Deep in the forest of Murambinda, in the Buhera district of eastern Zimbabwe, 16-year-old Netsai (not her real name) lies motionless, dizzy from pain and blood loss. Her eyes are unfocused and she is seemingly unaware of the bustling activity of the traditional birth attendants who surround her. As another wave of pain engulfs her, she clenches her teeth and convulses with agony.
None of the women at her side have been trained as birth attendants. They and Netsai belong to the Apostolic Church of Johane Masowe, which eschews modern healthcare and encourages pregnant women to give birth at so-called birth camps in the bush.
The elderly women urge Netsai on while the head birth attendant feels her distended belly, pressing down roughly with a gnarled hand. The head birth attendant orders the girl to push and, as the baby’s head crowns, she grabs it with her bare hands.
Netsai survived the traumatic birth and her baby boy is now a healthy two-year-old. But many more women like her do not live to tell their stories.
Complications during pregnancy and childbirth are the leading cause of death for women of childbearing age in Africa, according to the United Nations Population Fund. Girls aged 15 to 20 are twice as likely to die in childbirth as those in their twenties.
The single most important intervention for safe motherhood, according to the United Nations Children's Fund (Unicef), is to make sure that a trained healthcare provider with midwifery skills is present at every birth, that transport is available to referral services, and that quality emergency obstetric care is available.
A safe birth for every Apostolic woman
Women from Apostolic sects in Zimbabwe avoid giving birth in hospitals. Birth attendants in religious birth camps assist them, often under unhygienic conditions
Unsanitary conditionsBut conditions at Apostolic birth camps are often unsanitary and birth attendants lack the training and medical equipment to deal with childbirth complications such as excessive bleeding, infection, high blood pressure, cord prolapse, prolonged labour and breech presentation, which can put the lives of mother and baby at risk.
"During labour there is no sterile equipment and infection control procedures are not followed," says Karen Webb, operational director of research for the Organisation for Public Interventions and Development Trust (Ophid), a local trust that works to improve maternal and child healthcare in Zimbabwe.
A study into the birth practices of conservative Apostolic sects, conducted by Ophid in 2014, revealed that members consider the Holy Spirit to be the guiding force in healing. Illness is considered to have a spiritual cause and modern healthcare is seen as "heathen". Church members who seek medical services are thought to be weak of faith, having elevated the medical system above God.
Sheila Makuvaza, a birth attendant with the Johane Marange Apostolic sect says: "Miteuro (prayers), holy water and prophesies from anointed elders are used to treat pregnant women in the camp."
Apostolic sects are widespread in Buhera and other districts and, according to the Zimbabwe National Statistics Agency (Zimstat), 38% of Zimbabwean women identify as Apostolic and 74% of these live in rural areas.
Buhera is in Manicaland, the province with the largest population of Apostolic sects in the country. Zimstat says the maternal mortality rate – the number of women who die while pregnant or from causes related to pregnancy within 42 days after birth – was 516 per 100 000 live births in 2012, the last time a census was conducted. But many of the maternal deaths in the province are not recorded because birth camps often operate underground.
A nurse explains to a pregnant patient patient what antenatal care involves at a rural hospital in the Gokwe region.
Lucky to be aliveMarian Matiza, from Ward 23 in Buhera, knows only too well the negative effect religious doctrine can have on women’s reproductive health. Matiza says she is lucky to be alive, following the birth of her twins, who were born in the breech position.
"I nearly died while giving birth and that gave me the resolve to stand up and walk away from this church," Matiza says. "They used tsanga (reeds) to cut off the umbilical cord and clamped [it] with ropes."
Matiza now attends a more liberal sect that allows her to seek medical attention. She has since given birth twice at a clinic and is part of a local advocacy group that raises awareness among Apostolic members about the need to give birth in a hospital or clinic.
The group, known as a health centre committee, is an extension of the country's health system and has support from the government and nongovernmental organisations such as Save the Children. It has discussions with Apostolic leaders, faith healers and prophets on how to reduce the deaths of pregnant or lactating mothers and their babies.
Bernard Madzima, director of the Zimbabwean health ministry's family health unit, says the health centre committee project "ropes in leaders of the religious groups in programmes like the immunisation of children" and encourages women to attend antenatal care.
The ministry works with community representatives who help to conduct training and meetings. Feedback from the meetings is used to formulate further strategies to suit each group. Political leaders are also involved in such talks.
Madzima says less conservative Apostolic leaders have since joined efforts to encourage more radical groups to consider using health facilities.
Marked improvementsCharles Ngirau, an Apostolic church leader from Hopley, an informal settlement on the outskirts of Harare, says his congregation started taking children to health facilities after Joice Mujuru in 2013, during her term as Zimbabwe’s vice-president, implored them to seek proper medical services.
"Other [Johane Masowe] church branches are, however, still resisting the change," he says.
Zimbabwe's Unicef country representative, Reza Hossaini, says it's important that Apostolic sects are treated as equal partners in this initiative and that "their needs and belief systems must be understood, respected and accounted for within national health system policy".
Madzima says the church leader programme has yielded marked improvements in maternal and child health in the area. Manicaland had a maternal mortality rate of 1 060 in 2002, and that has since been halved. "There has even been a reduction in under-five deaths by 18%," he says.
Madzima believes the community representative strategy works because "government is not forcing the church to co-operate, but rather engages them in dialogue".
But there is still much that can be done to improve outcomes for mothers and babies who adhere to the Apostolic faith.
Members of the Apostolic church baptising a fellow member in the flowing Mukuvisi River near Waterfalls, Harare.
Standard precautionsOphid’s 2014 report says people should be informed of cost-effective interventions to help mothers and babies survive that include standard precautions for infection control during deliveries, such as washing their hands with soap and clean water, using surgical gloves, keeping newborns warm and keeping the baby’s umbilical cord clean after birth.
The organisation says there is also a need to work with Apostolic leaders and birth attendants to find ways to advocate for and improve the referral of pregnant women and new mothers to healthcare facilities.
Madzima says, although there’s been progress, it's important to realise that Apostolic sects have been conducting their own birth camps for years and their systems are firmly rooted in their way of life.
"[Change] will not happen overnight because it has been their way of doing things according to their beliefs, which they take very seriously," he says. "Much advocacy would be needed to change these deeply entrenched beliefs." - Additional reporting by Bhekisisa
Phyllis Mbanje was a Bhekisisa fellow in 2014.
Maternal deaths become a neglected tragedy in Zim
How to reduce maternal deaths in Africa
Prioritising maternal and child health
Mozambique decrimanalises abortion to curb maternal deaths
Science could be closer to unravelling the riddle of menstruation-related mood disorders
A little extra money in young women's homes can go a long way towards protecting them from HIV infection. So can a little bit of concern.
Ebola tore into the fabric of family life, and the relationships that bind them. These are two similar stories, with very different endings.
Bhekisisa means "to scrutinise" in Zulu
In South Africa, Zulu patients who would like to be thoroughly assessed by a doctor, would ask the physician to "bhekisisa" them.