As Salom Tsoka drives the one-hour journey to work each morning concerns about his two sons, aged three and six, haunt him: will his youngest son have an asthma attack today? Will the childminder watch out for them? Is he parenting the kids the way their mother would? And the more he thinks about them, the more he thinks of his wife, Elita.
“I am having a tough time balancing work and life. These children were more close to their mother,” says the 39-year-old widower.
Nine months ago Tsoka, who lives in the Malawian capital Lilongwe, lost his wife and newborn triplets in a scenario which even now he is failing to come to terms with. “We only found out they were triplets during delivery,” he says. “Throughout [the pregnancy], we were told that she was expecting twins. When she was six months pregnant, she had an infection, and when we visited the hospital she was administered with an antibiotic which, we found out later, triggered labour and she delivered prematurely.”
Unfortunately, the hospital did not have his wife’s blood group, leaving Tsoka to travel to other clinics trying to find the right blood, while his wife lay unconscious.
“The doctor later referred us to a central hospital, but he didn’t come to see her. He gave instructions on the phone. He never turned up until things fell apart.”
In this part of sub-Saharan Africa, Tsoka’s story is a familiar one. While worldwide there has been an overall reduction in the number of maternal deaths, sub-Saharan Africa lags behind. In 2015, 20 countries there had more than 500 deaths for every 100,000 pregnancies – Sierra Leone had as many as 1,360.
The World Bank puts Malawi’s rate at 634 deaths for every 100,000 pregnancies. USAid says it is higher at 675, although the ministry of health claims a much lower figure of 439.
Whatever the true figure, it will always be one too high for Paul Chisuse who also watched helplessly as his wife and baby died last year. “A day before her death she was fine and she even went to school,” said the 40-year-old father of three, whose wife was doing an MBA. “The specialist used to say the baby was bouncing but wouldn’t be born in a normal way and recommended a caesarean section.”
“So I was surprised on the day of our appointment when the nurses gave her drugs to induce delivery. We stayed from 11am to 9pm at the hospital but the specialist would not come to see her. He said he would only come the following morning if my wife didn’t deliver normally. He then stopped picking up the phone.”
By the next morning, Chisuse’s wife was dead from a ruptured uterus and the baby from taking in the blood. The specialist later admitted she shouldn’t have been given the drug in the first place.
These experiences are what led both men to become part of a movement of bereaved relatives, pushing for changes to maternity care in Malawi.
Moved by testimonies from other people during his wife’s funeral, Tsoka started No Woman Should Die Giving Birth, an organisation aimed to be “a voice to young mothers out there who are concerned with the ‘life-death’ scenario in Malawi”.
“We want to ensure that hospitals and workers are held accountable and supervised. We’d be happy even if one woman and baby were saved as result of our efforts. No woman – no one – should go through what I went through,” he adds.
The organisation aims to advocate for the recruitment of patient advocates who will bridge the information gap when maternal death occurs. Apart from investigating maternal-related deaths, it also aims to ensure transparency and accountability and would like to lobby for more resources for maternal health care.
The men are up against some huge institutional challenges, however. “The major reasons for [deaths during childbirth] are the critical shortage of health workers and long distances to hospitals,” says Dorothy Ngoma, president of the National Organisation of Nurses and Midwives of Malawi.
The health workers who are available are overworked. Ngoma has recorded complaints of her members working 24-hour shifts and one nurse at a remote clinic in Mulanje district described to the Guardian how should would oversee as many as 10 births in a 12-hour shift. If there was a complication with any of the births, the nurse is reliant on there being an ambulance available to transport the mother along a dusty, bumpy road to the district hospital, about 20km away. There’s a lot of scope for things to go wrong.
Ngoma believes the shortages aren’t just down to social-economic challenges though, but a lack of political will.
“Malawi needs about four times the current number of 4,000 midwives and nurses to curtail preventable deaths of pregnant mothers. But as I am speaking now, the government has not recruited all the nurses and midwives [who graduated in 2016].”
And where nurses and midwives are few, doctors here are needles in haystacks. There are only 300 doctors for a population of 18 million, according to Action Aid.
Like other African countries, Malawi suffers from “brain drain”, with its medical professionals seeking to work in wealthier countries, when they can’t find adequate employment in their own.
Peter Kumpalume, Malawi’s minister of health, says that the ministry will ensure it has enough resources to recruit all graduates and encourage donors to invest more in the health sector so “our graduates have no need to travel abroad for jobs”.
He says they are doing all they can to curtail the situation including conducting specific training for staff in the field and encouraging women to give births at facilities. He did not comment on the distance pregnant women currently have to travel to hospitals if they wish to give birth at one.
He did argue, however, that clinical officers and medical assistants, while not being included in Action Aid’s statistics, operate at the same level as doctors, adding: “We won’t compete with other countries and we don’t intend to. But we strive to provide excellent working environment for all staff.”
For Tsoka, changes can’t come quick enough. “We are now seeing many people coming forward who went through similar pain like me,” he says.