It's just 48 hours.
However, these 48 hours are crucial. During this period before, during and after the birthing process, the lives of both the mother and her baby are at risk of complications during birth, bleeding and infection.
In 2015, maternal mortality in Malawi was 634 deaths per 100,000 births while 42 out of 1,000 babies died during birth or shortly after. Figures as high as this tend to prevail only in the world's poorest developing countries, where mothers are often required to travel long distances to reach the nearest health centre suitable for childbirth. There is a of lack good hygiene, trained staff and modern medical equipment.
Dr Kai Gesing has worked as a doctor in a number of African countries. He is currently working as a specialist for KfW, supervising projects in countries like Malawi. He is familiar with the circumstances in which African women have to give birth. “Normally, they have to walk miles and miles over trails and paths to reach their nearest health station,” says Dr Gesing. In the worst-case scenario, they will be suffering incredible pain during the full throes of labour at the same time.
Because these journeys are usually very tough and fraught with danger, women in rural areas often give birth at home, where the standards of hygiene tend be poor and where they don't have access to a doctor or trained midwife. In 2012, the government in Malawi decided to pass a law that required women to give birth in health stations.
Although pregnant women don't have to pay to give birth, families are still required to pay for their transportation, accommodation and food. With a per capita income of around 370 dollars per year, these are costs that many people cannot afford. However, anyone who fails to comply with requirements is subject to punishment by the local authorities. Normally this involves giving up livestock, the only asset owned by many poor families.
One of the main aims of the German-Norwegian initiative to promote maternal and newborn health is to support poor women. KfW has been promoting the project since 2011. It provides families with financial support for transportation and accommodation. “Women are registered in their villages during the early stages of pregnancy,” explains Kai Gesing.
During this process, their family's financial situation is also assessed to see whether they are eligible for financial support. “The confirmation and registration form is given to the woman so that she can submit it when she arrives at the health station to give birth.” These documents mean that any costs arising from the privately organised transport service are reimbursed based on a flat rate per kilometre.
Once they have given birth in the health centre, mothers receive lump sum payments in two stages: one after 24 hours and another when they have been in the centre for 48 hours. This method has helped to make sure that women are more likely to use the participating centres and are also inclined to stay longer once they have given birth. Financing for transport and meals is a major factor when it comes to reducing the risk of fatal complications for both mother and baby.
Mothers-to-be are not the only group in Malawi receiving support from KfW. Another project is generating incentives to improve general medical standards in health centres. If stations are able to maintain specific quality standards, they will receive funds that they can then invest in further improvements.
Each centre is able to decide for themselves which measures they wish to apply.
Staff who perform well are rewarded in the form of advanced training, for example, or equipment, small-scale construction measures or small financial premiums. This scheme is in place at the health station in Mchinji, one of Malawi's 28 districts. In 2017, the staff here were able to use their premiums to complete construction on the Mother Waiting Hostel, a centre providing accommodation for women nearing their delivery date so that they don't have to travel while in labour.
This concept of performance-based financing is so successful that it has now gone beyond the project and been adopted into the country's health strategy.