Here's What Giving Birth Looks Like — In Two Very Different Worlds

Photo: Courtesy of Moa Karlberg.
This story was originally published on October 9, 2015.

Around 800 women die of complications related to pregnancy and childbirth each day, the World Health Organization estimates.

Although the overall maternal mortality rate has dropped nearly 50% since 1990, the miracle of life still comes with serious risk in some corners of the globe.

Tanzania is one of those countries. The East African nation reports startlingly high rates of women dying during childbirth. Nearly one-fifth of all deaths among women ages 15 to 49 in Tanzania are related to pregnancy and labor, the WHO estimates. The country's maternal mortality rate of 578 deaths per 100,000 live childbirths is more than two times the global average.

In Sweden, home of what's been rated one of the world's best healthcare systems, the statistics and experiences tell a much more optimistic story. The maternal mortality rate there is one of the world's lowest — just four women per 100,000 childbirths, according to the WHO.

A quick crunching of those numbers suggests that women are more than 100 times more likely to die in childbirth in Tanzania than they are in Sweden.

Moa Karlberg, a Stockholm-based photojournalist, said she wanted to capture those two very different realities of an experience shared by women around the globe. The resulting photo series, titled Hundred Times the Difference, seeks to show both the beauty and pain of labor and the disparate environments in which women give birth.

"During their lifetime, the majority of the world's women give birth to at least one child," she wrote in her project's introduction. "Although everybody goes through the same phases physically, the external conditions are fundamentally different."

Karlberg, who had photographed women in labor in her home country of Sweden for several years, traveled to Tanzania with the help of a scholarship from the International Women's Media Foundation to capture women giving birth there. She chose not to name the subjects or detail their individual stories, instead focusing in her own writing on her overall observations.

"For me, it is the common experience that I want to emphasize," Karlberg told Refinery29.

Karlberg shared her photos with Refinery29, as well as excerpts from the project and her thoughts about what can be done to lower the maternal mortality rate in places like Tanzania. She spoke with us from her home in Sweden.

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Photo: Courtesy of Moa Karlberg.
What drew you to labor and birth as a subject for your photography?
"I have always been drawn to authentic human expressions. Early in my career, I worked as an intern at a local newspaper. At the time, there was a baby boom in Sweden, and a reporter and I were sent to a maternity ward to follow a woman through the whole process of giving birth.

"Being in that small room, sharing such an emotionally intense and crucial moment, made a strong impression on me. It was one of the most real life situations I had ever photographed; I could just go with the flow and capture everything that happened. Everybody in the room focused on the mother and nobody cared about the photographer. During the following years, in my search for authentic expressions, I kept that experience in the back of my head until I could explore it further."

Photo caption: N., Sweden.
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Photo: Courtesy of Moa Karlberg.
How did you first become aware of the issues surrounding maternal mortality rates and disparities in medical facilities and care, particularly when it comes to Tanzania?
"I had always been aware of the fact that disparities exist, but it was not until I began photographing births in Sweden that I started understanding them on a deeper level.

"I realized how skilled the midwives and nurses are here, and what great access they have to all kinds of medical resources. I started comparing maternal mortality rates in different countries, and discovered how extremely different they are.

"Around 20 countries, nearly all of them in sub-Saharan Africa, have rates worse than Tanzania. Still, the situation in Tanzania is really bad; the risk of dying during pregnancy and childbirth is a hundred times higher for a Tanzanian woman than for a Swedish woman.

"The economic growth in Tanzania has contributed to meet several [United Nations] Millennium Development Goals, but the goal addressing maternal health is still way behind."

Photo caption: P., Tanzania.
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Photo: Courtesy of Moa Karlberg.
Your photos are tightly focused on the face and expressions of the women. Why did you choose to frame the photographs this way?
"Like many other themes, inequalities in maternal healthcare have been covered by photojournalists before. It's like people know how these photos will look before they even see them. If you want people to react, I think it's a must to change your visual language and methods once in a while. I find this the biggest challenge photojournalists have today.

"Generally, I like to leave something for the viewers themselves to fill in. For example, these photos show similarities rather than differences. When you look at them and read the text, you fill in the differences yourself."

Photo caption: K., Sweden.
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Photo: Courtesy of Moa Karlberg.
In Sweden, "if something goes wrong, additional staff and specialists show up within minutes. Premature babies end up in a neonatal unit, where they can survive birth as early as week 22," Karlberg wrote in "Hundred Times the Difference."

Photo caption: S., Sweden.
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Photo: Courtesy of Moa Karlberg.
But in Tanzania, "when complications inevitably arise, the lack of equipment and specialized staff becomes obvious," she added.

"There is no special assistance for premature babies. In a corner of the room marked 'planned premature unit' stands an incubator from a Swedish university hospital. It has been out of order for several years," Karlberg wrote.

Photo caption: J., Tanzania.
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Photo: Courtesy of Moa Karlberg.
Giving birth is such a personal, intimate experience. How did you find subjects willing to be documented in this way?
"Giving birth is a personal experience, and at the same time it is such a common event — many women go through the same thing every day in every place of the world. When I asked women in Sweden to photograph their deliveries, half of them said, 'Never!' and the other half said they would like to have professional photos from this special event. They thought they wouldn't mind an extra person in the room.

"In Sweden, I got in touch with all the women ahead of time, and then they called me when it was time to go to the hospital. Since births are impossible to schedule, I missed a whole lot when I happened to be out of town or busy with other things. That's why this project took so long to finish.

"In Tanzania, I could not spend enough time to apply the same method. Instead, I got help from an NGO who got me in to different clinics. Through the help of a very sympathetic translator, I asked women on the spot if they were willing to participate. Most of them said yes."

Photo caption: M., Sweden.
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Photo: Courtesy of Moa Karlberg.
"A nurse puts the stethoscope to the woman's belly, analyzes her contractions and the baby's heartbeat," Karlberg wrote. "No electrical equipment is being used. The woman about to give birth is lying on a bare, rusty bunk, covered in fabrics she brought with her. The water tap is not working, and even if it was, the water would not be drinkable. If she has to urinate, there is a bucket on the floor."

Photo caption: M., Tanzania.
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Photo: Courtesy of Moa Karlberg.
"The curves of the baby's heartbeats and the mother's contractions go up and down on the computer screen, which is connected to electrodes attached to the child's head," Karlberg wrote."The woman about to give birth is lying on the public hospital's white sheets, inhaling nitrous oxide through a hose from the wall."

Photo caption: B., Sweden.
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Photo: Courtesy of Moa Karlberg.
You note that skilled birth attendants and medical equipment are lacking in Tanzania. Did you witness specific scenarios or complications that really hit home the need for those elements?
"I didn't witness those scenarios personally, but I heard many stories from midwives I met. For example, in one clinic they didn't have resources to give anesthesia, so if an acute C-section was needed, they had to send the patient to another clinic far away. Same thing if a blood transfer was needed; they were out of blood supplies.

"In another clinic I visited, there was an incubator donated by a Swedish hospital. It had been out of order for several years and nobody knew how to make it work. They were also lacking infant formula, so if a baby didn't start breastfeeding by itself, there was a big problem."

Photo caption: A., Tanzania.
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Photo: Courtesy of Moa Karlberg.
Another difference you note is the availability of painkillers. In Tanzania, "the women need to save their strength for the pushing in the end," you write. How else did this affect labor? Did the births without painkillers seem more raw, unfiltered?
"I had the feeling Swedish women were acting out more, screaming more, even if they had painkillers. In one Tanzanian clinic I visited, the women were told to keep quiet to save their strength for the pushing in the end.

"This disparity might have something to do with Swedish women having their own rooms. If you would scream that much in a Tanzanian clinic, you would disturb other women in the same room."

Photo caption: A., Sweden.
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Photo: Courtesy of Moa Karlberg.
"The woman has her own room and her own bathroom with a tub. Painkillers are available upon request. A midwife comes in and puts an acupuncture needle in the woman's forehead. A while later, an anesthesiologist gives her spinal anesthesia, which is used in nearly half of all births in Sweden," Karlberg wrote.

Photo caption: F., Sweden.
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Photo: Courtesy of Moa Karlberg.
What aspects or elements of the birthing experience did you find were the same for the women you documented, despite the differences in the environments?
"I was struck by the many similarities when it comes to the physical process of natural births with no complications. The mental states of women seemed to be the same, which is what I want to show in these photos."

Photo caption: C., Sweden.
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Photo: Courtesy of Moa Karlberg.
"There is no family member by her side, but three other women, on similar bunks and in various stages of labor, share the room," Karlberg wrote. "As [the women] moan, the nurses tell them to be quiet. Since there are no painkillers, the women need to save their strength for the pushing in the end."

Photo caption: S., Tanzania.
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Photo: Courtesy of Moa Karlberg.
"Next to her is her husband, stroking her back, talking to her supportively, helping her to focus on her breathing. Low music comes from the speakers. Water and juice is on the table next to the height-adjustable bed," Karlberg wrote.

Photo caption: M., Sweden.
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Photo: Courtesy of Moa Karlberg.
I was interested in the differences in support you described — a husband stroking a woman's back in a private room in Sweden, versus no family in a room shared by multiple women in labor in Tanzania. What sort of impact did those differences have on the birth processes you witnessed?
"The Swedish midwives had more time to focus on each individual mother than the Tanzanian midwives.

"In Tanzania, I saw big differences between small and big clinics, depending on how many patients they had to take care of at the same time. The Swedish conditions seemed more alike in all clinics.

"In Sweden, it is rare to give birth at home, while around 50% of the Tanzanian women do that. That is probably the biggest difference that I didn't witness myself since all my photos are taken in clinics."

Photo caption: E., Tanzania
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Photo: Courtesy of Moa Karlberg.
You write that when it comes to lowering the maternal death rates, "many NGOs and midwives argue that the slow development is not about money but about priorities." What do you think it will take for this issue to be addressed?
"This was something I heard from many professionals I spoke with in Tanzania. The methods needed to improve the situation are well known: Expand the education in emergency obstetric care, and increase the access to clinics all over the country.

"One midwife mentioned that her profession should be more attractive when it comes to salary and working conditions. She also said that men seldom visit delivery wards and therefore don't understand the seriousness of this issue. Most politicians on high levels in Tanzania are men.

"I don't have a clear answer, but I guess a better general awareness and understanding could help put pressure on decision makers."

Photo caption: N., Tanzania.
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Photo: Courtesy of Moa Karlberg.
Why did you choose to produce this project in black and white?
"To put even more focus on the facial expressions and to emphasize the similarities. The details around were very different — for example, all sheets in Sweden are white, while the Tanzanian ones are colorful. The light conditions varied from dim night light to strong daylight."

Photo caption: L., Sweden.
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Photo: Courtesy of Moa Karlberg.
Do you think photographs like these have the ability to help inspire change?
"I certainly hope so. Some photos can have an immediate effect, like the photo of the dead Syrian boy on the beach that got widely spread a few weeks ago.

"Most photo stories impact in a slower, more incremental way. They widen people's concept of the world, and inform and raise awareness that can hopefully lead to actions, both on individual and political levels."

Photo caption: P., Tanzania.

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