A dim candle flame lighting the room can be seen from outside through the open door at a backyard maternity ward in Mabvuku, a populous and high-density suburb in the east of Harare, the capital of Zimbabwe.
Inside the tiny room, Rosemary Rambakupetwa, 21, is seated on a mat, staring at her new baby boy who is lying on top of brightly coloured baby blankets.
This is Rambakupetwa’s firstborn and, less than two hours after delivery, she cannot hide her excitement.
“Becoming a mother has always been my dream,” she says, smiling.
Rambakupetwa, who has been here since dawn, spent 16 hours in labour. Angeless Kunzara is the midwife who has been looking after her. Known as Mbuya Nyamukuta, a Shona name that translates to midwife in English, Kunzara, 68, had a mother who was a midwife. She started helping women to deliver in 1986 in her home in Goromonzi, a rural community 32km southeast of Harare.
“One day an expecting woman came to deliver and my mother was not around. I had no choice but to help her. When my mother came, she said I had done it correctly,” Kunzara recalls. That was the beginning of her midwifery work.
Trained by the best
Kunzara, a mother of 10, says though not professionally certified as a midwife, in 1995 she received training from nurses at clinics in her home area and senior midwives from her church.
By 2004, when she moved to Mabvuku following the death of her husband in 2001, she had vast experience in home deliveries. She left her job at a security services company in 2008 to become a full-time midwife, a job she loves.
Kunzara does not know the exact number of women she has helped to deliver. Rambakupetwa is one of the hundreds of women who have given birth at her rented house in Mabvuku.
Zimbabwe is experiencing its worst economic crisis in decades with uncontrolled inflation, stagnant salaries, widespread poverty and shortages of essentials such as water and electricity. The health sector has seen sporadic nationwide strikes by health workers for three years over poor remuneration.
The situation has been worsened by the Covid-19 pandemic. In 2020, nurses went on strike over shortages of medicines and personal protective equipment (PPE) that affected most medical facilities around Harare. Among them was Mabvuku Polyclinic, a council-owned clinic for Mabvuku residents that sent pregnant mothers elsewhere to deliver their newborns.
Finance minister Mthuli Ncube allocated 14.9% of the 2022 national budget to healthcare. Although up from last year’s 12%, the allocation still falls short of the 15% threshold recommended by the Abuja Declaration.
Crumbling public healthcare
Seeking medical care at the country’s private medical facilities is beyond the reach of many workers whose salaries have been eroded by high inflation.
Health authorities have also raised an alarm over staff shortages because of an exodus of healthcare workers. Nurses take home less than US$200 a month.
According to the Health Services Board, 2 000 Zimbabwean healthcare workers left the country for such countries as the United Kingdom, United States and Australia in 2021.
“Pregnant women being turned away at Mabvuku Polyclinic is unacceptable and they are violating women’s rights,” says Obert Nyatsuro, president of the Zimbabwe Confederation of Midwives.
“Some of the clinics are closed due to shortages of staff. Nurses are leaving to seek greener pastures. We have limited staff members to man those clinics that are opened.”
Faith-based midwives became popular in 2019 when nurses and junior doctors went on a strike that lasted several months. Public health facilities like Edith Maternity Clinic in Mbare, the biggest provider of maternity healthcare owned by the Harare city council, turned away expecting mothers.
Kunzara says that from 2020, when Zimbabwe recorded its first Covid-19 death, she has witnessed a surge in the number of pregnant women coming to her maternity ward. In 2020, at the peak of the pandemic, Kunzara helped four women to deliver on the same day – the most in a single day since she started this work.
About 2km from Kunzara’s house in Mabvuku is another maternity ward run by Ivy Gatsi, 63. Gatsi’s premises is near Mabvuku Polyclinic.
Like Kunzara, she is a member of the Apostolic Faith Church, and helps women from her church and non-church members including those who are not accepted by the nearby clinic.
“One woman was turned away from the clinic and her unborn baby was presumed to be dead. When she came to my ward, she delivered a healthy baby girl,” says Gatsi, who started her midwife career in 1992 in her home village of Murehwa, a township about 90km from Harare.
In the tiny room Gatsi uses as a maternity ward, there is a single bed where expecting mothers sleep. There is a plastic “mat” on the floor where they lie when giving birth.
This is where Jose Verde Kerstean, 34, gave birth to her twins Akiela and Kaylah Biswasi less than a month ago.
Kerstean, whose three children were all delivered at clinics, says she was supposed to deliver at Mabvuku Polyclinic but changed her mind when she feared that she would go for a caesarean section.
“I just opted for Gogo Gatsi and I delivered safely,” says Kerstean, while looking at her twins in bed wrapped with brightly coloured blankets and beneath a mosquito net.
It is a job that Kunzara and Gatsi do as an extension of their church work. Their church’s regulations prescribe that pregnant women are supposed to give them groceries or cash as a form of appreciation, but they do not turn away those who cannot afford this gesture, they say.
Both Kunzara and Gatsi say they use PPEs in their maternity wards to prevent the transmission of diseases including Covid-19.
“We buy PPEs or ask expecting mothers to bring them. These include surgical masks, umbilical cord clips, razor blades, spirits and medical aprons,” says Kunzara.
They say complications are rare. They do, however, refer expecting mothers with complications to Parirenyatwa Hospital, one of two relatively functional public hospitals in Harare.
“In November 2021, there was a pregnant woman who had high blood pressure. I referred her to Parirenyatwa Hospital where she delivered safely,” Kunzara says.
After delivery, Gatsi says, she encourages mothers to seek medical care at health facilities.
For Kerstean, her twins received injections mandatory for newborns in Zimbabwe at Mabvuku Polyclinic. Bacille Calmette-Guérin, a vaccine given to babies to protect them from tuberculosis, was administered to them.
Not free of risk
Itai Rusike, an executive director at the Community Working Group on Health, says that home deliveries are risky as pregnant women need services to support pregnancy and prevention of mother-to-child transmission of sexually transmitted infections.
The Zimbabwe Demographic and Health Survey estimates child mortality rates at 651 deaths per 100 000 live births in the country.
Even though Zimbabwe’s maternal mortality rate in the last five to 10 years shows a decline, Rusike describes it as “relatively high”. This is regardless of interventions instituted to date, he says, adding that the rise in the maternal mortality rate is attributed to poor quality of care within the country’s health delivery system.
“The contributing factors include limited access to appropriate and timely obstetric care services, staff attitudes, lack of reliable transport system, inadequate medicines and shortages of skilled personnel at the health facilities,” says Rusike.
Emmanuel Mahlangu, president of Nurses and Midwives in the Government Association of Zimbabwe, says families should seek medical care at approved health facilities.
“Nurses and midwives in these health institutions have undergone special training to ensure that they can handle emergencies arising in childbirth,” he says.
Meanwhile, Kunzara dreams of having sufficient accommodation to provide shelter to expecting mothers. “I need more space,” she says.
Rambakupetwa has vowed to come back to Kunzara’s maternity ward to deliver her next child. “Gogo is caring. I will deliver my children here,” she says, as she struggles to get into the car to return home with her newborn.