Outside Changoima Health Post in Chikwawa District, Malawi, community members watch as the area’s chief and elders recognise three women with the title of ‘Secret Mother’.  The women—Elifa Ndege, Anastasia Divala, and Hilda Mbendera—are respected members of the community, trustworthy, and have invested in the needs of others.

And as secret mothers, they are a critical bridge between expectant mothers and the community health workforce.

Community health worker Hemzi Mikundi uses an Ichis Tablet to track cases

In Malawi, where 83 percent of the population lives in rural and remote communities like Changoima, Last Mile Health partners with the Ministry of Health, training community health workers to deliver standardised primary health care one of which is Community-Based Maternal and Neonatal Care (CBMNC).

Malawi has one of the highest maternal mortality ratios globally, estimated at 439 maternal deaths per 100 000 live births, and neonatal mortality is estimated at 27 per 1 000 live births (MDHS, 2016). Malawi has a task to reduce maternal mortality and neonatal mortality to 70 and 12, respectively, by the year 2030. This cannot be achieved without strengthening community-based maternal and neonatal health initiatives.

CBMNC programme is one of the strategies highlighted in the roadmap to accelerate reduction of maternal and neonatal mortality and other birth complications in Malawi. It aims at empowering individual households and communities to take responsibility for their health with focus on equipping community health workers with knowledge on early antenatal care attendance as soon as the woman discovers she is pregnant or within the first three months of pregnancy and make sure she attends all the eight ANC visits according to Malawi guidelines. 

Community members are also given information on birth and complication readiness. Information on home management during pregnancy and after delivery is another important area covered during home visits as well as identification of danger signs and referral. Emphasis is also placed on early health seeking behaviour when either the mother or baby have any danger signs.

Identifying pregnant women is a critical first step in this process as fear, some cultural beliefs, uncertainty, and unfamiliarity with the formal health system often prevent women from seeking care.

This is where Secret Mothers step in.

“The main problem is that many pregnant women wait until they are visibly pregnant, some reach eight months pregnant before deciding to visit the hospital for antenatal checkups,” shares Mary Namboya, a community health worker who works closely with secret mothers in Changoima.

This emanates from deeply rooted cultural and religious beliefs—and can result in danger or death to mother or child. In addition, Namboya shares, many women feel they must wait for their husbands’ approval before seeking care.

As cultural beliefs intertwine with gender dynamics, Secret Mothers help bridge the gap between patients and the health system. Community leaders identify older women to serve in the role, chosen for their caring and friendly demeanour coupled with their strong desire to help others.

As experienced members of the community (and usually mothers themselves), Secret Mothers are trusted by younger women—and respected by husbands and community leaders. They identify and connect with pregnant women, breaking down fears about formal healthcare and encouraging expectant mothers to connect with community health workers as soon as possible.

“Secret mother volunteers are a crucial structure in the community which help community health workers raise community awareness by explaining to women, male partners, their relatives, and the community gatekeepers the importance of receiving early antenatal care, thereby helping to increase first trimester coverage,” says Sophie Chimwenje, Malawi’s National Coordinator for Community based Maternal and Neonatal Care within the Ministry of Health’s Reproductive Health Directorate.

“They assist in identifying pregnant women and teenage pregnant girls for trained providers to visit. They also identify danger signs during pregnancy, after childbirth, and in newborns, and they link women to community health workers for timely referral. They also help in explaining the importance of birth and complication readiness and where to seek childbirth and postnatal care services,” she adds. She concludes saying that it is important for the supply side to welcome the mothers with love, attending to them timely and making sure the resources are available to avoid demotivating the demand side.

Secret Mothers’ deep ties to their communities mean they know how to connect with their neighbours—even when the topic is deeply personal. “As secret mothers, we interact with other women so that we find out who in the village is expecting. We usually interact with these women at the maize mill, church, or by the well,” explains Ndege, a Secret Mother. “We approach them in a respectful and friendly manner so that they open up to us and tell us who is pregnant.”

When they visit the women their neighbours have identified, sensitivity and humour help the Secret Mothers earn their trust. “We say: ‘We have come here by the chief’s delegation and as Secret Mothers with much wisdom and experience. This tummy bump cannot just be the eating of a sweet potato!’” Ndege recounts. “The pregnant woman laughs. We come in peace so that they open up to us.”

Once a woman confirms her pregnancy, says Divala: “We ask, ‘so now that you know this, what are your next steps?’ Most say, ‘I will just stay at home until it is time to give birth.’ We change their mindset on this by sharing the benefits of hospital deliveries. For example, a pregnant woman bleeding profusely cannot be assisted properly and in good time if delivery is done at home. We also encourage them to meet community health workers and seek medical help via antenatal visits.”

Community health workers like Namboya, have come to rely on Secret Mothers. “We have community gatherings and coordinate with village committees, chiefs, and Secret Mothers. All those involved in healthcare in our community share the benefits of hospital deliveries, and the issues to do with harmful cultural practices are also addressed there,” Namboya explains.

Responding to health issues in Changoima is a collaborative effort, and Secret Mothers are a crucial thread in the fabric of the community. Namboya and other community health workers have observed an increase in antenatal visits and more women open to receiving counselling and support during their pregnancies. “The Secret Mothers are helping us a lot,” she says. “In the past, there were lots of home deliveries, but now working with them has reduced home deliveries. Pregnant women now know the benefits of hospital deliveries.”

For Ndege and her fellow secret mothers, their role is clear—and so is their mission. “We want women to share their experiences freely as we also share the importance of antenatal visits and hospital births,” says Ndege. “I want to ensure we reduce maternal deaths.”

Last Mile Health (LMH) has partnered with the Ministry of Health since 2019 to support the implementation of the National Community Health Framework (NCHF) and is currently supporting the development and deployment of the Integrated Community Health Information System (Ichis) and provides in-service trainings to community health workers to enable them to provide integrated health services in remote communities.

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