Health & Medicine

How ‘secret mothers’ make childbirth safer

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For women in the African nation of Malawi, giving birth brings a high risk of death. The predominantly rural country has long had one of the highest rates of maternal mortality in the world.

Chief Kwataine, the headman in the district of Ntcheu, says the situation in his part of Malawi was especially dire when he first became chief just over a decade ago.

“People were delivering everywhere — on the road, on their way to the hospital. A lot of women were dying of [loss] of blood,” he says. And a lot of newborn children were dying, too.

Kwataine says the root of the problem was a culture of secrecy. In Malawi, it has long been taboo for women to discuss sexual matters, including pregnancy and childbirth. And many people here believe in witchcraft. Kwataine says expectant mothers feared that if they spoke openly about their pregnancies, someone might put a spell on their unborn children.

This secrecy meant that pregnant women were not talking to doctors or nurses, and they were not getting prenatal care. Most women gave birth at home, Kwataine says, with untrained traditional birth attendants who would refer women to the hospital only in an emergency.

Kwataine began to wonder how he could break through what he calls this cocoon of secrecy. “That’s why I came up with the secret mothers,” he says.

Advising in private

“Secret mothers” are female elders, elected by their communities, who keep tabs on pregnant women in their villages.

“We respect [the women’s] privacy, and that makes them willing to speak with us,” says Rachel Kalungama, 57, who serves as a secret mother in Madzanje Village. She is responsible for about five to 15 expectant mothers at any given time.

Kalungama says she didn't seek the position, but when she was nominated and earned the most votes, she accepted.

She takes about one day per week off from her usual duties as a subsistence farmer to serve as a secret mother. She receives no salary, but she attends regular training sessions on maternal health and nutrition, and she carries a cell phone — a rarity in this part of Malawi — so she can call a medical center if a woman she is visiting has health problems.

As Kalungama heads out on her weekly rounds, she tucks a small black notebook into her chitenge, a brightly colored fabric wrapped around her waist as a skirt. She walks along a narrow dirt path, past green fields of corn and tobacco.

She approaches a small brick home with a thatched roof, where a girl with a protruding belly sits on the front step. Kalungama sits down beside the girl and greets her.

“How old are you?” Kalungama asks. The girl is sixteen. “When is the last time you had your period? Have you visited the prenatal clinic?” Kalungama continues, taking notes as the girl answers. Then she asks the girl for her “health passport” — a small green booklet with her medical history.

Kalungama advises the girl to visit the prenatal clinic again next month, and she recommends that the girl eat plenty of beans and leafy greens — foods that are high in iron and folic acid, which are essential for fetal development. She urges the girl always to sleep under her bed net, to avoid mosquitoes that transmit malaria.

Friend or spy?

Continuing her rounds, Kalungama comes to the hut of Emily Chiloembwe, 32, who recently returned from the hospital with her fourth child. She cradles the baby in her arms.

I ask Chiloembwe what it's like to be visited by a secret mother.

“Honestly, when the secret mother first came to see me here, it was difficult to discuss my sexual matters with her,” she says. “I didn’t understand why I had to talk about such personal things with someone I barely knew.”

Plus, she says, she felt a bit threatened by the visits.

By law, women in Malawi must give birth in a hospital or medical clinic, and if they fail to do so, the village chief can fine them. (In Chiloembwe’s village, the fine is approximately $7, a large sum in this part of the country.) Chiloembwe says she feared that the secret mother might report her to the village chief if she did not follow the rules.

But eventually, Chiloembwe says, she came to see her secret mother as a friend, and she believes the program is saving lives in her village.

“It’s been a long time since we’ve buried any of our children in the cemetery,” she says.

Chief Kwataine says it has also been a long time since any women in his district died giving birth. So he is now trying to spread his secret mothers program to other villages across the country.

“Every day, every night, I’m on the road, making sure that all chiefs should end the maternal deaths in our country,” he says.

Malawi appears to be moving closer to that lofty goal. In 2006, the country launched a series of measures to make motherhood safer, and since then the rate of maternal death has declined — from 840 deaths per 100,000 births in 2000, to 460 per 100,000 in 2010, according to the World Health Organization. Kwataine credits much of that success to the secret mothers, whom he calls the “hub” of the safe motherhood program.

He also says the culture of the villages he oversees has changed in the last few years. Today, women speak openly about their pregnancies and encourage one another to seek medical care. Messages about safe motherhood are scrawled on the walls of many homes.

Kwataine hopes the rest of Malawi will follow his district’s lead.

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    Anders Kelto

    Chief Kwataine (left) spends much of his time speaking with other traditional leaders about the importance of “secret mothers.” He is assisted by Timothy Bonyonga (right), the community mobilization coordinator for Malawi’s Safe Motherhood Initiative.

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    Anders Kelto

    By law, women in Malawi are required to give birth in a hospital or medical clinic. The fine for failing to do so is typically around $7 US – a large amount in rural Malawi. Many women in Chief Kwataine’s area give birth at the Ntcheu District Hospital, and they often travel long distances to get here.

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    Anders Kelto

    Georgina Paul walked for more than two hours to give birth at this rural medical clinic run by the Christian Health Association of Malawi. She arrived three weeks before her due date and stayed in a maternity waiting home at the clinic.

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    Anders Kelto

    Sister Masoya, who oversees the delivery room at this rural medical clinic, is trained as a midwife. She says she and the other nurses have seen fewer complicated deliveries since Malawi's Safe Motherhood Initiative began in 2006.

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    Anders Kelto

    Two men perform a short play about the dangers of using traditional, untrained midwives, who have been banned in Malawi. The men are part of a theater group that travels around the district of Ntcheu, educating communities about safe motherhood.

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    Anders Kelto

    On this day, the audience consisted mostly of children.

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    Anders Kelto

    Men perform a traditional 'nsindo' dance, while singing about the importance of giving birth in a hospital. This group has written several songs about safe motherhood and performs them in villages around central Malawi.

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    Anders Kelto

    Families in this part of Malawi are encouraged to write messages about safe motherhood on their homes, and many do. This message says, “Spacing out pregnancies contributes to good health and development.”

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    Anders Kelto

    Nasambiri Wilesi attended a meeting on safe motherhood in her village and wrote this on her home: “Safe motherhood reduces death from childbirth.”

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