For years Malawi was known for its high maternal mortality rate. In 1995, the maternal mortality rate was estimated at 1,000 per 100,000 deaths. Several years later the country had dramatic successes in the field of maternal and neo-natal health, significantly dropping to 460 per 100,000 deaths between 2012 and 2013.

Malawian President Joyce Banda’s Presidential Safe Motherhood initiative and the work of medical staff and non-governmental organisations (NGOs) have all contributed dramatically to the percentage decrease.

But ageing infrastructure, staff shortages and lack of medical supplies might reverse some of the gains.

"Salima Hospital is baby friendly" reads a sign in blue letters.

Some of the letters are fading and the sign could do with a fresh coat of paint.

Outside the hospital, several mothers wrap their newborn babies in colorful material – a piece of cloth used by most Malawian mothers. The faint sound of babies crying inside the hospital can be heard. Green lush grass, butterflies and several big trees surround the hospital.

Salima District Hospital (SDH) is the main hospital in District of Salima, which is located in Malawi's Central Region, about 90km from the capital Lilongwe.

Accurate numbers are hard to come by, but it is estimated that the area is home to close to 250,000 people. After the hospital opened its doors in 1989, the building was considered one of the most modern in the area. But 25 years later, it looks dilapidated and the ceiling is flaking.

Inside the hospital’s maternal wing, matron Alliet Botha is ensuring that the wards are clean and nurses are checking on mothers and their newborn babies.

She is also checking on birthing charts for mothers in labour. Her right-hand woman ensuring that everything is in top form is Nurse Rachel Champiti, the hospital’s "safe motherhood" coordinator.

With a friendly smile, Champtiti says it’s already been a busy day even though it's only early afternoon.

"We have had five babies today. At night we sometimes have 10 to 20 deliveries" she explains. SDH has seven delivery beds and four nurses on duty during the day. At night there are only three.

For the month of March the hospital had no maternal deaths, but there were 12 neonatal deaths.

Champiti says that in most cases were premature babies who had problems breathing. During November, December and January, the unit only had one maternal death each month. She says despite their best efforts most of the babies arrived too late at the hospital for nursing staff to assist.

In the birthing room, there is only one mother in labor. Three student nurses are monitoring the new mother.

“I am happy to be at a hospital with nurses that will ensure I give birth to a healthy baby” says the 27-year-old Beatrice Wake.

The mother of two has been in labour for the past three hours and Champiti says if all goes according to plan she could give birth in about four to five hours. 

“I feel safe here, and I am getting the best care,” says Wake.

New arrivals

A few meters away at the neonatal ward, several mothers and their newborn babies are bonding, while others are sleeping, exhausted from the birthing process.

The 23-year-old Pauline Yakobe has just given birth to a baby girl, and she’s been at the hospital for five days waiting for a full recovery. She echoes Wake’s sentiments and is thankful to have delivered a healthy baby and that they are both alive.

Many mothers live several kilometers away from the hospital and giving birth too often ends tragically for mothers who deliver at home. But since the inception of then Vice President Joyce Banda’s Safe Motherhood initiative, introduced in February 2013, mothers have been encouraged to come to the hospital to give birth.

Now Banda is president and her initiative has focused on mobilizing the community, construction of "maternity waiting homes", residential facilities located near medical centers for pregnant women; and training of community midwives.

This has drastically reduced Malawi’s maternal mortality rate, which now stands at 460 per 100,000 deaths for the year 2012 to 2013, down from 675 per 100,000 deaths reported in 2008.

In Salima there were 23 mothers who died this year. But the head of the Salima District hospital, Dr. Jessie Mbamba, says that number is actually an improvement.

"The combination of dedicated nursing staff and NGO's have helped us," she says.

Medical Supply shortage

Dr. Mbamba said that now that there's more women going to the hospital, the hospital should be able to provide the resources needed for safe delivery.

“But now we have difficulty to keep up with the demand,” explains Dr. Mbamba.

Champiti, a nurse for the past seven years and at SDH for one year, says she loves her job, but the challenges of infrastructure and medical supplies make the staff's work hard.

“We often run short of medical supplies and they have to make a plan,” says Champiti.

All the supplies are centralized and delivered from a central pharmacy. The centralized system was recently introduced in February 2014 and has had teething problems.

“We used to access drugs on our own and bought from private pharmacies; then came a ban from the ministry of health, and now we have to order from the central medical stores,” says Dr. Mbamba.

The other big problem is the shortage of blood, which is very worrying, says Dr. Mbamba.

“Last week we didn’t have any blood bags. We usually receive our blood from the Malawi blood transfusion, and there were none."

We never have enough blood, and this is such a challenge, especially now that it is malaria season and people contract malaria.”

Champtiti concurs: “Sometimes we run short of blood then we have to wait from Lilongwe. Sometimes we just do not have any, then we have to refer people to Central Hospital.”

One solution has come from the NGO MaiKhanda. They suggest that during antenatal care, mothers and fathers start donating blood and the hospital keeps a supply, so if a mother is in need of blood she is able to access it.

Ageing infrastructure 

SDH has only 135 beds, and the ageing infrastructure is causing Dr. Mbamba and the nursing staff sleepless nights.

Women are encouraged to deliver at hospital and not in the villages, but the infrastructure is not able to cope with the numbers says Champiti.

“More women are coming to deliver, and then we run out of supplies and we have a shortage of nurses, and sometimes you have up to 20 deliveries.”

“We try our very best despite the challenges. We are committed to trying our best, even with the little resources, to give quality care,” she adds.

The hospital would like to have mothers stay for a few days to ensure baby and mother is healthy but Champiti says there is simply not enough space, and they can only have mothers stay for up to forty-eight hours.

“In an ideal world, we would have a delivery suite with 10 beds and good equipment to ensure we provide comprehensive care,” says matron Botha.

HIV burden

At the Kangaroo Mother Care (KMC) section, 66-year-old Ester Andrew feeds her one-week-old granddaughter. The baby was born prematurely and weighs only 1.5kg.

The KMC was established to ensure nursing staff monitors premature babies and that the caretaker is able to nurture the baby with warmth and love.

Andrew is feeding the baby girl, who has not yet been named, with a small cup. 

“I am kangarooing the baby because the mother is sick,” says Andrew. Botha says the mother is HIV-positive and in postnatal care.

“The baby was a home delivery, and we had to start her with Nevirapine immediately, and she will be given a dosage for the next six weeks. In this way, the baby wont contract HIV and we are giving the mother, ARVs.”

If we have the right equipment and protection then we can help many more mothers” says Nurse Champiti.

Health Centers

Health centers are located in different communities and they are the first stop for many mothers.

At the local health center, Khombeza, about 50km from Salima District Hospital, the waiting room is full capacity. The room is hot and humid and with screaming babies. It’s difficult to concentrate.

The local health officer, Henry Mbaza, puts his hands up in the air.

“Today I am frustrated, there is no water and the supplies are looking thin.”

He says the hospital is unable to cope with the large numbers of people, especially mothers and babies. The area has about 60,000 people and about 11324 households.

Here again aging infrastructure and lack of water are the biggest concerns. “We work long hours and have to improvise all the time and it gets hard sometimes."

“The big challenge is that standards are falling. Nursing staff panic and the quality of service is not good; the workload is overwhelming, but we are all committed to ensure mothers and babies are safe.

Lifelines: The Quest for Global Health will air on Al Jazeera in 2014. " Between Life and Death " the sixth film in the series focusing on maternal and neonatal mortality in Malawi will premier on 15 May 2014 and be available online.

Source: Al Jazeera