Healthcare Services for Pregnant Women in Chilaweni, Rural Malawi Results from A Cross Sectional Questionnaire Survey Presenting authors : Freya Yoward, Miranda Geddes-Barton Additional authors: Katy Kuhrt, Katia Florman, Danielle Alexander, George Ryan, Gavin Stead

Objectives Background Healthcare structure in Malawi and AMECA Methods Results Key Findings Strengths and Limitations Discussion

This is Malawi! Landlocked country south east africa Economy relies on Agriculture – maize, tea, tobacco Under developed – 166? Out of 180 on Human development index???

Healthcare Statistics Malawi Population: 17,000,000 200 Physicians 15 Surgeons UK Population: 65,000,000 240,000 Physicians 20,000 Surgeons 3,000 x Health Workload https://data.unicef.org/topic/maternal-health/maternal-mortality/ Maternal Death Rate 634/100,000 (2015) Stillbirth Rate Neonatal Death Rate 21/1000 (2015) Illegal to give birth in villages without presence of a trained health professional Contraception free if covered by local service level agreement

Healthcare Structure 3 teir healthcare system. Government funded - Malawi Ministry of Healthcare in Malawi provide free basic service as well as the christian Hospital Association of Malawi. Replies hugely on NGO support and charities such as AMECA Data from the Malawi Health sector strategic plan 2011-2016 ?accuracy Primary care consists of healthcare clinics in the villages – not staffed by doctors and 60% shortage of nurses in the rural areas. Mostly HSA’s who have 10 weeks basic training and are responsible for multiple tasks including: immunisation, dispensing of essential drugs, and, more recently, HIV testing and counselling. Secondary care are the district and mission hospitals – approximately one in each district of Malawi 28 districts and 23 hospitals Most laboratory, imaging, and testing facilities are often only available at the major District Hospitals. Malawi has very few doctors (only one for every 88,300 people in Malawi), so hospitals are staffed by Clinical Officers (trained for a minimum of four years, and who are very experienced practitioners), and Medical Assistants (trained for a minimum of three years.) The Clinical Officers and Medical Assistants are usually in charge of their workplace, and manage any in-patient care. They diagnose, treat, and prescribe. All clinics and hospitals will have a team of nurses (trained in midwifery and nursing), who also diagnose and prescribe. Health Surveillance Assistants (HSAs) have a diverse role, including the management of the community health needs, assisting in clinics, collating all records, and performing VCT (Voluntary Counselling and Testing for HIV/AIDS.) Tertiary care No emergency systems in place - no free transport/ambulance service reply on the patient presenting to the facility https://www.researchgate.net/figure/262072786_fig1_Figure-1-Maternal-Healthcare-Delivery-System-in-Malawi http://www.ianphi.org/membercountries/memberinformation/malawi.html

AMECA Healthcare Clinic AMECA Charity : Alex’s Medical & Educational Clinic in Africa The Chilaweni area is comprised of ten surrounding villages; even if emergency cases could be transported the 15 Km by road to the nearest health facility, unfortunately this lies outside of the catchment area for free service level agreements. Currently the communities do not even receive visits from mobile clinics or any health visitors. AMECA, alongside the government, are currently determining the most beneficial services to offer. We conducted a survey to explore current access to, and need for further provision of antenatal and womens’ health services for pregnant women in these rural communities. 11 remote villages – 16,200 people Sustainable; memorandum of understanding taken with the Malawi Ministry of Health

Methods Meeting with District Health Officer in Blantyre and visited existing Health Clinic Designed a questionnaire to collect qualitative and quantitative data Employed field officers for translation Met with the Chiefs 2 weeks collecting data Met with DOH Met chiefs of local villages and local field officers from Josua charity for translation Visited …. Villages and chiefs rounded up pregnant women Questionnaire With support from the Ministry of Health in Malawi, village chiefs, and AMECA, we conducted interviews in 11 rural villages in Chilaweni, Malawi.

Data collection Using a specifically designed questionnaire both qualitative and quantitative data was collected from 60 pregnant women; age range 14-45, response rate 100% (60/60).

Results (n=60 pregnant women) 60 pregnant women; age range 14-45, average age 24, response rate 100% (60/60) 25% of women hadn’t seen a healthcare worker in this pregnancy The remainder had seen a healthcare worker at the local healthcare clinic 6-10km away

Results (n=60 pregnant women) Most (87%) women planned to give birth in a healthcare center and the remaining 13% in hospital 45 women had given birth previously 16% of these women had been unable to reach a healthcare centre and said that they had delivered en route A fifth (22%) of these 45 women had previously experienced the death of a child All women reported that their existing children had been vaccinated

Results (n=60 pregnant women) 92% of women had left school before completing secondary education 37% due to pregnancy 53% for financial reasons 2% ‘other’ On average women interviewed had 6 siblings On average women ideally wanted 4 children (48/60) 12 women hadn’t decided ideal number of children 66% reported their current pregnancy was unplanned 62% reported using DepoProvera contraception

Key Findings Nearest healthcare center 6-10km away All women planned to give birth in healthcare centre or hospital A fifth reported previously giving birth en route to health center 66% unplanned pregnancies 62% using DepoProvera contraception 92% of women had left school before completing secondary education - 37% due to pregnancy The majority of women wanted less children than the number of siblings they had Ease of completing the project due to immense help given from the chiefs/villagers/DHO office

Strengths and Limitations 100% response rate Hard to reach population Crucial data for planning of service provision Limitations ? % of pregnant women reached Inaccuracies due to self reporting of data legal issues (illegal to give birth outside of hospital/healthcare center) Inaccuracies due to use of translators

Discussion Birthing facilities Maternal death rate 5.1/1000 births A fifth reported giving birth en route to clinic (6-10km walk) No women reported planning to give birth at home with traditional birth attendant Contraception 66% unplanned pregnancies but 62% reported using DepoProvera contraception ?difficulty attending health clinic ?Unaware contraception only lasted 3 months ?Lack of resources at the clinic Education Improved family planning ?Further educational level for women Provision of general medical services

Conclusion http://ameca.org.uk/ Data along with the passion and enthusiasm felt amongst village chiefs and villagers strongly supports the need for maternal health service provision at the AMECA clinic £150,000 thought to be needed to build sustainable maternity unit. Fundraising in progress! http://ameca.org.uk/

References 1. Kumbani LC. Maternal and newborn health in Malawi. Malawi Med J. 2007;19(1):32-33. http://www.ncbi.nlm.nih.gov/pubmed/23878631. Accessed March 2, 2017. 2. Malawi African Region Maternal and Perinatal Health Profile Department of Maternal, Newborn, Child and Adolescent Health (MCA/WHO) Demographics and Information System Health status indicators -Maternal and Perinatal mortality