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President Obama's ambitious Global Health Initiative — announced to a receptive international community in 2009 — is faltering as budget constraints and shaky implementation limit the impact of the multibillion-dollar program.

Maternal death stalks Malawi’s rural poor

Politics disrupt international aid.

Chimphepo's house is a shrine to statistics. He had taped posters to walls and a door, all lined with numbers and percentages. From August 2008 to May this year, he administered 1,319 HIV tests (including 416 by going door to door), and counseled 159 people on family planning (including 41 women who started on birth control pills and 46 women who went to a health facility for longer-term birth control procedures.)

“At the moment, many want to use the pills,” he said. “Before, they were using native methods, such as boiling and drinking herbs, or roots of plants.”

On his rounds one day recently, he hopped off his bike to talk with one couple, Charles Jasi, 31, and Christina Charles, 29, whom he had previously counseled. 

“What he’s doing is very important,” Jasi said of Chimphepo. “Before he provided information to us, we thought it was no problem to have children born so close to one another. Now we know in the village that it’s good to space the children, for the mother’s health and also for the baby’s health.” 

The couple has five children, and Christina Charles recently had an implant that will prevent her from getting pregnant for five years. “That’s the end,” she said, laughing. “No more children.”

They said the decision not to have more children also was a relief. There was always the fear that something could go wrong during a pregnancy, and with Salima District Hospital more than 25 miles away, any complication could be life-threatening.

For many people in rural areas in Malawi — this accounts for 82 percent of the population — access to good health care is often many hours of travel from their homes. 

For Aliyatu Alola, that distance may have killed her. 

After the nurse at Salima District Hospital declared her dead, Alola’s husband and two other relatives placed her body back in the bed of the pickup truck and drove about 15 miles to the edge of Lake Malawi, stopping at a hilltop cemetery.

There, husband Mgwale Jabil, 26, told the story. The couple had been married for three years and had one child, a two-and-a-half year old girl. He said that his wife was an energetic and enthusiastic person. She loved playing netball and watching soccer matches, as well as planting maize and ground nuts in their garden.

A week before her death, Alola had come down with a high fever and he had taken her to a health center about 25 miles from his village, which was across the vast lake, east of Salima, near the Mozambique border. They waited for eight hours and when they finally saw a health worker, he said he had no drugs in stock and they should come back later. Days later, they did, and received an aspirin-like drug. Alola seemed to improve.
But on her last night, she broke out with a high fever.

Her husband said he had only two choices, both bad: Travel 110 miles over a rutted road, an eight-hour drive, to a hospital in his district, or cross the choppy Lake Malawi in a boat for Salima, a neighboring district — a journey of six hours in all, including three hours on the boat. He chose Salima. He put her on a bicycle and balancing her on the seat, he pushed her along a rutted path toward Lake Malawi, more than an hour’s walk.

He lifted her into the boat. Partway across the lake, Alola passed away.

She hadn’t been tested for anything — not HIV or malaria. Jabil knew nothing about the cause of death. As he prepared to bury Alola , the village chief, Sam Masese, spoke up angrily. “Every two weeks something like this happens,” he said. “Sometimes it’s a little baby, sometimes a pregnant woman. It’s dangerous when health care is so far away.”

He wouldn’t get an argument from those who work on U.S.-funded health programs. Back in Lilongwe, the death of Alola — one of an estimated 3,000 women who die each year in Malawi during pregnancy or around the birth of a child — was recounted to those who build health systems.

Rudi Thetard, the country director for Management Sciences for Health, the lead USAID contractor to improve the health system in the districts where Alola lived and died, said it was likely that her death could have been prevented.

“She took a three-hour boat trip because she didn’t feel comfortable enough with her local health clinic,” said Thetard, a South African who was a medical doctor for many years. “What we need to do is improve care everywhere. We can expand better care into remote areas, and we can expand family planning. We just need to find ways to standardize care.”

At the hospital, Sylvia Kandiyesa, 29, the nurse-midwife who examined Alola when she arrived, said that after the family took away the body, a chill descended on the ward. 

“It’s our expectation that pregnant women arrive in good condition, they give birth, and there is a good outcome,” she said. “There should be one live mother and one live baby. We feel very sad with what happened here.”

For several hours after Alola’s death, hospital nurses made the rounds — to check on the expectant mothers, but also to calm them down. “The mothers were so afraid,” Kandiyesa said. “They thought maybe it could happen to them. It didn’t because they had come here in time. If she had come much earlier, we could have saved her.”

Funding for this project is provided by the Henry J. Kaiser Family Foundation as part of its U.S. Global Health Policy program.