Research Interests:
Background: Maternal death auditing is widely used to ascertain in-depth information on the clinical, social, cultural, and other contributing factors that result in a maternal death. As the 2015 deadline for Millennium Development Goal 5... more
Background: Maternal death auditing is widely used to ascertain in-depth information on the clinical, social,
cultural, and other contributing factors that result in a maternal death. As the 2015 deadline for Millennium
Development Goal 5 of reducing maternal mortality by three quarters between 1990 and 2015 draws near, this
information becomes even more critical for informing intensified maternal mortality reduction strategies. Studies
using maternal death audit methodologies are widely available, but few discuss the challenges in their implementation.
The purpose of this paper is to discuss the methodological issues that arose while conducting maternal death review
research in Lilongwe, Malawi.
Methods: Critical reflections were based on a recently conducted maternal mortality study in Lilongwe, Malawi in
which a facility-based maternal death review approach was used. The five-step maternal mortality surveillance cycle
provided the framework for discussion. The steps included: 1) identification of cases, 2) data collection, 3) data analysis,
4) recommendations, and 5) evaluation.
Results: Challenges experienced were related to the first three steps of the surveillance cycle. They included: 1)
identification of cases: conflicting maternal death numbers, and missing medical charts, 2) data collection: poor record
keeping, poor quality of documentation, difficulties in identifying and locating appropriate healthcare workers for
interviews, the potential introduction of bias through the use of an interpreter, and difficulties with locating family and
community members and recall bias; and 3) data analysis: determining the causes of death and clinical diagnoses.
Conclusion: Conducting facility-based maternal death reviews for the purpose of research has several challenges. This
paper illustrated that performing such an activity, particularly the data collection phase, was not as easy as conveyed in
international guidelines and in published studies. However, these challenges are not insurmountable. If they are
anticipated and proper steps are taken in advance, they can be avoided or their effects minimized.
Keywords: Maternal death review, Maternal death audit, Maternal mortality, Surveillance cycle, Malawi
cultural, and other contributing factors that result in a maternal death. As the 2015 deadline for Millennium
Development Goal 5 of reducing maternal mortality by three quarters between 1990 and 2015 draws near, this
information becomes even more critical for informing intensified maternal mortality reduction strategies. Studies
using maternal death audit methodologies are widely available, but few discuss the challenges in their implementation.
The purpose of this paper is to discuss the methodological issues that arose while conducting maternal death review
research in Lilongwe, Malawi.
Methods: Critical reflections were based on a recently conducted maternal mortality study in Lilongwe, Malawi in
which a facility-based maternal death review approach was used. The five-step maternal mortality surveillance cycle
provided the framework for discussion. The steps included: 1) identification of cases, 2) data collection, 3) data analysis,
4) recommendations, and 5) evaluation.
Results: Challenges experienced were related to the first three steps of the surveillance cycle. They included: 1)
identification of cases: conflicting maternal death numbers, and missing medical charts, 2) data collection: poor record
keeping, poor quality of documentation, difficulties in identifying and locating appropriate healthcare workers for
interviews, the potential introduction of bias through the use of an interpreter, and difficulties with locating family and
community members and recall bias; and 3) data analysis: determining the causes of death and clinical diagnoses.
Conclusion: Conducting facility-based maternal death reviews for the purpose of research has several challenges. This
paper illustrated that performing such an activity, particularly the data collection phase, was not as easy as conveyed in
international guidelines and in published studies. However, these challenges are not insurmountable. If they are
anticipated and proper steps are taken in advance, they can be avoided or their effects minimized.
Keywords: Maternal death review, Maternal death audit, Maternal mortality, Surveillance cycle, Malawi
Research Interests:
Background: Burnout among maternal healthcare workers in sub-Saharan Africa may have a negative effect on services provided and efforts to mitigate high maternal mortality rates. In Malawi, research on burnout is limited and no empirical... more
Background: Burnout among maternal healthcare workers in sub-Saharan Africa may have a negative effect on
services provided and efforts to mitigate high maternal mortality rates. In Malawi, research on burnout is limited
and no empirical research has been conducted specifically among maternal health staff. Therefore, the aims of the
study were to examine the prevalence and degree of burnout reported by healthcare workers who provide
antenatal, intrapartum, and postnatal services in a district referral hospital in Malawi; and, to explore factors that
may influence the level of burnout healthcare workers experience.
Methods: In the current cross-sectional study, levels of burnout among staff working in obstetrics and
gynaecology at a referral hospital in Malawi were examined, in addition to individual and job characteristics that
may be associated with burnout.
Results: In terms of the three dimensions of burnout, of the 101 participants, nearly three quarters (72%) reported
emotional exhaustion, over one third (43%) reported depersonalization while almost three quarters (74%)
experienced reduced personal accomplishment.
Conclusions: Based on these findings, burnout appears to be common among participating maternal health staff
and they experienced more burnout than their colleagues working in other medical settings and countries. Further
research is needed to identify factors specific to Malawi that contribute to burnout in order to inform the
development of prevention and treatment within the maternal health setting.
services provided and efforts to mitigate high maternal mortality rates. In Malawi, research on burnout is limited
and no empirical research has been conducted specifically among maternal health staff. Therefore, the aims of the
study were to examine the prevalence and degree of burnout reported by healthcare workers who provide
antenatal, intrapartum, and postnatal services in a district referral hospital in Malawi; and, to explore factors that
may influence the level of burnout healthcare workers experience.
Methods: In the current cross-sectional study, levels of burnout among staff working in obstetrics and
gynaecology at a referral hospital in Malawi were examined, in addition to individual and job characteristics that
may be associated with burnout.
Results: In terms of the three dimensions of burnout, of the 101 participants, nearly three quarters (72%) reported
emotional exhaustion, over one third (43%) reported depersonalization while almost three quarters (74%)
experienced reduced personal accomplishment.
Conclusions: Based on these findings, burnout appears to be common among participating maternal health staff
and they experienced more burnout than their colleagues working in other medical settings and countries. Further
research is needed to identify factors specific to Malawi that contribute to burnout in order to inform the
development of prevention and treatment within the maternal health setting.
Research Interests:
In Malawi, it has been observed that some women are dying even when they reach a comprehensive emergency obstetric care facility where the quality is expected to be high and the maternal mortality low. The objective of this study was to... more
In Malawi, it has been observed that some women are dying even when they reach a comprehensive emergency obstetric care facility where the quality is expected to be high and the maternal mortality low. The objective of this study was to describe shortcomings within the maternal healthcare delivery system that might have contributed to maternal deaths in the district of Lilongwe. Retrospectively, 14 maternal deaths that occurred between January 1, 2011 and June 30, 2011 were reviewed. Interviews were conducted with healthcare workers who provided care to the deceased women. Triangulated data from the respective medical charts and interview transcripts were analyzed using a directed approach to content analysis. Excerpts were categorized according to three main components of the maternal healthcare delivery system: skill birth attendant (SBA), enabling environment (EE) and referral system (RS). Most of the shortcomings identified were grouped under SBA. They included inadequate clinical workups and monitoring, missed and incorrect diagnoses, delayed or incorrect treatment, delayed referrals and transfers, patients not being stabilized before being referred and outright negligence. The SBA component should be investigated further. Interventions based on evidence from these investigations may have a positive impact on maternal mortality
Research Interests:
Background: In Malawi maternal mortality continues to be a major public health challenge. Going beyond the numbers to form a more complete view of why women die is critical to improving access to and quality of emergency obstetric care.... more
Background: In Malawi maternal mortality continues to be a major public health challenge. Going beyond the numbers to
form a more complete view of why women die is critical to improving access to and quality of emergency obstetric care.
The objective of the current study was to identify the socio-cultural and facility-based factors that contributed to maternal
deaths in the district of Lilongwe, Malawi.
Methods: Retrospectively, 32 maternal death cases that occurred between January 1, 2011 and June 30, 2011 were
reviewed independently by two gynecologists/obstetricians. Interviews were conducted with healthcare staff, family
members, neighbors, and traditional birth attendants. Guided by the grounded theory approach, interview transcripts were
analyzed manually and continuously. Emerging, recurring themes were identified and excerpts from the transcripts were
categorized according to the Three Delays Model (3Ds).
Results: Sixteen deaths were due to direct obstetric complications, sepsis and hemorrhage being most common. Sixteen deaths were due to indirect causes with the main cause being anemia, followed by HIV and heart disease. Lack of
recognizing signs, symptoms, and severity of the situation; using traditional Birth Attendant services; low female literacy
level; delayed access to transport; hardship of long distance and physical terrain; delayed prompt quality emergency
obstetric care; and delayed care while at the hospital due to patient refusal or concealment were observed. According to the
3Ds, the most common delay observed was in receiving treatment upon reaching the facility due to referral delays, missed diagnoses, lack of blood, lack of drugs, or inadequate care, and severe mismanagement.
form a more complete view of why women die is critical to improving access to and quality of emergency obstetric care.
The objective of the current study was to identify the socio-cultural and facility-based factors that contributed to maternal
deaths in the district of Lilongwe, Malawi.
Methods: Retrospectively, 32 maternal death cases that occurred between January 1, 2011 and June 30, 2011 were
reviewed independently by two gynecologists/obstetricians. Interviews were conducted with healthcare staff, family
members, neighbors, and traditional birth attendants. Guided by the grounded theory approach, interview transcripts were
analyzed manually and continuously. Emerging, recurring themes were identified and excerpts from the transcripts were
categorized according to the Three Delays Model (3Ds).
Results: Sixteen deaths were due to direct obstetric complications, sepsis and hemorrhage being most common. Sixteen deaths were due to indirect causes with the main cause being anemia, followed by HIV and heart disease. Lack of
recognizing signs, symptoms, and severity of the situation; using traditional Birth Attendant services; low female literacy
level; delayed access to transport; hardship of long distance and physical terrain; delayed prompt quality emergency
obstetric care; and delayed care while at the hospital due to patient refusal or concealment were observed. According to the
3Ds, the most common delay observed was in receiving treatment upon reaching the facility due to referral delays, missed diagnoses, lack of blood, lack of drugs, or inadequate care, and severe mismanagement.
Research Interests:
Background: When and how to wean breastfed infants exposed to HIV infection has provoked extensive debate, particularly in low-income countries where safe alternatives to breastfeeding are rarely available. Although there is global... more
Background: When and how to wean breastfed infants exposed to HIV infection has provoked extensive debate,
particularly in low-income countries where safe alternatives to breastfeeding are rarely available. Although there is
global consensus on optimal infant-feeding practices in the form of guidelines, practices are sub-optimal in much
of sub-Saharan Africa. Policy-makers and health workers face many challenges in adapting and implementing these guidelines.
Methods: This paper is based on in-depth interviews with five policy-makers and 11 providers of interventions to
prevent mother-to-child transmission (PMTCT) of HIV, participant observations during clinic sessions and site visits.
Results: The difficulties with adapting the global infant-feeding guidelines in Malawi have affected the provision of
services. There was a lack of consensus on HIV and infant-feeding at all levels and general confusion about the
2006 guidelines, particularly those recommending continued breastfeeding after six months if replacement feeding
is not acceptable, feasible, affordable, sustainable and safe. Health workers found it particularly difficult to advise
women to continue breastfeeding after six months. They worried that they would lose the trust of the PMTCT
clients and the population at large, and they feared that continued breastfeeding was unsafe. Optimal support for
HIV-infected women was noted in programmes where health workers were multi-skilled; coordinated their efforts
and had functional, multidisciplinary task forces and engaged communities. The recent 2009 recommendations are
the first to support antiretroviral (ARV) use by mothers or children during breastfeeding. Besides promoting
maternal health and providing protection against HIV infection in children, the new Rapid Advice has the potential
to resolve the difficulties and confusion experienced by health workers in Malawi.
Conclusions: The process of integrating new evidence into institutionalised actions takes time. The challenge of
keeping programmes, and especially health workers, up-to-standard is a dynamic process. Effective programmes
require more than basic resources. Along with up-to-date information, health workers need contextualized, easy-tofollow
guidelines in order to effectively provide services. They also require supportive supervision during the
processes of change. Policy-makers should ensure that consensus is carefully considered and that comprehensive
perspectives are incorporated when adapting the global guidelines.
particularly in low-income countries where safe alternatives to breastfeeding are rarely available. Although there is
global consensus on optimal infant-feeding practices in the form of guidelines, practices are sub-optimal in much
of sub-Saharan Africa. Policy-makers and health workers face many challenges in adapting and implementing these guidelines.
Methods: This paper is based on in-depth interviews with five policy-makers and 11 providers of interventions to
prevent mother-to-child transmission (PMTCT) of HIV, participant observations during clinic sessions and site visits.
Results: The difficulties with adapting the global infant-feeding guidelines in Malawi have affected the provision of
services. There was a lack of consensus on HIV and infant-feeding at all levels and general confusion about the
2006 guidelines, particularly those recommending continued breastfeeding after six months if replacement feeding
is not acceptable, feasible, affordable, sustainable and safe. Health workers found it particularly difficult to advise
women to continue breastfeeding after six months. They worried that they would lose the trust of the PMTCT
clients and the population at large, and they feared that continued breastfeeding was unsafe. Optimal support for
HIV-infected women was noted in programmes where health workers were multi-skilled; coordinated their efforts
and had functional, multidisciplinary task forces and engaged communities. The recent 2009 recommendations are
the first to support antiretroviral (ARV) use by mothers or children during breastfeeding. Besides promoting
maternal health and providing protection against HIV infection in children, the new Rapid Advice has the potential
to resolve the difficulties and confusion experienced by health workers in Malawi.
Conclusions: The process of integrating new evidence into institutionalised actions takes time. The challenge of
keeping programmes, and especially health workers, up-to-standard is a dynamic process. Effective programmes
require more than basic resources. Along with up-to-date information, health workers need contextualized, easy-tofollow
guidelines in order to effectively provide services. They also require supportive supervision during the
processes of change. Policy-makers should ensure that consensus is carefully considered and that comprehensive
perspectives are incorporated when adapting the global guidelines.
Research Interests:
HIV/AIDS continues to constitute a serious threat to the social and physical wellbeing of African mothers and their babies. In the hardest hit countries of sub-Saharan Africa, more than 60% of all new HIV infections are occurring in... more
HIV/AIDS continues to constitute a serious threat to the social and physical wellbeing of African mothers and their babies. In the hardest hit countries of sub-Saharan Africa, more than 60% of all new HIV infections are occurring in women, infants and young children. Mother-to-child transmission (MTCT) constitutes 90% of new HIV infections among infants and young children. Most of these infections can be prevented. However, the social stigma of HIV/AIDS insidiously continues to undermine the success of prevention programs.
Ironically, some attributes or characteristics of prevention of
mother-to-child transmission (PMTCT) programs may in fact serve as catalysts to the stigmatization process. This paper identifies and discusses six potential initiators: (1) Routine HIV testing, (2) Six months exclusive breastfeeding, (3) Incentives, (4) Home visits, (5) Location of PMTCT program, and (6) PMTCT terminology. In all these areas, there are practical strategies that may be applied to reduce the chances of being stigmatized. These strategies are introduced and discussed.
Ironically, some attributes or characteristics of prevention of
mother-to-child transmission (PMTCT) programs may in fact serve as catalysts to the stigmatization process. This paper identifies and discusses six potential initiators: (1) Routine HIV testing, (2) Six months exclusive breastfeeding, (3) Incentives, (4) Home visits, (5) Location of PMTCT program, and (6) PMTCT terminology. In all these areas, there are practical strategies that may be applied to reduce the chances of being stigmatized. These strategies are introduced and discussed.