Advancing Maternal and Newborn Health in Malawi

Presented by Tambudzai Rashidi, Chief of Party MCHIP

Women Deliver Conference 8th June 2010

Introduction

In Malawi, the Ministry of Health (MoH) is focusing on the reduction of maternal, neonatal and child mortality towards the achievement of the Millennium Development Goals through targeted high-impact interventions at the facility and community levels. In collaboration with its maternal and newborn health (MNH) partners at the community level and with facilities in all 28 districts, the MoH promotes quality of reproductive health (RH) services including infection prevention (IP) and control practices, Basic Emergency Obstetric and Neonatal Care (BEmONC), and community-based MNH interventions along the Household to Hospital Continuum of Care (HHCC). In 2005, a Nationwide Assessment by the MoH exposed significant gaps in the delivery of BEmONC and Comprehensive Emergency Obstetric and Neonatal Care with only two BEmONC sites nationally (0.1 per 500,000 population).

Enabling Environment

Following the advocacy work of Jhpiego and Nurses and Midwives Council of Malawi (NMCM) and the RHU, the scope of practice of Nurse Midwife Technician (NMT)[1] was changed in 2007 thereby allowing them to practice the six signal functions (Intravenous antibiotics, oxytocins, anticonvulsants, manual vacuum aspiration, manual removal of placenta, vacuum extraction) and provide BEmONC services appropriately at the lowest level of care.

The Reproductive Health Unit (RHU) of the MoH, collaborated with key MNH stakeholders including Save the Children and the USAID-funded ACCESS program to develop an Integrated Maternal and Neonatal Care training package for pre and in-service training of providers in 2008. The package includes Focused Antenatal Care (FANC), BEmONC, and Essential Newborn Care (ENC). This three-week competency-based training package was formally adopted by the MoH as the standard training package. This training package enabled training institutions to train providers effectively and efficiently in a comprehensive spectrum of MNH services thereby improving the providers’ capability to provide MNH services at hospital and health center level.

The USAID-funded ACCESS program led by Jhpiego, worked closely with the MoH and NMCM to review the NMT syllabus and curriculum and integrate BEmONC skills and competencies. To date all 13 NMT training institutions are training graduate midwives using this syllabus and curriculum and the NMT licensure examination has included BEmONC knowledge and skills as a result of this work.

Quality of RH services remain a cross-cutting focus of the MoH. Since 2006, the MoH has worked with Jhpiego to develop a performance and quality improvement (PQI) approach which implements integrated national IP and RH standards for application at both hospital and health center levels. The PQI/RH model has been established in 16 district hospitals, all four central hospitals and is being piloted in 12 health centers; with plans to scale up countrywide to government hospitals in the remaining 12 districts. Two hospitals, Mzuzu Central Hospital and Mchinji District Hospital have been recognized as Centers of Excellence in RH service delivery.

Basic Emergency Obstetric and Neonatal Care

Starting in 2007, the ACCESS and MCHIP programs led by Jhpiego strengthened the knowledge and skills of 65 midwifery tutors, 48 preceptors and two clinical instructors from all 13 nurse-midwifery training institutions and their associated clinical training sites by updating them in evidenced-based BEmONC. To further enhance the coaching skills for tutors, ACCESS conducted a two-week Clinical Skills Training (CTS) for 20 tutors drawn from the training colleges. The CTS equips participants with additional teaching skills to provide enhanced clinical skills coaching. ACCESS provided additional supplies to the skills laboratories of Malawi College of Health Sciences Zomba Campus and Ekwendeni College of Nursing; these included Madam Zoe models, mucus extractors, newborn resuscitation model, Ambu bags, CD-ROMS, and vacuum extractors. In addition, ACCESS provided teaching materials including, Basic Maternal and Newborn Care: A Guide for Skilled Providers, Family Planning Global Handbook, Laminated Partograph, Charts on Positions used in Labor and Repair of the Perineum, to all 13 midwifery training colleges.

As a result of these interventions, 403 service providers in the country (nurses, medical assistants) are able to provide BEmONC services (327 from 98 BEmONC sites and 80 from 12 additional sites). In addition Magnesium Sulphate has been included on the drug list for health centers and made available. MVA kits, vacuum extractors have also been distributed to the BEmONC sites and 98/104 (94%) BEmONC sites have been established. The trainings and establishment of BEmONC sites has been supported by MoH, African Development Bank (ADB), USAID and UNICEF.

Community MNH Model

Building on an existing platform that brings basic MNH services closer to families and raises awareness and demand for high-quality, facility-based MNH services, RHU in collaboration with Save the Children and MCHIP is supporting scale up of the nationally adopted Community MNH (CMNH) model which includes Community Mobilization (CM). The CMNH model targets government employed Health Surveillance Assistants (HSA)[2] assigned to health centers to deliver essential MNH messages and enhance preventive care before, during, and after childbirth, and to promote the use of health care when necessary. The HSAs receive training to deliver CMNH messages at home and facilitate community mobilization to engage community members in defining and addressing local MNH challenges in partnership with the health system. Currently the CMNH model is being implemented in seven pilot districts and was recently scaled up to an additional two districts with support from WHO.

2

[1] NMT is the cadre of nurse-midwives who provide care at the health center level

[2] HSAs are Malawi’s cadre of community health workers