An American radical feminist and writer Andrea Rita Dworkin once said childbearing is glorified in part because women die from it.
Dworkin’s assertion is perhaps in connection with the originality of pakati, a local term for pregnancy.
Dworkin’s idea is mostly validated with the environment in which most African women, Malawi inclusive, go through before, during and after giving birth, as there is mostly not enough required support to reduce the natural pain which is associated with giving birth.
According to various local leaders, the term pakati simply means in between life and death. It means when a woman is pregnant, she must expect either to survive or die before or after or even during giving birth. This is so because, initially, more women used to die while giving birth because there were no trained midwives to assist them.
Sadly, the term pakati continues to be associated with pregnant women in the 21st Century when no woman is supposed to die because of giving birth.
Under all circumstances, giving birth is supposed to be a joyous moment for parents, especially mothers who in their struggles carry the unborn baby for about nine months before men and relatives join them to raise the child.
In a number of cases, childbearing brings out mixed feelings to many women. To some, the moment is so lovely such that it leaves behind indelible marks in their lives while to others, the same moment is good to forget as the process and its associated experience takes away their desire to give birth again.
Global statistics indicate that around four million newborns die in the first week of life worldwide. Additionally, an estimated 529,000 mothers die due to pregnancy-related causes.
This is so because in most low and/ or middle-income countries like Malawi, many women continue delivering at home and without the assistance of a trained midwife. This has generated serious concern, since women who develop life-threatening complications during pregnancy and delivery require appropriate, quick and accessible medical care by trained personnel.
A recent review by health experts reveals that about 30 percent of neonatal mortality could be reduced by implementing skilled birth-care services, emphasising that skilled birth attendants at delivery are important for preventing both maternal and newborn deaths.
Although the trade is the same, women that have gone through labour have different stories to tell. For those that have gone to labour for several times, the stories are even different because each pregnancy presents a different experience just as is the case with 28-year-old Martha Amin, a mother of three from Traditional Authority Mponda in Mangochi.
Her story is that of a woman who was deprived of an opportunity to experience a dignified and joyful childbearing.
Amin, like the majority of Malawians, lives about 15 kilometres away from the nearest fully equipped health facility. The facility, Koche Health Centre, is one of the Christian Health Association of Malawi-owned (Cham) facilities.
For Amin and people from her area, access to a health facility, either public or private, is a challenge they face each day as the distance from their home to a hospital is a hurdle they have to overcome before meeting a qualified medical personnel.
If they are lucky to meet the transport cost from home to the health facility, hospital fees become another challenge they have to bear.
In most mission hospitals such as Koche Health Centre, pregnant women are forced to pay about K12,500 whenever they go to the facility to deliver.
The situation was made worse with government’s ban of traditional birth attendants (TBAs) who, for a long time, have helped women living in rural areas in giving safe but unskilled delivery.
In most areas, like Njereza in Mangochi, chiefs have imposed a fine of a goat for every delivery that occurs at home.
TBAs were providing maternity care for women and had given birth to millions of children despite having no formal training. This is so despite reports of cases of women that die every day due complications related to giving birth assisted by TBAs.
“I have three children. The first one was delivered by a traditional birth attendant and it was okay with me,” Amin starts narrating her experience.
After some years, Amin says chiefs and some organisations started coming to her area announcing that TBAs have been banned by the government. To her, she thought that was a good development because she thought the government would construct a health facility in her area to prevent women from delivering at TBAs.
“The story was different with my second child because we were allowed to deliver at a hospital for free although it is difficult for us to reach the hospital when labour begins,” she says.
Life to her was normal. Amin and other women could visit Koche Health Centre to deliver and get malaria drug for free. By that time, she did not know that the government was settling all the bills for her and other pregnant women delivering at the hospital.
“When labour for my third child began, I rushed to the hospital as recommended by health officials and organisations championing safe motherhood such as White Ribbon Alliance [For Safe Motherhood]. This time around, I was surprised to be refused entry into a hospital because I did not have K12,500 to pay for the delivery,” she recalls.
Amin was kept waiting at the hospital as her husband looked for money to pay for the hospital fees. Time was also not on her side to travel to Mangochi District Hospital where services are free.
She groaned with labour pain while at the waiting bay.
She cursed the doctors for being cruel. But the doctors were just doing their job by demanding the money as the government owed Cham such that it had to suspend the service level agreement with the government.
“By this time, I wished I had delivered at home assisted by the TBAs. But I was afraid because our group village head imposed a stiff fine for women that will be delivering at home. And I didn’t want to risk a fine,” she says.
To some women, tradition and local customs prevent them from attending hospital while to others like Amin, it is the distance to the hospital that frustrates them.
Most Malawi women do not go to the hospital in time to give birth. They wait for labour pains. Hence TBAs provide them with all the care they need, both during and after pregnancy and childbirth.
The problem, however, is that many of these TBAs are not skilled. They are women who inherited the job from their mothers or, in some cases, they are just some old women who are respected and have given birth to many children, hence there experience is utilised.
Most of the times, more of these TBAs are illiterate and have learnt their skills from other TBAs or just through the course of their lives. They may consider themselves to be like private health practitioners but the sad reality is that they cannot identify birth complications in a woman or a child.
However, with insufficient health facilities and some associated costs in private hospitals, women in most rural areas have no choice but to deliver with TBAs, which is a health risk for them and the child considering the implications of HIV and Aids, fistula and other conditions.
It should, therefore, be emphasised that the support of women and their families through childbirth, breastfeeding and early parenting experiences must not be treated as separate areas of maternity care.
On the contrary, these two things should be treated as one because there is evidence that they have an impact on the health of the mother and the child.
Of particular is importance is the need for the government to improve access to health services to most local population. Service level agreements with mission hospitals should always be in place to ensure safe motherhood to rural Malawians who are mostly affected when the agreements are broken.
Mangochi District Health Officer Dr William Peno acknowledges that it was hard for women to deliver at Cham hospitals because there was some payment issues attached to the services because the government owed the facilities a lot of money.
But Peno says women now have no excuse to deliver at home because government has settled all the bills with Cham facilities.
“In fact, at the moment in Mangochi, we have increased the number of Cham hospitals from four to seven because we want to promote safe motherhood among our women. We are also challenging them to always go to the hospital in good time, they should not wait for labour to begin. Pregnant women need to be monitored by health personnel before delivering,” he says.
White Ribbon Alliance for Safe Motherhood National Coordinator Nancy Kamwendo encourages women to follow recommendations by doctors and to go to hospital before labour starts so that they can be assisted accordingly.
Kamwendo regrets that more women like Amin went through lots of difficulties the time government terminated service level agreements with Cham hospitals. But she expresses optimism that now pregnant women would utilise the hospitals because the agreements have been signed again.
“Most Malawians live in rural areas where most mission hospitals are also located. It was the most difficult time when Cham stopped assisting women. A lot of women went through difficulties to find money to deliver. But this is now a thing of the past. Our remaining challenge is the distance to hospitals which we believe can be addressed in the long term,” says Kamwendo.
However, she expresses the gratitude to the government for signing the service level agreement with mission hospitals and hopes that women will take advantage of the situation to go and deliver at hospitals where there are skilled midwives.
Kamwendo challenges Malawians to work towards improving health facilities for them to be in good condition to motivate women to deliver at the hospital, saying leaving everything in the hands of the government will make the battle to promote safe motherhood a difficult one.
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