FATIMA DEL ROSARIO Gonzalez Polanco sits alone in the back of a taxi for the bumpy ride to the hospital here in La Dalia, a small mountain town in the highlands of central Nicaragua.

As the driver maneuvers through the town's bustling marketplace, Fatima wants to call her mother to tell her what's happening, but she doesn't have a way.

At just 13 years old, Fatima is about to have her first baby.

Having never attended school and unable to write more than her first name, Fatima wears an expression that conveys the distance already traveled from innocence to an understanding of the harsh reality that awaits her.

Delivering at such a young age, she faces high risks — not to mention an uncertain future.

Often, in rural Nicaragua, poverty, culture and politics decide the fate of women and girls like her. Most must travel long distances to give birth in a hospital. Cervical-cancer rates are high. Adolescent pregnancy rates are also high — some of the highest outside Africa. And on average, rural women here have more pregnancies than women in developed countries, making their risk of dying in pregnancy or childbirth over the course of their lives seven times greater than it is in the United States.

And in rural Nicaragua, where husbands are typically in charge of family decisions, women generally don't have the choice or the ability to plan when to start having a family or when to stop. Husbands often object to their wives being seen by male medical professionals or taking birth control.

Rape and domestic violence are prevalent; one in three women is abused. In some cases, girls give birth as early as 9, and women have children well into their 40s.

Governments and nonprofits are investing in solutions, but the challenges are daunting.

The obstacles in Nicaragua are so great that many of these women and girls in rural areas can't expect to have a healthy life, says Margarita Quintanilla, Nicaragua country program leader for the Seattle-based health organization PATH.

"Women are dying," she says. "We need to do something."

MARGARITA QUINTANILLA knows the problems in Nicaragua well. She grew up as the youngest of four children in the capital city of Managua, where her mother taught philosophy and women's studies at a local university. Both her mother and grandmother were active in public service and taught her the importance of women supporting each other — especially about "what you can do or achieve."

Quintanilla learned those lessons, studying dentistry and, along the way, becoming interested in community health — especially in how it relates to violence against women. She decided to follow that interest and moved to Spain to study public health. By the time she returned to Nicaragua, her interest had become a passion. She started working as a community health coordinator, focusing on prevention through everything from hand-washing to midwife education.

Then came the chance to join PATH, the Bill & Melinda Gates Foundation's largest grantee in Seattle. In 2002, Quintanilla became the organization's first staff member in Nicaragua.

Her office has grown to 15 people, now working to improve the welfare of women, introduce health technology and build bridges between that work and supporters here in the Northwest.

PATH and Northwest-based Global Partnerships, for instance, worked with Pro Mujer, a women's development and microfinance organization, to improve its primary-health-care and education programs for clients in Nicaragua.

Quintanilla's work at PATH has concentrated on helping girls learn about health and their rights through community activities, schools and even soap operas.

PATH's Entre Amigas ("Between Girlfriends") project organized monthly meetings for preteen and teenage girls to talk about personal issues with mothers and teachers. All-girl soccer teams were formed to help develop trust and confidence. Working with the Nicaraguan Ministry of Health, PATH helped health-care workers visit schools regularly. The project also worked with a popular TV soap opera to introduce a new character — a 13-year-old girl dealing with adolescence and relationships. A similar program invited boys to join their own groups to talk about respect in family relationships.

Quintanilla is now helping develop a new soap opera that focuses on topics such as sexual exploitation and HIV. The plan is to distribute the program not only in Nicaragua but in other Latin American countries.

Adolescence "is one of the best moments to teach a better way for boys and girls," Quintanilla says. "The younger we can do that the better."

The Ministry of Health has recognized maternal health as one of its top priorities, and has increased efforts to help rural women deliver their babies in health institutions and to help community health workers distribute contraceptives in isolated areas. Yet, a 2006 law criminalized abortion in all circumstances, even to save the life of the mother.

So Quintanilla is arming health advocates with evidence from research to help government officials understand more about women's health issues.

For example, PATH is gathering data from a study of rural girls who got pregnant early and those who did not to discover what factors influenced the difference.

PATH is also working with the Ministry of Health to strengthen the ability of health workers to respond to violence against women. And they're setting up a mobile-phone text-messaging system to alert health workers to pregnant women and adolescents who are showing signs of complications.

But beyond money and technology, efforts to improve rural women's health will not work unless they address the underlying issues of inequality, says Quintanilla.

Quintanilla, who has three daughters of her own, says being able to decide, "by themselves, about their lives, about their bodies," is a right they need to have. Having opportunities and the ability to do what they want — to study, to get married or not — that, she says, "is huge."

IN THE MEANTIME, Nicaragua has found one relatively inexpensive but effective way to help women have babies safely: Red Nacional de Casas Maternas, a grass-roots network of maternity homes that are near hospital and offer rural mothers a safe place to stay before and after delivery, free of charge.

The Ministry of Health provides all medical care and an average of about 75 cents a day to each woman for basic nutrition. Mothers are asked to make a small contribution of money or raw goods to help cover expenses. But the women who have no money, and they are the majority, pay nothing.

As a result, most of the country's 79 casas maternas run on a deficit. So they are trying to establish small, individually administered businesses like laundromats or cafeterias to become self-sustaining. When times are tough, employees will bring food from home to share, and pregnant women sometimes have to sleep two in a bed or on pads on the floor. Turning away mothers in need is not an option, says Casas Maternas national coordinator Francisca del Carmen Espinoza Ortiz. Despite the lack of money, the casas maternas' work under Espinoza's leadership was honored in 2009 by the United Nations Population Fund.

Besides offering mothers temporary refuge, the casas work with traditional birth attendants to identify at-risk women and educate them about health, violence and their rights.

Mothers like Juana Partora Martinez. Now 45, she had her first child at age 15 and earlier this year was preparing to give birth to her 12th.

Outside of Matagalpa, she and her family grow corn and beans, but they sometimes run out of food for the children.

She came to Casa Materna Mary Ann Jackman, an internationally funded nonprofit named in honor of a young Nicaraguan who had helped families displaced by war. Here, expectant mothers slowly sway on wooden rocking chairs in the front room, watching the occasional soap opera or old movie on television. Before an education session, they gather to sing, play games and exercise. The brightly colored walls provide cheer, but the 14-year-old ambulance needs replacing, and money for food has dried up since the recession.

Kitty Madden, a volunteer social worker, says the cost of beans and rice has increased, and some mothers are arriving malnourished.

With every subsequent pregnancy, health risks to these mothers spike. And with fewer resources for each child, it will be harder for the next generation to escape the cycle of poverty.

"It scares you to have more," Martinez says. Knowing those risks, she made the decision that this baby would be "el ultimo," the last one.

At the hospital in La Dalia, 13-year-old Fatima seems just as convinced that her first baby will be her last.

When Fatima found out she was pregnant, she felt insecure and unsure what to do. The baby's father, a married man in her village, offers no support. With four other children, her parents cannot offer much help; she lives with another woman in her village.

Fatima will go to a larger hospital to have her baby by cesarean section. She has hopes that her child will be able to study, get a job and stay out of trouble.

For herself? School seems unlikely. Maybe she'll get a job with someone in her family. But for now, there is the delivery to think about.

With nothing more than a small, black duffel bag and her paperwork, she is off to have her baby, alone.

Kristi Heim is a Seattle Times staff reporter. Erika Schultz is a Times staff photographer.