When Agnes Lunkembesa gave birth to her ninth child, she decided enough was enough. But although she knew perfectly well how babies were made, she had no idea how to stop them being made.
Then she met Seraphine Lumfuankenda, a voluntary community health worker who walks 60 kilometres every week, going from village to village in the hills of southwestern Democratic Republic of Congo, offering advice about family planning and basic health care.
Agnes listened to what Seraphine told her, took her advice, and, four years after the birth of her ninth child, she has had no more. Outside her home, Seraphine leads her neighbours in a song, conducting vigorously with packets of contraceptives in each hand.
"Men and women must look after their health," they sing. "It is not good for a woman to have one baby on her back, another at her feet, and a third in her stomach." Even the village children join in.
"I talk to people about four things when I visit them in their homes," Seraphine says. "I tell them about how they can plan the number of children they have; about sexually transmitted diseases, about AIDS, and about miscarriages. I don't just hand out contraceptives when I first meet a couple - I tell them to discuss together what method they might prefer, and then to come to my home where I can give them what they decide on. Often, they come back later to see me again, to tell me how happy they are with the information I've given them."
Seraphine is a vital part of a coordinated community health structure that places special emphasis on maternal health and the health of newborn babies. It is supported by six United Nations health agencies which have come together under the rubric H4+ - H is for health, four is for the four agencies that originally launched the programme (UNFPA, UNICEF, WHO and the World Bank), and the + was added when UNAIDS and UN Women joined.
In places like Mbanza Ngungu, where Ms. Lunkembesa lives, deep in rural Congo, the programme is already making a real difference. Agnes is just one of thousands of women for whom H4+ has delivered life-changing - and often life-saving - results.
Dr Eugene Kongnyuy, the H4+ programme coordinator based in Kinshasa, says: "The DRC is a country that has gone through a long series of wars and internal conflicts. It's now considered a post-conflict fragile state, so its health system is also very fragile. What H4+ does is support the commitment of the government to ensure that basic services, people's basic human rights, are given to them."
Take the example of one woman whose two sisters had both died in childbirth. Their neighbours suspected witchcraft, so when the woman herself became pregnant, she was sent away in the expectation that she too would die. Fortunately, a community nurse found her and referred her to the local hospital, where she had a Caesarean section. Both mother and baby survived and are flourishing. "When we met her, she told us she couldn't believe she was still alive," says Dr. Kongnyuy. "There are so many stories we can tell to show how H4+ is saving lives."
The programme focuses particularly on two of the eight United Nations Millennium Development Goals (MDGs). These eight goals range from halving extreme poverty worldwide to halting the spread of HIV and AIDS and providing universal primary education, all by the target date of 2015.
The H4+ programme's priorities are MDG 4, which is to reduce by two-thirds the number of children who die from preventable causes before they reach their fifth birthday, and MDG 5, which is to reduce the number of women who die unnecessarily from causes related to childbirth by three quarters and provide for universal access to reproductive health.
It's at the local level that the numbers tell the story. In 2010, 14 women died in childbirth in Mbanza Ngungu. Last year, the number was six; between January and July of 2013, the number was zero.
The regional chief medical officer, Dr. Philippe Pululu, explains how they did it. "With the help of our international partners and the H4+ programme, we set up an obstetrics and neo-natal training programme, and trained some community health workers to offer family planning advice. We also involved local journalists and community leaders so that more people would know what danger signs to look out for during a pregnancy."
Dr Pululu himself has become something of a local celebrity, thanks to his regular appearances on a community radio station. "If a pregnant woman has breathing difficulties, or violent headaches, or complains that she can't see properly, that means something is wrong," he tells listeners. "That's when you must go to your local health centre."
In another part of this vast country, at Mosango district hospital, 400 kilometres east of the capital, a new antenatal unit has been equipped and funded with the help of the H4+ programme. With beds and bedding provided, it also provides medical care for women from outlying rural areas whose pregnancies require constant monitoring. Without it, at least some of them - and their babies - would die.
Earlier this year, Solange Sola Mubisambo, a 32-year-old schoolteacher, spent five weeks in the unit, under close medical supervision. Every day, nurses took her temperature, measured her pulse rate, and monitored the heartbeat of her unborn child.
Now back in her village, she tells her story as she sits in her simple, mud-walled home, with her husband at her side. "I have four children, three boys and a girl. The first two were born without any problems. But my third pregnancy was very difficult and the birth was very complicated. I had irregular contractions and prolonged labour."
When Solange became pregnant for the fourth time, she feared that both she and her unborn child could be in serious danger. Her husband, Mafalanga, 51, had already lost his first wife in childbirth, and he was terrified that the same thing might happen again.
"I went to the new ante-natal unit at Mosango," says Solange. "I was so well looked after - they gave me a bed, a plastic chair, and a container for water. The other women in the unit all had either difficult pregnancies or had had Caesarean sections in the past. Before the unit was opened, many of them would have had to give birth by the roadside.
"Now my little son Benjamin is five months old, but because of all the problems I'd had during the pregnancy, we decided that I would be sterilised. So now I know I won't have to go through the same thing again."
Solange and Agnes are just two women in one country who illustrate the huge potential benefits of the H4+ approach to women's and children's health. By co-ordinating the work of many different agencies, tackling root causes as well as immediate needs, it is already delivering real and long-lasting changes.
The programme's reach is far wider than that of individual agencies, taking in the education of girls and child marriage, gender inequality issues, and mother-to-child HIV transmission, as well as the more immediate issues surrounding family planning, pregnancy and childbirth.
"Child mortality is also a human rights issue because children don't ask to be born," says Dr Kongnyuy. "If they are born, we must take care of them. We must ensure that everyone, especially women and children, has the right to life, and the right to equal participation in society. That's what the H4+ programme aims to help to achieve."
A full set of photos of some of the programme's projects in DRC, taken by Sven Torfinn of Panos Pictures, can be seen here.
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