Notes from the Field: Malawi #1 (Global Understanding)


This column is the first of four from Malawi and illustrates one of the ACNM Global Health Competencies. If you are interested in submitting a Notes from the Field column, please read the instructions for submission to be considered.

Addressing ACNM Global Health Competency #1 Global Understanding

I’m now 68 years old. Long ago, in my twenties, I lived and worked in Kenya for four years, building and teaching at a fledgling secondary school in Nyanza Province with my husband, Chris. We loved our time in Kenya and have kept up friendships over the past 40 years with former students, politicians, and teachers.

In the decades that followed, I took time out from my Maine midwifery career to do some short-term stints in India, Armenia, and central America, usually working for 4-6 weeks at a time. Then, when I ended my Maine practice two years ago, I found I wanted again to experience the joys and challenges of working abroad.

My good friend, Linda Robinson, who is also a Maine midwife, was writing a weekly blog about her work in Blantyre, Malawi. She and her colleagues at Kamuzu College of Nursing were doing some initial work to create a Midwifery Led Ward at Queen Elizabeth Central Hospital (QECH). Her initial commitment was for one year through Seed Global Health. She loved the work and extended her contract for a second year. As we corresponded, I decided to apply to Seed Global Health myself to see if I could be placed either in the same position that Linda was currently in, or in another midwifery position in Sub-Saharan Africa.

Seed Global Health ultimately invited me to take over where Linda was leaving off in Malawi. I had the huge advantage of knowing Linda for many years, and we were able to have several conversations before I left the US. I felt well prepared to do the work that was assigned to me. If all went well, I would have the pleasure of helping to launch a Midwifery Led Ward within QECH over the next year, as well as of being an instructor for midwifery students at Kamuzu College of Nursing.

When I first arrived in Blantyre, I went through a mandatory six-week orientation program at the hospital. The six weeks of mostly observation allowed me to meet many of the midwives who work at QECH, as well as the Deputy Hospital Director. The average number of deliveries at QECH is 40 a day – vastly greater than the delivery rate in Portland, Maine!

Main Entrance to Queen Elizabeth Central Hospital

Malawi is one of the poorest countries in the world, with high maternal and infant mortality rates. The birth rate is 40.7/1000 population. The infant mortality rate in 2019 was 40/1000 live births. Life expectancy is 63 years. I saw these numbers up close on my first day in the labor ward, observing the deaths of three newborns and one mother, all in one shift. I went home crying, with a deep sense of despair.

One-fourth of Malawi is taken up by Lake Malawi, the fourth-largest freshwater lake in the world by volume. It is home to more species of fish than any other lake on earth. Because of the lake and a robust rainy season, water scarcity is not a problem for Malawi, but water sanitation and delivery are. The hospital often does not have running water in the sinks. The city of Blantyre has a water system, but sometimes there is no water, and most foreigners either filter or boil the tap water before drinking it.

Food scarcity is another challenge for Malawi. With 18 million people living in a country the size of Pennsylvania, if the rains do not come on time or are not consistent, the maize crop fails, leading to widespread hunger.

Market stalls next to QECH

In Malawi, midwives had been the leaders in maternal-child health care for decades, but in the 1980s, when the training of obstetricians reached a point where obstetrical residents were staffing the maternity unit at QECH, the midwives slowly lost control of their practice.  New edicts were issued by the physicians, which diminished the roles the midwives played in the care of laboring women. Currently, the care of both high and low risk patients occurs in the same over-crowded labor ward. This is an inefficient system for everyone, as it is difficult to triage and manage these two groups of patients in the same small area.

The purpose of the Midwifery Led Ward is to have the low risk patients cared for in a separate area, under the supervision of midwives. The ward will be run following international guidelines for respectful maternity care. That the midwives in the Maternity Led Ward will soon be practicing on their own will ensure they can practice to the full extent of their licensure, with collaboration from obstetrical colleagues as needed.

Space has been allocated within QECH for the Midwifery Led Ward near the current labor ward, allowing for the easy transfer of patients deemed high risk. However, the already space needs renovation before it can be used, which we have planned for. We had originally targeted March as our launch date, but that proved too optimistic. We obtained quotes from builders, carpenters, plumbers, and electricians, but we are still waiting for the go-ahead from the procurement office, as we were recently told that both an architect and a general contractor were necessary for a project of this size. This new information has been quite discouraging, as we thought once we had the needed quotes for the work, we could choose who would do the work and proceed.

Seed Global Health has a wonderful philosophy of working hand-in-hand with in-country partners to ensure longevity and follow-through on all projects. Thus, each step of this project has been done in concert with my colleagues at Kamuzu College of Nursing and at QECH. One of our first tasks was to obtain a Memorandum of Understanding between all stakeholders of the Midwifery Led Ward, which outlined each party’s separate and joint responsibilities in developing and maintaining the Ward. Getting this document finalized by the stakeholders was a huge victory. There was a lot of back-slapping and hand-clapping the day the document was signed!

Next week’s article will focus on ACNM Global Health Competency #6: Global Leadership.