Newborn survival in Malawi: a decade of change and future implications.

Malawi is one of two low-income sub-Saharan African countries on track to meet the Millennium Development Goal (MDG 4) for child survival despite high fertility and HIV and low health worker density. With neonatal deaths becoming an increasing proportion of under-five deaths, addressing newborn survival is critical for achieving MDG 4. We examine change for newborn survival in the decade 2000-10, analysing mortality and coverage indicators whilst considering other contextual factors. We assess national and donor funding, as well as policy and programme change for newborn survival using standard analyses and tools being applied as part of a multi-country analysis. Compared with the 1990s, progress towards MDG 4 and 5 accelerated considerably from 2000 to 2010. Malawi's neonatal mortality rate (NMR) reduced slower than annual reductions in mortality for children 1-59 months and maternal mortality (NMR reduced 3.5% annually). Yet, the NMR reduced at greater pace than the regional and global averages. A significant increase in facility births and other health system changes, including increased human resources, likely contributed to this decline. High level attention for maternal health and associated comprehensive policy change has provided a platform for a small group of technical and programme experts to link in high impact interventions for newborn survival. The initial entry point for newborn care in Malawi was mainly through facility initiatives, such as Kangaroo Mother Care. This transitioned to an integrated and comprehensive approach at community and facility level through the Community-Based Maternal and Newborn Care package, now being implemented in 17 of 28 districts. Addressing quality gaps, especially for care at birth in facilities, and including newborn interventions in child health programmes, will be critical to the future agenda of newborn survival in Malawi.

Criteria-based audit to improve women-friendly care in maternity units in Malawi.

AIM: To assess and improve women-friendly care in maternity units in Malawi. METHODS: We interviewed 280 women about the care they received during childbirth at 29 different health centers. Results were compared with standards for women-friendly care, developed locally and based on evidence from World Health Organization manuals. The audit results were presented, and recommendations were made and implemented. A re-audit (involving 367 women) was conducted 3 months later. RESULTS: Significant improvements were recorded on greeting clients (74.6 vs 87.7%; P < 0.001), respect for clients (91.1 vs 98.6%; P < 0.001), support by a companion during labor (58.9 vs 75.6%; P < 0.001), informing clients about different birthing positions (68.6 vs 79.3%; P = 0.002), allowing clients to adopt different birthing positions (67.9 vs 83.4%; P < 0.001), cleanliness of maternity wards (89.6 vs 97.0%; P < 0.001), speaking to clients using simple language (92.1 vs 98.6%; P < 0.001), ensuring privacy with curtains or screens (86.1 vs 92.1%; P < 0.012), and client willing to recommend the health facility to a friend (94.6 vs 98.6%; P = 0.004). However, there were no significant changes in the level of self-introduction by providers (62.5 vs 68.7%; P = 0.103) and provision of a clean bathroom and toilet (83.6 vs 80.4%; P = 0.282). Surprisingly, there was a significant deterioration in the use of linen to ensure privacy (86.4% vs 74.9%; P < 0.001). Overall, satisfaction of women increased by 9%. CONCLUSION: The criteria-based audit was associated with an improvement in the quality of women-friendly care services in maternity units in Malawi.

Facility-based maternal death review in three districts in the central region of Malawi: an analysis of causes and characteristics of maternal deaths.

PURPOSE: We sought to determine the causes and characteristics maternal deaths that occur in health facilities in Malawi. METHODS: Forty-three maternal deaths were reviewed in 9 hospitals in 3 districts in Central Malawi over a 1-year period. Causes and avoidable factors of maternal deaths were identified during the review, and recommendations made and implemented. MAIN FINDINGS: There were 28 (65.1%) direct obstetric deaths and 15 (34.9%) indirect obstetric deaths. The major causes of maternal deaths were postpartum hemorrhage (25.6%), postpartum sepsis (16.3%), HIV/AIDS (16.3%), ruptured uterus (7.0%), complications of abortion (7.0%), anemia (7.0%), antepartum hemorrhage (4.7), and eclampsia (4.7). Two thirds of the women were referred either from another health facility (51.2%) or by a traditional birth attendant (TBA; 11.6%), and up to 79.1% were critically ill on admission. Four groups of factors that contributed to maternal deaths were identified: 1) health worker factors, 2) administrative factors, 3) patient/family factors, and 4) TBA factors. The major health worker factors were inadequate resuscitation (69.8%), lack of obstetric life-saving skills (60.5%), inadequate monitoring (55.8%), initial assessment incomplete (46.5%), and delay in starting treatment (46.5%). The most common administrative factor was lack of blood for transfusion (20.9%). The major problems encountered include shortage of staff and other resources, difficulty in maintaining anonymity, poor quality of data, and difficulty in implementing recommendations. CONCLUSION: Adequate training on obstetric life-saving skills, addressing HIV/AIDS, and raising community awareness could be important factors for reducing maternal mortality in Malawi and countries with similar socioeconomic profiles.

Availability, utilisation and quality of basic and comprehensive emergency obstetric care services in Malawi.

OBJECTIVE: To establish a baseline for the availability, utilisation and quality of maternal and neonatal health care services for monitoring and evaluation of a maternal and neonatal morbidity/mortality reduction programme in three districts in the Central Region of Malawi. METHODS: Survey of all the 73 health facilities (13 hospitals and 60 health centres) that provide maternity services in the three districts (population, 2,812,183). RESULTS: There were 1.6 comprehensive emergency obstetric care (CEmOC) facilities per 500,000 population and 0.8 basic emergency obstetric care (BEmOC) facilities per 125,000 population. About 23% of deliveries were conducted in emergency obstetric care (EmOC) facilities and the met need for emergency obstetric complications was 20.7%. The case fatality rate for emergency obstetric complications treated in health facilities was 2.0%. Up to 86.7% of pregnant women attended antenatal clinic at least once and only 12.0% of them attend postnatal clinic at least once. There is a shortage of qualified staff and unequal distribution with more staff in hospitals leaving health centres severely understaffed. CONCLUSIONS: The total number of CEmOC facilities is adequate but the distribution is unequal, leaving some rural areas with poor access to CEmOC services. There are no functional BEmOC facilities in the three districts. In order to reduce maternal mortality in Malawi and countries with similar socio-economic profile, there is a need to upgrade some health facilities to at least BEmOC level by training staff and providing equipment and supplies.

A criterion based audit of the management of obstructed labour in Malawi.

OBJECTIVE: To assess and improve the management of obstructed labour in maternity units in Malawi. METHODS: A criterion based audit of the management of obstructed labour was conducted in 8 hospitals in three districts in Malawi. Management practices were: (a) assessed by a retrospective review of 44 cases notes, and (b) compared with local standards established, by a multidisciplinary team, based on the Malawi Ministry of Health guidelines and World Health Organisation manuals. Gaps in current practice were identified, reasons discussed, and recommendations made and implemented. A re-audit (41 case notes) was conducted 3 months later. RESULTS: There were significant improvements in the attainment of four standards: draining of urinary bladder (70.5 vs. 90.2%; P = 0.022), administration of broad spectrum antibiotics (72.7 vs. 90.2%; P = 0.039), commencement of Caesarean section within 1 hour or delivery of the foetus within 2 h of diagnosis (38.6 vs. 61.0%; P = 0.023), and maintaining an observation chart (45.5 vs. 61.0%; P < 0.001). However, there was no significant change in two standards: securing an intravenous line and hydrating the patient (95.5 vs. 97.6%; P = 0.804), and typing and cross-match of blood (77.3 vs. 63.4%; P = 0.197). There was a reduction in case fatality rate (9.1 vs. 2.4%; P = 0.361) and perinatal mortality (18.8 vs. 12.2%, P = 0.462). CONCLUSION: Criterion based audit can improve the management of obstructed labour in countries with limited resources.

Using criteria-based audit to improve the management of postpartum haemorrhage in resource limited countries: a case study of Malawi.

OBJECTIVE: The goal of this study was to assess and improve the management of postpartum haemorrhage (PPH) in maternity units in Malawi. The main objective was to determine whether criteria-based audit can improve adherence to standards for the management of PPH. METHODS: We used a before-and-after design and univariate statistics for data analysis. A retrospective review of 40 consecutive cases of PPH was conducted in eight hospitals and the results compared with standards for PPH, established based on World Health Organisation manuals. RESULTS: of the audit were presented to healthcare providers who made and implemented recommendations for improvement. A re-audit (45 cases) was conducted 3 months later. RESULTS: There was a significant improvement in adherence to three standards: typing and cross-match carried out (65.0% vs. 84.4%; P = 0.034), patient's hematocrit or haemoglobin established (67.5% vs. 86.7%; P = 0.029), and fluid intake/output chart maintained (0.0% vs 33.3%; P < 0.001). There was no significant change in close monitoring of vital signs (32.5% vs. 53.3%, P = 0.065) and case fatality rate (10.0% vs. 6.7%, P = 0.702), intravenous access achieved and intravenous fluids administered (100.0% vs. 97.8%; P = 0.735), and oxytocic drugs administered (100.0% vs. 95.6%; P = 0.357). CONCLUSION: Introduction of criteria-based audit can improve the management of postpartum haemorrhage in countries with limited resources. Future studies should consider using larger sample size to evaluate the effect of criteria-based audit on mortality.

Criteria-based audit to improve a district referral system in Malawi: a pilot study.

BACKGROUND: To study the feasibility of using criteria-based audit to improve a district referral system. METHODS: A criteria-based audit was used to assess the Salima District referral system in Malawi. A retrospective review of 60 obstetric emergencies referred from 12 health centres was conducted and compared with prior established standards for optimal referral of emergencies. Recommendations were made and implemented. Three months later, a re-audit was conducted (62 cases). RESULTS: There were significant improvements in 4 out of 7 standards: adequate resuscitation before referral (33.3% vs 88.7%; p = 0.001); delay of less than 2 hours from the time the ambulance is called to when the ambulance brought the patient to the hospital (42.8% vs 88.3%; p = 0.014); clinician attends to patient within 30 minutes of arrival to hospital (30.8% vs 92.6%; p = 0.001) and feedback given to the referring health centres (1.7% vs 91.9%; p <0.001). The rest of the three standards showed a high level of attainment (>95%) in both the initial audit and the re-audit: referred patients accompanied by a referral form; ambulances are available at all times and the district hospital is informed through short-wave radio by the health centre when a patient is referred. CONCLUSION: Criteria-based audit can improve the ability of a district referral system to handle obstetric emergencies in countries with limited resources.

Establishing standards for obstructed labour in a low-income country.

INTRODUCTION: Conventionally standards for maternity care are developed by a panel of experts (usually obstetricians) and then implemented by a multidisciplinary team. The present study concerns the feasibility of involving health professionals of all grades in the establishment standards for obstructed labour in Malawi. METHODS: Standards for obstructed labour were developed by a multidisciplinary team involving all cadres of health professionals working in maternity units, as well as hospital managers and policy makers, using evidence from Malawi national guidelines, World Health Organisation manuals and peer-reviewed journals. Each standard consisted of a clear objective with structure, process and outcome criteria. RESULTS: Seven objectives were agreed, and structure, process and outcome criteria were developed for each objective. The standards addressed different aspects of the management of obstructed labour, namely early recognition of prolonged labour by labouring women and traditional birth attendants, early arrival of women to health facilities during labour, proper use of partograph by healthcare providers, proper management of prolonged labour, proper management of obstructed labour, appropriate management of uterine rupture and early delivery of the baby. CONCLUSION: It is feasible to develop standards of emergency obstetric care in low-income countries using a multidisciplinary team that involves health professionals of all grades. The involvement of all health professionals might promote successful implementation, ownership and sustainability. The involvement of hospital managers and policy makers in the early stages of criteria-based audit might promote support from the hierarchy with regards to the allocation of resources.