MALAWI
The Making it Happen Programme
The aim of the Making it Happen Programme (MiH) is to reduce maternal and newborn mortality
and morbidity by increasing availability and improving the quality of Skilled Birth Attendance (SBA)
and emergency Obstetric and Newborn care (EmONC).
Between 2012 and 2015, the MiH Programme will be delivered in 11 countries: eight in Sub-Saharan
Africa (Ghana, Kenya, Malawi, Nigeria, Republic of South Africa, Sierra Leone, Tanzania and
Zimbabwe) and three countries in Asia (Bangladesh, India and Pakistan).
The Making it Happen Programme in Malawi has five outputs:
1. Increased health care provider capacity to provide Emergency Obstetric and Newborn Care
(EmONC). The target for the number of in-service health workers to be trained by the end of
2015 is 375.
2. Increased availability of EmONC for mothers and babies.
3. Strengthened accountability for results with increased transparency. This will be achieved by
training 106 health workers in Making it Happen with data.
4. Strengthened capacity to sustain improvements in maternal and newborn health service
delivery. By the end of 2015 sixty health care workers will be trained in Quality Improvement
in Maternal and Newborn Care.
5. Evidence generated by programme disseminated in order to inform national, regional and
global agenda.
The Centre for Maternal and Newborn Health (CMHN) at the Liverpool School of Tropical Medicine
(LSTM) serves as the global coordinating centre for the MiH Programme.
Making it Happen Programme in Malawi:
The Making it Happen Programme in Malawi will be implemented in four districts between 2013 and
2015: Mangochi, Mulanje, Mwanza and Neno.
In total, 64 facilities have been targeted to receive EOC/NC training, including District Hospitals,
Health Centres and Community Hospitals for the respective districts. In October 2012 a baseline
survey was conducted within each of the 64 facilities.
The results identified 375 health care providers working within maternity services for whom the
training is applicable. The programme also aims to train 50 master trainers who are able to deliver
the EOC/NC training across Malawi. To date 39 master trainers have been trained.
Making it Happen with data workshops will also be carried out to improve the record keeping and
monitoring capacity of facilities and they will aim to train 106.
BASELINE SURVEY RESULTS AND GRAPHS:
Under the Making it Happen Programme (MiH) baseline surveys were conducted in 2012 for 64
health care facilities. Of these, 7 health care facilities are designated to provide Comprehensive
EmONC and 57 are designated to provide Basic EmONC services. The survey identified that 4/7
CEmONC facilities (57%) were able to provide all nine required signal functions and only 5/57
BEmONC facilities (9%) were able to provide all seven required signal functions. The total number of
deliveries was 15,286 (BEmOC= 9015 and CEmOC= 6,271) in the previous 3 months of the baseline
surveys. The total number of Health Care Providers working in maternity area was 351 (BEmOC=189
and CEmOC=162). The Case Fatality Rate in all the facilities was 2.54 ((BEmOC=0.38 and
CEmOC=3.94). The Still Birth Rate in all the facilities was 1.89 (BEmOC=1.31 and CEmOC=2.71).
Graphs:
Figure1: Number of facilities surveyed; facilities identified for intensive M&E:
Number of facilities surveyed
Number of facilities
60
50
40
Type of facility
30
20
Facilities for intensive
M&E
10
0
BEmOC
CEmOC
Type of facility
Figure 2: Number of deliveries in the facilities:
Number of deliveries
Number of deliveries
15000
10000
Number of
deliveries
5000
0
BEmOC
CEmOC
Type of facility
Country Information
Malawi is a sub-Saharan African country bordered to the north and northeast by the United Republic
of Tanzania; to the east, south, and southwest by the People’s Republic of Mozambique; and to the
west and northwest by the Republic of Zambia.
The country is divided into three regions: the Northern, Central, and Southern Regions. There are 28
districts in the country. Six districts are in the Northern Region, nine are in the Central Region and
thirteen are in the Southern Region. Administratively, the districts are subdivided into traditional
authorities (TAs), presided over by chiefs. Each TA is composed of villages, which are the smallest
administrative units, and the villages are presided over by village headmen (MDHS, 2010)1. Malawi
has a population of about 15.4 million (World Bank, 2011)2.
1
National Statistical Office (NSO) and ICF Macro. 2011. Malawi Demographic and Health Survey 2010. Zomba, Malawi, and
Calverton, Maryland, USA: NSO and ICF Macro.
2 World Bank data. 2011. http://data.worldbank.org/country/malawi(accessed June 2013).
Key MNH Indicators





Maternal Mortality Ratio: 460/100,000 live births (2010) *4
% Skilled Birth Attendance: 71 (2012) **4
% Contraceptive Prevalence Rate: 46 (2012) +4
Total fertility rate: 5.7 (2011) ++4
Ante-Natal Care (at least one visit): 95 (2012) **4
*: WHO statistics, 2013 http://apps.who.int/gho/data/kenya: Trends in Maternal Mortality: 1990 to 2010. WHO, UNICEF, UNFPA and the
World Bank. Geneva, World Health Organization, 2012 (http://whqlibdoc.who.int/publications/2012/9789241503631_eng.pdf).
**: WHO global database on maternal health indicators, 2013 update. Geneva, World
Health Organization (http://www.who.int/gho).
+: World Contraceptive Use 2012. United Nations, Department of Economic and SocialAffairs, Population Division, 2012. WHO regional,
income-group and global aggregates refer to 2010. The methodology for the aggregates is available in World ContraceptiveUse 2012 and
in the technical paper: Alkema, et al. National, regional and global levels and trends in contraceptive prevalence and unmet need for
family planning between 1990 and 2015: a systematic and comprehensive analysis (forthcoming).
++: World Population Prospects: the 2010 Revision. New York, Population Division, Department of Economic and Social Affairs, United
Nations Secretariat, 2011.
Map of Malawi illustrating target regions and distribution of health care facilities for MiH
The Making it Happen Programme in Malawi will be implemented in the Southern Region between
2012 and 2015.
Organisation of Health Care delivery
In Malawi, nearly all formal health care services are provided by three main agencies: MoH provides
about 60%; the Christian Health Association of Malawi (CHAM) provides 37% and the Ministry of
Local Government (MLG) provides 1%. Other providers, namely private practitioners, commercial
companies, Army and Police provide 2% of health services. Health services are provided at three
levels: primary, secondary and tertiary. At primary level, services are delivered through rural
hospitals, health centres, health posts, outreach clinics and community initiatives such as Drug
Revolving Funds (DRFs). District hospitals and CHAM hospitals have some specialist functions that
provide secondary level health care services. The secondary level facilities are the referral level for
the primary level for surgical back-up services mostly for obstetric emergencies, general medical and
paediatric in-patient care for common acute conditions. The tertiary level provides services similar to
those at the secondary level along with a small range of specialist surgical and medical intervention.
Human Resource for Health
Malawi’s human resource shortages are somehow comparable to other countries in the region
although they are lagging behind. At 0.02 physicians and 0.59 nurses per 1,000 population, Malawi’s
human resource situation was worse off in 2004 compared to countries such as Zambia, Kenya,
Zimbabwe, Uganda and South Africa. The latest statistics show that out of the 33,766 workers in the
MoH, clinicians (doctors, clinical officers and medical assistants) constitute 4.9%, nurses constitute
13.2%, technicians and other health staff including patient attendants constitute 23.3%. A 2007
census of health workers in Malawi also reported a population physician ratio of 1:53,176; 1:2964
for nurses and 1:7,959 for all clinicians. This was, however, below the least health workforce ratio
and the least human resource skills mix ratio as recommended by the World Health Organization3.
Maternal Mortality Ratio (MMR) and Under-five Mortality Rate
The Maternal Mortality Ratio (MMR) for Malawi decreased from 630 per 100,000 live births in 2005
to 460 per 100,000 live births in 20104. Under five mortality is 112/1,000 live births (MDHS, 2010)1.
Maternal and Newborn Health Situation
The Total Fertility Rate (TFR) is estimated to be 5.74. As expected, women’s education is strongly
associated with fertility. The TFR decreases from 6.9 births for women with no education to 2.1
births for women who have completed secondary or higher education. The contraceptive prevalence
rate for married women in Malawi has increased from 13% in 1992 to 46.1% in 20114.
3
LSTM, RCOG and Malawi MoH. (2012) Making it Happen. Draft Proposal for Malawi; September 2012.
The Maternal Mortality Ratio (MMR) for Malawi decreased from 630 per 100,000 live births in 2005
to 460 per 100,000 live births in 20104. Infant Mortality has decreased from 134 per 1000 live births
in 1992 to 66 per 1000 live births in 2010. The stillbirth rate in 2009 was 24 per 1000 births. Infant
mortality has dropped from 98 per 1000 live births in 2000 to 53 per 1000 live births in 2011. There
is a strong association between infant mortality and mother’s education ranging from 42 deaths per
1,000 live births amongst children of mothers who had completed secondary or higher education
and 71 deaths per 1,000 live births amongst children of mothers with no education.
Currently, the neonatal mortality rate (NMR) is estimated at 33 deaths per 1,000 live births and it is
higher in rural areas (34/1,000) compared to urban areas (30/1,000). It is also higher among male
children (38/1,000) compared to female children (30/1,000). There was an increase in women
delivering at health centres from 57.2% in 2004 to 73% in 2010.
According to the zonal reports, data from district maternal death audits shows that sepsis and post
partum haemorrhage are the most likely causes of death in the majority of mortality cases based at
health facilities. Unlike the MDGs relating to child health, the maternity MDG targets are unlikely to
be met without significant additional investment to increase access to Emergency Obstetric Care
(EmOC) for many more pregnant women, and a similar investment in family planning to reduce the
total fertility rate. Using data from the 2010 EmOC survey, it is estimated that only half of the births
requiring emergency care are receiving such care.
The Government of Malawi through the Ministry of Health has underpinned strategies towards
expanding health services for mothers and children less than 5 years so as to increase accessibility. It
is equally working towards improving quality of the health services and making it well integrated.
Towards this end the government is working together with national and international partners in
providing better services particularly to women of reproductive age and children.
Skilled Birth Attendance and Emergency Obstetric and Newborn Care
95% of women age 15-49 received antenatal care (ANC) from a skilled attendant (doctor, clinical
officer, nurse or midwife) during their last pregnancy. 83% of women received ANC services from a
nurse or midwife, 12% from a doctor or clinical officer, 2% from an unskilled attendant and 1% from
a traditional birth attendant. 2% of women did not receive any ANC services.
73% of births in Malawi are delivered in a health facility; 24% of births occur at home.
71% of births in the five years preceding the survey were assisted by a skilled attendant (doctor,
clinical officer, and nurse midwife), 11% by a doctor or clinical officer and 61% aided by a nurse or
midwife. In the absence of a skilled attendant, a traditional birth attendant was the next most
common person assisting at delivery (14%).