BackgroundIn Malawi maternal mortality continues to be a major public health challenge. Going beyond the numbers to form a more complete view of why women die is critical to improving access to and quality of emergency obstetric care. The objective of the current study was to identify the socio-cultural and facility-based factors that contributed to maternal deaths in the district of Lilongwe, Malawi.MethodsRetrospectively, 32 maternal death cases that occurred between January 1, 2011 and June 30, 2011 were reviewed independently by two gynecologists/obstetricians. Interviews were conducted with healthcare staff, family members, neighbors, and traditional birth attendants. Guided by the grounded theory approach, interview transcripts were analyzed manually and continuously. Emerging, recurring themes were identified and excerpts from the transcripts were categorized according to the Three Delays Model (3Ds).ResultsSixteen deaths were due to direct obstetric complications, sepsis and hemorrhage being most common. Sixteen deaths were due to indirect causes with the main cause being anemia, followed by HIV and heart disease. Lack of recognizing signs, symptoms, and severity of the situation; using traditional Birth Attendant services; low female literacy level; delayed access to transport; hardship of long distance and physical terrain; delayed prompt quality emergency obstetric care; and delayed care while at the hospital due to patient refusal or concealment were observed. According to the 3Ds, the most common delay observed was in receiving treatment upon reaching the facility due to referral delays, missed diagnoses, lack of blood, lack of drugs, or inadequate care, and severe mismanagement.

BackgroundBurnout among maternal healthcare workers in sub-Saharan Africa may have a negative effect on services provided and efforts to mitigate high maternal mortality rates. In Malawi, research on burnout is limited and no empirical research has been conducted specifically among maternal health staff. Therefore, the aims of the study were to examine the prevalence and degree of burnout reported by healthcare workers who provide antenatal, intrapartum, and postnatal services in a district referral hospital in Malawi; and, to explore factors that may influence the level of burnout healthcare workers experience.MethodsIn the current cross-sectional study, levels of burnout among staff working in obstetrics and gynaecology at a referral hospital in Malawi were examined, in addition to individual and job characteristics that may be associated with burnout.ResultsIn terms of the three dimensions of burnout, of the 101 participants, nearly three quarters (72%) reported emotional exhaustion, over one third (43%) reported depersonalization while almost three quarters (74%) experienced reduced personal accomplishment.ConclusionsBased on these findings, burnout appears to be common among participating maternal health staff and they experienced more burnout than their colleagues working in other medical settings and countries. Further research is needed to identify factors specific to Malawi that contribute to burnout in order to inform the development of prevention and treatment within the maternal health setting.

Background: Improving maternal health in Ethiopia is a major public health challenge. International studies indicate that it is possible to improve maternal health outcomes through action on the Social Determinants of Health (SDH). This study aimed to explore the SDH that influence the antenatal care (ANC) utilization in Ethiopia over time. Methods: The study used data from the nation-wide surveys conducted by the Ethiopian Central Statistical Agency (CSA) and ORC Macro International, USA in 2005, 2011, and 2016. A negative binomial with random effects at cluster level was used to model the number of ANC visits whereas a multilevel binary logistic regression modeled binary responses relating to whether a woman had at least 4 ANC visits or not. The model estimates were obtained with the statistical software Stata SE 15 using the restricted maximum likelihood method. Results: Although the median number of ANC visits significantly increased between 2005 and 2016, the majority of the women do not obtain the four ANC visits during pregnancy as recommended. The odds of having at least four ANC visits were significantly lower among women: below 20 years, those living in the rural areas, having higher birth order, or Muslim. In contrast, higher educational attainment, higher socio-economic status, exposure to mass media, and self-reporting decision empowerment were significantly associated with having at least four ANC visits. Conclusion: The use of ANC visits is driven mostly by the social determinants of health rather than individual health risk. The importance of the various SDHs needs to be recognized by Ministry of Health policy and program managers as a key driving force behind the country's challenges with reaching targets in the health agenda related to maternal health, particularly related to the recommended number of ANC visits.

BackgroundThe consequences of living with obstetric fistula are multifaceted and very devastating for women, especially those living in poor resource settings. Due to uncontrollable leakages of urine and/or feces, the condition leaves women with peeling of skin on their private parts, and the wetness and smell subject them to stigmatization, ridicule, shame and social isolation. We sought to gain a deeper understanding of lived experiences of women with obstetric fistula in Malawi, in order to recommend interventions that would both prevent new cases of obstetric fistula as well as improve the quality of life for those already affected.MethodsWe conducted semi-structured interviews with 25 women with obstetric fistula at Bwaila Fistula Care Center in Lilongwe and in its surrounding districts. We interviewed twenty women at Bwaila Fistula Care Center; five additional women were identified through snowball sampling and were interviewed in their homes. We also interviewed twenty family members. To analyze the data, we used thematic analysis. Data were categorized using Nvivo 10. Goffman’s theory of stigma was used to inform the data analysis.ResultsAll the women in this study were living a socially restricted and disrupted life due to a fear of involuntary disclosure and embarrassment. Therefore, “anticipated” as opposed to “enacted” stigma was especially prevalent among the participants. Many lost their positive self-image due to incontinence and smell. As a way to avoid shame and embarrassment, these women avoided public gatherings; such as markets, church, funerals and weddings, thus losing part of their social identity. Participants had limited knowledge about their condition.ConclusionThe anticipation of stigma by women in this study consequently limited their social lives. This fear of stigma might have arisen from previous knowledge of social norms concerning bowel and bladder control, which do not take into account an illness like obstetric fistula. This misconception might have also arisen from lack of knowledge about causes of the condition itself. There is need therefore to create awareness and educate women and their communities about the causes of obstetric fistula, its prevention and treatment, which may help to prevent fistula as well as reduce all dimensions of stigma, and consequently increase dignity and quality of life for these women.

BackgroundWhen and how to wean breastfed infants exposed to HIV infection has provoked extensive debate, particularly in low-income countries where safe alternatives to breastfeeding are rarely available. Although there is global consensus on optimal infant-feeding practices in the form of guidelines, practices are sub-optimal in much of sub-Saharan Africa. Policy-makers and health workers face many challenges in adapting and implementing these guidelines.MethodsThis paper is based on in-depth interviews with five policy-makers and 11 providers of interventions to prevent mother-to-child transmission (PMTCT) of HIV, participant observations during clinic sessions and site visits.ResultsThe difficulties with adapting the global infant-feeding guidelines in Malawi have affected the provision of services. There was a lack of consensus on HIV and infant-feeding at all levels and general confusion about the 2006 guidelines, particularly those recommending continued breastfeeding after six months if replacement feeding is not acceptable, feasible, affordable, sustainable and safe. Health workers found it particularly difficult to advise women to continue breastfeeding after six months. They worried that they would lose the trust of the PMTCT clients and the population at large, and they feared that continued breastfeeding was unsafe. Optimal support for HIV-infected women was noted in programmes where health workers were multi-skilled; coordinated their efforts and had functional, multidisciplinary task forces and engaged communities. The recent 2009 recommendations are the first to support antiretroviral (ARV) use by mothers or children during breastfeeding. Besides promoting maternal health and providing protection against HIV infection in children, the new Rapid Advice has the potential to resolve the difficulties and confusion experienced by health workers in Malawi.ConclusionsThe process of integrating new evidence into institutionalised actions takes time. The challenge of keeping programmes, and especially health workers, up-to-standard is a dynamic process. Effective programmes require more than basic resources. Along with up-to-date information, health workers need contextualized, easy-to-follow guidelines in order to effectively provide services. They also require supportive supervision during the processes of change. Policy-makers should ensure that consensus is carefully considered and that comprehensive perspectives are incorporated when adapting the global guidelines.