In Wayali Hospital in Bagamoyo, Imani Msisi - just over eight months pregnant - lies motionless on a narrow metal bed, pressing a thin sheet to her chest.
She was referred to the hospital several days ago because of unusually sharp pains in her abdomen. There is no nurse or doctor in Msisi's village, only a health officer with some basic medical training. Fearing the worst, he sent Msisi in a taxi on the nearly hour drive to Wayali.
She was found to be having a false labor and was treated at the hospital, but is being kept there until she gives birth. If Msisi goes home and a complication does occur, she may not be able to make it back in time.
"In the villages they just have dispensaries. If [pregnant women] are hemorrhaging they are transferred here but sometimes they die before they leave, sometimes along the way. It happens," said Rehema Geni a nurse and head of the maternity ward at the hospital.
According to the most recent maternal mortality data collected by the Tanzanian government, 578 women died in 2004 per every 100,000 live births, and that rate has increased since 1999.
World Health Organization data paints an even bleaker picture, listing the Tanzania maternal mortality rate for 2005 at 950 deaths for every 100,000 live births. In comparison, the United States had 11 maternal deaths for every 100,000 live births in 2005.
Tanzania's health minister, David Mwakyusa called the situation "unacceptable."
"It works out to about 8,100 to 9,000 per year," he said. "I lose a lot of sleep because of that."
The leading cause of maternal death in Tanzania is excessive bleeding before or after birth, called hemorrhaging. Infection and high blood pressure also cause many maternal fatalities. The risks extend beyond the mother to the unborn baby as well.
"If something is going wrong on the mother's side and is not recognized because of lack of skills, the same thing will happen to the newborn," said Rose Mlay, the National Coordinator for the White Ribbon Alliance in Tanzania. "If a woman dies it is most likely that the newborn will die."
The often long distances between people's homes and any health facility, much less one that has medical staff that can deal with emergency surgeries or complications, is one of the main weaknesses in Tanzania's health system, said Mwakyusa.
"In the rural areas [it is] an average of 5 to 10 kilometers for someone to walk to the nearest health facility. That's a daunting problem ... consider a woman who's pregnant, is in labor," he said.
As part of a 10 year planned overhaul of Tanzania's health system, the ministry is planning to have a dispensary and health officer in each village, and is upgrading some dispensaries to health clinics, which can handle minor operations. The country is also working to train more health professionals to ease the dire nursing and doctor shortage in the country.
Assistant medical officers, with three years of medical training, have had to take up many of the responsibilities of doctors in Tanzania, and perform about 80 percent of cesarean sections.
While the government's program is still relatively new, it has a lot of ground to make up. The country has seen some improvements in child health and HIV treatment, but maternal mortality has stayed high.
The rate reflects the struggle to provide the needed care, within the necessary time, to a population that often still gives birth at home, and relies on traditional healers.
About 53 percent of deliveries in Tanzania are attended by unskilled people, while 47 are attended by skilled health care professionals at a dispensary, health center or hospital.
"I talk to my gynecologists, they will say ... [traditional healers] are a necessary evil," said Mwakyusa, because there simply are not enough health workers and some people only trust healers. In response the government is trying to provide some training to traditional healers, teaching them to recognize danger signs and providing them with antiseptics.
In the remote Tanzanian village of Tangenie, located in the foothills of the Uluguru Mountains, pregnant women in labor who do want a skilled attendant must hike uphill for half an hour from the village center to reach the local dispensary.
The last 200 meters, nearly a fifth of a mile, of that journey is totally inaccessible by car, should a vehicle be available to help transport her. In the event of an emergency, the closest hospital is nearly an hour drive says Deborah Kabudi, an assistant medical officer who works in the region.
Here, she says, maternal deaths are "just a part of life" and she estimates the Morogoro hospital sees as many as 20 maternal deaths in a month.
Dr. Meshack Massi, the regional medical officer in Mwanza agrees the situation is bad, and says it's not improving.
"From our observations in the hospitals, the deaths are not coming down."
He says the ideal situation is to bring quality care to the people, instead of them having to travel to hospitals. But the dispensary system needs improvement, he says, citing the one delivery kit available at each facility.
"You could have three or four births on one day," Massi said. "Sometimes if they are rushing they can't sterilize the equipment between births so that is dangerous."
Beatrice Im is a doctor at Bugando Hospital, a referral hospital in Mwanza that sees many of the worst complications. She said the referral system has it drawbacks and she often sees cases referred to the hospital too late to make a difference.
While assistant medical officers are an important resource, Im says she gets angry when she sees women suffering with botched cesarean sections, which should be a simple operation.
For all the remaining challenges, the minister of health says there are reasons to be optimistic. Efforts to educate women about the importance of antenatal care have been successful, with about 95 percent of pregnant women in the country now attending, and the enrollment is up for training new health workers.
"Before we started this program the intake into our training schools was about 1,000... now we are close to 4,000," said Mwakyusa.