Maternal mortality in Malawi, 1977-2012

Socio-demographic factors associated with early antenatal care visits among pregnant women in Malawi: 2004-2016

INTRODUCTION

In 2016, the WHO published recommendations increasing the number of recommended antenatal care (ANC) visits per pregnancy from four to eight. Prior to the implementation of this policy, coverage of four ANC visits has been suboptimal in many low-income settings. In this study we explore socio-demographic factors associated with early initiation of first ANC contact and attending at least four ANC visits ("ANC4+") in Malawi using the Malawi Demographic and Health Survey (MDHS) data collected between 2004 and 2016, prior to the implementation of new recommendations.

METHODS

We combined data from the 2004-5, 2010 and 2015-16 MDHS using Stata version 16. Participants included all women surveyed between the ages of 15-49 who had given birth in the five years preceding the survey. We conducted weighted univariate, bivariate and multivariable logistic regression analysis of the effects of each of the predictor variables on the binary endpoint of the woman attending at least four ANC visits and having the first ANC attendance within or before the four months of pregnancy (ANC4+). To determine whether a factor was included in the model, the likelihood ratio test was used with a statistical significance of P< 0.05 as the threshold.

RESULTS

We evaluated data collected in surveys in 2004/5, 2010 and 2015/6 from 26386 women who had given birth in the five years before being surveyed. The median gestational age, in months, at the time of presenting for the first ANC visit was 5 (inter quartile range: 4-6). The proportion of women initiating ANC4+ increased from 21.3% in 2004-5 to 38.8% in 2015-16. From multivariate analysis, there was increasing trend in ANC4+ from women aged 20-24 years (adjusted odds ratio (aOR) = 1.27, 95%CI:1.05-1.53, P = 0.01) to women aged 45-49 years (aOR = 1.91, 95%CI:1.18-3.09, P = 0.008) compared to those aged 15-19 years. Women from richest socio-economic position ((aOR = 1.32, 95%CI:1.12-1.58, P<0.001) were more likely to demonstrate ANC4+ than those from low socio-economic position. Additionally, women who had completed secondary (aOR = 1.24, 95%CI:1.02-1.51, P = 0.03) and tertiary (aOR = 2.64, 95%CI:1.65-4.22, P<0.001) education were more likely to report having ANC4+ than those with no formal education. Conversely increasing parity was associated with a reduction in likelihood of ANC4+ with women who had previously delivered 2-3 (aOR = 0.74, 95%CI:0.63-0.86, P<0.001), 4-5 (aOR = 0.65, 95%CI:0.53-0.80, P<0.001) or greater than 6 (aOR = 0.61, 95%CI: 0.47-0.79, <0.001) children being less likely to demonstrate ANC4+.

CONCLUSION

The proportion of women reporting ANC4+ and of key ANC interventions in Malawi have increased significantly since 2004. However, we found that most women did not access the recommended number of ANC visits in Malawi, prior to the 2016 WHO policy change which may mean that women are less likely to undertake the 2016 WHO recommendation of 8 contacts per pregnancy. Additionally, our results highlighted significant variation in coverage according to key socio-demographic variables which should be considered when devising national strategies to ensure that all women access the appropriate frequency of ANC visits during their pregnancy.

Maternal near-miss and mortality in a teaching hospital in Tigray region, Northern Ethiopia

Objective:

This study seeks to examine the prevalence of maternal morbidities and deaths in Ayder Comprehensive Specialized Hospital from 1 July 2018 to 30 June 2019.

Methods:

This was a cross-sectional study. Total purposive sampling method was employed to collect data prospectively using modified World Health Organization criteria for baseline assessment of maternal near-miss and mortality. Pregnant women or those who are within 42 days postpartum/any form of pregnancy termination that satisfy the inclusion criteria were enrolled.

Results:

A total of 691 mothers were recorded as having severe maternal complications. Out of these, 170 women developed severe maternal outcome, ending with 146 maternal near-miss cases and 24 maternal deaths. The maternal near-miss ratio and maternal mortality ratio were 28.5 per 1000 live births and 469.1 per 100,000 live births, respectively. The overall mortality index was 14%. The top underlying causes of severe maternal complications were the infamous triads of preeclampsia (n = 303, 43.8%), obstetric hemorrhage (n = 166, 24.0%) and sepsis (n = 130, 18.8%). About 62.5% of mothers who died were not admitted to intensive care unit.

Conclusion:

This study found that the infamous triads of preeclampsia, obstetric hemorrhage and sepsis persist as the commonest causes of severe maternal complications in the study area. A significant number of women with severe maternal outcome were not admitted to intensive care unit. It also highlights that the severe maternal complications, severe maternal outcome, maternal near-miss ratio and mortality index in the study area are disproportionately higher than the global average. These staggering numbers call for a system re-thinking at multiple junctures.

Determinants of postnatal care service utilization among mothers of Mangochi district, Malawi: a community-based cross-sectional study

Background

Postnatal care (PNC) service is a neglected yet an essential service that can reduce maternal, neonatal and infant morbidity and mortality rates in low and middle-income countries. In Malawi, maternal and infant mortality rates remain high despite numerous efforts by the government and its partners to improve maternal health service coverage across the country. This study examined the determinants of PNC utilization among mothers in Mangochi District, Malawi.

Methods

A community based cross-sectional study was conducted among 600 mothers who gave birth in the past 2 years preceding January 1–31; 2016. A multistage sampling technique was employed to select respondents from nine randomly selected villages in Mangochi district. A transcribed semi-structured questionnaire was pre-tested, modified and used to collect data on socio-demographic characteristics and maternal related factors. Data was coded in EpiData version 3.1 and analysed in Stata version 12. A multivariable logistic regression adjusted for confounding factors was used to identify predictors of PNC utilization using odds ratio with 95% confidence interval and p-value of 0.05.

Results

The study revealed that the prevalence of PNC service utilization was 84.8%. Mother’s and partner’s secondary education level and above (AOR = 2.42, CI: 1.97–6.04; AOR = 1.45, CI: 1.25–2.49), partner’s occupation in civil service and business (AOR = 3.17, CI: 1.25, 8.01; AOR =3.39, CI:1.40–8.18), household income of at least MK50, 000 (AOR = 14.41, CI: 5.90–35.16), joint decision making (AOR = 2.27, CI: 1.13, 4.57), knowledge of the available PNC services (AOR = 4.06, CI: 2.22–7.41), knowledge of at least one postpartum danger sign (AOR = 4.00, CI: 2.09, 7.50), health facility delivery of last pregnancy (AOR = 6.88, CI: 3.35, 14.14) positively associated with PNC service utilization.

Conclusion

The rate of PNC service utilization among mothers was 85%. The uptake of PNC services among mothers was mainly influenced by mother and partner education level, occupation status of the partner, household income, decision making power, knowledge of available PNC services, knowledge of at least one postpartum danger signs, and place of delivery. Therefore, PNC awareness campaigns, training and economic empowerment programs targeting mothers who delivered at home with primary education background and low economic status are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04061-4.

Direct maternal deaths attributable to HIV in the era of antiretroviral therapy: evidence from three population-based HIV cohorts with verbal autopsy

OBJECTIVE

To assess whether HIV is associated with an increased risk of mortality from direct maternal complications.

DESIGN

Population-based cohort study using data from three demographic surveillance sites in Eastern and Southern Africa.

METHODS

We use verbal autopsy data, with cause of death assigned using the InSilicoVA algorithm, to describe the association between HIV and direct maternal deaths amongst women aged 20-49 years. We report direct maternal mortality rates by HIV status, and crude and adjusted rate ratios comparing HIV-infected and uninfected women, by study site and by ART availability. We pool the study-specific rate ratios using random-effects meta-analysis.

RESULTS

There was strong evidence that HIV increased the rate of direct maternal mortality across all the study sites in the period ART was widely available, with the rate ratios varying from 4.5 in Karonga, Malawi [95% confidence interval (CI) 1.6-12.6] to 5.2 in Kisesa, Tanzania (95% CI 1.7-16.1) and 5.9 in uMkhanyakude, South Africa (95% CI 2.3-15.2) after adjusting for sociodemographic confounders. Combining these adjusted results across the study sites, we estimated that HIV-infected women have 5.2 times the rate of direct maternal mortality compared with HIV-uninfected women (95% CI 2.9-9.5).

CONCLUSION

HIV-infected women face higher rates of mortality from direct maternal causes, which suggests that we need to improve access to quality maternity care for these women. These findings also have implications for the surveillance of HIV/AIDS-related mortality, as not all excess mortality attributable to HIV will be explicitly attributed to HIV/AIDS on the basis of a verbal autopsy interview.

Predictors of Utilisation of Skilled Maternal Healthcare in Lilongwe District, Malawi

BACKGROUND

Despite numerous efforts to improve maternal and child health in Malawi, maternal and newborn mortality rates remain very high, with the country having one of the highest maternal mortality ratios globally. The aim of this study was to identify which individual factors best predict utilisation of skilled maternal healthcare in a sample of women residing in Lilongwe district of Malawi. Identifying which of these factors play a significant role in determining utilisation of skilled maternal healthcare is required to inform policies and programming in the interest of achieving increased utilisation of skilled maternal healthcare in Malawi.

METHODS

This study used secondary data from the Woman's Questionnaire of the 2010 Malawi Demographic and Health Survey (MDHS). Data was analysed from 1126 women aged between 15 and 49 living in Lilongwe. Multivariate logistic regression was conducted to determine significant predictors of maternal healthcare utilisation.

RESULTS

Women's residence (P=.006), education (P=.004), and wealth (P=.018) were significant predictors of utilisation of maternal healthcare provided by a skilled attendant. Urban women were less likely (odds ratio [OR] = 0.47, P=.006, 95% CI = 0.28-0.81) to utilise a continuum of maternal healthcare from a skilled health attendant compared to rural women. Similarly, women with less education (OR = 0.32, P=.001, 95% CI = 0.16-0.64), and poor women (OR = 0.50, P=.04, 95% CI = 0.26-0.97) were less likely to use a continuum of maternal healthcare from a skilled health attendant.

CONCLUSION

Policies and programmes should aim to increase utilisation of skilled maternal healthcare for women with less education and low-income status. Specifically, emphasis should be placed on promoting education and economic empowerment initiatives, and creating awareness about use of maternal healthcare services among girls, women and their respective communities.

Maternal and perinatal death surveillance and response in Ethiopia: Achievements, challenges and prospects

Background

Maternal and Perinatal Death Surveillance and Response (MPDSR) was a pilot program introduced in Tigray, Ethiopia to monitor maternal and perinatal death. However; its implementation and operation is not evaluated yet. Therefore, this study aimed to assess the implementation and operational status and determinants of MPDSR using a programmatic data and stakeholders involved in the program.

Methods

Institutional based cross-sectional study was applied in public health facilities (75 health posts, 50 health centers and 16 hospitals) using both qualitative and quantitative methods. Data were entered in to Epi-info and then transferred to SPSS version 21 for analysis. All variables with a p-value of ≤ 0.25 in the bivariate analysis were included in to multivariable logistic regression model to identify the independent predictors. For the qualitative part, manual thematic content analysis was done following data familiarization (reading and re-reading of the transcripts).

Results

In this study, only 34 (45.3%) of health posts were practicing early identification and notification of maternal/perinatal death. Furthermore, only 36 (54.5%) and 35(53%) of health facilities were practiced good quality of death review and took proper action respectively following maternal/perinatal deaths. Availability of three to four number of Health Extension Workers (HEWs) (Adjusted Odds Ratio (AOR) = 6.09, 95%CI (Confidence Interval): 1.51–24.49), availability of timely Public Health Emergency Management (PHEM) reports (AOR = 4.39, 95%CI: 1.08–17.80) and participation of steering committee’s in death response (AOR = 9.19, 95%CI: 1.31–64.34) were the predictors of early identification and notification of maternal and perinatal death among health posts. Availability of trained nurse (AOR = 3.75, 95%CI: 1.08–12.99) and health facility’s head work experience (AOR = 3.70, 95%CI: 1.04–13.22) were also the predictors of quality of death review among health facilities. Furthermore; availability of at least one cluster review meeting (AOR = 4.87, 95%CI: 1.30–18.26) and uninterrupted pregnant mothers registration (AOR = 6.85, 95%CI: 1.22–38.54) were associated with proper response implementation to maternal and perinatal death. Qualitative findings highlighted that perinatal death report was so neglected. Community participation and intersectoral collaboration were among the facilitators for MPDSR implementation while limited human work force capacity and lack of maternity waiting homes were identified as some of the challenges for proper response implementation.

Conclusion

This study showed that the magnitude of: early death identification and notification, review and response implementation were low. Strengthening active surveillance with active community participation alongside with strengthening capacity building and recruitment of additional HEWs with special focus to improve the quality of health service could enhance the implementation of MPDSR in the region.

Effect of results-based financing on facility-based maternal mortality at birth: an interrupted time-series analysis with independent controls in Malawi

INTRODUCTION

The aim of this study was to assess the impact of a results-based financing (RBF) programme on the reduction of facility-based maternal mortality at birth. Malawi is a low-income country with high maternal mortality. The Results-Based Financing For Maternal and Newborn Health (RBF4MNH) Initiative was introduced at obstetric care facilities in four districts to improve quality and utilisation of maternal and newborn health services. The RBF4MNH Initiative was launched in April 2013 as a combined supply-side and demand-side RBF. Programme expansion occurred in October 2014.

METHODS

Controlled interrupted time series was used to estimate the effect of the RBF4MNH on reducing facility-based maternal mortality at birth. The study sample consisted of all obstetric care facilities in 4 intervention and 19 control districts, which constituted all non-urban mainland districts in Malawi. Data for obstetric care facilities were extracted from the Malawi Health Management Information System. Facility-based maternal mortality at birth was calculated as the number of maternal deaths per all deliveries at a facility in a given time period.

RESULTS

The RBF4MNH effectively reduced facility-based maternal mortality by 4.8 (-10.3 to 0.7, p<0.1) maternal deaths/100 000 facility-based deliveries/month after reaching full operational capacity in October 2014. Immediate effects (changes in level rather than slope) attributable to the RBF4MNH were not statistically significant.

CONCLUSION

This is the first study evaluating the effect of a combined supply-side and demand-side RBF on maternal mortality outcomes and demonstrates the positive role financial incentives can play in improving health outcomes. This study further shows that timeframes spanning several years might be necessary to fully evaluate the impact of health-financing programmes on health outcomes. Further research is needed to assess the extent to which the observed reduction in facility-based mortality at birth contributes to all-cause maternal mortality in the country.

Analyzing the etiology behind mortality associated with antepartum, intrapartum, and post-partum cases in a tertiary care teaching hospital of West Bengal

OBJECTIVE

The study was undertaken to understand the causes and circumstances of maternal deaths in West Bengal.

MATERIAL AND METHODS

One hundred ten maternal deaths were reported during the period December 2010 through June 2012 in the Maternity Ward of Medical College and Hospitals, West Bengal. These deaths were reviewed using a facility-based Maternal Death Review protocol. The number and percentages were calculated and binary logistic regression analysis was performed.

RESULTS

The majority of the deaths occurred in the 20-24 years’ age group, those with Hindu religion, in the first and second gravida, and the postpartum period. One third of mothers had cesarean sections. The majority (78.2%) of deaths were among referred cases. Eclampsia was the leading cause of maternal death (29.1%). Approximately half of the deceased women sought care after 10 hours of developing complications. More than one-third of maternal deaths were registered with type 1 delays.

CONCLUSION

Our study demonstrates that maternal deaths occurred among young women, referred cases, with cesarean sections and type 1 delays. We recommend that imparting basic skills and improving awareness to the community about the danger signs of pregnancy could be an effective measure to detect maternal complications at an earlier stage.

The Use of Manual Vacuum Aspiration in the Treatment of Incomplete Abortions: A Descriptive Study from Three Public Hospitals in Malawi

Malawi has a high maternal mortality rate, of which unsafe abortion is a major cause. About 140,000 induced abortions are estimated every year, despite there being a restrictive abortion law in place. This leads to complications, such as incomplete abortions, which need to be treated to avoid further harm. Although manual vacuum aspiration (MVA) is a safe and cheap method of evacuating the uterus, the most commonly used method in Malawi is curettage. Medical treatment is used sparingly in the country, and the Ministry of Health has been trying to increase the use of MVA. The aim of this study was to investigate the treatment of incomplete abortions in three public hospitals in Southern Malawi during a three-year period. All medical files from the female/gynecological wards from 2013 to 2015 were reviewed. In total, information on obstetric history, demographics, and treatment were collected from 7270 women who had been treated for incomplete abortions. The overall use of MVA at the three hospitals during the study period was 11.4% (95% CI, 10.7-12.1). However, there was a major increase in MVA application at one District Hospital. Why there was only one successful hospital in this study is unclear, but may be due to more training and dedicated leadership at this particular hospital. Either way, the use of MVA in the treatment of incomplete abortions continues to be low in Malawi, despite recommendations from the World Health Organization (WHO) and the Malawi Ministry of Health.

Resource availability for the management of maternal sepsis in Malawi, other low-income countries, and lower-middle-income countries

OBJECTIVE

To assess the availability of key resources for the management of maternal sepsis and evaluate the feasibility of implementing the Surviving Sepsis Campaign (SSC) recommendations in Malawi and other low-resource settings.

METHODS

A cross-sectional study was conducted at health facilities in Malawi, other low-income countries, and lower-middle-income countries during January-March 2016. English-speaking healthcare professionals (e.g. doctors, nurses, midwives, and administrators) completed a questionnaire/online survey to assess the availability of resources for the management of maternal sepsis.

RESULTS

Healthcare centers (n=23) and hospitals (n=13) in Malawi showed shortages in the resources for basic monitoring (always available in 5 [21.7%] and 10 [76.9%] facilities, respectively) and basic infrastructure (2 [8.7%] and 7 [53.8%], respectively). The availability of antibiotics varied between Malawian healthcare centers (9 [39.1%]), Malawian hospitals (8 [61.5%]), hospitals in other low-income countries (10/17 [58.8%]), and hospitals in lower-middle-income countries (39/41 [95.1%]). The percentage of SSC recommendations that could be implemented was 33.3% at hospitals in Malawi, 30.3% at hospitals in other low-income countries, and 68.2% at hospitals in lower-middle-income countries.

CONCLUSION

The implementation of existing SSC recommendations is unrealistic in low-income countries because of resource limitations. New maternal sepsis care bundles must be developed that are applicable to low-resource settings.

Perceptions of quality across the maternal care continuum in the context of a health financing intervention: Evidence from a mixed methods study in rural Malawi

BACKGROUND

In 2013, Malawi with its development partners introduced a Results-Based Financing for Maternal and Newborn Health (RBF4MNH) intervention to improve the quality of maternal and newborn health-care services. Financial incentives are awarded to health facilities conditional on their performance and to women for delivering in the health facility. We assessed the effect of the RBF4MNH on quality of care from women's perspectives.

METHODS

We used a mixed-method prospective sequential controlled pre- and post-test design. We conducted 3060 structured client exit interviews, 36 in-depth interviews and 29 focus group discussions (FGDs) with women and 24 in-depth interviews with health service providers between 2013 and 2015. We used difference-in-differences regression models to measure the effect of the RBF4MNH on experiences and perceived quality of care. We used qualitative data to explore the matter more in depth.

RESULTS

We did not observe a statistically significant effect of the intervention on women's perceptions of technical care, quality of amenities and interpersonal relations. However, in the qualitative interviews, most women reported improved health service provision as a result of the intervention. RBF4MNH increased the proportion of women reporting to have received medications/treatment during childbirth. Participants in interviews expressed that drugs, equipment and supplies were readily available due to the RBF4MNH. However, women also reported instances of neglect, disrespect and verbal abuse during the process of care. Providers attributed these negative instances to an increased workload resulting from an increased number of women seeking services at RBF4MNH facilities.

CONCLUSION

Our qualitative findings suggest improvements in the availability of drugs and supplies due to RBF4MNH. Despite the intervention, challenges in the provision of quality care persisted, especially with regard to interpersonal relations. RBF interventions may need to consider including indicators that specifically target the provision of respectful maternity care as a means to foster providers' positive attitudes towards women in labour. In parallel, governments should consider enhancing staff and infrastructural capacity before implementing RBF.

Maternal and neonatal outcomes among women with HIV infection and their infants in Malawi

OBJECTIVE

To describe maternal and neonatal morbidity and mortality among women with HIV infection and their infants.

METHODS

A secondary analysis was undertaken of data obtained in the BAN Study, a trial of postnatal antiretrovirals among pregnant women with HIV infection enrolled in 2004-2010. Mothers and infants had 13 scheduled visits through 48 weeks of follow-up. Serious maternal morbidity and mortality were examined at delivery (n=2791), from delivery to 6 weeks later (n=2369) and from 7 to 48 weeks (n=1980). Neonatal morbidity and mortality were examined (n=2685).

RESULTS

Of 2791 deliveries, 169 (6.1%) were by cesarean (153 emergency). Compared with women with vaginal delivery, those with cesarean delivery had lower prenatal HIV viral loads (P=0.016) and increased odds of pre-eclampsia/eclampsia (odds ratio [OR] 10.8, 95% CI 4.4-26.8). Women with cesarean delivery also had increased odds of serious infection with 14 days of delivery (OR 3.0, 95% CI 1.3-7.4) and severe anemia (grade 3 or 4) by 6 weeks (OR 6.7, 95% CI 2.3-19.1). Infants born by cesarean had increased odds of a low 5-minute Apgar score (OR 8.1, 95% CI 3.5-18.6) and admission to an intensive care unit (OR 5.4, 95% CI 3.7-7.8).

CONCLUSION

Odds of serious maternal and neonatal morbidity were higher after cesarean than vaginal delivery, despite lower maternal viral loads.

Community-linked maternal death review (CLMDR) to measure and prevent maternal mortality: a pilot study in rural Malawi

BACKGROUND

In Malawi, maternal mortality remains high. Existing maternal death reviews fail to adequately review most deaths, or capture those that occur outside the health system. We assessed the value of community involvement to improve capture and response to community maternal deaths.

METHODS

We designed and piloted a community-linked maternal death review (CLMDR) process in Mchinji District, Malawi, which partnered community and health facility stakeholders to identify and review maternal deaths and generate actions to prevent future deaths. The CLMDR process involved five stages: community verbal autopsy, community and facility review meetings, a public meeting and bimonthly reviews involving both community and facility representatives.

RESULTS

The CLMDR process was found to be comparable to a previous research-driven surveillance system at identifying deaths in Mchinji District (population 456,500 in 2008). 52 maternal deaths were identified between July 2011 and June 2012, 27 (52%) of which would not have been identified without community involvement. Based on district estimates of population (500,000) and crude birth rate (35 births per 1000 population), the maternal mortality ratio was around 300 maternal deaths per 100,000 live births. Of the 41 cases that started the CLMDR process, 28 (68%) completed all five stages. We found the CLMDR process to increase the quantity of information available and to involve a wider range of stakeholders in maternal death review (MDR). The process resulted in high rates of completion of community-planned actions (82%), and district hospital (67%) and health centre (65%) actions to prevent maternal deaths.

CONCLUSIONS

CLMDR is an important addition to the established forms of MDR. It shows potential as a maternal death surveillance system, and may be applicable to similar contexts with high maternal mortality.

Inequalities in maternal health care utilization in sub-Saharan African countries: a multiyear and multi-country analysis

To assess social inequalities in the use of antenatal care (ANC), facility based delivery (FBD), and modern contraception (MC) in two contrasting groups of countries in sub-Saharan Africa divided based on their progress towards maternal mortality reduction. Six countries were included in this study. Three countries (Ethiopia, Madagascar, and Uganda) had <350 MMR in 2010 with >4.5% average annual reduction rate while another three (Cameroon, Zambia, and Zimbabwe) had >550 MMR in 2010 with only <1.5% average annual reduction rate. All of these countries had at least three rounds of Demographic and Health Surveys (DHS) before 2012. We measured rate ratios and differences, as well as relative and absolute concentration indices in order to examine within-country geographical and wealth-based inequalities in the utilization of ANC, FBD, and MC. In the countries which have made sufficient progress (i.e. Ethiopia, Madagascar, and Uganda), ANC use increased by 8.7, 9.3 and 5.7 percent, respectively, while the utilization of FBD increased by 4.7, 0.7 and 20.2 percent, respectively, over the last decade. By contrast, utilization of these services either plateaued or decreased in countries which did not make progress towards reducing maternal mortality, with the exception of Cameroon. Utilization of MC increased in all six countries but remained very low, with a high of 40.5% in Zimbabwe and low of 16.1% in Cameroon as of 2011. In general, relative measures of inequalities were found to have declined overtime in countries making progress towards reducing maternal mortality. In countries with insufficient progress towards maternal mortality reduction, these indicators remained stagnant or increased. Absolute measures for geographical and wealth-based inequalities remained high invariably in all six countries. The increasing trend in the utilization of maternal care services was found to concur with a steady decline in maternal mortality. Relative inequality declined overtime in countries which made progress towards reducing maternal mortality.

Too few staff, too many patients: a qualitative study of the impact on obstetric care providers and on quality of care in Malawi

BACKGROUND

Shortages 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.

METHODS

A 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.

RESULTS

Eighty-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.

CONCLUSION

This 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.

Cost-effectiveness and affordability of community mobilisation through women's groups and quality improvement in health facilities (MaiKhanda trial) in Malawi

BACKGROUND

Understanding the cost-effectiveness and affordability of interventions to reduce maternal and newborn deaths is critical to persuading policymakers and donors to implement at scale. The effectiveness of community mobilisation through women's groups and health facility quality improvement, both aiming to reduce maternal and neonatal mortality, was assessed by a cluster randomised controlled trial conducted in rural Malawi in 2008-2010. In this paper, we calculate intervention cost-effectiveness and model the affordability of the interventions at scale.

METHODS

Bayesian methods are used to estimate the incremental cost-effectiveness of the community and facility interventions on their own (CI, FI), and together (FICI), compared to current practice in rural Malawi. Effects are estimated with Monte Carlo simulation using the combined full probability distributions of intervention effects on stillbirths, neonatal deaths and maternal deaths. Cost data was collected prospectively from a provider perspective using an ingredients approach and disaggregated at the intervention (not cluster or individual) level. Expected Incremental Benefit, Cost-effectiveness Acceptability Curves and Expected Value of Information (EVI) were calculated using a threshold of $780 per disability-adjusted life-year (DALY) averted, the per capita gross domestic product of Malawi in 2013 international $.

RESULTS

The incremental cost-effectiveness of CI, FI, and combined FICI was $79, $281, and $146 per DALY averted respectively, compared to current practice. FI is dominated by CI and FICI. Taking into account uncertainty, both CI and combined FICI are highly likely to be cost effective (probability 98% and 93%, EVI $210,423 and $598,177 respectively). Combined FICI is incrementally cost effective compared to either intervention individually (probability 60%, ICER $292, EIB $9,334,580 compared to CI). Future scenarios also found FICI to be the optimal decision. Scaling-up to the whole of Malawi, CI is of greatest value for money, potentially averting 13.0% of remaining annual DALYs from stillbirths, neonatal and maternal deaths for the equivalent of 6.8% of current annual expenditure on maternal and neonatal health in Malawi.

CONCLUSIONS

Community mobilisation through women's groups is a highly cost-effective and affordable strategy to reduce maternal and neonatal mortality in Malawi. Combining community mobilisation with health facility quality improvement is more effective, more costly, but also highly cost-effective and potentially affordable in this context.

The association between government healthcare spending and maternal mortality in the European Union, 1981-2010: a retrospective study

OBJECTIVE

To determine the association between reductions in government healthcare spending (GHS) on maternal mortality in 24 countries in the European Union (EU) over a 30-year period, 1981-2010.

DESIGN

Retrospective study.

SETTING AND POPULATION

Twenty-four EU countries (a total population of 419 million as of 2010).

METHODS

We used multivariate regression analysis, controlling for country-specific differences in healthcare, infrastructure, population size and demographic structure. GHS was measured as a percentage of gross domestic product. Five-year lag-time analyses were performed to estimate longer standing effects.

MAIN OUTCOME MEASURES

Maternal mortality rates.

RESULTS

An annual 1% decrease in GHS is associated with significant rises in maternal mortality rates [regression coefficient [R] 0.0177, P = 0.0021, 95% confidence interval [95% CI] 0.0065-0.0289]. For every annual 1% decrease in GHS, we estimate 89 excess maternal deaths in the EU, a 10.6% annual increase in maternal mortality. The impact on maternal mortality was sustained for up to 1 year (R 0.0150, P = 0.0034, 95% CI 0.0050-0.0250). The associations remained significant after accounting for economic, infrastructure and hospital resource controls, in addition to out-of-pocket expenditure, private health spending and total fertility rate. However, accounting for births attended by skilled staff removed the significance of these effects.

CONCLUSIONS

Reductions in GHS were significantly associated with increased maternal mortality rates, which may occur through changes in the provision of skilled health professionals attending births. Examples of reduced GHS such as the implementation of austerity measures and budgetary reductions are likely to worsen maternal mortality in the EU.

Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery.

METHODS

We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values.

FINDINGS

292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0·3% (-1·1 to 0·6) from 1990 to 2003, and -2·7% (-3·9 to -1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0·4% (0·2-0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1-1262·8) in South Sudan to 2·4 (1·6-3·6) in Iceland.

INTERPRETATION

Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa.

FUNDING

Bill & Melinda Gates Foundation.

The role of health systems and policy in producing behavior and social change to enhance child survival and development in low- and middle-income countries: an examination of the evidence

Evidence-based behavior change interventions addressing health systems must be identified and disseminated to improve child health outcomes. Studies of the efficacy of such interventions were identified from systematic searches of the published literature. Two hundred twenty-nine of the initially identified references were judged to be relevant and were further reviewed for the quality and strength of the evidence. Studies were eligible if an intervention addressed policy or health systems interventions, measured relevant behavioral or health outcomes (e.g., nutrition, childhood immunization, malaria prevention and treatment), used at least a moderate quality research design, and were implemented in low- or middle-income countries. Policy or systems interventions able to produce behavior change reviewed included media (e.g., mass media, social media), community mobilization, educational programs (for caregivers, communities, or providers), social marketing, opinion leadership, economic incentives (for both caregiver and provider), health systems strengthening/policy/legislation, and others. Recommendations for policy, practice, and research are given based on fairly strong data across the areas of health service delivery, health workforce, health financing, governance and leadership, and research.