The flag of the African nation of Malawi shows a radiant red sun rising against a black background. It’s an apt symbol of hope for a country that is successfully using quality improvement tools and techniques to begin reducing one of the highest maternal mortality rates in the world.
At Likuni Mission Hospital in the capital city of Lilongwe, located in the country’s central region, the maternal death rate dropped from 0.31 percent in January 2006 to 0.16 percent in July 2007. During this period, the number of deliveries increased by 80 percent, from 1,609 to 2,911. Remarkably, the hospital recently celebrated a 197-day stretch with no maternal deaths at all, surpassing its goal of 170 days.
The achievement and celebration — attended by the nation’s Deputy Minister of Health and other dignitaries — were featured in the local newspaper. The article noted that the milestone is particularly significant because it spanned the months in the year when diseases such as malaria and conditions such as malnutrition typically peak.
The nurses and Matron of Likuni Mission Hospital
celebrating their success
IHI’s Director for Developing Countries, Barbara Tobin, attended the celebration; IHI is one of four organizations that comprise The Health Foundation Consortium, a group working together with the Reproductive Health Unit of the Malawi Ministry of Health to support the reduction of maternal and neonatal death in Malawi.
“What the hospital accomplished is really incredible,” says Tobin. “The goal of 170 days at first seemed unreachable, but the improvement team played a huge role and together they got to 197 days. They deserved to celebrate.”
The hospital’s improvement team, led by Matron Isabel Chimbili Banda, owes its success in part to Charles Makwenda, an Improvement Advisor working under The Health Foundation Consortium to teach improvement principles and methodologies at nine collaborative facilities and 23 health centers in Malawi.
Makwenda, a native of Malawi, says that a study of maternal deaths at Likuni Mission Hospital revealed that two fundamental issues have contributed to the maternal mortality rate. “The first is that many women go to a traditional birth attendant instead of the hospital for their delivery,” he says. And though women are often brought to the hospital if complications develop, Makwenda says that this delay in addressing problems often contributes to a poor outcome.
The second factor, he says, “was the hospital’s preparedness for such emergencies.” By this he means that when a woman did arrive in crisis, there was often a delay in mobilizing the people and equipment necessary to treat her.
The improvement project, which began in 2006, has focused on both factors, involving all staff, some of whom received training as improvement leaders. “Everyone working at the hospital, including administrators, nurses, guards, everyone signed a document saying they supported the campaign to reduce maternal deaths,” says Makwenda. The document also asked people to list their improvement suggestions. “There were quite a lot of ideas,” he says. The hospital also benefited from exchanging ideas with teams at other hospitals in the collaborative.
One important change that was tested with the patients of one nurse and later spread to all patients was aimed at helping the hospital become more accommodating to pregnant women and sensitive to cultural traditions surrounding birth. For example, during at-home births babies are typically received by their grandmothers, who attend the laboring mother along with a traditional birth attendant. But until recently most heath care facilities did not allow a companion to accompany a woman through labor and delivery.
Likuni Mission Hospital in Lilongwe now encourages women to bring a female companion, says Makwenda. “It may seem obvious in other parts of the world, but here, encouraging a woman to have a companion in the hospital is new. This is part of the woman-friendly cycle of changes that were made to help moms feel more at home in the hospital.”
Not only does this change provide women with the comfort of companionship and support in the hospital, but it also provides an extra layer of safety by freeing the nurse midwives from being the sole source of comfort and reassurance to focus more on their clinical duties.
To better prepare for unexpected maternity emergencies, the hospital has made several changes. “The team has created a checklist to help staff see if they have all their necessary supplies all the time,” says Makwenda. “And they have created delivery kits that have everything necessary for a delivery, including sterile instruments. With prepared delivery kits, they don’t have to look for anything.”
Getting staff mobilized quickly in an urgent situation was also part of the challenge. For example, if a delivering mother arrived in distress during the night and needed urgent attention, a hospital guard would go to the home of the doctor or midwife on call and wake him or her up to come to the hospital. “Now everyone has a cell phone,” says Makwenda, “so the maternity person on duty can call the team to come immediately to the hospital.”
Makwenda says he thinks the local publicity about the hospital’s successes is also helping change women’s perspective about having a hospital-based birth, and is mobilizing traditional birth attendants to refer patients more quickly to the hospital at the first sign of potential complications. “Everyone is beginning to understand better the value of going to the hospital,” he says.
One of the important lessons from this work, says Makwenda, is that “to improve things you don’t need all the resources you may wish for. You can make the best use of what you have and still take things to another level of quality.”
The hospital now has a large, gold-framed certificate prominently displayed for everyone to see. It says, in part, “Congratulations from The Health Foundation Board and Staff Members to Likuni Mission Hospital, In Recognition for Achieving a Record 197 Days Surpassing Their Campaign Target of 170 Days Without Maternal Deaths in the Year 2007. Keep Up the Good Work.”
The staff is taking that last advice to heart, and has set a new goal of 250 days with no maternal deaths.
04/14/2008
