The prevalence of disrespect and abuse during facility-based maternity care in Malawi: evidence from direct observations of labor and delivery

Abstract Background There is increasing evidence throughout the world that the negative treatment of pregnant women during labor and delivery can be a barrier to seeking skilled maternity care. At this time, there has been little quantitative evidence published on disrespect and abuse (D&A) in Malawi. The objective of this research is to describe the prevalence of disrespect and abuse during labor and delivery through the secondary analysis of direct clinical observations and to describe the association between the observation of D&A items with the place of delivery and client background characteristics. Methods As part of the evaluation of the Helping Babies Breathe intervention, direct observations of labor and delivery were conducted in August 2013 from 27 out of the 28 districts in Malawi. Frequencies of disrespect and abuse items organized around the Bowser and Hill categories of disrespect and abuse and presented in the White Ribbon Alliance’s Universal Rights of Childbearing Women Framework were calculated. Bivariate analysis was done to assess the association between selected client background characteristics and the place of delivery with the disrespect and use during childbirth. Results A total of 2109 observations were made across 40 facilities (12 health centers and 28 hospitals) in Malawi. The results showed that while women were frequently greeted respectfully (13.9% were not), they were often not encouraged to ask the health provider questions (73.1%), were not given privacy (58.2%) and were not encouraged to have a support person present with them (83.2%). Results from the bivariate analysis did not show a consistent relationship between place of delivery and D&A items, where the odds of being shouted at was lower in a health center when compared to a hospital (OR: 0.19; CI: 0.59–0.62) while there was a higher odds of clients not being asked if they have any concerns if they were in a health center when compared to a hospital (OR: 2.40; CI: 1.06–5.44). Women who were HIV+ had significantly lower odds of not having audio and visual privacy (OR: 0.34, CI: 0.12–0.97), of not being asked about her preferred delivery position (OR: 0.17, CI: 0.05–0.65) and of not being asked if she has any other problems she is concerned about (OR 0.38, CI:0.15–0.96). Conclusion This study is among the first to quantify the prevalence of disrespect and abuse during labor and delivery in Malawi through direct clinical observations. Measurement of the poor treatment of women during childbirth is essential for understanding the scope of the problem and how to address this issue

Extending beyond Policy: Reaching UNAIDS’ Three “90”s in Malawi

Malawi, like other countries with a generalized HIV epidemic, is striving to reach the ambitious targets set by UNAIDS known as the three 90’s for testing, provision of antiretroviral therapy and viral suppression. Assisted by Malawi’s progressive policies on HIV/AIDS, it appears possible that Malawi will attain these targets, but only by employing innovative program approaches to service delivery which help fill policy gaps. This article describes how a dedicated cadre of layperson testers and HIV-positive peers appears to have helped attain increases in HIV and viral load testing and retention in care in four districts in Malawi, and situates these innovations in a policy framework analysis

Medications in delivery area, in 24 hospitals and 60 health centers.

<p>Medications in delivery area, in 24 hospitals and 60 health centers.</p

Regression model of health worker performance during intrapartum care simulation (preterm delivery with complications).

<p>Regression model of health worker performance during intrapartum care simulation (preterm delivery with complications).</p

Regression model of health worker performance during intrapartum care simulation (normal, term delivery).

<p>Regression model of health worker performance during intrapartum care simulation (normal, term delivery).</p

Health facility service availability and readiness for intrapartum and immediate postpartum care in Malawi: A cross-sectional survey

<div><p>This analysis seeks to identify strengths and gaps in the existing facility capacity for intrapartum and immediate postpartum fetal and neonatal care, using data collected as a part of Malawi’s Helping Babies Breath program evaluation. From August to September 2012, the Maternal and Child Health Integrated Program (MCHIP) conducted a cross-sectional survey in 84 Malawian health facilities to capture current health facility service availability and readiness and health worker capacity and practice pertaining to labor, delivery, and immediate postpartum care. The survey collected data on availability of equipment, supplies, and medications, and health worker knowledge and performance scores on intrapartum care simulation and actual management of real clients at a subset of facilities. We ran linear regression models to identify predictors of high simulation performance of routine delivery care and management of asphyxiated newborns across all facilities surveyed. Key supplies for infection prevention and thermal care of the newborn were found to be missing in many of the surveyed facilities. At the health center level, 75% had no clinician trained in basic emergency obstetric care or newborn care and 39% had no midwife trained in the same. We observed that there were no proportional increases in available transport and staff at a facility as catchment population increased. In simulations of management of newborns with breathing problems, health workers were able to complete a median of 10 out of 16 tasks for a full-term birth case scenario and 20 out of 30 tasks for a preterm birth case scenario. Health workers who had more years of experience appeared to perform worse. Our study provides a benchmark and highlights gaps for future evaluations and studies as Malawi continues to make strides in improving facility-based care. Further progress in reducing the burden of neonatal and fetal death in Malawi will be partly predicated on guaranteeing properly equipped and staffed facilities in addition to ensuring the presence of skilled health workers.</p></div

Equipment and supplies in labor ward, in 24 hospitals and 60 health centers.

<p>Equipment and supplies in labor ward, in 24 hospitals and 60 health centers.</p

Equipment and supplies for newborn care, in 24 hospitals and 60 health centers.

<p>Equipment and supplies for newborn care, in 24 hospitals and 60 health centers.</p

The effectiveness of Community Based Distribution of Injectable Contraceptives using Community Health Extension Workers in Gombe State, Northern Nigeria

This study reports on findings of a pilot of community-based distribution (CBD) of injectable contraceptives in two local government areas (LGAs) of Gombe State, Nigeria. From August 2009 to January 2010, the project enrolled, trained and equipped community health extension workers (CHEWs) to distribute condoms, oral and injectable contraceptives in communities. The project mobilized communities and stakeholders to promote Family Planning (FP) services in the selected communities. Using anonymised unlinked routine service data, the mean couple years of protection (CYP) achieved through CBD was compared to that achieved in FP clinics. The CBD mean CYP for injectables- depo medroxy-progesterone acetate (DMPA) and norethisterone enantate was higher (27.72 & 18.16 respectively) than the facility CYP (7.21 & 5.08 respectively) (p<0.05) with no injection related complications. The CBD’s mean CYP for all methods was also found to be four times higher (11.65) than that generated in health facilities (2.86) (p<0.05). This suggests that the CBD of injectable contraceptives is feasible and effective, even in a setting like northern Nigeria that has sensitivities about FP. (Afr J Reprod Health 2013; 17[2]: 80-88).Cette étude porte sur les résultats d’un projet pilote de distribution à base communautaire (DBC) des contraceptifs injectables dans deux Administrations Locales (AL) de l’Etat de Gombe, Nigeria. D’aout 2009 au janvier 2010, a inscrit, a formé et a équipé des membres de personnel de santé communautaire (MPSC) pour distribuer des préservatifs, des contraceptifs oraux et des injectables dans les communautés. Le projet a mobilisé les communautés et les parties prenantes pour promouvoir la planification familiale (PF) dans les communautés choisies. , les L’utilisation des données de service de routine anonyme et non corrélées, la moyenne de couple d’années de protection (CAP) obtenue par la CDB a été comparée à celle obtenue dans les cliniques de PF. La DBC de CAP pour les produits injectables Depomedroxy-acétate de progestérone (DMPA) et l&apos;énanthate de noréthistérone était plus élevé (27,72 et 18,16 respectivement) que l&apos;installation (7,21 et 5,08 respectivement) CYP (p <0,05), sans des complications liées à l’injection. On a trouvé que la CAP moyenne de la DB pour toutes les méthodes a également était quatre fois plus élevée (11,65) que celles générées dans les établissements de santé (2,86) (p <0,05). Ceci suggère que la DBC des contraceptifs injectables est réalisable et efficace, même dans un milieu tel que le nord du Nigeria qui a des sensibilités de la PF. (Afr J Reprod Health 2013; 17[2]: 80-88)

Facilities surveyed in the study.

<p>Facilities surveyed in the study.</p