Background
The Centre for Reproductive Health of College of Medicine in collaboration with the Ministry of Health and Stakeholders organised a one and half days dissemination conference at the Cross Roads Hotel, Lilongwe from 13–14th August, 2009. The conference was graced by Her Honour, the Vice President of the Republic of Malawi, Mrs Joyce Banda who was also the African Union Goodwill Ambassador for Safe motherhood. Policy makers, program directors and managers, researchers, health care providers, local leaders, NGO representatives, academic staff and students from training institutions and development partners were also in attendance.
The purpose of this conference was to share research findings that College of Medicine, through Centre for Reproductive Health in collaboration with the Ministry of Health and partners, had undertaken in the past three years. During this conference, scientists provided the evidence (knowledge, experiences and data) that would help in designing evidence based interventions and improve reproductive health practice. Emphasis was on promoting dialogue among researchers, policy makers, health care providers, civil society and the community leaders in order to provide lasting practical solutions for the maternal and reproductive health problems that women, men and the young people face in this country. The conference programme covered a wide range of presentations which were classified under the following categories:
Reducing maternal morbidity and mortality through safe motherhood
Youth and reproductive health
Can maternal health improve without male participation?
HIV and AIDS prevention, treatment and care
Solving the human resource crisis to improve maternal and newborn health
Prevalence and impact of lower genital morbidity
Draft Communique
These presentations were mainly done by CRH team, Department of Obstetrics and Gynaecology, Queen Elizabeth Central Hospital, Community Health Department, UPENN Project team, Dream Project, Kamuzu College of Nursing and Gates Interns.
Opening remarks
The conference was officially opened by the Vice President of the Republic of Malawi, Mrs. Joyce Banda who was also the Guest of Honour at this event. In her opening remarks she highlighted the need for stakeholders and government to work together to address Reproductive Health (RH). The Vice President, reminded the participants on meaningful participation of men in maternal and child health. She indicated that most programs did not specifically address issues of male involvement despite the available evidence regarding the benefits of involving males in SRH programs. Given the lack of compelling and workable programmatic interventions on male involvement, delegates were called upon to map out the way forward.
The other dignitaries that made their speeches included the Minister of Health, Vice Chancellor of the University of Malawi, Principal of the College of Medicine, Director of Bill and Melinda Gates Institute of Population and Health and Director for Centre for Reproductive Health at the College of Medicine.
A synopsis of conference presentantions and debate
Reducing maternal morbidity and mortality through Safe motherhood.
Evidence from the above stated presentation largely, felt that documentation of labour using the partograph and critical thinking are the key drivers of positive outcomes of maternal and neonatal deaths. Community mobilization strategies involving the whole community to identify and give solutions to maternal and newborn health are dynamic and able to sustain actions to reduce maternal and neonatal morbidity and mortality. Other important findings from this study were:-
Provision of one-on-one support during labour and delivery process results in positive outcome of the labour. The other major finding was that increase awareness of patients' rights charter to enable the public to be aware of their rights in our health facilities.
Use of Identification for health service providers which will allow clients/patients to identify their care givers.
Youth and Reproductive Health
The Youth and sexual reproductive health presentation raised a lot of debate among delegates. The following issues were discussed and consensus reached:-
Multi-sector involvement and integration of youth activities with greater participation of the young people in planning, implementation and evaluation can enhance comprehensive service provision to the young people beyond health services. This should be coupled with information and education and communication on the importance of condom use for SRH and HIV prevention.
Emphasize on the zero grazing concept in relation to young people and condoms.
Government to work with other organisations that could help orphans' and their vulnerability and susceptibility to HIV infection.
Male participation towards improvement of maternal health
The presentations under this theme were dealing with issues of male participation in maternal health.
The following issues were raised and discussed:
Increasing need to redesign health facilities to allow companionship in labour especially to male partners that are willing to give psychoscial support to their spouses.
Participation of local traditional leaders in mobilizing communities and taking lead towards encouraging males to participate in maternal health and throughout the pregnancy period a well as labour and delivery.
Program planners should take caution to handle issues of male companionship in labour with a lot of sensitivity as it contravenes some cultural beliefs and traditions.. It was further stressed that the community mobilization should not only mean to increase awareness but rather, move further to building capacity of the communities to understand and appreciate maternal problems in the context of pregnancy. The male participation should be a process that moves from co-option to collection action. This takes into consideration that communities are the ones who appreciate the need of a male partner in the labour ward based on the clear defined and culturally appropriate roles she will be doing in the labour ward. Decision making of the communities of the issue is central to the success of the intervention.
Need for clear guidelines and policy on level of male involvement in maternal health.
Provision of male friendly infrastructure in the labour wards like is the case in some government new facilities like New Bwaila maternity wing.
Need for a blue print on level of male involvement in the country. Ministry of Health needs data on this issue.
Myths, misconceptions and stigma around male involvement pose as significant barriers to male participation in maternal health care. It was suggested that facilities should implement flexible hours (e.g. Saturdays) to allow for male participation especially during the antenatal period. This is subject to debate as this might work for the working class and not the 80% men and women who live in rural areas. The above is further compounded by long distances pregnant women have to travel to reach for service provision and poor attitude of the service providers.
HIV and AIDS prevention, treatment and care
On this thematic area, the following was discussed and agreed:
Maternal HAART for eligible women reduces HIV transmission from breast feeding, reduces maternal mortality, transmission of HIV from mother to child and reduces cases of stillbirth.
Explore other ways of reducing HIV infection e.g. use of Microbicides like gel 0.5% PRO 2000, which so far has a 30% efficacy of towards the contribution to protection against HIV prevention.
Effective behavioural interventions targeting multiple partnerships concurrency could significantly reduce exposure to HIV in populations affected by generalised epidemics.
Solving human resource crisis within the health care system-effective use of mid-level providers
The synthesis of major findings and discussions around factors optimising retention of mid-level providers in Malawi were as follows:-
The delegates felt the following to be a good direction towards human resources for maternal survival:-
Midlevel providers institute and maintain an effective collaboration to advocate for, and advance the professional interests of their members in relation to remuneration and resources.
Employment agencies including the Ministry of Health in collaboration with the Ministry of Education scale-up the development of human resources for health as a strategy for preventing staff burnout.
Develop meaningful strategies for motivating MLP's such as provision of housing in rural areas, instituting fair promotion and continuing education strategies.
Create an enabling environment for health practitioners to effectively deliver quality health care services; through infrastructure development and career development.
Need for a revolutionary thinking and actions around shifts geared towards attracting and retaining skilled midlevel cadres in remotest Christian Health Association of Malawi health facilities, which is currently a challenge.
Need for a functioning system of supervision and appraisal of MLP's.
Prevention of lower genital morbidity
The conference participants agreed to the following:
Scale up current cancer screening services beyond the current districts which are providing the services.
Government needs to do more e.g. Establishment of a fistula repair centre which will cater for the training of personnel in fistula care and management.
The Ministry of Health must put Cervical Cancer in the essential health package in-order secure resources within the Program of Work-Sector Wide Approach.
Government of Malawi/MoH should establish a Cancer centre whose role will be training service providers in therapeutics and palliative care.
Information and education of Reproductive Health issues must be done in appropriate local languages.
Government to establish SRH services targeting males e.g. Sexual dysfunction
Conclusions and Recommendations
The conference was closed with a general understanding that reducing maternal and neonatal morbidity and mortality was a priority within priorities of Ministry of Health Programme of Work.
The MoH promised to continue with expanding service level agreements with Christian Health Association of Malawi in order to increase access and coverage of maternal and neonatal health services especially in rural areas. The MoH will endeavour to improve the work environment and increase number of trained health workers in order to avoid brain drain. This will be done through increasing the intake of students in the health training institutions in order to meet the human resource demands in the health facilities.
The following recommendations were made in order to improve the quality of reproductive health care in Malawi:
Male companionship in labour. The conference resolved that the issue of companionship should be looked at in three dimensions: women should have a companion of their choice, labour ward infrastructure should ensure privacy for the women in labour and finally cultural norms surrounding the issue of childbirth should be taken into consideration. It was further resolved that before this recommendation is implemented, there's need to engage the communities to debate the issue and also sensitize them on the benefits of companionship in labour.
Burn out among service providers. On this issue the conference recommended that Government of Malawi should look at this issue as priority in order to stop the brain drain which has hit most health facilities in the country. Government of Malawi should look at ways of ensuring staff motivation like changing the hospital environment through the provision of good work infrastructure, equipment and supplies, proper housing and incentives for service providers.
Prevention of genital morbidities (Obstetric fistula (VVF) and cervical cancer). The conference recommended that there's need to raise awareness on these two problems. A brochure should be available to provide information on the problem of vesico vaginal fistula (VVF) and the cervical cancer prevention. Government of Malawi should also look into sourcing Ca Cx vaccine which will target girls aged 9 years.
One other aspect that was worrying is that the low involvement of parents in adolescent sexual reproductive health programs. Success of these programs will depend on parental involvement where their concerns can be addressed.