Diverse pre-service midwifery education pathways in Cambodia and Malawi: A qualitative study utilising a midwifery education pathway conceptual framework.

OBJECTIVES: Educated and skilled midwives are required to improve maternal and newborn health and reduce stillbirths. There are three main approaches to the pre-service education of midwives: direct entry, post-nursing and integrated programmes combining nursing and midwifery. Within these, there can be multiple programmes of differing lengths and qualifications, with many countries offering numerous pathways. This study explores the history, rationale, benefits and disadvantages of multiple pre-service midwifery education in Malawi and Cambodia. The objectives are to investigate the differences in education, roles and deployment as well as how key informants perceive that the various pathways influence workforce, health care, and wider health systems outcomes in each country. DESIGN: Qualitative data were collected during semi-structured interviews and analysed using a pre-developed conceptual framework for understanding the development and outcomes of midwifery education programmes. The framework was created before data collection. SETTING: The setting is one Asian and one African country: Cambodia and Malawi. PARTICIPANTS: Twenty-one key informants with knowledge of maternal health care at the national level from different Government and non-governmental backgrounds. RESULTS: Approaches to midwifery education have historical origins. Different pathways have developed iteratively and are influenced by a need to fill vacancies, raise standards and professionalise midwifery. Cambodia has mostly focused on direct-entry midwifery while Malawi has a strong emphasis on dual-qualified nurse-midwives. Informants reported that associate midwifery cadres were often trained in a more limited set of competencies, but in reality were often required to carry out similar roles to professional midwives, often without supervision. While some respondents welcomed the flexibility offered by multiple cadres, a lack of coordination and harmonisation was reported in both countries. KEY CONCLUSIONS: The development of midwifery education in Cambodia and Malawi is complex and somewhat fragmented. While some midwifery cadres have been trained to fulfil a more limited role with fewer competencies, in practice they often have to perform a more comprehensive range of competencies. IMPLICATIONS FOR PRACTICE: Education of midwives in the full range of globally established competencies, and leadership and coordination between Ministries of Health, midwife educators and professional bodies are all needed to ensure midwives can have the greatest impact on maternal and newborn health and wellbeing.

Reasons for delay in decision making and reaching health facility among obstetric fistula and pelvic organ prolapse patients in Gondar University hospital, Northwest Ethiopia.

BACKGROUND: Obstetric fistula and pelvic organ prolapse remain highly prevalent in sub-Saharan Africa, where women have poor access to modern health care. Women having these problems tend to stay at home for years before getting treatment. However, information regarding the reasons contributing to late presentation to treatment is scarce, especially at the study area. The objective of this study was to assess the reasons whywomen with obstetric fistula and pelvic organ prolapse at Gondar University Hospital delay treatment. METHOD: A hospital based cross-sectional study was conducted among 384 women. Delay was evaluated by calculating symptom onset and time of arrival to get treatment at Gondar University Hospital. Regression analysis was conducted to elicit predictors of delay for treatment. RESULT: Of the total 384 participants, 311 (80.9%) had pelvic organ prolapse and 73(19.1%) obstetric fistula. The proportion of women who delayed treatment of pelvic organ prolapse was 82.9% and that of obstetric fistula 60.9%. Fear of disclosing illness due to social stigma (AOR = 2; 1.03, 3.9) and lack of money (AOR = 1.97; 1.01, 3.86) were associated with the delay of treatment for pelvic organ prolapse,while increasing age (AOR =1.12; 1.01, 1.24) and divorce (AOR = 16.9; 1.75, 165.5) were were responsible for delaying treatment forobstetric fistula. CONCLUSION: A large numberof women with pelvic organ prolapse and obstetric fistula delayed treatment. Fear of disclosure due to social stigma and lack of moneywere the major factors that contributed to thedelay to seek treatment for pelvic organ prolapse,while increasing age and divorce were the predictors for delaying treatment for obstetric fistula.

Prevalence of obstetric fistula in Malawi.

OBJECTIVE: To estimate the prevalence of obstetric fistula in Malawi and explore the potential risk factors for developing the condition. METHODS: A community survey was conducted in 9 districts in Malawi, recruiting 3282 women aged at least 12 years using the sibling based method to identify cases of obstetric fistula. Hospital records from 9 district hospitals involved in the community survey and all hospitals offering fistula repair services in Malawi were reviewed. RESULTS: A total of 1107 women with obstetric fistula were identified: 575 from the community survey and 532 from hospital records. Median age was 29 years (range, 12-89 years). The prevalence of obstetric fistula was 1.6 per 1000 women. Women endured the condition for a median duration of 3 years. Comparison of women with and without obstetric fistula revealed significant differences in age (P=0.02), occupation (P<0.01), and tribal origin (P=0.02), but no differences in education level (P=0.73) or religion (P=0.08). CONCLUSION: Obstetric fistula remains a major problem in Malawi. Increased awareness of the condition, improvement of maternal care services, and an increase in skilled personnel to perform fistula repair are needed to reduce the burden of this condition.

Emergency obstetric care: how do we stand in Malawi?

OBJECTIVE: To assess the availability, accessibility, utilization, and quality of emergency obstetric care (EmOC) services in Malawi. METHODS: A complete enumeration was made of all hospitals and a 25% random sample of all health centers, in all districts of Malawi. Enumerators (nurses and midwives) collected data by reviewing facility registers and records, observations, and interviews with health workers to determine extent of utilization of services. In-depth interviews and focus group discussions were also held with key informants to identify barriers to utilization of services and explore participants' perceptions of quality of care. RESULTS: Almost twice the minimum number of recommended comprehensive EmOC facilities exist (1.8 facilities per 500,000 population), but only 2% of the recommended number of basic EmOC facilities. Met need was only 18.5%; cesarean delivery rate was less than 3%. The case fatality rate was 3.4% indicating poor quality of care, attributable partly to absence of skilled birth attendants and motivated staff, and the frequent shortage of drugs and medical supplies. CONCLUSION: Malawi needs to improve the provision of quality EmOC services by implementing evidence-based strategies for the reduction of maternal mortality. Consequently, the Malawi Road Map for accelerating improvement was developed through multidonor and multisector collaboration with the Reproductive Health Unit of the Ministry of Health. This Road Map is now being implemented in all districts of Malawi.