The next day we set off for the second half of the trip to Chitipa. Got to see the beautiful Lake Malawi for the first time, in a landscape that transitioned to cloud-covered forests.
We visited the Chitipa District Hospital and spoke with the management there, then went to visit a few of the health centers (which for most people are the first level of contact with the health system). If people have a problem the health center can’t address, the health center refers them to the district hospital. This seemingly-straightforward directive becomes more like an odyssey in this district. To try to give a sense of the difficulty of following the request “Go to the district hospital”, I’ll try to frame a hypothetical scenario (formed of the stories of many people I talked to on the trip) like a story:
Mwandida is 7 months pregnant with her fourth child and wants to go for a check-up. She lives in a small house on this mountain:
From her house it’s a three-hour walk to the main “road” (the paths are so steep that no cars or bikes can make it up them). The main road is a narrow dirt path with huge potholes. From this road, it’s about 20km (12 miles) to Ifumbo, the nearest health centre
which is staffed with two nurse-midwives and a medical officer (like a doctor but less training). The two nurses are supposed to both be available during regular business hours, but they’ve decided to trade shifts such that one is on duty 24 hours a day and the other one goes home; after a week they trade. Since only one is on duty at a time, they are tired and overworked. Even though women should come for their first antenatal care visit as soon as they know they’re pregnant, many nurses will turn women away if they’re not “showing” to reduce their workload. By the time Mwandida has reached the health center and gets to see a nurse, she is having pangs that may indicate the early signs of labor.
There is no power at this health center; there is a solar panel that worked for some time, but it needs a new battery which the district hospital, after two years, has yet to replace. So by 6pm, any procedures, no matter how delicate, must be done by candlelight.
Knowing the difficulty of travelling these distances when labor has started, many women in Malawi prefer to come to “waiting homes”, where they basically hang out for a week or two before delivery. Only women with some money and a “guardian” can do this, because that guardian, usually her mother-in-law, must daily fetch water and charcoal for cooking. Mwandida may not feel it’s worth it to wait at the Ifumbo health center’s waiting home, though:
Despite the known danger of delivering at home, many women prefer to give birth in the warm friendly atmosphere of their houses. Given the building’s condition, women who do choose to wait here are sitting outside; the room itself has become a store-room for charcoal and vegetables.
The nurse recognizes some potential danger signs: Mwandida’s hands and face are swollen, meaning she’s at risk for a condition called pre-eclampsia which kills thousands of women in Malawi each year. Malawi’s high maternal mortality rate, though dropping, speaks to the risk that pregnancy poses to a woman’s life if complications are not addressed. The nurse refers Mwandida to Chitipa District Hospital, which is about 50km (30 miles) away. [During the field visit, this stretch took us over 2 hours to drive, in a fairly new 4-wheel drive vehicle. The time would have been double during the rainy season, when large sections of the road become nearly or completely impassable to even cars.] The district hospital does have one ambulance, but between the bad roads, high demand and the persistent fuel shortages in Malawi, last time there was an emergency it took over 6 hours to arrive at Ifumbo. If Mwandida is lucky, Ifumbo may have a “motorbike ambulance”:
But even though Ifumbo should have one, the district has not yet distributed theirs, so it’s sitting, new and unused, at the district hospital. If Mwandida decides to and has the money, she may instead make the journey via a cart pulled by two cows.
If (by now you can tell there are a lot of “if’s” in this story)… If Mwandida does eventually manage to reach the district hospital—and has not delivered in the oxcart along the way—she will be able to deliver here:
where an actual doctor should be on hand to address complications. But until her baby comes, she will wait outside in the corridors
because the hospital’s waiting home (though in better shape than Ifumbo’s) is far too small to meet the demand. UNICEF donated a large tent for women to wait in, but no one uses it because visitors have to pass through it on their way to the morgue, and people feel it’s bad luck for a pregnant woman to be staying there.
Hopefully, if all the right conditions are met, Mwandida will undergo a safe delivery and bring home a happy and healthy newborn.
This story is fictitious, but each piece of it represents a scenario that women living in the outskirts of Chitipa may face on average 6-7 times in their lives when they become pregnant. I did my best not to over-dramatize the components, and simply reflect what we heard during our field visits.