In Chichewa, the widely-spoken language of southern Malawi, being pregnant or “kunkhala ndi pakati” translates to being in the middle of life and death. For many pregnant Malawian women, however, death comes much sooner.
As the African country with the second highest maternal mortality ratio, Malawi is struggling to eradicate a crisis that in 2006 claimed the lives of would-be mothers at a rate of 807 deaths per 100,000 live births. And while 2006 figures showed an improvement on those of 2004 – 984 deaths per 100,000 live births – the 2010 Malawi Millennium Development Goals Report has already projected that Malawi will not achieve the targets of the fifth MDG to improve maternal health by 2015.
Contributing factors identified in the 2005 Ministry of Health (MoH) “Road Map for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Malawi” include shortage of staff and weak human resource management, limited availability and utilisation of quality maternal health care services, and weak procurement and logistics systems for drugs, supplies and equipment. Underlying such problems of infrastructure and resources, the report reads, are harmful social and cultural beliefs and practices.
Naswit Chitalo of Namila Village in Traditional Authority (T/A) Mlilima in Chikhwawa District is easily able to recall a time when “most pregnant women were dying from pregnancy complications” because of social and cultural beliefs, which include the belief that the firstborn child should be delivered by a traditional birth attendant (TBA) in the home as opposed to a health facility.
“I actually know of three women we lost in 2009 because they sought the services of elderly women from the village instead of rushing to the hospital,” said Chitalo, adding that TBAs would use herbs to make pregnant women “feel so confident about the outcome of their pregnancy” that professional maternal health care would be neglected altogether.
According to Malawi Health Equity Network (MHEN) Executive Director Martha Kwataine, these kinds of social and cultural beliefs surrounding TBAs have done more harm than good when it comes to maternal mortality in Malawi.
“There have been several researches whose results have shown that traditional birth attendants have made cases on maternal death high because they are not properly equipped,” said Kwataine. “We tried to train them so that they should handle referral cases but they did not comply.”
President Joyce Banda has also added her voice to the case against TBAs; on June 18, after laying a foundation stone for a maternity holding shelter at Mulanje Hospital, the first of 130 holding shelters pledged as part of the Presidential Initiative on Safe Motherhood launched in April, Banda told TBAs to stop offering delivery services to expectant women.
“Traditional birth attendants must stop giving delivery services,” she said at the function, adding that “traditional birth attendants can have a good role to play… because they are experienced they can be referral point.”
News of the ban on TBAs has been met with both controversy and commendation throughout the country. But to women like Chitalo, the rationale behind the ban is not news at all; as one of the T/As where the Centre for Alternatives for Victimised Women and Children (CAVWC) has been working to realize the MoH Road Map objective of improving obstetric care, a new, “good role” for TBAs is already one of Mlilima’s best kept secrets.
In 2010, CAVWC identified two women in each village of T/A Mlilima and T/A Kasisi to be “Secret Women.” The women, many of whom had been working as TBAs, attended three days of training on maternal health using a standardized MoH handbook.
According to CAVWC Project Officer Talimba Bandawe, women like Chitalo were trained to take on four main roles and responsibilities: referring pregnant women to antenatal facilities by carrying out door-to-door campaigns; educating women on family planning; collaborating with Village Health Committees to form Community Safe Motherhood Task Forces and conduct awareness-raising community meetings; and recording how many pregnant women deliver in the community or in a health facility.
“We depend on these Secret Women because they have been trained; they can convince a woman on the importance of delivery at a health facility with a skilled attendant, because in the rural areas they are used to having TBAs,” said Bandawe. “We’re trying to change that mindset – that anything could happen with a TBA so it’s better to deliver at a health facility.”
Bandawe said the women are called “Secret Women” because of the social and cultural beliefs and practices surrounding pregnancy in Malawi.
“When you talk about traditions and beliefs, the pregnant woman is vulnerable,” she said, adding that traditional beliefs in witchcraft scare some women off of sharing how many months they are into their pregnancy.
“The concept of Secret Women is based on that whatever you talk about with a Secret Woman should be kept confidential,” she continued. “Whatever issues that you discuss, the Secret Woman is not expected to go and disclose that anywhere because some of the things can be really private.”
According to Esnart Dzoma, who has been volunteering as a Secret Woman in Namila Village for two years, “the most important thing is confidentiality.”
“If I begin to shout that ‘so and so sought this help from me’ they will inform each other, and we will have the health problems that used to compound issues such as pregnancy again,” said Dzoma. “I have an obligation to help these women with compassion, and without malice… the secret to being an effective Secret Woman is to be open-minded.”
Based on principles of compassion and confidentiality, Bandawe said the Secret Women project has helped to address some of the harmful social and cultural beliefs and practices, “especially through the door-to-door campaigns” as pregnant women have been comforted by and more likely to accept confidential counselling.
“The Secret Women were really successful in that a number of women were referred to the hospital,” she said, adding that other Road Map interventions such as the provision of bicycle ambulances and village bylaws enforcing fines for births that take place outside of a health facility have also contributed to the success of the initiative.
The data collected by the Secret Women also speaks to their success; in 2009, when CAVWC was working to reach out to practicing TBAs and provide safe-birthing training and equipment, approximately 30 percent of pregnant women in the two T/As were reportedly giving birth at a health facility. In 2012, the Secret Women are reporting that 54 percent of pregnant women are now giving birth at a health facility.
But despite their success, Bandawe said that the new role for TBAs has not been implemented without resistance.
“Some women still resist the counseling of the Secret Women, and sometimes even the husband can be a challenge,” she said.
“There are some materials that the hospital recommends that you should have when you go to the hospital – a plastic paper, a razor blade and a basin. Some of the husbands don’t welcome this idea, so (the Secret Women) have a negative reception from some of the families.”
For their part, Bandawe said that CAVWC will “revive the Secret Women” by holding refresher training courses at the end of June.
“It is really important to have these sorts of people in the communities, mainly in the rural areas where literacy levels are low,” she said.
“Maybe after there has been a lot of sensitization, when everyone even in the rural communities is aware of the health benefits of delivering at the hospital and when we have managed to reduce the maternal mortality ratio, that’s when we can do without the Secret Women. But right now, they still have a major role to play.”
With files from Richard Chirombo and Madalitso Musa