Effie Chipeta

The lived experience of Malawian women with obstetric fistula

Data on women who experience obstetric fistula paints an often tragic picture. The majority of previous research has focused on facility-based data from women receiving surgical treatment. The goal of this qualitative study was to gain an understanding of the lived experience of obstetric fistula in Malawi. Forty-five women living with fistula were interviewed in their homes to learn how the condition affected them and their families on a daily basis. Findings indicate that the experiences of Malawian women with fistula were more varied than anticipated. Concerning relationships with husbands and family, we found high rates of divorce and stigma, yet these outcomes were far from universal or inevitable. Many women, in addition to their families, discussed high levels of support from those individuals closest to them. Nonetheless, many women experienced the fistula as a direct assault on their ability to fulfil social expectations of them as women, wives and mothers. Women identified fertility and continued childbearing as central concerns. The data suggest that we cannot discount the experiences of women living with fistula from continued participation in marriage, community and childbearing. Programmes for outreach and services should consider a broadened range of outcomes of women living with fistula.

What makes staff consider leaving the health service in Malawi

BackgroundMalawi faces a severe shortage of health workers, a factor that has contributed greatly to high maternal mortality in the country. Most clinical care is performed by mid-level providers (MLPs). While utilization of these cadres in providing health care is a solution to the current shortages, demotivating factors within the Malawian health system are pushing them into private, non-governmental, and other non-health related positions. This study aims to highlight these demotivating factors by exploring the critical aspects that influence MLPs’ intention to leave their jobs.MethodsThis descriptive qualitative study formed part of the larger Health Systems Strengthening for Equity (HSSE) study. Data presented in this paper were collected in Malawi using the Critical Incident Analysis tool. Participants were asked to narrate an incident that had happened during the past three months which had made them seriously consider leaving their job. Data were subjected to thematic analysis using NVivo 8 software.ResultsOf the 84 respondents who participated in a Critical Incident Analysis interview, 58 respondents (69%) indicated they had experienced a demotivating incident in the previous three months that had made them seriously consider leaving their job. The most commonly cited critical factors were being treated unfairly or with disrespect, lack of recognition of their efforts, delays and inconsistencies in salary payments, lack of transparent processes and criteria for upgrading or promotion, and death of patients.ConclusionStaff motivation and an enabling environment are crucial factors for retaining MLPs in the Malawian health system. This study revealed key ‘tipping points’ that drive staff to seriously consider leaving their jobs. Many of the factors underlying these critical incidents can be addressed by improved management practices and the introduction of fair and transparent policies. Managers need to be trained and equipped with effective managerial skills and staff should have access to equal opportunities for upgrading and promotion. There is need for continuous effort to mobilize the resources needed to fill gaps in basic equipment, supplies, and medicine, as these are critical in creating an enabling environment for MLPs.

Too few staff, too many patients: a qualitative study of the impact on obstetric care providers and on quality of care in Malawi.

BackgroundShortages of staff have a significant and negative impact on maternal outcomes in low-income countries, but the impact on obstetric care providers in these contexts is less well documented. Despite the government of Malawi’s efforts to increase the number of human resources for health, maternal mortality rates remain persistently high. Health workers’ perceptions of insufficient staff or time to carry out their work can predict key variables concerning motivation and attrition, while the resulting sub-standard care and poor attitudes towards women dissuade women from facility-based delivery. Understanding the situation from the health worker perspective can inform policy options that may contribute to a better working environment for staff and improved quality of care for Malawi’s women.MethodsA qualitative research design, using critical incident interviews, was used to generate a deep and textured understanding of participants’ experiences. Eligible participants had performed at least one of the emergency obstetric care signal functions a in the previous three months and had experienced a demotivating critical incident within the same timeframe. Data were analysed using NVivo software.ResultsEighty-four interviews were conducted. Concerns about staff shortages and workload were key factors for over 40% of staff who stated their intention to leave their current post and for nearly two-thirds of the remaining health workers who were interviewed. The main themes emerging were: too few staff, too many patients; lack of clinical officers/doctors; inadequate obstetric skills; undermining performance and professionalism; and physical and psychological consequences for staff. Underlying factors were inflexible scheduling and staff allocations that made it impossible to deliver quality care.ConclusionThis study revealed the difficult circumstances under which maternity staff are operating and the professional and emotional toll this exacts. Systems failures and inadequate human resource management are key contributors to the gaps in provision of obstetric care and need to be addressed. Thoughtful strategies that match supply to demand, coupled with targeted efforts to support health workers, are necessary to mitigate the effects of working in this context and to improve the quality of obstetric care for women in Malawi.

Men's Perceptions of Delivery Care in Rural Malawi: Exploring Community Level Barriers to Improving Maternal Health

In this cross-sectional survey with qualitative components (n = 389), we explored how husbands perceive delivery care in rural Malawi. Most husbands decide on maternal health care seeking, believe in antenatal care, and prefer institutional delivery. Men acknowledge that their unfaithfulness and violence can harm the pregnancy. Most husbands feel responsible for birth preparedness, but poor availability and unforeseeable transport costs hinder care seeking in pregnancy complications. Our findings suggest that innovative birth preparedness and transport interventions that involve men, as well as the extension of antenatal care (ANC) services to men, can help overcome obstacles to improving maternal health at the community level.

Fertility and pregnancy outcomes among women with obstetric fistula in rural Malawi

To assess the fertility and pregnancy experiences of rural Malawian women living with obstetric fistula and following surgical repair of fistula.

Experiences with fistula repair surgery among women and families in Malawi

Abstract Fistula treatment through surgery is reported to be successful in 80–90% of cases. Success in fistula repair has been defined by medical professionals in terms of clinical outcomes; beyond these definitions, it is important to understand how women perceive a positive clinical outcome and how it affects her family and home environment. This research was conducted in the Mangochi District of Malawi to answer these questions through interviews with women living with fistula and after surgical repair, as well as their partners and families. Over 104 interviews were conducted in June and October 2007. While eventually experiencing clinically successful surgical outcomes, women reported difficulty in seeking and receiving healthcare. Bureaucratic challenges were complicated by community misperceptions about the condition and fear of the healthcare system. Perspectives of womens families suggest that burdens and social disabilities caused by fistula extended beyond the individual to affect these family members. When women experienced surgical treatment, positive outcomes spread to her family and community. Positive experiences with the healthcare system turned women into advocates for healthcare in their communities. These findings illustrate that issues of obstetric fistula are not limited to individual women, but can dramatically affect their families, partners and communities.

Incidence of induced abortion in Malawi, 2015

Background In Malawi, abortion is legal only if performed to save a woman’s life; other attempts to procure an abortion are punishable by 7–14 years imprisonment. Most induced abortions in Malawi are performed under unsafe conditions, contributing to Malawi’s high maternal mortality ratio. Malawians are currently debating whether to provide additional exceptions under which an abortion may be legally obtained. An estimated 67,300 induced abortions occurred in Malawi in 2009 (equivalent to 23 abortions per 1,000 women aged 15–44), but changes since 2009, including dramatic increases in contraceptive prevalence, may have impacted abortion rates. Methods We conducted a nationally representative survey of health facilities to estimate the number of cases of post-abortion care, as well as a survey of knowledgeable informants to estimate the probability of needing and obtaining post-abortion care following induced abortion. These data were combined with national population and fertility data to determine current estimates of induced abortion and unintended pregnancy in Malawi using the Abortion Incidence Complications Methodology. Results We estimate that approximately 141,044 (95% CI: 121,161–160,928) induced abortions occurred in Malawi in 2015, translating to a national rate of 38 abortions per 1,000 women aged 15–49 (95% CI: 32 to 43); which varied by geographical zone (range: 28–61). We estimate that 53% of pregnancies in Malawi are unintended, and that 30% of unintended pregnancies end in abortion. Given the challenges of estimating induced abortion, and the assumptions required for calculation, results should be viewed as approximate estimates, rather than exact measures. Conclusions The estimated abortion rate in 2015 is higher than in 2009 (potentially due to methodological differences), but similar to recent estimates from nearby countries including Tanzania (36), Uganda (39), and regional estimates in Eastern and Southern Africa (34–35). Over half of pregnancies in Malawi are unintended. Our findings should inform ongoing efforts to reduce maternal morbidity and mortality and to improve public health in Malawi.

Young People's Preferences for Family Planning Service Providers in Rural Malawi: A Discrete Choice Experiment.

Objective To quantify the impact of service provider characteristics on young people’s choice of family planning (FP) service provider in rural Malawi in order to identify strategies for increasing access and uptake of FP among youth. Methods and Findings A discrete choice experiment was developed to assess the relative impact of service characteristics on preferences for FP service providers among young people (aged 15–24). Four alternative providers were included (government facility, private facility, outreach and community based distribution of FP) and described by six attributes (the distance between participants’ home and the service delivery point, frequency of service delivery, waiting time at the facility, service providers’ attitude, availability of FP commodities and price). A random parameters logit model was used to estimate preferences for service providers and the likely uptake of services following the expansion of outreach and community based distribution (CBDA) services. In the choice experiment young people were twice as likely to choose a friendly provider (government service odds ratio [OR] = 2.45, p<0.01; private service OR = 1.99, p<0.01; CBDA OR = 1.88, p<0.01) and more than two to three times more likely to choose a provider with an adequate supply of FP commodities (government service OR = 2.48, p<0.01; private service OR = 2.33, p<0.01; CBDA = 3.85, p<0.01). Uptake of community based services was greater than facility based services across a variety of simulated service scenarios indicating that such services may be an effective means of expanding access for youth in rural areas and an important tool for increasing service uptake among youth. Conclusions Ensuring that services are acceptable to young people may require additional training for service providers in order to ensure that all providers are friendly and non-judgemental when dealing with younger clients and to ensure that supplies are consistently available.

Sexual pleasure, partner dynamics and contraceptive use in Malawi

CONTEXT Despite increases in the use of modern contraceptives, Malawian women have a high unmet need for contraception. Because current understanding of contraceptive use ignores sexual pleasure and partner dynamics, this study explores the links between sexual pleasure seeking, partner dynamics and contraceptive use. METHODS As part of a larger qualitative study conducted in 2012, 23 focus group discussions among married women and men and 10 in-depth interviews with service providers were conducted with a total of 192 participants in two districts of Malawi. Thematic analysis was performed to identify recurrent categories and patterns. RESULTS Method choice and consistent use were affected by the quantity and quality of sex desired and, most important, by any perceived change in sexual pleasure for respondents or their partner. For women, more so than for men, experiences of sexual pleasure were intertwined with gender norms, womens perceived role of providing pleasure in sexual relationships and the relationship dynamics this generated. These partner dynamics ultimately created a formidable barrier to contraceptive use or promoted contraceptive discontinuation. CONCLUSION Family planning programs should consider the nuanced ways in which notions of sexual pleasure, partner dynamics and the broader social context are involved in decision making regarding contraceptive use.

Pilot study of home-based delivery of HIV testing and counseling and contraceptive services to couples in Malawi

BackgroundHIV counseling and testing for couples is an important component of HIV prevention strategies, particularly in Sub Saharan Africa. The purpose of this pilot study is to estimate the uptake of couple HIV counseling and testing (CHCT) and couple family planning (CFP) services in a single home visit in peri-urban Malawi and to assess related factors.MethodsThis study involved offering CHCT and CFP services to couples in their homes; 180 couples were sampled from households in a peri-urban area of Blantyre. Baseline data were collected from both partners and follow-up data were collected one week later. A pair of male and female counselors approached each partner separately about HIV testing and counseling and contraceptive services and then, if both consented, CHCT and CFP services (pills, condoms and referrals for other methods) were given. Bivariate and multivariate logistic regression analyses were done to examine the relationship between individual partner characteristics and acceptance of the services. Selected behaviors reported pre- and post-intervention, particularly couple reports on contraceptive use and condom use at last sex, were also tested for differences.Results89% of couples accepted at least one of the services (58% CHCT-only, 29% CHCT + CFP, 2% CFP-only). Among women, prior testing experience (p < 0.05), parity (p < 0.01), and emotional closeness to partner (p < 0.01) had significant bivariate associations with acceptance of at least one service. Reported condom use at last sex increased from 6% to 25% among couples receiving any intervention. First-ever HIV testing was delivered to 25 women and 69 men, resulting, respectively, in 4 and 11 newly detected infections.ConclusionsHome-based CHCT and CFP were very successful in this pilot study with high proportions of previously untested husbands and wives accepting CHCT and there were virtually no negative outcomes within one week. This study supports the need for further research and testing of home- and couple-based approaches to expand access to HCT and contraceptive services to prevent the undesired consequences of sexually transmitted infection and unintended pregnancy via unprotected sex.