By Wanangwa Tembo:
The waiting shelter at Chamwavi Health Centre is full to capacity. Under the scorching heat of October, some pregnant women and guardians are seated in a shed under a nearby tree while others are taking a siesta on reed mats.
Rachael Banda, a women action group (Wag) chairperson, joins the women. She is on her daily routine of providing health and peer education on the importance of deliveries at hospital and risks associated with home deliveries.
“We don’t encourage home deliveries in this area. If one is found to have delivered at home, she is fined K5,000 and a goat. As such, we visit villages, teaching women the importance of delivering at the hospital,” she explains.
Since the 2009 World Health Organisation (WHO)’s ban of traditional birth attendants (TBAs) conducting baby deliveries, various reproductive health stakeholders, led by the Ministry of Health, have been conducting campaigns urging women to deliver in hospitals.
This campaign, among other activities, has seen the construction of waiting shelters in hospitals so that women can report early for delivery.
According to the Malawi Demographic and Health Survey (MDHS) Report of 2015/16, institutional deliveries in the country are pegged at 91 percent while home deliveries account for only seven percent – a significant rise and reduction from 55 percent and 43 percent, respectively, in 1992.
However, the rise in the number of hospital deliveries has also brought with it challenges especially because most health centres lack proper water, sanitation and hygiene (Wash) facilities.
In the case of Chamwavi, located some 17 kilometres from Kasungu Boma in Traditional Authority Chilowamatambe in the district’s south-east constituency, home deliveries have been rampant in the recent past due to lack of proper sanitation facilities at the health centre.
The situation forced women to avoid hospital deliveries.
“We did not have water nearby. We almost closed the facility because of water problems. In the end, we reached an agreement with the member of Parliament, chiefs and other committees that those that come to the hospital to seek help should first be drawing water before they are assisted,” Lottie Makowa, who is in charge
He recalls that the situation at the hospital was discouraging patients and pregnant women from seeking help there.
“For pregnant women, they could come very late or not come at all. Even postnatal and antenatal attendance was being affected. So we had a situation where mothers would come late or opted to deliver at home. Inside the hospital, infection prevention was heavily compromised because the water we were using was dirty and contaminated,” he explains.
Through a Maternal and Neonatal Health Governance Project called Kubadwitsa Chamoyo (Deliver Life) implemented by WaterAid and the National Initiative for Civic education (Nice) Public Trust, Chamwavi has benefitted from a complete Wash package that includes reticulated water supply, latrines, bathrooms, incinerators and ash and placenta pits.
Makowa says the new Wash facilities have improved the situation at the hospital especially the lives of healthcare workers and pregnant mothers.
“We are happy and we work happily. Our work is procedural and we are happy with that. Attendance has improved as women no longer fear coming to hospital because they are no longer required to draw water.
“Additionally, they are comfortable with modern facilities like toilets and bathrooms. The waiting shelter is full now,” he says.
Kubadwitsa Chamoyo is being implemented in the districts of Kasungu, Machinga and Nkhotakota – mainly through the construction of Wash facilities and involvement of community structures like Wags and citizen forums in the delivery of health services using governance approaches.
The construction works have been initiated by the Evangelical Lutheran Development Services with funding from the Department for International Development (DFID) through WaterAid while the role of Nice has been mobilising communities to be part of the development processes so that there is citizen participation, transparency and accountability.
“Nice ensures that there is citizen participation, transparency and accountability in the implementation of this project. We believe that most of the challenges we face in relation to Wash and maternal and neonatal health are a result of poor governance.
“Corruption is compromising quality in most community projects; as such, Nice through community structures like citizen forums and wags, provides checks and balances so that we get the best out of this project,” Enock Chinkhuntha, coordinator of WaterAid projects at Nice, says.
According to the project coordinator at WaterAid Malawi, Natasha Mwenda, each health centre is benefitting from Wash facilities worth K60 million on average.
“Through this project, we have seen an improvement in healthcare-seeking behaviour, increase in hospital deliveries in the targeted clinics and reduced cases of maternal and neonatal mortality. The reduction of maternal and neonatal mortality is also attributed to the work of wags,” she said.
The Ministry of Health acknowledges that healthcare services, during pregnancy and childbirth and after delivery, are important for the survival and wellbeing of both the mother and the infant.
It notes that delivery at a health facility, with skilled medical attention and hygienic conditions, reduces the risk of complications and infections.
However, gaps still remain in addressing the linkages between the absence of Wash and maternal and neonatal morbidity and mortality despite efforts by various organisations working to reduce maternal and new-born mortality at different levels.
When pregnant women attend healthcare facilities, there is an expectation that they will receive good medical care and that they and their new-born will be at reduced risk of complications. However, in many cases, they will be attending a facility that lacks safe water and has no latrine.
A 2015 WHO and Unicef report on the state of Wash in health facilities in low and middle income countries shows that 38 percent of health facilities do not have improved water sources and 19 percent without improved sanitation.
Consequently, mothers and babies can often be at greater risk of complications and can experience a worse level of care than if they had stayed at home.
Malawi’s maternal mortality ratio remains one of the highest in Africa, with 439 deaths per 100,000 according to the MDHS. And according to United Nations Development Programme’s Human Development Index of 2013, 344 million people were without safe water and 644 million without basic toilets in sub-Saharan Africa.
Kasungu District has a water coverage rate of 67 percent and 74 percent for sanitation, according to WaterAid reports.
“The spread of infection in places where patients seek care erodes the trust that people have in the healthcare system and compromises efforts to reduce maternal and neonatal mortality and morbidity. WaterAid aims to drive change so that Wash is considered a key component of healthcare provision,” Chinkhuntha says.
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