Malawi getting to zero maternal deaths: Charles Simango ‘Thinking Aloud’

 There was once a District Commissioner (DC) for Fort Manning, now Mchinji, known as Bwana Canyon. This DC had a reputation for stopping funeral processions whenever he came across one so he could inquire about the gender of the deceased. If the deceased happened to be male, the DC would, politely, request the pallbearers to put the reed coffin down (in those days the dead were wrapped in reed mat). Then, without warning, Bwana Canyon would go into a tirade, cursing and kicking the dead man until the reed mat came asunder.“Bambo wopusa, iwe!” he would scream in Chichewa, “Wathawa msonkho!” (You stupid man, you have run away from paying tax!).

In those days, all men were required to pay some annual tax and any man’s death was, according to Bwana Canyon, an act of betrayal to both the Queen and the British Empire. And he took it upon himself to be punishing the dead.

Well, as a result, whenever a funeral procession ran into Bwana Canyon, all corpses, regardless of their gender, were female.

Much as his actions were a bit of an overkill, I believe that his model can be applied, today, to effectively deal with a more serious and yet avoidable situation – the alarming numbers of Malawian women dying due to pregnancy and child birth complications. Just today, no less than five women will die due to these complications. A similar number died yesterday; another set will die tomorrow with yet another lot dying the following and each day after that, for the rest of the year.

Now, you will be forgiven for thinking that I am suggesting that the best way to stop this madness is by kicking the corpses of women who die in this manner. Close, but not quiet. My proposal, rather, is that we should start punishing, not the dead, but the living on account of their dead. My target, here, is those who get paid for looking after the welfare of people in communities – chiefs. And, yes, the punishment will, somehow, involve corpses.

Picture this. A woman and, probably, her baby die needlessly during delivery. Needless because mother and baby would have lived had the chief done his job: making sure the woman is old enough before she is allowed to take on motherhood and then making certain that she and everyone else in the village is well educated about matters antenatal.

But because the chief did not do his job, the woman believes that some witch in her village will use magic to steal her baby during delivery and so she decides to conceal the onset of her labour and proceeds to have her baby delivered in the secrecy of her home. As bad luck would have it, complications follow and she dies.

Using my ingenious, safe motherhood solution, this death would not even have happened. In fact, I can guarantee that I would be able to attain 0% maternal deaths within a year by applying one, simple, measure: make the chief pay. And this is how it would work.

Canyon Model

Every village headman will be held responsible for any maternal death that occurs in his or her village. I would have them arrested and then fine them heavily or let them serve 9 months with hard labour. I would also fine the group village headman to whom the village headman reports, and similarly, the sub-traditional authority, then the traditional authority and go all the way up to senior chief and paramount chief of that area.

At more than 5 deaths per day, my Safe Motherhood Program would actually become self-financing with hordes of cash to spare – or for that matter, lots of cows, the preferred currency of the chiefs.

Now, I am aware that some clever chiefs are imposing some form of punishments on their subjects for failing to adhere to safe motherhood standards. I have two problems with this.

Firstly, it is clear that such chiefs are doing this on a voluntary basis, which, in my book, is wrong. At 5 deaths per day, Malawi is in a state of war and you do not fight a war with volunteers. You conscript, you recruit by force.

Secondly, by imposing the punishment on their subjects, these chiefs are excluding themselves from the list culprits. That is not right. They are the ones who get paid for taking care of their subjects’ welfare; they should also be the ones to take the flack for any failures.

Anyway, as stated earlier, my solution would definitely see Malawi’s maternal death rate plunge to the lowest numbers, worldwide. In fact, there would very few maternal deaths if any at all from the very day I make the pronouncement. And therein, lies the problem.

You see, the sudden end of maternal deaths would not be due to the fact that women would stop dying due to childbirth complications. Women would continue to die but the chiefs would find ways of preventing the reporting of such deaths. No chief would willingly choose to expose himself to punishment. As a result, maternal deaths would go underground with chiefs and everyone participating in the cover up. And this is where the Canyon antics would become handy.

Using the Canyon Model of Compliance and Enforcement, I would ensure that no dead body of a female of childbearing age is buried without medical approval. On top of that, I would also establish a funeral police to be patrolling villages, stopping funeral processions to investigate corpses. I would also set up an anonymous reward system to encourage members of the general public to report such deaths, anonymously. Yes, it will cost a lot of money, but don’t all good things do? Besides, this Safe Motherhood Program would be self-financing, remember? Fully, funded – by the culprits.

But fortunately for our chiefs, I am not in charge of the Safe Motherhood Program in Malawi. Instead of arresting and punishing them, President Joyce Banda and her Presidential Initiative on Safe Motherhood are actually wining and dining the chiefs.

“Please”, she says, ‘try not to let women die during labour’.

But maybe – just may be – the president is right. You see, for some reason, we, men tend to prefer fixing things instead of working things out. It is just bad genes, I suppose, but somehow, every man seems to be hardwired to think like a hammer, seeing each and every problem as being nothing but a steel nail. In real life, though, very few problems are nails and not all nails need the force of a hammer. Some types of nails need coaxing. You will get nowhere with a hammer, for instance, when dealing with screws. You will need a screwdriver – and lots of patience.

Walking dead

Similarly, most of our social problems, maternal deaths included, are caused by more than just one factor. Granted, the bulk of maternal deaths are a direct result of failure to attend and adhere to antenatal care and advice. But maternal deaths also occur right in hospitals, taking the lives of women who have been anything but compliant.

A good friend of mine, someone I shared a desk with in college for four years died during her very first childbirth. And it was not for lack of compliance or anything like that. In fact, she went for and received the best antenatal care her money could buy. At least, until things all went wrong during labour.

Then there was a cousin of mine, a couple of years my junior. A village girl, poor as a church mouse. She, too, followed all the antenatal advice she could get. Even spent the last days of her pregnancy at the hospital, waiting for her due date. When her time came she was wheeled to the delivery room. And, a couple of hours later, she was wheeled back – dead.

Two women. One was a graduate with means that enabled her to pay for private antenatal and maternity service.  She may not have been rich but she, certainly, was not poor. The other was uneducated and poor. So poor she had to spend days at the hospital waiting her due date or else she could not make it to the hospital in time. They both lost their lives while giving life.

It has no favorites, this monster called maternal deaths. It takes graduates and village girls alike, it does not discriminate between poor and rich. Surely, chiefs can help form the first line of defense in this war. But bringing maternal mortality under control will require more than just one intervention.

As of today, hospitals across the country can barely cope with patients due to dire shortage of medical staff.Meanwhile, the erratic supply of delivery kits, critical drugs and other supplies continue to dog the health sector. And where personnel and facilities are in such short supply, successful delivery even of the simplest of pregnancies ought to be celebrated as miracle. Pregnant women who have had a lot of children as well as those who get pregnant at a very young age are as good as walking dead.

Sleeping nation

It is a daunting task, dealing with maternal mortality. But thanks to HIV and Aids we are battle-hardened veterans of plague wars. We are doing well with HIV and Aids. It is not over yet but the scourge is, certainly, not flying its flag on the rooftops of our citadel. And the one single secret we learnt from this war was to fight together, fight everywhere, and fight with anything. Every person, every community, every organization, has had to dip into the basket of war, pick their battle and go to war. For such wars are best won by winning the small battles, a lot of them and securing the gains as we advance.  Mainstreaming, they call it.

Sadly, I must say, I am not seeing much of that in the war for safe motherhood. I believe the president is doing a great job and her team is making the right noises. But she cuts a lone figure, standing there, trying to rally a nation that is, to me, sleeping. I was hoping to see the nation respond in kind with the right support by doing their part as it happened with the war on HIV/Aids. Somehow, I am not seeing much of that.

There is very little, if any, closing of ranks. I am not seeing organizations rise up to the occasion in numbers needed to form the required critical mass. Efficacy at individual levels is almost absent while those communities that are engaging are mostly doing it in isolation.

But it is possible that I am feeling this way because I am, personally, affected. I must say I was really angry about those two deaths. I still am. I could not believe people still die from maternal complications. It was like when a friend or relative dies from malaria. You feel sad but for the most part you feel angry that it happened because you know death by malaria avoidable. And most of the times you are angry with yourself for having done nothing.

May be that is what is required to make sure everyone is affected. And I may just have a plan for doing that: No dead woman should be buried without medical clearance. And all male corpses must be checked for proof that they are actually male. Put roadblocks everywhere. That way everyone will be affected. And maybe that is what it will take for the nation to rise up in arms against this enemy.