Blog Posts

Global maternal mortality: the dignity of life and the tragedy of death

When I hear the phrase “integral human development,” the picture that comes to mind is a developing fetus—the beginning of human development. Human development begins with the conception, gestation, and birth of a baby, which we tend to think of as a joyous moment worth celebrating. 

To a pregnant mother, the birth of her baby is the culmination of a “forty-week” journey marked by numerous bodily changes, emotional swings, and other challenges. Although the journey from pregnancy to childbirth can be difficult, we often tell pregnant women, using an all-too-common phrase, that “you will soon have your bundle of joy.” Many pregnant women look forward with anxious anticipation to the birth, imagining baby snuggles and all of the beauty they will witness in and through their child. 

Many pregnant women around the world are deprived of the opportunity, however, to watch their baby grow and become an integral part of society. For them, pregnancy and childbirth arouse mixed emotions. This is particularly true for women who have been deprived of their rightful access to maternal health care. The joy in anticipating their baby’s arrival is tempered with the dread of the real possibility of sacrificing their lives in the process. The “joy of childbirth,” for many women and their families, is complicated and overshadowed by the “fear of childbirth.”

“A deep, dark continuous stream of mortality . . . how long is this sacrifice to go on?”This cry of concern was voiced in 1838 by William Farr, the first registrar general of England and Wales. Although women have been dying since time immemorial from preventable causes related to pregnancy and childbirth, it wasn’t until 1987 that a global initiative was launched to reduce the number of preventable maternal deaths: the safe motherhood initiative. 

A mother’s right to life

Why did it take so long for a mother’s right to life to become a priority on the global development agenda? Over three decades later, too many women are still sacrificing their lives each day to give life. The question remains: “how long will this sacrifice linger?”

Maternal mortality, defined by the World Health Organization (WHO) as the death of a woman while pregnant or within forty-two days of the end of pregnancy, is a critical global health challenge. It is unacceptably high, particularly in developing countries. Although there was a 38 percent reduction in the global maternal mortality ratio between 2000 and 2017, the WHO estimates that around the world, a jaw-dropping 810 women die every single day due to complications of pregnancy and childbirth. Nearly 94 percent of these deaths occur in low and lower-middle income countries, and the vast majority of these deaths (two-thirds) occur in sub-Saharan African countries, making it the region with the greatest maternal mortality burden. 

Sadly, the United States is not immune from this preventable tragedy. Estimates from the WHO indicate that the US maternal mortality ratio (MMR) is nineteen maternal deaths for every 100,000 live births, compared to the average of eleven deaths per 100,000 live births for all other high-income countries. For comparison, the MMR for every 100,000 live births is two in Norway, four in Spain and Sweden, five in Belgium and Netherlands, six in Australia, seven in the United Kingdom and Germany, eight in France, and ten in Canada. 

Even more troubling, while maternal mortality ratios are generally decreasing globally, the US has been heading in the opposite direction with increasing maternal mortality. Maternal deaths here in our university’s own state of Indiana, for example, have been consistently higher than the US national average for several years. 

Racial inequities

Further, there is compelling evidence that racial inequities play a significant role in America’s maternal mortality burden. Black women are more than three times more likely than White women and Hispanic women to die during pregnancy, childbirth, and the postpartum period. A google search of Black maternal mortality will bring up several stories that indicate that the inequities Black mothers face in maternal deaths extend beyond pre-existing educational and socioeconomic inequities that contribute to poorer access to care.

Institutional racism across many levels of America’s health care system plays a significant role in the Black maternal death crisis. From the death of Kira Johnson in 2016 to the death of Shalon Irving in 2017, there are numerous cases of Black mothers dying in the United States from preventable causes, much like in less developed countries. 

Global initiatives

The United Nations’ Sustainable Development Goal 3 of “ensuring healthy lives and promoting well-being at all ages” provides a number of key global health targets. The first is to decrease the global maternal mortality ratio from 211 to below seventy maternal deaths per 100,000 live births by 2030. In addition, no individual country should have a maternal mortality ratio more than twice the global average.

For many countries in Sub-Saharan Africa, achieving this goal by 2030 is far-fetched. Socioeconomic and cultural factors, poor access to health care facilities, and poor quality of care remain significant obstacles to maternity care in the region. As the global community strives to decrease preventable maternal deaths, interventions, programs, and policies must target women who are most vulnerable to this scourge of maternal mortality. 

Historically, global initiatives, programs and interventions for mothers and babies have been combined (maternal/newborn health or maternal/child health interventions). This makes sense during pregnancy, because the mother carries the fetus and her health affects the baby’s health. It also makes sense immediately after birth, because the mother is the primary caregiver of the newborn, and in many cases, the primary source for their infant’s nutritional needs. 

While this combined mother-baby approach is well-intentioned, more often than not it prioritizes the baby’s health over the mother’s health. In Maternal Mortality–A Neglected Tragedy: Where is the M in MCH?, a 1985 article published in the Lancet, Rosenfield and Maine drew attention to the fact that causes of maternal deaths are different from those of infant mortality, and therefore should merit unique interventions. They called on global actors like the World Bank to make maternity care one of its priorities. In a major step forward, the Millennium Development Goals, specifically Goal 5A, and, now, the Sustainable Development Goal 3.1, specifically targets maternal deaths. 

Neglect of the mother’s health is seen especially after birth or the postpartum period, when postnatal care of the baby becomes more important than postpartum care of the mother. I would argue that the neglect of quality postpartum care of the mother is a major contributing factor to high maternal death rates. In the design of integrated Maternal/Newborn Health (MNH) or Maternal Child Health (MCH) programs and interventions, particularly in the postpartum period, the “M” in MCH or MNH should not be forgotten: postnatal care of the baby without postpartum care of the mother is a job half done!

Current research

My research is dedicated to improving maternal health outcomes during the postpartum period, the timeframe when mothers are at highest risk for maternal deaths. Specifically, I examine patient and healthcare facility factors that influence access to quality postpartum care among vulnerable populations in Sub-Saharan Africa and the United States. In many settings in Sub-Saharan Africa, quality postpartum care, education, and support for the mother are often missing components in postnatal care, which focuses on care of the baby. In Malawi, I examined whether women who delivered in health facilities received the recommended postpartum clinical assessments before discharge, and found that although women delivered in health facilities with skilled birth attendants, most were not examined after delivery. I have also assessed midwives’ knowledge of postpartum care and complications among 245 midwives in four hospitals in Tamale and found significant knowledge gaps in care of the postpartum patient and recognition of warning signs of life-threatening complications.

I am currently working to improve postpartum care and education of mothers by implementing and evaluating an intervention known as Focused-PPC in four health centers in Tamale, Ghana. Focused-PPC is an innovative postpartum care, education and support model that integrates recommended clinical care for mother and baby, and includes education and support for mothers in a group setting for up to twelve months after birth. Each group will meet at one-to-two weeks, six weeks, and monthly thereafter for up to one year postpartum following the Ghana Health Service postnatal care schedule. Led by trained midwives in the health centers, each group session will consist of postpartum clinical assessments for mother (in addition to baby), education, and support. Our model will ensure that mothers receive quality postpartum care and education as recommended by the World Health Organization and Ghana Health Service. 

Every woman should have the right to quality maternity care services, regardless of where they live or give birth. Mothers are integral to human development. The impact of maternal deaths has lifelong consequences for their babies, older children, families, and the community at large. 

Let us persist in our quest to ensure healthy lives for all human beings, including the lives that give life.

Previously Published by the author in Dignity & Development, a series of blog posts by the Keough School of Global Affairs, University of Notre Dame, that provides in-depth analysis of global challenges through the lens of integral human development.

How Skilled are Our “Skilled” Maternity Care Providers?

In ten years (i.e. by 2030), we should have worked hard enough to decrease the global maternal mortality ratio from 216 to below 70 deaths out of every 100,000 live births in order to meet the Sustainable Development Goal on maternal mortality. One of the indicators for measuring this goal is the proportion of births attended by skilled health personnel, commonly referred to as a skilled birth attendant (SBA). Globally, a major focus of safe motherhood interventions has been to increase the number of deliveries by skilled birth attendants. Skilled birth attendants are typically doctors, nurses, or midwives who have the competence to provide quality care to women and newborns. Skilled birth attendants must have the ability to promptly identify and manage pregnancy, delivery and postpartum complications or refer to an appropriate level of care/health facility. This is important because timely identification and management of complications is critical in decreasing maternal deaths. Most maternal deaths are due to complications such as hemorrhage, hypertensive disorders, infections, and other complications from delivery. Most of these complications can be adequately managed if a woman has timely access to a skilled health professional.

Sub-Saharan Africa has shown progress in the number of births in the region attended by a skilled birth attendant, with 59%  of births between 2012 and 2017 attended by a skilled health professional . Globally, 80% of births are attended by a skilled health professional. There remains work to be done to ensure that more women have access to skilled health professionals during pregnancy, childbirth, and postpartum.

While it is important that women have access to and actually use the services of skilled health professionals, it is equally important that providers actually have the knowledge and skill set to identify and manage women’s conditions appropriately. Poor knowledge of postpartum care and potential complications directly impacts the ability of midwives to provide quality care to patients after childbirth. An important question we must ask is “how skilled are our skilled health personnel?”

Findings from our survey of 245 midwives in Ghana revealed significant knowledge gaps among midwives related to postpartum care and postbirth warning signs, immediate newborn care, and management of complications. Most midwives gave incorrect answers on postpartum care questions related to location of fundus, postpartum examination, and care during the first 2 hours after birth. While most midwives were knowledgeable about breastfeeding and immediate hemorrhage intervention, many lacked knowledge on cord care, thermal protection, newborn resuscitation, contraindications for vacuum extraction, treating metritis, and performing a cervical repair. Our findings also revealed significant knowledge gaps on recognition of warning signs of life-threatening complications such as pulmonary embolism, cardiac events, and postpartum depression. More specifically, only 47.5%, 57.0%, and 57.0% of midwives were able to identify pain in chest, obstructed breathing, and thoughts of hurting oneself as warning signs of postpartum complications respectively.

The postpartum period is high-risk for maternal mortality. There is a need for additional training of midwives in how to care for postpartum patients and accurately identify warning signs of life‐threatening complications after childbirth. We found that more years of experience was a significant predictor of midwives’ knowledge. Thus, there must be comprehensive onboarding training programs for new midwives, as well as frequent in-service trainings on postpartum care, newborn resuscitation, and potential postpartum complications. We will not make significant progress in decreasing maternal deaths if our maternity care providers do not have the supposed knowledge, skills, and confidence to recognize and manage complications in a timely manner.

Why Women Do Not Use Postpartum Care Services in Developing Countries

Postpartum care is care provided to a woman within 6 weeks or 42 days after birth. The World Health Organization recommends that postpartum care should be provided by a skilled health personnel, such as a doctor, midwife, or nurse in a health care facility. Postpartum care is very important because it helps in the timely identification and management of postpartum complications.

Lack of or inadequate postpartum care has become an issue of major concern, especially in developing countries. Most maternal deaths occur in the postpartum period from complications such as severe bleeding, infections, hypertensive disorders, and complications from delivery and unsafe abortion.

Many women do not receive any postpartum care after birth despite high maternal death rates in the postpartum period. Many researchers have conducted studies in several developing countries to determine the barriers to postpartum care after birth. I conducted a review of the literature to synthesize research findings on why women do not use postpartum care services in developing countries.

In this post, I highlight the most common reasons why women decide not to seek postpartum care after birth, summarized below.

• The view that postpartum care is not necessary/needed
• Lack of support or encouragement from husband or family
• Cost of services
• Lack of awareness of postpartum care
• Cultural barriers
• No complications and no awareness of complications
• Lower level of women’s education
• Women’s farming occupation or unemployment
• Lower level of husband’s education
• Husbands farming occupation or agricultural work

Participants in several studies reported that they did not seek postpartum care because they thought postpartum care was not necessary; they did not have support from husbands or family members; they could not afford the cost of postpartum services; they did not know about postpartum care; and they could not seek care due to cultural barriers. These barriers call for community-based health intervention programs. Some of the interventions could focus on educating women on the importance of postpartum care, the timing of postpartum care visits, and why they should attend visits even when they “feel fine” or do not observe any immediate signs of complications.  Community campaigns should also encourage support from husbands and family members to women to motivate them to seek postpartum care. In addition, clear guidelines on when women should return for postpartum visits after birth should be communicated to them prior to their discharge from health care facilities.

Findings from the review also indicated that women are less likely to use postpartum care services if they had no complications or no concern about complications, if they or their husbands are less educated, and if they or their husbands are farmers or involved in agricultural work. This points to the importance of educating not only women, but also their husbands, about warning signs of postpartum complications and when to seek care. It is equally important that women and their husbands are educated to return for their postpartum visits even if the woman did not have any complications during birth. This is because life-threatening complications are usually unpredictable and may require rapid action. Finally, interventions to encourage postpartum care use should target uneducated families and farming communities.

For the full article, see: Adams, Y. J., & Smith, B. A. (2018). Integrative Review of Factors That Affect the Use of Postpartum Care Services in Developing Countries. Journal of Obstetric, Gynecologic & Neonatal Nursing, 47(3), 371-384 (https://www.sciencedirect.com/science/article/pii/S0884217518300212).

 

 

Postpartum Care OR Postnatal Care? Let’s Get Specific!

There seems to be a lot of confusion in the use of the terms postpartum care and postnatal care. I recently conducted a literature review on factors affecting the use of postpartum care in developing countries. During this review, I noticed that while some authors used postnatal care to refer to care provided to the baby and mother, others used the term to refer to care provided to the mother. However, care provided to the mother should be referenced as postpartum care, not postnatal care.

Even among academics, postpartum care and postnatal care have been used interchangeably. The only thing postpartum care and postnatal care share in common is the period during which care is received – after the birth of a baby. A widely accepted definition of the postpartum and postnatal periods is the time immediately after birth to 6 weeks after birth of a baby. A common confusion in the use of the terms postpartum care and postnatal care stems from the reference to timing. To the extent that both terms are pointing to time after birth, they can be used interchangeably. However, postpartum care and postnatal care have different connotations when it comes to who is the intended recipient of the care provided. Specifically, postpartum care refers to care provided to the mother after the birth of a baby, while postnatal care refers to the care of the baby after birth.

The interchangeable use of the terms antepartum care and antenatal care may help explain why so often postpartum care and postnatal care lose their distinct meanings. Antepartum care is care given to pregnant women from conception to the onset of labor. Care during this period is also called antenatal care or prenatal care. The interchangeable use of antepartum and antenatal (prenatal) care makes sense because during this time, the woman is pregnant with the baby, and care for the two is not entirely separate. It is much more important to be specific in the period after birth because care for the mother after birth is quite different from care for the baby, whether in the immediate postpartum period or at follow-up visits. Postpartum visits are usually provided through the woman’s obstetric office, while a pediatrician is responsible for the baby’s health and well-being. In developing countries, although both postpartum and postnatal care may be provided by the same maternity care provider (most commonly a nurse/midwife), care provided to the mother is still different from care provided to the baby.

It creates a lot of confusion and makes the maternity care literature difficult to navigate when there is no clear distinction between postpartum care and postnatal care in the literature. One should not have to read a significant portion of an article just to determine whether the study was focused on care for the mother, care for the baby, or both. The term postpartum care, NOT postnatal care, should be used to reference care of the mother, at all times. This I believe, will make the literature clearer and easier to navigate.

More importantly, distinctions between the two should be made clear to patients, since postpartum care is often a neglected aspect of maternity care. Many women are aware of the need for postnatal care for their babies, but not the need for postpartum care for their own health and wellbeing. From my integrative review, the view that postpartum care is not needed and a lack of awareness about postpartum care were frequent reasons women gave for not attending postpartum visits.

Let’s be specific in terminology, and let’s be specific in informing patients about the need and importance of postpartum care!

Decision to Seek Postpartum Care: The Power of Nurse/Midwife Advice

Postpartum care in developing countries is beginning to gain a lot of attention as statistics show that the majority of maternal deaths occur during the postpartum period. Researchers, including myself, are busy trying to understand the fundamental reasons behind poor access to and delivery of postpartum care in Sub-Saharan Africa, a region where many women do not receive postpartum care after childbirth.

Current empirical evidence shows that socio-economic, demographic, and geographic factors can explain access to postpartum care. In particular, low level of education or illiteracy is associated with less use of postpartum care, as are residence in a rural area and farming as major occupation.

One of the questions of growing interest is: why do women decide not to return to health facilities for recommended postpartum care? Aside socio-economic factors, scholars are discovering that lack of women’s autonomy to make decisions, lack of husband support, and limited access to postpartum information or lack of awareness, tend to prevent women from seeking timely postpartum care.

Paying attention to barriers to postpartum care use is commendable, and has enhanced our understanding of areas to target for interventions. However, much less attention has been paid to the extent to which nurse/midwife advice influences women to seek postpartum care. My work in Malawi has showed that nurses/midwives serve as an important medium for postpartum information flow to women and their families, and may be one avenue to improve the use of postpartum care.

My research on the use of postpartum care, conducted in central Malawi has targeted rural subsistence farmers, a vulnerable population with even lesser use of postpartum care as the research evidence suggests. To my surprise, I found that almost all the participants in my study returned for the recommended one-week postpartum care visits. I asked a follow-up question: “why did you decide to seek postpartum care in the health facility?” The top reason women gave for deciding to return for their recommended postpartum visit, was that they were advised by the midwife to return!

This highlights the importance of midwife advice in improving postpartum care use. Nurse/Midwife advice to patients and their family to return to a health facility for postpartum care per country or WHO guidelines, is a simple, inexpensive intervention that could potentially improve postpartum care use among rural women in Sub-Saharan Africa!

Where are the Husbands? Male Participation in Maternity Care in Sub-Saharan Africa

The importance of male participation in maternity care in Sub-Saharan Africa is becoming increasingly important. This is because husbands have a role to play in ensuring that their wives’ obstetric care needs are met. The involvement of husbands in their wives maternity care is especially critical in Sub-Saharan Africa because in many settings of the region, husbands decide when and where obstetric care is sought, even during complications. It is therefore essential to understand and increase men’s involvement in their wives’ care in Sub-Saharan Africa. Since husbands are important decision-makers, an important first step is to increase their knowledge and awareness of obstetric care, to enable them to make informed decisions about where and when to seek care.

In Sub-Saharan Africa, cultural perceptions and gender norms often constrain men’s involvement and participation in maternity care. Maternity care in Sub-Saharan Africa is still seen by many as women’s business, and the role of husbands is often limited to providing financial and material support. This historically female-centered view of maternity care has led to lack of space to accommodate men in maternity care units in many health facilities. Further, maternity care providers easily exclude husbands from the education provided to wives prior to discharge from health facilities. Thus, male participation often ends at accompanying the wife to a health facility. As a result, husbands tend to have very little knowledge of the care their wives actually receive at health facilities, since they usually have to wait outside the health facility.

As part of my research on postpartum care in rural Malawi, I found that most husbands are unaware of routine postpartum clinical assessments such as blood pressure, temperature, abdominal, vaginal, and breasts exams their wives 20151006_143527receive in health facilities after delivery. Husbands who are aware of some of these services get the information from their wives. Also, many husbands do not usually attend postpartum care visits with their wives. Even for husbands who accompany their wives for care, they seldom enter the health facility.

An important finding was that the lack of knowledge of husbands and non-attendance at postpartum visits did not mean the husbands were not interested in the well-being of their wives. Many husbands permitted their wives to return for their postpartum visits because they were interested in her well-being. The non-attendance and lack of knowledge of postpartum care may be due to limited opportunities for husbands to participate in their wives care, because of the female-centered view of maternity care.

It is important to encourage husbands to support their wives in seeking postpartum care for the well-being of the wife. It is also important for health care providers to welcome husbands as partners in their wives care, when they accompany them to a health facility, by allowing them into private examination rooms (where available). For health care facilities without private examination rooms, health care providers can provide husbands with information on the status of their wives health. Maternal health education should be provided to both men and women, so that they are both equipped to make prompt, informed decisions about concerns that may arise, especially during obstetric complications. Further, women should be encouraged to have open discussions with their husbands about care they received in health facilities, and any health issues or concerns from visits.

Husbands’ participation in their wives maternity care, beyond accompanying wives to a health facility, could result in more knowledge and awareness of their wives health, and could enhance communication between husbands and wives related to obstetric care. This improved knowledge and communication may help in prompt decision-making for seeking emergency obstetric care, especially given the economic dominance and decision making power of men in Sub-Saharan Africa.

Time to Focus On Postpartum Care in Sub-Saharan Africa

Sub-Saharan Africa Carries the Greatest Burden of Maternal Deaths

Sub-Saharan Africa carries the greatest burden of maternal mortality. It is the region with the highest maternal mortality ratio (MMR), defined as the number of maternal deaths per 100,000 live births. According to estimates reported by the World Health Organization (WHO), Sub-Saharan Africa alone accounted for 62% of all maternal deaths globally in 2013. The same report indicated that the MMR in Sub-Saharan Africa is 510 compared to 140 in South-Eastern Asia, 85 in Latin America and the Caribbean, and 69 in Northern Africa. The rate of decline of maternal deaths has been slower in Sub-Saharan Africa than any other developing region. The majority of countries that made no progress or insufficient progress in meeting their Millennium Development Goal 5a targets of decreasing maternal mortality ratios by 75% by 2015were in Sub-Saharan Africa. It is of critical importance that the high maternal mortality in Sub-Saharan Africa be addressed.

Postpartum Care: The Often Neglected Aspect of Maternal Healthcare

Proportion of maternal deaths by days postpartum (Source: WHO technical consultation on postpartum-postnatal care)

The majority of maternal mortality cases occur in the often neglected postpartum period, defined as the time from 1 hour after delivery of the placenta to six weeks after delivery of the baby. The time of highest risk for maternal death is the immediate (first 24 hours) and early postpartum periods (days 2-7 after delivery). Life-threatening postpartum complications are often unpredictable and require rapid response. Postpartum care is essential for maternal health and survival because it enables skilled health providers, such as doctors and nurses/midwives to prevent potential postpartum problems, identify, and treat complications promptly.

The World Health Organization(WHO) recommends that postpartum care should be provided to mothers for at least 24 hours after birth in a health facility, and then at 48-72 hours, days 7-14, and six weeks after birth. Recommendations by the WHO on the content of postpartum care (for the mother) include physical assessment of the mother (vaginal bleeding, uterine contraction, fundal height, temperature, heart rate, blood pressure, urine void, etc.), counseling/information about the physiological process of recovery, iron and folic acid supplementation for at least three months, prophylactic antibiotics for women with third and fourth degree perineal tears, and psychosocial support. However, many women in Sub-Saharan Africa still do not receive any postpartum care. Percentages of women who do not receive any postpartum care after delivery in Sub-Saharan Africa remain very high, for example 74.1% in Uganda, 55.1% in Kenya, 55.2% in Nigeria, and 49.8% in Zambia. Obviously, these are missed opportunities for skilled health providers to prevent and detect any postpartum problems and complications in a timely fashion, and this can consequently lead to the death of a mother. Systematic and regular postpartum care is inadequate even for women who deliver in health facilities.

Call to Action

A need exists for more primary research on postpartum care provision and use in Sub-Saharan African countries. Research interventions during the postpartum period can decrease postpartum maternal mortality rates. To develop effective interventions that will decrease maternal mortality rates in Sub-Saharan Africa, it is critical to identify the key factors affecting postpartum care use, and understand challenges health facilities face in providing postpartum care. Research efforts must address access to care, especially for rural women. New research strategies are needed to ensure that mothers, especially those who are marginalized, have access to quality postpartum care services.

 

Statistics From:

Trends in maternal mortality: 1990 to 2013. Estimates by who, unicef, unfpa, the world bank and the united nations population division. Geneva, Switzerland.

Zureick-Brown, S., Newby, H., Chou, D., Mizoguchi, N., Say, L., Suzuki, E., & Wilmoth, J. (2013). Understanding global trends in maternal mortality. International perspectives on sexual and reproductive health, 39(1).

Wang, W.J., Alva, S., Wang, S.X., & Fort, A. (2011). Levels and trends in the use of maternal health services in developing countries: DHS Comparative Reports. Calverton; USA: ICF Macro.

WHO recommendations on postnatal care of the mother and newborn. Geneva, Switzerland.

Malawi, The Warm Heart Of Africa

How I ended up in Malawi

I wanted to work internationally, especially in Sub-Saharan Africa with a focus on maternal health. I was led to Malawi through my PhD advisor and my husband. I met my husband Ellis in 2012, the first year of my PhD program at Michigan State University. Through Ellis, I got to know a lot more about Malawi. He had already visited the country for some pre-dissertation work, and was planning on going back for his final dissertation data collection. All the while I had not the slightest hint or inclination that my research will take me the same site as my husband’s.

In 2013, I began working under a new  PhD advisor, Dr. Barbara Smith, who was interested in international research and therefore wanted to mentor me towards that route. She had well established contacts and collaborators in Kenya and Malawi, giving me the option of choosing between the two countries. At first thought, I leaned more towards the Kenya option. However, before I could make any concrete decisions, the Principal (Dean) of the Kamuzu College of Nursing at the University of Malawi, Dr. Address Malata, visited the MSU College of Nursing. My advisor arranged for me to meet with her and discuss the possibility of working with her in Malawi. After a series of conversations with this accomplished, successful, and influential woman, Kenya was no longer in the picture. From then onwards, my work in Malawi began.

Map of Malawi
Map of Malawi

About Malawi

Malawi is known as ‘the warm heart of Africa’ because its people are friendly and very welcoming. It is a small country in the Southeastern part of Africa. The country is divided into three regions: north, central, and south Malawi. The capital city of Malawi is Lilongwe, located in the Central Region. Even though Chichewa is the most common language spoken by the people in Malawi, there are also other languages. English is however the official language. You may visit http://www.malawi.gov.mw/, the official site of the Malawi Government for more information and country profile. Malawi has many attractions including beautiful landscapes, national parks and wildlife reserves, and the famous Lake Malawi. More on tourism and attractions can be found on http://www.malawitourism.com/.

Indeed, the Warm Heart of Africa

I had the privilege of visiting Malawi for the first time in August 2014. As we touched down in Lilongwe on a Kenyan Airways Flight, I was filled with excitement. Ellis came to the airport with his friend, Chawezi, who was gracious enough to come pick me up with his old Jeep Cherokee. He was very friendly and made the ride to my new home comfortable although I barely saw anything in the pitch dark and moonless night.

The next day, I met my host family, a couple who rented to me their guest apartment. Indeed, they made sure I was comfortable throughout my stay. I could not have had a better living arrangement. I spent a lot of time at the Kamuzu College of Nursing (KCN). I was pleased to see what beautiful building the College of nursing had. Dr. Malata introduced me to her staff and faculty, and made arrangements for a faculty member to help me get around. The faculty at KCN were of such great assistance. Throughout my time at KCN, I met many people, and made friends. When I visited the Lilongwe District Office, I received a warm welcome from the District Health Officer, who embraced my research ideas, offered suggestions, answered numerous questions, and ensured that I received all the documents that I needed from his office before I had to leave Malawi. Everyone I met or came in contact with treated me with  kindness and offered the assistance I needed: the administrative staff and midwives at the various health facilities I visited, the people I interviewed, the people I encountered each day, the taxi driver Mr. Brown who took me around, the people I met in church…..everyone. Indeed, the people of Malawi are warm-hearted.

Chambo with rice
Chambo with rice

My friends at KCN ensured that I learned some Chichewa before I left. By the time I was leaving, I could at least greet in Chichewa and say thank you. I had heard of ‘chambo’ the famous Malawian fish even before I got to Malawi, and could not wait to eat it. When I finally tried it, it was one of my happiest moments, indeed delicious. From then on, most of my restaurant orders were chambo (if they had it) with rice or chips (fries). My other favorite meal was chicken with peri-peri spice and chips from the fast-food restaurant called Galitos. The commonest dish in Malawi is Nsima, made from cornmeal. It is quite similar to TZ (TuoZaafi), a meal from Northern Ghana. I did not eat a lot of Nsima while I was in Malawi, but truth is, my husband and I have come to like it and actually make it in our home sometimes, of course, with a little Ghanaian touch :). I loved and enjoyed the fresh vegetables in Malawi. It was certainly not difficult to cook healthy meals (corn, peas, tomatoes, spinach, kale, carrots, green beans, okra, and many many more). My visit to Lake Malawi in Salima was fun. Ellis and I spent the day with Dr. Address Malata and her family. It was nice to take a break and walk along the beach. The restaurant on the beach had an awesome buffet lunch served….so delicious. I also visited the Lilongwe Sanctuary and Wildlife Center. The three-week stay was so much fun but Malawi has so many more attractions that I could not visit.. I hope to visit many more places when I go again.

Lake Malawi in Salima
Lake Malawi in Salima

Zikomo! (Thank you)

My Unexpected Journey to the PhD in Nursing

It was Monday, August 13 2012. Judith, my sister in law, who was then my brother’s (Nathan) girlfriend, and I decided to go to Grand Rapids from Ann Arbor (both in Michigan) to get our hair braided. Ridiculous…. I know… but to us it made perfect sense. I went to Calvin College in Grand Rapids for my BSN (Bachelor of Science in Nursing), and had a friend there who will braid my hair nicely but for  a discounted price. We wanted to have good looking hair for a cheaper price. We were to drive there early morning, get both of our hair braided, and make a return journey. We were in my other brother’s (Obed) house in Ann Arbor. Judith and I woke up so early for the trip to Grand Rapids that Obed, who was already awake and preparing for work expressed surprise. He could not believe our ridiculous plan … but looking back …he now knows there was another reason why I had to go to Grand Rapids that day. God was up to something!

While Judith was getting her hair braided, I decided to call Dr. Adejoke Ayoola, my advisor at Calvin College, who was and is still a great mentor in my life. I called her to request for a reference letter for a job application and also to update her about issues  and developments in my life … the fact that I could not afford to pay upfront fees and attend any of the schools I had been accepted into due to lack of financial support (International students cannot apply for FAFSA, what I was being offered), and also that every potential job opportunity somehow eventually failed. I declined offers to pursue nurse practitioner programs at the University of Illinois in Chicago (UIC), University of Pennsylvania (UPENN), and the University of Michigan all because of lack of financial support. You see, whenever I am in Grand Rapids, I usually try to see Dr. Ayoola and say hello if there is time. I would probably not have called her that week if I had not gone to Grand Rapids to braid my hair.

I updated Dr. Ayoola on my life stories, and her response is one to remember for a long time. Ooooo Joyce, I am so sorry to hear that. You know, I am actually just on my way home from Michigan State University (MSU) where I attended an annual meeting on the Calvin-MSU partnership I previously talked to you about. You know I have been telling you about their PhD program. They were even telling me they still have space for more students, and there is some financial aid left that they can offer. I always tell you to go for a PhD instead of doing a masters. It is not too late, and I would still encourage you to think about it. Maybe this is the opportunity…laugh…you know…maybe that is why nothing else is working out. But yea they have the space and the money, and I can send an email to them if you want to apply. I think you should go for it. I would encourage you to apply and see if it works out; you can always choose to decline the offer. So think about it tonight, and let me know your decision tomorrow.

During my final year at Calvin, when I started thinking about next steps, Dr. Ayoola thought a PhD in Nursing would be the best for me and had no doubt that I was capable. It’s funny, because during meetings, we would talk at length about the PhD and how it could help me achieve my dreams of transforming the lives of mothers in Sub-Saharan Africa, and then I would later come to her office with another master’s level application instead. I wanted to practice nursing, and be there for my patients. I wanted to put the “compassionate and caring Joyce to good use.” I always knew I wanted to go to graduate school, that is why I decided to do it right after my bachelors, but I thought I had to be a nurse practitioner to be able to impact lives. Now I know I was wrong, not because it was untrue, but because I had not yet seen the full picture of what opportunities a PhD will open for me to follow my dreams. I did not yet know what Gods plan for my life was nor where I was headed professionally.

Of course the rest of my day I was thinking about it. I talked with my brothers about it, prayed about it, and slept over it. The next day, Tuesday August 14, Dr. Ayoola emailed me to ask if I had made a decision. I decided I would give it a try, as I wait for my open door for a RN (registered nurse) job. I got back to Dr. Ayoola to let her know I would give it a try, and she immediately passed along the information to the right people. It was time to begin the application process. I was told I needed to take the GRE as soon as possible! The GRE …. Really … This is the same GRE that I had INTENTIONALLY avoided in my masters applications. I ensured that I applied to only schools that waived the GRE for students with a certain GPA (Grade point average). But now I had to take it, I had no choice, there was no waiver, and WAIT…. I did not have months or weeks to prepare for it! I told myself not to be perturbed, I will take it, and if this whole thing is God’s will, then it will work out. That night, I read about the GRE and registered for the exam. I could not get an exam date for Friday, but was able to get one for Monday.

The next day, Wednesday, I went out to buy one GRE book in store (It’s not like I had time to read more than one book). My GRE exam was scheduled for Monday, and I had exactly 4 days to study and fill out application forms and submit essays. I started working on the application to the College of Nursing, and the Graduate School of Michigan State University. On Thursday, I worked on references and transcripts, personal statement, research statement, and a short academic statement among other application materials. I then used Friday, Saturday, and Sunday to study for the GRE exam. I was scheduled for an admission interview on Tuesday, August 21.  I received an email to come for the New PhD Student orientation on Friday, August 24. I signed my acceptance form at the orientation. However, admission and registration details were still being finalized, even though classes were to start the next Wednesday.

On Monday, August 27th, I announced to my parents and other people about my new program, and right after making all those calls (no kidding), I got an unexpected call from the University of Iowa Hospital for an interview! I had given up waiting for that call…and then it came. I was scheduled for an interview on August 31, and I went for it. Why did I go? … well, that was my original plan … before the whole PhD craziness started. Judith and I had thought we would be roommates when I got the job. She was in dental school in Iowa. It was a great interview, and they told me to expect a call in two weeks.  Meanwhile, on the MSU side of things, I got an email that the admissions office needed an affidavit of $$$$$; let’s just say a ton of money to prove that I could afford tuition before they could process the admission. Once again, I needed to show proof of finances for the tuition before an I-20 (important document International students must have) could be processed. I had to tell yet another school that I did not have money. But this time around, things worked out! The college of nursing gave some funding on admission, and I was able to apply for and obtain a graduate assistantship within the college.

This is a BSN to PhD program, and students in this track take masters level courses in the first year (at that time). Two out of three of my courses that semester were online. But I did not yet have access to the online courses! The week of September 3 to 7…..classes were ongoing, and I did not have access to ANGEL (the online system). As late as September 10-14, I still did not have access. I finally got my official admission letter from MSU that week. At long last, I was able to register for classes, and get access to ANGEL. It was tough, because I had a ton of school work to catch up on. To shed some light on this, one of the courses was an online statistics course. First of all, I did not even know statistics could be offered online (first experience). Now, imagine playing catch up on three weeks’ worth of statistics BY YOURSELF while still working on the current course material. Even the professor of the course was worried that I would not be able to pass the class joining in that late. But I was determined, and worked my hardest in that class. I made it!!! … No, I did not just pass with a 3.0….I actually got a 4.0. That was good motivation to forge ahead, perhaps a sign that I was cut out for this PhD journey after all.

IN THE END, THINGS WORKED OUT! When I finally got the job offer at the University of Iowa Hospital, I declined. I had been waiting to hear from them for so long, but when I finally did, God had already taken me on a different path. The whole PhD thing worked out really well, and I am amazed at how far God has brought me, and thankful for every provision and achievement. I have so much passion for my research area, and cannot wait to graduate and start work….work that will impact and improve the lives of many mothers in Sub-Sahara Africa. I thank everyone who in any way, helped me get this far along.

About Yenupini Joyce Adams

I obtained my PhD in Nursing from Michigan State University, East Lansing, Michigan in December 2016. A number of factors inspired my decision to pursue a PhD in nursing but my passion for improving maternal health and promoting safe motherhood was the prime motivator. My research aims primarily to improve maternal health, promote safe motherhood, and decrease maternal mortality among vulnerable populations in the United States and Sub-Saharan Africa, where the burden of maternal mortality is most severe. My dissertation work focused on reducing delays in seeking postpartum care in rural Malawi. I explored reasons for decision to seek postpartum care, evaluated postpartum care received after delivery in health facilities, and examined husband’s knowledge and attendance at their wives’ postpartum care. My current research specifically focuses on postpartum complications and knowledge of warning signs of complications. My current research spans two interrelated areas: 1) maternity care providers’ knowledge of postpartum care and complications, and ability to manage potential complications and 2) patients knowledge of warning signs of postpartum complications.

Yenupini and Husband (Ellis Adams)

I was born in Tamale, a city in the Northern Region of Ghana where I spent most of my childhood. I am the youngest of five children. At age 20, I moved to Grand Rapids, Michigan, to attend Calvin College where I obtained a Bachelor of Science in Nursing Degree (BSN). After obtaining my BSN, I decided to continue with my educational journey and went straight to graduate school, where I met my husband Ellis, an amazing man and a strong support for my work and  vision. In my free time, I enjoy listening to music, hanging out with friends and family, and spending quality time with my husband. I love going on trips. I have had the pleasure of visiting India, Malawi, Canada, Jamaica, Kenya, and Mexico, and thoroughly enjoyed my time in all these places. I hope to visit several other countries in the future.