same in the future. It was an awkward dilemma; how does one balance long-term considerations with life-and-death immediacy? My conscience screamed that there was an overwhelming moral - and human - obligation to help a young mother clinging to life.
Thatcher suggested that we call the regional hospital to check on Maimou. The doctor we spoke with indicated that while Maimou was still in danger, her condition was stable and the unborn baby was still alive. He thought she was strong enough to make it to Niamey.
I felt a twinge of guilt for deliberating as Thatcher and I counted out 18,000 francs [about $36] and handed it to Maimou's two relatives. They shook our hands, thanked us and hurried off down the dusty dirt road.
That night, after a quiet dinner with my colleagues, I once again had a stifling, restless sleep under the broad, starry sky. I wondered what my colleagues thought of what we had done. I second-guessed my distrust and reluctance in giving money the second time. Most of all, though, I just hoped that what we'd done would help to save two lives that night.
The uneasiness of silence
Early the next morning, we again followed Maimou's path, driving to Niamey to prepare for our next-day departure to Uganda. Once we arrived, we were eager to hear news of Maimou and, hopefully, her new child.
Despite the best efforts of several Mercy Corps staff, no one could find out anything about her - or even ascertain where she was. Thatcher and I deliberated whether or not to go looking for her, but in the end decided that it was better to let the family have their time and space. We had done everything we could.
We left Niger without news of Maimou. It wasn't until two days later, when I checked e-mail in the lobby of my Kampala hotel, that I learned her fate.
I opened the message from Christy Collins, Mercy Corps' Country Director in Niger with a sinking feeling in my heart.
"I'm sorry to tell you that the woman you helped in Sanam died. I do not know the circumstances - if it was in transit, or after delivery of the second twin (who also did not survive).
"I've a notion to look up the first twin to see if he is doing all right (probably very vulnerable). I'm sure your and Thatcher's care in responding to the mother's needs is appreciated."
In Kampala I bowed my head, prayed and quietly mourned the heart-rending passing of two young lives.
Back in Sanam's health clinic, health staff, with Mercy Corps assistance, was weighing babies, distributing emergency food and helping mothers learn how to keep their young children healthy. Nearby, a long, mournful wail arose from a family that had lost a daughter, a wife, a sister - and her child.