Malawi is one of the poorest countries in Africa, with 50% of its population living in poverty. A landlocked country located in East Africa between Tanzania, Mozambique and Zambia, it received independence from British rule in 1964. It would take another 30 years for free elections. The country has made headlines in the last few years in the Western press. Madonna adopted three children from the country (and not without controversy) and also built a children’s hospital. Rihanna donated some bicycles. Paul Farmer’s non-profit organization Partners in Health (PIH) also has been working to improve maternal-infant health outcomes in the country.
One specific program is a collaboration between PIH and the University of California, San Francisco’s School of Nursing (UCSF). The UCSF-GAIN Initiative (Global Action to Improve Nursing & Midwifery Care) works with PIH, which has ten years of experience caring for the community in a rural, low-resource region of Malawi to improve maternal healthcare. I spoke recently with nurse-midwife Maria Openshaw who arrived in Malawi in September as part of the program. The interview has been edited for length.
How did you become interested in midwifery? Why did you want to practice midwifery in an international setting?
I initially became interested in women’s health through my work with immigrant women in a community health center in Boston. Maternity care is a particularly pivotal moment in women’s health because it [pregnancy] is a developmental period during which we are not only open to changing behaviors and receptive to new ideas, but also particularly vulnerable to the effects of sub-optimal health care. As a community health worker [before I became a midwife], I spent a lot of time collecting women’s healthcare stories and I thought, perhaps naively, that as a healthcare provider I would be able to have a greater impact on the health of women I met.
I found out about nurse-midwifery when conducting maternity chart audits as a research assistant, but, to be honest, I jumped in without knowing too much — I actually applied to midwifery school without ever having attended a vaginal birth! I’m pretty lucky that I love what I do, because there are quite a few elements of the job (body fluids, nighttime awakening, medico-legal risks) that could’ve been strong deterrents. But at this point, I can’t imagine doing anything else.
Global health has always been in my mind because of my interest in working with immigrant and refugee populations. After three years in Boston, I was seeking professional challenges, and my personal beliefs compel me to use my midwifery skills to improve as many lives as possible.
What is your definition of midwifery? Has this changed since you started practicing in Malawi?
The practice of midwifery in the U.S. plays out along several lines. Our profession recognizes birth as a normal process, emphasizing physiologic, low-intervention birth. But there is also the “midwife for every woman” camp, which recognizes that medical intervention is sometimes necessary or desired, but that even the highest-risk woman can benefit from the midwifery care philosophy.
In Boston, I split my practice time between an academic hospital that practiced high-tech and sometimes high-intervention care, and a hospital-owned natural birth center where I cared for women who were highly committed to a low-intervention birth. And I wasn’t any more or less of a midwife depending on where I was working on that day.
Midwifery in Malawi definitely falls into the “midwife for every woman” category — low-intervention births occur not because of philosophy or maternal preference, but based on resource availability.
Midwives and nurses attend about 7 in 10 deliveries in Malawi and, by necessity, they manage complications that would’ve required a medical consultation or referral in the U.S. Malawian midwives therefore have a greater practice autonomy than those back at home and a huge impact on the way maternity care is provided here.
Can you tell us a little bit about the program? Who runs it? How did you find out about it? What are its main goals? What is your role in the program?
I am working in Malawi through the UCSF-GAIN Initiative as a nurse-midwife mentor, so I provide clinical teaching and support to nurse-midwife leaders in the hospitals and health centers in the rural district where I live. This includes bedside care, where I attend deliveries alongside local nurse-midwives and coach them in best practices, as well as some technical assistance around quality improvement and practice change at the organizational level.
How does working in Malawi compare to your work in East Boston? Both in clientele, hospital conditions, midwifery culture, and Malawi culture?
One of the biggest challenges practicing here has been the language barrier. Though all the nurse-midwives I mentor speak English, the majority of the midwifery clientele are monolingual speakers of Chichewa, the local language. At home, I cared for an incredibly diverse population of women but had 24/7 access to language interpreters, so I do miss interacting and bonding with the pregnant and laboring women, and hearing their concerns and complaints in their own words. On the other hand, not speaking the local language does help me to maintain my role as a mentor, and has made me a more precise speaker and teacher when working with my mentees.
The tremendous thing about this profession is that babies are born the same way all over the world. The physiology is the same; the interventions to promote safe delivery are the same. But while much of the technical expertise of a midwife applies across settings, my mentees are teaching me the local context and soft skills needed to care for Malawian women. And there is often an instant camaraderie with nurses and midwives across cultures, based on our shared commitments to improving maternal care.
What do you see as the biggest challenges to improving Malawian women’s health outcomes?
Malawi needs more nurses and midwives providing direct clinical care. The national government actually spends a reasonable percentage of public expenditure on healthcare, but it’s such a poor country that the money doesn’t go far. There is also a “brain-drain” phenomenon by which some of the best and brightest clinicians depart to other African or Western nations seeking better compensation.
There is also an internal brain drain where experienced midwives often work in administrative or educational roles (due to better working conditions and compensation), which leaves fewer experienced clinicians at the bedside. I was fortunate to learn from several 20- and 30-year experienced midwives in my practice in Boston, but Malawian midwives don’t generally get that same transmission of history and expertise.
How do you see global politics in relation to race, gender, and nationality playing out on the ground?
Part of my role as nurse-midwife mentor is to elevate the voices of local midwives. I spend a lot of time listening to their perspectives on maternity care challenges and then reconciling them with my own observations. The power dynamics in nursing are complex, with gradients between nurses, the medical establishment, as well as between nurses and our patients.
Race and gender are interwoven with power in medicine, and being an expat practitioner means that sometimes my perspective is unduly privileged. I try to make it clear that my ideas about how to improve maternity care aren’t necessarily better or any different than those of local Malawian midwives, but it is my responsibility to bring the conversation to a larger audience.
Paul Farmer, Infections and Inequalities: The Modern Plagues, Updated Edition with New Preface (Berkeley, CA: University of California Press, 1999).
Meghan Vaughan, The Story of an African Famine: Gender and Famine in Twentieth-Century Malawi (Cambridge: Cambridge University Press, 1987).
Laurel Thatcher Ulrich, A Midwife’s Tale: The Life of Martha Ballard, Based on her Diary, 1785-1812. (New York: Vintage Books, 1990).