Background/Aims Research into midwifery decision making to date is limited and, where it exists, ... more Background/Aims Research into midwifery decision making to date is limited and, where it exists, theoretical understanding has focused on the cognitive aspects of the process. Understanding the real-life context in which midwives work and how this influences their decision making during labour is important for safer maternity care. This study aimed to explore the contextual factors that influence the decision making of midwives at secondary and tertiary level health facilities during the first stage of labour in the real context of practice. Methods Using a focused ethnographic methodology, data from nine midwives working in two hospital labour ward settings were collected from October 2013 to May 2014. A total of 27 participant observations of midwives supporting women in the first stage of labour, 26 semi-structured interviews with midwives, and a documentary analysis of maternal labour records were conducted. All data were analysed using theme and category formation. Results Four...
Background/Aims The partograph is a tool used to monitor events during labour and was recently mo... more Background/Aims The partograph is a tool used to monitor events during labour and was recently modified by the World Health Organization to improve intrapartum care. However, it is unknown how obstetric care providers in Malawi perceive this modified partograph. This study aimed to evaluate the perceived strengths and challenges regarding the World Health Organization's modified partograph design among obstetric care providers in Malawi. Methods For this qualitative study, data were collected from a sample of 34 obstetric care providers from two purposively-selected urban health facilities through in-depth interviews and focus group discussions. The data were subjected to thematic analysis, with the strengths and challenges of using the modified partograph designated as the two major themes. Results The participants reported that there were more challenges than strengths with utilisation of the modified partograph. Two subthemes emerged among the strengths: the partograph is com...
Background Sub-Saharan Africa has the world’s highest rates of maternal and perinatal mortality a... more Background Sub-Saharan Africa has the world’s highest rates of maternal and perinatal mortality and accounts for two-thirds of new HIV infections and 25% of preterm births. Antenatal care, as the entry point into the health system for many women, offers an opportunity to provide life-saving monitoring, health promotion, and health system linkages. Change is urgently needed, because potential benefits of antenatal care are not realized when pregnant women experience long wait times and short visits with inconsistent provisioning of essential services and minimal health promotion, especially for HIV prevention. This study answers WHO’s call for the rigorous study of group antenatal care as a transformative model that provides a positive pregnancy experience and improves outcomes. Methods Using a hybrid type 1 effectiveness-implementation design, we test the effectiveness of group antenatal care by comparing it to individual care across 6 clinics in Blantyre District, Malawi. Our first...
International Journal of Environmental Research and Public Health
Background: The main symptom of obstetric fistula is urinary and or fecal incontinence. Incontine... more Background: The main symptom of obstetric fistula is urinary and or fecal incontinence. Incontinence, regardless of the type is debilitating, socially isolating, and psychologically depressing. The objective of this study was to explore the strategies that women with obstetric fistula in Malawi use to manage it and its complications. Methods: A subset of data from a study on experiences of living with obstetric fistula in Malawi was used to thematically analyze the strategies used by women to cope with their fistula and its complications. The data were collected using semi-structured interviews. Nvivo 10 was used to manage data. Results: Participants used two forms of coping strategies: (1) problem-based coping strategies: restricting fluid intake, avoiding sexual intercourse, using homemade pads, sand, corn flour, a cloth wreathe and herbs, and (2) emotional-based coping strategies: support from their families, children, and through their faith in God. Conclusion: Women living with...
IntroductionThe maternal mortality ratio is decreasing globally, although it remains high in Mala... more IntroductionThe maternal mortality ratio is decreasing globally, although it remains high in Malawi. Unsafe abortion is a major cause and treatment of complications after abortion is a big burden on the health system. Even though manual vacuum aspiration (MVA) is the recommended surgical treatment of incomplete abortions in the first trimester, many hospitals in Malawi continue to use sharp curettage. It is known to have more complications and is more expensive in the long run. The purpose of this study was to determine the effectiveness of a structured MVA training programme in the treatment of incomplete abortions in Malawi.MethodsA quasi-experimental before-and-after study design was employed in an MVA training programme for health personnel at three hospitals in Southern Malawi. A total of 53 health personnel at the Queen Elizabeth Central Hospital and the district hospitals of Chikwawa and Chiradzulu (intervention hospitals) were trained in the use of MVA. Kamuzu Central Hospit...
International journal of environmental research and public health, Jan 21, 2018
Malawi has a high maternal mortality rate, of which unsafe abortion is a major cause. About 140,0... more Malawi has a high maternal mortality rate, of which unsafe abortion is a major cause. About 140,000 induced abortions are estimated every year, despite there being a restrictive abortion law in place. This leads to complications, such as incomplete abortions, which need to be treated to avoid further harm. Although manual vacuum aspiration (MVA) is a safe and cheap method of evacuating the uterus, the most commonly used method in Malawi is curettage. Medical treatment is used sparingly in the country, and the Ministry of Health has been trying to increase the use of MVA. The aim of this study was to investigate the treatment of incomplete abortions in three public hospitals in Southern Malawi during a three-year period. All medical files from the female/gynecological wards from 2013 to 2015 were reviewed. In total, information on obstetric history, demographics, and treatment were collected from 7270 women who had been treated for incomplete abortions. The overall use of MVA at the ...
The consequences of living with obstetric fistula are multifaceted and very devastating for women... more The consequences of living with obstetric fistula are multifaceted and very devastating for women, especially those living in poor resource settings. Due to uncontrollable leakages of urine and/or feces, the condition leaves women with peeling of skin on their private parts, and the wetness and smell subject them to stigmatization, ridicule, shame and social isolation. We sought to gain a deeper understanding of lived experiences of women with obstetric fistula in Malawi, in order to recommend interventions that would both prevent new cases of obstetric fistula as well as improve the quality of life for those already affected. We conducted semi-structured interviews with 25 women with obstetric fistula at Bwaila Fistula Care Center in Lilongwe and in its surrounding districts. We interviewed twenty women at Bwaila Fistula Care Center; five additional women were identified through snowball sampling and were interviewed in their homes. We also interviewed twenty family members. To ana...
Ursula K. Kafulafula, Mary K. Hutchinson, Susan Gennaro, Sally Guttmacher, Ellen Chirwa
Rates of exclusive breastfeeding in Malawi remain low despite the acknowledged benefits of exclus... more Rates of exclusive breastfeeding in Malawi remain low despite the acknowledged benefits of exclusive breastfeeding for the infant’s wellbeing and the prevention of mother-to-child transmission of HIV. Creating an environment supportive of exclusive breastfeeding is critical to increase the rate of exclusive breastfeeding among HIV-positive mothers. However, little is known on factors that influence the environment within which HIV-positive mothers in Malawi practise exclusive breastfeeding. Therefore, the exploratory qualitative study on which this article is based was conducted at the Chatinkha maternity unit of Queen Elizabeth Central Hospital in Malawi from April 16, 2009 to May 8, 2009 to explore perceived practice environment related barriers to exclusive breastfeeding among HIV-positive mothers. Data were obtained through indepth interviews with 16 purposively selected breastfeeding HIV-positive mothers between 18 and 35 years old and two focus group discussions with women of ...
BACKGROUND: Few studies have looked inside the black box to examine the processes through which p... more BACKGROUND: Few studies have looked inside the black box to examine the processes through which peer group interventions change HIV risk behaviors. The purpose of this process evaluation was to identify changes in group member engagement, peer leader (PL) facilitation skills, and other aspects of group process across 6 sessions of an HIV-prevention intervention for adults and health workers in Malawi. METHODS: Trained observers used our collaboratively developed observation guide to rate standardized descriptors of engagement and facilitation behaviors, critical elements of the peer group approach. To capture change within each 2 hour session and across sessions, we observed a convenience sample of 235 sessions (49 groups, mean 10.39 members per group, observed 2 or more sessions each), in 30-minute blocks within each session and across 6 sessions. RESULTS: Engagement increased significantly (p<.05) from the initial 30-minute block to subsequent blocks within each session. Engage...
HIV-positive mothers are likely to exclusively breastfeed if they perceive exclusive breastfeedin... more HIV-positive mothers are likely to exclusively breastfeed if they perceive exclusive breastfeeding (EBF) beneficial to them and their infants. Nevertheless, very little is known in Malawi about HIV-positive mothers' perceptions regarding EBF. In order to effectively promote EBF among these mothers, it is important to first understand their perceptions on benefits of exclusive breastfeeding. This study therefore, explored maternal and health care workers' perceptions of the effects of exclusive breastfeeding on HIV-positive mothers' health and that of their infants.
Exclusive breastfeeding is an important component of child survival and prevention of mother-to-c... more Exclusive breastfeeding is an important component of child survival and prevention of mother-to-child transmission of HIV in resource-poor settings like Malawi. In Malawi, children under the age of six months are exclusively breastfed for an average duration of 3.7 months. This falls short of the recommendations by the World Health Organization as well as the Malawi Ministry of Health that mothers exclusively breastfeed for the first six months of the child's life. Understanding factors that influence exclusive breastfeeding duration among HIV-positive mothers is important in promoting exclusive breastfeeding among these mothers. An exploratory study was therefore conducted to determine factors that influence HIV-positive mothers' prenatal intended duration of exclusive breastfeeding and their likelihood to exclusively breastfeed for six months. This paper is based on data from a longitudinal, descriptive and correlation study that was conducted at Queen Elizabeth Central Ho...
To investigate the use of manual vacuum aspiration in postabortion care in Malawi between 2008-20... more To investigate the use of manual vacuum aspiration in postabortion care in Malawi between 2008-2012. A retrospective cross-sectional study was done at the referral hospital Queen Elisabeth Central Hospital, and the two district hospitals of Chiradzulu and Mangochi. The data were collected simultaneously at the three sites from Feb-March 2013. All records available for women admitted to the gynaecological ward from 2008-2012 were reviewed. Women who had undergone surgical uterine evacuation after incomplete abortion were included and the use of manual vacuum aspiration versus sharp curettage was analysed. Altogether, 5121 women were included. One third (34.2%) of first trimester abortions were treated with manual vacuum aspiration, while all others were treated with sharp curettage. There were significant differences between the hospitals and between years. Overall there was an increase in the use of manual vacuum aspiration from 2008 (19.7%) to 2009 (31.0%), with a rapid decline aft...
Background/Aims Research into midwifery decision making to date is limited and, where it exists, ... more Background/Aims Research into midwifery decision making to date is limited and, where it exists, theoretical understanding has focused on the cognitive aspects of the process. Understanding the real-life context in which midwives work and how this influences their decision making during labour is important for safer maternity care. This study aimed to explore the contextual factors that influence the decision making of midwives at secondary and tertiary level health facilities during the first stage of labour in the real context of practice. Methods Using a focused ethnographic methodology, data from nine midwives working in two hospital labour ward settings were collected from October 2013 to May 2014. A total of 27 participant observations of midwives supporting women in the first stage of labour, 26 semi-structured interviews with midwives, and a documentary analysis of maternal labour records were conducted. All data were analysed using theme and category formation. Results Four...
Background/Aims The partograph is a tool used to monitor events during labour and was recently mo... more Background/Aims The partograph is a tool used to monitor events during labour and was recently modified by the World Health Organization to improve intrapartum care. However, it is unknown how obstetric care providers in Malawi perceive this modified partograph. This study aimed to evaluate the perceived strengths and challenges regarding the World Health Organization's modified partograph design among obstetric care providers in Malawi. Methods For this qualitative study, data were collected from a sample of 34 obstetric care providers from two purposively-selected urban health facilities through in-depth interviews and focus group discussions. The data were subjected to thematic analysis, with the strengths and challenges of using the modified partograph designated as the two major themes. Results The participants reported that there were more challenges than strengths with utilisation of the modified partograph. Two subthemes emerged among the strengths: the partograph is com...
Background Sub-Saharan Africa has the world’s highest rates of maternal and perinatal mortality a... more Background Sub-Saharan Africa has the world’s highest rates of maternal and perinatal mortality and accounts for two-thirds of new HIV infections and 25% of preterm births. Antenatal care, as the entry point into the health system for many women, offers an opportunity to provide life-saving monitoring, health promotion, and health system linkages. Change is urgently needed, because potential benefits of antenatal care are not realized when pregnant women experience long wait times and short visits with inconsistent provisioning of essential services and minimal health promotion, especially for HIV prevention. This study answers WHO’s call for the rigorous study of group antenatal care as a transformative model that provides a positive pregnancy experience and improves outcomes. Methods Using a hybrid type 1 effectiveness-implementation design, we test the effectiveness of group antenatal care by comparing it to individual care across 6 clinics in Blantyre District, Malawi. Our first...
International Journal of Environmental Research and Public Health
Background: The main symptom of obstetric fistula is urinary and or fecal incontinence. Incontine... more Background: The main symptom of obstetric fistula is urinary and or fecal incontinence. Incontinence, regardless of the type is debilitating, socially isolating, and psychologically depressing. The objective of this study was to explore the strategies that women with obstetric fistula in Malawi use to manage it and its complications. Methods: A subset of data from a study on experiences of living with obstetric fistula in Malawi was used to thematically analyze the strategies used by women to cope with their fistula and its complications. The data were collected using semi-structured interviews. Nvivo 10 was used to manage data. Results: Participants used two forms of coping strategies: (1) problem-based coping strategies: restricting fluid intake, avoiding sexual intercourse, using homemade pads, sand, corn flour, a cloth wreathe and herbs, and (2) emotional-based coping strategies: support from their families, children, and through their faith in God. Conclusion: Women living with...
IntroductionThe maternal mortality ratio is decreasing globally, although it remains high in Mala... more IntroductionThe maternal mortality ratio is decreasing globally, although it remains high in Malawi. Unsafe abortion is a major cause and treatment of complications after abortion is a big burden on the health system. Even though manual vacuum aspiration (MVA) is the recommended surgical treatment of incomplete abortions in the first trimester, many hospitals in Malawi continue to use sharp curettage. It is known to have more complications and is more expensive in the long run. The purpose of this study was to determine the effectiveness of a structured MVA training programme in the treatment of incomplete abortions in Malawi.MethodsA quasi-experimental before-and-after study design was employed in an MVA training programme for health personnel at three hospitals in Southern Malawi. A total of 53 health personnel at the Queen Elizabeth Central Hospital and the district hospitals of Chikwawa and Chiradzulu (intervention hospitals) were trained in the use of MVA. Kamuzu Central Hospit...
International journal of environmental research and public health, Jan 21, 2018
Malawi has a high maternal mortality rate, of which unsafe abortion is a major cause. About 140,0... more Malawi has a high maternal mortality rate, of which unsafe abortion is a major cause. About 140,000 induced abortions are estimated every year, despite there being a restrictive abortion law in place. This leads to complications, such as incomplete abortions, which need to be treated to avoid further harm. Although manual vacuum aspiration (MVA) is a safe and cheap method of evacuating the uterus, the most commonly used method in Malawi is curettage. Medical treatment is used sparingly in the country, and the Ministry of Health has been trying to increase the use of MVA. The aim of this study was to investigate the treatment of incomplete abortions in three public hospitals in Southern Malawi during a three-year period. All medical files from the female/gynecological wards from 2013 to 2015 were reviewed. In total, information on obstetric history, demographics, and treatment were collected from 7270 women who had been treated for incomplete abortions. The overall use of MVA at the ...
The consequences of living with obstetric fistula are multifaceted and very devastating for women... more The consequences of living with obstetric fistula are multifaceted and very devastating for women, especially those living in poor resource settings. Due to uncontrollable leakages of urine and/or feces, the condition leaves women with peeling of skin on their private parts, and the wetness and smell subject them to stigmatization, ridicule, shame and social isolation. We sought to gain a deeper understanding of lived experiences of women with obstetric fistula in Malawi, in order to recommend interventions that would both prevent new cases of obstetric fistula as well as improve the quality of life for those already affected. We conducted semi-structured interviews with 25 women with obstetric fistula at Bwaila Fistula Care Center in Lilongwe and in its surrounding districts. We interviewed twenty women at Bwaila Fistula Care Center; five additional women were identified through snowball sampling and were interviewed in their homes. We also interviewed twenty family members. To ana...
Ursula K. Kafulafula, Mary K. Hutchinson, Susan Gennaro, Sally Guttmacher, Ellen Chirwa
Rates of exclusive breastfeeding in Malawi remain low despite the acknowledged benefits of exclus... more Rates of exclusive breastfeeding in Malawi remain low despite the acknowledged benefits of exclusive breastfeeding for the infant’s wellbeing and the prevention of mother-to-child transmission of HIV. Creating an environment supportive of exclusive breastfeeding is critical to increase the rate of exclusive breastfeeding among HIV-positive mothers. However, little is known on factors that influence the environment within which HIV-positive mothers in Malawi practise exclusive breastfeeding. Therefore, the exploratory qualitative study on which this article is based was conducted at the Chatinkha maternity unit of Queen Elizabeth Central Hospital in Malawi from April 16, 2009 to May 8, 2009 to explore perceived practice environment related barriers to exclusive breastfeeding among HIV-positive mothers. Data were obtained through indepth interviews with 16 purposively selected breastfeeding HIV-positive mothers between 18 and 35 years old and two focus group discussions with women of ...
BACKGROUND: Few studies have looked inside the black box to examine the processes through which p... more BACKGROUND: Few studies have looked inside the black box to examine the processes through which peer group interventions change HIV risk behaviors. The purpose of this process evaluation was to identify changes in group member engagement, peer leader (PL) facilitation skills, and other aspects of group process across 6 sessions of an HIV-prevention intervention for adults and health workers in Malawi. METHODS: Trained observers used our collaboratively developed observation guide to rate standardized descriptors of engagement and facilitation behaviors, critical elements of the peer group approach. To capture change within each 2 hour session and across sessions, we observed a convenience sample of 235 sessions (49 groups, mean 10.39 members per group, observed 2 or more sessions each), in 30-minute blocks within each session and across 6 sessions. RESULTS: Engagement increased significantly (p<.05) from the initial 30-minute block to subsequent blocks within each session. Engage...
HIV-positive mothers are likely to exclusively breastfeed if they perceive exclusive breastfeedin... more HIV-positive mothers are likely to exclusively breastfeed if they perceive exclusive breastfeeding (EBF) beneficial to them and their infants. Nevertheless, very little is known in Malawi about HIV-positive mothers' perceptions regarding EBF. In order to effectively promote EBF among these mothers, it is important to first understand their perceptions on benefits of exclusive breastfeeding. This study therefore, explored maternal and health care workers' perceptions of the effects of exclusive breastfeeding on HIV-positive mothers' health and that of their infants.
Exclusive breastfeeding is an important component of child survival and prevention of mother-to-c... more Exclusive breastfeeding is an important component of child survival and prevention of mother-to-child transmission of HIV in resource-poor settings like Malawi. In Malawi, children under the age of six months are exclusively breastfed for an average duration of 3.7 months. This falls short of the recommendations by the World Health Organization as well as the Malawi Ministry of Health that mothers exclusively breastfeed for the first six months of the child's life. Understanding factors that influence exclusive breastfeeding duration among HIV-positive mothers is important in promoting exclusive breastfeeding among these mothers. An exploratory study was therefore conducted to determine factors that influence HIV-positive mothers' prenatal intended duration of exclusive breastfeeding and their likelihood to exclusively breastfeed for six months. This paper is based on data from a longitudinal, descriptive and correlation study that was conducted at Queen Elizabeth Central Ho...
To investigate the use of manual vacuum aspiration in postabortion care in Malawi between 2008-20... more To investigate the use of manual vacuum aspiration in postabortion care in Malawi between 2008-2012. A retrospective cross-sectional study was done at the referral hospital Queen Elisabeth Central Hospital, and the two district hospitals of Chiradzulu and Mangochi. The data were collected simultaneously at the three sites from Feb-March 2013. All records available for women admitted to the gynaecological ward from 2008-2012 were reviewed. Women who had undergone surgical uterine evacuation after incomplete abortion were included and the use of manual vacuum aspiration versus sharp curettage was analysed. Altogether, 5121 women were included. One third (34.2%) of first trimester abortions were treated with manual vacuum aspiration, while all others were treated with sharp curettage. There were significant differences between the hospitals and between years. Overall there was an increase in the use of manual vacuum aspiration from 2008 (19.7%) to 2009 (31.0%), with a rapid decline aft...
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