George Nkhoma is a midwife in Malawi. Growing up without a mother – because she died while giving birth to him – has made George passionate about the state of maternal and newborn care in the country. The zealous midwife is now an advocate for Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) for White Ribbon Alliance (WRA) in Malawi, and his community recognizes him as being exemplary in his work as he is very helpful and, unlike other midwives, treats them with respect. But George is often seen as the exception.
Citizens’ Hearings held in Malawi brought to light that many midwives often treat expectant mothers disrespectfully during childbirth at the health centers and hospitals. “We are suffering in the hands of these midwives, they beat us, shout at us saying ‘I have examined you already, it’s not yet time for another examination. They don’t bother to listen to you,” one of the women said during a Citizens’ Hearing session held under the theme “Communities must demand quality maternity care and recognize a midwife.”
The disparities between respectful and disrespectful maternity care were discussed during the RMNCAH Citizen-led Accountability Coalition Campaign Strategy and Capacity Building Workshop in Maputo Mozambique, where a coalition of partners shared their experiences in organizing Citizens’ Hearings, how they’ve helped strengthen government accountability and ways to make them more effective.
Championed by WRA and its partners, Malawi’s Citizens’ Hearings started in June 2016 and have so far taken place in 10 districts in the country attracting more than 6,000 citizens. It’s a bit hard for people to leave their work or families to attend community meetings. WRA Malawi and partners used the allure of traditional dancers to attract the masses to the hearings where community members share their views and opinions. And that is how it came to light that communities viewed the mistreatment by midwives as their greatest challenge to maternal, new-born health.
One mother had this to say:”I have been beaten at the health center by a midwife. She said she was not the one who impregnated me, I should be calling my husband, not her, I should not bother her.” Only one community, from the 10 communities where the hearings were held, was happy with their midwife to the extent of asking their District Health Officer (DHO) not to remove this midwife from their Health Center or face protest.
The communities also revealed many other challenges they face in the health center, challenges for the midwives themselves including lack of water, electricity, and ambulance services and poor maternity infrastructure. Accessing health services is further curtailed by long distances to the health facility.
Malawi, which is riddled with a maternal mortality rate of 574, has a high incidence of teen pregnancies and deaths due to the numerous complications that these young mothers suffer at the door of child birth. Other challenges include the lack of male involvement in maternal and new-born health care, older women in the communities discouraging pregnant women from going to the hospital when labor has just started and poor communication between the midwives and patients. George Nkhoma talked about other challenges faced by midwives in Malawi, sometimes keeping them from providing quality maternity care such as shortage of staff, lack of adequate resources including funding from the Ministry of Health, lack of recognition of midwives, lack of recognition by their superiors and the problem of magnifying only issues where a midwife has done a wrong thing. After the citizen hearings and with more support from WRA and its partners, Malawi has registered improvements in service delivery.
The matrons who head the maternity units in these health centers reported the communities’ displeasure at the disrespect and abuse to their subordinates. They also started conducting monthly meetings at the departmental level to remind and encourage staff not to be abusive and disrespectful. Respectful Maternity Care is now included in staff performance appraisals. This has helped to improve quality of care given to women in maternity departments and many women are acknowledging the change in behavior of most midwives. The responsible authorities have also installed solar power in health facilities with no electricity and ambulances have been provided in areas where the citizen hearings were conducted, improving conditions for midwives and the women seeking their care. Additionally, there is commitment from community leaders to push for and deliver upon the demands of the people. TA Mwaulambya, a community leader in Chitipa district had this to say: “We will ask the community members to contribute money to buy mattresses for the hospital. We must not leave everything for the government, let’s take part.”
Remarkably, the citizens are taking a greater interest in their health decisions. For example, when the citizens in Makata, Blantyre complained about the lack of infrastructure, a maternity wing was built. However, the building is already falling apart due to poor workmanship and the community is taking none of it. They are taking their DHO to task for engaging this contractor without involving them, the reason for the shoddy work.
The Ministry of Health has also employed Nurses/Midwives who finished school but were not employed. These new midwives have been deployed to some of these health centers. A councilor in one area volunteered to mobilize his fellow councilors in the catchment area of the health facility to fundraise for allowances of part time midwives to improve numbers of midwives on duty. When an article appeared in the newspapers about the long distances that expectant mothers have to travel to access ANC services, Lilongwe City Council opened an outreach ANC in response to the article in the newspaper.
The challenge of teen pregnancies is also being addressed. By-laws have been developed to protect teen pregnancies and early marriages. This has been done with resource assistance from Gender Equality for Women Empowerment (GEWE) and Livingstonia Synod AIDS Program (LISAP) to consolidate the by-laws. In collaboration with courts, now a man who impregnates an underage girl is taken to court and charged. The drafting of these laws involved relevant stakeholders including police and magistrates. The community has appreciated WRA Malawi and partners for giving them a platform to speak about their health concerns which has led to improvements in service delivery.
This post originally appeared on the White Ribbon Alliance blog.