Providing women friendly care in Malawi
The Health Foundation Consortium
Quality Improvement in Malawi
Community intervention projects can help women understand maternity care and the services they are entitled to receive
Maternal and neo-natal death is one of the biggest healthcare issues facing developing countries. Malawi has one of the highest maternal death rates in the world. To help tackle this, The Health Foundation is running a three year programme dedicated to improving the quality of healthcare for mothers and babies in the country.
An overview of the programme is provided in a previous case study: Reducing maternal death rates in Malawi.
One key element of the programme is ensuring that healthcare becomes more women-friendly, both in local communities and in hospitals. Dorothy Flatman from Women and Children First has been working to help women to understand maternity care, including the services and standards of care they are entitled to receive. The aim is to empower women, through local groups and communities, to take control of their own healthcare.
“Women in Malawi are often not the decision makers, they don’t have a voice,” Dorothy comments. “We want to engage women who are either pregnant or have recently given birth, and talk to them about the problems that they may have faced. While there is a health education component, we’re starting off by listening to women and talking about their concerns and how some of those problems could be addressed. We’re really trying to help women have a better dialogue with their own communities.”
In order to set up the local groups, Dorothy’s team starts by talking to village leaders about what the programme is trying to achieve and how they want to work with the community. A series of meetings are then set up in each village, where a facilitator works with the women to guide their discussions and help them identify and prioritise the main problems. They then try to come up with ideas to resolve the problems using local resources.
“We support the women in looking for solutions that women can test out themselves,” Dorothy explains. “If there’s a transport problem in one village, for instance, the group might look at setting up an emergency fund, with each member of the group giving a small amount of money. The fund would build up and then if a woman needs emergency transport, she could use that money. Another community might decide to plant a vegetable garden to grow iron rich foods for pregnant women.”
“It’s early days but we’ve definitely raised awareness of some issues that really need addressing and the women are keen to participate” Dorothy adds.
Facilities management
Volunteers identify pregnant women at the hospital door and make sure they are registered within three minutes
On the hospital side, meanwhile, Nynke Van Den Broek from Liverpool School of Tropical Medicine is working to ensure that healthcare facilities provide services that meet women’s needs. “We’ve done a baseline assessment of healthcare facilities in the three districts we work in,” she explains. “We want to make sure that all women have skilled attendants at birth and access to emergency obstetric care. We found that all the facilities provide some of the things we’ve highlighted, but none can provide the full complement.”
One of the problems the team is addressing is the low attendance rate by pregnant women at healthcare facilities which, at just over 50 per cent, means that nearly half of women giving birth in Malawi do so without the benefits of skilled staff or modern medicine.
“One of the reasons why women are not using the facilities is because of the poor quality of care,” Nynke explains. “Until we improve care so that it is not just clinically effective but also woman-friendly – in the sense that women feel they’ve been treated with dignity and respect and have been listened to – we can’t expect them to use the facilities.”
To help achieve this, Liverpool School of Tropical Medicine has introduced two tools to the hospitals: a standards-based audit and a maternal death audit. As with the community side, the team started by holding a workshop for healthcare providers, where they asked clinicians to set out what they thought constituted women-friendly care. They also asked patients what it was they didn’t like about going into hospital.
The team used the results of these exercises to come up with key standards of care that the facilities agreed they should be providing and that staff could work towards. “This could mean that they introduce themselves to patients by name and explain what they’re doing to them, that they let women adopt their preferred delivery position and that they don’t leave patients uncovered unnecessarily,” Nynke says.
“There’s now a continuous process of examining the quality of care that’s provided,” she continues. “We measure it and, if we find that women are still not happy, we sit down and decide what else needs to be improved.”
The maternal death review is used in a similar way to examine the worst cases of breakdowns in care – when the women or baby dies. “If there has been a maternal death, which unfortunately happens fairly frequently in these hospitals, we sit down as a group of healthcare providers and examine in a blame free way what happened to this woman, why she died, what could have been done better and what we can do next time a similar patient comes in,” Nynke explains.
“People are really beginning to examine their care to see where it can be improved and are becoming proud of saying ‘Okay, we managed to do this better this time’,” she adds.
Skills are also improving in the hospitals after clinicians asked for training in how to deal with complications such as massive post-partum haemorrhage and shoulder dystocia. “In the last workshop, we started doing training with dummies, which is the way we often train healthcare providers in the UK and internationally,” Nynke says. “We create scenarios such as a woman on a bed who seems to be in shock or a pelvis with a baby stuck in it, and we let people act out their responses.”
Joined up working
Using ‘kangaroo care’, the mother acts as an incubator by wearing a garment designed to keep her baby warm
The next stage is to link up the community and provider sides of the programme, in order to encourage women to seek timely and appropriate care from hospitals. “We’re trying to improve the links between women who need healthcare services and the service providers,” Dorothy says. “We want to have a dialogue where the communities say ‘these are our issues and concerns’ and, at the same time, the facilities are improving their receptiveness to women and their technical skills.”
The team is also keen to ensure that local practitioners have the skills to continue improving services after the programme comes to an end. “Sustainability is about people discovering what it is they can do for themselves to improve their practice and the quality of care they are delivering,” Nynke says. “That can act as a real motivator. Every healthcare provider wants to see their patient leave the hospital alive and it does improve people’s morale to say ‘we can actually do this, and it doesn’t cost a fortune’.”
08 August 2007
