International Women's Day: Malawi's missing midwives
I just read the article posted in The Guardian UK's blog yesterday regarding Malawi's nursing and midwifery shortage at: http://bit.ly/gX59T6
(short article, worth the quick read).
I am a Nurse Practitioner currently living and working in Malawi's capitol, Lilongwe, as the volunteer Clinical Office Administrator for Chimwemwe mu'bereki, translated as "Joyful Motherhood" in English. We are a small NGO founded in 2007 to address the crisis of maternal, neonatal and infant mortality in Lilongwe by sending experienced nurses to the village homes of high risk infants (such as newly orphaned, premies and multiples) as well as caring for critically ill mothers postpartum after hospital discharge.
I do agree with the article's intent, to point out that there is a severe shortage of nurses and midwives in Malawi. However, the statistic on “three quarters vacant positions” is questionable. It depends on who you ask...are these actual posted positions that would be filled if there were applicants? Or are these “ideal numbers” that the current medical community dreams of but can't actually afford to fill? I have read numbers ranging from 1/3 to 1/2 vacant positions, and even one of the leading medical technical advisers from the Ministry of Health whom I spoke with today, states there is no real vacant position number, because it depends on your point of view.
The article points out that nurses are tired and overworked. However, this is not just because there are too few of them in one particular clinical setting (which is often the case). An interesting twist is that thousands of nurse midwives have more than one job, working after hours as “locum” nurses, an idea the government put forth some time back in order to fill at least part of the vacancies. However, in many cases this has resulted in a nurse leaving her day job shift and going directly to her locum job at another clinic and literally falling asleep on the job or being so exhausted that mistakes are more easily made.
A common reason given for the lack of nurses in Malawi is that they are leaving for better paying jobs abroad. For a long time this may have been partially true, but apparently the government now requires that nurses trained in the government schools work for a minimum amount of years within the country before being granted visas to work abroad. Alternatively, the incredibly high amount of NGOs within Malawi, and especially the capitol, have been a “brain drain” in many ways to the highly experienced and skilled nursing community. Organizations that are too numerous to mention have had no qualms about luring the best and the brightest of the nursing community away from the government positions with higher salaries and and attractive benefits. This is one of the practices that Joyful Motherhood strives to avoid by hiring only retired nurses, so as not to deplete the pool of current government employees.
The fact is, is that there is a shortage. However, in my short experience here it has become clear to me that it is not simply a matter of too few midwives or nurses, but how to get to them. The poor infrastructure and lack of transportation appear to be bigger culprits in the maternal deaths that we see everyday at the main district hospital in Lilongwe. The fact that a woman who is laboring in her community, who may know the benefits of and fully intend to give birth in a hospital setting, has to wait half a day to locate someone with an oxcart to take her to the nearest hospital or health center, some 5 or 6 more hours away, means that prolonged labors and emergency births on the road are commonplace.
As the person entering most of the data on our patients, I can say that the main cause for maternal death is prolonged labor leading to ruptured uterus and/or hemorrhage. Most of these women have come from far distances and arrived too late or are dead upon arrival to the hospital. A far distance could be a mere 60kilometers, a relatively short drive for someone in the UK or the US making the trip to the hospital in their family car down a main highway. But for a woman in Malawi, where even locating a single bicycle to ride on the back of may be impossible, 60 kms on mud/dirt “roads” and then to a highway to catch a “minibus” packed with people to find her way to a hospital can be an all day/night or longer ordeal.
Would putting more midwives in village settings work? A trained and educated midwife is unlikely to work in a tiny village health center because the pay even at the district hospitals isn't enough to cover rent for a tiny house, so a career in a rural health center would be an absolute sacrifice for the midwife and her family, putting her in debt rather than earning a real living.
Looking at the big picture, I believe that at least part of the answer is for the Malawian government to invest in infrastructure and access. Building more hospitals in rural areas would mean better access for women. Improving roads and public transport would do the same. Training more midwives and nurses would help in the district hospitals, which would certainly relieve the burden of working 24 hour shifts or having patient loads that are too high for any human being to care for at a time, but I don't believe this will address the entire problem of the access that women need.