"We are seeing behaviour changing all over the country," said Antonieta Martins, a UN Population Fund (UNFPA) adviser to the Ministry of Health. "More women are visiting hospitals as they see services improve." According to UNFPA, 38 percent of women gave birth in a hospital in 2009, up from 29 percent in 2003.
Dr Inghala Na Uaie, director of San Domingos hospital, 90km north of the capital, Bissau, confirmed the trend in this remote region. "More and more women are coming to the hospital early for consultations - even before any complication may have arisen . and then return for the birth. Maternal mortality has gone down a lot here."
A few years ago, most women came to the hospital only when they suffered complications. "They usually came too late, and they usually came to die." He estimated that now approximately one in twenty of the pregnant women who came in, died in childbirth.
This is lower than the national average of one in thirteen women who die from pregnancy-related complications, one of the world's highest maternal death rates.
Martins expects the next health survey - due in 2010 - to show a further drop.
The government has been running a countrywide campaign to reduce maternal mortality by encouraging women to visit hospitals and clinics for pre-natal consultations, and providing them with mosquito nets as an incentive.
"We have been making announcements on the radio, and when our teams go village to village to weigh children we tell the women to come to the hospital," Na Uaie told IRIN.
Services in hospitals are slowly improving as donors and UN agencies help equip them. San Domingos hospital now has a scanner so doctors can detect early complications, but Na Uaie still has to refer patients to Ziguinchor, in neighbouring Senegal, or Bissau, for Caesarean sections, a five-hour journey.
All six of the country's referral hospitals now have ambulances, but only three - in Bissau, Gabu and Mansoa - can perform Caesarean sections, the director of health and reproductive services in the Ministry of Health, Alfredo Claudino Alves, told IRIN.
Not yet out of a job
Despite the changing attitudes among women, Seydi, a traditional birthing attendant in the capital, Bissau, told IRIN she had no shortage of work, and her client load had not decreased. She does not give her patients drugs and performs no procedures other than cutting the umbilical cord, which she does with an unsterilized knife or shell. "I give women bissap [a local fruit] juice to get rid of the bad blood after they have given birth," she said.
Seydi has no formal training and learned her craft from her mother; she rarely refers women to hospital. "Women bleed too much [during birth] only when they seek birthing assistance long before they are ready to," she explained to IRIN.
Training traditional birthing attendants would speed up a drop in the maternal mortality rate, said Pozzi Morena, health adviser at a Portuguese NGO, VIDA, which works to lower maternal mortality in the Cacheu region.
VIDA encourages birthing attendants to sterilize their equipment and spot complications for early referral to a hospital or clinic, but she stressed that, ultimately, women would only visit hospitals if adequate service was provided, rather than seeing them as places to go to die.