BLANTYRE, Malawi (AP) — Prenatal services at the clinic were free, but the motorcycle taxi fare cost more than Monica Maxwell could afford. Just four weeks before delivering her baby, she cobbled together 1,400 kwacha ($1.75) for the 50-kilometer (31-mile) round trip. It was only her third visit — fewer than her first two pregnancies. The money she made selling tomatoes dried up amid the pandemic. Her husband’s income selling meat also dwindled.

“It was the most difficult period of our lives. We had no money for our daily survival,” Maxwell, 31, said. “Mostly we stayed home.”

In a country where hospitals are so bare that women are expected to bring their own razor blades for cutting umbilical cords, the deepening poverty sparked by COVID-19 is further imperiling women’s lives.

Officials say far fewer pregnant women in Malawi are getting the health care they need amid the pandemic, with many forgoing medical visits and relying solely on traditional birth attendants, who provide emotional support and administer herbal treatments but are banned by the government from delivering babies because they lack formal training. Many families can’t afford clinic visits, or the needed transportation; they also fear they’ll catch coronavirus in hospitals.

At risk are the gains that Malawi — a largely rural sliver of a country, with 18 million people — has made over the past decade to combat its poor record of maternal deaths. Malawian women face a 1-in-29 lifetime risk of death related to a pregnancy or birth, according to the United Nations Population Fund.

The country has 439 such deaths per 100,000 live births — a figure it worked to reduce from 984 per 100,000 in 2004. Still, Malawi’s rate is southern Africa’s third-highest.


This story is part of a yearlong series on how the pandemic is impacting women in Africa, most acutely in the least developed countries. AP’s series is funded by the European Journalism Centre’s European Development Journalism Grants program, which is supported by the Bill & Melinda Gates Foundation. AP is responsible for all content.


Hospitals also suffered staffing shortages when nurses were mobilized to treat coronavirus patients — leading to some lack of experienced personnel for births, said Young Hong, of the United Nations Population Fund.

“Not only did the pandemic affect availability of manpower, it also exerted much pressure on the entire health system, including the stock out of certain medicines, equipment, basic medical supply,” said Hong, who noted that eight Malawian women die daily of pregnancy complications, higher than COVID-19’s toll. “This had a huge impact on the quality of maternal health service.”

At the Ndirande Health Center, northeast of the country’s commercial capital of Blantyre, about 100 pregnant women visited daily before the pandemic. That number’s now 15 to 20, said Jacqueline Kolove, a clinic nursing officer.

Sometimes even the women who come for prenatal care are afraid to deliver at the clinic, preferring their homes. Malawian women are encouraged to give birth without medical intervention; many believe emergency measures are shameful. Giving birth at home, though, can be deadly if complications arise — most women live far from clinics.

“We explain to them why such a decision might have the dire consequences … sometimes even calling their husbands and parents to try to reason with them,” Kolove said.

At Ndirande and other clinics, nurses, aides and medical midwives give pregnant women ultrasounds and use equipment to monitor mother and baby. Woman can undergo cesarean sections if needed; medications are available to stop severe bleeding. Staff take courses, observe simulated births, and become licensed.

Traditional birthing attendants learn from elders who pass down knowledge through generations and use little to no medical equipment — they listen to women’s bellies by placing their ears there, for example, and gather herbs to induce labor.

Malawi banned attendants’ delivery work in 2007, but the practice continues; the ban’s rarely enforced. Attendants such as Lucy Mbewe, 56, charge nothing. She says her work is key for women who can’t afford anything else.

Even the colorful African cloth used to wrap babies, carry them on mothers’ backs or create makeshift diapers can be a potential obstacle, Mbewe noted. “Hospitals recommend that a woman who is going to deliver needs to carry with her at least 10 pieces of cloth, which is a deterrent to those that cannot even afford to put food on the table,” she said.

Women are even expected to bring bed coverings, buckets for water, and sometimes candles or flashlights. Mbewe provides clothing and soap when she helps women give birth. She pays for transportation. Some women reimburse her; she uses that money for other clients, she said.

Trained midwives say the use of attendants has increased complicated deliveries. Mbewe says the complications are attributable to expectant mothers getting pregnant younger — a trend confirmed by a government report.

Midwives and health officials also say they’re fighting misinformation about the virus and vaccines. Malawi has seen a rise in coronavirus cases, part of a surge across southern Africa.

Malawi’s government has administered less than 213,000 doses of the AstraZeneca vaccine. Officials destroyed about 20,000 expired doses provided by COVAX, the U.N.-backed program to ship vaccines to poor countries. Across Africa, just 1% of the population has had one dose, according to the Africa Centers for Disease Control and Prevention.

Nurses and midwives say some women fear they’ll secretly be given vaccines.

“They feel, as health workers, we are giving them the COVID-19 vaccine instead of oxytocin,” said nursing officer Kolove, referring to medicine that strengthens contractions and reduces bleeding risks. “They feel we are cheating them.”

Medical staff also understand the higher risks of contracting coronavirus. Staff try to educate women, and they take every precaution, even though their work makes keeping physical distance impossible, said Keith Lipato, of the Association of Malawian Midwives.

“We make sure that all midwives are screened and tested so that those with signs and symptoms are excused from work, and given the necessary medical treatment,” Lipato said.

Lipato and others fear the pandemic will have long-lasting effects on women’s health.

Patricia Gunde, 26, hasn’t received prenatal services during her first pregnancy. She prefers her attendants’ herbs. Gunde doesn’t plan to be vaccinated.

“I am afraid,” she said. “I have heard many stories about it.”

With the birth attendant, she feels at ease because women are seen one at a time.

When the attendant brings Gunde in for care, neither wears a mask.


AP writers Krista Larson in Dakar, Senegal, and Andrew Meldrum in Johannesburg contributed.