Pregnant women and girls in Zimbabwe continue to risk life-changing childbirth-related injuries, including obstetric fistula, as many shun public health care facilities in favor of home-based deliveries, a recent Amnesty International report found.
Obstetric fistula is a curable and preventable condition that the World Health Organization and United Nations Population Fund have described as the “most devastating birth injury.” In most cases, it is caused by lengthy or obstructed labor without access to emergency services. Unaddressed, it causes continuous and uncontrollable leaking of urine or feces, which in turn results in social stigmatization and lifelong emotional scars for women affected.
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Estimates suggest that it affects between two and three million women and girls in Asia and Sub-Saharan Africa, with between 50,000 and 100,000 women worldwide developing the condition each year. The condition has been eliminated in Europe and the United States.
Although Zimbabwe’s Ministry of Health and Child Care advises women to give birth in health facilities, the Amnesty report found that nearly one-quarter of women in the country give birth without skilled assistance, citing cultural and religious beliefs, economic concerns, and fears that they will receive poor care in a formal health setting.
The latest statistics peg Zimbabwe’s maternal mortality ratio at 462 per 100,000 live births — a decrease of slightly more than half since 2010. But Amnesty warns that these fragile gains can be easily reversed due to a decline in health spending.
“Zimbabwe has one of the highest maternal mortality rates in the world and pregnant women have to gamble with their lives by opting for home births due to underfunded and under-resourced government hospitals or because they cannot afford the costs of care,” Deprose Muchena, director for East and Southern Africa at Amnesty International, said in a statement.
Some women interviewed by Amnesty indicated that home births were in line with a traditional custom which dictates that the first child should be delivered at the paternal home, to allow the mother-in-law to witness the birth and verify paternity.
“Cultural beliefs also mean that some women don’t have a choice but to submit to home births administered by untrained family or community members,” Muchena said.
“In the past, they used to be really strict about not using hospitals. The sisters in the church would deliver and women [in labor] would spend days with them, the children would not get birth certificates and could not go to school.”— Fay Ndlovhu, member, Apostolic church
Amnesty found that in some cases home births were influenced by traditional and religious practices which encourage births by untrained birth attendants rather than medical professionals for confirmation of paternity or due to pressure from religious authorities. These practices expose pregnant women and girls to dangerous health complications and in some cases even violence.
Amnesty International found that religious beliefs, especially among Apostolic sects — followed by nearly a third of Zimbabweans — were also a key factor, due to preaching that discouraged the use of formal health services.
One respondent stated that “some churches will kick you out if you use health care,” while another added that traditional birth attendants from the Apostolic faith were well-placed to deal with complications in labor “because they have the spirit within them to guide them.”
More than a quarter of births among women in the Apostolic sect take place without any skilled assistance and studies have found that Apostolic followers usually first seek help from traditional birth attendants and spiritual healers. Women of the Apostolic faith also have a significantly higher risk of maternal mortality.
“In the past, they used to be really strict about not using hospitals. The sisters in the church would deliver and women [in labor] would spend days with them, the children would not get birth certificates and could not go to school,” said Fay Ndlovhu, a 40-year-old member of the Apostolic church and mother of two. While some members still shun hospitals, she said, “More and more women are now using hospitals and children are now going to school.”
Fungisai Dube, executive director at Citizens Health Watch — a local organization in Zimbabwe that monitors health care delivery in public and private hospitals — explained that there are different sectors within the religion with different rules.
“There are some who will say you can go to the hospital while others will say we will assist you [and] have their own makeshift system that they use to help women deliver,” she said.
Amnesty’s report found that the COVID-19 pandemic has further negatively affected programming for obstetric fistula in Zimbabwe and warned that the fragile gains registered in previous years had now been reversed.
Some women surveyed who may have wanted to give birth in health facilities were unable to do so because they were financially dependent on partners or families who were unwilling or unable to pay.
Dube said informal surveys her organization had conducted have also found “a fundamental shift regarding women’s access or even attitude towards giving birth in health facilities,” during the lockdowns and even post COVD-19 lockdowns as sources of income were affected by the pandemic.
“They [the government] will tell you that in government facilities maternal health services are free. What is free is the service of the doctor or nurse coming to attend to you,” she said. “But you still have to find all the [medical equipment] that will make it possible for you to deliver and those in itself are costly.”
In Seke district, northeastern Zimbabwe, CHW has worked closely with women who have decided against delivering in a hospital due to the cost and with a network of home birth attendants seeking training — and formal recognition — from the government.
“We might want to be [similar to the] first world in approach but the reality on the ground speaks differently,” Dube said, “So they are saying ‘Why can't we be trained? And also, don’t criminalize our work.’”
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