Malawi, a landlocked country in southern Africa, has one of the highest rates of maternal mortality in the world. However, the country has seen a notable decline of deaths resulting from complications during childbirth. Leadership at the district levels and political will of government leaders was key, along with educating communities on family planning, maternal health, and the importance of delivering in a health facility. Malawi’s Safe Motherhood Initiative (SMI) plays an important role in these areas. SMI is a country-wide program that was conceived in the office of the President and aims to improve maternal health by training up to 2,000 community midwives, constructing maternity waiting homes, and mobilizing traditional leaders, also known as chiefs, as agents of change in their districts.

SMI’s Community Mobilization Coordinator, Timothy Bonyonga, was working as an OBGYN Clinical Officer when he felt inspired to do more outside the ward. “I was attending to a lot of complications and I was seeing a lot of women dying due to preventable causes. I decided to really take action on behavior change.” SMI’s discussions focus on preventing what he describes as “too early, too many, too frequent and too late pregnancies”. This means discussing healthy timing and spacing of pregnancies, pregnancy-induced hypertension brought on by bearing too many children, and HIV testing before and during pregnancy with an emphasis on couples testing and counseling. The SMI team target not only expecting mothers, but chiefs, husbands, and school children.

In Malawi maternal health was traditionally framed as a women’s issue, but among stakeholders there is general consensus that male involvement is worthwhile for promoting safe motherhood. In the beginning Timothy received pushback from some communities when trying to involve males, and he accredits the influence and leadership of chiefs for the change of attitude. It doesn’t hurt that chiefs have instituted bylaws which penalize nonparticipation in community sensitization meetings. The hope is that, after these discussions, men will begin escorting their wives to the antenatal clinic for HIV testing and HIV counseling, if necessary. Timothy adds, “It’s very important because men in our society are regarded as heads of families and considering that religious following among our women is very high, it was really difficult for women to adopt family planning methods without male involvement. In communities where men have really been involved, things are really working.”

Another vital target group for SMI is adolescents (age 10-19) because they are the next generation. According to the U.S. Agency for International Development, this age group counts for 20% of maternal deaths in the country.  An underlying cause of maternal death is early childbearing which in Malawi begins at the average age of 19. Interrelated to this is child marriage which is high; half of Malawian girls are married by the age of 18. Earlier this year the passage of the Marriage Bill gave hope to child’s rights advocates by raising the legal age of marriage to 18. And SMI discourages early childbearing by advising women to hold off on pregnancy until after age 21. Timothy thinks the legal age of marriage should be raised to 21 or 22, to not only align with this but with school completion and financial independence. “[Family planning] will work much, much better if the girl child is empowered through formal education. Once a woman is educated, things work much better, whether she’s married or not.”

Among the barriers that come with gender are religion and deeply rooted cultural beliefs. To combat this, the Safe Motherhood Initiative conducts “Influential Leaders Trainings” whose participants are a combination of religious leaders, teachers, and other prominent members of a community. The purpose of the trainings is to try and understand what approaches are appropriate and effective to engage with community members. An important outcome of working with religious leaders is to counter religious arguments and texts that contradict SMI’s family planning messages. Timothy describes another challenge which he calls “intellectual poverty” as something demonstrated by those who are the educated elite. “They block some of the messages that I give because of their cultural beliefs. They are educated but aren’t knowledgeable on some of the issues we discuss with people.”

In addition to seeing a reduction of maternal deaths, the Safe Motherhood Initiative has seen an increase in hospital deliveries, young mothers returning to school, and a demand for cervical cancer screenings. Malawi is showing that using a range of interventions can contribute to SMI’s vision of a healthy mother, healthy baby and healthy Malawi.

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