Maintaining momentum: the role of ‘chapters’ in Malawi’s safe motherhood movement
By Enock Mnyenyembe and Nancy Kamwendo, WRA Malawi
The challenges of making it to Koche Health Centre in Mangochi District in Malawi at night, were worsened by watchmen who forced women in labor to pay for access to the facility. This was a frustrating setback to women in the throes of childbirth who, in most cases, did not have the money demanded by the watchmen, and had travelled long distances to access the facility. When members of White Ribbon Alliance-Njereza Chapter, whose area includes Koche Health Centre, learnt about this malpractice, they alerted the centre’s management who disciplined the watchmen, immediately stopping this habit.
White Ribbon Alliance Malawi (WRA Malawi) has fourteen chapters spread across seven districts. These chapters are comprised of volunteer members from the community who help ensure that all pregnant women can and do access skilled maternity care. Chapter members include local area leaders, health workers, housewives, clan heads, business people and teachers, among others.
Passionate and committed to reducing the number of maternal deaths in Malawi (currently at 439 maternal deaths per 100,000 live births), WRA Malawi trains these volunteers to identify maternal and newborn health problems in their communities and to address them using existing resources and structures. As a result, WRA Malawi chapters form a valuable grassroots network that can support pregnant women in many parts of the country.
To improve the performance of these chapters, WRA Malawi conducted a series of workshops with all 14 of its chapters. Chapter members were educated on various issues including the importance of attending antenatal check-ups and delivering in a health facility, the rights of child bearing women, the significant role a trained midwife can play, how to recognize and address disrespect and abuse, and how to promote the overall rights and responsibilities of women and the community regarding maternity care.
How chapters are promoting safe motherhood
The leading causes of pregnancy and childbirth related deaths are preventable, but only if communities understand the causes and how to address them. That is why WRA Malawi advocacy strategies include educating and empowering people about their health and rights so they know what quality healthcare looks like, and then demand it. For example, in Chipwera, chapter members often bring people together with village headmen to discuss their rights and responsibilities regarding maternity care. They solicit reports from citizens on existing challenges in their community and suggestions about how to deal with them. One result was that community leaders developed by-laws that encourage women to deliver at health facilities where they are assisted by skilled birth attendants and receive antenatal care by the third month of pregnancy. These initiatives and subsequent standards go a long way ensuring healthy women, pregnancies, births and newborns.
In regular workshops and trainings, WRA Malawi equips chapters with skills to influence decision makers to respond to their communities’ needs. An example of this happened in Kasungu District where they had built a new Chilembwe Health Centre, but it had to be closed because there were no health workers. Chapter members brought up this issue with their Member of Parliament who in turn engaged the District Health Officer (DHO). In response, the DHO assigned a midwife to the facility and opened it to eliminate home deliveries in the area.
Early marriages and teenage pregnancies are some of the leading causes of maternal and childbirth-related deaths in Malawi. However, many communities are ignorant about the implications of marrying off underage girls, making it a generally acceptable practice. In advocating for safe motherhood, WRA Malawi’s Kankondo Chapter organized sensitization campaigns about the dangers of teenage pregnancies in their community. Working together with their community, chapter members have so far helped to withdraw 15 girls from early marriages.
Other examples include:
· Mangochi Chapter members work to discourage entrenched cultural beliefs about early marriages and sex with young girls who have just come out of initiation ceremonies.
· In Chinyamba, the long distance to the health facility contributed to women delivering on the way to hospital or giving birth at home. Chapter members working together with the community leaders mobilized community members to construct a health centre at Kapyanga, which is much nearer to the community. This health centre is now open and women no longer have to walk long distances to access health care.
· In Wimbe, chapter members realized that women who were referred to Kasungu District Hospital would still go to Wimbe Health Centre because they were not aware of the reasons why they were referred. Chapter members involved health workers to better explain reasons for referring women before the onset of labour.
· Kankondo Chapter, also in Kasungu District, was experiencing the same challenge. Women who were referred to Kasungu Hospital to deliver would go to their pastor to pray for them not to go to hospital and instead give birth at the local health centre. As a member of the WRA Malawi chapter, the pastor prays for them but also encourages them to go to the district hospital and the women now understand and comply because of his encouragement.
Successful community engagement needs to consider the local context. After the new marriage law increasing the age of marriage from 16 to 18 years was passed, Chinyamba Chapter conducted an awareness campaign to educate their community about the benefits of the new law with respect to safe motherhood. To their shock, community members who gathered for the village meeting started walking off. It later emerged that the culture of this community considers public discussion of marriage issues uncouth, hence the walk-off. Nevertheless, Chinyamba Chapter persisted with more engagements about the increased risk that teenage girls face during pregnancy. With time, community members started to appreciate the information that the Chapter was sharing with them and started to cooperate by resisting to marry-off their underage girls.
WRA Malawi Chapters have also done a lot of work to integrate men and educate them about their role in ensuring healthy women, pregnancies, childbirth and babies. In Chinyamba, men were not interested in taking part in maternal care issues. But, with persistence from the chapter, men have started going to the clinics together with their wives, where they receive couples counselling and test for HIV together.
After educating their community, Masyesye Chapter members went back to check on health statistics to determine if their work was having impact on community behaviour. They were happy to learn that 45 women had been escorted to antenatal care (ANC) visits by their husbands, 55 women had delivered at the hospital and there were no home deliveries.
Chapters eradicating disrespect and abuse in maternity care
During the chapter engagements, it was revealed that disrespect and abuse is the leading reason women in labour prefer to give birth away from most health facilities. We know that when women are treated respectfully, they are more inclined to go to health centres, and the reverse is also true.
There are numerous examples of WRA Malawi chapters addressing this issue:
· Masyesye Chapter sent one member to the hospital to conduct exit interviews with women to check on issues of disrespect and abuse, and all women reported that they did not experience any. When cases of disrespect and abuse do come up, chapters step in to make sure they are addressed. At Mpondasi Health Centre, a woman complained that she had been abandoned and delivered without assistance from the midwife. When Mpondasi Chapter members learnt this, they intervened and the midwife apologised to the mother and the case was settled amicably.
· In Mulanje, chapter members intervened in a tragic case where a woman referred from their health centre to Mulanje District hospital lost her life due to negligence. The chapter raised the case with human rights bodies and the Nurses and Midwives Council. The midwife and the ward-in-charge were suspended. In another case, a midwife at Mulanje Health Centre was disrespectful and abusive to pregnant women. Chapter members raised the case with the District Health Officer, who transferred the abusive midwife and appointed a new midwife in her place, who women report is very good and caring.
· In Dowa District, Mponela Chapter intervened when a male midwife slapped a new mother for holding a mother badly when he was administering medicine. When the midwife refused to cooperate with the charges at hand, chapter members informed the District Health Officer about the issue and the midwife was suspended.
· In Dedza District, Mtakataka chapter has experienced a drastic drop in the number of disrespect and abuse (D&A) complaints since they started community sensitization on the issue. “If all midwives were like these, motherhood would have been easy and not dangerous,” the chairperson of Mtakataka Chapter commended the improvement in the way midwives were treating expectant mothers, further encouraging them to give birth in health facilities.
Innovations and sustainability
Chapters have also started to explore innovative ways to financially support their initiatives. In Chinyamba, members together with their community bought two mats to be used by women to deliver at the hospital. They were also able to financially assist more than 15 women with transport to enable them to deliver at the hospital. To permanently deal with the transport challenge for women in labour, they are now fundraising to buy a bicycle.
Such have been the achievements of WRA Malawi chapters, which have proved to be an effective way of engaging citizens in the safe motherhood movement. Community members are happy to be part of the solution to problems affecting them. They have seen change happening because of their engagements, driving momentum to advocate for safe motherhood across the country. In some districts, the chapter model has turned out to be a fantastic way to sustain White Ribbon Alliance advocacy efforts within the communities even after projects have ended, which is the heart of the WRA movement.
When you involve people, progress accelerates and everybody wins.