The Motherland of Malawi

Article and photos by Amanda Formoso

The morning walk to the hospital in Malawi.

The glistening newborn gives his first cry just before Mercy hands him to his exhausted mother, Mwishe, who reclines on a simple cot lined with black plastic.

"What are you going to name him?" I ask Mwishe as I move to the head of the cot to get a closer look at the baby.

"I will name in a few months. If he still alive," Mwishe says as she rolls on her side and cradles the infant to her breast.

In Malawi, an African country with one of the lowest life expectancies in the world, death is familiar. I learned this within days of my arrival at the Dedza District Hospital as a newly graduated nursing student from the United States, eager to learn more about healthcare in the developing world.

***

"Do you mind if I observe the next delivery?" I ask Mercy, a tall, thin nursing student with high cheekbones, dark brown skin, and dark brown eyes.

Mercy is only 19 years old but is almost middle-aged here in Malawi. She wears a neatly pressed nurse's uniform – a white shirt, white skirt, and navy blue sweater. A white nurse's cap is pinned into her short, curly hair.

"Yes, please do. The next patient is Mwishe," she says and motions to the young girl lying between Mercy and me on the cot.

Mwishe has the same short haircut as Mercy, and the rusty white legs of the cot creak when she shifts her weight. She is young and naked except for a colorful cloth of turquoise, brown, and orange stretched across her stomach. She lies on a torn black mattress about 6 inches thick, lined only with a thin sheet of black plastic.

Mercy has one of her small-gloved hands o on Mwishe's bent leg, which she gently taps as she coaches her to push with the contractions. Mwishe is on her back, legs bent at the knees, spread-eagle, hands wrapped around her ankles as she pushes. A vein bulges from her forehead. Her whole body glistens with sweat.

Quiet, muffled moans fill the room. The smell of fresh urine, blood, bleach, and unwashed bodies overwhelms me. Only a cool early morning breeze flows through the window, saving me as my head starts spinning from the raw stench.

Mercy explains, "Mwishe, arrive here at 6:00 a.m. She walk all night from the village. She thinks she had the baby a week or two weeks ago… but nothing. So, she started to walk here yesterday afternoon."

Mwishe squints until her eyes shut clenches her jaw and grinds her teeth together as she pushes. She is quiet, practically silent, unlike those women who scream in Hollywood movies.

"I tell her to walk around the ward, but she is too tired. To walk helps the baby drop down. So maybe this delivery will be little difficult. I give shot of glucose just a little while ago — to help push. She eat just small amount yesterday. Nothing today, so no energy," Mercy says.

The delivery room of the Maternity ward is filled with six cots. A young woman lies on the cot to Mwishe's left, and four other women are on the cot to Mwishe's right.

The maternity ward in a Malawian district hospital.

The woman to Mwishe's left rolls off her cot and stands up. Her belly is as big as a basketball. She puts one hand on her cot to keep her balance and the other on her lower back. Her face is scrunched in pain. She staggers a few steps to the bucket between her and Mwishe's cot. I hear the slap of her bare feet on the smooth concrete. She squats and pees in a yellow bucket that sounds like a drum. A fly landed on her nose, and she slapped it away.

There are no IV pumps, fetal heart monitors, or anesthesiologists running around here. There are no rooms with mood lighting, private bathrooms, places for visitors to sleep, or balloons and banners to congratulate the new mom. Deep beige and baby blue paint peels from the walls, along with WHO (World Health Organization) posters, which give directives on delivering health care in ideal settings. They talk of treatment with ideal medications and ideal medical supplies, which I will learn is merely a fantasy here.

As Mwishe pushes with the contractions, beads of sweat drip from her forehead onto the black plastic sheet. Her eyes squint tighter and tighter and shut with each push.

“Did you give her any pain medication?” I ask.

"No, none of these women take any pain medication," she says and motions to the women on the cots. "We must save it for the mothers who have caesarean. Sometimes we don't have anything for them either, though. Last month there wasn't a single Tylenol in the entire hospital," she says.

This is a public hospital operated by the Ministry of Health, free to citizens of Malawi, but funded mainly through outside donors like USAID. Most people rushing around the ward with white coats and stethoscopes are students, clinical officers, nurses, and technicians. There are no doctors. This district hospital serves 600,000 people, but all doctors have left for opportunities that pay a livable wage, offer less dangerous working conditions, and provide resources that allow them to effectively treat patients.

Midwives speak to mothers about prenatal and postnatal care.

Patients wait to be triaged outside of the hospital each morning.

Mwishe pushes again. She moans a long, steady "ehhhhhh…" Her eyes are shut so hard, her jaw clenched so tight, hands around her ankles, flexed feet in the air. She is determined. And then there's… the head. It's a tiny human head, malformed, too pointy at the top, and covered in gunk. Its little eyelids are shut, and its face is motionless. Mercy now has the back of its little head in the palm of her hand and continues to coach Mwishe. Mwishe catches her breath, waits for the next contraction… and then… tiny shoulders, arms, legs, feet… Mercy pats the baby boy on his back to clear the lungs… and… then a cry. Mercy places the baby on Mwishe's stomach.

“It’s a boy,” she says.

The black plastic sheet beneath Mwishe fills with pools of mysterious green and yellow liquid, blood, and feces. I look at the gunky, nameless baby. I feel a little light-headed and a little nauseous, and a few stars flash in my eyes. It was the first time in my life that I felt like I was going to faint.

A minute later, Mwishe tells me that she isn't even confident that the baby will live long enough to be given a name.

***

A month after I saw Mwishe's baby boy born, I sat on a small concrete block outside of the hospital on a cool morning in late February. I have seen and assisted with many births since then, and I have gotten somewhat used to the fact that some of the babies will live and some of the babies will die. Still, I don't have the familiarity with death that my Malawian colleagues have, and I must mentally prepare myself before I start my shift each morning. It's a factory of life and death.

I walk 30 minutes to the hospital along dirt roads lined with fields of maize and children who wave and scream "Azungu!" (white person) as I pass. I walk along streets lined with coffin shops that are booming with business. When I arrive at the hospital, I sit outside, eat a peanut butter sandwich, drink black tea, and watch Malawian mothers with their babies and children. I study the long line of patients who wait outside for the intake department to open so they can be triaged and treated. I know that some will go to the hospital and never come out. It's a factory of life and death in there.

I finish the last few bites of my sandwich, wipe the breadcrumbs off my forest green scrubs, stand up, and follow a group of women into the Maternity ward.

***

The first patient today is Sithembre. She is a tall, thin, 23-year-old woman from a nearby village, pregnant with her first child. She is naked, with only the black plastic sheet beneath her. She holds on to the white metal post of the cot with her left hand and makes the super squinty face that Moishe made a month ago as she pushes.

But this time I’m prepared for what’s coming. 

This time, I don't feel dizzy and nauseous. This time, I hold Sithembre's hand as she pushes, and Mercy coaches her. This time, I help Mercy guide the baby's shoulders out of the birth canal as Sithembre pushes. This time, I place the baby on Sithembre's stomach and clamp the umbilical cord.

This time, I have a better understanding of what this all means. I realize just how fragile life is. My life, this baby's life, Sithembre's life, every human being's life. The most valuable thing we can ever do is care for one another. I wrap the newborn in a new orange and brown chitenge cloth and hand him to Sithembre.

Amanda Formoso is a public health nurse in Portland, OR. She has been a Kung Fu student in China, a Peace Corps volunteer in Thailand, and an English teacher in Japan. In her spare time, she plots her next big international adventure.