Reproductive Health and Maternal Sacrifice: Women, Choice and Responsibility

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Moreover, participants mentioned the notion that a stepmother would withhold equal treatment and affection, and as a result, maternal family members choose to keep orphans under their own care rather than send them to live with their fathers. As one participant stated:. The other problem is when this man decides to take these [his biological] children we always fear that they [the children] will not be treated well by the stepmother, as it can be seen that many are women who are not able to take care of a child earnestly who are not their own.

This compels relatives of the children to not allow the children to be taken by the father, rather they keep the children staying with them, and share with the children the little [resources] that they are able to find. Registration at the health facility of a maternal death and the health status of the orphaned infant is critical to ensuring that children are enrolled into appropriate programs, including nutritional and other support services that are provided through health facilities.

However, the remoteness, physical i. Particularly when a mother dies at home or en route to a health facility, the likelihood is substantially reduced that the death and status of the infant will be recorded at the health facility. Participants commented that the most immediate impacts of maternal death are often felt by surviving infants who are in need of breast milk. Many expressed concern that index children were small for their age and were not getting appropriate nutrition and care.

According to one key informant:. Under national policy, health facilities are supposed to provide milk substitute for the first three to six months of life free of charge, and flour for porridge after six months. Nevertheless, in practice, our study results reveal that these critical nutritional supplements were available inconsistently. Many participants felt that the amount and duration of support were insufficient and that weekly visits to the health facility added an additional economic and practical burden to taking care of the orphan s.

While these concerns were most acute for the youngest children, older children faced other health and nutritional risks related to lack of caloric consumption and protein. When asked about the health of older orphaned children in the community, this stakeholder said:. There will be problems in terms of development because as I have already said that food is insufficient for their bodies, and it is not nutritious food because there is no way you can just be feeding a baby on pumpkin leaves daily without anything else.

And this stakeholder added that orphaned children are particularly vulnerable to infection:. Most of these children, simply for the reason that they had a bad background nutritionally, they look sickly. Most of the time when there is an outbreak, just like we had an outbreak of chicken pox Varicella , these are the children [maternal orphans] who become more vulnerable because of low immunity. At health facilities, families face additional barriers including poor quality of care and critical shortages of health workers. Our study highlighted staffing shortages as a key barrier to receiving quality care, for both women and children, noting that staff were too overburdened to provide sufficient information, counseling, and follow-up to mothers attending health facilities for antenatal and delivery care.

One quarter of family members interviewed described labor and delivery experiences that involved referrals between multiple facilities that were supposed to, but ultimately did not, have the requisite staff or expertise to care for the laboring woman. Family members also cited a shortage of nursing staff at facilities, causing women to deliver their babies alone, and limiting access to care for orphans at the community level:. While it was customary for female family and community members to take on caregiving responsibilities following a maternal death, we found that many already had children of their own, and were therefore forced to further stretch household resources to meet the additional needs of orphans:.

In the first place, it should be mentioned that these children land in needy families who are already struggling to earn a living, so normally there is an over stretched household budget because there are some additional items that will be sought specifically for the orphaned children. As such, the families will intensify [the time they devote to] Ganyu activities [informal, small-task labor], which do not suffice to fill the needs for the household.

As this stakeholder explained, in an attempt to absorb the immediate financial shock of taking in an orphan, families often turn to short-term labor, or ganyu , which includes weeding or other forms of field labor, as an immediate source of income.

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Further, the stigma attached to ganyu , which is seen as a sign that a family has run out of food, can have negative social implications for a family within the village [ 24 ]. Moreover, despite the high proportion of female-headed households in Malawi, women are paid less than men for ganyu , and have fewer hours to devote to any form of income generating labor, due to caregiving responsibilities [ 24 , 25 ], substantially diminishing the overall return. You can see my situation, I can no longer go to farm in the gardens to get some money.

You can see that I can no longer farm in my gardens because I have to pay close attention to the child. Furthermore, female relatives who became new caretakers following a maternal death stated that integrating children into their families could be a source of tension with their husbands, contributing to conflict within the home, further limiting their financial security and stability. As one key informant recalled:. So I was left with the other children and other relatives promised to assist, but they never came back and because I was taking care of my relatives my husband was having difficulties with that and we separated.

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As described above, the additional burden on caregivers often translated to a burden on children to help pick up the slack. Where resources were limited, stakeholders noted that non-orphaned children would be given preference for expenses related to school and nutrition, with orphaned children often fed separately, after non-orphan children had eaten, or not at all if food was scarce. Orphaned children were also required to take on additional household chores and labor in the fields, which could prohibit them from attending school.

As one focus group participant said:. There is remarkable [school] absenteeism [among orphan children] due to lack of basic needs such as soap.

Others give priority to their children and not the orphans, as a result there is a lot of [school] absenteeism in these children as compared to the other children in normal families. Other guardians will even buy clothes but just for their children…[while the orphaned child is] sent to do household chores such as drawing water, cooking etc. As a result, the child is never free to go to school. Surviving children face numerous disadvantages as new caretakers struggle to integrate these children into their households. As explained by one participant:.

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Surviving children are given a lot of work to do which is beyond their age. Some may be abused sexually by their guardians just to get support. This may lead them to drop out of school and for girls they end up in early marriages and early pregnancies which may also end up maternal death. While primary school is free in Malawi, fees must be paid in order to attend secondary school. Even if a family is able to pay the required fee, participants commented on the additional fees associated with school supplies and appropriate clothing, and the discrepancy in allocation of resources for these materials between orphans and non-orphans.

Guardians may easily sacrifice even their livestock for [their biological] child as compared to an orphan. Priority is given to their children as compared to orphans in cases of school fees, clothing as well as food.

It is almost impossible for these guardians to sacrifice something for the orphans. Boys are also seriously affected by maternal morbidity and mortality. As this orphan who was 16 when his mother passed away and 22 at the time of the interview stated:. I stopped going to school to take care of my mother while she was sick and she became pregnant and died after giving birth.

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Things have been different after her death. As of now I have the burden of taking care of that child. Participants mentioned that girl children may be expected to take on caretaking and other household responsibilities, often caring for their orphaned younger siblings, making it difficult for them to continue attending school.

As one focus group participant mentioned, this pressure seems to disproportionately affect female orphans compared to biological girl children:. Some guardians, once they have seen that the child is of age, force them into early marriages instead of encouraging them to go to school so that they will be relieved of their responsibility [to care for the girl child] and they will make sure that their [biological] children go ahead with school….

Losing a mother does not just have practical implications for girl children relating to household economics, there are informational, emotional and social costs as well. When a mother dies her daughter loses a vital source of information about gender roles, relationships, behavior, the body and reproductive health. Maternal orphanhood could have negative health implications for girl children, such as early sexual debut and pregnancy [ 27 ]. As one focus group participant described, the mother is responsible for ensuring that children adopt appropriate values and behavior, and additionally, the mother has specific responsibilities to set a positive social example for girl children, something which fathers cannot provide:.

I am seeing something here, when a mother is alive she controls proper dressing for a girl child as well as boy child and instills in them cultural norms and values and they become well behaved. As a family, a man and a woman advise their children according to what is expected of a girl and a boy, both by the mother, and what is expected of a boy by the father, but I as a man cannot go and advise my daughter on what is [appropriate] for women.

This would rarely happen in a single parent situation and would [negatively] affect the girl child. Many participants did not know about the different forms of support that were available to them through governmental institutions and NGOs, and the processes for accessing such support.

Women, Choice and Responsibility

When participants did seek support, or were aware of such programs, they stated that the programs were often ineffective, non-transparent, or difficult to access. Challenges receiving support from NGOs and government programs included delays in receiving services once selected as a program recipient and difficulties returning to the health facility or other distribution sites to receive regular services and supplies. As one key informant explained:. Yes, the problem [with the government welfare program] was that…they just wrote down our names…They just wrote our names and then they kept quiet, they did not assist us.

There are other organizations that take care of orphans but none of them accept him to be enrolled in their centers, saying that he is too old. As such, I just engage the child in piece works [ganyu] as a herd boy, or organize some firewood for him to sell, so I feel sorry for the child. Our results add to an emerging body of evidence on the impacts of a maternal death on children, extended families and communities, as well as the mechanisms through which vulnerabilities emerge and are perpetuated following maternal death [ 15 , 17 , 18 ].

Our findings revealed that maternal death serves as a catalyst for vulnerabilities specific to orphaned children related to health, nutrition, education, employment, early partnership, pregnancy, and household and caretaking responsibility. We found that fathers are, in the majority, relatively uninvolved in the care of their children following a maternal death, particularly among those who have remarried.

Women disproportionately bear household burdens associated with taking in additional children and are often forced to take on paid labor alongside their usual caregiving responsibilities. Following maternal deaths, orphaned children, and particularly the index child and other young children in our sample, are at increased risk of health complications and decreased likelihood of receiving appropriate nutrition, as well as education and other social development opportunities.

We found that girl orphans in particular face high risks of school dropout, early marriage and early childbearing which, compounded with high birth rates and lower household wealth, among other factors, increases risk of maternal mortality [ 26 , 28 ] and perpetuates a cycle of poverty for the children who are left behind—girls who become pregnant before age 15 are five times more likely to die of maternal causes than women who are pregnant over the age of 20 [ 26 , 28 ].

In this context of high fertility coupled with high unmet need for contraception, both of which are driven by gender inequalities and weak health systems, women faced a greater risk of maternal mortality, thereby increasing the risk that children will be orphaned.

Reproductive Health and Maternal Sacrifice Women, Choice and Responsibility

These results should be interpreted with limitations in mind. While this study illuminates the intergenerational impacts of maternal death on children in Neno, Malawi, our findings are not meant to be generalized beyond the study population. As referenced above, we conducted six sex-stratified focus groups in an effort to create a comfortable environment for participants to express themselves, and remove gender-based power differentials, which are particularly salient in Malawian culture. Focus group facilitators conscientiously engaged all participants, and utilized neutral open ended questioning techniques in an attempt to minimize response bias and mitigate additional socially-based power differentials amongst participants; yet we were unable to fully control for recall bias or the effect of any bias towards responses deemed to be more socially acceptable within groups.

Our study population included only adult participants with a minimum age of 18 years. There were only two adult orphans that we were able to include as key informants in our study population. This combination of factors resulted in an underrepresentation of orphans, men, and stepmothers in our study and the perspectives of these groups may not be depicted accurately in our findings. Malawi is a resource-limited country, and Neno a very remote, extremely poor area, in which the health system is inadequately supplied to respond to the needs of the population.

The government of Malawi has emphasized health system strengthening in its Health Sector Strategic Plan HSSP , particularly through increasing the number of skilled health workers.

Despite these efforts, attracting staff to work in remote, rural areas has proven challenging. Achieving Millennium Development Goal 5, reducing maternal mortality and providing universal access to reproductive health, will not be met without significant investment in strengthening health systems, with an emphasis on integrated sexual and reproductive health and rights, including providing accessible, quality Emergency Obstetric and Neonatal Care EmONC , as well as contraceptive options, for all pregnant women, including those residing in remote areas [ 29 ]. The findings of our study are similar to those of other researchers looking at the impact of maternal death on living children [ 12 , 13 , 15 ], and add insight into the far-reaching and intergenerational impacts of maternal mortality, particularly in the context of weak health systems and gender norms that favor women as caretakers while limiting their economic independence in caring for their households.