Malawi is a sub-Saharan African country bordered to the north and northeast by the United Republic of Tanzania; to the east, south, and southwest by the People’s Republic of Mozambique; and to the west and northwest by the Republic of Zambia.
The country is divided into three regions: the Northern, Central, and Southern Regions. There are 28 districts in the country. Six districts are in the Northern Region, nine are in the Central Region, and thirteen are in the Southern Region. Administratively, the districts are subdivided into traditional authorities (TAs), presided over by chiefs. Each TA is composed of villages, which are the smallest administrative units, and the villages are presided over by village headmen (MDHS, 2010). Malawi has a population of about 15.4 million (World Bank, 2011).
Key MNH Indicators for Malawi (Malawi End line Survey 2014- MICS report)
- Maternal Mortality Ratio: 574/100,000 live births
- % Skilled Birth Attendance: 87.4 %
- % Contraceptive Prevalence Rate: 58.6%
- Total Fertility Rate (per woman): 5.0
- Ante-Natal Care (at least one visit): 96.1 %
CMNH has been working in Malawi since 2011 and has been involved in the following projects/studies:
- Making it Happen programme (MiH)
- Evaluation of “Improving Maternal and newborn health in Nkhotakota district, Malawi”
- External evaluation of “Improving the health of pregnant women and children in Malawi” project in Ntcheu district, Malawi”
- Causes of Stillbirth in Referral Facilities in Malawi
- Knowledge and Skills Retention Study (KSRS)
- Maternal Morbidity Study
- Improving Quality of Care for Mothers and Babies in Malawi
- Community health workers for maternal for maternal and newborn health; case studies from the field
- Evaluating the benefit of training non-physician clinicians for maternal and newborn care in Sub-Saharan Africa
The Making it Happen programme aims to reduce maternal and newborn mortality and morbidity by increasing the availability and improving the quality of Skilled Birth Attendance (SBA) and Emergency Obstetric and Newborn Care (EmONC).
The programme was delivered in 11 countries: in Sub-Saharan Africa and in Asia between 2011- 2015.
The MiH programme in Malawi was implemented in partnership with UNICEF to support the Malawi Ministry of Health.
The programme has resulted in building the capacity of:
- 495 in service health care workers trained in EmONC
- 53 course facilitators trained in EmONC
- 36 tutors trained in EmONC
- 121 health care workers trained in data collection and usage
- 19 health care workers trained in quality improvement methodologies.
The study “Improving Maternal and Newborn Health in Nkhotakota District” is funded by Big Lottery Fund through the Women and Children First (WCF) UK. The project aims to reduce maternal and neonatal mortality through a range of community-based and facility-based interventions targeting a population of approximately 360,000 people. CMNH was selected by the Women and Children First to conduct the external evaluation of the programme.
The evaluation aims to provide an in-depth understanding of the differences that the project has made in care seeking behaviours and in the quality and availability of maternal and newborn health (MNH) services.
CMNH provides technical assistance and quality assurance to WCF in the design of the project monitoring systems and tools, and in the collection and analysis of project monitoring data. CMNH is using a mix of quantitative and qualitative research methods to assess the impact of project activities on maternal and newborn health outcomes.
External evaluation of “Improving the health of pregnant women and children in Malawi” project in Ntcheu district, Malawi”
The study “Improving the Health of Pregnant Women and Children in Malawi” was funded by Comic Relief through Women and Children First (WCF), and it has been implemented by the Malawian NGO Perinatal Care Project (PCP) in Ntcheu District, Malawi from 2010 to 2014.
The project aimed to improve the health and to reduce the mortality of women and children in Ntcheu District, through a range of community-based and facility-based interventions targeting a population of approximately 80,000 people from 144 villages.
The CMNH was selected by the WCF to conduct the external final evaluation of the intervention. The final evaluation aimed to provide an in-depth understanding of the differences that the project has made in care seeking behaviours and in the quality and availability of maternal and child health services.
The CMNH has used concurrent mixed methods approach to address the evaluation questions. A household survey was designed and delivered by the evaluation team, to measure coverage of essential interventions in target communities (417 household surveys). A Health Facility assessment was conducted in 14 target facilities, to assess the availability and quality of care. Key informant interviews and focus group discussions were administered to various stakeholders, to understand the perceived impact of project activities.
The stillbirth study aims to investigate the cause of, and factors contributing to, stillbirth in low- and middle-income countries. The study focuses on four countries: Kenya, Malawi, Sierra Leone and Zimbabwe. Under the project, healthcare providers in three targeted facilities per country have been trained to conduct perinatal death reviews. A total of 1300 cases of stillbirth across the four countries have been reviewed and data collected for analysis. The outcomes of the study are identification of the major cause of, and factors contributing to, stillbirth in these countries. Development of tools to help healthcare providers in low-resource settings to identify cause of stillbirth, and take action to reduce mortality.
The KSRS was conducted in six African countries including Malawi assessing how long knowledge and skills are retained after EOC&NC training and looking at the optimum time for the retraining of health care.
The study also identified factors that influence knowledge and skills retention post training including workload and cadre of staff. Skills and knowledge were tested before and immediately after training and then at 3, 6, 9 and 12 month intervals.
The total recruitment across the five countries was 512 health care providers or 87.5% of the target.
• Nurse/midwives knowledge and skills at 12 months were higher than levels immediately post training
CMNH conducted a study of maternal morbidity in 4 countries including Malawi. The cross-sectional study assessed women across the five stages of pregnancy: Early natal (<20 weeks), late natal (>20 weeks), at birth (within 24 hours of delivery), early postnatal (day 1-7), late postnatal (1-12 weeks).
Socio-demographic factors, subjective (self-reporting) and objective (clinical examination and investigations) health outcomes were assessed. The relationship between ill health and maternal characteristics were investigated using logistic regression analysis.
A total of 11,453 women were assessed across the 4 countries, 2923 of which were in Malawi. Overall, the findings were:
• 20% were depressed, reported poor quality of life and poor satisfaction with health
• 76% reported more than one physical symptoms, the commonest gastrointestinal
• 47.4% were anaemic
• 32.2% had clinical signs of early sepsis
This UNICEF funded programme aims to reduce maternal and newborn mortality and morbidity by increasing the availability and improving the quality of Skilled Birth Attendance and Emergency Obstetric Care. The programme includes the following key components:
• Identification of the ‘bottle necks’ to providing Quality of Care at CEmONC and BEmONC levels
• ‘Skills and drills’ training in EmONC, antenatal and postnatal care
• Introduction of a Quality Improvement process in selected BEmONC and CEmONC facilities
• Support to pre-service training of nurse-midwives
• Capacity building in the use of routine MNH data
• Supportive supervision and monitoring & evaluation of the impact and outcomes resulting from the interventions
• Operations Research to assess ‘what works where and how’
Community health workers for maternal and newborn health; case studies from the field
This operational research lends itself to the global discussions and debates on the health workforce shortage noted by WHO in 2006. It seeks to identify the scope of practice of community health workers providing maternal and newborn healthcare in low-and-middle-income countries, explore the factors influencing their effective performance and document stakeholders’ recommendations for improving the performance of community health workers. Using qualitative methods, we conducted key informant interviews and focus group discussions with over 300 stakeholders at different levels of the health system in Bangladesh, India, Kenya, Malawi and Nigeria.
Evaluating the benefit of training non-physician clinicians for maternal and newborn care in Sub-Saharan Africa
Weak health systems are an underlying factor contributing to the situation in Low and Middle Income Countries (LMICs), including lack of qualified health workforce (GHWA 2013). In recognition of the pivotal role qualified healthcare workers have in reducing maternal and neonatal mortality, recruitment, development, training and retention of the health workforce particularly in LMIC is part of the Sustainable Development Goals (Goal 3(b)) (Osborn 2015).
Through Enhanced Training and Appropriate Technologies for Mothers and Babies in Africa (ETATMBA) program non-physician clinicians (NPCs) from selected districts in Malawi and Tanzania were trained on emergency obstetric care, neonatal care and leadership skills between 2011 and 2013. The focus of this research is understanding the effect of the training on roles performed by non-physician clinicians, their retention at workplace and service delivery.
This operational research uses a qualitative approach, based on interviews with NPCs and quarterly mapping of where they work, for the whole cohort of the programme (48 NPCs in Malawi and 70 NPCs in Tanzania). Data collection is currently ongoing using face-to-face, phone and social media communication. Additionally, key information interviews and document review are used to contextualize the NPC perspectives.