Reducing maternal death rates in Malawi

As part of the work to improve the quality of care in hospitals, Karen Zeribi from the US-based Institute for Healthcare Improvement has drawn together a number of ideas that have been shown to work in other countries. “We call this a change package,” she explains. “It’s a menu of ideas that evolves over time. As teams come up with new ideas that we didn’t think of, we add them into the package.”

The change package has been tried out by teams from different hospitals, who then meet to share their experiences of what works, and what doesn’t, in improving care.

“We’re creating a learning network of hospitals that have similar missions and goals,” Karen says. “The workshops are driven by things that the teams have learned and done, so they’re teaching each other as they develop areas of expertise. In between the workshops the teams also visit each other’s hospitals, which provides a valuable opportunity for observing how other teams operate on site.”

One area where an idea developed by one team has spread to the other hospitals is managing medicine and equipment supplies. The maternity staff at Bwaila Hospital were feeling discouraged because they never had the right supplies or equipment. They introduced a new process where they measured what they used, quantified what they needed and used this information to more accurately predict their future needs.

“This process has really helped their relationship with the pharmacy,” Karen says. “In the past, the pharmacy didn’t believe them because they knew that they weren’t measuring, so they’d only send half of what they ordered. As a result, they had a patient attendant who spent a lot of time running from the maternity wing to the pharmacy to get more supplies.”

“Now the pharmacy trusts the maternity wing, they actually send what they’ve ordered, and the patient attendant has been freed up to be used in other ways,” she continues. “Since then, we’ve had three hospitals replicate and adapt some of these ideas.”

The community strand of the programme, meanwhile, has focused on empowering women through local groups to take control of their own healthcare.

“Women in Malawi are often not the decision makers, they don’t have a voice,” Dorothy Flatman from Women and Children First explains. “So we work to engage with women’s groups to identify problems and how we might help. Often, it’s the simplest things that make the biggest difference to quality, like ensuring that the baby is delivered in a clean environment.”

The programme team is also working to make healthcare facilities more women-friendly, in order to encourage more women to use them and thereby reduce the numbers giving birth in uncontrolled environments without skilled attendants.

“It’s important for women to feel they’ve been treated with dignity and respect,” Nynke Van Den Broek from Liverpool School of Tropical Medicine explains. “This could mean that we introduce ourselves by name and explain what we’re doing to them, that we let them adopt their preferred delivery position and that we don’t leave them uncovered unnecessarily.”

The team has developed a standards-based audit to measure whether women are satisfied with the care they receive, and are using this to improve their clinical practice. They are also using a maternal death audit to examine what went wrong in the worst cases, in a blame free environment, and to prevent the same mistakes happening again.

An important factor behind much of the programme’s successes to date has been improving the quality of data which can be used by hospitals to monitor and improve standards of care.

Roger LeCompte has been working with the Institute for Healthcare Improvement to improve the reporting of data through the use of forms. “In many places, the basic medical record consists of some ad hoc handwritten notes on a piece of blank paper and the protocol by which information is collected is in the nurses’ heads,” Roger says. “For example, when a woman comes in, they have to remember to get her name, how many babies she’s had before, her blood pressure, temperature and so on, but the protocol is rarely in front of them and they don’t always collect all the necessary information for good decision-making.”

To tackle this problem, the team has been developing a new obstetric patient record, with a series of check boxes and lists. They expect this to speed up the intake process, improve the completeness of the data and reduce the ambiguity of the information that is written down. “Pre-printed forms that simply require ticking a box or circling a word are much easier to read and faster to complete,” Roger explains.

The same approach has been used to improve the quality of data by which hospitals count and report how many deliveries of each kind take place in a given month. “This process was very much ad hoc and prone to error,” Roger says. “You’d find variances between what’s actually happened and what was written down of sometimes 100 per cent. By creating some forms and standard procedures we’ve been able to improve that as well.”

Roger believes that this rigorous approach to data has been of tremendous benefit to the programme. “The process of recording what happens is very important but it’s also very neglected, and not just in Malawi,” he comments. “With this project, we’ve focused on the fundamental process of how people gather information and act on it from the very beginning.”

If the programme is successful, Karen has ideas for how to spread the learning further.

“One of the natural steps I would take is to try to spread it to other districts,” she says. “I think exchanging ideas with people who have done similar work in other parts of the world would also be useful, particularly on how you take methods that have been established in rich countries into an environment like Malawi, that is extremely resource poor.”

At the local level, Karen is confident that healthcare practitioners will be able to take the skills they’ve learned on the programme and apply them elsewhere. “I think it’s really a set of skills that we’re teaching: how to look at what you have; recognise what is in your control to change; and work on the things that will have the greatest impact,” she says. “I think those things are very sustainable because they’re about making changes to what you already have.”

Even at this early stage of the programme, it is clear that improvements have been made. Ultimately, the project will not only leave local healthcare practitioners with enhanced skills, it will also have a direct impact on the health and healthcare of some of Malawi's least fortunate mothers and children.

• Read more: Providing women friendly care in Malawi