This case study is an excerpt from a collection of 22 case studies by the Evidence for Action-MamaYe! programme based on their experiences. These case studies bring to light new learning about the specific ways in which evidence, advocacy and accountability must work together to bring about change.
Evidence for Action-MamaYe! was established in 2011 through funding from the UK Department of International Development. The programme’s goal is to save maternal and newborn lives in Ethiopia, Ghana, Malawi, Nigeria, Sierra Leone and Tanzania, through better resource allocation and improved quality of care.
When the Evidence for Action-MamaYe (E4A) programme first started operations in Malawi, we observed that while some facilities and districts were carrying out maternal death reviews, committees met only rarely and did not communicate systematically with other levels. Rudimentary action plans were sometimes developed, but there were no follow-up meetings to track change. Furthermore, the maternal death review process did not include the community level. Consequently, community factors that might have contributed to facility deaths and maternal deaths occurring within communities were not recorded, no explanation was fed back to families or communities on the reasons for facility-based deaths, and no actions were taken in response. This led to distrust between community members and facility staff, who themselves often blamed the families for bringing the woman to the facility too late.
The E4A Malawi country team advocated and technically supported the Ministry of Health to transform the existing, uncoordinated maternal death reviews into a national Maternal Death Surveillance and Response (MDSR) system. A national MDSR links information about maternal deaths occurring at different levels of the health system so that an adequate response can be taken at the appropriate level for future deaths to be prevented.
E4A Malawi led a broad programme of capacity-building across all levels of the Malawi MDSR system, by supporting the Ministry of Health in drafting the national MDSR guidelines and providing support to the system’s most senior level, the National Committee for Confidential Enquiry into Maternal Death (NCCEMD), to review data and monitor progress against action plans.
As part of this work, the E4A Malawi country team persuaded the national Ministry of Health that integrating the community into a national MDSR system was crucial for building trust, revealing vital information, and for the MDSR system to function as an effective accountability system driving quality improvements for improved survival. By marshalling the evidence from a community-MDSR (c-MDSR) system in Mchinji district, which E4A had supported, we convinced decision-makers that including communities in the national MDSR system was feasible.
Description of the case study
The Mchinji demonstration site was based on a project implemented in 2011-12 by a local organisation called MaiMwana, whereby community members conducted maternal death reviews. We adapted the pilot’s original tools to integrate the community into the full MDSR system. This involved linking the community’s maternal death reviews to the health system’s MDSR, placing an emphasis on action and response.
In December 2014, the E4A Malawi country team trained 20 c-MDSR teams to use these tools across two traditional authorities (TAs) in Mchinji: Mkanda and Mduwa. Each c-MDSR committee includes three community members, three health surveillance assistants (HSA, which are community health workers) and the group village headman (GVH).
All maternal deaths in Mchinji are now fully investigated. When a maternal death occurs, regardless of whether it takes place in the community or the facility, a health surveillance assistant and another member of the c-MDSR committee conduct a verbal autopsy with the family to understand any community-level contributing factors, and collect the woman’s health records. This has improved participants’ understanding of the full range of factors behind maternal deaths, and improved the estimation of the number of deaths that actually take place.
Secondly, the system has strengthened linkages between different levels of the system. The location for the full review will either be at district or facility level, depending on where the death took place. A representative of the health facility MDSR committee attends reviews conducted at the district level, and a representative of the district committee attends facility MDSR reviews. An HSA and the group village headman are also invited to represent the community. The district MDSR committee sends quarterly reports to the zonal level, where they are aggregated and sent to the National Committee for Confidential Enquiry into Maternal Death (NCCEMD) biannually. These communications flowing “up” the health system have enabled actions to be taken at a range of appropriate levels and not just at the facility level, as was the case previously.
Furthermore, there is a strong flow of information going “down” the health system, as action plans and progress against them are communicated to lower levels. For example, the action plan developed at facility level is fed back via the GVH to the c-MDSR team, then to the family, and if the family consents, there is a community feedback session. This is crucial for addressing the previous mistrust, since it demonstrates that the community’s views have been considered and used to inform the action plan. The downward flow of information is also important for accountability. The district committee and health facility MDSR committees meet quarterly to review completion of actions and progress is then communicated to c-MDSR committees who inform their communities, as well as upwards to the NCCEMD who has overall oversight.
Experiences in Mchinji have demonstrated the importance of securing commitment from leaders at all levels in order for actions to be implemented. For example, having support from chiefs has been invaluable in renegotiating cultural norms that were contributing to maternal deaths while district health officers need to drive the reform process and set aside funding in their district implementation plan.
There have been multiple examples of how the new system has supported better use of resources in Mchinji district, at all levels. At the facility-level, for example, one review showed that a woman had been discharged 24 hours after delivery, although the Ministry of Health protocol is 48 hours. Now the facility ensures all women remain in their care for the full 48 hours. At the district level, when one review identified that transport was a major issue and this was communicated to the district level, it was realised that several bicycle ambulances were sat in storage. These were subsequently released and distributed.
At the community level, several communities have started schemes to support transport arrangements, especially during fuel shortages at facility level. There has also been a strong influence on reversing the perceived “inevitability” of maternal mortality, and it is clear that communities are much more likely to demand action when a death occurs. A c-MDSR committee member Mbewa asserted that:
“We feel more powerful to save women’s lives.”
At national level, MaiMwana and E4A Malawi presented the results from the Mchinji experience to the National MDSR Tool Development Committee and succeeded in persuading national stakeholders that involving the community in the national MDSR system was crucial to its success. The community aspect of MDSR was subsequently incorporated by the Ministry of Health into the national MDSR guidelines, using the tools tested in Mchinji.
The national MDSR guidelines were launched in March 2015. By August 2015, 120 members of MDSR teams from district and central hospitals had been trained in facility-level MDSR by the Ministry of Health with support from partners, including E4A Malawi. This training is still continuing around the country. To date, E4A Malawi has carried out community-level training on verbal autopsies with more than 350 members of village health committees in five districts (Mchinji, Balaka, Kasungu, Mangochi and Ntchisi). A national database is being developed by the NCCEMD to keep track of who has been trained in facility-level and community-level MDSR. This database will help identify which districts need further training.
To read Malawi’s MDSR guidelines, please click here.
To read Malawi’s latest report on Confidential Enquiry into Maternal Deaths (2008-2012), please click here.
This case study was informed by interviews with our Malawi Team Member and Maimwana Senior Health Officer Hilda Chapota, E4A Malawi Project Manager Lumbani Banda, and the c-MDSR committee in GVH Mbewa.
Photo credit: MamaYe! Africa