The "Blog": Updates on Projects in Malawi to Improve Maternal and Neonatal Mortality




This blog, created by Karen Zeribi (left) in 2007, IHI's Program Manager in Malawi at the time, provides snapshots of local quality improvement work on maternal health. The intent is to explore the successes and challenges of the work while highlighting the local partners dedicated to improving maternal and neonatal care.



IHI’s work in Malawi is part of a partnership between four organizations that have come together to form The Health Foundation Consortium (THFC). This work in Malawi, supported by The Health Foundation (UK), partners with nine referral hospitals in the Salima, Kasungu and Lilongwe districts (see map for location).


To learn more about the background of this project, including The Health Foundation Consortium.








Hello to Training and Goodbye to Karen
Charles Makwenda reports on the progress in Malawi and bids a "bon voyage!" to Karen Zeribi.
The Health Foundation Consortium in Malawi, with an objective of embedding improvement in the health care system, has started training a group of selected individuals from the nine facilities to go through an advanced course in quality improvement. By the end of two courses this team must be able to:
  • Explain with expertise the Model for Improvement
  • Critique team aim statements and measurement strategy
  • Be able to understand the line graph variations and the process/system underlying it
  • Understand reliability concepts
This group will coach their teams on enhancing the use of data and the systems/processes approach. The teams will also be challenged to push their processes to level two reliability.
The first session was held on July 2, 2007, at Green House in Lilongwe and drew 11 personnel, both clinicians and nurses. The second session will be held in September. A learning session/exchange visit followed this training with an objective of planning 90-day projects for the team. 

The faculty Charles Makwenda, Dr. Uma Kotagal, Karen Zeribi and the Malawi teams. Gracing the occasion, Jill Allen from The Health Foundation in the UK (first row, second from right) and Barbara Tobin (standing forth from left), the newly appointed IHI Director for Developing Countries.   


On a sad note Karen Zeribi, one of the founding members and IHI's Program Manager in Malawi, was saying goodbye to the teams, going back to USA after spending a year in Malawi.


In the picture below, the Salima and Mlale teams bid farewell to Karen who was given an African drum  they all listened her beat.




Their message “we wish her a safe trip home and please come again.” The teams will miss Karen. Congratulations to Karen for the great work and the mark she has left.


Coming together is a beginning, keeping together is progress, and working together is success.
Improving Data Records to Advance Maternal Health Outcomes — May 2007
Roger LeCompte is a faculty advisor working on measurement in the Developing Countries Malawi project. He recently visited hospitals in Malawi and had this to say:
We’ve discovered that improving quality in Malawi hospitals also means improving the quality of the data that define our measures and indicators. Although there is a national system for record keeping, our experience quickly showed that the available data was not reliable. For example, one of our primary outcome measures is the number of women who die of complications from pregnancy in hospitals. We have found instances where neither the numerator is correct (number of maternal deaths) nor the denominator (what they died of).
Despite the efforts of tremendously hard working staff, patient care is often compromised with incorrect data records. The staff report near universal frustration with using existing reports for decision making. In up to half of death audits, QI teams find that there is insufficient information in the file to get to the root cause of a death.
While many analysts believe that the solutions to these problems is technology, we have made a decision to build on the strong local manual record keeping tradition of many decades, focusing improvements where they are most likely to increase the quality of the project’s indicators.
We feel that the most productive place to start change is ensuring the integrity of the primary clinical record through use of standard forms. By reducing the ambiguity of entries on the form (e.g., forcing a “yes” or “no” choice, circling a choice from a list, etc.) clinicians and data clerks alike will make fewer errors. Forms also enforce good clinical practice by mimicking established protocols.
Diagramming the flow of information makes it clear that there are numerous opportunities for error.
Diagram Flow of Information.gif

Many of these occur in the process of transcription of information from one file to another (e.g., patient record to a register form). Other errors stem from the absence of self-evident instructions about definitions and calculated values. In one instance, a data clerk routinely forced the monthly number of hospital “deliveries” to be the same as “live births.” No one had ever informed her that “deliveries” were mothers, and “live births” were babies, and how to make adjustments for twins, triplets and stillbirths.
The Malawi QI project is addressing these and other data issues as part of its breakthrough collaborative with QI teams from nine hospitals in Lilongwe, Salima, and Kasungu Districts. It is our hope that as this project grows its innovations can spread to services other than maternity in these hospitals.

Introduction to the Malawi Blog and Background — March 2007

Karen Zeribi, IHI's Program Manager in Malawi
The days that my children were born are one of the happiest moments of my life, despite complications that could have resulted in adverse outcomes for my children and me. My daughter’s birth was rushed after my obstetrician observed a plummet in her fetal heart rate. My son was born by Cesarean section after a long labor did not progress. My work here in Malawi is a daily reminder of how lucky I am to be alive with two healthy children. 
The expression for pregnancy in Chichewa (the language predominately spoken in Malawi) translates into English as “in between life and death.” When you look at the statistics for maternal death in Malawi, this morose expectation isn’t too surprising. The average woman in Malawi has more than six children throughout her lifetime.  Her lifetime risk of dying during or immediately after pregnancy is approximately one in seven. [Maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy.]


Malawi is considered to have one of the highest maternal mortality rates in the world with an estimated 984 deaths per 100,000 live births [Malawi DHS, 2005]. To provide a point of comparison, the adjusted maternal death rate in the United States is less than 10 deaths per 100,000 live births [CDC, March 2006]. The neonatal mortality rate is also high in Malawi with an estimated 42 deaths per 1,000 live births [Malawi DHS, 2000]. One of the reasons that maternal and neonatal deaths are believed to be high is because only 55% of women deliver their babies with a skilled birth attendant. 


My role with THFC here in Malawi is to bring IHI’s quality improvement methods to hospitals and health centers wishing to improve maternal and neonatal care. I moved to Lilongwe, Malawi, with my family seven months ago to help THFC launch the quality improvement work. Please check this “blog” often as I provide updates on the adventures and successes of the quality improvement teams!

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