WHEN a baby is born in the Maasai village of Sitoka, Kenya, the women in attendance shout the news as far as their voices will travel across the Mara. It is the sound the men have been waiting for, and the cue for the father to serve up the goat he has prepared for slaughter.

But when death rather than life arrives, there is silence.

Stories of birth - even those that are close to tragedy - can be spoken of in the open, under the shade of a tree. Death, on the other hand, is spoken about quietly, hesitantly, at a safe distance from the centre of the village.

"Even talking about it is taboo," Tom Opee explains. He is a community field-officer for the Transmara Rural Development Programme (TRDP), Christian Aid's partner in the region, run by the diocese of Kericho, in the Anglican Church of Kenya. "If you ask for someone who has died, they will say 'I'm sorry, he is gone.' If you ask 'Where?' they will walk away."

It is an act of courage and sacrifice when Nashoro Ndayia, aged 43, agrees to tell us what happened to her daughter Semeyian. Seated on a broken chair under a tree outside her home in the village of Pusangi near by, she looks defeated. A mother of eight children (the youngest is ten, the oldest 31), she is currently looking after six. The youngest, Liaram, playing in front of us, was born to Semeyian two years and five months ago.

"She was in labour for two days," Mrs Ndayia recalls. "By the time she delivered she was exhausted and weak, but the placenta was retained. Around 6 p.m. she tried to deliver the placenta, and was bleeding very much. Around 8 p.m. we looked for a vehicle, and our neighbour had one and took our girl to hospital, but she never made it because of the bleeding." 

SEMEYIAN was 19 years old. Her two other children have been taken in by her sisters. Mrs Ndayia, since the death of her husband in November - he was 67 and had been suffering from TB - has become the family's breadwinner, burning charcoal to sell, milking and grazing the cows, and now looking after a toddler. She looks exhausted, and Liaram looks hungry. The TRDP team are visibly worried.

Although her husband was reluctant to sell a cow to raise the money to transport their daughter to hospital, Mrs Ndayia does not blame him for her death: "Many have delivered at home, and we hoped she would deliver well. He never meant anything by it." She agrees, however, that an ambulance would have made a difference. "Other people demand money. If an ambulance had been here, even if my husband had refused, I would have done it myself."

In Sitoka village, 18 kilometres away, an ambulance, funded by TRDP, is a mobile-phone call away. The women are conscious of their relative good fortune. "A spot of light is being shone on Sitoka," Elizabeth, a 28-year-old mother of four, says. "But it is not broad daylight. Please look for other vulnerable places."

Two months ago, the ambulance came to the rescue of a friend of Noorkitoip Joyce Julius. Her friend was a 34-year-old mother of eight who was suffering her third consecutive miscarriage. "I thought she could bleed to death," Mrs Julius tells us. "We called the ambulance, and she was taken to Kilgoris - she was very weak, but conscious. She lost the baby. But she could have died otherwise." 

AN EMERGENCY journey to Kilgoris is one that Mrs Julius made herself, several years ago, after delivering her third child. Dizzy, and eventually unconscious, she was carried on a blanket by six men for the entire 48-kilometre journey. Like Semeyia Ndayia, she had retained the placenta - a significant cause of maternal mortality throughout the developing world. Only after it had been removed did she regain consciousness. She went on to deliver four more children - the youngest four hover shyly in the doorway to the hut - at home.

"It's totally different now," she says. "I advocate for all mothers, where possible, to give birth in a health facility."

This position represents a revolution in Maasai culture, where women, starting as early as 12, give birth to an average of seven to nine children over the course of a lifetime. They are assisted by traditional birth attendants (TBAs).

Clustered under a large tree, in brightly coloured shawls, the TBAs in Sitoka were the first people we met on arrival in the village. They were hesitant to speak at first, hands clasped in their laps, heads cocked, curious, rising above the many hoops of beads on their necks. They were incredulous that the three British women interviewing them had only one child between them.

The chief skill of a TBA is massage, one explained, demonstrating on the thigh of her neighbour. She can discern whether all is well - "it is a God-given skill" - and, if the baby is not in the right position for delivery, she can move it into place.

Later, in the sub-district hospital at Lolgorian, a nurse explains that "external turning" used to be standard practice in the health service in Kenya until it was found to rupture the uterus. In Sitoka, however, the skill is revered. 

THE Ministry of Health in Kenya is keen to "rebrand" TBAs as birth companions who will refer women to hospital. But, although those in Sitoka admit that they see signs of their work ending, the journey from the village to the hospital means that their assistance remains in demand. Just recently, one recalls, a woman gave birth in the doorway.

Getting women to give birth in hospital is a main aim of TRDP. In the UK, where home births for "low-risk" pregnancies were recommended this month, a mother can swiftly be driven to the nearest hospital; but, in Sitoka, even when a vehicle can be found, she faces a journey on roads that are, in many places, just stretches of grass flattened by previous tyres. The taxi fare is prohibitively high - vastly inflated above the rate charged in Nairobi.

Although Kenya is set to achieve many of the Millennium Development Goal targets by next year, its record on maternal and child health-care is one of the worst in the world. Approximately one woman dies every hour from causes related to pregnancy and childbirth. Only 44 per cent of births are assisted by health-care professionals - well below the target of 90 per cent. The infant mortality rate is almost ten times that in the UK.

The Kenyan government has not been inactive. This year, the First Lady, Margaret Kenyatta, launched the Beyond Zero Campaign, which includes the roll-out of mobile clinics, and a focus on preventing the transmission of HIV. This year, the Ministry of Health allocated $US 400 million to prevent the rate of HIV transmissions, reduce maternal and child death, and increase the number of skilled health-care workers and facilities in the country. 

BUT there is a long way to go. For women in Sitoka, even with the arrival of the ambulance, a successful transfer to hospital is no guarantee of a happy ending. At Lolgorian Sub-district Hospital, we are told that, in the past two months, two women have died. Once they arrive with complications, it is too late, Margaret Nyachoka Omwenga, the matron, observes, sadly. "One lady came here with very high blood pressure, went into a coma, and died on the way."

Like many of the Kenyans we met during our trip, Mrs Omwenga speaks not of "problems", but of "challenges". It is the word that she uses while giving us a tour of the hospital, where we learn that it is missing a theatre, two extra nurses, and a washing machine (the laundry is piled high with bed linen that staff will have to wash by hand). All surgical instruments must be sterilised with boiling water and bleach, because there is no electric sterilisation kit.

The labour ward has just two beds; and a lack of incubators means that, if four mothers give birth prematurely, Mrs Omwenga must teach one to hold her baby "kangaroo style" to keep it warm.

MRS OMWENGA estimates that about 20 per cent of births result in complications. There are no scanning facilities or theatre; so options are limited. A doctor currently away in Nairobi undergoing training has promised to return, but only if there is a theatre in which he can practise his new skills. "Truly speaking, we cannot rely on the Kenyan government, because we are missing a lot of things," she says.

Waiting for her in the maternal and child-health unit - they travel early, she explains, to avoid elephants - are about 40 women, many holding tiny babies wrapped in thick blankets and crowned with woollen bobble hats.

Those we interview are complimentary about the hospital. Large charts announce that treatments are free of charge, and, within a couple of hours, the clinic is empty. Children have been weighed, vaccinations have been completed. In one of the rooms, counselling takes place before HIV tests are carried out. The prevention of mother-to-baby transmission is crucial in a country in which AIDS continues to be the leading cause of death.

Mrs Omwenga has seen children who have been raped - sometimes by their fathers or uncles - who are seeking post-exposure prophylaxis two or three months afterwards, when it is too late.

She is encouraged by the uptake of family planning: "A mother has the right to do family planning; but here you can't," she says. "I have given women the injection secretly. Gender is a big problem in this place. To change someone who does not want to be changed is hard . . . We cannot have perfect people, but we try to change them gradually." 

IN SITOKA, it is the day of the opening of a new dispensary - one of three funded, in part, by TRDP. Within minutes of the cutting of the ribbon, women fill the waiting room, with babies to be weighed and vaccinated.

Although the building is now complete, and stocked with medicine, it remains unstaffed. The chief executive of TRDP, the Archdeacon of Transmara, the Ven. Dominic Santeto, believes that the community must take ownership of the facility, and announces an impromptu fund-raiser. While a teenage boy taps out a tune on a keyboard under a tree, the men make their way up to the front to throw notes into a plastic baby-bath - part of a kit that is to be given to all new mothers.

It is the women who lead the celebrations, singing a call-and-response song in praise of God while gradually gathering in concentric circles, ululating while performing a dance.

In Pusangi, Mrs Ndayia wishes that healthcare was not so distant from the village. "Our area is beautiful, and maybe you are saying it is beautiful," she says, glancing around her. "But it is meaningless to have cows, and have this beautiful land, and people are still dying.

"Now you have seen the problem we are going through. If it is possible to help in any way to have a permanent dispensary around, God is going to bless you. Our health is the priority."

Madeleine Davies travelled to Kenya with Christian Aid. For details of the Christian Aid Christmas appeal, visit www.christianaid.org.uk/deliverhope or phone 0845 7000 300. Donations made before 6 February 2015 will be matched by the UK Government up to £5 million.