Motherhood in Malawi is a battle against medical odds

In a rural village on the outskirts of Lilongwe, chubby-cheeked Pemphero Cosmas is crying in the arms of her uncle, confused by the group that have gathered around her. She’s too young to understand that her mother, Eliza, died a year ago, haemorrhaging while giving birth on the back of a bicycle as she tried to reach a health centre.

It’s her visitor that has attracted all this attention. Nitta Chakanika is a nurse with a tiny Malawian NGO called Joyful Motherhood which delivers baby formula, sanitary equipment and life-saving advice to babies left behind when their mothers die.

Malawi is one of the most dangerous places to give birth – one in 36 Malawian women will die in childbirth (in Ireland, it's one in 8,100). As Dorothy Ngoma, head of Malawi's Safe Motherhood Initiative, puts it, "being pregnant is described as having one foot in the grave".

Maternal danger
Ngoma set up Malawi's first health workers' union at a time when there were more Malawian nurses in the UK than in Malawi. She campaigned for higher wages, better training and safer working conditions and reversed that trend. Now she is working to reverse Malawi's abysmal record on maternal health. She's been helped by Joyce Banda, the country's first female president, who came to power in April 2012. Since then the Safe Motherhood Initiative has been a priority.

Tradition dictates that most women in Malawi give birth at home, with the help of local women known as “traditional birth attendants”. They are often hours or even days away from a medical centre. And, in a country where three-quarters live below the poverty line and 11 per cent are HIV-positive, malnutrition and disease are rife. Pregnant women here are already at much greater risk of a difficult delivery.

Traditional birth attendants were banned by the last president in 2007. But the ban failed to engage Malawi's real leaders – the locally appointed chiefs who dictate life in remote, rural villages where 85 per cent of the population live. To tackle this, Banda has recruited a council of chiefs, lead by the particularly charismatic Chief Macjulio Kwataine of Ntcheu, to challenge tradition.

But as that campaign gains traction, the government has to convince pregnant women hospitals are where they want to be.

Bwaila Hospital in Lilongwe has the busiest labour ward in the country. Last year 18,272 women passed through its doors, up from 15,678 the year before. The labour ward has become a place expecting mothers want to come to.

"Bwaila used to be known as a place women came to die," says Rachel MacLeod Spring, an English midwife sponsored to train staff at Bwaila by a small Irish NGO, the Rose Project, working in HIV and maternal health. Bwaila used to be a massively under-resourced central hospital to which only serious cases were referred, often too late. Sixteen or more women could deliver in beds side by side, some even on the floor.

The maternity wing was rebuilt by the Rose Project in 2009. It’s a bright, open network of blue corridors, green, sun-filled courtyards and tidy rooms lined with beds. There are women everywhere, pregnant women shuffling along the corridors, mothers and sisters holding tiny babies with bigger babies in slings on their backs.

On the new labour ward, MacLeod explains, women give birth in private rooms. Though sometimes they will double up, it’s a luxury compared with what went before.

But good facilities are only half the battle – the main challenge is motivating staff. In the past, Bwaila had a reputation for negligence. Like every other hospital in the country it suffers from chronic drug and equipment shortages which have a profound effect on morale. In January, the government revealed that the central medical supplies stores were almost empty – it hadn’t procured drugs since 2009.

Economic crisis
The country is in the midst of an economic crisis. During the last presidency, key donors, the US, UK and World Bank among them, fell out with a president they saw as frivolous and withheld aid. When Banda came to power the economy was close to collapse. To bring the donors back in, she enacted harsh austerity measures, which hit wage-earners hard, causing a mass strike in the civil service in January.)

“The biggest thing I try and teach is that what we do makes a difference and that’s also the hardest thing,” says MacLeod. “If a woman needs medication or blood and you don’t have it, it doesn’t matter how good a midwife you are. She is not going to make it.”

Many of the nurses and midwives she works with are supporting their entire extended family as unemployment and culture in Malawi dictate. Often they work long hours for extra pay and suffer from exhaustion. “When you’ve been here a long time, you see why midwives have this attitude,” MacLeod explains. “At the beginning they are angry. After a while I suppose, they lose that anger and it becomes apathy.”

MacLeod acts a mentor for midwives but also as a liaison for the many stakeholders involved in the hospital – a group in the US who have donated machinery or a Norwegian university that sends volunteers. She is very conscious of her delicate position, working as part of an NGO but within a government system. “In the end we are visitors here, we can’t do anything without the approval and support of the local staff.”

Grassroots staff
District Health Officer Mwawe Mwale is a handsome young doctor in scrubs whom I met on his way into the operating theatre where he works every Thursday. He is also responsible for running Bwaila and 132 health facilities in Lilongwe district.

“Every NGO comes in with an agenda and at times some can be quite forceful with what they want.” he says. “But one of three things will happen, they conform with what you want as a district, they go somewhere else or they bully you into towing their line and you watch as their project goes up in flames.” He chuckles with typical Malawian good humour. “But it’s really nice when you’ve got those partners that ally themselves with the district.”

Without donors, he says, the new wing at Bwaila would never have been built. And, in the same vein, it’s unlikely Safe Motherhood will succeed. As I followed MacLeod around on an average, hectic day, she popped into the team at Joyful Motherhood, also based at Bwaila. A group of well-meaning but misinformed donors had decided they didn’t want their money spent on formula milk. “Where do they think the milk is going to come from? There are no mothers!” she says.

Despite her longevity at Bwaila – she’s been there five years –MacLeod knows she is just a stopgap solution to Malawi’s maternal health problem. “We need a Malawian Rachel.”

Dorothy Ngoma agrees. “I wish I had a 100 Rachels in every hospital” .

When I spoke to her, Ngoma had spent the last week running around the country scrabbling together donations to build 130 shelters where women who live far from a health centre can stay towards the end of their pregnancy.

Unbending hope
"I keep on knocking on the doors, asking, 'Can you support the president in this cause because you will be helping her save women's lives?"

A metal roof here, a truckload of cement or a volunteer electrician there – her project, like much of Malawi's development, relies on donors. But it also relies on her initiative, determination and unbending hope. Often, when a woman dies, the community will come to her saying, "This is an act of God." But this is something she will no longer accept. "If we fail to do the right thing we cannot blame it on God. We need to take responsibility and prevent these deaths," she says. "It can be done."

Stephanie Hegarty is based in London and works for the BBC World Service