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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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.

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.