A tale of two pregnancies and two different outcomes
The maternity ward at Mangochi District Hospital bursts at the seams as pregnant women occupy all the beds and others sleep on the floor, even in the hospital corridors. But Esther Makumba is neither expecting nor nursing a baby. Her baby died in the womb. “My mother was trying to deliver my baby at home,” she says from her hospital bed. By her side is her mother, Fatima Ali, who cannot hide her anxiety. She tries to occupy her five-year-old grandson but her mind is clearly on her daughter's poor health.
Makumba takes time to catch her breath. She has developed a fever. “I was in labour for four days. I was in a lot of pain, so I wanted to go to the hospital, but my mother refused.” Instead, her mother decided to give her mwana wa mphepo, a local herb that speeds up contractions. Makumba's uterus ruptured and the race to save her life was on. As there was no telephone network or public transport in her village, family members took Makumba on a bicycle to the nearest health centre. It took them two hours to navigate the potholed dirt road. At the centre, the nurses phoned an ambulance and Makumba was transferred to Mangochi District Hospital where she arrived unconscious. An emergency operation removed the dead foetus.
Makumba's is not an isolated case. In fact, she is lucky to have survived. As many as one in every 18 women dies from pregnancy-related complications, making Malawi one of the world's riskiest places to have a baby. By stark contrast, the odds of a woman in Sweden dying from pregnancy-related complications are one in 17,400. The main causes of maternal deaths in Malawi are haemorrhage, sepsis, pregnancy-induced hypertension, obstructed labour and complications from abortions.
The newborn baby also has a high risk of dying. The World Health Organization estimates that in developing countries, 40% of babies die within the first week of life, and most of the deaths are largely preventable. Childbirth, a completely normal and natural process, can often be a life and death affair.
“There is a lack of knowledge, as most women are illiterate,” says Amina Makanjira, the safe motherhood coordinator at Mangochi District Hospital. “The herb that Makumba's mother gave her is widely used but it is very dangerous,” she says. Other traditional beliefs also contribute to deaths. “People believe that they should have their first baby at home so that the father can confirm it is his,” adds midwife Makanjira.
Yet even when expectant mothers want to deliver at a hospital, there is little or no public transport. Many have to make the journey, heavily pregnant or in labour, on foot or by bicycle, along bumpy unmetalled roads. Complications often develop when the mothers are too young to have children or do not space their pregnancies. Only about 54% of pregnant women in Malawi are assisted by a skilled attendant at birth. These life-threatening risks have prompted the government, with support from UNICEF and other partners, to mount a campaign to convince women to deliver in hospital. Community members, including village chiefs and Health Surveillance Assistants, are playing a key role. In some areas, UNICEF has supported the distribution of 'motorbike-ambulances', a scooter attached to a stretcher on wheels that is covered with a plastic tent to keep out the dust.
Mangochi's maternity ward bears testimony to the successful campaign. Makanjira says staff now face the challenge of a heavy workload and overcrowded wards. The hospital also has a 'Kangaroo Mother Care' facility where newborns are kept warm through continuous skin-to-skin contact with their mothers. By keeping mother and newborn together, Kangaroo Mother Care encourages mother and child to bond emotionally and enables the baby to breastfeed at will, giving the baby the energy to produce its own body heat. In some cases, this minimizes the need for incubators, which are prohibitively expensive for developing countries like Malawi.
Thirty-five-year-old Asiatu Sampson, a mother of six, is waiting to give birth in hospital for the first time. All of her six babies were delivered by a traditional midwife at home. She recently gave birth to twins but one died. However, it was not the death of her baby that persuaded Sampson to come to hospital this time. Sampson, who has never been to school, says, “It was the traditional chief who told me to do so.” The midwife thinks that Sampson is expecting twins again. The two-hour journey on a bicycle was arduous. Yet, says Sampson, “I feel sure that this pregnancy will work out well.” She has attended ante-natal consultations and sleeps under the long-lasting treated mosquito net she received during her first consultation. Sampson also took two doses of intermittent preventive treatment for malaria as well as iron and folic acid.
By contrast, Makumba's situation does not look hopeful. She is still weak and unwell. The nurse is not sure whether she will be able to have any more children. She is still young, but does not know her age and, like her mother, has never been to school.
Her mother looks sorry and worried. “I have learnt my lesson now. The next time my daughter goes into labour, I will make sure I bring her to the hospital,” she says.