Upsurge in home deliveries derails HIV fight

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WITH streams of sweat flowing down his face, Tsakilani Makondo battles to control the squeaking wheelbarrow as he negotiates his way through the belly of the forest in the wee hours of the night.

By Tatenda Chitagu

He is racing against time and needs to reach the neighbouring village where a revered traditional midwife lives before his heavily pregnant wife, who is groaning in pain, gives birth.

His two sisters are in tow, but they cannot push the rickety wheelbarrow for a long distance, so he has to shoulder the burden.

Around 3am, Makondo finally gets there, tired, but certain that his pregnant wife who is now motionless can deliver by candlelight with the assistance of the midwife. This is the same midwife that also oversaw his birth some 30 years ago.

With health facilities very far away or the roads sometimes impassible in the remote Mwenezi District’s Nyangambe Turf Ranch, for Makondo and thousands of other inhabitants of this area — particularly the Tshangani tribe — traditional midwives have been, for years, the only alternative for them.

“This has been our life ever since. We rely on midwives because clinics and hospitals are far away. Mwenezi Clinic is 80 kilometres away, while Chikombedzi Clinic is even further than that. Gezani Clinic is the nearest, which is 50km away, but when it is during the rainy season, the roads are impassible, or we cannot cross flooded rivers. Again, there is no reliable public transport here,” he said.

Makondo said both his children have been delivered at home.

“I was delivered at home. So I took my wife to the same midwife who is well known in the area for making safe deliveries. There are others, but she is the best,” he said.
Makondo’s predicament mirrors that of thousands of villagers in Mwenezi.

Bester Chauke, who delivered two children at the same midwife, said other reasons that make people from the area resort to home births is that they cannot afford the maternity fees charged at hospitals as well as money for transport to the health centres.

“My two children were delivered at home with the assistance of the same midwife. Apart from distance, most people here cannot raise the money to pay at the hospital, as well as bus fare. We do not have any source of income here, there are no employment opportunities, we rely on subsistence farming, but there are always droughts. It is not like we do not want to go to hospitals, but circumstances dictate that,” she said.
Another woman, Memory Gwamure said she was fortunate to deliver at a health facility after selling a beast to raise the money.

“For me, I gave birth at the hospital. Few who want to go and give birth at hospitals have to sell a beast. Others do not have cattle and just visit the midwives, who charge little for their services,” she said.
However, the village midwife, Maria Sibanda says she does not charge much as she sees her decades-old role as a community service.

“Because of our situation, we have been assisting women to give birth. We do not charge much as we do not see this as a business, but a community role we should do. Usually, we need two hens, cooking oil and soap and a few dollars,” she said.

She said the practice has been going on since time immemorial and is being passed from one generation to another.
“I also visited another midwife when I was giving birth. It’s now our tradition (of helping expecting mothers to give birth) which is being passed from generation to generation. My mother taught me this midwifery business long back as she was also one, but when I was expecting my first child, she had already passed on,” she said.
Sibanda admits that not all home births are smooth: sometimes the mother, the child-or both die under her watch.
“There are times when the process does not come out good. Mothers do die or their infants, or both. First pregnancies are the most difficult ones,” she said.

According to the Zimbabwe Demographic and Health Survey (ZDHS), the infant mortality rate stands at 50 deaths per 1 000 live births, while those who die within one month of birth (neonatal) are 29 per 1 000 live births. The under-five mortality rate, which is higher in rural areas where there are no adequate hospitals, stands at 69 deaths per 1 000 live births. According to the ZDHS, slightly more than six women die during pregnancy, during childbirth or within two months after childbirth countrywide.

World Health Organisation’s 2015 world health statistics show that Zimbabwe had the second largest maternal mortality with 443 deaths per 100 000 live births. Sitting on first position was Malawi (634 deaths per 100 000 live births), Mauritius (53 deaths per 100 000 live births), South Africa (138 deaths per 100 000 live births), Swaziland (389 deaths per 100 000 live births) and Zambia at 224 deaths per 100 000 live births.

For under five mortality for 2015, Zimbabwe topped the list, with 70,7 deaths per 1 000 live births, followed by Swaziland at 60,7 per 1 000 live births. Malawi and Zambia tie at (64,0 deaths per 1 000 live births, while South Africa had 40,5 deaths per 1000 live births. Mauritius had the least, with 13, per 1 000 live births.

Angela Mushavi, national pediatric HIV care and treatment and prevention of mother to child transmission (PMTCT) co-ordinator in the Health and Child Care ministry, said while government previously trained village midwives, they are now not supposed to oversee home deliveries.

“Sometime back, there were some rural midwives who were actually trained by the government as some women will go into labour without transport. But now, they are not supposed to do home deliveries. Instead, our government-trained village midwives should facilitate movement of expecting mothers to health centres as there may be complications at birth which they may not be able to deal with. There can be emergencies which village midwives may not handle like excessive bleeding and high blood pressure,” she said in a telephone interview with Southern Eye.

According to Mushavi, 20% of expecting mothers do not give birth at health institutions and thus are shut out from pre and post-natal care.

“Currently, 80% are delivering at clinics and hospitals, while 20% do so at home. Those that do not go to clinics and hospitals will not get the PMTCT facility to avoid trasmitting HIV and Aids to their babies. Under PMTCT, pregnant women receive anti-retroviral drugs before, during and after birth. However, when the babies are delivered, they should also receive ARVs and prophylaxis, so if they are not delivered at health facilities, they will not get the drugs. So we encourage institutional delivery,” she said.

UNAids’ 2017 data on Zimbabwe reveals that the HIV prevalence rate is 13,5%, while an estimated 1,3 million were living with the disease in 2016. The country also has 40 000 new HIV infections and experienced 30 000 Aids-related deaths in 2016.

While maternity user fees have been scrapped at government health institutions, some council clinics still demand cash upfront. Mushavi admitted that the user fees — which range from $5 to $50 — are beyond the reach of some of the rural folk.

“User fees vary from province to province and district to district, but the First Lady Auxillia Mnangagwa, had a campaign advocating for a waiver for pregnant women which has been approved. But the exemption only applies at government clinics and hospitals. Health institutions under city councils still charge user fees ranging from $5 to $30, but many people in the rural areas without a reliable source of income cannot afford the fees,” she
said.

National Aids Council (NAC) Masvingo provincial manager Edgar Muzulu said his organisation will continue to advocate for the scaling up of PMTCT particularly in rural areas.

“NAC will continue to collaborate with other healthcare providers to intensify community mobilisation and provide regular health education to HIV-positive mothers, so as to increase PMTCT intervention, institutional delivery and proper follow-up at the exposed infants care clinic. The best intervention will be to increase the number of health institutions in rural areas such as Mwenezi, if resources permit, so as to lessen the distance that has to be travelled by pregnant women to health centres,” Muzulu said.

Citizens Health Watch (CHW) trustee Fungisayi Dube said failure of these women to access or present themselves for health services derails the country’s HIV and Aids fight.

“This presents a loophole for continued transfer of HIV to the next generation. Efforts to contain transfer of HIV pre, during and post-delivery are thus scuttled by the failure to give birth at health institutions by expecting mother who may have the disease,” she said.

Dube said apart from the inaccessibility of health facilities which is the major contributor to the increasing home births, there are also various factors ranging from religious and social factors.