Tag Archives: maternal health

Secret Women

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.

Former traditional birth attendant Dalia Issa stands with her husband outside of their Namila Village home. In 2010, with training from the Centre for Alternatives for Victimised Women and Children, Issa stopped offering village-based delivery services and took on a new role as a Secret Woman. Photo submitted.

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.

A bicycle ambulance donated by the Centre for Alternatives for Victimised Women and Children being used in Namila Village. Photo submitted.

“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

Road from Jacobu to Abuakwa - Photo by Luv FM.

“The Road Not Taken”: maternal mortality in rural Ghana

My colleague and I took a two hour journey to a village outside of Kumasi to conduct interviews for his documentary on maternal mortality in the Ashanti region; we stopped at a hospital in Jacobu where the matron pointed us in the right direction.

“It’s only thirty minutes from here,” she kindly informed us.

An otherwise smooth journey began to change: potholes, ridges, unintentional speed bumps. The final thirty minute stretch felt like hours, and not just for me. My colleague, Kwabena Ampratwum, had traveled to many rural areas on similar roads but few were as rough as this.

At last, we pulled into the village of Abuakwa. Until two years ago, most pregnancies there were managed by traditional birth attendants – TBAs – who were usually untrained; then the Abuakwa Health Center opened.

Maternal mortality is seemingly low in the village: since 2010, we were told that one resident died of pregnancy complications. While this statistic sounds promising, it unfortunately does not reflect the grim reality of maternal health in the area.

The Ashanti region had 253 maternal deaths in 2011, the highest recorded in Ghana. 154 of these deaths occurred at Komfo Anokye Teaching Hospital in Kumasi. Last month alone, KATH had 17 maternal deaths – including the one from Abuakwa.

Many of KATH’s cases are referrals from villages outside of Kumasi. By the time patients reach the facility, it is often too late. Part of the solution is having smoother, more efficient roads and access to vehicles. The Abuakwa Health Center does not have a car or ambulance so they depend on surrounding villages.

“The bias towards large-scale transport still exists in national governments and donor agencies, and is reflected in terms of budgets, personnel and professional training,” found a recent study from Kwame Nkrumah University of Science & Technology.

We spoke to Vida, a midwife at the center. “It becomes so difficult. Sometimes we have to send a motorbike from this town to the next village, which is almost an hour, before we can get a car to transport our clients.”

“Two weeks ago, we had a lady who was delayed in the second stage of labour,” the head nurse of the Health Center told us. “We referred her at 1 pm… we were waiting for a car, making calls… the car got here at around 5.”

They put her in a stretcher headed toward St. Peter’s Catholic Hospital in Jacobu, the first referral point. In addition to the pain of being in labour for four hours, she was taken on a turbulent route that can induce other complications for her and the child. Approximately forty minutes later, she reached Jacobu.

“The uterus could no longer contract. The lady started bleeding, so Jacobu had to refer her to Komfo Anokye,” the nurse continued.

She was then taken for an hour-long journey to Kumasi. The roads are paved but the traffic is often congested. Even when the roads are wide open, the trip is long enough to worsen critical conditions. She arrived at the hospital over six hours after her complications began.

Sadly, her story ended there.

There were multiple moments throughout the story where her life could have been saved. Inadequate resources, poor communication, and lack of personnel all likely played a role. Transportation is a particularly troubling factor, and addressing it will require a heavy reallocation of funding towards rural development.

Road from Jacobu to Abuakwa - Photo by Luv FM.

Stone ‘babies’ and fertility shame

Mother of the "stone" baby, Agnes Musulo

On a cool July evening in Malawi in 2009, 20-year-old Agnes Musolo went into labor.

She was only 24 weeks pregnant and, after having already suffered four stillbirths, she feared the worst for her unborn child.

But she was struck by another surprise—the “baby” was, in fact, a stone.

Interestingly, it wasn’t the first time Musolo had given birth to a stone, nor was it the last time that such cases would arise in the country.

The story was immediately picked up by the Malawian media and became a spectacle, but it points to a graver problem.

Some women suffering reproductive difficulties in Malawi resort to extreme measures in order to feign pregnancy rather than face the shame of being barren.

“Fertility is very important in Malawian culture,” says Faith Phiri, executive director of the Girls Empowerment Network (GENET) in Blantyre. “You can have nothing—no money, no house, but if you have children, it means you have wealth.”

And having children also garners a family esteem.

“Without children, if you are a woman, you don’t have respect,” Phiri continues. “It doesn’t matter whether you don’t have money to feed them . . . as long as you bear many children, you are woman enough.”

When a woman is unable to conceive, it is, as Phiri puts it, nothing short of a “disaster.”

“If a woman cannot conceive, that woman faces a lot of rejection,” Phiri explains. “People will ridicule you, they will blame you for not conceiving, for not being a real woman.”

For all of the rejection, humiliation, desperation and sadness that a woman must endure when faced with reproductive difficulties, it’s no wonder some are trying to disguise their condition.

As Dr Francis Kamwendo, professor of Obstetrics and Gynecology at the College of Medicine, explains, some women will simulate pregnancy then shift the blame when the baby they were meant to deliver turns out to be a stone. Others will experience a false or hysterical pregnancy, where the symptoms of true pregnancy are experienced but the woman is in fact not pregnant. Yet others will even go to the extent of stealing other people’s babies from the hospital.

Most recently, a woman from Mangochi in the Southern Region of Malawi delivered what The Daily Times described as a “rock-like object.”

And just two weeks earlier, Leticia Wyson, 26, from the Dedza District in the Central Region of Malawi delivered two plastic bags containing a piece of charcoal, two mango seeds, a millipede, nine stones and a snail.

Both women had faced multiple miscarriages prior to their bizarre birthing experiences, and in all of the cases mentioned, the fetus’ transformation was attributed to witchcraft.

While science cannot explain witchcraft, there does exist a clinical explanation for the “stone” baby phenomenon.

According to Dr Kamwendo, it’s possible for a woman to have a miscarriage where the dead fetus is not effectively dispelled from the womb. As weeks and months go by, it calcifies, becoming more or less like a stone.

Agnes Musolo did eventually give birth to a healthy baby boy.

But while her days of ostracization may be over, the issue of fertility shame remains entrenched for some women who face reproductive difficulties.

For Phiri, education is the key when it comes to changing current attitudes and curbing such extreme practices.

“We need to mobilize the whole community to support women and not to look down on women, whether they are able to conceive or not, whether they have children or not.”