Death, Belief and Politics in Central African History

CHAPTER VIII - Maternal Mortality in Malawi: History and Moral Responsibility

CHAPTER VIII Maternal Mortality in Malawi: History and Moral Responsibility Megan Vaughan When Joyce Banda became President in April 2012, the people of Malawi had acquired a leader with a well-earned reputation for furthering the interests of women. Unlike some of the region’s ‘first ladies’, whose philanthropic foundations, typically aimed at women and children, have been founded more in the interests of self-promotion than of their declared beneficiaries, Banda had a track record. Malawian public discourse in recent years has become saturated with the vocabulary of human rights, and the rights of women and children in particular, but the precise meaning of this language to those articulating it is not always very clear.1 Joyce Banda, however, had already spoken publicly of the personal experiences that informed her advocacy on the part of women. She spoke of her abusive first marriage and she spoke of her experience of childbirth: I have been through an abusive marriage and I am a victim myself of childbirth complications. In 1984, after having my fourth child, I suffered from post-partum haemorrhage. It occurred to me that the only reason I am alive is because of the status that I had and because my husband was a high court judge. He had a friend who knew a gynaecologist who rushed and saved my life.2 In 1997, using prize money from an African leadership award, Banda had established the Joyce Banda Foundation. She worked closely with the UNFPA and in 2009/2010 was appointed Goodwill Ambassador for Safe Motherhood by the African Union. She has often spoken of her horror at the fact that Malawi has one of the highest maternal mortality rates in the world: ‘We were at 807 women dying per 100,000 births – the highest being Sierra Leone, which had been at war.’ In government, and now as President, Banda has restated her commitment to addressing this issue. 294 megan vaughan Figure 1: President Joyce Banda of Malawi President Banda was and is right to be worried about Malawi’s maternal health statistics. Measuring maternal mortality is far from straightforward in countries without a comprehensive vital registration system and where a high proportion of births take place outside medical centres, but whichever way you look at it, Malawi’s record, until very recently, has been a dismal one, as President Banda herself acknowledges.3 In particular, the estimates of maternal mortality ratios (the number of maternal deaths per 100,000 live births) in the 1990s and early 2000s were alarming, hovering around and above 1000, with 1140 being a widely quoted figure for the early 2000s.4 This latter figure placed Malawi very close to the bottom of global tables, at 179 out of 181 countries. Along with a number of other countries in Africa (notably Ethiopia and Rwanda), Malawi appears to have recently registered a marked improvement.A2012WHOreport,whichsummarizedestimates from WHO, UNICEF, UNFPA and the World Bank, put Malawi’s 2010 maternal mortality ratio at 460, which, if correct, represents a percentage change of -4.4 in the period 1990– 2010.5 Interpreting these figures is a complex task and no account is likely to be completely conclusive. The appalling figures for the 1990s and early 2000s have to be read in light of the HIV/ AIDS epidemic, since we know that HIV/AIDS is one ‘indirect’ cause of maternal deaths.6 Following from this, and contributing to the recent improvement in the figures, is the greater availability of anti-retroviral treatments. But HIV/AIDS, though very significant, is not likely to be the whole story. In the 1990s and 2000s Malawi’s already fragile public health system came under ever more strain as a consequence of economic crisis and poor management, and in the early 2000s the country suffered repeated food crises. Complicating the analysis of trends further is the fact that baseline data from the 1970s and 1980s is patchy and unreliable. Certainly the incomplete data hampers our chapter viii 295 ability to say anything definitive about epidemiological trends. But on the other hand, as advocates in the field of maternal health frequently remind us, we know enough about the major causes of maternal mortality and enough about what policies and practices are effective in reducing it, not to be paralyzed by the imperfections of the data.7 Malawi still has a very serious problem with maternal health, but the recent improvements in...