Kenyan midwife Zeena Abdalla Ramadhan - or Mama Zeena as she's known - has many horror stories to tell about the dangers of giving birth in poor, conflict-torn countries.

In Liberia, for example, where she coordinates training at a midwifery school backed by the government and British medical aid agency Merlin, a woman whose baby dies during delivery sometimes suffers the indignity of having her child removed from her uterus by a traditional healer using a spear.

"This is done without considering the damage to the woman's organs," says Mama Zeena. "And if the woman survives, she will be outcast because she may have problems controlling her urine and stools."

Following an exodus of medical staff precipitated by Liberia's 14-year civil war, the country has just 297 certified midwives for the entire country, and the eighth highest maternal mortality rate in the world. Such shocking statistics are typical of poor countries in the throes of, or recently emerged from, conflict.

According to a report released by Merlin ahead of the International Day of the Midwife (on May 5), 13 of the 15 countries with the highest rates of maternal death have suffered violent conflict in the last 10 years. These fragile states - including Sierra Leone, Afghanistan, Democratic Republic of Congo and Somalia - have very little money to build health systems and train healthcare workers, leaving most mothers without access to skilled care.

The U.N. Children's Fund estimates there's an average of less than one health worker per 1,000 people in fragile states, and one in four women delivers her child alone or with a family member. Half of women who die in childbirth each year live in these countries, yet Merlin says three-quarters could be saved with access to a midwife or emergency obstetric care.

Mama Zeena agrees. She decided to train as a midwife after losing a baby of her own. "I realised how important this kind of care is," she explains. "The story of women in crises is that no one attends to them when they are pregnant because there are no health workers. Most lose their lives unnecessarily, and their deaths could be prevented."

The softly spoken midwife has spent her career trying to improve conditions for mothers in tough environments like Chad and Kenya's Kakuma refugee camp - a calling that's led to her being hijacked and kidnapped. But amid all the difficulties, her work has saved lives.

At Kakuma, a huge camp in northwestern Kenya sheltering tens of thousands of refugees mainly from Sudan, Somalia and Ethiopia, Mama Zeena and a team of trained birth attendants would deliver as many as a dozen babies a day - by candle light when working at night and without any medical equipment. They did their best to diagnose any problems by finding out each woman's story and "touching and feeling".

"In six months, there were no maternal deaths, and a World Health Organisation representative visited the camp to see the secret behind our success," she says proudly.

But if, as Mama Zeena's experience proves, it's possible to make a difference without sophisticated facilities, drugs and equipment, why do 536,000 mothers continue to die each year?

MORE AND BETTER AID

Merlin says a large part of the problem lies with the quantity and quality of aid. In 2007, fragile states received less than 40 percent of total official development assistance given by rich governments.

And within the health sector, donors have preferred to fund programmes that tackle particular diseases rather then investing in national and local healthcare systems and their staff.

In 2006, Liberia was awarded a grant of $27 million by the Global Fund to Fight AIDS, Tuberculosis and Malaria - dwarfing its national health budget of $5 million - but the money was never spent because the health system and its workers didn't have the capacity to absorb it. Merlin points out that a small fraction - $840,000 - could have funded the extra 1,200 midwives the country needs.

The medical charity warns that, without urgent investment in midwives, the Millennium Development Goal (MDG) of reducing the world's maternal mortality rate by three quarters by 2015 and providing universal access to reproductive health will not be reached.

"We cannot hope to meet global maternal health goals if we don't reallocate our focus, and funding, to countries in crisis," says Merlin Chief Executive Carolyn Miller. The agency is calling on international donors and national governments to invest £2.4 billion ($3.6 billion) - or £2.71 ($4) per person per year - in improving health in fragile states.

This money, it argues, could double the health workforce, including rapid expansion of midwife training to ensure there is one skilled birth attendant for every 175 women. It would also provide the medical supplies and drugs needed, as well as incentives for staff to carry on working in under-served and rural areas.

"Maternal deaths lead to global productivity losses of $7.5 billion each year," says Miller. "Reallocating aid to fragile states will not only save hundreds of thousands of lives, it makes clear financial sense."

The midwife school Merlin has set up with Liberia's ministry of health and social welfare is a small step towards reducing the country's high mortality rate, which shot up by 74 percent since the war ended in 2003, and now stands at 1,200 deaths per 100,000 women.

The first intake of 45 students began their two-year training in December, and once they graduate, they'll work across six areas in the south of the country.

The Liberia initiative is based on a model that has been trialled in Afghanistan, where the government has joined forces with non-governmental organisations (NGOs) to train community midwives. The number of skilled birth attendants there has risen from 467 in 2003 to 2,200 in 2008, enabling them to deliver babies for nearly a fifth of women, compared with just six percent in 2002. But up to 8,000 attendants are needed to provide an adequate level of care.

Merlin supports two midwife schools in two remote provinces, which have trained 89 midwives who are now committed to working in their communities for at least three years.

Linda Doull, Merlin's director of health and policy, admits it's not been easy. First, the agency had to spend some months persuading male leaders and other men of the value of the training. And then there's the tricky issue of working in conflict situations like Afghanistan where partnerships with governments can lead to security risks for both agency staff and local participants.

But Doull says donors have finally started to grasp the importance of backing longer-term health programmes in fragile states which can be sustained by national or local authorities once aid groups leave.

"The delivery of essential services can be seen as a promoter of stability," she says. "In difficult environments where there are governance issues, it may be more effective to deliver a service through NGOs. The challenge then is to get it going, and as the capacity of the ministry (of health) improves, to hand it over."

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