Conversations between women
I am extremely fascinated by the bonds between women. As a little girl I would cheekily eavesdrop on my aunts and mother’s conversations. I remember lingering around my older sisters long enough to ‘accidentally’ overhear something I shouldn’t have. Though I loved the bulk of the gist, it was the exchange of advice and opinions about exclusively female experiences that drew me in – what women tell women about things only women experience. Last year, my curiosities lead me to Likoma Island where I interviewed mothers and health workers about maternal health (I finally used my nosiness for some good).
Maternal health on Likoma Island, Malawi
Maternal health refers to the medical attention women receive during pregnancy, childbirth and after birth. And the lack of ‘proper’ or ‘adequate’ maternal health care may lead to complications or fatalities. The World Health Organization will tell you that up to 99% of all maternal deaths occur in the developing world with up to 50% of those deaths occurring in Sub-Saharan Africa (Maternal Mortality Fact Sheet, 2014). To add salt to injury, the UN and the WHO explain that many of these deaths are preventable. In attempts to improve these stats the UN set goals for Member States to meet by 2015 (ummm, this year) known as the Millennium Development Goals (MDGs). MDG 5A is to improve maternal health by reducing maternal mortality. The 2014 MDG progress report below shows the maternal mortality ratio in Sub-Saharan Africa in 1990, 2000 and 2013 (Maternal deaths per 100,000 live births, women aged 15–49). The green line is where we are meant to be (umm, this year).
In Malawi, UNICEF states that the risk for women dying a maternal death is 1 in 36 (Fund, 2013). Clearly, there are health disparities between the Global North and the Global South but even amongst the underprivileged there are those who are more privileged than others. The difference in the access to quality healthcare facilities between the rural and urban areas is to say the least, a problem. I chose to study women in Likoma because I’d travelled to the island many times and wondered what it is like to be expectant and give birth in an area that is not only rural but is isolated (transport to the island is not the most reliable). With great privilege comes choices, on the island there aren’t too many choices. St.Peter’s Hospital is the only hospital on Likoma Island serving up to the 10,000 residents of the island and 70,000 people from nearby Mozambique and Tanzania (African Steps , 2014).
St. Peter’s Hospital has 10 nurses, no doctors, and 1 ambulance.
After spending an entire semester putting all my findings into a concrete thesis paper, I learnt just how multifaceted maternal health research is. To make this paper an easier read for you (and really to keep myself from going off on tangents) I have decided to write a series of conversations on maternal health starting off with personal autonomy. Autonomy simply put means the personal rights one has and the ability to exercise them – choices. I wondered about the dynamics of the social realties of these women and what influenced the choices when it came to their maternal health. Did they, like I, eavesdrop on elder female members of their family when conversations about motherhood came up? Did they, like I, peruse through biology textbooks studying the female body? Where did they learn what they knew about pregnancy and how did this shape the choices they made when their time came?
My sample comprised of 8 tremendous women between the ages of 20 and 54 from different parts of the island (Chinyanya, Khwazi, and Ulisa). Of the women, 1 had completed secondary school, 1 had a certificate from a vocational school, and 3 had been to secondary school. Primary education is free or subsidized if you include the costs of school uniforms and books, the women cited the lack of funds to purchase these items as the reason for dropping out of school. A report on the Nkhata Bay and Likoma districts states that 3 out of 4 women in the Nkhata Bay and Likoma districts are literate and 1 in 20 women complete a secondary education (Bureau, 2014).
What knowledge prepared them for childbirth?
Previous studies have positively linked maternal education and the development of a child. When I started asking these ladies where they learnt about pregnancy and childbirth there was no mention of school. If the majority of what they remember didn’t come from school, where did they learn it? What knowledge prepared them for childbirth? From the interviews I identified four major parties that contributed to their maternal health choices: their elder female family members, health workers at St. Peter’s hospital, traditional birthing attendants and traditional healers.
All of the women mentioned some involvement of female family members in their maternal health decisions. Aunts, mothers, older sisters and female neighbors offered them advice and would be the ones to walk them to the hospital when it was time to deliver. From pregnancy to delivery. When Mary found out she was pregnant her family sat her down and told her “You are now between life and death. You have to stay strong and not cry.” One of the Chichewa words for pregnancy is pakati, which translates literally into the ‘middle’ or ‘in between’– pregnancy being the state in between life and death. Mary’s family and the families of the other mothers in this study made her cognizant of the risks of pregnancy and childbirth. Limbani’s family warned her not to cry during her pregnancy and delivery because crying could constrict the birth canal. When Beatrice’s water broke and she waited on makolo/ parents or akuluakulu or elders (women who had delivered before) to tell her to start walking. One night a pregnant Gloria was restless and saw a red stain on her panties and ran to her mother and aunts who told her it was time. When Mary fell during her pregnancy she told no one, she went home and kept going to and from the bathroom. Mary says that her aunts and her mother kept asking her if she’d fallen and she kept denying it. “I don’t know how they knew. They are wise because have given birth before. They insisted I go to the hospital.”
One of the Chichewa words for pregnancy is pakati, which translates literally into the ‘middle’ or ‘in between’– pregnancy being the state in between life and death.
Another group of individuals that influenced these women’s decisions are the highly controversial yet widely used zambas or traditional birthing attendants. Malawi stopped licensing traditional birthing attendants in 2007 in attempts to help curb maternal and infant mortality rates (Analysis, 2007). In 2011, that ban was lifted in by Dr Bingu wa Mutharika yet in Likoma mothers and zambas face fines for homebirths.Many of the women in this study showcased a reliance on traditional birthing attendants not only in making their decision as where to deliver but also as antenatal care advisors. A zamba was called when Anne started feeling labor pain. Reaching into Anne the zamba felt the baby’s hair and knew that Anne would not make it to the hospital by ambulance or by foot, so she delivered the baby. Some zambas travel from village to village advising pregnant women, other zambas attend to the women within their community and are there for them throughout the pregnancy.
It was from a zamba that Limbani says she first heard of where a baby comes from.
Wearing my chitenje around my hips and rocking a buzz cut, I tried to not look conspicuous as I observed the antenatal clinic at St. Peter’s hospital. A health worker opened each session with a prayer and then led a group of about 15 women in a few songs about self-care and childcare. I watched as the women were weighed and chaperoned from room to room with their yellow health books in their hands. It is here where the ladies undergo medical tests, are told about their condition, told about nutrition, informed about warning signs, given fansidar, iron tablets as well as mosquito nets and are asked to come in two weeks before they are due with supplies (cloths, a bucket, food, and sometimes a razor blade). The women mentioned some of the danger signs, good hygiene habits and what foods to eat that I overheard the health worker tell other mothers. Monica, a first-time mother, remembered that vaginal bleeding, a racing heartbeat, back pain, dizziness and swelling are among the danger signs and that experiencing any of these things was indication that it was time to go to the hospital. Gloria commented on how she paid close attention to what she was told at the hospital after all “They are learned, I am not. I listened to all they told me”.
Traditional medicine also played a role in the decision-making of some of these mothers. 6 of the 8 women in this study reported going to a traditional healer at some point during their pregnancy and one woman said she saw no difference between a traditional healer and a ‘skilled’ doctor. Limbani stated, “I would still go to the traditional healer even if the hospital was near by”. Those who visited a traditional healer entrusted them with treating their reproductive issues like infertility, repeated miscarriages and abnormalities in the development of the fetus. Gloria credits a traditional healer with curing her infertility. When she was pregnant Limbani could not feel her babies kicking so she went to the traditional healer who gave her chicken and tealeaves that she believes helped. Lisungu stated that after having three miscarriages she went to the traditional healer for her fifth pregnancy and the medicine he gave her resulted in her healthy son. From our conversations about traditional medicine it was clear to me that the women who endorsed traditional medicine understood that because pregnancy is a state between life and death it makes women vulnerable to outside interference that could cause problems in their pregnancy.
Talking to these women I learnt that though a majority of them did not have formal education their families, zambas, antenatal clinic visits and traditional medicine all prepared them for this exclusively female experience. When in between life and death on a rural and isolated island with limited choices mothers made due using what they had.
African Steps . (2014). Retrieved from African Steps: http://www.africansteps.org.uk
Analysis, H. N. (2007, October). MALAWI: Role of traditional birth attendants to change. Retrieved from Humanitarian News and Analysis.
Bureau, P. R. (2014, September ). Smaller Families, Healthier Families in Nkhata Bay and Likoma Districts. Retrieved from Population Reference Bureau .
Fund, U. N. (2013, December 27). UNICEF Malawi. Retrieved from UNICEF: http://www.unicef.org/infobycountry/malawi_statistics.html
Nations, U. (2009). Millennium Development Goals and Beyond 2015. Retrieved from United Nations: http://www.un.org/millenniumgoals/maternal.shtml
World Health Organization. (2014, May). Maternal Mortality Fact Sheet. Retrieved from World Health Organization: http://www.who.int/mediacentre/factsheets/fs348/en/