Malawi Program Making GAINs in Maternal Health
Clinicians at Partners In Health-supported facilities around the world provided more than 30,000 safe, facility-based childbirths in 2017, according to year-end estimates—and thanks to a growing collaboration, more and more of those safe childbirths are happening in a rural district in Malawi.
Nurse midwife Maria Openshaw said Global Action to Improve Nurse Midwifery & Care, or GAIN, is a mentoring program designed to improve maternal and child health care in vulnerable populations, by training and empowering nurses and midwives.
The GAIN work that Openshaw is helping lead in Neno District, Malawi, is PIH’s first program in the country focused on building clinical capacity for nurses and midwives, who provide the majority of care for women in labor. The program is a partnership between the Center for Global Health at the University of California-San Francisco’s School of Nursing; Abwenzi Pa Za Umoyo, as PIH is known in Malawi; and Malawi’s Ministry of Health.
“We’re really excited about this effort,” PIH Director of Nursing Cory McMahon said. “We’re integrating leadership, management and quality improvement with pediatric and maternity skills, for a more comprehensive approach to improving clinical practices and systems.”
The need is dire. Malawi had 634 maternal deaths per 100,000 live births in 2015, according to the World Health Organization, which ranked Malawi’s rate as the 13th-worst in the world. The WHO ranked the U.S. as the 138th-deadliest country to have a baby that year, for comparison, with 14 deaths per 100,000 live births.
Openshaw said maternal deaths account for 16 percent of all deaths of women in Malawi, and infant mortality stands at 42 deaths per 1,000 live births.
On the brighter side, Openshaw said 91 percent of pregnant women in Malawi are now delivering their babies in a health facility—much safer than delivering at home—and 95 percent of new mothers are getting prenatal care.
PIH supports two hospitals in Neno District, along with 12 district health centers. Openshaw said midwives attend the majority of deliveries at all those facilities.
“Midwives are kind of the drivers of the maternity system in Malawi,” Openshaw said.
But understaffing is a constant concern, she added. Midwives in Malawi have numerous additional responsibilities—everything from stocking medicines to cleaning delivery wards—that wouldn’t be part of their jobs if they were in the U.S.
“It’s a very broad job description,” Openshaw said.
McMahon said the GAIN program focuses not only on training, but also on applying lessons in real patient settings—meaning, at bedsides—and addressing systemic gaps that affect clinical care. PIH and the University of California-San Francisco developed the program through extensive focus groups and local assessments, engaging clinical leaders and nurses with PIH and the Ministry of Health to specifically fit the context of health care in Malawi.
Fifteen nurse midwives are in the first GAIN cohort in Neno District. Another cohort will start the program in March.
Openshaw said she and Esnath Kapito, a Malawian nurse who also teaches at a nursing school, do side-by-side clinical mentoring with the 15 midwives, along with clinical case reviews, birth monitoring, and more.
The program’s impacts are extending well beyond Malawi.
Viola Karanja, director of nursing for PIH in Liberia, traveled to Malawi in September to join a training on maternity care, for example. McMahon said Karanja already is implementing key concepts from the training in maternal health initiatives she’s leading in Liberia.
One of those concepts is Kangaroo Mother Care, which involves immediate skin-to-skin contact between mothers and newborns. Kangaroo care helps regulate newborns’ temperature and vital signs, and supports breast-feeding. The practice is widely used in Malawi for preterm babies. Full-term babies, however, are routinely separated from their mothers and swaddled immediately after birth, which can lead to cold stress and even hypothermia.
In the September training, GAIN mentors discussed the benefits of kangaroo care for all newborns, not just those born early. Openshaw said she soon saw results.
“When I came to the Neno District Hospital Labor Ward in the weeks after the training, I saw our midwife trainees already starting to use skin-to-skin for prevention and treatment of hypothermia in term babies,” Openshaw said. “In turn, Kangaroo Mother Care is not routinely used in Liberia, so Viola Karanja was able to learn the technique from our Malawian colleagues, and now has plans to institute Kangaroo Mother Care in Liberia.”
Dr. Emily Wroe, PIH’s chief medical officer in Malawi, said GAIN is having broad impacts on how nurses are trained in Neno District. Training models across the country traditionally have focused on classroom time, she said, with little follow-up in clinical care. She said the GAIN program’s hands-on support and mentorship is creating a “special and unique” program.
“We accompany patients,” Wroe said, citing a fundamental PIH ethic. “This is like accompanying staff.”