Vusumuzi Dube
Fairness Moyana in Hwange
*Luzibo screams in pain as she struggles through the labour pains. Her waters have broken. It’s almost time as the elderly women from the village begin making preparations to help in the delivery of her second child. These “village midwives” seemingly played a leading role in the promotion of home deliveries during the Covid-19 outbreak.
Scenes like these, while normal in some parts of Binga in Matabeleland North province due to various reasons, among them limited access to maternal health services, worsened at the height of the Covid-19 pandemic with subsequent lockdowns which resulted in an increase in home deliveries.
Covid-19, which subsequently resulted in national lockdowns, saw an increase in home deliveries as restriction and lack of access to maternal health services weighed down on already vulnerable rural communities. With a lot of restrictions placed on the movement of people such as exemption letters for travel, fuel for hospital vehicles became costly while other means of transport were simply out of reach especially for rural communities.
According to research, the most important barriers to maternal health are transportation barriers to health facilities, economic factors, and cultural beliefs, in addition to lack of family support and poor quality of care.
The Zimbabwe Vulnerability Assessment Committee (ZimVAC) 2022 Rural Livelihoods Assessment Report shows that while nationally, 75% of the rural households had access to health related information, physical access was still a huge hindrance with some walking distances of over 30km to get to the nearest clinic. The World Health Organisation (WHO) recommended walking distance to the nearest health centre is less than 5km. However, that is not the case with Binga District and most parts of Matabeleland North province where the few clinics available are far apart.
Maternal, neonatal and child mortality continues to be a major public health challenge in Zimbabwe with the 2019 Multiple Indicator Cluster Survey (MICS) revealing that under-five mortality rates stand at 65 deaths per thousand lives making it the highest in Africa. As the nation’s economy took a knock due to the nationwide Covid-19 restrictions, families were also left exposed facing increased poverty as a result of being unable to work during the lockdown period.
For many pregnant women and girls, the cost of accessing health care was somewhat beyond their reach as most couldn’t afford the costs of transport to health facilities to give birth. This, coupled with the lockdown restrictions, left them with no choice but to opt for a home delivery often times under the assistance of unskilled “village midwives” with compromised hygienic conditions.
The district has very few health centres servicing over 200 000, with people having to endure kilometres of up to 60 to get to the nearest clinic. For her first child, Luzibo says she had to endure a 40km bumpy journey to her closest health centre, Siansundu Clinic by scotchcart in the searing heat.
“When I was about to deliver my second child, Covid-19 locked us down as there were restrictions on travelling. I was forced to resort to the help of nene (grandmother) who has vast experience in assisting women in giving birth,” said Luzibo.
Pregnant women risk life-changing childbirth-related injuries, including obstetric fistula during home deliveries. The World Health Organisation (WHO) describes Obstetric fistula, a curable and preventable condition, as “the most devastating birth injury.”
Health experts say the condition, brought on in most cases by lengthy or obstructed labour without access to emergency services, leaves women leaking urine, faeces or both, and often leads to chronic medical problems.
The 23-year-old mother says while she is aware of the risks associated with home deliveries like many new mothers who were facing impossible decisions like this due to the pandemic, she opted for a home delivery which however, was riddled with complications.
Another woman, Ms Praise Ndlovu from Nekabandama in Hwange District which is also affected by long distances to the nearest health facility said, “It was very frightening, the lockdowns banished us indoors as there was general fear of traveling especially considering that there were reports of some people being beaten up for violating regulations. We learnt through social media that security forces had been deployed to patrol and man roadblocks so some pregnant women like myself then decided to get assistance in giving birth from the elderly women. I didn’t have much of a choice given that my husband lost his job and we couldn’t afford to hire a car to take me to a waiting shelter.”
Matabeleland North Provincial Medical Officer, Dr Admire Kuretu said the province witnessed a 60 percent increase in home deliveries as restrictions on traveling during the lockdown cut off women from accessing maternal health care services.
“Pregnant women delivered at home due to transport challenges as you are aware that our province is a rural one therefore services such as Antenatal Care, labour delivery, Post Natal Care were affected.
Women were not able to access these services during the lockdown also due to movement restrictions and transport. In addition, adolescents were not able to access Family Planning, HIV testing services, counselling, Sexual Gender Based Violence (SGBV) services due to these restrictions and transport challenges. During that period, there was high home deliveries compared to previous years by over a 60 percentage increase. This exposed pregnant women to risks of maternal mortality and morbidity,” said Dr Kuretu.
One senior woman with ostensibly vast experience in assisting women to give birth said there was nothing amiss about home deliveries which she argued was part of the African culture practised way before modern medicine came.
“I have assisted many women to deliver their babies without any problem. This has been something that has been practised for many, many years and I don’t see anything strange about it. I was delivered at home and so were my children. Most of the women come from disadvantaged families and some can’t afford medical expenses associated with clinics or hospitals. Besides that, here in Binga we don’t have clinics as would be the case with other places. This flu that came actually affected a lot of pregnant mothers,” said the 79-year-old “village midwife”.
However, as noted by the ZimVAC report, government partnered various key stakeholders and communities to construct clinics and health posts throughout the country to reduce distances travelled by communities to access health care services. Binga Rural District Council chief executive officer, Mr Joshua Muzamba said council had embarked on a massive health infrastructure drive using money from the Devolution Funds with a number of health centres having been completed to reduce the walking distances.
Notably, multi-donor pooled funding mechanisms assisted in strengthening health systems particularly in rural areas through construction of mothers’ waiting shelters, a proportion of community deliveries has also been growing steadily over the years
According to data obtained from the Afro-barometer report, maternal mortality remains stubbornly high in the SADC region. The regional average is 396 deaths per 100 000 deliveries. Just two of 16 SADC countries, Seychelles and Mauritius, have met the Sustainable Development Goals target 3.1 of reducing maternal mortality to fewer than 70 deaths per 100 000 live births. Maternal mortality decreased in DRC and Zimbabwe but increased in Mozambique and Angola. The SADC Sexual Reproductive Health Rights (SRHR) milestone scorecard shows that Maternal Mortality ratio per 100 000 deliveries, Zimbabwe had 651 in 2019 a downward variance when compared to 2021 which stood at 462.
The shelters where expectant women can stay during their last six weeks of pregnancy are playing a huge role in saving lives in rural Zimbabwe. Notably, the waiting shelters contribute considerably to prevention of complications such as haemorrhages while dealing with the long distance factor associated with accessing maternal quality care.
Five countries (Botswana, Lesotho, Eswatini, South Africa and Zimbabwe) had over 70% of pregnant women having at least four antenatal visits. In almost all countries, the urban/rural divide is bigger, partly as a result of access to clinics and the distances that pregnant women have to travel to get to them.
The report notes that if states are to reach the targets set in the SADC gender Protocol and the SDGs, they will need to take steps to improve the Sexual Reproductive Health Rights (SRHR) of their populations including updating policies and frameworks, implement programmes to increase access to maternal health services such as antenatal care, skilled birth attendance and neonatal care especially in rural areas, invest in and develop partnerships to facilitate roll out of Universal Health Coverage including SRHR services.
The findings show that the most important barriers to maternal health are transportation barriers to health facilities, economic factors, and cultural beliefs, in addition to lack of family support and poor quality of care. Health rights activists argue that further research is required to guide policymakers towards firm multi-sectoral action to ensure appropriate and equitable access to maternal health in line with the Sustainable Development Goals to the year 2030.
*Not her real name
Online Reporter