MALAWI AND MATERNAL HEALTH

BY: Dr Burnett Lunan. He has recently retired as a consultant obstetrician/gynaecologist at Glasgow Royal Infirmary.

In May/June 2006 I visited Malawi as part of the Scottish Executive Partnership Programme. As a recently retired consultant obstetrician/gynaecologist my remit was to look at ways Scotland might contribute to improving maternal health in Malawi. Maternal mortality is acknowledged to be among the worst in the world outside conflict zones. Statistics are difficult to compile and estimates vary between 1000 and 1800 maternal deaths per 100,000 pregnancies - equivalent to a mortality of 1 - 2 per cent and a lifetime risk of dying in pregnancy of approximately 1 in 10! This is more than 100 times worse than developed countries.

The reasons are many - poverty and malnutrition are widespread and affect women’s health. The health facilities are often poorly equipped and maintained, and most experience shortages of medical and nursing/midwifery staff. In many hospitals women have to pay for maternity care, discouraging the poorest women from attending despite being the most vulnerable.

HIV/AIDS probably affects about 30% of pregnant women. Anti-retroviral (ARV) drugs are becoming available but some women decline testing on account of the risk of stigmatisation or offending their partner. In a situation where transmission from an infected mother to her newborn child can be substantially reduced by medication and proper management, it is essential to overcome the obstacles to diagnosis and treatment.

There is a serious shortage of obstetricians and gynaecologists (as in most specialties). The annual output of around 20 medical graduates is insufficient for the country’s requirements. This is now being doubled to around 40 and it is planned to increase further to 80 - 100 but this will need a huge expansion of teaching personnel and facilities.

Improving the postgraduate training and retaining of medical and nursing/midwifery graduates is another priority. Many trained personnel quickly find work with NGOs, CHAM (Christian Hospitals Association of Malawi) hospitals, and abroad where working conditions and financial rewards are seen to be better. Opportunities for training in the UK should be supported but not as a way of propping up the NHS and denying Malawi essential services.

The role of Clinical Officers - personnel who are not medically qualified but provide the backbone of the medical services throughout the country - remains controversial. Doctors tend to disparage the contribution of the clinical officers but without them most district hospitals and health centres would have almost no service. Some clinical officers have been locally trained to undertake complex procedures such as hysterectomy or even fistula repair, but remain undervalued.

The majority of deliveries in Malawi are conducted without trained attendants, and often it falls to Traditional Birth Attendants (TBAs) or family members to provide support. Until sufficient numbers of midwives are trained and women are able to access their services most mothers will look to TBAs to attend them in childbirth.

Good primary health services - antenatal care, family planning, treatment of anaemia and infections - can reduce maternal mortality modestly but significant reduction depends on medical skills to deal with complications such as haemorrhage, obstructed labour, ruptured uterus, convulsions and sepsis and to provide safe anaesthesia, safe blood transfusion, and surgical intervention.

In the shorter term, Emergency Obstetric Care has been identified as an area where all health workers involved in maternity care can benefit from good basic training. Teams from Scotland have already been spear-heading such a programme and there are plans to modify the content of the programme to reflect the needs and resources of Malawi.

In the longer term, improving the in-country postgraduate training of specialists is necessary. At present most postgraduates have to leave Malawi to train in South Africa or elsewhere. This denies Malawi the clinical services of these doctors while in training. By supporting basic science training within Malawi and then strengthening clinical skills training in-country, Scottish clinicians could make a valuable contribution to raising standards. It would be helpful also if the specialist qualification was examined and awarded on a regional basis (e.g. East and Central Africa) as this would give the degree an international status and make it attractive locally.

For any health programme to be successful there must be government support but in maternal health there must also be a commitment at every level in the community to demand the best possible services for the pregnant women.