Background: Clinical officers perform much of major emergency surgery in Malawi, in the absence of medical officers. The aim of this study was to validate the advantages and disadvantages of delegation of major obstetric surgery to non-doctors.

BackgroundShortages of staff have a significant and negative impact on maternal outcomes in low-income countries, but the impact on obstetric care providers in these contexts is less well documented. Despite the government of Malawi’s efforts to increase the number of human resources for health, maternal mortality rates remain persistently high. Health workers’ perceptions of insufficient staff or time to carry out their work can predict key variables concerning motivation and attrition, while the resulting sub-standard care and poor attitudes towards women dissuade women from facility-based delivery. Understanding the situation from the health worker perspective can inform policy options that may contribute to a better working environment for staff and improved quality of care for Malawi’s women.MethodsA qualitative research design, using critical incident interviews, was used to generate a deep and textured understanding of participants’ experiences. Eligible participants had performed at least one of the emergency obstetric care signal functions a in the previous three months and had experienced a demotivating critical incident within the same timeframe. Data were analysed using NVivo software.ResultsEighty-four interviews were conducted. Concerns about staff shortages and workload were key factors for over 40% of staff who stated their intention to leave their current post and for nearly two-thirds of the remaining health workers who were interviewed. The main themes emerging were: too few staff, too many patients; lack of clinical officers/doctors; inadequate obstetric skills; undermining performance and professionalism; and physical and psychological consequences for staff. Underlying factors were inflexible scheduling and staff allocations that made it impossible to deliver quality care.ConclusionThis study revealed the difficult circumstances under which maternity staff are operating and the professional and emotional toll this exacts. Systems failures and inadequate human resource management are key contributors to the gaps in provision of obstetric care and need to be addressed. Thoughtful strategies that match supply to demand, coupled with targeted efforts to support health workers, are necessary to mitigate the effects of working in this context and to improve the quality of obstetric care for women in Malawi.

BackgroundMid-level cadres are being used to address human resource shortages in many African contexts, but insufficient and ineffective human resource management is compromising their performance. Supervision plays a key role in performance and motivation, but is frequently characterised by periodic inspection and control, rather than support and feedback to improve performance. This paper explores the perceptions of district health management teams in Tanzania and Malawi on their role as supervisors and on the challenges to effective supervision at the district level.MethodsThis qualitative study took place as part of a broader project, “Health Systems Strengthening for Equity: The Power and Potential of Mid-Level Providers”. Semi-structured interviews were conducted with 20 district health management team personnel in Malawi and 37 council health team members in Tanzania. The interviews covered a range of human resource management issues, including supervision and performance assessment, staff job descriptions and roles, motivation and working conditions.ResultsParticipants displayed varying attitudes to the nature and purpose of the supervision process. Much of the discourse in Malawi centred on inspection and control, while interviewees in Tanzania were more likely to articulate a paradigm characterised by support and improvement. In both countries, facility level performance metrics dominated. The lack of competency-based indicators or clear standards to assess individual health worker performance were considered problematic. Shortages of staff, at both district and facility level, were described as a major impediment to carrying out regular supervisory visits. Other challenges included conflicting and multiple responsibilities of district health team staff and financial constraints.ConclusionSupervision is a central component of effective human resource management. Policy level attention is crucial to ensure a systematic, structured process that is based on common understandings of the role and purpose of supervision. This is particularly important in a context where the majority of staff are mid-level cadres for whom regulation and guidelines may not be as formalised or well-developed as for traditional cadres, such as registered nurses and medical doctors. Supervision needs to be adequately resourced and supported in order to improve performance and retention at the district level.

Objectives:We analysed the epidemiology of ectopic pregnancy (EP) during a 28 year period, 1970-97, using methods applicable to ecological studies in order to test the hypothesis that a reduction of pelvic inflammatory disease (PID) will be associated with a decrease of EP. Methods: Hospital records of patients aged 15-54 admitted to our department of gynaecology were reviewed for EP and PID for the period 1 January 1970 to 31 December 1997. EP for the period 1970-4 was based on available statistics. The total number for EP was 1270 and for PID 2559. The total population for the catchment area was 100 000-120 000 during the study period. Incidences were age standardised and calculated using oYcial population statistics to represent the average female population in the five 5 year periods 1970-4, 1975-9, 1980-4, 1985-9, 1990-4, and in each of the consecutive years 1995, 1996, and 1997. Incidences for EP were calculated per 1000 women and per 1000 pregnancies while those for PID per 1000 women. National statistical data of EP were available for 1975-94 and were used for comparison with the local study. Results: The EP incidences increased from 7.7 per 1000 pregnancies in the first 5 year period to 13.4 in the second, and continued to rise for another decade reaching the peak figures of 16.6 in 1985-9-that is, more than a twofold increase. Since then and to 1997 the EP incidence has decreased by 30%. PID admissions increased during the study period from 2.7 per 1000 women in the first 5 year period to 3.2 in the second. From then on they continuously decreased and reached a low of 0.5 in 1997. The greatest changes occurred in women <24 years of age. The peak incidence for this age group was 7.7 in 1975-9, and the lowest was 0.4 per 1000 women in 1996. The greatest reduction of EPs was noted for women <24 years old, from a high of 10.0 in 1975-9, coinciding with the peak incidence of PID, to a low of 4.0 in 1997, a reduction of 58.4%. The incidence of EP was two to three times higher in women >25 years old, most obvious in those >30 years, with peak figures of 20.9 per 1000 pregnancies in 1985-9, and 13.9 in 1997, a reduction of 33.4% and the lowest figures for the past 23 years. For women aged 25-29 years the incidence peaked in the previous 5 year period 1980-4-that is, one 5 year period later than for those <24 years, which we interpret as cohort eVects in relation to PID. Conclusions: Reduction of PID was strongly associated with a decline of EP. The decline was greater and immediate for women <24 years old, than for those >25 years. The two to three times higher EP incidence in women >25 years of age was most probably due to a cohort eVect as the peak of PID occurred a decade earlier in women <24 years old. Prevention of PID may not only reduce EP but also reduce adverse eVects on tubal patency. (Sex Transm Inf 2000;76:28-32)

BackgroundMalawi faces a severe shortage of health workers, a factor that has contributed greatly to high maternal mortality in the country. Most clinical care is performed by mid-level providers (MLPs). While utilization of these cadres in providing health care is a solution to the current shortages, demotivating factors within the Malawian health system are pushing them into private, non-governmental, and other non-health related positions. This study aims to highlight these demotivating factors by exploring the critical aspects that influence MLPs’ intention to leave their jobs.MethodsThis descriptive qualitative study formed part of the larger Health Systems Strengthening for Equity (HSSE) study. Data presented in this paper were collected in Malawi using the Critical Incident Analysis tool. Participants were asked to narrate an incident that had happened during the past three months which had made them seriously consider leaving their job. Data were subjected to thematic analysis using NVivo 8 software.ResultsOf the 84 respondents who participated in a Critical Incident Analysis interview, 58 respondents (69%) indicated they had experienced a demotivating incident in the previous three months that had made them seriously consider leaving their job. The most commonly cited critical factors were being treated unfairly or with disrespect, lack of recognition of their efforts, delays and inconsistencies in salary payments, lack of transparent processes and criteria for upgrading or promotion, and death of patients.ConclusionStaff motivation and an enabling environment are crucial factors for retaining MLPs in the Malawian health system. This study revealed key ‘tipping points’ that drive staff to seriously consider leaving their jobs. Many of the factors underlying these critical incidents can be addressed by improved management practices and the introduction of fair and transparent policies. Managers need to be trained and equipped with effective managerial skills and staff should have access to equal opportunities for upgrading and promotion. There is need for continuous effort to mobilize the resources needed to fill gaps in basic equipment, supplies, and medicine, as these are critical in creating an enabling environment for MLPs.

Measures aimed at reducing incidences of gonorrhea and genital chlamydial infection will reduce the incidences of one of the most serious complications of these STDs, acute PID, and, in turn, its long-term sequelae.

Millennium Development Goal (MDG) 5 commits us to reducing maternal mortality rates by three quarters and MDG 4 commits us to reducing child mortality by two-thirds between 1990 and 2015. In order to reach these goals, greater access to basic emergency obstetric care (EmOC) as well as comprehensive EmOC which includes safe Caesarean section, is needed.. The limited capacity of health systems to meet demand for obstetric services has led several countries to utilize mid-level cadres as a substitute to more extensively trained and more internationally mobile healthcare workers. Although this does provide greater capacity for service delivery, concern about the performance and motivation of these workers is emerging. We propose that poor leadership characterized by inadequate and unstructured supervision underlies much of the dissatisfaction and turnover that has been shown to exist amongst these mid-level healthcare workers and indeed health workers more generally. To investigate this, we conducted a large-scale survey of 1,561 mid-level cadre healthcare workers (health workers trained for shorter periods to perform specific tasks e.g. clinical officers) delivering obstetric care in Malawi, Tanzania, and Mozambique. Participants indicated the primary supervision method used in their facility and we assessed their job satisfaction and intentions to leave their current workplace. In all three countries we found robust evidence indicating that a formal supervision process predicted high levels of job satisfaction and low intentions to leave. We find no evidence that facility level factors modify the link between supervisory methods and key outcomes. We interpret this evidence as strongly supporting the need to strengthen leadership and implement a framework and mechanism for systematic supportive supervision. This will promote better job satisfaction and improve the retention and performance of obstetric care workers, something which has the potential to improve maternal and neonatal outcomes in the countdown to 2015.

Objectives: Establishing a connection between the emerging urogenital tract pathogen Mycoplasma genitalium and upper genital tract infection in women would be of major importance. The aim of this study was to evaluate the association between M genitalium antibodies and pelvic inflammatory disease (PID) and ectopic pregnancy (EP) using a lipid-associated membrane protein-enzyme immunoassay (LAMP-EIA) method. Methods: The LAMP-EIA was used to analyse sera obtained from patients with clinical PID and EP collected in Sweden between February 1984 and April 1986. Sera from healthy pregnant women (Ctrl) collected during approximately the same period were used as controls. Evidence of chlamydial infection was investigated using a commercial anti-Chlamydia trachomatis EIA assay. Results: The LAMP-EIA was specific as determined by a lack of cross-reactivity with other Mycoplasma species. The LAMP-EIA showed that 17% (33/193) of the PID patients were M genitalium positive as compared to 18% (15/82) of the EP patients and 15% (36/246) of the Ctrl women. No significant association could be demonstrated between M genitalium antibodies and PID or EP in crude or adjusted logistic regression. Antibodies against C trachomatis were demonstrated in 54% of the PID and 57% of the EP patients, and also in 37% of the Ctrl women, showing a statistically significant association. Conclusion: No statistically significant association between PID or EP and M genitalium antibodies could be found using the LAMP-EIA, although a slight tendency toward association was found when focusing on younger individuals. P elvic inflammatory disease (PID) almost exclusively affects sexually active fertile women, who then face an increased risk of infertility, ectopic pregnancy (EP) and chronic pelvic pain. The best known causative agents of PID are Neisseria gonorrhoeae and Chlamydia trachomatis. Some studies have indicated that non-gonococcal rather than gonococcal infections of the upper genital tract are more likely to result in infertility and EP.1-3 Although many cases are caused by C trachomatis, some studies have also shown an association between Mycoplasma genitalium infection and PID and infertility. [4][5][6][7] M genitalium was discovered in 1981 when it was isolated from the urethra of two men with non-gonococcal urethritis. 8The infection is sexually transmitted, but the complete pattern of diseases caused by M genitalium has not yet been completely elucidated. The infections tend to run a chronic course and are often asymptomatic.9 10 Experiments with female monkeys where M genitalium was inoculated into the oviducts, resulted in salpingitis followed by a specific antibody response.11 The cross-reactions between M pneumoniae and M genitalium 12 13 have made it difficult to use serology for diagnosis and epidemiological studies, but Wang et al developed and evaluated a Triton X-114 extracted lipid-associated membrane protein (LAMP) assay and found no cross-reactions. 9 14 In the present study we have used sera obtained in the 1980s from women ...