Midwifery in Malawi. In-depth country analysis

Midwifery in Malawi In-depth country analysis Prepared by Andrea Nove May 2011 This analysis has been prepared as a background document to The State of the World s Midwifery Report 2011 The recommended citation is Nove A. Midwifery in Malawi: In-depth country analysis. May 2011. Background document prepared for the State of the World s Midwifery Report 2011. Unpublished. Disclaimer: While all efforts have been made to verify the information in this report, responsibility for the contents and presentation rest with the author. The views and opinions expressed in the report do not necessarily correspond with those of the State of the World s Midwifery Report 2011 Editorial Committee, nor with those of the government of the country.

1 General data 1.1 introduction Midwifery in Malawi: In-depth country analysis Malawi became an independent state in 1964. Since it adopted a strategy to eradicate poverty in 1994, it has introduced free primary school education, a free market economy, a bill of rights, and a parliament with three main parties. In 1994 it also adopted the National Population Policy, which aimed to improve family planning and health care programmes, to increase school enrolment with an emphasis on raising the proportion of female students to 50% of total enrolment, and to increase employment opportunities, particularly in the private sector 1. With a population of 15.4 million and a population density of 130 per square kilometre, Malawi is densely populated relative to the rest of sub-saharan Africa. It has an exceptionally young population, with nearly half of its people (45.9%) aged under 15 2. HIV/AIDs is very prevalent in 2006, just eight countries had a higher proportion of HIVinfected adults 3. With a predominantly agricultural economy, only 15% of Malawi s population is classified as urban, making it one of the least urbanised countries in Africa. Administratively, the country is divided into three regions: North, Central and South. According to the World Health Organisation (WHO), in 2006 Malawi s expenditure on health was US$70 per capita, representing 12.3% of GDP 4. According to UNICEF, 7% of central government spending between 1998 and 2008 was on health 5, but according to DFID, this went up to 12.3% in 2008/9 6 and the 2010/11 budget projected that 15.5% of spending would go to the health sector 7. 1.2 General indicators Table 1: General population indictors for Malawi Demographic and health highlights Population mid-2010 15,400,000 Rate of natural increase (%) 2.9 Projected population, 2025 22,900,000 Projected population, 2050 37,400,000 Infant deaths per 1,000 live births 80 Lifetime births per woman (total fertility rate) 6.0 Life expectancy at birth, male 48 Life expectancy at birth, female 50 HIV/AIDS among adult population, ages 15-49, 2005/2006 (%) 11.8 GNI PPP per capita, 2005 (US$) 650 Density (population/sq. km.) 130 Ever-married females ages 15-19 (%) 37

Family planning Contraceptive use among married women, all methods, ages 15-49 (%) 41 Unmet need for family planning (%) 30 Indicators on women Births attended by medically trained personnel, poorest fifth (%) 43 Births attended by medically trained personnel, middle fifth (%) 51 Births attended by medically trained personnel, richest fifth (%) 83 Births attended by skilled personnel (%) 56 Maternal deaths per 100,000 live births, 2000 1,800 HIV-infected adults who are women population, 2003-04 (%) 57 Literacy rate, ages 15-24, 2000-04, female (%) 71 Literacy rate, ages 15-24, 2000-04, male (%) 82 Secondary school enrolment, female, 2000/2004 (as % of school-age 29 enrolment) Secondary school enrolment, male, 2000/2004 (as % of school-age 37 enrolment) Sources for statistics: 2006 World Population Data Sheet, PRB; Women of Our World 2005, PRB; The Wealth Gap in Health, PRB; Making the Link: Population, Health, Environment, PRB; and Family Planning Worldwide 2002 Data Sheet, PRB; World's Youth 2006, PRB. (Population Reference Bureau, http://www.prb.org/). Specific national data emanating from national survey are indicated where needed. Although the above table shows that 29% of secondary-school-age girls enrolled in secondary school, the 2009 Malawi Welfare Monitoring Survey 8 found that 6% of secondaryschool-age girls who had been in school the previous year had dropped out (similar to the 5% recorded for boys). An annual drop-out rate of 6% over the four years of secondary school age (14-17) would translate to approximately 23% of girls finishing secondary school (compared with approximately 30% of boys). This will impact negatively on girls future health and economic prospects, and also on the pool of educated women available to train as maternity care providers. The 2009 Welfare Monitoring Survey found that the main reason for 14-19 year-old girls not being in education was that they were married. 1.3 MMR over time Malawi s maternal mortality ratio (MMR) is high (510 per 1,000 live births in 2008), with a lifetime risk of maternal death of 1:7 9. Table 2 shows that the MMR fell by 44% between 1990 and 2008. Progress towards MDG5 has been faster since 2000, with an annual percentage change of -4.2% between 2000 and 2008.

Table 2: Evolution of Maternal Mortality Ratio (MMR) Estimated MMR 1990 1995 2000 2005 2008 % Change in MMR between 1990 and 2008 Annual % change in MMR between 1990 and 2008 910 830 770 620 510-44.0-3.2 Source: UNICEF (http://www.childinfo.org/maternal_mortality_ratio.php) Despite the relatively steep fall in Malawi s MMR since 2000, Figure 1 shows that Malawi will not achieve its target under MDG5 unless the MMR starts to fall more sharply than it has over recent years. Figure 1: Evolution of Maternal Mortality Ratio (MMR) compared to the desired evolution to attain MDG5 Demographic and Health Survey (DHS) MMR estimates are somewhat different to the UNICEF figures quoted above (984 in 2004, 1,120 in 2000 and 620 in 1992), and these figures are widely quoted in the literature.however, the 2004 DHS report noted that: It is unlikely that maternal mortality has gone up and then down again so dramatically, especially since the reference periods for the estimates overlap each other. Maternal mortality ratios measured in this way are subject to very high sampling errors and cannot adequately indicate trends over the short term. 1.4 SBA percentage over time The UNFPA figures in Table 3 indicate that, in recent years, just over half of deliveries in Malawi have been attended by a skilled birth attendant (SBA):

Table 3: Trends in the percentage of deliveries attended by SBA, 2005-2010 2005* 2006** 2007** 2008** 2009** 2010** 56% 61% 61% 54% 54% 54% * From Women of our World 2005 ** From State of the World Population Report for the respective years Figures from Demographic and Health Surveys (DHS) are based on live births rather than all deliveries, and are broadly similar to those shown above. Additionally, DHS figures (see Figure 2) indicate that the proportion of live births attended by skilled health personnel has not changed significantly since 1992. Figure 2: Trends in the percentage of live births attended by SBA, 1992-2006 The 2004 DHS found that 50% of live births were attended by a nurse or midwife, and 6% by a doctor/clinical officer. Correspondingly, 57% of live births took place at a health facility. Women living in urban areas were much more likely than those living in rural areas to be attended by a SBA (84% and 53% respectively in 2004). This imbalance in access to SBAs between urban and rural areas has been evident in all DHS surveys since 1992, and the gap has not narrowed over time 10.

2 History of midwifery 2.1 Historical heritage, first midwifery training At independence in 1964, the only registered nurse/midwives in Malawi were those who had trained in other countries. The Kamuzu College of Nursing (KCN) was the first Malawian training institution, opening its doors in 1979. Since the mid-1960s, the Nurses and Midwives Council of Malawi has maintained that the training of nurse/midwives should prepare them to perform functions that, in developed countries, would normally be provided by physicians, e.g. starting intravenous fluid and attending high-risk deliveries. This is due to there being a more severe shortage of physicians than of nurse/midwives (see Section 4.4). This has resulted in the evolution of specialist nurse/midwife roles, especially in relation to the care of women and children 11. 2.2 Evolution of the framework for midwifery services Malawi was one of the first African nations to have developed a Road Map for maternal and neonatal health. The Road Map was first developed in 2005, and was updated in 2007 9. According to UNFPA 12, Malawi was one of only two countries to have secured more than 50% of the required funding for the implementation of the first phase of the plan. The Road Map identified several contributing factors to Malawi s high MMR, of which the four most important were: (1) staff shortages and weak human resource management, (2) limited availability and utilisation of maternal health care services, (3) weak referral systems and (4) weak community participation and involvement. In the Road Map, the Government recommended a minimum health expenditure of US$17.53 per capita per year, significantly higher than the US$12 that was estimated in 2007. The Ministry of Health (MoH) produced a six-year pre-service training plan to run from 2002-2008, with the aim of increasing the supply and improving the distribution of essential health service providers. In 2003, the Health Service Commission (HSC) was established, with responsibility for filling health worker vacancies. From 1998-2004, a Safe Motherhood Project (SMP) was run in the Southern region, but failed to achieve the desired outcomes. According to DFID, this failure was largely due to lack of SBAs 6. In response to the continuing shortage of qualified health professionals, the MoH launched an Emergency Human Resource Programme (EHRP) to run from 2004-2010, with funding of US$273 million 13. A National Health Sector Deployment Policy was produced in 2008, with the goal of attracting, training and retaining adequate numbers of health workers and to ensure they are distributed appropriately across the country. A Sector Wide Approach (SWAp) was adopted in 2004, to co-ordinate the activities and expenditure of all health development partners. According to DFID, over the years 2004-2010, US$735 million was allocated to the SWAp, representing about half the amount that WHO estimated was required to achieve the MDGs 6. Through the SWAp, an Essential Health Package (EHP) has been provided, comprising interventions against 11 health conditions, one of which is poor reproductive and neonatal health. Malawi was one of the first countries to sign up to CARMMA (Campaign for Accelerated Reduction of Maternal Mortality) in 2009. One of CARMMA s objectives is to accelerate actions aimed at the reduction of maternal mortality in Africa.

3 Midwifery situation 3.1 Who provides midwifery services In Malawi, midwifery is not a separate discipline from nursing, which makes it difficult to estimate the numbers of health professionals with midwifery expertise. Between 1979 and 1990, all students on the nursing BSc degree undertook a year s midwifery training, but since 1990 midwifery training has not been compulsory on the BSc course (see Section 5.2). There are two cadres of nurse/midwife: those who have passed the BSc course (registered nurse/midwives) and those who have a diploma in nursing (enrolled nurse/midwives). The 2008 Health Worker census reported that there were three times as many registered nurse/midwives as enrolled nurse/midwives (2,928 and 968 respectively) 13. Most nurse/midwives have midwifery skills (79% in 2007 6 ). Traditional Birth Attendants (TBAs) have traditionally been very active, especially in rural areas. In 1976 a training course for TBAs was launched in Lilongwe, and in 1982 the course was rolled out nationally. By 2008 it was estimated that there were about 5,000 TBAs, of whom about 2,000 had received formal training 14. 3.2 Practices and beliefs what is the place of the TBA and of the SBA, and how do people deal with pregnancy and birth TBAs tend to be highly respected in rural areas, despite a perception among health professionals that the care they provide is of poor quality due to low literacy, poor supervision and old age 14. In 2007 TBAs were banned from providing maternity care due to concerns about their lack of skills, but anecdotal evidence indicated that they were continuing to practise in secret. In 2010 the ban was lifted because the government felt that it was better to train TBAs than to forbid them from practising. Whilst some traditional practices in Malawi are beneficial to reproductive health (e.g. the practice of a female relative coming to support the pregnant women in late pregnancy and early motherhood), other practices are injurious to maternal health.many women are disempowered both economically and in terms of their ability to seek health care. Women tend not to make decisions about how to spend family income. Delay in seeking maternity care is common, because women have to wait for male family members to decide whether or not they should seek care 15.In some parts of the country, pregnant women are discouraged from eating eggs and offal, which are often the cheapest sources of protein. Abstinence from sexual intercourse is often recommended for the final trimester of pregnancy and up to six months after the birth, which can lead to men seeking sexual relations outside of marriage and therefore to transmission of STIs 16. 3.3 Role of the private sector in the provision of midwifery services Primary care is provided at health centres, health posts, dispensaries and rural hospitals. Secondary care is provided at district hospitals. Central and private hospitals provide specialist services. Two main agencies provide nearly all of the health care services in Malawi: the MoH and the Christian Health Association of Malawi (CHAM). Other services are run by the Ministry of Local Government (MoLG) and NGOs. Table 4 shows that, in 2008, 63% of the country s health facilities were owned by the MoH (including all the central and district hospitals) and 26% were owned by CHAM:

Table 4: Number of health facilities, by ownership, 2008 Ministry of Health (MoH) Christian Health Association of Malawi (CHAM) Ministry of Local Govt (MoLG) Banja La Mtsogolo (NGO) Other NGO Total Central hospital 4 0 0 0 0 4 District hospital 22 0 0 0 0 22 Mental hospital 1 1 0 0 0 2 Rural hospital 19 27 0 0 0 46 Health centre 288 115 12 1 0 416 Clinic 2 8 4 27 1 42 Maternity centre 2 1 12 3 0 18 Rehabilitation centre 0 1 0 0 0 1 VCT centre 0 0 0 0 3 3 Dispensary 54 8 4 0 0 66 Total 392 161 32 31 4 620 Source: Ministry of Health HMIS Unit, 2008 Figure 3 shows that the majority of professional nurse/midwives (64.5%) were employed by the government, with 21.5% employed by CHAM and 14.0% by the private sector. By contrast, half of general medical practitioners were employed in the private sector. Figure 3: Employers of general physicians and professional nurse/midwives, Malawi, 2008 Source: 2008 Health Worker census

4 Numbers, distribution and movements 4.1 How many maternity care professionals are in the country? The 2008 Health Worker Census 13 reported that there were 20,908 health workers, including 2,739 management, administrative and support staff. Excluding these 2,739 workers, there were 1.39 health care providers per 1,000 population. Among these, there were 2,928 nursing professionals (i.e. registered nurse/midwives) and 968 nursing associate professionals (i.e. enrolled midwives), totalling 3,896, or0.30 per 1,000 population. As noted in Section 3.1, 79% of nurse/midwives are estimated to have midwifery skills, which translates to about 3,080 midwives. 4.2 How are midwives distributed per region? Figure 4 shows that the geographical distribution of nurse/midwives by administrative region broadly mirrors the population distribution, with most practitioners being based in the more densely-populated Central and Southern regions. The distribution of nurse/midwives is, however, slightly skewed towards the Northern and Southern regions, with just 37% of professional nurse/midwives being based in the Central region despite it being home to 42% of the population. By contrast, 53% of general physicians are based in the Central region. Figure 4: Regional distribution of general physicians and professional nurse/midwives, compared with regional population distribution Source: population figures from 2008 population census, health professional figures from 2008 Health Worker census Although Figure 4 shows that the overall regional distribution of maternity care professionals broadly mirrors the distribution of the population, Figure 5shows that the vast majority of these health professionals are based in urban areas, whereas the vast majority of the population is based in rural areas. This indicates extremely restricted access to suitably qualified health professionals among rural women in Malawi.

Figure 5: Regional distribution of general physicians and professional nurse/midwives, compared with regional population distribution Source: population figures from 2008 population census, health professional figures from 2008 Health Worker census 4.3 Attrition, retirement, abandon, migration MoH figures from 2004 14 showed that 64% of the established nursing/midwifery positions in Malawi were vacant. A 2003 study 17 quoted figures from the MoH which suggested that only 53% of registered nurse/midwife posts and 82% of enrolled nurse/midwife posts were filled. Although these estimates are quite different, it is clear that there is a severe shortage of nursing/midwifery staff. The 2003 study found that the two main reasons for nurse/midwives leaving nursing/midwifery jobs in Malawi were death (a large proportion of which occurred before the age of 45 and were almost certainly HIV/AIDs-related) and migration. The 2006 World Health Report estimated that 453 nurse/midwives who had trained in Malawi were working in OECD countries, representing 4% of the Malawian nurse/midwife workforce. It has been suggested that reasons for migration are more to do with push factors than with pull factors, i.e. the poor working conditions and remuneration in Malawi are a stronger influence than the better pay and conditions available in developed countries 1718. If so, migration is part of a vicious circle, because as the more experienced personnel leave the health facilities, the working conditions of the remaining personnel worsen, which in turn makes them more likely to leave 15. 4.4 What are the needs? The World Health Report 2006 19 recommended that, to achieve 80% skilled attendance at birth, there should be at least 2.3 professional care providers per 1,000 people. However, a ratio of health care providers to the size of the population will be inaccurate in a high-fertility country such as Malawi, so it is more appropriate to consider the ratio of care providers to births. Overall, WHO suggests a ratio of one midwife for every 175 births per year, assuming: a compact population, each midwife spends all her time on midwifery and only the bare minimum of care is provided 20. The Malawi National Statistical Office (NSO)

estimates 660,000 births in 2010 and 740,000 in 2015 21. This translates to the need for 3,771 midwives in 2010 and 4,228 in 2015. As noted in Section 4.1, in 2008 there were 2,928 nursing professionals and 968 nursing associate professionals, making a total of 3,896, of whom about 3,080 had midwifery skills. Even if all of these spent all or most of their time on midwifery (which is highly unlikely), this represents a significant shortfall. Furthermore, the World Health Report 2005 22 stated that there should be 4 doctors for every 3,500 births. This translates to the need for 754 doctors in 2010, and 845 in 2015. There were just 190 general medical practitioners and 67 specialist medical practitioners (total = 257). This large discrepancy means that nurse/midwives will be expected to provide far more than the bare minimum of care due to their having to care for the more complicated cases who ideally would be attended by a specialist physician. In 2008 the MoH started work on projections of health workforce requirements, but did not complete the exercise 13. Before the project was stopped, the MoH had estimated that, by 2017, Malawi would need: 2,834 professional nurses, 20,091 associate nurse/midwives (not all of which would specialise in midwifery) and 580 doctors.

5 Midwifery education 5.1 Institutions for midwifery education (public, private and capacity) The Kamuzu College of Nursing (KCN) and Malawi College of Health Sciences provide registered nurse/midwife training. Several other institutions provide training for enrolled nurse/midwives, most of which are run by CHAM 13. According to the Mzuzu University website, about 50 registered nurse/midwives graduate each year. Figure 6 shows that in the years 2005-2008, the number of entrants to the nursing training institutions was far lower than the number of graduates, indicating that numbers of graduates in the coming few years will be smaller than in recent years. Constraints on intake are reported to include a lack of student accommodation, too few tutors and inadequate classroom space 18. Figure 6: Numbers of entrants and graduates at nursing training establishments, 2005-2008 Source: Training School Submissions, August 2008 5.2 Curriculum The KCN training consists of a four-year BSc course, which may include a one-year midwifery course (this used to be compulsory but since 1990 has been open only to those demonstrating an interest in and aptitude for midwifery) 18. The curriculum is described in Table 5:

Table 5: Subjects covered in KCN Nursing BSc course Year Curriculum 1 English language and communication; Sociology; Chemistry & Physics; Medical Microbiology & Parasitology; Human Anatomy & Physiology; Introduction to Nursing; Fundamentals of Nursing; Health Assessment; Clinical Nursing 2 Pharmacology; Medical/Surgical Nursing; Biochemistry; Community Health Nursing; Principles and Practice of Education; English Language & Communication; Statistics; Professionalism; Human Nutrition; Clinical Nursing 3 Medical/Surgical Nursing; Community Health Nursing; Mental Health/Psychiatric Nursing; Paediatric Nursing; Principles of Management; Clinical Nursing 4 Research Project; Community Health Nursing; Medical/Surgical Nursing; Clinical Preceptorship Source: KCN 23 In addition to the 4-year BSc course, KCN also offers a two-year BSc course to people who already hold a diploma in nursing, a certificate in midwifery and who have at least two years practical experience 18.Enrolled nurse/midwife courses last for three years. 5.3 Teachers and tutors (ratio to students, skills) In the 1990s, there was great concern over low nursing/midwifery tutor retention rates in Malawi, and in 1997 the MoH instituted a salary supplement scheme, funded by overseas donor organisations. The scheme had a positive effect on tutor numbers in CHAM training institutions,which went up from 43 in 2000 to 100 in 2006. With approximately 500 students enrolling per year for a 3-year course, this is a ratio of 1 tutor per 15 students, against anmoh target of 1:10. Furthermore, the overall ratio disguises the fact that some classes are very large, with 30-50 students in a class 24. In 2001 there were 57 teaching staff at KCN 25. 5.4 Supervision and support, in-service training The MoH has a Human Resources Development policy, which contains eligibility criteria for in-service training via short competency-based courses and long-term professional development programmes.

6 Regulation, status and legislation 6.1 Regulation and status of the profession (presence of a Board or Council) The Nurses and Midwives Council (NMC) of Malawi is the sole regulatory body of nursing and midwifery education, training, practice and professional conduct of nursing and midwifery personnel in the country. The Council has a mandate to formulate professional education and/training standards and to regulate health services based on professional standards, and is currently working towards this 26. The overall objective of the Council is to develop, maintain, monitor, evaluate and control the profession of nursing and midwifery thereby contributing to the national health goal of raising the health status of Malawians. Its Mission Statement is: The council exists to ensure that the public receives quality and ethical (safe and competent) nursing and midwifery care/services through determining,monitoring all matters affecting the education, training and practice of persons in and the performance of the practices pursued, by nurses and nursing technicians. 27 All nurse/midwives are required by law to register with the NMC. In 2005 NMC figures showed that there were 3,633 practising nurse/midwives in Malawi, 1,838 non-practising nurse/midwives and 162 working abroad 28. 7 Professional organisations / associations/unions/colleges The Association of Malawian Midwives (AMAMI)was established in 1997 and has about 300 members, despite membership being open to all midwives regardless of employer, even if they are still in training, retired or working in a different profession 29. AMAMI collaborates with its counterpart organisation for nurses and the ICM, but does not have formal partnerships with these or other organisations. AMAMI s stated mission is to: Safeguard and promote a safe environment for mothers, neonates & their families Safeguard and promote the interest of midwives as unique & and critical health care professionals Be an official voice for midwives Be a link between midwives & government & other stakeholders As the only professional association for midwives, AMAMI has the potential to be highly influential. However, with no dedicated office or secretariat and the need to lobby a government with many conflicting demands on its resources, AMAMI struggles to convince nurse/midwives of the benefits of membership and thus does not reach its full potential in terms of influencing policy and practice 17.

8 Inputs from international and donor agencies According to the World Bank, in Malawi the net Official Development Assistance (ODA) per capita was US$61.5 in 2008, having risen steadily from US$42.0 in 2005 30. Malawi s GDP in 2008 was US$288 per capita, indicating that ODA accounted for approximately 21% of GDP.According to WHO, about 60% of the country s total health expenditure is contributed by development partners 31. The World Bank 32 lists Malawi s main donors as: DFID, EC, World Bank, African Development Bank, Norway, Germany, USAID, and China. These account for over 90% of Malawi s development assistance. Other donors include the traditional UN institutions (notably UNDP, UNICEF, WHO, and WFP), Global Fund, JICA, ICEIDA, and Ireland.

9 Main challenges By any objective measure, Malawi suffers from a severe shortage of maternity care professionals, due to a number of issues, including: a low proportion of young people completing secondary education, the practice of girls marrying young, a shortage of nursing/midwifery tutors, midwifery not being a separate profession from nursing, short life expectancy resulting in high levels of death in service and brain drain. Steps have been taken to address many of these issues by the Malawian government and development partners, but much more needs to be done. The HR shortage means that the working conditions of the existing maternity care professionals are poor, which creates a vicious circle in terms of the difficulty of staff retention and also in terms of the number of experienced practitioners available to support and supervise those who have recently qualified. The shortage is particularly marked in rural areas. In common with many developing countries, the vast majority of maternity care professionals are based in urban areas, whereas in Malawi the vast majority of the population lives in rural areas. This means that most Malawian women do not have easy access to trained maternity care professionals. It also means that the provision of support and supervision to the small number of rural practitioners is a major challenge. A shortage of qualified tutors means that, as well as concern about insufficient maternity care professionals being trained, there is concern over class sizes and therefore the quality of the education and training being received. High workloads caused by staff shortages will also make it difficult for qualified practitioners to take part in continuing education and training in order to further their careers and ensure that the care they are providing is of the highest quality. Malawi is a high-fertility country, and current projections predict that the number of births per year will continue to rise until at least 2050. Projections of the number of health professionals with midwifery skills needed in Malawi must take into account that most of the population lives in rural areas (which limits the size of the geographical area that each midwife can cover) and that there is a high TFR. Population-based methods of working out the required number of midwives will therefore underestimate the number needed in Malawi. Furthermore, the shortage of qualified physicians is even more severe than the shortage of nurse/midwives, which means that,in addition to their normal duties, nurse/midwives can be expected to perform functions that would normally be performed by doctors. Unless and until the shortage of doctors can be addressed, therefore, the required number of professionals with midwifery skills will be higher than would be the case in a country with adequate physician cover.

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