Last month, the Moderator of the General Assembly of the Church of Scotland, Lord Jim Wallace, took a virtual visit to Mulanje Mission Hospital to hear about life on Malawi's healthcare frontline. He was joined on the call by his wife, Lady Rosie Wallace, and chaplain, Rev Fraser Macnaughton. Together with members of the EMMS team, they met with Dr Arie Glas and Dr Lisanne Glas to hear about the work of the hospital.
Here are some insights into their conversation and the life and work of Mulanje Mission Hospital. This meeting happened before tropical storm Ana made a devastating path through southern Malawi, adding to the healthcare crises of the region. Lord Wallace is currently acting as an ambassador for EMMS International's work in Malawi, including the Climate of Change for Girls campaign.
Tackling the rise in teenage pregnancies
We begin with an introduction into Mulanje Mission Hospital's recent work to tackle the rise of teenage pregnancies in southern Malawi:
Teen Pregnancy and the COVID-19 Pandemic
Malawi has one of the highest teenage pregnancy rates in the whole world. In the most recent statistics, it says 141 births per 1000 women. In Mulanje, it's a bit higher than that. But that's already three times higher than the global average. In Mulanje, we've been having about 20.6% of our pregnancies in teenagers (defined from 10 to 19 years of age). This dramatically increased in 2020 during COVID to 41%. It doubled in 2020. And we think most likely this was due to the closing of schools due to COVID-19.
There are several risks and effects of teenage pregnancies. One of them is that the maternal mortality in adolescent girls is much, much higher. They are more at risk for infections. They're more at risk of complications while giving birth and for things like preeclampsia. The other thing is the baby is also at risk. They're more at risk for premature birth or low birth weights and for stillbirth.
Next to that, there are also the health risks for both the mum and the baby, so the moms they're at risk for obstetric fistula. Especially when they're not properly attended to in a healthcare setting, and they don't deliver by caesarean. Sometimes they'll go through labour for a couple of days, and they're really at risk for developing fistulas. And the baby is more at risk for infections during their young age.
Then there is the social and economic part also. These girls are really at risk for stopping school, not going further and going into a cycle of poverty. These are enough reasons to do something against it.
Understanding the challenges
So we did a literature review. We also spoke with people around us - chiefs, people that were involved in the community, people that were involved in the churches, and we asked them, what's the problem? How can we deal with these problems? One of the things that we noticed is that level of sexual and reproductive health understanding amongst people, and especially amongst the youth, is really low. And, and the second one is that all the different community leaders, which are the church leaders, but also the chiefs, the imams, and the healthcare workers, all spread a different message. And they're actually quite conflicting. Many people promote abstinence. But then, in the same way, during the initiation rituals, it's really promoted to have sex at an early age. It's very confusing for most youth. And the other thing is that people find it very difficult to discuss contraceptives.
Initiation rituals for girls are very prevalent. When they start to menstruate, they become a woman, and they have to go through an initiation. And we know that about 60% of girls still go through these ceremonies. And amongst those traditions is 'kusasa fumbi', it's 'removing of the dust' where they're taught to have sex and quite explicitly how to have sex. And these girls are quite young, around the age of 11 and 12.
Sex inequality is still very prevalent. There's gender-based violence and gender inequality. So usually, it is the man who decides whether a woman is allowed to use contraceptives or whether they're allowed to use a condom. And finally, many girls fail to see a future. They don't have hope for their future, and they feel they may just as well get pregnant and have something to do in their life.
A holistic plan to prevent teenage pregnancies
Our conclusion was this is a very complex problem with many, many different aspects. And this needs a holistic and culturally sensitive approach. Making a difference will cost a lot of time, but we did believe that we could definitely make a change here. We started with several themes in the project to address these problems. One of them is we established mentoring network. We found peers, adolescents, that were trained as mentors to be role models to other girls and other boys. We also established youth-friendly health services. We have a clinic in our youth centre, where healthcare workers provide care for the youth, so they don't have to go to the hospital grounds. They don't have the risk to walk into their chief or to walk into their uncle or aunt. And they're able there to get contraceptives if they want, but also to just get information on sexual reproductive health, to get HIV testing, etc.
We also improved sexuality education. Through girls' conferences, we talk with girls about the issues of teenage pregnancies, but also how can we strengthen them and how can we help them to be resilient. How can we help them to make a future for themselves? What do they want? And how can we help them to get there and to plan for it?
We have comprehensive sexuality education in all the schools in our catchment area. We have also held several talent shows to talk with the youth. They perform dances and they sing songs about sexuality, child marriage or how to protect yourself against HIV. We've had several radio programmes to discuss the same issue.
We work with the community and influential leaders on how we can change the initiation rituals. And how can we speak with one voice all together, and that's very, very useful. And I can say that that's been really helpful. And the people realised that we needed to change this, and they really feel this is the moment to make a change.
Since we know that it's usually men who decide on contraceptives, but also on whether to have sex, yes or no, we also wanted to involve the men and boys. So we've had a lot of talks with them and a lot of training with them as well.
And the last part, which is also a part of the programme, is to give girls hope for the future. Many of them fall out of school. And the parents really find it difficult to pay schools fees for the girls. If they have the choice, pay for a boy child because they know the girl can easily fall pregnant or can drop out or can marry. So we are putting 60 girls into secondary school and 60 girls into vocational training. And those 60 girls that are in vocational training are usually young moms that we really want to help to get out of that cycle of poverty and be able to take care of their babies.
In discussion with the Moderator
Do you have a different approach to what you do in terms of training and engaging with young girls? Depending on their age? I mean, if they're, you're 17,18, 19, do you use a different approach with the training or induction or than you would if they were 11 or 12?
My experience from being in schools and during the initiation rituals is that they know a lot already when they're really young. So we've decided to be very open also to the young ones because you want to actually explain to them on sexuality, and also about the possibility to choose whether you want to have sex before they start to be sexually active. And that's, that's around the age of 11 to 12.
But still, the later they get married, the better. Even when we're talking about older teenagers, they're still in primary school, actually. They're really delayed. Often until the age of at least 16, they're still in primary school. So when we would use the age of 16, many of them haven't actually finished primary school. And as soon as they marry, they have to stop school.
You said you've been going doing this for about a year now. And it's very early, and you said it would take time. But are there any signs so far of making breakthroughs or even just small shoots?
The teenage pregnancies that we've recorded so far are much, much lower than last year. Definitely, I think we're more towards 2019 figures to the 20.6%. But I think that's most likely due to the closure of schools. I think we have to see next year whether those numbers are actually also going down. There's more awareness, and we do see much more youth coming to the youth centre to get contraceptives or to get treatment. It starts with awareness, and this discussion has really opened amongst chiefs. I think that's a good start.
You also talk about trying to reduce HIV, which must be quite prevalent. Are you able to address the issues of HIV as well?
Yeah, so our HIV numbers are high; they're about 21% here, and in young girls even higher. So that's one of the reasons it's a combination of improving sexual reproductive health by reducing teenage pregnancy by contraceptives or telling them not to have sex if they don't want to. But also how you prevent HIV and how you prevent sexually transmitted infections and also cervical cancer. So we always discuss those and options to prevent them.
Rev Fraser Macnaughton
What is the role of the church? How does the church respond to traditional culture or customs?
The church has an active role in initiation rituals. It was always run within villages, but no one really had a hold on it. So churches decided that they had a part to play to show how can you be a good wife, how can you live a godly life. But then, still, the church has difficulties talking explicitly or openly about sex or about sexual reproductive health. So that's why I think it's a good idea to work together with the church.
We are doing it together. A church person always joins us when we go to a school or to an initiation ceremony. We will discuss sexual reproductive health and contraception. And they will discuss the biblical part, which I think is a perfect way to do it together. Up until now, that more medical part was missed, and I think that was really a missed opportunity.
I appreciate that very much indeed. How do you see the future? The next 12 months? The next two years?
Yeah, I think we should just keep going with the programme, keep discussing everything. We do everything on a yearly basis. We really need to do it, again and again. And discuss again with the chiefs and find out how they feel about it. It's actually really motivating to discuss with them. And I think, slowly, we're moving forward.
The discussion continues
In a further instalment from this fruitful discussion, we’ll share dialogue regarding the Mokwanira Project – a collaboration between EMMS and Mulanje Mission Hospital to tackle a wide range of health challenges in southern Malawi.