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Malawi

Increasing Utilization of Maternal and Newborn Health Services

Hospital employees dancing at recognition ceremony for Chiradzulu hospital achieving national infection prevention standards.

Health Surveillance Assistant Home Visits Save Lives

“If it was not for the visiting HAS, I would be dead by now.” – Mrs. Chatha

Health Surveillance Assistants (HSAs) trained by the ACCESS Program are conducting home visits to improve maternal and newborn health (MNH) in Malawi. Through home visits during pregnancy and the first week postpartum, HSAs are providing health education and counseling to mothers, husbands and significant family members on MNH, screening for danger signs, and referring to health facilities when complications arise.

Agnes Chatha was one such woman identified by an ACCESS-trained HSA, Rose Kamphandira, when she was six months pregnant. During two antenatal home visits, Ms. Kamphandira provided Mr. Chatha with the first information on labor and delivery he had received, although it was the couple’s eighth pregnancy. When labor started, Mrs. Chatha hid it from her husband because of the cultural belief that a woman is weak who goes immediately to the health facility. However, Mr. Chatha noticed that his wife was in labor and remembered the advice of the HSA to obtain health care services quickly.

At the Ntosa Health Centre, a nurse-midwife identified that Mrs. Chatha’s pregnancy was a twin pregnancy. Thirty minutes after her husband escorted her to the health facility, the first baby was born. However, the nurse-midwife noted that the second twin was in transverse lie and that Mrs. Chatha would not be able to deliver normally. Immediately, she referred Mrs. Chatha to Nkhotakota District hospital where a caesarean section was performed and the second twin was delivered.

Today, both the mother and babies are alive and well thanks to the HSA program, quick, informed decisions by Mr. Chatha, an effective referral system, and the availability of comprehensive emergency obstetric care services.

In Malawi, ACCESS is improving the availability of and access to sustainable maternal and newborn health (MNH) services at the facility and community levels. Specifically, ACCESS is supporting Ministry of Health (MoH) and USAID efforts to increase utilization of these services and the practice of healthy behaviors to reduce maternal and neonatal morbidity and mortality.

Since October 2007, ACCESS has been working at the community, district and national levels to integrate focused antenatal care, basic emergency obstetric and newborn care (BEmONC) and postpartum care along the Household-to-Hospital Continuum of Care (HHCC). Program initiatives have formed an integral part of the MoH's roadmap for reducing maternal and neonatal morbidity and mortality, and ACCESS has achieved a number of important measurable results in Malawi:

With funding from the President’s Malaria Initiative (PMI) and in collaboration with the National Malaria Control Program (NMCP), ACCESS is strengthening Malawi’s national capacity to prevent malaria in pregnancy through the promotion of intermittent preventive treatment in pregnancy (IPTp) using directly observed therapy (DOT). Program staff worked with partners to: train nearly 700 service providers from all 28 districts in Malawi; and provide basic IPTp supplies for 100% coverage of all health facilities. ACCESS has also developed priority information, education and communication materials for facility-based IPTp, including gestational wheels and job aides, and distributed these materials to facilities throughout the country.
ACCESS has helped to strengthen Malawi's midwifery pre-service and in-service training curricula, and the knowledge and clinical training skills of midwifery tutors and preceptors who teach future generations of nurse-midwives. The MoH has adopted the ACCESS three-week competency-based model for BEmONC and postabortion care as the national training approach.
To increase community awareness of MNH, ACCESS is equipping Health Surveillance Assistants (HSAs) with the knowledge and skills to identify, counsel, refer and follow up pregnant and postnatal mothers. At the request of the MoH, ACCESS has trained HSAs from 12 health facilities in a nationally adopted community MNH package, which was developed in collaboration with UNICEF and Save the Children. Coupled with the community MNH home-visiting program, ACCESS also helped to develop a national community mobilization model with the aim of empowering and mobilizing communities to access MNH services and adopt healthy behaviors. The combined community MNH package and community mobilization initiative is being implemented as one model in three districts within 10 health center catchment areas.
To assist providers in caring for low birth weight newborns, ACCESS has helped to establish Kangaroo Mother Care (KMC) services at 10 health facilities and trained 15 KMC trainers and nearly 50 service providers in the provision of KMC services and essential newborn care. The Program will continue to provide supportive supervision to all trained providers to ensure that high-quality services are being provided and positive outcomes established.
ACCESS has supported the MoH to introduce and expand the Performance and Quality Improvement Initiative in Reproductive Health (PQI/RH). The initiative, which uses an approach known as Standards-Based Management and Recognition (SBM-R), has been scaled up to 16 district hospitals and all 4 central hospitals—all of which have shown a dramatic improvement in RH services. ACCESS also continues to support hospitals in their efforts to improve infection prevention (IP) through the process, resulting in three facilities achieving scores above 80% on IP standards and being nationally recognized by the MoH. The PQI initiative was partially funded by PEPFAR to increase the number of health care workers trained in injection safety by improving the performance of service providers and the quality of RH services. Remarkable improvements in the provision of high-quality labor and delivery services are beginning to have an impact on RH outcomes, including decreased neonatal and puerperal sepsis.
ACCESS is leading efforts to integrate prevention of mother-to-child transmission of HIV (PMTCT) into maternal, newborn and child health (MNCH) service provision in two pilot districts, Phalombe and Nkhotakota, which were identified by the partners in collaboration with the MoH for the initiation of the integration activities. ACCESS successfully developed and integrated PMTCT standards into existing facility-based reproductive health standards and assisted with refining two training packages—updating PMTCT content in the BEmONC training package used to train providers, and updating the PMTCT content in the existing community MNH training package. Using the two integrated training packages, ACCESS has trained 19 providers, 10 tutors and 8 preceptors in the two districts. In conjunction with several other partners (including John Snow Inc.’s BASICS program, Management Sciences for Health, and Population Services International), ACCESS is also developing an evidence-based global learning resource package which will include policy and operational program guidance, tools, and job aides for PMTCT-MNCH integration.