Birth is a Dream

Women's Voices Now
The WVoice
Published in
7 min readAug 20, 2018


Maternal mortality and reproductive health are rarely-discussed social issues. Yet, women — mothers — die every day in a silent war. I have seen this with my own eyes.

BY: Paolo Patruno

“There isn’t any pregnancy that could be the same as the other, but is only God who is upon us.
It’s only God who helps us to deliver.” — Elisabeth, Kabale, Uganda, 2012.

Maternal mortality and reproductive health are rarely-discussed social issues. Yet, women — mothers — die every day in a silent war. I have seen this with my own eyes.

To draw attention to the hush placed over this overlooked women’s rights issue, throughout the last decade I traveled throughout Africa documenting social challenges relating to women and birth. In 2011, I started a photography project called “BIRTH IS A DREAM,” which aims to document and raise awareness about the maternal mortality crisis in Sub-Saharan Africa. I’ve already shot across Cameroon, Democratic Republic of Congo (DRC), Ethiopia, Malawi, Morocco, Mozambique, Uganda, and Zimbabwe.

Every day, about 800 women die due to complications of pregnancy and childbirth. Almost 60 percent of maternal deaths occur in Sub-Saharan Africa, since adequate health services are often unavailable or inaccessible, and because many women still give birth at home without skilled providers.

A mother’s death is a human tragedy — no matter where it occurs — that traumatically affects families and communities. In the case of women in Africa, the females are the ones responsible for providing food for the family and carrying out other duties of the home. This is why a mother’s death makes it harder for the family to obtain the basic necessities of life left in her wake.

In 2011, I started my project in Malawi. There I met an English midwife, who practiced for nearly 14 years in Spain before relocating to Africa in order to work as a clinical midwife in the labor ward of the Bwaila Hospital in the capital, Lilongwe. She introduced and explained to me maternal health challenges in Africa.

A nurse using a razor blade to remove sutures from the belly of a woman who delivered by C-section.
Kabale, Uganda, 2012.

Maternal health and maternal mortality are very complex matters. That is why “BIRTH IS A DREAM” is a long-term project. I realized it would be impossible to document and tell this story just through a single work. I am trying to use and explore many different angles to show and raise awareness about all the aspects that can and do influence and affect maternal health.

Many expectant mothers choose to deliver at home with the help of traditional birth attendants.
Concerned about rough treatment in hospitals, they turn to family for comfort despite the risks.
Kabale Hospital, Kabale, Uganda, 2012.

I had the opportunity to visit hospitals and health centers in rural areas, where I looked at the facilities’ conditions as well as witnessed the nurses’ and midwives’ daily heroic efforts to save mothers and children’s lives. I visited women in rural villages documenting home births. I documented child marriages and cases of early pregnancies — of girls becoming women too early — missing their childhood and adolescent years. In fact, Africa has the world’s highest rate of adolescent pregnancy, a factor that affects the health, education, and earning potential of millions of African girls. I also visited the female section of a Cameroonian prison, to tell the story of maternal health behind the bars. All of these experiences showed me how complex pregnancy and childbirth are in Sub-Saharan Africa.

I can’t really forget that day, a lady from the social service came in and said firmly, ‘Madame today we have come to take the baby.’ It was the most difficult. Even more difficult than entering prison being pregnant. To be separated from your child when you are still alive. It was as if I was dead and the baby had no mother.” — Cecile Douala, Cameroon, 2014
Bizunesh has been a midwife for almost 30 years, a life dedicated to supporting women through
the pains of labor. Jinka, Ethiopia, 2013.
Christine, 17 years old, already married and lost her first child by the age of 16.
In the photo she is in her seventh month of pregnancy. Bakumba, Cameroon, 2014.

Lack of well-equipped health facilities and skilled professionals are only the superficial and more obvious obstacles to maternal health. Cultural and traditional behaviors also affect maternal health and mortality. In the name of tradition, the decision to have home births in villages rather than at health facilities are made, sometimes, in disregard of the well being of the expecting mother. If it is acceptable for a village’s women to give birth in a health facility, due to the fact that hospitals are very far for most of the populations living in rural areas, women may need to find a place to stay near to the hospital two to three weeks prior to giving birth. These women are thus faced with the difficult decision of leaving their families for a long period of time, or delivering in the village so as to avoid a prolonged absence that may jeopardize the health and wellbeing of her other children.

The labor ward is just a room where women deliver one next to the other,
without even a screen for a bit of privacy. Kabale, Uganda, 2012.

Due to the more intimate and familiar atmosphere that the home provides, often women decide, and even prefer, home delivery with a traditional birth aid (TBA) to giving birth in a health facility. In hospitals there is almost no privacy, with women delivering one next to the other, sometimes totally naked, with many male medical staff in the room. You might hear nurses or midwives shouting at women to stop crying too loud. Home birth is totally different, providing a very familiar and intimate atmosphere.

Young new midwives being trained at Arba Minch College.
They will eventually join the cadre of skilled healthcare workers in the community.
Traditional Birth Attendants’ boarding home, Arba Minch, Ethiopia, 2013.

In Malawi, the words for pregnancy in the local language — pakati and matenda — translate into: “between life and death” and “sick.” This always makes me remember an interaction that I had with a woman while documenting home birth in Uganda. There I met a woman, Elisabeth, who told me: “There isn’t any pregnancy that could be the same as the other, but is only God who is upon us. It’s only God who helps us to deliver.”

I think these words best explain how most African women go through pregnancy and giving birth, always aware of the great possibility that delivery may be treacherous, possibly bringing them to the brink of death, or actually crossing over.


In 2015, after more than four years of work in Africa, I decided to expand my project to document and to raise awareness on maternal health matters in developed/industrialized countries. This is why I traveled to Orlando, Florida, to produce my first documentary film, “The AMERICAN dream.”

“I want the natural birth because I feel that can bring me closer to my baby.” — Miracle
Orlando, Florida, 2015.

The United States has the highest maternal mortality rate of any industrialized country in the world. And while other countries, both developed and developing, have reduced their maternal mortality ratios, for the past 25 years the United States is experiencing an unprecedented rise in the numbers of women lost during pregnancy, birth, or postpartum.

In an effort to make a connection with my work in Africa, I decided to start documenting stories from African-American women in the United States. This population of American women is nearly four times more likely to die of pregnancy-related complications than white American women.

“I feel different races have different options.” — Joanne

Women of color in the United States are less likely to go into pregnancy in good health because of a lack of access to primary health care services; they are also less likely to have access to adequate maternal health care services. In fact, the maternal death rate is 42.8 per 100,000 live births for black women, compared with 12.5 for white women, and 17.3 rate for women of all other races.

In the “The AMERICAN dream,” nine African-American women tell their stories. In doing so, they share their hopes, their fears, and their conception of the American dream as it relates to maternal health in the United States.

Documenting maternal health in Africa and in Florida is probably the most challenging work I could have chosen for myself as a male photographer. I’m a man, a white man, a white man with a camera trying to document the most intimate and private moments in a woman’s life. But as a social photographer I use my camera with the intention of giving respect and dignity to my subjects.

I invite you to join me in raising the voices of these women by bearing witness to their stories, too:


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Women's Voices Now is a non-profit organization that uses the medium of film to advocate for global women's rights. We move audiences from empathy to action.