Labor

The maternity ward at Nakalanzi Health Centre

“The mother Mary suffered while she was giving birth, so why shouldn’t we?” asked midwife Soko, mother of 5, after I told her about the common use of epidurals in America. The maternity ward at Nakalanzi consists of a large room with 12 beds, and  a smaller delivery room with 3. Women come from near and far, at all hours, to deliver. If they’re lucky, they will arrive by bicycle taxi, but more often they walk, sometimes from miles away.

Malawi has one of the highest birth rates in Africa, and it is growing. On average, around 60 women deliver at Nakalanzi per month. That statistic may not seem like a lot, but given the size of Nakalanzi, and that there are only two midwives, it is a startling statistic. Earlier this year, the Malawian government enacted a law that forbid traditional healers from delivering babies (they are fined 4 goats, which is a lot in a village) in an attempt to lower the maternal mortality rate. Even though this may have prompted more women to deliver at hospitals, most hospitals, Nakalanzi included, are still ill-equipped to handle common complications during birth, including breech deliveries and malaria.

It takes more than resources to ensure a healthy pregnancy and delivery, too. A few weeks ago, I read from a government-produced (and USAID funded) teaching aid during antenatal clinic. It urged expectant mothers to eat healthy, take the proper precautions to prevent malaria, and to make sure to rest twice a day. When I mentioned this last suggestion, the women couldn’t help but to laugh in my face. Even pregnancy isn’t seen as an excuse to take it easy, especially when there is water to be fetched, firewood to be chopped, and crops to be harvested.

Once I entered the delivery room to get a record-keeping book while a woman was in the throes of labor. Amayi Soko and the two birth attendants were sitting, casually chatting, as the woman screamed in pain. Amayi Soko turned to me, smiled, and said, “One day, this will be you.” I smiled back, but thought to myself, “Thank goodness for epidurals.”


Balancing Act

Among one of the more frustrating things I do each day is carrying water from the water source to my house. In a country where girls grow up carrying huge buckets filled to the brim, I can barely manage the 30 feet despite my 23 years of age. My inability, coupled with the fact that Malawians find it quite humorous to watch, often makes water fetching an anxiety-inducing endeavor.

When I told Dan about this after a hard day where I almost spilled 20 liters in front of a big crowd on the road, he urged me to think about what it means to have to carry tons of water on your head each day, and unclean water at that.

Although water sources in Malawi are fairly abundant compared to other poor countries, the water sometimes carries viruses and bacteria if left untreated, especially from an unprotected source like an open well, river, or stream. Most common among these are typhoid, cholera, and dysentery. According to Malawi’s 2004 Demographic Health Survey (a more recent one is due this year) 64 percent of Malawian households have access to clean water, 20 percent from piped water and 44 percent from protected wells. The median time to a water source is 19 minutes.

It is important to note, however, that this “clean” water still carries the risk of disease. Many Malawians, especially in villages, do not take the extra precautions such as filtering, boiling, and chlorination because of the expense, time, and taste.  As a health volunteer here, I will teach water sanitation techniques and how to prevent water-borne illness, but my words can only go so far. Behavior change is something that takes a lot more than an hour of demonstrating the effects of water guard in broken Chichewa.

To think, all of that work to carry something that may make you sick, or even be fatal. Now, when I look at my empty buckets, I think twice before groaning. My situation cannot even begin to be compared to a lifetime of water-fetching, or having a life source be a possible cause of disease. Next time I can drink from the tap, or open a bottle of water, it won’t be taken for granted.


Don’t forget the little people

Under a large balboa tree in a village called Kasakala, a group of 30 women gather, sitting on the sandy ground, tending to their children. It is 8:30 in the morning, the third Friday of the month.  A man on a bike approaches with a cooler, some boxes, and notebooks strapped to the back.

Every Tuesday at Nakalanzi, there is an under-5 clinic, but for some families it is not feasible to travel the long distance to the center, or to make time to come. So every Friday, the Health Surveillance Assistants (HSAs) go out into the field and conduct outreach clinics in neighboring villages. Shots are administered, weight is measured, and women sing and learn about health topics. All out in the open air.

Children dangle from a scale hanging from a branch of the tree, wrapped in chitenjes, squirming and sometimes crying. Mothers offer health passports, often torn or worn out, containing the vaccination history, weight chart, and vital statistics of their child. HSAs scramble to make sense of the chaos, leafing through the pages of the passports, recording the information in oversized government record-keeping notebooks, and telling the women to line up.

Child mortality is a serious problem in Malawi, not in the least because of lack of resources and knowledge. Between epidemics of HIV and malaria, and common ailments such as typhoid and diarrhea, preventable disease and illnesses kill thousands of children each year. As of the latest health survey from 2004, the the infant mortality rate was 76 per 1,000 live births, and child mortality was 62 per 1,000, resulting in an overall under-five mortality rate of 133 per 1,000 live births. Additionally, only 51 percent of children had received all of the proper vaccinations by age 1. These vaccines prevent tuberculosis, diphtheria, whooping cough, tetanus, polio, and measles.

After weight is taken and shots are done, the women pray, and then break into song on cue. There are about six or seven different health-related songs, including one about family planning and what constitutes a proper house. After the songs, the HSAs talk to the women about a certain health topic, whether it is vaccinations, hygiene, or family planning. The women listen intently, even over the coos and cries of their children.

I often look out into the crowd, happy to know that these children are getting the right start. I only wish there were more.


.5 milliliters at a time

Nakalanzi Health Centre is a small, Catholic-run institution in a village called Mtakataka,, about 5 kilometers from Lake Malawi. Each morning at 7:20 a bell rings, signaling the start of the day. The staff of 19 congregates in one of the main waiting rooms to pray and go over announcements. The sun shines through the stucco walls and the just-mopped floors glisten.

My first day at Nakalanzi, I wasn’t expecting to do much of anything except observe. But this wasn’t an ordinary Monday. It was the first day of a national measles campaign in Malawi. This year, Malawi had a measles outbreak that killed close to 200 people and infected thousands of others, so the government funded a week-long initiative to vaccinate all children under 15.

At Nakalanzi, swarms of mothers and children piled into a tiny examination room as the health workers and I filled one-time use syringes with .5 milliliters of the live virus. We followed the UNICEF guidelines for vaccination campaigns, in which the child’s left thumb is marked with a black permanent pen to signal that he or she has received the vaccine. It is against Peace Corps policy for me to administer the actual injection (and I have no experience or credentials to do so) but the health workers were grateful I was able to help in some way since it was such a chaotic scene. Tallies were kept by community volunteers, and by the end of the day, over 500 people had been vaccinated.


Funeral

The second to last week in our training village, Chiphazi, a man hanged himself in a graveyard after a night of drinking and fighting. The morning after the suicide, I heard intense chatting and yelling in my neighborhood and knew that something was amiss, though I couldn’t figure out exactly what. It was confirmed when my amayi brought a rope to the breakfast table to help explain what had happened. Not knowing whether or not my family was close to him, I bowed my head and said sorry.

That same day, the police came to confirm that it was a suicide, and then the official mourning began. The women in the village sat in a vigil around the body in a tiny hut near the home of the deceased. Those who could not fit inside sat outside in clusters, tending to their babies, wailing in remembrance, or both. The cries undulate for hours on end, especially for immediate family and close friends.

To show respect, you enter the room where the deceased is lying without shoes and kneel to greet the family members who are mourning inside. When you shake the hands of the family members, the shake lingers, with the two people rocking hands side to side in unison. It is only slightly different from a typical handshake, but offers more comfort and connection.

The men in the village do not sit with the women during the initial grieving, but congregate elsewhere. Only when the body is taken to be buried do men and women combine, and even then the groups remain somewhat separate. The men also wail out of respect, but in fewer numbers than the women.

Grieving is a process that not only differs with culture, but also with situation. It is common for Peace Corps volunteers to attend a few funerals over the two years, but since this was a suicide, the protocol was different. Instead of singing, which is typical for Malawi, the burial only had a few speeches.


Superwoman

The day is hot, with an occasional wind that creates tiny dustbowls in the middle of the road. A woman in her mid-twenties carries her 1-year-old on her back, wrapped in a bright cloth full of patterns and colors. The baby is snug against her mother’s back, resting and hiding from the world around her.

In the mother’s left hand is an empty blue bucket, with tiny world cup 2010 logos embellished on the sides. She swings the bucket back and forth with her stride, humming a song that the neighborhood kids sing incessantly near her house.

In the distance is a borehole, with a handful of kids hanging around it. The woman approaches the water source, asking the children to pump while she holds the bucket. They do it without pause, smiling at their newfound task.

After the 20 liter bucket is filled to the brim, a few kids help hoist the bucket onto the woman’s head. This is how she will carry it back to her home, without any trouble, or any hands.

Woman in Malawi are awe-inspiring, not in the least because of their brute strength. Some days I would watch my host mother (amayi) in disbelief, whether she was carrying a huge bucket of water on her head, touching fire with her bare hands, breastfeeding her baby while eating, or chopping firewood at the break of dawn.

I saw the beginning of this strength in my amayi’s eldest child, Sophine, who turned five this past month. Sophine has a sweet smile, and wears her chitenje (the bright, all-purpose cloth) as a little cape when she’s cold. Although she’s still a bit too young to help out with most chores, my amayi has started showing her little by little. Sophine will start primary school in September, and her responsibilities will grow.

That’s why when Sophine showed me the school bag she will use in the fall, I couldn’t help but smile. It was a superman backpack.


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