Yes! Behind Suzgo’s existence is a heartbreaking story of a mother losing her life to let her daughter live.

About 19 months ago, Nyuma’s friends and relatives buried her remains seven feet below in the village’s grave belly.

On her red earth tomb, a wooden cross still stands erect bearing three clearly marked dates: Born on 16 May 1970; Died on 15 October 2009; Buried on 16 October 2009. What is more painful is that Nyuma’s passing on could have been easily avoided.

Nurses and midwives had, during her seventh baby’s delivery clearly tipped her not to fall pregnant anymore to safeguard her health and life. Nyuma promised them to comply but she had no choice as her husband, Zondwayo, demanded one more child from her.

“I paid lobola [bride price] to your family therefore, I will tell you when to stop bearing children for me,” furiously charged Zondwayo said.

In fact Zondwayo threatened to divorce Nyuma if she would not get pregnant again to bore one more child for him.

Last breath

But when delivery time came just few hours after giving birth to a beautiful baby girl (Suzgo) at Mzimba District Hospital, Nyuma breathed her last due to heavy blood loss and other childbirth related complications.

In Nathenje, a remote settlement sharing common boundary with Lilongwe City a court case went on being arbitrated by the village headman.

The issue involved a married couple about to divorce because of a puzzle that could otherwise easily be resolved between themselves. Yes! The man sued his own wife claiming that she stinks!

“Hey! Bambo (Sir), please tell me real valid reasons why you want to divorce your young and beautiful wife because no human being stinks except that person is dead. Only dead people rot and smell, not those who are alive,” reasoned the chief. But the 29-year-old man stuck to his guns.

“If you don’t believe me that my wife stinks let any man in this village take her to bed and sleep with her to prove my point,” he said.

The man was right, but ignorant of fistula, the cause of his 22-year-old wife’s stench.

During the birth of the couple’s child just few months ago an obstruction occurred when the woman was delivering- the woman’s pelvis was too small against the baby’s too big head tearing on her birth canal in the process.

“Fistula usually occurs when a woman has an obstructed labour and can’t access a caesarean section when needed,” said UNFPA Executive Director Thoraya Ahmed Obaid.

She disclosed that a pregnant woman can be in labour for many hours or even days without medical help.

“If the mother survives, she is left with extensive tissue damage to her birth canal that renders her incontinent,” said Obaid.

She added, “Every year millions of women suffer from pregnancy and birth-related complications, as well as injuries. Through working together we can ensure that fistula is something of the past.”

The UN says fistula affects as many as 3.5 million women worldwide especially in poor developing countries where births per woman and fertility rates are high and girls become mothers at a very tender age.

The 193-country member New York based organization even discloses that $750 million (K112.5 billion) is required to treat women from fistula worldwide until 2015.

In Malawi the UNFPA has embarked in an ambitious project to treat 100 women countrywide suffering from fistula often stripped off their dignity, suffering from trauma, treated as outcasts including losing marriage due to the problem!

Take an over 600 Km tiresome drive from Lilongwe to Kaporo a fish smelling lakeshore settlement on the shores of Lake Malawi in Karonga, Malawi’s district in the north sharing common boundary with Tanzania and meet 40-year-old Wakisa.

She has a secret that will make your hair rise and itch. For over 10 years now Wakisa has been hiding her oral birth control pills in a black plastic bag underneath the family’s mayawe (cassava flour) for nsima in the flour basket.

Why? During the delivery of her seventh born daughter Walinase, 12 years ago, Wakisa nearly lost her own life due to childbearing complications.

She fainted after losing a lot of blood and after recovery, thanks to the availability of blood at Karonga District Hospital’s blood bank with support from the Malawi Blood Transfusion Servive (MBTS) then, nurses and midwives advised her against ever falling pregnant again.

Pains and sorrows

Wakisa took the message to her husband, Gerald, however, he could not buy the idea.

“So to safeguard my own life I have no option but take oral birth control pills without my husband’s knowledge to avoid falling pregnant again,” said Wakisa.

The above incidents are just some of the pains and sorrows women have to silently go through in Malawi and in most sub-Saharan Africa since time immemorial.

In this region women are inferior to men due to gender inequality and cultural beliefs value children as human assets in families and this has turned women into heavily burdened child bearing machines for many years.

Yes! Women in sub-Saharan Africa are expected to bear as many children as they can with a belief that the offsprings will later provide the husband and wife including members of the extended family with social security including food, clothing, shelter and other necessities and even luxuries.

The children have to provide these as a token of appreciation that they exist in the world because of their parents and members of the extended families.

This is however, among other things, putting mother’s and children’s health at risk, fueling poverty as well as increasing population beyond government funded inadequate available social services such as health, education, safe water, education just mentioning a few which are mainly donor dependent.

Grace Mlava, a Reproductive Health Specialist with UNDP in Malawi said Malawian women continue to experience a lot of suffering and their lives endangered by childbirth complications.

“Statistics indicate that the number of women dying of childbirth complications in Malawi has dropped from 807 to 675 per 100, 000 live births,” said Mlava.

However, she was quick to add: “But despite this reduction the number of women dying due to childbearing complications is still too high.”

The UNFPA Executive Director disclosed that new estimates have in recent years worldwide shown that it is possible to prevent many more women from dying from pregnancy related complications and what is required is for countries to invest in their health systems and in the quality of care.

"Every birth should be safe and every pregnancy wanted," said Obaid adding, "The lack of maternal health care violates women's rights to life, health, equality, and non-discrimination. MDG5 can be achieved. But we urgently need to address the shortage of health workers and step up funding for reproductive health services."

To help Malawi Government in Reproductive Health (RH) including reduce maternal deaths, Management Sciences for Health (MSH) is implementing an integration of Family Planning (FP) services HIV and AIDS programmes through the Community Based Family Planning and HIV and AIDS Services (CFPHS) project in Chikhwawa, Balaka, Mangochi, Phalombe, Karonga, Kasungu,Nkhotakota and Salima.

MSH Policy and Advocacy Advisor, Olive Mtema said the project was introduced appreciating that Malawi’s population growth is still swelling due to high fertility rate perpetrated by among other things lack of FP and low access to Sexual Reproductive Health (SRH) services.

“On average, a Malawian woman approximately bears six children in her lifetime,” said Mtema adding that currently people aged below 18 make over half of Malawi’s 13 million plus population.

A document jointly authored by Malawi’s Economic Planning, Development and Cooperation Ministry and the Ministry of Health unveiled some months ago in Lilongwe concurs with Mtema.

The paper predicts that Malawi’s population will swell from the current over 13 million to 41 million in the next three decades if the current fertility rate is left unchecked.

Malawi Government therefore according to the document proposes that the current high fertility rate of 6.0 births per woman be reduced by an average of 3.0 births per woman in her lifetime, which is as good as three children per woman.

The document titled ‘Resources for the Awareness of Population Impacts on Development (Rapid)’ highlights how rapid population growth can affect Malawi’s social and economic goals and strategies during the next 30 years.

It says if Malawi could make women stick to three children instead of six, population would increase from the current over 13 million to 31 million people in 2040, which means the country would register nearly 10 million fewer people during the projected period.

The book discloses that HIV and AIDS does not have an important demographic impact on the Malawian population over time, saying even with HIV prevalence continuing at a high level, the population would still grow from 13 million people in 2008 to 41 million in 2040.

The document further states that in 2040, Malawi’s population would be 45 million under the “Without HIV” bracket while 41 million people would be under the “With HIV” bracket, registering a difference of just 4 million people, representing 10 percent of the population.

Mtema said it was possible to slow down Malawi’s population growth speed through integrating SRH services with HIV and AIDS programmes as the two’s combination could increase access to SRH services and Family Planning (FP).

“In Malawi more attention and resources are allocated to HIV and AIDS than SRH yet the two can be integrated because they have one common denominator which is sex,” said Mtema.

She added that if Malawi’s population is to slow down however, the youth especially girls should be targeted with SRH strategies to curb early teenage pregnancies.

During a recent training and site visit by journalists in integrating Family Planning and HIV and AIDS Services in Lilongwe and Nkhotakota respectively organized by the Washington based United States based Population Reference Bureau (PRB) clients especially women testified the impact integration of the services introduced by MSH has had on their lives
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Nkhotakota Nursing Officer also FP coordinator Carol Gondwe said under the Integrated MSH project clients are able to access FP services, Prevention and Management of Sexually Transmitted Infections (STIs)/HIV and AIDS, Prevention of Mother To Child Transmission (PMTCT), Post abortion care, HIV Testing and Counseling (HTC), Youth Friendly Health Services, Prevention, early detection and management of Reproductive Health including screen for cancers.

Other services also include access to safe motherhood-maternal and child health, prevention of harmful sexual practices and male involvement in reproductive health issues.

“Since clients get all these services under one roof in one stop shop they are able to save their time and even money they would have otherwise spent to travel to another health facility where such services were available if they were not available here,” said Gondwe.

FP methods

Margaret Fisi from Selemani 111 Village, Traditional Authority (T/A) Mphonde in Nkhotakota started accessing FP services through a Community Based Distribution Agent (CBDA) operating in her area, Alima Twaibu.

“We have two children and without family planning I would have had borne six or even eight children by now and struggle to take care including feeding them,” said Fisi whose family is among poor Malawians spending less than $1 (K150) a day.

She disclosed that her husband encourages her to use FP methods to avoid falling pregnant.

“He says as a family we should have children by choice not chance to be well cared for through providing them with adequate needs including food, clothing and shelter,” said 29-year-old Fisi.

Some of the challenges in scaling up FP services alongside HIV and AIDS services however, include lack of financial, material and human resources and MSH in its project has been providing them.

On human resource alone the MSH project among others to build capacity trained 1003 CBDAs, 296 CBDA supervisors, 96 nurses and Clinical Officers including 15 Trainers of Trainers and 205 service providers.

Several studies have supported the rationale behind integrating FP and HIV services, especially in sub-Saharan Africa where HIV is prevalent (host to 60 percent of the 30 million plus global HIV and AIDS infections) and unmet need for FP is high.

However, political as well as programmatic challenges are forestalling the benefits and savings from linking the two.

Combining FP services with HIV counseling, testing, and treatment has been shown to make better use of limited resources because the people seeking contraception have many of the same needs and concerns as those seeking HIV-related services.

A 2009 World Health Organization (WHO) review of integration studies found that linking reproductive health and HIV services leads to higher quality and better used services.

In addition, a 2006 study by the United States Agency for International Development (USAID) estimated that providing FP at HIV care treatment centres saves almost $25 (K3, 750) for every $1(K150) spent.

“Linking these services provides an opportunity for both family planning and HIV information and services to reach a broader range of people. Young people, for example, are especially vulnerable to HIV,” says the agency.

It adds that of 2.7 million people who become infected with HIV each year, 45 percent are between the ages of between 15 and 24.

“This is also the age group that has the highest rates of sexually transmitted infections, which increases the risk of acquiring HIV,” says the agency.
According to UNAIDS, close to half of the 1.2 million young people who become infected with HIV each year do not have accurate and complete information about HIV.

The benefits of integration are particularly evident for women with HIV.
A 2009 study published in AIDS, the journal of the International AIDS Society, revealed that nearly 75 of every 100 HIV-positive women in Kenya and Malawi did not want to become pregnant in the next two years or ever.

“However, less than one-third in Kenya and only 20 percent in Malawi were using contraception. For HIV-positive women who want to have a child, family planning counseling and services in combination with HIV treatment can help space births at healthy intervals (at least two years) and prevent mother-to-child transmission when they give birth,” says the society.

The UNFPA says poor developing countries such as Malawi can achieve Millennium Development Goals (MDG) number five [which dating from 1990 urges countries to put strategies to cut maternal deaths by half by 2015] if women are empowered with the choice in childbearing than their sexual decisions dictated by men.

“The freedom to choose how many children, and when, is a fundamental human right. Better access to safe and affordable contraceptive methods is key to achieving MDGs,” says the agency.

The agency further discloses that women with few children [born according to family planning] are empowered, share decisions including negotiating sex with spouses, healthier hence live longer and able to contribute to their society’s social-economic development at all levels.

Social problems

Women overburdened by childbearing without family planning on the other hand the agency says often are stuck in a cycle of social problems including poverty, gender based violence, at higher risk of contracting STIs including HIV and AIDS from their own spouses therefore, their lifespans shorter.

Media Training Consultant Pushpa Jamieson said recognizing that illiteracy rates are high among women than men, most SRH decisions are done by men in families and this was fueling childbearing without FP in Malawi hence there is a need for journalists to interpret these matters to influence masses to change, PRB recently, organized a workshop in Lilongwe and a site visit in Nkhotakota.

“The training and the site visit was organized to among other things, empower members of the press in Malawi with skills to competently report the strong links between Sexual Reproductive Health and HIV and AIDS,” said Jamieson, a veteran journalist and media entrepreneur.

She added: “We believe that if journalists are able to interpret the links between the two in their stories, programmes, features and documentaries in return Malawian couples will fully understand these things better and make best choices to seek HIV and AIDS treatment, care and support, Sexual Reproductive Health services including Family Planning."