"In Malawi we say that when a women is pregnant she is in a place between life and death.”These words from a Malawian tribal chief reflect the deadly reality of childbirth in the African state. One in 36 Malawian women are at risk of dying while giving birth during their lifetime. In the US it is one in 2,400. Now a national campaign is addressing the complex and culturally sensitive causes of maternal mortality.
Lilongwe, Malawi // It was a watershed moment in the survival hopes of pregnant women in a rural area of southern Malawi. The young heir to a chiefdom in Ntcheu District witnessed a woman in labour - a close friend - die en route to hospital following childbirth complications.
Rapidly losing blood and hours from the nearest medical facility, the woman had little chance of survival. Appalled at the tragic waste of life, McJullior Kwataine vowed that when he became chief, he would take steps to address maternal mortality.
“This woman was a close friend of mine. We went to school together,” he said. “She got married very young and when she was pregnant with her third child she began to lose a lot of blood after delivery. No one knew how to help her.
“I was in the ambulance and saw her lose the fight. It forced me to stand up and vow that when I became chief, no woman should give birth in the hands of untrained people and no woman should give birth before arriving at a medical facility. I learned a bitter lesson because of her death.”
25 years after his friend’s death, Chief Kwataine now chairs Malawi’s Safe Motherhood Initiative (SMI), a presidential campaign introduced in 2012 to address the country’s multiple causes of maternal mortality.
It is urging women to avoid having babies at a young age. The legal age of marriage in Malawi is just 15-years-old, with women having on average six children in their lifetime. Half of all Malawian women are married by the age of 18. SMI members regularly visit villages and hospitals giving lectures in the form of songs that warn women about the physical dangers and financial strain of having children while still in their teens.
SMI is increasing accessibility to medical services in Malawi’s vast swathes of rural land. Some 85 per cent of the country is agricultural with hundreds of villages isolated from main roads and towns. Young women from these villages are being trained in midwifery with the intention of returning to their communities to put their skills into practice. And with support from the Bill & Melinda Gates Foundation, hundreds of new community waiting homes will be built to care for women in the latter stages of pregnancy.
The SMI’s most pressing concern, however, is reversing Malawi’s deep set cultural traditions surrounding childbirth.
In Malawi, it is considered inappropriate for a pregnant woman to share news of her pregnancy with anyone other than her mother. As a result, they typically forgo prenatal care and give birth at home under the supervision of an unskilled traditional birth attendant - a trusted family friend who is usually unequipped to deal with potentially lethal complications.
SMI members soon found that taking on these customs could only be achieved by engaging Malawi’s 2,000 or so tribal chiefs - respected leaders such as Chief Kwataine.
“Chiefs are the custodians of the communities they serve,” said Timothy Bonyonga, community mobilisation coordinator at SMI. “Only by educating them about the dangers of traditional childbirth customs can we achieve behaviour change among pregnant women.”
Mr Bonyonga and the SMI team travels thousands of miles throughout Malawi holding ‘chief mobilisation workshops’. He teaches tribal elders about the importance of women giving birth in a hospital, the dangers of using untrained birth attendants, and the benefits of using contraception to ensure safe timing and spacing of pregnancies.
Chiefs pass on these messages and methods to their communities. Some impose fines to ensure they are followed. In Ntcheu a woman who uses a birth attendant or gives birth at home can be fined an animal, such as a chicken or goat, or the equivalent monetary value.
Chief Kwataine’s area of jurisdiction proves what can be achieved when a tribal chief embraces the guidance of the SMI.
When a woman becomes pregnant, she reports to a ‘secret mother’ - typically a trusted female elderly - who acts as the link between the pregnant woman and professional healthcare services. The secret mother monitors the woman’s health, ensures she has access to pre natal care, delivers in a health facility, and receives post natal follow up care. Eventually even these secret mothers will be phased out under the SMI's midwife training scheme.
Families are given family planning advice and contraceptives to limit multiple teenage pregnancies and ensure young women finish their education before having children.
Gladys Kaponda, a 30-year-old Ntcheu resident who recently gave birth to a healthy boy, said she feared becoming pregnant for the first time.
“Some of my friends had died while giving birth,” she said. “I was scared. With my first child the hospitals were far from here and it took a long time to receive care when labour started.
“The situation was different with the birth of this child. With Safe Motherhood we’re no longer afraid. We know more about giving birth and we have the right to choose when to have a baby.”
The SMI has had a calculable impact in Chief Kwataine’s area of authority. No woman has died giving birth there this decade.
The SMI hopes this trend can be replicated throughout Malawi. The country aims to reduce the national maternal mortality rate to 228 deaths per 100,000 births by next year. In 2000 it was 770 per 100,000 births.
“In Malawi, a lot of women were dying giving birth due to preventable causes - those days are gone," said Chief Kwataine. "Now when you listen to the radio or watch TV, a day cannot pass without hearing a chief talk about safe motherhood. This shows that we are winning the battle. My hope is that safe motherhood programmes are here to stay.”
The Safe Motherhood Initiative is a Malawian presidential campaign. It is supported by the University of North Carolina, which utilises a grant from the Bill & Melinda Gates Foundation. These are the SMI’s aims:
- Encourage women to avoid multiple pregnancies at a young age and instead use contraceptives to properly space their births. The SMI tours hospitals and villages throughout Malawi passing on these messages to women through the words of songs.
- Tackle poor access to medical services in isolated rural areas by training thousands of young woman in professional midwifery and returning them to their communities after graduating.
- Deter heavily pregnant women from travelling hundreds of miles to reach a hospital by building hundreds of maternity waiting homes in rural areas. One waiting home - built using Gates Foundation funds - has already opened on the outskirts of Lilongwe.
- End the practice of Malawi’s outdated and potentially fatal childbirth traditions, especially the use of birth attendants to deliver babies. Attendants are typically family friends who lack the training to deal with serious birth complications.