• Gyerekmunka
  • Két gyerek
  • Gyerekek a családban
  • Öregek
  • Asszony tánc
  • Asszonyok terménnyel
  • Városkép
  • Tanítás
  • Always on  the road
  • Bare Eyes
  • Black albino
  • Children of Misery
  • Kids of Kenya
  • Maasai Chief
  • Maasai children
  • Maasai village
  • Maasai women
  • Past and the future on her face
  • Smiling in chador
  • The English teacher

"A természeti kultúrák "megszentelt föld, megszentelt szex" bölcsessége erre irányult: maradjunk egyensúlyban a földdel."

Dolores LaChapelle, mélyökológus
E-mail mégegyszer:*
Melyik csoportot képviseli?:*

A matter of life and birth in Malawi


The Hungarian translation you find here.

A chronic shortage of medical staff and facilities in Malawi has led to the adoption of task-sharing among health workers, which is having a positive effect on family planning and obstetric care



Rosemary Banda's son Adam was stillborn 38 years ago. When she was eventually seen by a traditional birth attendant in a remote Malawian village, it was too late. She was 16 years old.

"I was not able to conceive again and was disowned by my family," she says. Banda now lives abroad and raises funds to help young mothers in Malawi. As a way of dealing with the trauma of losing her only child, she has created an image for herself of what Adam would have become – a well-dressed, smiling doctor helping young mothers. "Now I'm helping them instead of him," she says.

"We only have about 300 doctors in Malawi and 2,000 registered nurses," says Dorothy Ngoma, newly appointed national co-ordinator for safe motherhood in the Office of the President. "But we try to do everything we can to ensure that family planning services are available to all women, especially in the rural areas."

Women attend a clinic run by Banja la Mtsongolo (Families of Tomorrow).

Photograph: Tony Karumba for the Guardian


One such service is tubal ligation, a permanent form of female sterilisation. Mercy is undergoing the procedure in a clinic on the edge of Malawi's capital, Lilongwe. She has given birth to eight children. Two have died. But her 49-year-old husband, Steven, does not want her to be sterilised. "I'm here with her, but I don't agree with it," he says. "Tubal ligation is good for other women, but when your wife's getting it that's a different story. I want more children, my own blood."

Mercy is seen by a clinical officer – a middle-level health worker trained to perform the minor surgery. If Malawi did not have a chronic shortage of medical staff, particularly physicians, tubal ligation would be performed by a doctor.

"This is task-sharing – what should have been done by medical doctors is done by clinical officers," explains Abel Kawonga, registrar at the Medical Council of Malawi. Dr Ann Phoya, sector-wide approach director at Malawi's ministry of health defines task-sharing as "expanding the scope of practice for somebody to ensure that things that are waiting to be done are done". For instance, health surveillance assistants, the lowest level in Malawi's public health system whose job is to monitor environmental health, are providing injectable contraceptives. And community-based distribution agents – unsalaried volunteers – distribute condoms and oral contraceptives.

Necessity is the mother of task-sharing. Ngoma's mission is to "make sure that the women don't die". Mortality rates in Malawi are very high for mothers in childbirth, mostly affecting women at either end of the reproductive spectrum – under the age of 15 and over the age of 45.

But despite this, the country's population has swelled from 4 million in 1966 to 14.8 million in 2012, with an average of 5.7 births per woman. At the London Summit on Family Planning, in July, NGO Marie Stopes International (MSI) pledged to double the number of women using contraception provided by them globally to 20 million by 2020. But the Population Reference Bureau (PRB) estimates that, even if the fertility rate declined to 4.6 births per woman by 2020, the population of Malawi will hit 26 million in 2030.

One of the reasons for this is that Malawian girls marry young – the legal marriage age is still 15. Newlyweds are expected to produce a child within the first year of marriage, and family planning does not start before they have had two or three children. "Sixty-four per cent of women in Malawi start child bearing before the age of 19. Trying to get young women to delay it is still a challenge," says Brendan Hayes, projects director at Banja La Mtsogolo, a partner of MSI.

Everybody has a role to play in task-sharing – including traditional rulers. "Chiefs who are committed to promoting task-sharing bring other influential players like the church, which has a lot of interest in family planning," says Dorothy Nyasulu, assistant representative at United Nations Population Fund in Malawi.

The private sector provides 40% of healthcare in Malawi, mostly via faith-based organisations, such as churches or religious NGOs. Geographical accessibility also plays a role. "Our policy is to make sure that people walk no more than eight kilometres to a health facility," says Phoya.

"Task-sharing needs a holistic approach," says Banda. "Working at policy and community levels is one thing, but you need infrastructure to reach remote areas on time. And you need resources for it. And that's what I'm doing – and I'm doing it for my son."

"The benefits of task-sharing are obvious: the contraceptive prevalence rate [the proportion of people of reproductive age who use modern contraception] has increased from 28% in 2004 to the current 42%," says Nyasulu.

Opposition to contraception

Although family planning significantly reduces the number of maternal deaths, Steven is not in favour of any form of contraception. "It is natural to have lots of children. It means you're a real man. And they will look after you when you're old."

Luckily, other men hold a more enlightened view. "Men are now feeling the pinch," says Sandra Mapemba, country co-ordinator at PRB. " They're the breadwinners and they have to provide for their large families."

Still, Steven is not convinced. He plans on taking a second wife – polygamy is not uncommon. "I had a deal with my wife: if I come to the clinic with her, she will allow me to marry again," he says.

Malawi has come a long way on task-sharing, but there are still no incentives for doctors to work in Malawi, especially in hard-to-reach areas. "There were times when there were more Malawian doctors in Manchester than in Malawi," says Edgar Kuchingale, an obstetrician and president of the Medical Association of Malawi.

Kawonga says Malawi would not be where it is now without task-sharing – and women such as Rosemary Banda who, instead of being swallowed by her pain, is helping her countrywomen.

"You can never recover from the loss of your child," Banda says, "but then you know that nothing worse can happen to you. And that makes you strong, and makes you want to do good things. I can feel that Adam is proud of me."

Some names have been changed


This trip was hosted by Marie Stopes International






A Föld népessége most: