Better hospital care and women’s groups reduced neonatal mortality in Malawi by a quarter

BMJ 2013; 346 doi: (Published 27 June 2013) Cite this as: BMJ 2013;346:f4127
  1. Anne Gulland
  1. 1London

The introduction in Malawi of a hospital quality improvement programme, combined with community action to encourage pregnant women to seek antenatal care earlier, has led to a 23% drop in neonatal mortality, a study has found.

The MaiKhanda project, led by the UK Health Foundation, was a five year programme aimed at improving maternal healthcare in three districts in Malawi covering a population of two million people.

An evaluation of the project found that the interventions reduced neonatal mortality from 34 to 27 deaths per 1000 live births between 2006 and 2011.1 The rate of reduction increased over time, so that in the last 15 months of the study neonatal mortality fell by 28% in total.

The study, which compared 14 576 births at baseline and 20 576 over the study period, found that most of the reduction in newborn mortality resulted from community action to encourage pregnant women to seek antenatal care earlier but that this was enhanced by efforts to improve quality at care facilities.

The paper looked at the effect of each intervention individually. Where just the hospital quality improvement programme had been implemented, neonatal mortality fell to 28.3 deaths per 1000 live births; and in areas where just the community mobilisation was implemented, it fell to 29.9 deaths per 1000 live births.

The programme was based on the “three delays” model, with the aim of reducing delays in seeking care, delays in identifying and reaching the appropriate medical facility, and delays in receiving quality routine and emergency maternal and neonatal care.

Community action was based on the establishment of women’s groups, designed to improve knowledge of maternal and neonatal health and encourage women to attend health facilities for antenatal and postnatal care and delivery. A report of the project by the Health Foundation said it was unlikely that “full dosage” was achieved, with a ratio of only one group for every 1200 women, against a target of one for every 500 women.2

The hospital quality improvement methods were based on similar programmes run in hospitals in high income countries. These included death reviews, neonatal resuscitation drills, and use of protocols for the prevention and management of postpartum haemorrhage, sepsis, and eclampsia.

Martin Msukwa, director of the MaiKhanda Trust, which is being funded by the Health Foundation until 2015 and has won funding from a South African charity, said that the twin track approach was important.

“It doesn’t make sense to mobilise the community and then when women get to the facility there are no services for them,” he said.

He added, “Right now in Malawi there’s a lot of political will to see a reduction in neonatal and maternal mortality and a lot of support from the president [Joyce Banda]. There’s a big push from the government on family planning, which would be the long term solution to neonatal and maternal mortality.”

While the programme was ongoing the Malawi government banned the use of traditional birthing attendants, and women were urged to deliver their babies at health facilities. The proportion of women who delivered at hospitals rose from 45% to 75%, but there was no accompanying increase in resources.

Stephen Thornton, chief executive of the Health Foundation, said that the project showed what could be achieved in a resource poor setting.

“This is a social and system intervention. There were no new cures, and no one thought up some brand new way of caring for women in pregnancy. Everything was a tried and tested intervention, and it was about bringing them all together and trying to ensure they were reliably implemented,” he said.

He added that the Malawian health ministry had already implemented some of the lessons learnt in the project nationally.


Cite this as: BMJ 2013;346:f4127


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