Malawian Mommy Wars

We continue to collect the data, the maternal and neonatal mortality audit committee at CLI is meeting to review cases, and patterns are emerging.

The project is organically evolving and the team is identifying potential interventions to solve the problems identified as recurring obstacles to safe pregnancies and deliveries.

photo: Child Legacy
photo: Child Legacy

The main pattern we’re identifying is delivery without skilled assistance. It’s kind of like the mommy wars of Malawi. Only instead of the clash of crunchy ‘all natural’ modern moms against more traditional American women who just go to the hospital and let the OB GYN be the expert, you have women who hardly even form their own opinions about their deliveries, since their husbands, aunts, and mother-in-laws have so much more to say about it.

Women who lose their neonates describe situations where going to a professional facility is to insult their family and the Traditional Birth Attendant who would have otherwise delivered the baby. The woman’s mother would ask why she needs to go to a hospital when “I delivered six of you at home alone and got along fine.”

We have to also recognize that this definition of ‘fine’ is highly acculturated. If stats like these appeared for one or another type of delivery method in the Western world, there would be no debate. The outcomes would speak for themselves. But in low income communities, losing a child is just a part of life. The child is mourned and the mother is grief stricken, but it is more of a common tragedy than it is a devastating event that catches a community’s attention.

What’s interesting is that these women do interact with the modernized health system. Most have health passports–record books of their medical histories they take to all health appointments. Most even have multiple prenatal exam appointments. It seems to be the delivery itself that is so deeply embedded in the culture as something that takes place at home or at the TBA’s chosen setting.

TBA Supply Reduction

The first potential intervention that comes to mind is to target the TBAs. What they’re doing is already against the local policy, however, so it’s likely that they are doing this work with some knowledge that their work carries risk or is frowned upon by officials including village headsmen.

Things get tricky as an international visitor trying to implement an intervention with such serious cultural implications. We cannot disregard cultural norms entirely for the sake of what we think is best. I imagine that one of the first steps to going the TBA route is to identify why they continue to do the work that they do. Is it about status? Money? Community? How can we repurpose their roles in the community without causing them to lose those important benefits of their current work?

TBA Demand Reduction

We could also try an intervention to make sure women in labor go to a facility instead of a TBA. The women are going to facilities (ours and others nearby) for prenatal exams, so it should be easy, right?

Things get complicated when the mothers aren’t free agents to make such decisions. We aren’t always able to know who makes the call on going to a facility or TBA, and we might not have the same access to that individual as we have to the mother.


These are the kinds of questions I’ll be exploring during my visit back to Malawi this August. It will be a speedy two week trip but I’m looking forward to revisiting the team and moving us through the next steps of the project.


yes, Joana does always kill it in the wardrobe dept.

In other, semi-related news, my advisor won a grant from Ohio State to develop a new Center for Research, Learning and Innovation at CLI! Very exciting to see them get resources they need to build an even stronger research program on site.