Malawi’s missing midwives

The Guardian March 8, 2011

 Just found this article by Brigid McConville on a day when new President, Joyce Banda took a leaf from Bingu’s (the late President) notebook and banned Traditional Birth Attendants TBAs.

In the past 3 years few nurses were trained, as Bingu’s government failed to fund nursing student fees. So my question is where will the nurses come from. One of the most serious issues in Malawi today

Is there any chance of up-skilling the more skilled TBA’s in the short term?

• Brigid McConville is director of the White Ribbon Alliance for Safe Motherhood (UK)
In Malawi the risks of women dying in childbirth are among the highest in the world, and local women need to be empowered to press for change. Malawi is crucially lacking in midwives and nurses, with around three-quarters of staff positions vacant. On a fact-finding missing to Malawi, I can’t help noticing a 5 metre-high billboard at Lilongwe airport: a young woman in jogging gear and headphones advertising an offer of high-speed downloads, live TV, music and video calls. Mobile phone technology has truly arrived.

But midwives and nurses still haven’t. Around three-quarters of staff positions in Malawi are vacant, and sometimes women are arriving at health facilities in rural areas to give birth – to find only a cleaner to assist them. It’s only 50-50 that a woman in Malawi will have a midwife, nurse or doctor on hand in childbirth; the rest give birth alone or with only a neighbour to help.

In this small country, the risks of women dying in childbirth are among the highest in the world: 510 women will die for every 100,000 who give birth, compared with 12 in the UK. The loss of newborns is so common that they are not buried as other people are, but often in a nameless, limbo category of their own.

Lennie Kamwendo, a stalwart of the White Ribbon Alliance for Safe Motherhood and former president of the Association of Malawian Midwives, has been a newspaper agony aunt for many years. In a country where it’s difficult to talk about sexual health openly, she put her mobile phone number on her column and took calls from women day and night – at no charge.

Kamwendo is immensely proud of the profession of midwifery. Yet her colleagues, especially in the remote rural areas where 90% of Malawians live, are often working alone, day and night, to save women’s lives without the back-up they need. When things go wrong, they get blamed. When the health clinic is late to open because the nurse or midwife needed a few hours of sleep, lives are put at risk and communities are angry. When exhausted midwives respond rudely, word gets out and women don’t come – again putting lives at risk.

A few years ago, the government simply cancelled all training of health workers; the midwives trade union and others threatened a strike, and training was restored – but a year’s “crop” of health workers was lost. And that was only 500. Meanwhile, the system lacks accountability. A medic told me how this year, as in previous years, doctors knew that blood banks didn’t have enough supplies to get through the Christmas season. But their views were not heard, and women died as a result. Did a minister or senior civil servant lose their job as a result? No.
Why aren’t people up in arms about this needless loss of life? Levels of literacy in Malawi are low, and only around half of women can read. Midwives told me that women tend to think of professional healthcare as a privilege rather than as their right. So when things go wrong, they don’t complain.
Only when women are aware of the dangers of giving birth without skilled care, and know their rights to health services, can they press for change. Only when they are asked about their experiences – and listened to by policy-makers – will things move forward.
The White Ribbon Alliance in Malawi wants to make a film that will do just that – and show it in villages, on television, in parliament. Maybe the music will come from the charming permanent secretary at the ministry of health? Apart from his day job, he is a popular “selector”, known as Dr DJ. I heard about him from a young advocate in Lilongwe who regularly checks Facebook on her mobile phone.
So if phones and Facebook are available across Malawi, why not nurses and midwives?

The international community has promised resources to cut maternal deaths by three-quarters. The Malawian government has promised to invest in health workers. Let’s make sure these promises are kept.

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Our co operation with St John of God Services in Mzuzu

Irish Times, Dec 14 2010:
Eithne Donnelan

HELPING HAND: HOW ONE MAN GOT HIS LIFE BACK ON TRACK THANKS TO THE ST JOHN OF GOD MENTAL HEALTH SERVICES

It is customary among certain tribes in Malawi for men to pay a lobola to the family of a woman they plan to marry. Sometimes, the lobola or dowry equivalent, usually a few cows, is paid upfront before the wedding, but more often than not part of it is paid later when the newly married couple have built up sufficient resources to discharge the debt.

When in 2001 Bina Msiska’s sister-in-law and mother of three died of pneumonia, aged just 23 years, his brother Vincent had only paid her family part of the lobola they were due. They demanded one more cow before they would give permission for her burial.

A stand-off between the families ensued for three days, bringing shame on the Msiska family as everyone then knew they couldn’t afford the extra cow. Eventually before nightfall on the third day, neighbours clubbed together sufficient monies to pay off Vincent’s in-laws.

It all became too much for Msiska who suffered a nervous breakdown. His father took him from their home in the Rumphi district to the acute mental health service run by St John of God in Mzuzu, where he spent two months as an inpatient.

“I don’t remember going into the hospital. I was very sick at the time,” he recalls.

“When the problem started, some people said I had HIV or was smoking marijuana or something, and that it was this which was disturbing my brain. In our culture, they think it must be something like that.”

After he recovered, he continued to attend St John of God services where he studied horticulture, and now works full-time as a “plant propagator”, sowing apple, mandarin and many other plants on a farm near Mzuzu funded by the Wells for Zoë organisation run by Irish couple John and Mary Coyne.

They have overseen the construction of cheap but effective water pumps in many surrounding villages and also recently funded a two-bed birthing clinic for one rural community to replace a straw-roofed shed with a stone slab, the only facility local women previously had when going into labour, unless they undertook the journey to a city hospital.

Thirty-five-year-old Msiska, now married with five children, has managed to make a living out of his horticultural skills, which earn him around 13,000 kwacha (€65) a month.

This and his earlier work for St John of God has been sufficient to enable him buy a little plot of land on which he has built a temporary home with clay bricks and a thatch roof for his family.

Using his entrepreneurial skills he has also built a second temporary home on the site which he rents out for 1,000 kwacha or €5 a month.

He attributes his current health and lifestyle to the services run by St John of God. “They have done great for me,” he enthuses.

At first when he was discharged from hospital, people would run the other way when they saw him coming. “They would say you are a mad one. But in the hospital they taught us to educate them and point out mental illness is like any disease and it can happen to anybody. Then they will not do that again.”

women of malawi

Women of Malawi

The title maybe indicates the main focus of my life at the moment, but it is the name of a wonderful organisation working in Malawi as well , http://www.womenofmalawi.org. The driving force is Dr Valerie Donnelly and I have taken the following from the website.

“LIVING THROUGH CHILDBIRTH”
My name is Valerie Donnelly. I am a practicing Obstetrician in Mount Carmel Hospital, Churchtown, Dublin 14 since 2000 and am presently the Lead Clinician. I qualified in 1985 from the Royal College of Surgeons and trained in Obstetrics and Gynaecology in Ireland and Australia.
I first went to Malawi in November 2007 to help give a course in Emergency Obstetrics with the Irish College of Anaesthetists to Clinical Officers. I visited a local hospital and was so overwhelmed by the poor facilities, lack of supplies and of trained staff, the workload of the doctors and condition of the mother. Even in the hospital many of the babies died and the maternal mortality was totally unacceptable. The mothers are sick with anaemia, malaria, HIV/AIDS and general malnutrition.
Infant mortality, within the hospital, is 10%. Maternal mortality, within the hospital, is 1 in 2000. This compares to a ratio of 1 in 100,000 in Ireland. UNICEF publishes a figure of Lifetime risk of Maternal Death of 1:18. The principle cause of maternal death is haemorrhage. Many of the women have severe anaemia due to a lack of iron in the diet. The provision of iron to pregnant women would have significant impact on the maternal mortality rate.
I returned in July 2008 to work at the hospital for a month as a volunteer. I brought supplies of sutures and drugs which I knew to be lacking. I transported these by DHL while I was there so that I could ensure they got to the right place.
In November 2008 I went back to the hospital and brought 27 boxes of supplies, theatre gowns, ventouse cups, sutures, drugs, drapes etc., Many of these items were donated to me and I organised pick up and distribution through the hospital agent, including an Ultrasound scanning machine. While working at the hospital I interviewed and gathered information on more than 500 women. I began to identify some of the most important issues were knowledge about pregnancy and the general wellbeing of the pregnant women. Most of the women were poorly educated and unaware when they should come to the hospital and many left their visit too late. Also many of the women were severely anaemic which was the major contributor to their problems and, I believe, to the deaths of some of them. In addition a lack of simple medical supplies lead to poor outcomes of routine medical procedures.

In January 2009 I returned to give another teaching programme with the Irish College of Anaesthetists.

In March 2009 I will visit again to set up a project to get information to the women in the villages. I am also looking to coordinate the delivery of an operating theatre to a district hospital. The operating theatre is the gift of an Irish entrepreneur.

On behalf of the Women of Malawi I thank you for your support.

MATERNAL MORTALITY
The death of a mother in childbirth is a tragedy in any society. Women and children are our life for the future. In Ireland, when a woman dies in childbirth, this event can make headline news. 1 in 100,000 women die in labour in Ireland. In Malawi the maternal mortality rate is 1 in 1,800. In a single government hospital in Malawi, where I work, two or three women die each month. 85% of Malawian society lives in a rural agricultural setting, and this is where the majority of mothers deliver their babies. There is little data on the rural populations in Malawi, which means that the above-mentioned maternal death rate is likely higher – we actually have no accurate idea how many women die in childbirth in rural areas though this is being addressed by government bodies at present.
SOLUTIONS
While there are many ways to help reduce maternal mortality The Women of Malawi Charity has decided to focus on three core issues.Proven ways to reduce the carnage in childbirth are:
Improving the mother’s health during pregnancy.
Having a skilled attendant at birth;
Educating the women about childbirth and;Preventing anaemia.
The main cause of death in childbirth is from haemorrhage. Mothers die because of lack of blood for transfusions, but they would not be so prone to blood loss if their iron level were higher in the first place. (Iron is a major mineral in blood that contributes to coagulation.) The average iron levels, at Mount Carmel Hospital in Dublin where I work, during pregnancy is 11-12. At Bwaila Hospital in Lilongwe where I volunteer on a regular basis, the average iron level is 6-7 in expectant mothers. This leaves the women susceptible to infections and death due to haemorrhage, and complicates delivery with preterm birth and small babies.
Thank you for taking the time to learn more about this cause.
Takulandilani indepo, Zicomo
(Welcome and Thank You in Chichewa, the language widely spoken in Malawi.)

Born in a Stable

Born in a stable

(mainly from June 21,2009)

The Christmas nativity story is well known to Christians all over the world. The Census, the 90 mile trek to Bethlehem, the donkey, no room in the inn and the manger, the farm animals, the angels, the star, and the wise men’s presents are re-lived in the warmth of the festive season over and over again.
This song by Pierce Pettis puts the miracle in place for me, it’s one of my favourite Christmas songs and an ode to Mary, the mother of Jesus who was a real woman, who had a real child birth.

MIRIAM
by Pierce Pettis

No banners were unfurled
When God stepped into the world
Held in the arms of a little girl
Named Miriam

Who would ever believe
Your fiance, your family
The teenage pregnancy
Of Miriam

But laws of nature were suspended
Death sentences rescinded
Throughout all the world
And all because of a little girl named Miriam

Medieval paintings glaring down
Stony figures judge and frown
Wearing a halo like a crown
Could that be Miriam

Gentile temples stained glass swirls
Cherubim with golden curls
How unlike your Hebrew world
Miriam

I don’t know if you ascended
I don’t care what’s been amended
There was one sure miracle
The faith of a little girl named Miriam

Oh you are blessed indeed
Blessed is the fruit of your tree
Yeshua kings of kings
And son of Miriam

No banners were unfurled
When God stepped into the world
Held in the arms of a little girl
Named Miriam
Named Miriam
Was it a real stable, was it a cave, was it part of the inn, was it the room over the animals, was there water, a midwife and lights are all realistic questions, , for me.
Mary (Miriam in Hebrew), a teenage girl, had her baby, in less than perfect conditions in Bethlehem over 2000 years ago, a frightening fact in the Ireland of today.
No hygiene, heart monitors, HSE, consultants, or ultrasound: how could it be done?
If Jesus was born in Malawi last Year, Mary would have a 1 in 8 chance of dying in the stable during or after the birth. Jesus would fare a little better having a 90% chance of surviving the birth, but a bigger risk of not reaching 5. For all our sakes, as Christians, it’s a good job that they chose Palestine.
So why am I talking about Christmas on the longest day of the year with the sun cracking the stones outside: because I’m thinking of the six or seven thousand women who die, needlessly, in Malawi each year in, or as a result of childbirth.
Malawi has a population of, maybe 14 million people, with maybe three quarters of a million births annually, has seven child friendly hospitals offering rudimentary services, spends about 4 euro per capita on health and where trained midwives are few.
We work with the rural, remote poor where the statistics are worse.
The tragedy of a mother dying anywhere is horrific, but in Malawi where women do practically ALL the work it is a calamity. On the other side about seventy or maybe a hundred thousand babies die neonatally, annually (registration of births is extremely haphazard in areas where babies are not born in hospital), and that’s a very considerable number.
A World Health Organisation comment:
Malawi’s maternal mortality rate is among the highest in the world.
– Women there have a one in eight risk of dying in childbirth or as a result of pregnancy complications – that’s 961 times greater than women in Ireland- – No other death rate in Malawi is so unequal.
From what I know, birthing in Malawi is often assisted by what are called Traditional Birth Attendants (TBA’s), women who have got some little training and who have acquired some skills. I make a very crude comparison to my youth on a farm where if a cow had complications with calving, there was a man who had the skill to deliver the calf safely.
Now horror of horrors, the Malawi Government, in it’s wisdom, have terminated this little help and banned the TBA’s, without any type of replacement. Can’t imagine it was a woman living 50 miles from a hospital, with no transport except maybe a bad bicycle or a wheelbarrow, thought this one up. Probably a man, who won’t experience childbirth or doesn’t care, or some female airhead from an air conditioned office in New York, London, or even Dublin. Some cultural, ritual practices in Malawi are barbaric, But working with communities and education on reproductive health, in the villages, really works, but this ban is just a recipe for more suffering and death.
My first thought would be to train the TBA’s while you try and improve the hospital situation, a practice in many developing countries, but maybe the donors wouldn’t like it, or pay for it.
Christmas in Malawi is hard. No turkey, pudding, tree, santa claus, lights, snow, or even reindeer.
Most remote families live in the crib, a young mother with a new baby knows exactly how Mary felt.
Maybe you can look at the crib differently this year. And make Him the reason for the season.

Meeting at Luvuwu

Meeting at Luvuwu

The man in the suit is the school principal and until recently, when we replaced the roofing material, he had a thatched roof which leaked!!
The man in the foreground contacted HIV 20 years ago from a blood transfusion his wife got. As a couple they are open about their condition which is a great help to others in the community as they are in very good health using ARV drugs.
The community support group idea is simple. The community support each other and we support the group.

Liam writes:

We had a meeting with the Women and the HIV Support group in Luvovo today. Over 50 women and about 10 men were in attendance.

The meeting was to discuss the possibility of starting a micro-credit scheme for small-scale business in the village. The village chief had met the idea with an enthusiastic reception when we approached him and called his people to attend today.

The people eagerly welcomed the idea of assistance with business, and immediately went to work discussing options among each other, facilitated by community leaders and the school teachers.

After the meeting a lady came forward with a bag of oranges. She was wanting to give a gift as she wanted to get involved with the HIV support group. Another man came up to inform me that his brother, Venji, had died. Venji had been one of the two people who were suffering heavily from HIV when we first visited, to the extent that it severely hampered his ability to leave the house and his mood. He died on 10th December, but since then his brother has become even more involved in the support group and is eager to get more men to come forward and join.

Dying for change, on Mother’s Day

Monday, 3 March 2008
I am thankful to Stories on Malawi: http://www.storiesonmalawi.blogspot.com, for this most informative piece on the inequity of our world. Visit Stories on Malawi for daily news.
What could be more basic?
Right to life?
The success of Womens Lib?
Home Births?

It was Mothers’ Day yesterday, and in those 24 hours about 1,500 women will have died giving birth, as they do every day of the year. Almost all the deaths will have been in the world’s 75 poorest countries. Most would have been preventable in more affluent nations. Maternal health is a bald and unforgiving indicator of the state of a country’s medical services – and its civil society. After all, most women give birth. A society that neglects their needs is a society that institutionally discriminates against women.

In a report released on Mothers’ Day, MPs on the international development select committee have established that the true number of deaths might be 50% higher than the official estimates: perhaps as many as 870,000 women die annually in the days around birth. For every death, another 30 women are reckoned to be left in some way disabled. In sub-Saharan Africa things are actually getting worse.

In development circles there is agreement about what needs to be done. Governments need to make it happen. Slender budgets – and not just in health – fail to reflect women’s needs. In Bangladesh, educating girls has been the key to reducing maternal deaths. Educated young women are more likely to seek antenatal care, and more likely to give birth in clinics.

Rural sub-Saharan Africa presents particular problems. The worldwide shortage of midwives is at its most acute, and scarce clinics are poorly equipped. Most women give birth without skilled assistance, so complications are often detected too late for women to reach distant medical help. Governments must reward staff for working in those backwaters where they are currently reluctant to locate. In Katine, Uganda, where the Guardian is a co-sponsor in a three-year project, the skills of traditional birth attendants are being upgraded, while staff are being recruited and trained to work in rural clinics. New ways must also be found to help women travel in the event of emergency. In Malawi a scheme has been set up where police transport can be called in.

Safe birth is only part of the equation. More than one in 10 maternal deaths is linked to unsafe abortion. Improving access to abortion, and above all to contraception, could, the MPs point out, save thousands of women a year. But the most powerful tool right now is advocacy. The White Ribbon Alliance campaign for improved facilities aims to force governments to reconsider their priorities. The rate of maternal death will not fall by the 75% demanded by the millennium development goal without a transformation in attitudes. Less progress has been made here than in any of the other goals for 2015 set by the UN. That is not a reason for giving up. It is a reason for shouting louder.

Tiawanese eviction can affect up to 50,000 patients in the Mzuzu area

The big worry today in Mzuzu is the potential aftermath of the severence of ties with Taiwan in favour of a new diolomatic relationship with China. The Tiawanese are departing rapidly, bringing their personel and equipment with them. The 41 year relationship has come to a very abrupt end.

Judith Moyo, writes in the Nyasa Times on 22 January, 2008

Malawi’s recent severance of diplomatic ties with Taiwan will have devastating effects on the people of northern Malawi as government does not have contingency plans on the management of essential services, Nyasa Times has established.

Staff at Mzuzu Central Hospital is worried as to what will befall the patients as well as the HIV/AIDS programmes following news that the 20 Taiwanese medical experts are leaving the facility.

“We have been told that the hospital will have to scale down on the number of patients’ intake from the district hospitals because the Taiwanese specialist doctors who operate most of the medical equipment are leaving one by one.

“We haven’t been communicated to by the Ministry [of Health] as to what will happen when they [Taiwanese] finally leave,” said a source from the hospital’s administration.

Taiwan, in 2001 funded the construction of the only regional referral hospital in the northern region, Mzuzu Central Hospital.

The medical facility also operates an HIV/AIDS program in Mzuzu City that includes a therapeutic follow-up, which relies on a monitoring electronic system developed by the Taiwanese.

The region has very limited health facilities and the hospital is responsible for providing 40 per cent of the city’s primary in-hospital health care services and its HIV/Aids program benefits 7,900 patients with ARVs in the city. The program extends to over 70 local clinics in the region with a reach of over 50,000 patients accessing the services.

The Taiwanese have been sent packing with the end of diplomatic romance with Malawi who has roped in Mainland China.

Another project in the region affected is the Karonga-Chitipa road that has since stalled following the divorce of a 41-year diplomatic marriage.

Chinese Embassy Charge d’Affaires Fan Guijin could not commit his country on the medical personnel despite inheriting the Karonga-Chitipa road which the Chinese say will finish two years earlier than Taiwanese planned.

China pledged to support Malawi in its efforts to develop its economy when they established formal ties.

Ministry of Health officials could not provide clear answers on how government plans to replace the medical experts at Mzuzu Hospital.