Following on from our post about adapting and adopting the baby box, Prof Barry Doyle has been to Lusaka in Zambia to discuss our project and in particular the Chitenge for Change idea being developed by Prof David Swann at Sheffield Hallam. During the visit I met with a range of partners from educational institutions, the Ministry of Health, local health providers and representatives of the charity, St John Zambia. I also spoke to a group of Zambian Medical Students, visited a rural health centre and met up with some leading Zambian historians. And at the end I had time to visit a safari park and spot a giraffe!
As a historian of interwar health care I was most struck by the similarities between the current challenges facing maternity care providers in Zambia and those encounters by health professionals between the wars, especially in rural areas.
Most obvious was the lack of money to deliver high quality services. Zambia has recently received significant support from the EU to upgrade their frontline maternity and child welfare services. This mirrors the support given to the countries of central Europe by the Rockefeller Foundation in the 1920s and 30s, especially to develop health centres and train health visitors and community midwives. But huge gaps still remain in Zambia, especially in the countryside. A particular stumbling block to engaging mothers with health centres and antenatal provision in Zambia is the requirement parents face to provide a range of materials for the birth of the child if the baby is delivered in a health centre. Addressing similar problems was at the root of the original Finnish Baby Box scheme – which sought to provide poor mothers in rural areas with a set of minimal requirements for their new born babies. In other European countries between the wars maternity centres also provided some basics. In England, for example, municipal Maternity and Child Welfare Centres distributed layettes to the poorest mothers.
A key aim of Zambian health policy is to get women to give birth in health centres or hospitals. As in late nineteenth century Britain or inter war central Europe, there is an acute shortage of trained maternity workers and midwives, with many women continuing to make use of village wise women. These traditional birth attendants cause concern for the maternity services both through their limited professional qualifications and the dangers associated with giving birth in remote areas. As with Britain and France in the early twentieth century, there is a big push to train more midwives and to get them into the community – a policy supported by Rockefeller in the 1920s and the EU today – but this is slow and barriers remain to taking up institutional delivery. In addition to the cost, many women live up to 20 kilometres from a health centre and with no access to transport have to walk or be carried – even by wheelbarrow! The centre we visited did have an ambulance stretcher, but this was one vehicle for a substantial area and was used only in extreme emergencies.
Delivering health education is also constrained by very high levels of illiteracy, especially among women in rural areas. Again, similar issues were encountered in central Europe, especially in the eastern areas of Czechoslovakia and Poland. In these contexts image based health education materials proved particularly important as did taking the message to women in the villages. Interestingly, the recent EU maternity package programme did not include health education as a central feature of the delivery, focusing on raising post natal attendance with the mother and baby pack as an incentive. While in Zambia I made contact with volunteers and staff from St John Zambia who have recently run a Mama na Mwana (Mother and Baby) scheme using volunteers to visit expectant mothers to deliver health education on a face to face basis. The importance of volunteers in this project echoes the extensive network of charitable Infant and Chid Welfare Centres operating in interwar Britain, like the Leeds Baby’s Welcome or the work of the Croix Rouge Francaise in France at the same time.
A number of other problems were identified, particularly in remote areas. Traditional myths continue to surround childbirth. Health official were cautious about revealing too much about what these were but it is clear they impede their work, especially around early registration of the pregnancy and engagement with the health centre. Health workers in central, and especially south-eastern Europe experienced similar problems into the 1930s with religion, fear of the health system and superstitions all preventing health education and intervention. Gender relations also act as a barrier in some areas with men exerting considerable control over their wives maternity choices. This can be beneficial – we were told of one village where the chief was fining husbands whose wives used the wise women as birth attendants instead of going to the health centre. In general, health professions are seeking to involve husbands in the pregnancy, especially given the cost involved in a health centre birth. This is an area in which the contemporary experience is very different to interwar Europe – I have not come across any historical examples of husbands’ involvement with childbirth or of health professionals expecting or encouraging such involvement. This was very much a post Second World War development in Europe.
Overall, this was an amazing opportunity. I will continue to work with the contacts I made while in Zambia to develop our initiative – the Chitenge for Change – more of which in the near future. Thanks to the University of Huddersfield GCRF Health Sandpit and to my colleagues in Huddersfield, Sheffield Hallam and especially Christine and Shadrick in Lusaka.