BackgroundMaternal, perinatal and neonatal mortality remains high in low-income countries. We evaluated community and facility-based interventions to reduce deaths in three districts of Malawi.MethodsWe evaluated a rural participatory women’s group community intervention (CI) and a quality improvement intervention at health centres (FI) via a two-by-two factorial cluster randomized controlled trial. Consenting pregnant women were followed-up to 2 months after birth using key informants. Primary outcomes were maternal, perinatal and neonatal mortality. Clusters were health centre catchment areas assigned using stratified computer-generated randomization. Following exclusions, including non-birthing facilities, 61 clusters were analysed: control (17 clusters, 4912 births), FI (15, 5335), CI (15, 5080) and FI + CI (14, 5249). This trial was registered as International Standard Randomised Controlled Trial [ISRCTN18073903]. Outcomes for 14 576 and 20 576 births were recorded during baseline (June 2007–September 2008) and intervention (October 2008–December 2010) periods.ResultsFor control, FI, CI and FI + CI clusters neonatal mortality rates were 34.0, 28.3, 29.9 and 27.0 neonatal deaths per 1000 live births and perinatal mortality rates were 56.2, 55.1, 48.0 and 48.4 per 1000 births, during the intervention period. Adjusting for clustering and stratification, the neonatal mortality rate was 22% lower in FI + CI than control clusters (OR = 0.78, 95% CI 0.60–1.01), and the perinatal mortality rate was 16% lower in CI clusters (OR = 0.84, 95% CI 0.72–0.97). We did not observe any intervention effects on maternal mortality.ConclusionsDespite implementation problems, a combined community and facility approach using participatory women’s groups and quality improvement at health centres reduced newborn mortality in rural Malawi.

Malawian women in all sectors of society are suffering from social implications of unwanted pregnancy and unsafe abortion. Unwanted pregnancies occur among women who have limited access to family planning and safe abortion. A legally restrictive setting for safe abortion services leads many women to unsafe abortion, which has consequences for them and their families. In-depth interviews were conducted with 485 Malawian stakeholders belonging to different political and social structures. Interviewees identified the impact of unwanted pregnancy and unsafe abortion to be the greatest on young women. Premarital and extramarital pregnancies were highly stigmatized; stigma directly related to abortion was also found. Community-level discussions need to focus on reduction of stigma.

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.

BackgroundThere is increasing evidence throughout the world that the negative treatment of pregnant women during labor and delivery can be a barrier to seeking skilled maternity care. At this time, there has been little quantitative evidence published on disrespect and abuse (D&A) in Malawi. The objective of this research is to describe the prevalence of disrespect and abuse during labor and delivery through the secondary analysis of direct clinical observations and to describe the association between the observation of D&A items with the place of delivery and client background characteristics.MethodsAs part of the evaluation of the Helping Babies Breathe intervention, direct observations of labor and delivery were conducted in August 2013 from 27 out of the 28 districts in Malawi. Frequencies of disrespect and abuse items organized around the Bowser and Hill categories of disrespect and abuse and presented in the White Ribbon Alliance’s Universal Rights of Childbearing Women Framework were calculated. Bivariate analysis was done to assess the association between selected client background characteristics and the place of delivery with the disrespect and use during childbirth.ResultsA total of 2109 observations were made across 40 facilities (12 health centers and 28 hospitals) in Malawi. The results showed that while women were frequently greeted respectfully (13.9% were not), they were often not encouraged to ask the health provider questions (73.1%), were not given privacy (58.2%) and were not encouraged to have a support person present with them (83.2%). Results from the bivariate analysis did not show a consistent relationship between place of delivery and D&A items, where the odds of being shouted at was lower in a health center when compared to a hospital (OR: 0.19; CI: 0.59–0.62) while there was a higher odds of clients not being asked if they have any concerns if they were in a health center when compared to a hospital (OR: 2.40; CI: 1.06–5.44). Women who were HIV+ had significantly lower odds of not having audio and visual privacy (OR: 0.34, CI: 0.12–0.97), of not being asked about her preferred delivery position (OR: 0.17, CI: 0.05–0.65) and of not being asked if she has any other problems she is concerned about (OR 0.38, CI:0.15–0.96).ConclusionThis study is among the first to quantify the prevalence of disrespect and abuse during labor and delivery in Malawi through direct clinical observations. Measurement of the poor treatment of women during childbirth is essential for understanding the scope of the problem and how to address this issue.

Maternal death review (MDR) is an accepted process that is implemented across Malawi and 'underlying cause of death' is assigned by healthcare providers using a standard MDR form. Mixed-methods approach. Key informant interviews with eight stakeholders involved in MDR. Secondary analysis of MDR forms for 54 maternal deaths. Comparison of assigned cause of death by healthcare providers conducting MDR at health facility level with cause assigned by researchers using the International Classification of Diseases Maternal Mortality (ICD-MM) classification. MDR teams, analysts and policymakers reported facing challenges in completing the forms, analysing and using information. The concepts of underlying (primary) and contributing (secondary) causes of death are often misunderstood. Healthcare providers using only MDR forms reported cause of death as non-obstetric complications in 39.6% and pregnancy-related infection in 11.3% of cases. For 30.2% of cases, no clear clinical cause of death was recorded. The most commonly assigned underlying cause of death using ICD-MM was obstetric haemorrhage (32.1%), non-obstetric complications (24.5%) and pregnancy-related infection (22.6%). There was poor agreement between cause(s) of maternal death assigned by healthcare providers in the field and trained researchers using the new ICD-MM classification (j statistic; 0.219). The majority of cases could be reclassified using the ICD-MM and this provided a more specific cause of death. A more structured and user-friendly MDR form is required. Accurate classification of cause of death is important. Dissemination of, and training in the use of the new ICD-MM classification system will be helpful to healthcare providers conducting MDR in Malawi.Keywords ICD-MM, maternal death classification, maternal death reviews, maternal deaths.

BackgroundInequities in both health status and coverage of health services are considered important barriers to achieving Millennium Development Goal 4. Community-based health promotion is a strategy that is believed to reduce inequities in rural low-income settings. This paper examines the contributions of community-based programming to improving the equity of newborn health in three districts in Malawi.MethodsThis study is a before-and-after evaluation of Malawi’s Community-Based Maternal and Newborn Care (CBMNC) program, a package of facility and community-based interventions to improve newborn health. Health Surveillance Assistants (HSAs) within the catchment area of 14 health facilities were trained to make pregnancy and postnatal home visits to promote healthy behaviors and assess women and newborns for danger signs requiring referral to a facility. “Core groups” of community volunteers were also trained to raise awareness about recommended newborn care practices. Baseline and endline household surveys measured the coverage of the intervention and targeted health behaviors for this before-and-after evaluation. Wealth indices were constructed using household asset data and concentration indices were compared between baseline and endline for each indicator.ResultsThe HSAs trained in the intervention reached 36.7% of women with a pregnancy home visit and 10.9% of women with a postnatal home visit within three days of delivery. Coverage of the intervention was slightly inequitable, with richer households more likely to receive one or two pregnancy home visits (concentration indices (CI) of 0.0786 and 0.0960), but not significantly more likely to receive a postnatal visit or know of a core group. Despite modest coverage levels for the intervention, health equity improved significantly over the study period for several indicators. Greater improvements in inequities were observed for knowledge indicators than for coverage of routine health services. At endline, a greater proportion of women from the poorest quintile knew three or more danger signs for pregnancy, delivery, and postpartum mothers than did women from the least poor quintile (change in CI: -0.1704, -0.2464, and -0.4166, respectively; p < 0.05). Equity also significantly improved for coverage of some health behaviors, including delivery at a health facility (change in CI: -0.0591), breastfeeding within the first hour (-0.0379), and delayed bathing (-0.0405).ConclusionsAlthough these results indicate promising improvements for newborn health in Malawi, the extent to which the CBMNC program contributed to these improvements in coverage and equity are not known. The strategies through which community-based programs are implemented likely play an important role in their ability to improve equity, and further research and program monitoring are needed to ensure that the poorest households are reached by community-based health programs.

BackgroundLighthouse Trust operates two public HIV testing, treatment and care clinics in Lilongwe, Malawi, caring for over 26 000 people living with HIV, 23 000 of whom are on antiretroviral treatment (ART). In August 2010, Lighthouse Trust piloted a step-wise integration of sexual and reproductive health (SRH) services into routine HIV care at its Lighthouse clinic site. The objectives were to increase uptake of family planning (FP), promote long-term reversible contraceptive methods, and increase access, screening and treatment for cervical cancer using visual inspection with acetic acid.Methods and resultsPatients found integrated SRH/ART services acceptable; service availability appeared to increase uptake. Between August 2010 and May 2014, over 6000 women at Lighthouse received FP education messages. Of 859 women who initiated FP, 55% chose depot medroxyprogesterone acetate, 19% chose an intrauterine contraceptive device, 14% chose oral contraceptive pills, and 12% chose an implant. By May 2014, 21% of eligible female patients received cervical cancer screening: 11% (166 women) had abnormal cervical findings during screening for cervical cancer and underwent further treatment.ConclusionsSeveral lessons were learned in overcoming initial concerns about integration. First, our integrated services required minimal additional resources over those needed for provision of HIV care alone. Second, patient flow improved during implementation, reducing a barrier for clients seeking multiple services. Lastly, analysis of routine data showed that the proportion of women using some form of modern contraception was 45% higher at Lighthouse than at Lighthouse's sister clinic where services were not integrated (42% vs 29%), providing further evidence for promotion of SRH/ART integration.

In 2009, many women seeking postabortion care in Malawi presented with complications. Advocacy is needed to influence policies that will allow expanded access to safe abortion services for women of all ages and in all areas.