Republic of Malawi
Ministry of Health
Malawi 2010 EmONC Needs Assessment
Final Report
UNICEF
UNFPA
WHO
AMDD
December 2010
TABLE OF CONTENTS
List of Tables and Figures................................................................................................. iv
List of Acronyms...............................................................................................................x
Foreword..........................................................................................................................xii
Acknowledgments............................................................................................................xiii
Executive Summary........................................................................................................ xv
Chapter 1: Introduction................................................................................................... 1
1.1 Geography, history and administration..................................................................... 1
1.2 Social economic situation.......................................................................................... 1
1.3 Malawi health care delivery system.......................................................................... 2
1.4 Maternal and newborn health in Malawi.................................................................. 3
Chapter 2: Methodology................................................................................................. 7
2.1 Survey overview ....................................................................................................... 7
2.2 Establishment of country core team......................................................................... 7
2.3 Finalisation and submission of research protocol...................................................... 8
2.4 Selection of facilities.................................................................................................. 8
2.5 Module adaptation and pre-testing ......................................................................... 10
2.6 Completion of national information module............................................................ 10
2.7 Data collector training............................................................................................... 11
2.8 Research ethics.......................................................................................................... 12
2.9 Data collection........................................................................................................... 12
2.10 Data entry and analysis........................................................................................... 13
2.11 Quality assurance.................................................................................................... 16
2.12 Limitations of the survey......................................................................................... 17
Chapter 3: Emergency Obstetric and Newborn Care Indicators in Malawi ..................... 18
3.1 Indicator 1: Availability of EmONC Services............................................................ 18
3.2 Indicator 2: Geographic distribution (national and sub-national) of EmONC
Facilities...................................................................................................................... 28
3.3 Indicator 3: Proportion of all births in health facilities............................................. 32
3.4 Indicator 4: Met need for EmONC services............................................................. 34
3.5 Indicator 5: Caesarean section as a proportion of all births ..................................... 36
3.6 Indicator 6: Direct obstetric case fatality rate (DOCFR) ........................................... 38
3.7 Indicator 7: Intrapartum and very early neonatal death rates................................... 42
3.8 Indicator 8: Proportion of maternal deaths due to indirect causes............................ 42
3.9 Recommendations................................................................................................... 44
Chapter 4: Facility Infrastructure, Transport and Communication, and User Fees........... 46
4.1 Ratio of beds to 1000 deliveries................................................................................ 46
4.2 Availability of electricity and water........................................................................... 48
4.3 Availability of emergency communication and transport.......................................... 52
4.4 Time to nearest first referral level with surgical capacity.......................................... 54
4.5 User fees for services and recovery schemes............................................................ 57
4.6 Recommendations..................................................................................................... 58
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Chapter 5: Human Resources........................................................................................... 59
5.1 Health facility staffing levels and recommended levels............................................... 59
5.2 Basic and comprehensive EmONC training................................................................ 69
5.3 Availability of health worker cadres 24/7.................................................................. 70
5.4 Regulatory policies and practice on the frontline...................................................... 70
5.5 Ratios of health workers to expected births and the population................................80
5.6 Recommendations ....................................................................................................81
Chapter 6: Availability of Drugs, Equipment and Supplies............................................... 86
6.1 Management and stock outs of drugs .................................................................... 86
6.2 Essential drugs ..................................................................................................... 92
6.3 Guidelines, supplies and medical equipment in labour & delivery and maternity
wards....................................................................................................................... 94
6.4 Operating theatre and equipment............................................................................. 98
6.5 Laboratory equipment and supplies for blood transfusion......................................... 98
6.6 Recommendations....................................................................................................... 98
Chapter 7: Performance of Other MNH Services and Procedures..................................... 99
7.1 Overview of maternal and newborn services in all facilities....................................... 99
7.2 Length of stay for women after a normal delivery...................................................... 101
7.3 Provision of other essential services in facilities that provide delivery care................. 101
7.4 Recommendations .................................................................................................102
Chapter 8: Case Reviews.............................................................................................. 104
8.1 Partograph reviews................................................................................................ 104
8.2 Caesarean delivery reviews.................................................................................... 108
8.3 Maternal death reviews.......................................................................................... 114
8.4 Recommendations................................................................................................. 118
Chapter 9: Interview with Service Providers................................................................ 120
9.1 Pregnancy and delivery care....................................................................................120
9.2 Unsafe abortion and sexual violence...................................................................... 122
9.3 Newborn care........................................................................................................ 123
9.4 Training and recent delivery of services ................................................................ 124
9.5 Competency in newborn resuscitation................................................................... 128
9.6 Recommendations ...................................................................................................128
Chapter 10: Discussion and Recommendations........................................................... 130
Appendix (Tables)......................................................................................................... 132
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List of Tables and Figures
Chapter 1: Introduction and Background
Table 1.1: Maternal mortality in Eastern, Central and Southern Africa: Levels
and Trends 1990-2008......................................................................................................... 4
Chapter 2: Methodology
Table 2.1: Distribution of surveyed facilities according to facility type by
district and sector............................................................................................................. 9
Table 2.2: List of adapted Modules.......................................................................................10
Table2.3: Weighting procedures for calculation of population-based EmONC indicators...14
Chapter 3: Emergency Obstetric and Newborn Care Indicators
Table 3.1: Signal functions used to identify basic and comprehensive EmONC
services.............................................................................................................................. 18
Table 3.2: Distribution of EmONC facilities by sector and facility type............................. 20
Table 3.3: Percent of facilities that performed each signal functions in last 3
months ................................................................................................................................22
Table 3.4: Percentage of facilities that did not provide the signal functions in the last 3
months and reasons for not providing, by function (among facilities that do deliveries)....23
Table 3.5: Number and percent of hospitals that did not perform each signal function
among hospitals lacking 1 or 2 signal functions................................................................. 24
Table 3.6: Number and percent of health centres that did not perform each signal
Function among hospitals lacking 1 or 2 signal functions.................................................. 25
Fig. 3.1: Percent of facilities using parenteral oxytocics.................................................... 25
Fig. 3.2: Percent of facilities using parenteral anticonvulsants.......................................... 26
Fig. 3.3: Percent of facilities that removed retained products........................................... 27
Table 3.7: Percent of facilities that performed assisted vaginal delivery in last 12
months............................................................................................................................... 28
Fig. 3.4: Map of Malawi showing fully functioning basic and comprehensive sites........... 30
Fig. 3.5: Map of Malawi showing partially functioning sites............................................ 31
Table 3.8: Percentage of births attended in all facilities and EmONC facilities, by region
(EmONC Indicator 3).........................................................................................................32
Fig. 3.6: Proportion of births in institutional and EmONC facilities.................................. 34
Table 3.9: Type of facilities where deliveries took place.................................................. 34
Table 3.10: Percentage of women with major direct obstetric complications treated in all
facilities and EmONC facilities, by district ........................................................................ 35
Table 3.11: Percent of women with expected major direct obstetric complications
treated in surveyed facilities............................................................................................ 36
Table 3.12: Percentage of all births by caesarean section in all facilities by district........... 37
Table 3.13: Percentage of institutional deliveries by caesarean section by sector.............38
Table 3.14: Direct obstetric case fatality rate in all facilities and EmONC facilities
by district........................................................................................................................... 39
Fig. 3.7: Percent distribution of direct causes of maternal deaths................................... 40
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Fig. 3.8: Cause specific case fatality rates of direct obstetric complications.................... 41
Table 3.15: Numeric and percent distribution of all maternal deaths, by type of facility....42
Table 3.16: Percent distribution of maternal deaths due to indirect causes in all
facilities and EmONC facilities........................................................................................... 43
Fig. 3.9: Percent distribution of maternal deaths by direct, indirect or unknown cause..... 44
Chapter 4: Facility Infrastructure, Transport and Communication and User Fees
Table 4.1: Ratio of maternity beds and couches to 1000 deliveries, by facility type/sector
and region ......................................................................................................................... 47
Table 4.2: Percent distribution of surveyed facilities according to primary source of
electricity........................................................................................................................... 49
Table 4.3: Percent distribution of surveyed facilities according to primary source of
water.................................................................................................................................. 51
Table 4.4: Percent distribution of surveyed facilities with functional mode of
communication.................................................................................................................. 53
Table 4.5: Percent distribution of surveyed facilities with functional mode of
Transport............................................................................................................................ 54
Table 4.6: Number of facilities by time to nearest surgical facility, by type of facility,
and region ......................................................................................................................... 55
Table 4.7: Percent of facilities charging women separately for selected items................. 57
Chapter 5: Human Resources
Table 5.1: MOH recommended staffing levels for institutions................ ........................ 61
Table 5.2: CHAM recommended staffing levels for institutions.............. ........................ 62
Table 5.3: National targets and number of selected health worker cadres currently
working in surveyed facilities............................................................................................ 63
Fig. 5.1: National level targets for selected health worker cadre in surveyed facilities...... 65
Fig. 5.2: Central hosp. targets for selected health worker cadre in surveyed facilities....... 66
Fig. 5.3: District hosp. targets for selected health worker cadre in surveyed facilities....... 67
Fig. 5.4: CHAM hosp. targets for selected health worker cadre in surveyed facilities........ 68
Fig. 5.5: Govt. health centre targets for selected health worker cadre in surveyed
facilities............................................................................................................................ 68
Fig. 5.6: CHAM health centre targets for selected health worker cadre in surveyed
facilities............................................................................................................................69
Table 5.4: Total number of health workers currently working, who left and who were
posted in the last 12 months, by type of facility and cadre of health worker ................... 70
Table 5.5: Number and percentage of health centres staffed with at least 2
midwives and 2 medical assistants, by district................................................................ 71
Table 5.6: Regulatory policies for basic and comprehensive EmONC signal functions), by
signal function and health worker cadre......................................................................... 73
Table 5.7: Percentage of hospitals and health centres that provided EmONC signal
functions by health worker cadre.................................................................................... 75
Figure 5.7: Percentage of facilities with at least one health worker who could perform
the signal function (including newborn blood transfusion) ............................................. 78
Table 5.8: Percentage of hospitals and health centres that provided other
essential services or procedures, by health worker cadre ............................................ 80
Figure 5.8: Ratio of midwives and skilled birth attendants to 100 expected births............82
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Chapter 6: Availability of Drugs, Equipment and Supplies
Figure 6.1: Status of drug stock cards ........................................................................ 84
Figure 6.2 Stock out status of oxytocin at hospitals and health centres ........................ 84
Figure 6.3 Stock out status of ergometrine at hospitals and health centres................... 85
Figure 6.4 Stock out status of magnesium sulphate at hospitals and health centres....... 86
Figure 6.5 Stock out status of ketamine at hospitals and health centres....................... 87
Figure 6.6 Stock out status of atropine at hospitals and health centres........................ 87
Table 6.1: Percentage of facilities that had contraceptives and other drugs, by type of
facility (among facilities with a pharmacy/supply of medicine).................................... 89
Table 6.2: Percentage of facilities that had the indicated guidelines maternity
ward by type of facility............................................................................................ 90
Table 6.3: Percentage of facilities that had the indicated materials for infection
prevention in maternity area by type of facility......................................................... 91
Table 6.4: Percentage of facilities with basic and emergency newborn supplies and
equipment in the maternity area, by type of facility ................................................... 92
Chapter 7: Performance of Specific Procedures and other MNH Services
Fig. 7.1: Percentage of surveyed facilities providing selected services, by
district and facility type/sector................................................................................ 96
Table 7.1: Percentage of facilities providing selected services, by district and facility
type/sector.............................................................................................................97
Figure 7.2: Percentage of facilities that did not perform other essential services in
the last 3months, by service and type of facility ........................................................99
Chapter 8: Case Reviews
Table 8.1: Use of the partograph among all facilities, by type of facility..................... 101
Table 8.2: Percent distribution of women with partographs according to hours
between first exam and delivery, by type of facility ................................................. 102
Table 8.3: Number of women with partographs and times those key measurements
were taken and recorded, by hours between first exam and delivery .........................103
Table 8.4 Partograph assessment by progress of labour and augmentation, by type of
facility.................................................................................................................. 104
Table 8.5: Partograph assessment by progress of labour and type of delivery and foetal
outcome............................................................................................................... 105
Table 8.6: Percent distribution of facilities where caesarean delivery reviews were
performed according to number of cases reviewed, type of facility, sector and EmONC
status................................................................................................................... 106
Table 8.7: Percent distribution of women whose caesarean deliveries were reviewed
according to the indication for surgery, type of caesarean, and use of partograph among
emergency caesareans, by sector........................................................................... 107
Table 8.8: Number of women whose caesarean deliveries were reviewed and their
indications, by type of caesarean and whether the partograph was use.................... 109
Figure 8.1: Time lapse between the decision to perform a caesarean and actual surgery
............................................................................................................................ 110
Table 8.9: Percent distribution of women whose deaths were reviewed according
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to primary cause of death, by facility type................................................................ 112
Table 8.10: Percent distribution of women whose deaths were reviewed according to
age, location of delivery, type of delivery and condition of newborn ........................... 114
Chapter 9: Interviews with Service Providers
Table 9.1: Knowledge scores related to select maternity care, by health worker cadre...118
Table 9.2: Knowledge scores related to abortion care and care for victims of sexual
violence, by health worker cadre ................................................................................... 120
Table 9.3: Knowledge scores related to newborn care and morbidity, by health worker
cadre ............................................................................................................................... 121
Table 9.4: Percentage and number of providers who reported training in various services
and percentage of those trained who provided the service in the past 3 months, by
health worker cadre........................................................................................................ 123
Table 9.5: Knowledge scores related to diagnosis and management of birth asphyxia
among midwives and nurses with either training or experience in neonatal resuscitation
........................................................................................................................................ 125
Tables in Appendix
Chapter 2: Methodology
Table 2.1A: Members of the country core team.............................................................129
Table 2.2A: List of technical experts............................................................................130
Table 2.3A: Survey teams.............................................................................................. 131
Table 2.4A: Data entry clerks........................................................................................ 133
Chapter 3: Emergency Obstetric and Newborn Care Indicators
Table 3.1A: Distribution of facilities according to EmONC status, by district .................. 134
Table 3.2A: Availability of EmONC facilities per 500,000 population by district
and type ......................................................................................................................... 136
Table 3.3A: EmONC facilities, classified according to 3 months or 12 months, by
district ........................................................................................................................... 138
Table 3.4A: List of facilities surveyed and signal functions performed in the last
3 months ........................................................................................................................ 139
Table 3.5A: Percent distribution of health centres by number of signal functions
missing by sector and district ........................................................................................ 151
Table 3.6A: Percent distribution of hospitals by number of signal functions missing
by sector, facility type and district ................................................................................. 152
Table 3.7A: Percentage of facilities that administered parenteral oxytocics in
the last 12 months, by type of oxytocic, type of facility and sector .............................. 153
Table 3.8A: Percentage of facilities that administered parenteral anticonvulsants
in the last 12 months, by type of medication, facility type and sector .......................... 154
Table 3.9A: Percentage of facilities that removed retained products in the last 12
months, by method, type of facility and sector .............................................................. 155
Table 3.10A: Numeric and percent distribution of direct and indirect
complications and maternal deaths ............................................................................... 156
Table 3.11A: Stillbirth and very early neonatal death rate in all facilities and
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in EmONC facilities, by district ...................................................................................... 157
Chapter 4: Facility Infrastructure, Transport and Communication and User Fees
Table 4.1A: Percentage of facilities with a functional mode of communication
by district ..................................................................................................................... 159
Table 4.2A: Percentage of facilities with a functional mode of transport, by district ...... 161
Table 4.3A: Percent distribution of facilities according to their system of waiving
maternity fees for poor women, by district ................................................................... 162
Chapter 5: Human Resources
Table 5.1A: Percentage of hospitals and health centres with health workers
present on-duty and on call during the week and during weekends, by health
worker cadre ................................................................................................................. 163
Table 5.2A: Percentage of hospitals and health centres with at least one health
worker who could perform signal functions by signal function and district .................. 165
Table 5.3A Percentage of hospitals and health centres with at least one health
worker who could perform other essential services or procedure by service and
district ........................................................................................................................... 168
Table 5.4A: Numbers and ratios of midwives and skilled birth attendants (SBA)
to 100 expected births, by district ................................................................................ 171
Table 5.5A: Numbers and ratios of midwives and skilled birth attendants (SBA)
to 5,000 population, by district ..................................................................................... 172
Table 5.6A: Ratios of select cadres of health worker per 100,000 population, by
district ............................................................................................................................ 173
Chapter 6: Availability of Drugs, Equipment and Supplies
Table 6.1A: Percentage of facilities with a supply of medicines with registers and
sources of drugs and supplies, by type of facility ........................................................ 175
Table 6.2A: Percentage of facilities according to mechanisms for ordering drugs,
by type of facility.......................................................................................................... 176
Table 6.3A: Percentage of facilities reporting most common cause of delay of
delivery of supplies, by type of facility/sector ............................................................ 177
Table 6.4A: Percentage of facilities reporting on pharmacy-related items, by type
of facility (among facilities with a pharmacy/supply of drugs).......................................177
Table 6.5A: Percentage of facilities reporting on stock out of ergometrine,
magnesium sulphate, oxytocin, ketamine and atropine, by type of facility
(among facilities with pharmacy/supply of drugs) ...................................................... 178
Table 6.6A: Percentage of facilities that have the drugs related to the signal
functions and emergencies, by type of facility (among facilities with pharmacy/
supply of drugs)............................................................................................................ 180
Table 6.7A: Percentage of facilities that have anaesthetics and other drugs, by type
of facility (among facilities with pharmacy/supply of medicine) ................................... 181
Table 6.8A: Percentage of facilities with basic diagnostics and supplies in the
maternity area, by type of facility ............................................................................. 182
Table 6.9A: Percentage of facilities with items for cervical / perineal repair pack,
delivery set items, dressing instrument set items, and gynaecological
equipment and equipment for other procedures in the maternity area, by type
viii
of facility ........................................................................................................................ 183
Table 6.10A: Percentage of facilities with selected furnishings and amenities
in the maternity area, by type of facility ...................................................................... 184
Table 6.11A: Percentage of facilities with autoclave, sterilization and incineration
items in the maternity area, by type of facility ............................................................ 185
Table 6.12A: Percentage of hospitals with an operating theatre (OT) and among
those with an OT, the percent with select equipment and supplies ............................. 185
Table 6.13A: Percentage of facilities with a laboratory and among those the
percent with equipment and supplies for blood transfusion, by type of facility ............ 186
Table 6.14A: Percentage of facilities with laboratory supplies, by type of facility (among
facilities with a laboratory) ...................................................................................... 187
Chapter 7: Performance of Specific Procedures and other MNH Services
Table 7.1A: Percentage of facilities providing selected services by district..................... 189
Table 7.2A: Median length of stay (hrs) after normal delivery, by facility
type/sector and district deliveries) .............................................................................. 191
Table 7.3A: Percentage of facilities that did not provide the service in last 3
months and reasons for not doing so .......................................................................... 192
Chapter 8: Case Reviews
Table 8.1A: Percent distribution of time spent in facility prior to and following
caesarean delivery and mean duration of stay by type of caesarean, infection
status and indication.................................................................................................... 193
Table 8.2A: Percent distribution of newborn outcomes after caesarean,
by selected characteristics .......................................................................................... 194
Table 8.3A: Percentage of women whose caesareans were reviewed according
to foetal outcome, by indication for caesarean........................................................... 195
Table 8.4A: Percentage distribution of women whose deaths were reviewed
according to time of death, by primary cause of death ............................................... 196
Table 8.5A: Percent distribution of women whose deaths were reviewed
according to EmONC classification of facility where she died, referral status,
day of week death occurred and factors contributing to the death .............................. 197
Chapter 9: Interviews with Service Providers
Table 9.1A: Percent distribution of health providers interviewed and mean number of
deliveries, by health cadre (n=740) ........................................................................... 198
Table 9.2A: Percentage of providers with knowledge of focused antenatal care practices
and which pregnant women are at risk, by health worker cadre ................................. 198
Table 9.3A: Percentage of providers who know when a woman is in labour, what to
monitor, where to record information, and steps of active management of the third
stage of labour (AMTSL), by health worker cadre ...................................................... 199
Table 9.4A: Percentage of providers who know the signs of postpartum haemorrhage
(PPH), how to treat PPH and retained placenta, by health worker cadre...................... 200
Table 9.5A: Percentage of providers who recognize complications of abortion, how to
intervene, and what to do for victims of sexual violence, by health worker cadre........ 201
Table 9.6A: Percentage of providers who know steps of immediate newborn care, signs
of newborn complications and the appropriate responses, by health worker cadre..... 202
ix
Table 9.7A: Place of training, diagnosis and management of birth asphyxia, among
midwives and nurses with either training or experience with neonatal resuscitation.... 203
LIST OF ACRONYMS
AMDD
Averting Maternal Death and Disability
APH
Antepartum Haemorrhage
BEmONC
Basic Emergency Obstetric and Newborn Care
CEmONC
Comprehensive Emergency Obstetric and Newborn Care
CFR
Case fatality rate
CHAM
Christian Health Association Of Malawi
CMED
Central Monitoring and Evaluation Department
CMS
Central Medical Stores
CPD
Cephalo-pelvic disproportion
D&C
Dilatation and Curettage
DFID
Department for International Development Of The United Kingdom
EHP
Essential Health Package
EMOC
Emergency Obstetric Care
EU
European Union
FGD
Focus Group Discussion
GNI
Gross National Income
GNP
Gross National Product
ICPD
International Conference on Population and Development
IV
Intravenous
JICA
Japanese International Cooperation Agency
MDG
Millennium Development Goal
MK
Malawi Kwacha
MMR
Maternal mortality ratio
x
MOH
Ministry of Health
MOLG
Ministry of Local Government
MPRSP
Malawi Poverty Reduction Strategy Paper
MVA
Manual Vacuum Aspiration
NGO
Non-Governmental Organisation
NORAD
Norwegian Agency for Development
NSO
National Statistical Office
PHC
Primary Health Care
PMM
Prevention of maternal mortality
POA
Programme of Action
PPH
Postpartum Haemorrhage
QECH
Queen Elizabeth Central Hospital
RHU
Reproductive Health Unit
SMP
Safe Motherhood Project
TA
Traditional Authority
TBA
Traditional Birth Attendant
UN
United Nations
UNFPA
United Nations Population Fund
UNICEF
United Nations Children's Fund
USAID
United States Agency for International Development
VCT
Voluntary Counselling and Testing
WHO
World Health Organization
xi
FOREWORD
Over the years the Government of Malawi has provided sexual and reproductive health
services, including maternal and newborn health care to the people of Malawi.
The Government with the support from various development partners notably DFID,
UNICEF, UNFPA, WHO, USAID, NORAD, EU, JICA, the World Bank, has implemented safe
motherhood programmes in various districts of the country.
Despite all these efforts, maternal mortality has continued to rise. A number of studies have
helped to shed light on the maternal mortality situation in the country, documenting the
low quality of health care services provided to women during pregnancy, childbirth and the
postnatal period as the main causes and predisposing factors to maternal deaths. These
studies have suggested an urgent need to further strengthen the provision of quality
maternal and newborn health care, in order to reduce the high maternal mortality in
Malawi.
Consequently the Reproductive Health Unit of the Ministry of Health conducted this
assessment, as a follow up to the 2005 EmONC assessment, to determine the capacity of the
health care delivery system to reduce maternal mortality and to propose an action
orientated plan. The assessment was carried out in collaboration and with financial support
from UNFPA, UNICEF and WHO in all districts.
The results of this assessment confirm the findings of previous studies and specifically
identify progress made towards the reduction of maternal mortality, and the availability and
functioning of emergency obstetric and newborn care (EmONC) in Malawi.
This is yet another Government effort to improve health care service delivery for the people
of this country in line with the ICPD Programme of Action, and the MDGs. It is hoped that
the report will guide policy makers, programme managers, development partners, service
providers and communities in their efforts to support the Ministry of Health in its quest to
address maternal and newborn health issues in Malawi.
We thank all those who, in diverse ways, helped to make this assessment a success.
Mr. Willie Samute
Secretary for Health
xii
ACKNOWLEDGEMENTS
The Reproductive Health Unit of the Ministry of Health, under the leadership of Dr. Chisale
Mhango, Director of Reproductive Health, carried out this assessment in collaboration and
with financial support, from UNFPA, UNICEF and WHO in all districts of the country. We
would like to express our sincere gratitude and thanks to these partners for the support,
without which this assessment would not have been possible.
We thank all the numerous institutions and individuals for their encouragement and
support. In particular, the following deserve special mention:




The Honourable Minister of Health, Prof. David Mphande
The Secretary for Health, Mr. Willie Samute, for his encouragement, continued
commitment and direction, and for giving approval for the study
Senior officials of the Ministry of Health for their encouragement
All District Health Officers and their staff, and staff of the various health facilities for
the support during fieldwork.
Koyejo Oyerinde, Laura Harris, Wasihun Gobezie and Aline Mukundwa of AMDD, Columbia
University, New York and Jose Rolando Figueroa of the UNICEF Regional Office, Nairobi,
Kenya deserve special thanks for providing technical support throughout the process. We
are grateful to all the enumerators, supervisors, facilitators, data entry clerks, statisticians,
and support staff for their dedication and commitment without which this assessment could
not have succeeded. Our gratitude also goes to staff of the Reproductive Health Unit for
their support and for coordination of this assessment.
Special gratitude goes to the following organizations and persons involved in the national
EmONC assessment:
MINISTRY OF HEALTH
Dr. Chisale Mhango
Mrs. Fannie Kachale
Mr. Hans Katengeza
Mr. Patrick Naphini
UNICEF
Dr. Aye Aye Mon
Mrs. Grace Mlava
Mr. Nyson Chizani
Dr. Jose Rolando Figueroa (Regional Office)
UNFPA
xiii
Miss Juliana Lunguzi
WHO
Dr. Leslie Mgalula
Mrs. Harriet Chanza
Mr. Reggis Katsande (Regional Office)
COLLEGE OF MEDICINE
Dr. Bonus Makanani
PHARMACY, MEDICINES AND POISONS BOARD
Mr. Aaron Sosola
Mr. Wilford Mathiya
KAMUZU COLLEGE OF NURSING
Mrs. Martha Kamanga
AMDD
Dr. Koyejo Oyerinde
Miss. Laura Harris
Mr. Wasihun Gobezie
Dr. Aline Mukundwa
xiv
Executive Summary
In 2010, the Reproductive Health Unit of the Ministry embarked on a large emergency
obstetric and newborn care (EmONC) facility-based survey that involved all hospitals and
selected health centres belonging to Government, CHAM and the private sector. This was a
follow up needs assessment to the one conducted in 2005 and the objective of this
assessment was to provide evidence of progress compared to the baseline assessment of
2005 which would be useful in determining progress to date in line with the 2007 Road Map
for accelerating the reduction of maternal mortality and morbidity. This needs assessment
would also provide guidance in policy, planning, and (re)prioritization where necessary to
address any gaps and strengthen the health system by continuing to use EmONC as a point
of entry.
A total of 314 facilities were visited between June and July 2010 by 15 teams of health
professionals which included 16 junior doctors, 4 clinical officers and 25 nurse midwives.
The final analyses were based on 299 facilities that provided deliveries in the twelve months
preceding the survey. Two independent consultants (a statistician and a technical
coordinator) managed the survey while AMDD provided technical support throughout all
phases of the survey. Data for service availability mapping were provided by the CMED
section of the Ministry. Data were double entered into CSPro 4.0 and subsequently
exported into SPSS version 16 and Microsoft Excel for analysis. Data analysis and report
writing involved extensive collaboration and participation of core group members with
support from local and international experts.
EmONC Indicators
One of the key specific objectives of this assessment was to measure the UN EmONC
indicators that determine:
 If the number of fully functioning EmONC facilities is sufficient for the entire
population of the country,
 If the distribution of these facilities is equitable,
 If pregnant women access these facilities for delivery,
 If women with major obstetric complications access these facilities,
 If enough critical services (e.g. caesarean deliveries, blood transfusion) are being
provided,
 If emergency newborn care is available, and
 If the quality of care is adequate.
A short list of well defined ‘signal functions’, or life-saving interventions, was used to assess
and monitor the level of care that a facility was actually providing. When a facility has
performed all 9 signal functions in the last 3 months, it was designated as fully
comprehensive while performance of all 9 signal functions except surgery and blood
transfusion would designate it as fully basic. The UN guidelines contained in Monitoring
emergency obstetric care: A handbook, recommend that there should be at least 5 EmONC
facilities for every 500,000 population, at least one of which provides comprehensive care.
xv
Given its population, Malawi should therefore have 131 EmONC facilities, out of which 26
should offer services comprehensively. Out of the 89 hospitals that were assessed, there
were only 42 that were offering services comprehensively (i.e. 47%) and out of the 210
health centres assessed, only 5 (i.e. 2%) were offering services at a basic level. Malawi
therefore does not have the recommended number of EmONC facilities per 500,000
population. The results also mean that there has been no improvement from the 2005
assessment in the number of fully functioning EmONC facilities because in 2005, there were
also 42 facilities offering EmONC comprehensively and 8 health facilities nationally offering
EmONC at a basic level. Furthermore, the targets set in the 2007 roadmap of having 50% of
health centres providing Basic EmONC and 80% of hospitals providing comprehensive
EmONC by 2010 are far from being met. However, the Ministry and its partners should be
congratulated for actually surpassing the minimum number of facilities providing
comprehensive care.
Facilities that missed one or two signal functions were designated as partially functioning
facilities. If these facilities were strengthened to fully functioning status, then the number of
health centres providing basic EmONC would increase eleven-fold, to 54 representing 26%
of health centres where as the number of hospitals providing comprehensive EmONC will
increase to 66 representing 74% of hospitals. This makes a case therefore to immediately
strengthen these partially functioning facilities to fully functioning status if the roadmap
targets are to be realised. An important consideration would be to strategically select
hospitals for upgrade to full CEmONC status in order to ensure equitable geographical
distribution of the CEmONC facilities. The signal functions that were often missing included
provision of parenteral anticonvulsants, provision of assisted vaginal delivery (with vacuum
extraction), removal of retained products and manual removal of placenta. Many of these
facilities were also lacking skills and equipment.
An assessment was made to determine if EmONC sites were equitably distributed at district
level. In fact, this wasn’t the case as evidenced by the fact that only two districts in Malawi
(i.e. Phalombe and Mwanza) met the recommended number of EmONC sites per 500,000
population. However, all districts except Nkhotakota have the minimum number of
comprehensive sites which is an improvement from the 2005 assessment in which only 22
out of 27 districts (81%) had the minimum acceptable number of comprehensive sites.
Nationally, 65% of births took place in health facilities and out of these 22% were in EmONC
facilities. From surveyed facilities, hospitals were responsible for 61% of the births while
health centres contributed the remaining 39%. Government facilities accounted for 73% of
births, CHAM facilities accounted for 26% and private sector contributed the remaining 1%.
The 2007 roadmap target of 40% of pregnant women receiving skilled care at delivery by
2010 would only be met if all institutional deliveries were attended to by skilled personnel.
The target of having 40% of deliveries in EmONC facility is yet to be realised.
xvi
Ideally, all women with major obstetric complications should seek medical attention and be
treated, hence, the indicator of met need for emergency obstetric care. Although it is
difficult to predict, for example, who will have a postpartum haemorrhage or prolonged
labour, these and other obstetric complications can be treated. While all pregnant women
who are likely to develop a major obstetric complication should receive treatment, met
need (the percentage of expected complications that receive care in facilities) was only 22%
in EmONC facilities and 50% in all facilities.
To determine if enough critical life-saving procedures are performed, the EmONC indicator
is the proportion of expected births delivered by caesarean (caesarean section rate). A
range between 5% and 15% is considered acceptable assuming both foetal and maternal
indications are included. The EmONC assessment indicates that less than 4% of deliveries in
Malawi were by caesarean delivery. The study also revealed that 57% of institutional
deliveries in the private for-profit sector were resolved by caesarean section compared to
14% in Government and 11% in CHAM.
Quality of EmONC is measured by the direct obstetric case fatality rate, which should be less
than 1%. Nationally, the direct obstetric case fatality was 2% in EmONC facilities and 1% in
all facilities. The reason for the higher rate in EmONC facilities may be a reflection of the fact
that women with obstetric complications are being referred and treated in these facilities.
Cause-specific case fatality rates indicated that the most lethal complications for the mother
were ruptured uterus (7.9%), postpartum sepsis (6.9%), postpartum haemorrhage/retained
placenta (3.9%), ectopic pregnancy (2.4%) and severe pre-eclampsia/eclampsia (1.8%). The
commonest direct causes of maternal deaths were PPH/Retained placenta followed by
postpartum sepsis and ruptured uterus. Most maternal deaths in hospitals (65%) were
caused by direct causes, 27% indirect and 9% unknown causes. On the contrary, most
maternal deaths in health centres (79%) were due to unknown causes and direct causes
were responsible for only 17% of the deaths. This may be attributed to poor record keeping
in health centres as staff may not correctly document the cause of death.
In addition to the case fatality rates, the institutional stillbirth and very early neonatal death
rate was calculated (the number of stillbirths + very early neonatal deaths (< 24hours)
divided by the number of deliveries that occurred in the facility). This rate was 37 deaths per
1000 deliveries in EmONC facilities and 29 deaths per 1000 deliveries in all facilities.
Accurate classification and recording of newborn deaths remains a challenge when
computing this indicator.
Finally, the last EmONC indicator is the proportion of maternal deaths due to indirect
causes; in this case it was 26% in EmONC facilities and 24% in all facilities and the primary
indirect cause of death was anaemia. Indirect causes of maternal deaths are likely to be
underestimated owing to the fact that these deaths are not likely to be found in obstetric or
gynaecology wards but rather in medical wards and therefore more difficult to identify and
measure.
xvii
Infrastructure
The availability of electricity and water are critical for the delivery of health services, the
quality and safety of patient care, as well as provider safety. Nationally, 85% of the surveyed
facilities had a source of electricity and out of these, 94% had electricity at time of
interview. Twenty-eight percent of facilities had ESCOM (national power grid) with back-up
generator. All central hospitals, district and CHAM hospitals had ESCOM with back-up
generator. Only 20% of Government rural hospitals and 47% of CHAM rural hospitals had
ESCOM with back-up generator. At health centre level, 24% of Government, 12% of CHAM
and 20% of private health centres had no source of electricity.
The survey revealed that most health facilities use piped water as their primary source of
water. This includes all hospitals except some rural hospitals where a small proportion use
borehole. Two out of seven health facilities surveyed in Chiradzulu and one out of eleven
health facilities surveyed in Thyolo did not have a source of water. All private health centres
use piped water but only 60% of Government health centres and 69% of CHAM health
centres use piped water. The rest of the health centres without piped water tend to use a
borehole. A total of 2% of CHAM health centres reported using a river as their primary
source of water.
Communication and transport are two elements at the centre of a referral system and when
used effectively and expediently can save women’s and their babies’ lives during pregnancy,
childbirth and the postpartum period. Nationally, 21% of surveyed facilities had a
functioning land telephone in maternity while 29% had a functioning land telephone
elsewhere in facility. Fifty-six percent of surveyed facilities reported having a functioning
two-way radio and 24% reported having a functioning public telephone in vicinity. While all
central and district hospitals had functioning land telephone in maternity, only 59% of
CHAM and 40% of private hospitals had functioning land telephones in maternity. Only 7%
of Government health centres and 6% of CHAM health centres had a functioning land line in
maternity.
Two-way radio communication is an effective means of communication between primary
and secondary level facilities, and yet only 45% of CHAM hospitals, 33% of Government rural
hospitals and 20% of CHAM rural hospitals have two-way radio communication. At health
centre level, only 64% of Government health centres and 60% of CHAM health centres have
radio communication. A functioning mode of transport is essential for referral. At national
level, 44% of surveyed facilities reported availability of a functioning motor vehicle
ambulance, 23% reported a functioning motor vehicle and 14% reported availability of a
functioning motor cycle ambulance. At health centre level, 23%, 37% and 40% of
Government, CHAM and private health centres reported availability of a functioning motor
vehicle ambulance. When it comes to referral to nearest surgical facility, time is of the
utmost essence. The data collected shows that in 28% of hospitals, patients have to travel
more than 2 hours to the nearest surgical facility while in 18% of health centres, they have
to travel more than 2 hours to the nearest surgical facility.
xviii
Human resources
The scarcity of skilled human resources is one of the critical challenges for effective delivery
of health services in Malawi. As one way of addressing this gap, Government commissioned
a functional review in 2007 and came up with concrete recommendations for staffing levels
at health centre, community and hospital levels. A similar initiative was undertaken by
CHAM. Using these recommended staffing levels, the needs assessment revealed huge
shortfalls in staff of all cadres except medical assistants. At national level, there are only
40% of targeted enrolled nurses (or nurse/midwife technicians), 47% of the targeted
registered nurses, 28% of the targeted clinical officers and 43% of the targeted medical
officers.
While the target for clinical officers is nearly met at central hospital level (i.e. 89%), there
are only 45% of the required nurse/midwife technicians, 28% of the required registered
nurses and 64% of the required medical officers. At district hospital level, there is severe
shortfall of clinical officers (21%) and medical officers (27%). However, there are 57% of the
targeted nurse/midwife technicians, 39% of the required registered nurses and 37% of the
required medical assistants.
Even though the CHAM targets are less ambitious but more realistic, there are still
shortfalls. CHAM hospitals have severe shortfall (27%) of targeted clinical officers, 63% of
the required nurse/midwife technicians, 55% of the required registered nurses and 36% of
the required medical officers. The situation in health centres is dire as Government health
centres have 14% of the required nurse/midwife technicians and 11% of the required clinical
officers while CHAM health centres have 6% of the required clinical officers and 46% of the
required nurse/midwife technicians. The minimum staffing complement for a health centre
would include two medical assistants and two nurse/midwives. Even at this level, only two
districts (i.e. Neno and Chiradzulu) had at least 50% of their health centres meeting this
target. Most of the health centres surveyed did not have this minimum staffing
complement.
EmONC must be available 24 hours a day, 7 days a week, if maternal and newborn survival is
to be ensured. Emergencies of any kind happen around the clock and the ability to respond
effectively and efficiently to emergencies is of paramount importance. During the Monday
through Friday week, more than 50% of the hospitals reported having on-site medical
doctors (58%), clinical officers (89%), registered nurses (80%), nurse midwife technicians
(93%) and medical assistants (80%). These percentages dropped drastically at night and on
weekends when clinicians including specialists were only available on call.
When it comes to performance of signal functions, regulation is clear regarding the various
cadres allowed to perform signal functions. Registered nurse/midwives and nurse/midwife
technicians have been trained and authorised to perform all the signal functions except
dilatation and curettage, obstetric surgery and provision of anaesthesia. However, nurses
who have received extra training in anaesthesia are authorized to provide anaesthesia. It is
not surprising to find that most signal function performance is by nurse/midwives. An
example is manual removal of placenta in which hospitals depended mostly on
obstetrician/gynaecologist (83%), clinical officers (76%), medical doctors (58%), registered
nurse/midwives (73%) and nurse/midwife technicians (64%).
xix
Drugs, equipment and supplies
All hospitals and health centres (100%) reported having a supply of drugs or a pharmacy at
the time of the survey. Among these facilities, 95.6% of hospitals and 97.3% of health
centres had drug stock cards in place; however, 81.5% of the hospitals and 79.3% of the
health centres had up-to-date drug stock cards. The prominence of ‘stock out at the central
store’ as a cause of the unavailability of drugs and supplies highlights the key challenges for
the Central Medical Stores.
The most commonly reported causes of delay of supplies in Government hospitals were
‘stock out at central store’ (38%), ‘inadequate transport (20%), and ‘administrative
difficulties’ (16%). While in CHAM hospitals, the most common causes of delay were stock
out at central level (30%) and financial problems (20%). Financial, transportation, and other
administrative difficulties were encountered in the procurement of drugs and supplies and
these account for many cases of unavailability of drugs and supplies in health centres. In
general, where health facility pharmacies were available, they were well managed.
However, many districts had poor 24-hour accessibility of health facility pharmacies.
Most hospitals had anaesthetics and most of the important drugs used for the delivery of
EmONC services but most health centres did not have many of the drug groups needed to
function as basic EmONC facilities. Health facilities had sporadic stocks of uterotonic drugs
as evidenced by the fact that 28% of hospitals and 39% of health centres had stock out of
oxytocin in the last 12 months while 42% of hospitals and 36% of health centres had stock
outs of ergometrine. Parenteral oxytocin is the recommended first line drug for prevention
and treatment of postpartum haemorrhage and should ideally be available all the time.
Where oxytocin is not available, parenteral ergometrine or misoprostol can be used.
Misoprostol was commonly found in hospitals (83%) and health centres (78%) and this is
despite the fact that Central Medical Stores has never stocked this drug in the last two years
which raises questions regarding the source of misoprostol. The fact that 34% of hospitals
had stock out of magnesium sulphate in last 12 months and that 46% of health centres
never stocking it represents a missed opportunity for a cheap and simple approach to the
management of one of the main contributors to maternal mortality in Malawi – eclampsia.
Most facilities had clinical guidelines for the common tasks they are required to perform.
Clinical guidelines that were often missing in facilities included those to do with postabortal
care (24%), family planning (52%), focussed antenatal care (52%) and infection prevention
(55%). The availability of clinical guidelines in hospitals was far from desirable.
A vacuum extractor is the instrument of first choice for assisted vaginal delivery and this
procedure should be performed at the health centre level. However, only 33% of health
centres had vacuum extractors. This lack of equipment could explain the very low
percentage of health centres that performed the signal function of assisted vaginal delivery.
All health centres are expected to perform basic neonatal resuscitation but only 29% had
mucus extractors, 73% had face masks and 80% had ventilator bags. This was a recurring
theme with other equipment, drugs and supplies in health centres.
xx
Recommendations
Each chapter concludes with a list of concrete recommendations related to the topic of each
chapter including policy level recommendations and recommendations for program
implementation and these are summarized below:
EmONC Indicators
 The process of upgrading health facilities to fully functioning status requires
identifying which health facilities to target first. Several strategies could be
employed: selecting those health facilities with the high numbers of deliveries,
complications, and referrals; upgrading those that are missing only one or two signal
functions, or strategically selecting health centres located in areas where the gap
between the actual number of functioning EmONC facilities and the target is
particularly high.
 For those facilities that are missing one or two EmONC signal functions, a plan
should be made to ensure that staff have the skills and the enabling environment to
perform the signal functions. Training on Manual removal of placenta, assisted
vaginal delivery, removal of retained products, provision of parenteral
anticonvulsants to all skilled birth attendants in all the partially functioning health
facilities with more than 20 deliveries per month.
 Reduce high DOCFRs and cause-specific CFRs by strengthening the referral system
through 1) development of protocols for senders and receivers, 2) the readiness to
respond at each level, and 3) provision of adequate emergency transport and
communication services.
 Conduct focused research on indirect maternal deaths to determine the mechanisms
by which indirect conditions cause maternal death and programs that could reduce
them.
 Improve HMIS training, supervision and mentoring especially with regard to the
classification of stillbirths, newborn and maternal deaths. In addition, routine
maternal deaths audit should help improve the correct classification of cause of
death.
Infrastructure
 All hospitals and health centres should have at least one source of electricity, and
ideally all should have a generator as a back-up source of electricity.
 All hospitals should have piped water and all health centres should have piped water
or borehole.
 Provide source of water for all facilities that do not have it such as some facilities in
Chiradzulu and Thyolo.
 Ensure piped water in operating theatre for all facilities with operating theatre.
 Emergency patients should be accompanied by a qualified health professional, and
the vehicle used for transport should also have telecommunications available (cell
phone or radio communication).
 The 30 hospitals (mostly rural) that lack an operating theatre should be upgraded,
adding a well-equipped and staffed operating theatre.
 Abolishment of user fees at the point-of-care for all routine and emergency MNH
services in all public and CHAM facilities.
xxi
Human resources
 Increase supply of skilled birth attendants through support for increased enrolment
into training institutions for uptake of nurses and clinicians; as well as the
development of a retention plan for providers already in service.
 Recruit and train 2-3 senior clinicians and midwifes per district to conduct EmONC
trainings in their districts
 Training must be prioritized for implementation in those districts that have had few
or no staff trained in EmONC.
 Human resources who can provide blood transfusions for mothers and newborns
appear to be the biggest gap in districts.
 Prioritize pre-service and in-service training on neonatal resuscitation for all skilled
birth attendants.
 Consideration should be given to bonding of skilled health workers for specific
number of years after graduation to prevent attrition.
Drugs, equipment and supplies
 Improve supply chain management with a focus on the availability of key drugs in all
facilities such as oxytocin, magnesium sulphate, PMTCT drugs and testing kits and
anaesthetics.
 Revise the essential drug list to enable health centres to perform all basic signal
functions especially with respect to the approval of the use of magnesium sulphate
and misoprostol in health centres.
 Conduct supplies and logistics management training to ensure appropriateness and
sustainability of drug procurement and distribution in all rural hospitals and health
centres.
 Ensure availability of health facility inventory registers and ensure that staff is
trained to keep them up-to date.
 Compliance with the stock management guideline to refill when stock falls to third is
needed.
 Maintain an emergency stock of key drugs (in operating theatres, labour wards and
maternity wards) in all facilities even where pharmacies are always open. The
emergency stock could then be refilled at re-order level.
xxii
xxiii
Chapter 1: Introduction
1.1
Geography, History and Administration
Malawi is a landlocked country south of the equator in sub-Saharan Africa. The United
Republic of Tanzania borders it to the North and Northeast, Mozambique to the East, South,
and Southwest, and Zambia to the West and Northwest. The country is 901 kilometres long
and ranges in width from 80 to 161 kilometres. It has a total surface area of 118,484 square
kilometres of which about 80% is land. The remaining area is mostly composed of Lake
Malawi, which is about 475 kilometres long and runs down Malawi's eastern boundary with
Mozambique.
Malawi is divided into three regions: the Northern, Central, and Southern Regions. There
are 28 districts in the country: 6 districts are in the Northern Region, 9 in the Central Region,
and 13 in the Southern Region. Administratively, the districts are subdivided into Traditional
Authorities (TAs). Traditional Authorities are composed of villages, which are the smallest
administrative units. It has a tropical, continental climate with maritime influences. Rainfall
and temperature vary depending on altitude and proximity to the lake. From May to August,
the weather is cold and dry. From September to November, the weather becomes hot. The
rainy season begins in November and continues until April. The geographic terrain is
generally low with small hills scattered all over the country. Most villages are accessible
throughout the year through tarmac or earth roads maintained by the Ministry of Transport
and Public Infrastructure through the National Roads Authority.
The total population of Malawi is 13,077,160 with females comprising 51% of the total
population1. Of these 45% is said to be in the reproductive age bracket (15-49), 19 % is aged
15-24 years, i.e. youths, and 23% are adolescents (10-19). Childbearing starts quite early in
Malawi with a mean age at first childbirth reported at 19 years. Malawi has experienced
rapid urbanization from 8% in 1977 to 15.0% in 2008, which has a great impact on the social
services including health.
1.2
Socio-economic situation
Malawi is one of the poorest countries in the world. Its estimated GNI per capita in 2009
was only US$ 2802. It has a predominantly agricultural economy. Tobacco, tea, and sugar are
the major export commodities. Tobacco exports and development assistance provide the
bulk of Malawi's foreign earnings. Eighty five percent of the population lives in rural areas,
mostly in small farm households. Sixty five percent of the population is defined as poor and
unable to meet its daily consumption needs; The Profile of Poverty in Malawi (2000) shows
1
2
2008 Malawi population and Housing Census, Zomba, Malawi
World bank 2009 accessed on line on 30th October 2010: data.worldbank.org/country/malawi
1
that 65.6% of women are poor as compared with 57.9 of men3. Adult literacy rate for
women in Malawi is 59% as compared to 69% of men4.
1.3
Malawi Health Care Delivery System
Health care services in Malawi are provided by three main agencies. Government through
the Ministry of Health (MOH) provides about 60%; the Christian Health Association of
Malawi (CHAM) provides 39% plus a small contribution from the private-for-profit health
sector. 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 also through community health initiatives. District and CHAM hospitals
provide secondary level health care services to back up the activities of the primary level
while tertiary hospitals provide secondary level services and specialized services. All
maternity-related services are offered free of charge in Government facilities. Of late,
service agreements between Government and CHAM have resulted in free maternity
services in some CHAM facilities.
Health care resources are unevenly distributed. Only 46% of the population has access to
formal health facility within a 5km radius, and only 20% of the population lives within 25 km
of a hospital (EHP document 2004). Access is worse in rural areas. There is a particularly
significant mal-distribution of health personnel, which favours urban areas, and the
secondary and tertiary levels of care. A Ministry of Health report published in 2003 showed
that half of Malawi's doctors worked in its four central hospitals together with 25% of the
nurses5. While the majority of Malawians live in the rural areas, 97% of clinical officers and
82% of nurses in the public sector are in urban areas6.
Malawi's health system is grossly under-resourced. Per capita expenditure is now about US$
12, which is inadequate for delivery of basic primary health care. In 2002, an extensive
exercise to determine the cost of delivering an "Essential Health Package"(EHP) of wellproven and cost effective health services that would deal with the main burden of disease,
calculated a figure of US$ 17.53 per capita per year7.
1.4
Maternal Health in Malawi
Of the 210 million women that become pregnant every year worldwide, 30 million (15%)
develop complications which lead to death in around 358,000 of them with developing
3
Government of Malawi: Malawi Poverty Reduction and Strategy paper (MPRSP)
2008 Malawi population and Housing Census, Zomba, Malawi
5
Malawi Health Facility Survey. Preliminary presentation of findings. Lilongwe, Malawi, 2003
6
Government of Malawi. Situation analysis on human resource in the light of EHP implementation. June 2003,
Lilongwe, Malawi.
7
Ministry of Health, RHU, Report of a nationwide assessment on emergency obstetric care services in Malawi,
Lilongwe, July 2005
4
2
countries accounting for 99% of these deaths8. The majority of these deaths (80%) are
caused by severe bleeding (21%), unsafe abortion (13%), eclampsia (12%), sepsis (8%) and
obstructed labour (8%)9. For every maternal death, about 30 more suffer serious conditions
that can affect them for the rest of their lives. The tragedy is that almost all of these deaths
are preventable and it is estimated that almost 80% of maternal deaths are avoidable.
However, while many other health indicators have improved in the developing world over
the last decades, maternal mortality and morbidity continue to take a high toll10.
Five years remain until the 2015 deadline to achieve the Millennium Development Goals
(MDG) adopted at the 2000 Millennium Summit. There are two targets for assessing
progress in improving maternal health (MDG 5): reducing the maternal mortality ratio
(MMR) by three quarters between 1990 and 2015, and achieving universal access to
reproductive health by 2015. Closer examination of maternal mortality levels is needed to
inform planning of reproductive health programmes, to guide advocacy efforts and research
at the national and international levels, and to inform decision-making for the achievement
of MDG 5. To be useful for the latter purpose, the country estimates must be internationally
comparable11.
It has been a challenge to assess the extent of progress towards the MDG 5 target due to
the lack of reliable and accurate data on maternal mortality – particularly in developingcountry settings where maternal mortality is high. Recently, the World Health Organization
(WHO), the United Nations Children’s Fund (UNICEF), the United Nations Population Fund
(UNFPA) and the World Bank have published internationally comparable estimates of
maternal mortality for 1990, 1995, 2000, 2005 and 200812. These estimates revise and
improve upon the earlier methodology used. According to these recent estimates, Malawi
has one of the highest rates of maternal mortality in Eastern, Central and Southern African
Region, but has shown decreasing trends since 1990 (Table 1.1). However, similar studies
published elsewhere have shown conflicting results. For instance, a recent review of
maternal mortality for 181 countries, 1980-2008 published in the Lancet in May 2010,
indicated a maternal mortality for Malawi of 743 in 1990, 1662 in 2000 and 1140 in 200813.
8
Trends in Maternal Mortality: 1990 to 2008; WHO, UNICEF, UNFPA and the World Bank; 2010
9
UNFPA 2001, http://www.unfpa.org/mothers/facts.htm.
10
Ministry of Health, RHU, Report of a nationwide assessment on emergency obstetric care services in
Malawi, Lilongwe, July 2005
11
Trends in Maternal Mortality: 1990 to 2008; WHO, UNICEF, UNFPA and the World Bank; 2010
12
Trends in Maternal Mortality: 1990 to 2008; WHO, UNICEF, UNFPA and the World Bank; 2010
13
Hogan, M.C., Foreman K.J., Naghavi, M. Et al. Maternal mortality for 181 countries, 1980-2008: a systematic
analysis of progress towards millennium development Goal 5, Lancet, May 8, 2010, vol 375
3
Table 1.1: Maternal mortality in Eastern, Central and Southern Africa: Levels and Trends
1990-2008 (Source: WHO, UNICEF, UNFPA & World Bank; Trends in maternal mortality
1990 to 2008; 2010)
MMR - (Maternal deaths per 100,000 live births)
1990
1995
2000
2005
2008
Angola
1,000
1,000
880
720
610
Botswana
83
130
310
280
190
Burundi
1,200
1,200
1,200
1,100
970
Congo
460
520
590
590
580
Congo DR
900
910
850
740
670
Kenya
380
460
560
580
530
Lesotho
370
340
470
570
530
Madagascar
710
680
580
490
440
Malawi
910
830
770
620
510
Mozambique
1,000
890
780
640
550
Namibia
180
170
220
240
180
Rwanda
1,100
1,400
1,100
720
540
South Africa
230
260
380
440
410
Swaziland
260
220
340
440
420
Tanzania, UR
880
920
920
860
790
Uganda
670
690
640
510
430
Zambia
390
490
600
560
470
Zimbabwe
390
450
670
830
790
Country
4
A number of studies have helped to shed light on the high rates of maternal mortality in
Malawi. An in-depth confidential inquiry into 312 institutional maternal deaths that
occurred in 2001 in the Southern Region of Malawi showed that roughly two thirds of
deaths were due to direct obstetric causes, whilst one third were due to indirect causes.
The majority of direct maternal deaths were due to sepsis, obstructed labour and ruptured
uterus, obstetric haemorrhage (APH and PPH), complications of abortion and eclampsia14.
The Malawi Obstetric Quality of Care Assessment (MOQA), which was carried out in
October 2003, in 18 randomly selected health facilities in 4 districts (Ntcheu, Salima, Nsanje
and Karonga) revealed inadequacies in the formulation, dissemination, implementation and
reinforcement of policies and guidelines related to EmOC. Another major finding was the
poor quality of care in terms of service provision, client education and availability of
equipment, drugs and supplies.
The 2005 EmOC needs assessment reported that ruptured uterus and obstructed/prolonged
labour were the most common causes of maternal deaths, accounting together for 36% of
all deaths recorded. This was followed by postpartum sepsis (19%), obstetric haemorrhage
(14%), pre-eclampsia/eclampsia (8%) and complications of abortion (5%)15. A separate
analysis of 81 maternal death audit reports (2005) from various districts in the country
showed that 85% of the deaths took place in rural areas, compared to 15% in urban areas.
Since 1997 to date, Government of Malawi, through the Reproductive Health Unit of the
Ministry of Health, and with support from development partners: DFID, WHO, UNICEF,
UNFPA and USAID, has implemented several initiatives in response to the increased
maternal mortality. The initiatives focused on some of the following areas:








Implementation of the Safe Motherhood Project, which was operational in the 12
districts in the Southern Region of Malawi with funding from DFID.
Human resource strengthening through increased intake in pre-service training
institutions and through in-service training of service providers
Development of Obstetric Life Saving Skills trainers’ and service providers’ manuals.
In-service training of health workers in Obstetric Life Saving Skills, Infection
Prevention and Maternal Death Audit.
Updating of curricula for Nurses/Midwife technicians to include all 7 BEmONC signal
functions.
Provision of communication materials including installation of radio communications
and bicycle and motorised ambulances.
Increasing number of BEmONC sites
Upgrading hospitals, health centres and maternity units to equip them with standard
utilities;
14
Ratsma, Y.E. 2003. Why more mothers die. The confidential enquiries into institutional maternal deaths in
the Southern Region of Malawi, 2003.
15
Ministry of Health, RHU, Report of a nationwide assessment on emergency obstetric care services in Malawi,
Lilongwe, July 2005
5


Making maternal deaths notifiable and institutionalising routine maternal death
reviews and
Development of integrated manual for BEmONC targeting enrolled nurse/midwives
and medical assistants.
Despite all the above efforts maternal morbidity and mortality in Malawi has remained high.
The Government of Malawi would like to know why maternal morbidity and mortality
remains high, and what actions are needed to reduce the number of women developing
complications and dying during pregnancy and childbirth.
It is against this background that Government of Malawi felt the need to conduct a followup EmONC needs assessment which will inform the country on the progress that has been
made this far with the following specific objectives:
a) Provide evidence of progress compared to the baseline assessment of 2005 which
will be useful in determining progress to date in line with the Road Map for
Accelerating the Reduction of Maternal and Neonatal Morbidity and Mortality
b) Guide policy, planning, and (re)prioritization where necessary to address any gaps
and strengthen the health system by continuing to use EmONC as a point of entry
c) Measure the availability of infrastructure, human resources, drugs, equipment and
supplies to provide basic and comprehensive EmONC
d) Measure knowledge and competency levels of human resources regarding obstetric
and newborn care
e) Carry out case reviews of the partograph, caesarean, and maternal deaths
f) Map EmONC services as part of service availability mapping
g) Establish a mid-term progress assessment for monitoring the availability, geographic
distribution, level of utilization, and quality of EmONC (using the EmONC Indicators)
that will be linked to the Health Management Information System (HMIS) towards
achievement of MDGs 4 & 5 by 2015
h) Formulate concrete recommendations that will guide policy and planning and help
translate the study findings into best practice
6
Chapter 2: Methodology
2.1
Survey Overview
The Malawi 2010 EmONC needs assessment was a national cross-sectional facility-based
survey that utilised 10 modules as data collection instruments. A total of 309 facilities were
surveyed and this included a census of all hospitals and a 50% sample of all health centres
providing deliveries. Data collection took place from 28th June to 24th July 2010. Report
writing was finalized in November 2010.
Activity
May
June
July
Aug
Sept
Oct
Nov
Preparation
Proposal
Submission
Module
Adaptation
Data collector
Training
Data collection
Data entry
Data validation
Data cleaning
Data
analysis
and
Report
writing
2.2
Establishment of Country Core Team
By May 2010, Malawi had already mobilized a country core team to coordinate the needs
assessment by securing funding, resources, access to facilities and ensuring government
representation and legitimacy. The core team was entrusted with the following key tasks:

Participation in the development of the 2010 Malawi needs assessment
schedule

Participation in development of the research protocol including budget
preparation
7










Ensuring that budget is adequate for the needs assessment process
Working closely with the technical coordinator with regard to recruitment
of data collectors and data entry staff and management of field work and data entry
Working closely with the technical coordinator in acquiring an updated list
of health facilities providing maternal and neonatal care
Participation in completing the national information module
Participation in adaptation and pre-testing of modules
Participation in data collector training program
Monitoring progress of field work including making site visits for quality
assurance
Planning, organizing and participation in data analysis workshop
Participation in data cleaning, data interpretation and oversee report
writing
Participation in dissemination of results.
Table 2.1A in the appendix has a list of the country core team that was trusted with
coordination of the Malawi 2010 needs assessment. In addition to the country core team,
local and international technical experts from the public and private sector were engaged to
support various stages of the needs assessment process including protocol development,
module adaptation, data collector training, data analysis, data cleaning, data interpretation,
report writing. Table 2.2A in the appendix has a list of these technical experts.
2.3
Finalisation and Submission of Research Protocol
By mid June 2010, the study protocol was finalized and submitted to the National Health
Sciences Research Committee.
2.4
Selection of Facilities
A three-step approach was followed to identify facilities for the assessment. The first step
involved getting an updated list from DHOs of health facilities in the country providing
maternal and neonatal care. This was facilitated by the Reproductive Health Unit of the
Ministry who communicated by e-mail to all DHOs and Zonal Officers requesting them to
submit an updated list of health facilities in their districts providing maternal and neonatal
care. This letter was also sent to DHOs by fax and consultants followed up with telephone
calls to all DHOs. By Mid June 2010, all DHOs had submitted their list of facilities. In total,
there were deemed to be 534 facilities in Malawi providing MNH services. This list included
92 hospitals and 443 health centres. The second step involved selection of all hospitals in
the country providing MNH services regardless of type and ownership. All the 92 hospitals
were therefore included in the survey.
The third step involved random selection of 50% of all the health centres. This resulted in
222 health centres being selected for the survey. It was later discovered that 5 of these
health centres were either non-functional or providing OPD services only and these were
excluded from the survey, resulting in 217 health centres included in the survey. Even
8
though random sampling was done nationally, there was district level representation. Table
2.1 has the distribution of surveyed facilities according to facility type by district and sector.
It also includes the health centre sampling frame by district and sector.
Table 2.1: Distribution of surveyed facilities according to facility type by district and sector
Hospitals Surveyed
Central
Hospital
District Rural
Hospital Hospital
Other
Hospital1
Health
Centres
surveyed
Health
Total
Centre
number of Sampling
facilities
Frame
surveyed
National
n
4
n
23
n
30
n
35
n
217
309
n
438
Sector
Government
CHAM
Private for profit
4
0
0
23
0
0
15
15
0
3
22
10
160
52
5
205
89
15
317
103
18
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
Thyolo
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
Neno
0
0
0
0
1
0
0
0
0
0
0
1
0
0
0
0
0
1
0
1
0
0
0
0
0
0
0
0
1
1
1
1
1
0
1
1
1
1
1
0
1
1
1
1
1
0
1
0
1
1
1
1
1
0
1
1
1
4
1
3
2
0
2
1
0
1
0
3
4
0
1
2
0
3
0
0
0
1
0
1
0
0
0
0
0
0
0
1
4
1
0
1
0
2
0
9
0
1
0
1
0
3
1
6
0
1
1
1
1
1
0
0
3
5
8
3
17
1
9
7
6
5
5
17
5
16
11
17
9
10
5
11
1
8
10
7
8
6
3
4
5
10
10
8
25
2
12
10
7
9
6
30
10
18
13
21
10
17
7
18
2
11
12
10
10
7
4
5
7
11
15
10
42
1
19
14
9
18
13
41
8
26
22
25
14
21
9
20
3
20
17
15
12
10
8
8
9
1. Other Hospital includes [Private, CHAM, Bwaila, Army and Police]
2.5 Module Adaptation and Pre-testing
The country core team with extensive consultation with technical experts from AMDD,
University of Malawi College of Medicine, Malawi Pharmacy, Medicines and Poisons Board
were responsible for the initial adaptation of modules which was completed by mid June
2010. Adaptation was based on the generic modules from AMDD but also from the tools
used in the 2005 Malawi needs assessment. These modules were further refined during the
data collectors training that took place from 18th to 21st June 2010 and following pre-testing
of these tools. Permission was obtained from the Ministry of Health to use 3 of its facilities
to pre-test the tools. These facilities included Area 18 health centre, Kawale health centre
and Bwaila hospital. The final set of modules was produced as shown in table 2.1 below.
Table 2.2: List of adapted modules
MODULE NUMBER
NAME
0
National Information Module
1
Identification of facility and Infrastructure
2
Human Resources
3
Essential Drugs, Equipment and Supplies
4
Facility Case Summary
5
EmONC Signal Functions and Other Essential Services
6
Partograph Review
7
Provider Knowledge and Competency for Maternal and
Newborn Care
8
Caesarean Review
9
Maternal Death Review
Following finalization of these modules, WHO was requested to procure printing of these
tools ready for data collection exercise.
2.6
Completion of National Information Module
10
The national information module was completed during the planning phase of the
assessment. Information from this module relates to health worker training institutions,
curriculum content and policies and this information was critical for data analysis and
formulation of policy and training recommendations. It also provided a good reference for
the development and adaptation of other modules.
The technical coordinator with support from core group members took responsibility for
completion of this module in consultation with the following organisations:










The RHU section of the Ministry of Health
The National Statistical Office
The Medical Council of Malawi
The Nurses and Midwives Council of Malawi
The CMED section (formally HMIS section) of the Ministry of Health
The HIV and AIDS Section of the Ministry of Health
The College of Medicine
Central Medical Stores
The CHAM secretariat
The Human Resources section of the Ministry of Health
2.7
Data Collector Training
Classroom training was scheduled from 18th to 21st June 2010 at Kalikuti hotel in Lilongwe.
In order to ensure quality in data collection, an inclusion criteria for selection of data
collectors was critical. Data collectors were selected based on familiarity with clinical
settings in Malawi and a good understanding of EmONC services. They were from a
background of nursing, midwifery and clinical medicine. The technical coordinator with
support from core group members recruited 45 data collectors as follows:

16 junior medical doctors

4 experienced clinical officers

25 experienced nurse midwives
For a complete list of data collectors, survey teams and survey facilitators, please see Table
2.4A in the appendix.
The consultants with support from some core group members played a leading role in
coordinating the training program including:

Managing logistics for the training

Preparing training materials i.e. modules, training manuals, facilitation
manuals, laptop and LCD projector

Communicating with participants before training

Preparing training site and field-based training activities

Facilitating the training alongside other trainers.
The methodology used for training included:

Pre-course test

Power point/ Flip chart presentations
11






Classroom reading of participant manual
Group discussions and plenary presentations
Role play sessions
Question and answer sessions
Familiarisation and getting acquainted with all the facility registers used for
maternal and neonatal care
Field visit
Data for service availability mapping were provided by the HMIS section of the Ministry of
Health and because of this it was not necessary to collect information on geographic
coordinates using GPS Units.
2.8
Research Ethics
The data collectors were trained on the principles of confidentiality. No person’s name was
recorded on any of the modules except that of the data collector. Permission was requested
from in-charge of facilities to visit the facility and interview members of staff. Team leaders
carried with them letters of introduction from the Ministry of Health. The facility in-charges’
responses and those of members of staff were always respected. Providers who were
interviewed for module 7 provided oral consent.
2.9
Data Collection
Data collection was scheduled from 28th June to 24th July 2010. Logistics for field work were
finalized and included:

Arranging data collection teams

Arranging team leaders and facilitators for data collection teams

Determining schedules for and routes for data collection teams

Arranging transportation for each data collection team including car, boat,
air travel as appropriate

Determining fuel allocation for each survey team

Informing data collection teams of possible lodging locations while in the
field

Distribution of copies of authorization letter from Ministry of Health to
data collection team leaders to bring to each facility

Sending authorization letters to all DHOs by e-mail and fax

Printing of enough modules for field work and ensuring that there were
extras

Distribution of supplies including pencils, pens, erasers, staplers, big
envelopes (for completed questionnaires), air time vouchers, carrier bags, contact
numbers for facilitators

Developing a plan for collecting completed questionnaires from the field

Scheduling quality assurance and support visits by members of the core
team

Establishing communication plan between team leaders, facilitators and
technical coordinator
12

Tracking completion rate of facilities in each region
From the 314 facilities earmarked for data collection, 5 health centres were not surveyed
because they were either non-functional at the time of the survey or were only offering OPD
services. These facilities were Gogode and Newa in Kasungu District; Malambo in Ntchisi
District and Gombe and Nsabwe in Thyolo district. Because of this, data were only collected
in 309 facilities. From the 309 facilities, it was further discovered that there were no
deliveries being conducted in 2 hospitals (i.e Mumbwe private hospital in Mzimba North and
Elim private hospital in Blantyre) and 8 health centres (i.e. Chilumba Garrison in Karonga;
Nkhorongo in Mzimba North; Machinjiri in Zomba; 24Hours clinic, Area 30, Bunda College,
Chilobwe and Mbwatalika all in Lilongwe). Data were only collected for modules 1-3 in these
facilities.
2.10 Data entry and analysis
Initial data entry was conducted from 5th July to 31st July 2010. The data manager, with
support from AMDD was responsible for preparation of data entry screens in CSPro 4.0.
Experienced data entry clerks were recruited to assist with data entry (Table 2.5A in the
appendix). Subsequently, data was validated through double entry between 16 th to 27th
August 2010. The core team supervised the initial cleaning of data which were then sent to
AMDD for further cleaning. Cleaning continued throughout the process of preparing
preliminary findings.
Cleaned files were exported into SPSS version 16 for analysis. Table shells were developed
and discussed in a core group workshop which took place in Zomba between 9 th to 21st
August 2010. At this workshop, there was representation from MOH (Reproductive Health
Unit), UNFPA, WHO, UNICEF, College of Medicine (Obstetrics and Gynaecology specialist),
Pharmacy, Medicines and Poisons Board, data collection team leader, data collector and
AMDD. This working session served to finalize table shells, identify additional tables, revise
existing tables and prepare a report outline.
Weighting Procedures for the calculation of population based EmONC Indicators in the
2010 Malawi EmONC Needs Assessment:
Since the survey utilized a census of Hospitals and a sample of health centres, weighting and
extrapolation are crucial for the national and district level calculations against UN indicators.
Such weighting is necessary because some of the indicators are population-based. The
weighting was done based on the total number of sampled health centres that do deliveries
(sampled health centres represent nearly 50% of the total number of health centres in the
country). The weighting process considered district level homogeneity of health centres in
terms of service delivery. This means that all health centres in a certain district are given
equal weights keeping other considerations constant (unchanged).
13
For example, if we take number of deliveries as one indicator in district X, the mean number
of deliveries observed in the sampled health centres is proportionate to the mean number
of deliveries in non-sampled health centres in that district. In district X, the total number of
deliveries is the sum of the total number of deliveries in hospitals plus the actual number of
deliveries in sampled health centres and extrapolated number of deliveries in non-sampled
health centres. This means that if there are 5 sampled and 8 non-sampled health centres,
the mean number of deliveries of the 5 sampled health centres is multiplied by the number
of non-sampled health centres (8) and added to the total deliveries found in the 5 sampled
health centres to get the total number of deliveries in ALL health centres in district X. Details
of weighting procedure is indicated in the following matrix of indicators (Table 2.4).
Table 2.3: Weighting Procedures for the calculation of population-based EmONC
Indicators in the 2010 Malawi EmONC Needs Assessment
EmONC
indicator
Description
Acceptable Level
Weighting Procedure for Health Centre
Data
Availability of
EmONC: Basic
EmONC
&
Comprehensive
EmONC
facilities
Ratio
of
EmONC
facilities to the
population
>
5
EmONC First, the weighting procedure for Basic
facilities
per EmONC Health Centres is =
500,000
Actual number of health centres that are
population
sampled that have performed all the 7
>
1 basic signal functions in the past 3 months
comprehensive
facility
per +
500,000
Actual number of health centres that have
population
performed all the 7 basic signal functions in
the past 3 months that are found in the
sample multiplied by total number of nonsampled health centres divided by total
number of sampled health centres.
Finally, the indicator is calculated as
follows:
Ratio of EmONC facilities = Total number
of EmONC facilities (calculated from ALL
hospitals and health centres in the country)
divided by country population
Geographic
distribution
EmONC
facilities
Ratio
of Same as above
of EmONC
facilities
at
sub-national
level
Same as above
calculations
but
District
level
Proportion
all births
of Proportion of Recommended
Expected Birth is calculated from a CBR of
in all births in the level to be set
14
EmONC
indicator
Description
EmONC
facilities
population in locally
EmONC
facilities
Acceptable Level
Weighting Procedure for Health Centre
Data
50 per 100016.
Total number of institutional deliveries in
Malawi =
Total number of deliveries in ALL hospitals
+
Total number of deliveries in sampled
health centres that do deliveries
+
Total number of deliveries in sampled
health centres multiplied by number of
non-sampled health centres, divided by
number of sampled health centres
Proportion of all births in facilities = total
number of institutional deliveries/total
number of expected births
Proportion of all births in population in
EmONC facilities = same calculation in
EmONC hospitals and health centres
divided by Expected births in the
population
Met need for Proportion of 100%
women with
EmONC
major direct
obstetric
complications
treated
in
EmONC
facilities. The
estimated
number
of
women with
direct
obstetric
complications
Same calculation procedures to obtain
TOTAL number of women with Direct
Complications treated in ALL EmONC
health centres in the country/district level;
Met need for EmONC =
(Total number of women with direct
complications
treated
in
EmONC
HOSPITALS
+
16
Ministry of Health, Health Management Information Bulletin Annual Report July – June 2009;
Lilongwe, Malawi.
15
EmONC
indicator
Description
Acceptable Level
is 15% of all
expected
births in the
population.
Weighting Procedure for Health Centre
Data
Total number of women with direct
complications treated in EmONC HEALTH
CENTERS)
divided
by
Expected
complications in the population (which is
15% of expected births)
Caesarean
Proportion of 5-15%
section as a all births in the
proportion of population by
all births
caesarean
section in All
facilities
Direct obstetric Proportion of < 1%
case
fatality women with
major direct
rate
obstetric
complications
who die in
EmONC
facilities
Caesareans were reported only in
HOSPITALS and weighting is not needed for
the HEALTH CENTERS
Intrapartum
and very early
neonatal death
rate
Proportion of To be decided
births
that
results in an
intrapartum or
a very early
neonatal
death within
the first 24 h
in
EmONC
facilities
Since Perinatal mortality rate = (stillbirths
+ very early neonatal deaths)/(number of
deliveries),
Percentage of None set
all maternal
deaths
in
EmONC
facilities due
to
indirect
causes
Total number of Maternal Deaths due to
INDIRECT causes / Total number of
Maternal Deaths is a rate that involves the
same weight in the numerator and
denominator;
Proportion of
maternal
deaths due to
indirect causes
DOCFR (direct obstetric case fatality rate) =
(number of maternal deaths by direct
causes)/(number of women with direct
complications) is a rate that involves the
same weighting procedure as the previous
indicators
Same weighting methodology to calculate
stillbirths and very early neonatal deaths in
All health centres
2.11 Quality Assurance
Quality assurance activities were conducted at field level (i.e. during data collection), before
data entry, after data entry and during data analysis and report writing. During data
16
collection, team leaders played a crucial role in making sure that each module was
completed correctly. In addition to this, a facilitator was assigned to each team. The role of
the facilitator was to provide support to the data collection teams, providing logistical
support where needed, reviewing of the modules for completeness, collection of completed
modules for submission to national coordinator. All members of the core group were
involved in supportive supervision, spot checking and validation of the data.
During data entry, there was close supervision by core group members and in particular the
data manager who was responsible for handling all queries from data entry clerks. After
data entry, all questionnaires were filed systematically in arch back files for easy access and
retrieval during data validation and analysis stages.
After data entry, there was a rigorous cleaning and validation process which involved
AMDD, core group members and consultants to ensure the data was cleaned to the
required standard. Frequencies and cross-tabulations were run to do consistency checks and
maintain quality of the data. In addition, re-categorization was done as part of quality
assurance system. During data analysis, consistency checks were also conducted using table
shells which also involved handling missing facilities for specific questions, synthesising
findings and triangulating with secondary documents for cross-checks and reliability of
responses.
2.12 Limitations of the Survey
DHOs and Zonal Officers were requested to provide an updated list of facilities providing
maternal and newborn care and because of this, a substitute list of health facilities was not
prepared in the event that some facilities did not provide maternity services. It was however
observed during data collection that not all facilities provided maternity services. In this
case, a substitute list would have been essential.
Accessibility and availability of facility records and documentation was a big challenge in
many facilities such that some facilities were visited more than once. Incomplete records
made data aggregation difficult during data collection.
Indirect obstetric complications and maternal deaths due to indirect causes are not likely to
be found in maternity wards and as result, extensive record search outside the maternity
area was necessary in order to get accurate data. Furthermore, complications and deaths
are frequently under-recorded and therefore underestimated. Under-recording of
complications and deaths will also have an impact on the direct obstetric case fatality rate.
In view of the fact that a sample of health centres was taken in the survey, when reporting
at district levels, the extrapolated results (weighted data) may not reflect the true nature of
the data at facility and district level.
17
Chapter 3: Emergency Obstetric and Newborn Care Indicators
The EmONC indicators refer to the availability and use of facilities and the performance of
health care systems in saving the lives of women with obstetric complications17. These
indicators can be used to set priorities for programmes in Malawi as well as to monitor
them. A total of 8 EmONC indicators have been described as follows:
 Indicator 1: Availability of emergency obstetric care: basic and comprehensive care
facilities
 Indicator 2: Geographic distribution of emergency obstetric care facilities
 Indicator 3: Proportion of all births in emergency obstetric care facilities
 Indicator 4: Met need for emergency obstetric care
 Indicator 5: Caesarean sections as a proportion of all births
 Indicator 6: Direct Obstetric case fatality rate
 Indicator 7: Intrapartum and very early neonatal death rate
 Indicator 8: Proportion of maternal deaths due to indirect causes in emergency
obstetric care facilities
The service statistics used to calculate these indicators were based on data collected during
the period June 2009 to May 2010. The data used to determine whether a signal function
was performed were based on the immediate 3 or 12 months period prior to the facility
visit. Extrapolation was done to the National and District levels for the majority of these
indicators as the survey was a census of hospitals and a sample of health centres.
3.1
Indicator 1: Availability of EmONC services
The availability of EmONC services is measured by the number facilities that perform the
complete set of signal functions in relation to the size of the population (Table 3.1).
Table 3.1: Signal functions used to identify basic and comprehensive EmONC services
BASIC SERVICES
COMPREHENSIVE SERVICES
(1) Administer parenteral antibiotics
Perform signal functions 1-7 plus
(2) Administer uterotonic (e.g. parenteral oxytocin)
(8) Perform surgery
caesarean section
(e.g.)
(3) Administer parenteral anticonvulsants for pre-eclampsia and (9) Perform blood transfusion
eclampsia (e.g. magnesium sulphate)
(4) Manual removal of placenta
(5) Removal of retained products (e.g. manual vacuum
extraction, dilatation and curettage)
(6) Perform assisted vaginal delivery (e.g. vacuum extraction)
17
WHO, UNFPA, UNICEF and AMDD., A handbook on monitoring emergency obstetric care., WHO, 2009
18
(7) Perform basic neonatal resuscitation (e.g. with bag and mask)
When staff has carried out the 7 signal functions of basic EmONC in the 3-month period
before the assessment, the facility is considered to be a fully functioning basic facility. The
facility is classified as functioning at the comprehensive level when it offers the 7 signal
functions plus surgery and blood transfusion.
In our context, all hospitals were assessed at a comprehensive level and all health centres
were assessed at a basic level. Hospitals lacking 1 or 2 signal functions were defined as
‘partially functioning’ hospitals while health centres lacking 1 or 2 signal functions were
defined as ‘partially functioning’ health centres. Non-functioning facilities were those that
lacked 3 or more signal functions either at a comprehensive or basic level.
Using the above definitions and Table 3.2, out of 89 hospitals conducting deliveries, there
was a total of 42 fully functioning hospitals (47%), 24 partially functioning hospitals (27%)
and 23 non-functioning hospitals (26%). In addition, out of 210 surveyed health centres
conducting deliveries, there were 5 fully functioning basic health centres (2%), 49 partially
functioning health centres (23%) and 156 non-functioning health centres (74%). Thus, we
can extrapolate that there were 10 fully basic health centres nationally and a total of 52 fully
basic and comprehensive facilities nationally (Table 3.2A). The 5 surveyed health centres
that were fully basic included Namulenga in Mulanje district, Phalombe in Phalombe district,
Katsekera in Ntcheu district, Nkhunga in Nkhotakota district and Kaluluma in Kasungu
district.
It will be noted therefore, that there has been no improvement from the 2005 assessment
in the number of fully functioning EmONC facilities because in 2005, there were also 42
facilities offering EmONC comprehensively and 8 health facilities nationally offering EmONC
at a basic level18. In the 2010 assessment, the number of comprehensive sites has remained
the same while that of basic sites has marginally increased from 8 to 10. Furthermore, the
targets set out in the 2007 roadmap of 50% of health centres offering basic EmONC and 80%
of hospitals offering comprehensive EmONC by 201019 have not been met.
However, when comparing with 2005 data, it is important to note that at this time there
were only 6 basic signal functions and 8 comprehensive signal functions as neonatal
resuscitation was not a signal function then. When the data are analyzed according to the
2005 definition, there is slight variation in numbers of health facilities performing signal
functions at either basic or comprehensive level. We find that there would be 43 fully
functioning hospitals (48%), 23 partially functioning hospitals (26%), 23 non-functioning
hospitals (26%), 5 fully functioning basic health centres (2%), 52 partially functioning health
centres (25%) and 153 non-functioning health centres (73%).
If all partially functioning facilities were strengthened to fully functioning status, then the
number of health centres providing basic EmONC would increase eleven-fold, to 54
18
Ministry of Health, Emergency Obstetric care services in Malawi, Report of a Nationwide Assessment.
Lilongwe, Malawi, July 2005.
19
Ministry of Health, Roadmap for accelerating the reduction of maternal and neonatal mortality and
morbidity in Malawi. Lilongwe, Malawi, March, 2007.
19
representing 26% of health centres where as the number of hospitals providing
comprehensive EmONC will increase to 66 representing 74% of hospitals. This makes a case
therefore to immediately strengthen these partially functioning facilities to fully functioning
status if the roadmap targets are to be realised. An important consideration would be to
strategically select hospitals for upgrade to full CEmONC status in order to ensure equitable
geographical distribution of the CEmONC facilities.
Table 3.2: Distribution of EmONC facilities by sector and facility type
No
of Nonfacilities
functioning
conducting
deliveries
Basic
Hospitals
Health centres
n
89
210
%
26
74
Partial
%
N/A
23
Central Hospital
District Hospital
4
23
0
0
Other Hospitals
Government
CHAM
Private
3
22
7
Rural Hospital
Government
CHAM
Health Centre
Government
CHAM
Private
Comprehensive
Full
%
N/A
2
Partial
%
27
N/A
Full
N/A
N/A
N/A
N/A
0
17
100
83
67
0
71
N/A
N/A
N/A
N/A
N/A
N/A
0
36
14
33
64
14
15
15
53
53
N/A
N/A
N/A
N/A
33
40
13
7
155
50
5
74
74
80
23
24
20
3
2
0
N/A
N/A
N/A
N/A
N/A
N/A
%
47
N/A
For a complete list of health facilities’ EmONC functioning status, by district, together with
missing signal functions, please see Tables 3.1A and 3.4A in the appendix.
Five districts in Malawi do not have a fully comprehensive site and these are Rumphi,
Likoma, Nkhotakota, Nsanje and Neno. Mwaiwathu is the only private hospital providing
EmONC services comprehensively while 3 rural hospitals were offering services
comprehensively i.e. Kabudula in Lilongwe, Monkey Bay and Mulibwanji in Mangochi
district.
UN guidelines recommend that there should be at least 5 emergency obstetric care facilities
(including at least 1 comprehensive facility) for every 500,000 population20. The minimum
20
WHO, UNFPA, UNICEF and AMDD., A handbook on monitoring emergency obstetric care., WHO, 2009
20
acceptable number of comprehensive EmONC facilities is determined by dividing the total
population by 500,000. Multiplying this number by 5 gives the overall minimum acceptable
number of facilities both basic and comprehensive. These numbers are compared with
actual numbers in order to classify the services as fully functioning at either basic or
comprehensive level.
Therefore, Malawi, with a total population of 13,077,160 should have 131 EmONC facilities
out of which at least 26 should be comprehensive. Table 3.2A in the appendix shows that
Malawi only has 52 EmONC facilities (weighted per district) which include 42 comprehensive
hospitals. Therefore, nationally, Malawi only has 40% of the recommended EmONC facilities
per 500,000 population. However, the country has exceeded the recommended number of
comprehensive facilities by 62%. Only 2 districts have the recommended number of EmONC
facilities per 500,000 population i.e. Mwanza and Phalombe. The district targets are shown
in Table 3.2A in the appendix.
This indicator was also calculated based on the performance of the signal functions in the
12-month period prior to the survey. This longer reference period increases the number of
fully functioning facilities. At national level, the number of EmONC facilities increased from
52 to 75 while the number of comprehensive sites increased from 42 to 53. Table 3.3A in
the appendix gives results when the reference period is extended to 12 months and the gap
that remains to achieve the desired number of EmONC facilities.
Performance of Signal Functions
Table 3.3 shows the health facilities that performed signal functions in last 3 months by
facility type. While signal function performance by central hospitals was at 100%, for district
hospitals, it was 100% except for manual removal of placenta and surgery both at 96%.
Parenteral antibiotics, parenteral oxytocics and parenteral anticonvulsants were performed
in almost all the hospitals except private ones. Four signals functions (i.e. provision of
parenteral anticonvulsants, manual removal of placenta, removal of retained products and
assisted vaginal delivery), were poorly performed by health centres regardless of sector.
Table 3.4A in the appendix gives a list of facilities surveyed and signal functions performed
in the last 3 months.
21
Table 3.3: Percent of facilities that performed each signal function in the last 3 months, by type of facility and sector
(among facilities that do deliveries)
National
Total
number of Parenteral
facilities
Antibiotics
that
do
deliveries
%
299
91%
Parenteral
Oxytocics
Parenteral
Anticonvuls
ants
%
99%
%
58%
Signal Function
Manual
Removal
Removal
of
of
Retained
Placenta
Products
%
%
45%
39%
Facility Type
Central Hosp
District Hosp
4
23
100%
100%
100%
100%
100%
100%
100%
91%
100%
96%
100%
100%
100%
100%
100%
100%
100%
96%
Other Hosp
Govt
CHAM
Private
3
22
7
100%
100%
86%
100%
100%
86%
100%
100%
29%
33%
77%
57%
33%
91%
86%
33%
95%
29%
67%
95%
43%
100%
95%
57%
33%
100%
71%
Rural Hosp
Govt
CHAM
15
15
100%
100%
100%
100%
80%
47%
60%
73%
73%
73%
60%
53%
100%
100%
40%
67%
20%
13%
Health Centre
Govt
CHAM
Private
157
48
5
88%
88%
60%
98%
100%
100%
44%
60%
20%
32%
31%
20%
22%
17%
20%
11%
15%
0%
80%
73%
40%
NA
NA
NA
NA
NA
NA
Assisted
Vaginal
Delivery
Neonatal
Blood
Resuscitation Transfusio
n
Surgery /
Caesarea
n
%
31%
%
82%
%
24%
%
20%
22
23
Reasons for not performing signal functions
If a health facility did not perform a signal function, members of staff were asked the reason
for not performing that signal function and more than one reason was allowed to be
reported for non-performance. Signal functions that were not performed commonly
included assisted vaginal delivery (69%), removal of retained products (60%), manual
removal of placenta (55%) and provisional of parenteral anticonvulsants (42%) (Table 3.4).
Table 3.4: Percentage of facilities that did not provide the signal functions in the last 3
months and reasons for not providing, by function
Signal Function
Facilities
that did
not
perform
the
procedur
e in last 3
months
Facilities that responded that the procedure was not provided in the last
3 months due to lack of (multiple responses allowed):
availability training
of human issues
resources
%
%
Parenteral
8%
0%
antibiotics
Parenteral
1%
0%
oxytocics
Parenteral
42%
0%
anticonvulsants
Manual removal 55%
3%
of placenta
Removal
of 60%
7%
retained
products
Assisted vaginal 69%
10%
delivery
Neonatal
17%
0%
resuscitation
Blood
20%
11%
transfusion1
Surgery
34%
20%
1
(caesarean)
1
Only hospitals are included (n = 92)
The
most
common
explanations
supplies/
equipment
/ drugs
manage
ment
issues
policy
issues
no
indicatio
n
%
0%
%
0%
%
0%
%
0%
%
96%
0%
33%
0%
0%
67%
0%
11%
1%
4%
90%
18%
7%
4%
3%
75%
37%
51%
4%
20%
19%
38%
55%
6%
14%
21%
2%
39%
4%
4%
63%
17%
78%
11%
72%
6%
0%
43%
3%
17%
10%
for
non-performance
included
lack
of
supplies/equipment/drugs and training issues. The commonest reason for not providing
oxytocics was ‘no indication’ (67%). For hospitals, the common reasons for not performing
24
blood transfusion were lack of supplies/equipment/drugs (78%), policy issues (72%) and
training issues (17%) while the common reasons for not performing surgery were lack of
supplies/equipment/drugs (43%), lack of human resources (20%) and policy issues (17%).
The fact that 30 out of 92 hospitals assessed (i.e. 33%) did not have an operating theatre
(Table 6.12 in the appendix) may explain why surgery was not performed in 33% of the
hospitals. We find that only 6 out of the 30 rural hospitals providing deliveries (i.e. 20%),
had operating theatre. The 6 rural hospitals with operating theatre were Kabudula, Mitundu
and Mlale in Lilongwe district, Monkey Bay and Mulibwanji in Mangochi district and Ngabu
in Chikhwawa district.
For hospitals lacking 1 or 2 signal functions (i.e. partially functioning hospitals), the
frequently missing signal functions were caesarean delivery, provision of parenteral
anticonvulsants, assisted vaginal delivery, manual removal of placenta and removal of
retained products (Table 3.5). For percentage distribution of hospitals by number of signal
functions missing by sector and district, please refer to Table 3.6A in the appendix.
Table 3.5: Number and percentage of hospitals that DID NOT perform each signal function
among hospitals lacking 1 or 2 signal functions
Signal function
C-1
C-21
Total number of facilities
n
15
n
9
Blood transfusion
Caesarean delivery
Parenteral anticonvulsants
Assisted vaginal delivery
Neonatal resuscitation
Manual removal of placenta
Removal of retained products
Parenteral antibiotics
Parenteral oxytocics
0
4
0
1
1
6
3
0
0
2
6
3
2
1
3
1
0
0
1. Multiple responses allowed. C-1 facilities are missing one signal function; C-2 facilities are missing 2 signal
functions.
Similarly, for partially functioning health centres, the frequently missing signal functions
were provision of parenteral anticonvulsants, assisted vaginal delivery, manual removal of
placenta and removal of retained products (Table 3.6). This is the same as the national
25
trends in missing signal functions. For percentage distribution of health centres by number
of signal functions missing by sector and district, please refer to Table 3.5A in the appendix.
Table 3.6: Number and percentage of health centres that DID NOT perform each signal
function among health centres lacking 1 or 2 signal functions
Signal function
B-1
%
Total number of facilities
Parenteral anticonvulsants
Assisted vaginal delivery
Neonatal resuscitation
Manual removal of placenta
Removal of retained products
Parenteral antibiotics
Parenteral oxytocics
29%
36%
0%
21%
14%
0%
0%
n
14
4
5
0
3
2
0
0
B-21
%
26%
74%
3%
43%
54%
3%
0%
n
35
9
26
1
15
19
1
0
1. Multiple responses allowed. B-1 facilities are missing one signal function; B-2 facilities are missing 2 signal
functions.
Administration of parenteral oxytocics
Nationally, a total of 85% of facilities administered parenteral oxytocics in the last 12
months. Eighty-five percent of these facilities administered only oxytocin, 7% used both
oxytocin and ergometrine, 5% used syntometrine – the ergometrine-oxytocin combination
drug and 3% administered ergometrine. (Fig. 3.1 and Table 3.7A in the appendix).
Fig. 3.1: Percentage of facilities using parenteral oxytocics in last 12 month
26
Administration of parenteral anticonvulsants
Nationally, a total of 81% of facilities administered parenteral anticonvulsants in the last 12
months from which diazepam was commonly used (48%), followed by magnesium sulphate
(30%) and a combination of both magnesium sulphate and diazepam (22%) (Fig. 3.2 and
Table 3.8A in the appendix). Hospitals tend to use magnesium sulphate more than health
centres while health centres opt for diazepam. Only 24% of Government health centres and
17% of CHAM health centres use magnesium sulphate only while diazepam is used at 61%
and 64% of these facilities respectively.
Fig. 3.2: Percentage of facilities using parenteral anticonvulsants in last 12 months
Provision of removal of retained products
Nationally, 52% of facilities performed removal of retained products in the last 12 months
and manual vacuum aspiration was commonly used (52%), followed by a combination of
both manual vacuum aspiration and dilatation and curettage (27%). Misoprostol was used
by 6% of facilities (Fig. 3.3 and Table 3.9A in the appendix).
27
Fig. 3.3: Percentage of facilities that removed retained products in last 12 months
From Table 3.9A in the appendix, we find that in general, hospitals tended to use a
combination of MVA and D&C while health centres nearly always used MVA. This is
consistent with the fact that health centres do not have the capacity to perform D&C or D&E
since these procedures would normally require theatre and sometimes administration of
anaesthesia. Also 100% of health centres in the private sector used MVA.
Provision of assisted vaginal delivery
In all facilities surveyed, the only method used for providing assisted vaginal delivery was by
vacuum extractor. Forceps delivery is not commonly practiced for provision of assisted
vaginal delivery in Malawi. Nationally, 38% of facilities provided assisted vaginal delivery in
the last 12 months. A total of 100% of central and CHAM hospitals, 96% of district hospitals
and 14% of private hospitals provided assisted vaginal delivery (Table 3.7).
28
Table 3.7: Percentage of facilities that performed assisted vaginal delivery in the last 12 months,
by method and sector
Percentage of
facilities that
performed
assisted
vaginal
delivery in last
12 months
Among facilities that
performed assisted vaginal
delivery in last 12 months,
percent that used:
Vacuum extractor only
%
%
National
38%
100%
Facility Type
Central Hospital
District Hospital
100%
96%
100%
100%
Other Hospitals
Government
CHAM
Private
33%
100%
14%
100%
100%
100%
Rural Hospital
Government
CHAM
87%
80%
100%
100%
Health Centre
Government
CHAM
Private
18%
21%
20%
100%
100%
100%
Vacuum extraction is performed less commonly by Government health centres (18%),
CHAM health centres (21%) and private health centres (20%).
3.2
Indicator 2: Geographic distribution (national and sub-national) of EmONC facilities
This indicator is calculated in the same way as the first indicator but takes into consideration
the geographical distribution and accessibility of facilities. This helps programme managers
and planners to gather information about equity in access to services at district level. To
ensure equity and access, all districts should have the minimum acceptable numbers of
EmONC facilities i.e. at least 5 facilities (including at least one comprehensive facility) per
500,000 population.
29
Table 3.2A in the appendix, shows that 26 out of 28 districts in Malawi do not have the
recommended number of EmONC facilities per 500,000 population. In fact, only Phalombe
and Mwanza meet this minimum number. However, all districts except Nkhotakota have the
minimum number of comprehensive sites which is an improvement from the 2005
assessment in which only 22 out of 27 districts (81%) had the minimum acceptable number
of comprehensive sites. Fig. 3.4 is a representation of fully functioning comprehensive and
basic sites while Fig. 3.5 depicts partially functioning comprehensive hospitals and partially
functioning basic health centres.
30
Fig. 3.4: Map of Malawi showing fully functioning Basic and Comprehensive sites
31
Fig. 3.5: Map of Malawi indicating partially functioning sites
32
3.3
Indicator 3: Proportion of all births in EmONC facilities
Indicator 3 is the proportion of all births in an area that take place in EmONC health facilities
(basic or comprehensive). The numerator being the number of women registered as having
given birth in facilities classified as EmONC while the denominator is an estimate of all live
births expected in the area regardless of where the birth takes place. Even though no
minimum acceptable level has been set internationally, it is recommended that at least 15%
of births should occur in EmONC facilities21. Table 3.8 shows the percentage of expected
births attended in all facilities and EmONC facilities by district.
Table 3.8: Percentage of expected births attended in all facilities and EmONC facilities, by
district (EmONC Indicator 3)
Population1
Number of
expected
births2
Number of
births
attended in
facilities3
Percent of
expected
births
Number of
births
attended
in EmONC
facilities
Percent
expected
births
National
13,077,160
653,858
425,678
65%
143,439
22%
District
Mwanza
Chitipa
Salima
Mangochi
Dowa
Chiradzulu
Mulanje
Mzimba
Chikwawa
Ntcheu
Blantyre
Lilongwe
Karonga
Kasungu
Machinga
Zomba
Balaka
Ntchisi
Nkhata Bay
Mchinji
Thyolo
92,947
178,904
337,895
797,061
558,470
288,546
521,391
861,899
434,648
471,589
1,001,984
1,905,282
269,890
627,467
490,579
667,953
317,324
224,872
215,789
456,516
587,053
4,647
8,945
16,895
39,853
27,924
14,427
26,070
43,095
21,732
23,579
50,099
95,264
13,495
31,373
24,529
33,398
15,866
11,244
10,789
22,826
29,353
4270
7177
11536
27409
14394
10423
14604
28034
13978
16065
32549
56804
7715
16824
22518
24930
8364
6934
5298
16800
22210
92%
80%
68%
69%
52%
72%
56%
65%
64%
68%
65%
60%
57%
54%
92%
75%
53%
62%
49%
74%
76%
3,769
2,884
5,072
11,550
7,946
3,993
6,979
11,017
5,533
5,818
11,549
21,781
3,073
6,881
5,127
6,644
3,111
2,117
2,031
4,208
4,861
81%
32%
30%
29%
28%
28%
27%
26%
25%
25%
23%
23%
23%
22%
21%
20%
20%
19%
19%
18%
17%
21
of
WHO, UNFPA, UNICEF and AMDD., Monitoring emergency obstetric care: A handbook, WHO, 2009
33
Population1
Dedza
Phalombe
Nkhotakota
Rumphi
Likoma
Nsanje
Neno
624,445
313,129
303,659
172,034
10,414
238,103
107,317
Number of
expected
births2
31,222
15,656
15,183
8,602
521
11,905
5,366
Number of
births
attended in
facilities3
17751
10118
8444
8014
334
9011
3172
Percent of
expected
births
57%
65%
56%
93%
64%
76%
59%
Number of
births
attended
in EmONC
facilities
Percent
expected
births
5,107
1,684
704
0
0
0
0
16%
11%
5%
0%
0%
0%
0%
of
1. Source of Population Estimates: [Malawi Population Census in 2008]
2. Crude birth rate = 39.5 per 1000 population for national] Source: Malawi Population Census, 2008. However, based on the MOH Annual
Report 2008-9, a crude birth rate of 50 per 1000 population was used to estimate expected births
Proportion of births in health facilities
From the survey, nationally, 65% of births were institutional deliveries which is above the
2010 target set in the roadmap (40%) and already surpasses the 2015 roadmap target
(60%). This figure is also higher than that of 2005 EmONC assessment which was 44%.
Rumphi had the highest rate of institutional deliveries (93%) followed by Machinga (92%),
Chitipa (80%) and Thyolo (76%). The lowest rates were registered in Nkhata Bay (49%),
Dowa (52%), Balaka (53%) and Kasungu (54%).
Proportion of births in EmONC facilities
Nationally, the proportion of births that took place in EmONC facilities was 22% which is
lower than that set in the 2007 roadmap (40%) but slightly higher than the 2005 EmONC
assessment which was at 19%. With the exception of Mwanza which had the highest
proportion of births in EmONC facility at 81%, all districts had very low proportion of births
in EmONC facilities ranging from 32% (Chitipa) to 5% (Nkhotakota). (Table 3.8 and Fig. 3.6).
A possible explanation to the low proportion of births in EmONC facilities could be that the
EmONC facilities that exist are not accessible to the women that need them.
34
Fig. 3.6: Proportion of births in all facilities and EmONC facilities by district
Neno
Nsanje
Likoma
Rumphi
Nkhotakota
Phalombe
Dedza
Thyolo
Mchinji
Nkhata Bay
Ntchisi
Balaka
Zomba
Machinga
Kasungu
EmONC
Karonga
All Facilities
Lilongwe
Blantyre
Ntcheu
Chikwawa
Mzimba
Mulanje
Chiradzulu
Dowa
Mangochi
Salima
Chitipa
Mwanza
0
20
60
40
80
100
Percent
Table 3.9 shows the type of facilities where deliveries took place. Hospitals accounted for
61% of deliveries and health centres 39%. As expected and owing to number of facilities,
most deliveries took place in Government facilities (73%) followed by CHAM (26%) and
35
private 1%. In hospitals, the average institutional delivery is higher in Government, followed
by CHAM and private; while the average delivery is higher in CHAM health centres, followed
by Government and private (Data not shown). This shows the burden is more in
Government hospitals and CHAM health centres. There could be other explanations on why
more women access Government facilities than the rest.
Table 3.9: Type of facilities where deliveries took place in surveyed facilities by facility
type and sector
Type of Facility
Hospital
Health Centre
Sector
Govt
CHAM
Private
Number of Deliveries
%
184,512
120,424
61
39
222,494
80,450
1,992
73
26
1
3.4
Indicator 4: Met need for EmONC services
‘Met need’ is an estimation of the proportion of all women with major direct obstetric
complications who are treated in a health facility providing EmONC (basic or
comprehensive). The direct obstetric complications included in this indicator include
haemorrhage (antepartum and postpartum), prolonged and obstructed labour, postpartum sepsis,
complications of abortion, severe pre-eclampsia and eclampsia, ectopic pregnancy and ruptured
uterus.
The recommendation is that 100% of women estimated to have major direct obstetric
complications should be treated in emergency obstetric care facilities. The number of
women who would have major obstetric complications is estimated as 15% of expected
births during the same period in a specified area. In our case, this figure is 98,079 (i.e. 15%
of 653,858). During the 12-month survey period, a total of 49,524 women with direct
obstetric complications were treated in health facilities resulting in met need of 50%.
Similarly, 21,648 women with complications were treated in EmONC facilities giving a met
need of 22%. The EmONC met need in this assessment is lower than the target in the 2007
roadmap (40%) but slightly higher than the previous assessment (18.5%).
At district level, met need in EmONC facilities was lowest in Nsanje (2%) and highest in
Chitipa (65%). For district distribution of met need, please see Table 3.10.
36
Table 3.10: Percentage of women with expected major direct obstetric complications
treated in all facilities and EmONC facilities, by district (EmONC Indicator 4 - Met Need)
Expected
births1
Expected
complications
National
653,858
98,079
All Facilities
Number
of Met
women with need
direct
complications
treated
in
facility
49,524
50%
District
Balaka
Blantyre
Chikwawa
Chiradzulu
Chitipa
Dedza
Dowa
Karonga
Kasungu
Likoma
Lilongwe
Machinga
Mangochi
Mchinji
Mulanje
Mwanza
Mzimba
Neno
Nkhata Bay
Nkhotakota
Nsanje
Ntcheu
Ntchisi
Phalombe
Rumphi
Salima
Thyolo
Zomba
15,866
50,099
21,732
14,427
8,945
31,222
27,924
13,495
31,373
521
95,264
24,529
39,853
22,826
26,070
4,647
43,095
5,366
10,789
15,183
11,905
23,579
11,244
15,656
8,602
16,895
29,353
33,398
2,380
7,515
3,260
2,164
1,342
4,683
4,189
2,024
4,706
78
14,290
3,679
5,978
3,424
3,910
697
6,464
805
1,618
2,277
1,786
3,537
1,687
2,348
1,290
2,534
4,403
5,010
1,163
6,361
726
1,392
1,063
2,404
1,876
1,744
2,019
51
7,343
1,628
3,221
1,230
1,721
271
2,235
331
577
969
562
1,385
952
1,427
760
1,999
1,743
2,370
49%
85%
22%
64%
79%
51%
45%
86%
43%
65%
51%
44%
54%
36%
44%
39%
35%
41%
36%
43%
31%
39%
56%
61%
59%
79%
40%
47%
EmONC Facilities
Number
of Met
women with need
direct
complications
treated
in
facility
21,648
22%
659
3532
285
533
877
828
1013
840
1409
0
2973
796
1593
398
699
256
1143
0
0
319
43
0
726
409
612
0
1079
626
28%
47%
9%
25%
65%
18%
24%
41%
30%
0%
21%
22%
27%
12%
18%
37%
18%
0%
0%
14%
2%
0%
43%
17%
47%
0%
25%
12%
37
Table 3.11 gives the percentage of women with expected major direct obstetric
complications treated in surveyed facilities by facility type and sector. When it comes to
treatment of women with major direct obstetric complications, nearly half of them are
treated in hospitals and other half in health centres. In terms of sector, most complications
(71%) were treated in government facilities with CHAM contributing 28% (Table 3.11).
Table 3.11: Percentage of women with expected major direct obstetric complications
treated in surveyed facilities by facility type and sector
Number of direct obstetric %
complications
Type of Facility
Hospital
Health Centre
Sector
Govt
CHAM
Private
27,615
21,909
56
44
36,700
11,338
503
71
28
1
3.5
Indicator 5: Caesarean section as a proportion of all births
The proportion of all deliveries by caesarean section in a geographical area is a measure of
access to and use of a common obstetric intervention for averting maternal and neonatal
deaths and for preventing complications such as obstetric fistula. The numerator is the
number of caesarean sections performed in EmONC facilities for any indication during a
specific period while the denominator is the expected number of live births (in the whole
catchment area, and not just in institutions) during the same period.
The optimum caesarean section rate is unknown although WHO guidelines give a range of 515%. The roadmap 2010 target is to have 5% of births delivered by caesarean section. From
the survey, nationally, 3.7% of all institutional deliveries were by caesarean section while in
EmONC facilities, the rate was 3.6%. Even though these rates fall short of the roadmap
target, they are slightly higher than the previous assessment which was at 2.8%. At district
level, the highest rate was recorded in Likoma (10.6%) and lowest in Mulanje 2.0%. Only 4
districts’ rates were within 5-15% i.e. Rumphi (5.1%), Chiradzulu (6.2%), Mwanza (8.7%) and
Likoma (10.6%) (Table 3.12).
38
Table 3.12: Percentage of all expected births by caesarean section in all facilities and in EmONC
facilities, by district (EmONC Indicator 5)
Region
National
District
Balaka
Blantyre
Chikwawa
Chiradzulu
Chitipa
Dedza
Dowa
Karonga
Kasungu
Likoma
Lilongwe
Machinga
Mangochi
Mchinji
Mulanje
Mwanza
Mzimba
Neno
Nkhata Bay
Nkhotakota
Nsanje
Ntcheu
Ntchisi
Phalombe
Rumphi
Salima
Thyolo
Zomba
Expected
births1
653,858
15,866
50,099
21,732
14,427
8,945
31,222
27,924
13,495
31,373
521
95,264
24,529
39,853
22,826
26,070
4,647
43,095
5,366
10,789
15,183
11,905
23,579
11,244
15,656
8,602
16,895
29,353
33,398
All Facilities2
Number of
caesareans
24,044
667
2646
673
899
315
808
1017
467
709
55
3844
940
1333
676
514
402
1765
0
383
682
342
898
434
440
436
803
768
1128
Percent of
expected
births
by
caesarean
3.7%
4.2%
5.3%
3.1%
6.2%
3.5%
2.6%
3.6%
3.5%
2.3%
10.6%
4.0%
3.8%
3.3%
3.0%
2.0%
8.7%
4.1%
0.0%
3.5%
4.5%
2.9%
3.8%
3.9%
2.8%
5.1%
4.8%
2.6%
3.4%
EmONC Facilities
Number
of Percent
of
caesareans
expected births
by caesarean
23,818
3.6%
667
2464
673
899
315
808
1017
467
709
55
3800
940
1333
676
514
402
1765
0
383
682
342
898
434
440
436
803
768
1128
4.2%
4.9%
3.1%
6.2%
3.5%
2.6%
3.6%
3.5%
2.3%
10.6%
4.0%
3.8%
3.3%
3.0%
2.0%
8.7%
4.1%
0.0%
3.5%
4.5%
2.9%
3.8%
3.9%
2.8%
5.1%
4.8%
2.6%
3.4%
1. Expected births are calculated as (population) * 5% considering that CBR = 50 per 1000 population
2. Caesareans are reported only in Hospitals (not weighted because all Hospitals are included in the survey)
Caesarean performance by public and private facilities
The population-based caesarean rate is the preferred indicator but most facilities that
perform caesareans also calculate their own institutional rate. Because hospitals and other
facilities that provide major obstetric surgery differ in terms of their patient mix, whether
they are a referral centre or whether other hospitals are located nearby, no evidence-based
standards exist as a guide about what is the most appropriate institutional caesarean rate.
Nevertheless, Table 3.13 shows that 57% of the deliveries in the private for-profit sector
were resolved by caesarean section compared to 14% and 11% in Government and CHAM
39
sectors, respectively. These results raise questions about why such differences exist and the
implications of associated morbidity, the indication for caesarean, the quality of care that
women receive, and the costs that they and the health system incur.
Table 3.13: Percentage of institutional deliveries by caesarean section by sector
Sector
Caesarean
deliveries
No of
Total
deliveries
%
Govt
17,907
131,762
14%
CHAM
5,547
51,708
11%
Private
590
1,042
57%
Total
24,044
184,512
13%
3.6
Indicator 6: Direct Obstetric Case Fatality Rate (DOCFR)
Direct causes of death are those ‘resulting from obstetric complications of the pregnant
state (i.e. pregnancy, labour and puerperium), from interventions, omissions, incorrect
treatment, or from a chain of events from any of the above’. The direct obstetric case
fatality rate is the proportion of women with direct obstetric complications, or who develop
such complications after admission, that die before discharge. It is used as a rough estimate
to measure the quality of EmONC services by looking at the percentage of direct obstetric
complications seen in EmONC facilities that result in death. The maximum acceptable level
is less than 1%. The Malawi 2010 roadmap target is 2.5%.
In the 12-month period between June 2009 to May 2010, 597 maternal deaths were
recorded in 49,524 women with major direct obstetric complications giving a DOCFR in all
facilities of 1%. Similarly, there were 22,785 women with direct complications in EmONC
facilities and 467 women died giving a DOCFR of 2% in EmONC facilities (Table 3.14). This is
an improvement when compared with the 2005 assessment which was at 3.4%.
At district level, Chitipa and Mwanza had highest rates in all facilities (6%) while Mchinji and
Mwanza had highest rates in EmONC facilities of 8% and 6% respectively. However, one
ought to be cautious when interpreting this indicator because the reliability of DOCFR
depends among other things on correct diagnosis, on the quality and completeness of
record keeping and reporting of maternal deaths and obstetric complications. If very few
maternal deaths are recorded, the quality of care may falsely appear to be good and
conversely, if few complications are recorded, the DOCFR may be artificially high.
Furthermore, the DOCFR may not be such an accurate measure of quality of care. For
instance, owing to various delays, some women arrive at a health facility in such poor
40
conditions that no matter how good obstetric services are, health workers will still not be
able to save them.
A significant number of maternal deaths occurred in central hospitals. Out of 597 maternal
deaths nationally, Queen Elizabeth central hospital (QECH) contributed 121 deaths (20%),
Kamuzu central hospital contributed 17 deaths (3%), Mzuzu central hospital contributed 12
deaths (2%) and Zomba central hospital contributed 10 deaths (2%). In total, the central
hospitals contributed 160 maternal deaths (27%), the district hospitals contributed 252
deaths (42%), other hospitals contributed 92 deaths (15%) and health centres contributed
93 deaths (16%). For Blantyre district, close to 90% of maternal deaths took place at Queen
Elizabeth central hospital. Even though QECH is the largest referral and teaching hospital in
the country, there may be other contributing factors to the large number of maternal
deaths at this facility which need to be explored.
Table 3.14: Direct obstetric case fatality rate (DOCFR) in all facilities and EmONC facilities, by
district (EmONC Indicator 6)
National
District
Balaka
Blantyre
Chikwawa
Chiradzulu
Chitipa
Dedza
Dowa
Karonga
Kasungu
Likoma
Lilongwe
Machinga
Mangochi
Mchinji
Mulanje
Mwanza
Mzimba
Neno
All Facilities
Number of
Number
women with
of
direct
maternal
complications1 deaths by
direct
cause1
49,524
597
1,163
6,361
726
1,392
1,063
2,404
1,876
1,744
2,019
51
7,343
1,628
3,221
1,230
1,721
271
2,235
331
4
137
11
6
59
3
20
14
26
0
48
0
41
34
27
16
25
0
DOCFR2
1%
0%
2%
2%
0%
6%
0%
1%
1%
1%
0%
1%
0%
1%
3%
2%
6%
1%
0%
EmONC Facilities
Number of
Number
DOCFR2
women with
of
direct
maternal
complications1
deaths
by direct
cause1
22,785
467
2%
659
3532
285
533
877
828
1013
840
1409
0
2973
796
1593
398
699
256
1143
0
4
133
8
6
7
3
19
14
26
0
40
0
41
33
24
16
15
0
1%
4%
3%
1%
1%
0%
2%
2%
2%
0%
1%
0%
3%
8%
3%
6%
1%
0%
41
Nkhata Bay
Nkhotakota
Nsanje
Ntcheu
Ntchisi
Phalombe
Rumphi
Salima
Thyolo
Zomba
577
969
562
1,385
952
1,427
760
1,999
1,743
2,370
18
14
12
18
9
15
5
13
5
16
3%
1%
2%
1%
1%
1%
1%
1%
0%
1%
319
43
0
726
409
612
0
1079
626
1137
10
0
0
18
9
9
0
13
3
16
3%
0%
0%
2%
2%
1%
0%
1%
0%
1%
1. Direct complications and direct causes of maternal death include: APH, PPH, obstructed/prolonged
labour, ectopic pregnancy, severe abortion complications, retained placenta, ruptured uterus,
postpartum sepsis, severe pre-eclampsia/eclampsia. Excludes "other" direct complications or causes
of death including non-severe abortion complications. Weighted for total number of health centres.
2. DOCFR (direct obstetric case fatality rate) = (number of maternal deaths by direct causes)/(number
of women with direct complications)
Fig. 3.7: Distribution of direct causes of maternal deaths in health facilities (n=529)
The most common direct cause of maternal deaths was PPH/Retained placenta (34%)
followed by postpartum sepsis (17.8%) and ruptured uterus (11%) (Table 3.10A in the
appendix and Fig. 3.7).
42
Cause-specific case fatality rates
Ruptured uterus had the highest cause-specific case fatality rate at 7.87%, followed by
postpartum sepsis (6.85%), PPH/Retained placenta (3.86%) and ectopic pregnancy (2.38%)
(Fig. 3.8). These findings are similar to the 2005 assessment although the actual rates are
different.
Fig. 3.8: Cause-specific case fatality rates of direct obstetric complications
Type of facility where women died
The distribution of the causes of maternal death varied depending upon the types of facility
(Table 3.15). Most maternal deaths in hospitals (65%) were caused by direct causes, 27%
indirect and 9% unknown causes. On the contrary, most maternal deaths in health centres
(79%) were due to undocumented causes and direct causes were responsible for only 17%
of the deaths. As earlier observed, the large percentage of undocumented causes of deaths
in health centres may be due to poor record keeping and inaccurate diagnosis.
43
Table 3.15: Percent distribution of all maternal deaths, by type of facility
Hospitals
Health centres
n
517
32
175
21
%
65%
4%
22%
3%
n
12
5
5
1
%
17%
7%
7%
1%
58
94
50
7%
12%
6%
0
0
1
0%
0%
1%
40
15
32
5%
2%
4%
0
0
0
0%
0%
0%
Indirect causes
Malaria
HIV/AIDS - related
Anemia
Other indirect causes
214
31
58
63
62
27%
4%
7%
8%
8%
3
0
0
3
0
4%
0%
0%
4%
0%
Unknown causes
68
9%
56
79%
TOTAL
799
100%
71
100%
Direct causes
APH
PPH/Retained placenta
Obstructed/prolonged
labour
Ruptured uterus
Postpartum sepsis
Severe pre-eclampsia /
eclampsia
Complications of abortion
Ectopic pregnancy
Other
3.7
Indicator 7: Intrapartum and very early neonatal death rates
Indicator 7 is the proportion of births that result in a very early neonatal death (<24 hours)
or an intrapartum death (fresh stillbirth) in a health facility. The objective of this indicator is
to measure the quality of intrapartum and newborn care and it is recommended that
newborns under 2.5 Kg be excluded as low birth weight infants have a high fatality rate in
most circumstances. No standard has been set to depict maximum acceptable level.
At the national level, the stillbirth and very early neonatal death rate was 29.35 per 1000
live births in all facilities and 37.13 at EmONC facilities (Table 3.11A in the appendix). Ntcheu
had the lowest rate at 9.27/1000 while Nkhata Bay had the highest rate of 68.15/1000.
Challenges exist in data collection for this indicator in view of problems with classification
and recording of newborn deaths.
3.8
Indicator 8: Proportion of maternal deaths due to indirect causes
Indirect causes of death result from ‘previous existing disease or disease that developed
during pregnancy and which was not due to direct obstetric causes, but which was
aggravated by the physiologic effects of pregnancy. This indicator does not have an
acceptable level. Instead, it highlights the larger social and medical context and has
implications for intervention strategies, especially in addition to emergency obstetric care,
44
that target the major indirect causes that kill many women of reproductive age. Examples of
indirect causes are infections (e.g. malaria, HIV, hepatitis), tuberculosis, cardiovascular
diseases, psychiatric illnesses (e.g. suicide and violence), epilepsy, diabetes. Table 3.16 gives
the percentage of maternal deaths due to indirect cause as 26% in EmONC facilities and 24%
in all facilities.
Table 3.16: Percentage of maternal deaths due to indirect causes in all facilities and EmONC
facilities, by district (EmONC Indicator 8)
National
Number
of
maternal
deaths
due to
indirect
cause1
206
All Facilities
All
Percent of
maternal
all
2
deaths
maternal
deaths
due to
indirect
cause
857
24%
EmONC Facilities
Number
All
Percent of
of
maternal
all
2
maternal
deaths
maternal
deaths
deaths due
due to
to indirect
indirect
cause
cause1
202
787
26%
District
Balaka
2
14
14%
2
6
33%
Blantyre
51
201
25%
51
199
26%
Chikwawa
0
38
0%
0
38
0%
Chiradzulu
0
8
0%
0
8
0%
Chitipa
0
14
0%
0
8
0%
Dedza
4
7
57%
4
7
57%
Dowa
6
26
23%
6
26
23%
Karonga
1
16
6%
1
16
6%
Kasungu
8
44
18%
8
34
24%
Likoma
0
0
0%
0
0
0%
Lilongwe
34
85
40%
34
85
40%
Machinga
1
1
100%
1
1
100%
Mangochi
1
54
2%
1
44
2%
Mchinji
6
40
15%
6
40
15%
Mulanje
20
47
43%
20
45
44%
Mwanza
0
17
0%
0
17
0%
Mzimba
12
57
21%
12
32
38%
Neno
0
0
0%
0
0
0%
Nkhata Bay
4
17
24%
4
16
25%
Nkhotakota
8
30
27%
8
30
27%
Nsanje
2
14
14%
2
14
14%
Ntcheu
0
18
0%
0
18
0%
Ntchisi
2
11
18%
2
11
18%
Phalombe
2
13
15%
2
11
18%
Rumphi
10
15
67%
8
13
62%
Salima
12
25
48%
11
24
46%
Thyolo
7
12
58%
7
12
58%
Zomba
13
33
39%
12
32
38%
1. Includes maternal deaths due to malaria, anaemia, HIV-AIDS related and other indirect causes
2. Includes all recorded maternal deaths in facilities regardless of cause (also includes maternal
deaths due to unknown cause)
45
Fig. 3.9 and Table 3.10A in the appendix show the proportion of maternal deaths due to
direct and indirect causes. Indirect causes of maternal deaths are likely to be
underestimated owing to the fact that these deaths are not likely to be found in obstetric or
gynaecology wards but rather in medical wards and therefore more difficult to identify.
Fig. 3.9: Percent distribution of maternal deaths by direct, indirect or unknown cause
(n=529).
3.9




Recommendations
The process of upgrading health facilities to fully functioning status requires
identifying which health facilities to target first. Several strategies could be
employed: selecting those health facilities with the high numbers of deliveries,
complications, and referrals; upgrading those that are missing only one or two signal
functions, or strategically selecting health centres located in areas where the gap
between the actual number of functioning EmONC facilities and the target is
particularly high.
For those facilities that are missing one or two EmONC signal functions, a plan
should be made to ensure that staff have the skills and the enabling environment to
perform the signal functions. Training on Manual removal of placenta, assisted
vaginal delivery, removal of retained products, provision of parenteral
anticonvulsants to all skilled birth attendants in all the partially functioning health
facilities with more than 20 deliveries per month.
Reduce high DOCFRs and cause-specific CFRs by strengthening the referral system
through 1) development of protocols for senders and receivers, 2) the readiness to
respond at each level, and 3) provision of adequate emergency transport and
communication services.
Conduct focused research on indirect maternal deaths to determine the mechanisms
by which indirect conditions cause maternal death and programs that could reduce
them.
46

Improve HMIS training, supervision and mentoring especially with regard to the
classification of stillbirths, newborn and maternal deaths. In addition, routine
maternal deaths audit should help improve the correct classification of cause of
death.
47
Chapter 4: Facility infrastructure; transport, communication and user fees
Most aspects of infrastructure are important for all patient services in surgical, medical and
obstetric/gynaecological wards and are crucial prerequisites for effective maternal and
newborn care. Infrastructure development is one of the key areas that was earmarked for
strengthening in the 2007 roadmap proposal.
4.1 Ratio of beds to 1000 deliveries
According to the Essential elements of obstetric care at first referral level (WHO, 1991),
there should be 24 beds per 1000 deliveries in the maternity ward (for both prenatal and
postnatal patients). The labour and delivery room should have 6-8 beds. Overall, therefore,
the standard would be approximately 30-32 beds for every 1000 deliveries at a facility that
would be considered 'first referral level.' This is the equivalent to a district level hospital for
about 100,000 population. Table 4.1 shows the overall number of beds, maternity beds and
delivery couches and the ratio of beds to 1000 deliveries for each region and facility
type/sector. Ratios are used to make comparisons more easily.
48
Table 4.1: Ratio of maternity beds and couches to 1000 deliveries, by facility type and sector
Sector & Facility
Type
Total
number
of
facilities
Number of
institutional
deliveries
National
309
304,936
17,699
5,686
875
Ratio of
maternity
beds to
1,000
deliveries
19
Facility Type
Central Hospital
District Hospital
4
23
17,804
81,292
3,005
5,137
648
1,204
38
150
36
15
2
2
39
17
Other Hospitals
Government
CHAM
Private
3
22
10
13,152
39,527
1,042
279
3,649
206
168
894
47
18
88
12
13
23
45
1
2
12
14
25
57
Rural Hospital
Government
CHAM
Private
15
15
NA
19,514
12,181
NA
644
1,155
NA
214
345
NA
52
45
NA
11
28
NA
3
4
NA
14
32
NA
Health Centre
Government
CHAM
Private
160
52
5
90,732
28,742
950
2,258
1,312
54
1,467
659
40
353
110
9
16
23
42
4
4
9
20
27
52
All beds
Number of:
Maternity
beds
Delivery
bed
Ratio of delivery
beds to 1,000
deliveries
Ratio of maternity
beds plus delivery
beds to 1,000
deliveries
3
22
Deliveries from the period of July 2009 to March 2010
49
Three ratios of beds to 1000 institutional deliveries were calculated: 1) maternity beds (for
prenatal and postnatal care), 2) delivery couches (for delivery), and 3) the sum of maternity
beds and delivery couches. At the national level, there were 19 maternity beds for every
1000 deliveries, 3 delivery couches for every 1000 institutional deliveries, and a total of 22
maternity beds plus delivery couches per 1000 institutional deliveries. Hospitals had larger
ratios than health centres of maternity beds to deliveries, but smaller ratios of couches to
deliveries. In addition to the recommendation that there should be 24 maternity beds for
every 1000 deliveries, 6-8 beds are needed for labour and delivery. In sum, this would mean
between 30 and 32 beds for every 1000 deliveries. First referral level facilities are similar to
district hospitals and generally provide comprehensive EmONC services. Most facilities
surveyed fall below this standard of 30-32 beds for every 1000 deliveries except for central
hospitals, CHAM rural hospitals and private facilities.
4.2 Availability of electricity and water
The availability of electricity and water are critical for the delivery of health services, the
quality and safety of patient care, as well as provider safety. Nationally, 85% of the surveyed
facilities had a source of electricity and out of these, 94% had electricity at time of
interview. Twenty-eight percent of facilities had ESCOM with back-up generator. All central
hospitals, district and CHAM hospitals had ESCOM with back-up generator. Only 20% of
Government rural hospitals and 47% of CHAM rural hospitals had ESCOM with back-up
generator. At health centre level, 24% of Government, 12% of CHAM and 20% of private
health centres had no source of electricity (Table 4.2).
50
Table 4.2: Percent distribution of surveyed facilities according to primary source of electricity and, among those with electricity, percent
with functioning electricity at time of interview, by facility type/sector and district
No
electricity
ESCOM
only
%
33%
Generator
only
Solar only
ESCOM with
back-up
generator
Number of
facilities with
any source of
electricity
Among facilities
with any source
of electricity,
percent with
electricity at time
of interview
%
94%
Total number
of facilities
National
%
15%
%
1%
%
23%
%
28%
%
85%
Facility Type
Central Hosp
District Hosp
0%
0%
0%
0%
0%
0%
0%
0%
100%
100%
100%
100%
100
100%
4
23
Other Hosp
Govt
CHAM
Private
0
0
0
0%
0%
10%
0%
5%
0%
0%
0%
0%
100%
100%
90%
100%
100%
100%
100%
95%
100%
3
22
10
Rural Hosp
Govt
CHAM
Private
0%
0%
NA
73%
47%
NA
0%
0%
NA
7%
7%
NA
20%
47%
NA
100%
100%
NA
100%
93%
NA
15
15
NA
Health Centre
Govt
CHAM
Private
24%
12%
20%
38%
40%
40%
1%
0%
20%
34%
31%
0%
4%
17%
20%
76%
88%
80%
88%
98%
100%
160
52
5
309
51
No
electricity
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
Thyolo
Mulanje
Chikwawa
Nsanje
Phalombe
%
20%
10%
30%
13%
28%
0%
0%
30%
14%
11%
0%
7%
0%
17%
8%
29%
10%
12%
43%
0%
0%
36%
33%
20%
0%
0%
ESCOM
only
%
0%
70%
30%
38%
28%
0%
33%
30%
0%
22%
17%
27%
40%
33%
38%
19%
30%
35%
29%
56%
0%
45%
25%
30%
60%
29%
Generator
only
Solar only
%
0%
0%
0%
0%
0%
100%
0%
0%
0%
0%
0%
0%
0%
0%
0%
10%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
%
60%
0%
30%
25%
20%
0%
42%
20%
71%
33%
33%
13%
40%
33%
38%
19%
30%
18%
0%
11%
50%
0%
17%
20%
20%
43%
ESCOM with
back-up
generator
%
20%
20%
10%
25%
24%
0%
25%
20%
14%
33%
50%
53%
20%
17%
15%
24%
30%
35%
29%
33%
50%
18%
25%
30%
20%
29%
Number of
facilities with
any source of
electricity
%
80%
90%
70%
88%
72%
100%
100%
70%
86%
89%
100%
93%
100%
83%
92%
71%
90%
88%
57%
100%
100%
64%
67%
80%
100%
100%
Among facilities
with any source
of electricity,
percent with
electricity at time
of interview
%
100%
100%
71%
100%
94%
100%
75%
100%
100%
100%
100%
93%
80%
93%
100%
93%
100%
100%
100%
100%
100%
100%
88%
88%
90%
86%
Total number
of facilities
5
10
10
8
25
2
12
10
7
9
6
30
10
18
13
21
10
17
7
18
2
11
12
10
10
7
52
No
electricity
Balaka
Neno
%
0%
0%
ESCOM
only
%
25%
80%
Generator
only
%
0%
0%
Solar only
%
25%
0%
ESCOM with
back-up
generator
%
50%
20%
Number of
facilities with
any source of
electricity
%
100%
100%
Among facilities
with any source
of electricity,
percent with
electricity at time
of interview
%
100%
80%
Total number
of facilities
4
5
53
Sources of water by type of facility and ownership
Table 4.3 shows that most health facilities use piped water as their primary source of water.
This includes all hospitals except some rural hospitals where a small proportion use
borehole. All private health centres use piped water but only 60% of Government health
centres and 69% of CHAM health centres use piped water. The rest of the health centres
without piped water tend to use a borehole. A total of 2% of CHAM health centres reported
using a river as their primary source of water. While health facilities in most districts have a
source of water, two out of seven health facilities surveyed in Chiradzulu and one out of
eleven health facilities surveyed in Thyolo had no source of water.
Table 4.3: Percent distribution of facilities according to their primary source of water, by district
and facility type/sector
No water
Borehole
Well
River
Other
%
Piped
water
%
%
%
%
%
Total number
of facilities
n
1%
73%
23%
2%
0%
0%
309
Facility Type
Central Hospital
District Hospital
0%
0%
100%
100%
0%
0%
0%
0%
0%
0%
0%
0%
4
23
Other Hospitals
Government
CHAM
Private
0%
0%
0%
100%
100%
100%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
3
22
10
Rural Hospital
Government
CHAM
Private
0%
0%
NA
87%
93%
NA
13%
7%
NA
0%
0%
NA
0%
0%
NA
0%
0%
NA
15
15
NA
Health Centre
Government
CHAM
Private
2%
0%
0%
60%
69%
100%
34%
25%
0%
3%
4%
0%
0%
2%
0%
1%
0%
0%
160
52
5
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
100%
60%
60%
50%
56%
50%
50%
60%
43%
89%
83%
0%
40%
20%
50%
40%
50%
50%
30%
57%
11%
17%
0%
0%
20%
0%
0%
0%
0%
10%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
4%
0%
0%
0%
0%
0%
0%
5
10
10
8
25
2
12
10
7
9
6
National
Facility Type and
Ownership
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
54
No water
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
Thyolo
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
Neno
Borehole
%
Piped
water
%
Well
River
Other
%
%
%
%
Total number
of facilities
n
0%
0%
0%
0%
0%
0%
0%
29%
0%
0%
9%
0%
0%
0%
0%
0%
0%
77%
100%
100%
62%
48%
80%
82%
43%
100%
100%
64%
83%
70%
100%
86%
100%
80%
23%
0%
0%
15%
48%
10%
18%
29%
0%
0%
27%
17%
30%
0%
14%
0%
20%
0%
0%
0%
23%
5%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
10%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
30
10
18
13
21
10
17
7
18
2
11
12
10
10
7
4
5
4.3 Availability of emergency communication and transport
Most countries in Africa suffer from weak referral systems – broadly defined to include the
full range of steps from recognition of complications at the household level through to the
appropriate and timely treatment at a referral facility. Communication and transport are
two elements at the centre of a referral system and when used effectively and expediently
can save women’s and their babies’ lives during pregnancy, childbirth and the postpartum
period. Communication can serve to request transportation and to inform the receiving
facility that a patient is en route and in what condition. Telephones or radios can also be
used to obtain medical advice and to provide counter-referral measures.
Nationally, 21% of surveyed facilities had a functioning land telephone in maternity while
29% had a functioning land telephone elsewhere in facility. Fifty-six percent of surveyed
facilities reported having a functioning two-way radio and 24% reported having a
functioning public telephone in vicinity (Table 4.4).
While all central and district hospitals had functioning land telephone in maternity, only 59%
of CHAM and 40% of private hospitals had functioning land telephones in maternity. As
expected, only 7% of Government health centres and 6% of CHAM health centres had a
functioning land line in maternity.
Two-way radio communication is an effective means of communication between primary
and secondary level facilities, and yet only 45% of CHAM hospitals, 33% of Government rural
hospitals and 20% of CHAM rural hospitals have two-way radio communication. At health
centre level, 64% of Government health centres and 60% of CHAM health centres have
radio communication. District level data is given in Table 4.1A in the appendix.
55
Table 4.4: Percentage of surveyed facilities with a functional mode of communication by facility
type and ownership
On-site communication
Functioni
ng public
telephon
e
in
vicinity
Total
number
of
facilities
Functioning
land
telephone in
maternity
Functioning
land
telephone
elsewhere in
facility
Functionin
g two-way
radio
Functionin
g mobile
phone
owned by
facility
Functionin
g mobile
phone
owned
individual
%
21
%
29
%
56
%
22
%
93
%
24
309
Central Hosp
100
100
25
50
100
100
4
District Hosp
100
96
87
57
87
78
23
Govt
100
100
0
67
100
0
3
CHAM
59
86
45
32
100
55
22
Private
40
90
0
50
100
10
10
Govt
20
33
33
27
93
33
15
CHAM
7
27
20
27
67
13
15
Private
0
0
0
0
0
0
0
Govt
7
10
64
10
93
16
160
CHAM
6
15
60
19
98
10
52
Private
20
20
0
80
100
20
5
National
Facility Type
Other Hosp
Rural Hosp
Health Centre
A functioning mode of transport is essential for referral. At national level, 44% of surveyed
facilities reported availability of a functioning motor vehicle ambulance, 23% reported a
functioning motor vehicle and 14% reported availability of a functioning motor cycle
ambulance (Table 4.5). At health centre level, 23%, 37% and 40% of Government, CHAM and
private health centres reported availability of a functioning motor vehicle ambulance.
District data is given in Table 4.2A in the appendix.
56
Table 4.5: Percentage of surveyed facilities with a functional mode of transport by facility type and
ownership
Motorized transport
Total
number of
Functionin Functionin Functionin At
least Boat
g
Motor g
motor g
motor one
ambulance facilities
surveyed
vehicle
vehicle
cycle
functioning
ambulance
ambulance mode
of
motorized
transport
%
%
%
%
%
n
National
44
23
14
57
1
309
Facility Type
Central
Hosp
District Hosp
100
50
0
100
0
4
100
91
35
100
0
23
Other Hosp
Govt
CHAM
Private
100
91
40
0
68
40
0
14
0
100
100
70
0
5
0
3
22
10
Rural Hosp
Govt
CHAM
Private
73
87
0
13
47
0
20
13
0
87
100
0
0
0
0
15
15
0
Health Centre
Govt
23
CHAM
37
Private
40
8
12
60
15
6
0
39
42
60
1
0
0
160
52
5
4.4 Time to nearest first referral level with surgical capacity
When it comes to referral to nearest surgical facility, time is of utmost essence. Table 4.6
gives the number of facilities by time to nearest surgical facility nationally and by district.
The table indicates that in 28% of hospitals, patients have to travel more than 2 hours to the
nearest surgical facility while in 18% of health centres, they have to travel more than 2
hours to the nearest surgical facility.
The table also indicates that 88% of the hospitals are within 90 minutes reach of the nearest
surgical facility while 72% of the health centres are within 90 minutes reach.
57
Table 4.6: Number of facilities by time to nearest surgical facility, by type of facility, and district
Hospitals1
30
30
minutes minutes
or less
- 1 hour
National
31
32
Between
1 hour
but less
than 2
hours
9
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
0
1
0
0
3
0
1
1
0
2
0
7
3
0
1
1
1
4
1
4
0
1
2
2
3
2
1
1
0
1
2
1
5
1
1
0
0
0
1
1
0
0
0
0
0
0
2
0
1
1
0
0
0
1
1
0
1
1
0
0
0
0
0
Total
number
more
than 2 of
hospitals
hours
20
72
Health centres
30
30
Between more
minutes minutes 1 hour than 2
or less
- 1 hour but less hours
than 2
hours
90
67
22
38
1
2
0
2
1
0
0
1
0
0
0
0
0
1
0
2
0
2
0
3
1
2
5
2
5
8
1
3
3
1
4
1
13
5
2
2
4
1
7
2
7
1
0
4
2
1
5
0
2
2
5
3
2
12
4
6
3
9
2
3
2
6
0
1
0
2
2
5
1
5
3
1
1
1
4
1
5
2
3
2
4
1
4
0
1
1
1
0
1
0
1
1
0
0
2
0
0
1
2
2
1
2
1
0
1
1
0
3
0
6
0
1
1
0
1
0
1
0
4
4
3
4
1
1
1
0
Total
number of
health
centres
visited
3
5
8
3
17
1
9
7
6
5
5
17
5
16
11
17
9
10
5
11
1
217
58
Table 4.6: Number of facilities by time to nearest surgical facility, by type of facility, and district
Hospitals1
30
30
minutes minutes
or less
- 1 hour
Thyolo
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
Neno
0
0
1
0
0
0
0
2
2
2
0
1
0
0
Total
number
Between more
1 hour than 2 of
hospitals
but less hours
than 2
hours
1
0
3
0
0
2
0
0
3
0
2
2
0
0
1
0
1
1
0
1
1
Health centres
30
30
Between more
minutes minutes 1 hour than 2
or less
- 1 hour but less hours
than 2
hours
4
2
0
2
5
4
1
0
2
3
0
2
2
5
0
1
2
2
2
0
1
1
0
1
1
2
1
0
Total
number of
health
centres
visited
8
10
7
8
6
3
4
1 Hospitals are classified as all Central Hospitals, District Hospitals, Other Hospitals and Rural Hospital
59
4.5 User fees for services
Fees for users or medications and supplies are well known as obstacles that deter women
from seeking medical services for themselves and/or their newborn children. Government
health facilities generally do not charge for the services they deliver (except in paying units
of central hospitals and some district hospitals) and this is reflected in the data in Table
4.7.It was however reported that one of the central hospitals was charging for food and bed
but it is likely that this was charged in the paying unit. User fees are administered in CHAM
facilities where among other things, they charge for bed, blood transfusion, neonatal
intensive care and to a lesser extent, food. Not charging for the service may also mean that
the service is not being offered. Table 4.3A in the appendix gives the percent distribution of
facilities according to their system of waiving maternity fees for poor women, by district.
Table 4.7: Percentage of facilities charging women separately for selected items among
facilities that offer deliveries, by facility type/sector
Number of
facilities that
do deliveries
Services
Bed
Food
Blood
transfusion
Neonatal
intensive
care
299
%
8
%
2
%
8
%
7
Facility Type
Central Hospital
District Hospital
4
23
25
0
25
0
0
0
0
0
Other Hospitals
Government
CHAM
Private
3
22
7
0
36
43
0
5
57
0
41
86
0
50
29
Rural Hospital
Government
CHAM
Private
15
15
0
0
20
0
0
0
0
0
47
0
0
20
0
Health Centre
Government
CHAM
Private
155
50
5
0
18
0
0
0
0
0
6
0
0
6
20
Sector
Government
CHAM
Private for profit
200
87
12
1
23
25
1
1
33
0
22
50
0
20
25
National
60
4.6 Recommendations







All hospitals and health centres should have at least one source of electricity, and
ideally all should have a generator as a back-up source of electricity.
All hospitals should have piped water and all health centres should have piped water
or borehole.
Provide source of water for all facilities that do not have it such as some facilities in
Chiradzulu and Thyolo.
Ensure piped water in operating theatre for all facilities with operating theatre.
Emergency patients should be accompanied by a qualified health professional, and
the vehicle used for transport should also have telecommunications available (cell
phone or radio communication).
The 30 hospitals (mostly rural) that lack an operating theatre should be upgraded,
adding a well-equipped and staffed operating theatre.
Abolishment of user fees at the point-of-care for all routine and emergency MNH
services in all public and CHAM facilities.
61
Chapter 5: Human Resources
This chapter provides an overview of:
 How well the MOH and CHAM targets have been met for clinicians, midwives and
nurses, medical assistants at hospital and health centre levels
 How many health care workers were found currently working in the facilities visited
and recent turnover
 How many nurses and midwives have been trained in Basic EmONC and how many
clinicians have been trained in Comprehensive EmONC
 The on-site availability of health workers to provide care 24 hours a day 7 days a
week (24/7) by cadre and type of facility
 The availability of health workers who provide the EmONC signal functions and other
essential services by cadre and type of facility, and
 Population to health worker ratios including ‘skilled attendant’.
5.1 Health facility staffing levels and recommended levels
The functional review report produced by the Ministry of Health in October 2007 has
recommended the following staffing levels for health centres, district and central hospitals
(Table 5.1). A similar schedule for CHAM institutions is shown in Table 5.2. Using the
recommended staffing levels in Tables 5.1 and 5.2, we were able to work out the targeted
numbers of selected health worker cadres in the surveyed facilities by type of facility and
sector and this was compared with the existing cadres in those facilities (Table 5.3).
Table 5.1: MOH recommended staffing levels for institutions (Source: Human Resource
Section, MOH, October 2007)
Central
hospital
District
Hospital
Rural
hospital
Urban health Rural health
centre
centre
26
7
0
0
0
Obstetrician/Gynaecologist 10
0
0
0
0
General surgeon
9
0
0
0
0
Paediatrician
9
0
0
0
0
Clinical Officer/Technician
86
65
Medical Officer
2
5
5
Nursing Officer
106
18
0
0
0
Nurse Technician
302
70
28
16
16
Medical
Technician/Assistant
Laboratory technician
0
24
4
4
2
19
6
2
1
1
62
Table 5.2: CHAM recommended staffing levels for institutions (Source: Department of
Human Resource, CHAM Secretariat, October 2007)
CHAM
Hospital
Rural
hospital
Health centre
Medical Officer
4
2
0
Obstetrician/Gynaecologist
0
0
0
General surgeon
0
0
0
Paediatrician
0
0
0
Clinical Officer/Technician
14
8
4
Nursing Officer
18
1
0
Nurse Technician
7
12
3
Medical Technician/Assistant
4
5
0
Laboratory technician
4
3
0
63
Table 5.3: National targets and number of selected health worker cadres currently working in surveyed facilities, by sector and facility type
Number of:
Number
Target for of
Facilities
Medical
Assistants
Medical
Officers
Target
for
Medical
Officers
Clinical
Officers
Target
for
Clinical
Officers
Registered
Nurse
Midwife
Target for
Registered
Nurse
Midwifes
Enrolled
Nurse
Midwife/
Nurse
Midwife
Technicia
n
Target for Medical
Enrolled
Assistant
Nurse
Midwife/
Nurse
Midwife
Technicia
n
National
165
383
869
3136
486
1029
2824
7144
571
558
309
Sector
Government
CHAM
Private
120
36
9
265
118
NA
683
169
17
2234
902
NA
344
114
28
838
191
NA
1991
705
128
5798
1346
NA
456
112
3
380
178
NA
205
89
15
67
104
305
344
119
424
540
1208
3
0
4
44
161
312
1495
163
414
915
1610
204
552
23
Other Hospitals
Government
CHAM
Private
5
32
8
NA
88
NA
13
129
14
NA
484
NA
23
97
23
NA
176
NA
81
459
116
NA
726
NA
21
63
1
NA
88
NA
3
22
10
Rural Hospital
Government
2
0
18
75
16
0
92
420
34
60
15
Facility Type
Central
Hospital
District
Hospital
64
Table 5.3: National targets and number of selected health worker cadres currently working in surveyed facilities, by sector and facility type
Number of:
CHAM
Health Centre
Government
CHAM
Private
Medical
Officers
Target
for
Medical
Officers
Clinical
Officers
Target
for
Clinical
Officers
Registered
Nurse
Midwife
Target for
Registered
Nurse
Midwifes
Enrolled
Nurse
Midwife/
Nurse
Midwife
Technicia
n
2
30
28
210
11
15
127
Target for Medical
Enrolled
Assistant
Nurse
Midwife/
Nurse
Midwife
Technicia
n
360
20
2
2
1
0
0
NA
35
12
3
320
208
NA
23
6
5
0
0
NA
363
119
12
2560
260
NA
194
29
2
Number
Target for of
Facilities
Medical
Assistants
90
15
320
0
NA
160
52
5
1 Assumes positions for Nursing Officers
65
At national level, the target for medical assistants has been met. However, there are only
40% of targeted enrolled nurse midwives/nurse midwife technicians, 47% of the targeted
nursing officers, 28% of the targeted clinical officers and 43% of the targeted medical
officers (Fig. 5.1).
Fig. 5.1: National level targets for selected health worker cadre in surveyed facilities
National level targets
8000
7144
7000
6000
N
u
m
b
e
r
5000
4000
3136
3000
Actual
2824
Target
2000
1029
1000
165
383
571 558
869
486
0
Medical
Officer
Medical
Assistant
Reg. Nurse
Midwife
Clinical
Officer
ENM/NMT
For central hospitals, the target for clinical officers is nearly met (89%). However, there are
only 45% of the required nurse/midwife technicians, 28% of the required nursing officers
and 64% of the required medical officers (Fig. 5.2).
66
Fig. 5.2: Central Hospital targets for selected health worker cadre
Central hospital targets
1400
1208
1200
1000
N
u
m
b
e
r
800
600
540
Target
424
400
305
200
67
Actual
344
119
104
3
0
0
Medical
Officer
Medical
Assistant
Reg. Nurse
Midwife
Clinical
Officer
ENM/NMT
At district hospital level, there is severe shortfall of clinical officers (21% of the required
number) and medical officers (27% of the required number). However, there are 57% of the
targeted nurse/midwife technicians, 39% of the required nursing officers and 37% of the
required medical assistants (Fig. 5.3).
67
Fig. 5.3: District Hospital targets for selected health worker cadre
District hospital targets
1800
1610
1600
1495
1400
N
u
m
b
e
r
1200
1000
915
Actual
800
Target
552
600
414
400
312
161
200
204
163
44
0
Medical
Officer
Medical
Assistant
Reg. Nurse
Midwife
Clinical
Officer
ENM/NMT
The figures for CHAM hospitals are similar to the district hospitals in that there is severe
shortfall of clinical officers (27% of the required number). However, the medical assistant
target has been met. There are only 63% of the required nurse/midwife technicians, 55% of
the required nursing officers and 36% of the required medical officers (Fig. 5.4).
68
Fig. 5.4: CHAM Hospital targets for selected health worker cadre
CHAM hospital targets
800
726
700
600
N
u
m
b
e
r
484
500
459
400
Actual
Target
300
176
200
100
88
32
63
88
129
97
0
Medical
Officer
Medical
Assistant
Reg. Nurse
Midwife
Clinical
Officer
ENM/NMT
For Government health centres, there is severe shortfall in number of nurse/midwife
technicians (14% of the required number), 61% of the required medical assistants and 11%
of the required clinical officers (Fig. 5.5).
Fig. 5.5: Government health centre targets for selected health worker cadre in surveyed
facilities
Government health centre targets
3000
2560
2500
N
u
m
b
e
r
2000
1500
Actual
1000
500
Target
194
320
320
23 0
363
35
0
Medical
Assistant
Reg. Nurse
Midwife
Clinical
Officer
ENM/NMT
69
For CHAM health centres, there is 6% of the required clinical officers and 46% of the
required nurse midwife technicians (Fig. 5.6).
Fig. 5.6: CHAM health centre targets for selected health worker cadre in surveyed facilities
CHAM health centre targets
300
260
250
N
u
m
b
e
r
208
200
150
119
100
50
Actual
Target
29
0
6
0
12
0
Medical
Assistant
Reg. Nurse
Midwife
Clinical
Officer
ENM/NMT
Posting and transfers are important aspects of human resource management and is
generally the responsibility of health authorities at national or district level. The total
numbers of health workers currently working in the facilities visited, and of staff lost and
posted in the last 12 months are shown in Table 5.4. It should be noted that medical
doctors, some clinical officers and nursing officers can be assigned managerial jobs rather
than clinical work, so these numbers may include administrators or managers in addition to
clinical staff. For hospitals, there was net gain of staff in all cadres except the
Obstetric/Gynaecology specialist and enrolled nurse/nurse technicians. At health centre
level, there was net loss for clinical officers, nursing officers and enrolled nurse/nurse
technicians.
70
Table 5.4: Total number of health workers currently working, who left and who were posted in the last 12 months, by type of facility and cadre of health
worker
Currently
working
Hospitals1
In the last 12 months:
Currently
staff
staff
net gain working
left
posted
(loss)
Health Centers2
In the last 12 months:
staff
staff
net
left
posted
(loss)
160
16
16
8
819
183
452
85
75
8
1
0
96
28
48
21
98
6
4
11
108
55
58
16
23
-2
3
11
12
27
10
-5
5
0
0
0
50
13
34
57
2
0
0
0
14
7
7
16
2
0
0
0
9
1
10
9
0
0
0
0
-5
-6
3
-7
2330
181
264
83
494
96
129
33
346
47
502
455
225
73
80
7
Health worker cadre
Medical doctor
Obstetrician/Gynaecologist
General surgeon
Paediatrician
Clinical officer
Registered Nurse
Registered Nurse Midwife
Enrolled
nurse/Nurse
technician
Enrolled Nurse Midwife/Nurse
Midwife Technician
Medical Assistant
gain
1. Total number of hospitals is 92
2. Total number of health centres is 217
71
The minimum staffing complement for a health centre would include at least two medical
assistants and two nurse/midwives. According to Table 5.5, only Neno and Chiradzulu
districts had at least 50% of their health centres meeting this target. Most of the health
centres surveyed did not have this minimum staffing complement.
Table 5.5: Number and percentage of health centres with at least two midwives and two medical
assistants currently working, by district
n
%
National
28
13%
Total number of
health
centres
surveyed
217
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
Thyolo
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
Neno
0
1
1
0
1
0
0
2
2
0
0
4
0
1
0
0
0
1
3
5
0
1
1
0
1
2
0
2
0%
20%
13%
0%
6%
0%
0%
29%
33%
0%
0%
24%
0%
6%
0%
0%
0%
10%
60%
45%
0%
13%
10%
0%
13%
33%
0%
50%
3
5
8
3
17
1
9
7
6
5
5
17
5
16
11
17
9
10
5
11
1
8
10
7
8
6
3
4
5.2 Basic and comprehensive EmONC training
By March 2009, 262 service providers were trained in basic emergency obstetric and
newborn care from all the zones across the country as follows: Northern Zone (37); Central
East Zone (51); Central West Zone (90); South East Zone (60) and South West Zone (24). It
72
not clear how many of these were nurse/midwives and how many were clinicians and from
which facilities22.
5.3 Availability of health worker cadres 24/7
Labour and delivery and obstetric emergencies often occur at inconvenient hours of the day
and night, requiring facilities to be open 24/7 with staff who can attend patients quickly.
Table 5.1A in the appendix shows the overall availability of different cadres in hospitals and
health centres and whether the cadre was available on-site or on call Monday – Friday,
Saturday – Sunday, during the day and at night. For example, by reading the first column of
the top panel (for hospitals) only 13% of hospitals had an obstetrician/gynaecologist.
Between Monday – Friday daytime, 10% had one on-site and 3% had one on call. The
pattern shifted at night as only 1% of facilities had an obstetrician/gynaecologist on-site and
12% on call. This was also the basic pattern on the weekend for both day and night.
During the Monday through Friday week, more than 50% of the hospitals reported having
on-site medical doctors (58%), clinical officers (89%), registered nurses (80%), enrolled nurse
midwives/nurse midwife technician (93%) and medical assistant (80%). On the weekends
and at night (Monday – Sunday), facilities reported few cadres at the rate of 15% or above:
medical doctors, clinical officers and medical assistants. Clinical officers and doctors of all
types tended to be on call on weekends and at night.
At health centres, few categories of health workers were found at this same level of
frequency (75% or greater) because health centres generally do not have medical or surgical
specialists. Only enrolled nurse midwives/nurse midwife technicians – regardless of the day
of the week or time of day – were found at 75% or more of health centres. During the day
Monday – Friday medical assistants were also likely to be present (89% of health centres).
5.4 Regulatory policies and practice on the frontline
Table 5.6 is a matrix that shows the different cadres of health workers and which of the
signal functions they are trained to perform. The purpose of this table is to enable a
comparison between what the different health care professionals are trained to do as far as
obstetric and newborn complications are concerned, and what they actually are doing in the
facilities where they work, which can be seen in Table 5.7 for hospitals and health centres.
‘Yes’ means that policy clearly supports the cadre to make the decision that a function
should be performed and ‘No’ indicates clear non-support at policy level.
In analyzing Table 5.7, it is worth noting that according to job descriptions, doctors generally
prescribe medications that are then administered by midwives and nurses. Where there are
no doctors, clinical officers are authorized to write prescriptions. In health centres with
neither doctors nor clinical officers, medical assistants write prescriptions and nurses
administer medications. Quite often, certain drugs such as sedatives or pain killers are not
dispensed at health centres. Table 5.7 reflects decision making regarding the administration
or performance of a drug or procedure as well as the actual carrying out of the intervention.
22
Ministry of Health, RHU 2008-2009 Report, Lilongwe, Malawi
73
Table 5.6: Regulatory policies for basic and comprehensive EmONC signal functions by signal function and health worker cadre
Perform assisted vaginal delivery with
forceps
Resuscitate newborn with bag and
mask
Perform obstetric
caesarean delivery)
Perform blood transfusion
Administer anaesthesia (e.g., spinal,
general, ketamine)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
No
No
No
No
No
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
No
Yes
No
surgery
and
dilatation
(e.g.,
Perform assisted vaginal delivery with
vacuum
Yes
curettage
Yes
drugs
Perform dilatation and evacuation
(D&E)
Registered
Nurse/Midwife
Perform
(D&C)
Registered Nurse
Perform manual vacuum aspiration
(MVA) or electric aspiration
Clinical Officer
Perform manual removal of placenta
Paediatrician
Administer parenteral anticonvulsants
General surgeon
Administer uterotonic
parenteral oxytocics
Obstetrician/
Gynaecologist
Administer parenteral antibiotics
Medical
doctor
(general practitioner)
Perform assisted
vaginal delivery
Normal vaginal delivery
–
Remove retained products
74
Perform dilatation and evacuation
(D&E)
Perform assisted vaginal delivery with
vacuum
Perform assisted vaginal delivery with
forceps
Resuscitate newborn with bag and
mask
Perform obstetric
caesarean delivery)
Perform blood transfusion
Administer anaesthesia (e.g., spinal,
general, ketamine)
No
Yes
No
No
No
No
No
No
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
(e.g.,
curettage
surgery
and
Perform
(D&C)
Yes
dilatation
Perform manual vacuum aspiration
(MVA) or electric aspiration
–
No
drugs
Perform manual removal of placenta
Nurse
Anaesthetist(Some
procedures
like
normal
vagina
delivery
are
performed if he/she
is also a midwife)
Administer parenteral anticonvulsants
Doctor/Clinical
Officer
Administer uterotonic
parenteral oxytocics
Enrolled
Nurse
Midwife/Nurse
Midwife technician
Administer parenteral antibiotics
Enrolled
Nurse/Nurse
technician
Normal vaginal delivery
Remove retained products
Perform assisted
vaginal delivery
75
Perform manual vacuum aspiration
(MVA) or electric aspiration
Perform
(D&C)
Perform dilatation and evacuation
(D&E)
Perform assisted vaginal delivery with
vacuum
Perform assisted vaginal delivery with
forceps
Resuscitate newborn with bag and
mask
Perform obstetric
caesarean delivery)
Perform blood transfusion
Administer anaesthesia (e.g., spinal,
general, ketamine)
Yes
Yes
Yes
No
No
No
No
No
Yes
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
(e.g.,
curettage
surgery
and
Perform manual removal of placenta
Yes
dilatation
Administer parenteral anticonvulsants
–
Yes
drugs
Administer uterotonic
parenteral oxytocics
Laboratory
technician
Administer parenteral antibiotics
Medical Assistant
Normal vaginal delivery
Remove retained products
Perform assisted
vaginal delivery
76
Table 5.7: Percentage of hospitals and health centres that provide EmONC signal functions, by health worker cadre
HOSPITALS (n=92)
Health
cadre
Parenteral Drugs
Facilities Antibioti
cadre
cs
present
worker %
%
Oxytoci
cs
Anticonvulsan
ts
Manual
removal
of
placenta
%
%
%
Medical Doctor
58%
32%
38%
40%
58%
Obstetrician/Gyn 13%
42%
75%
75%
83%
aecologist
General surgeon 12%
27%
18%
27%
45%
Paediatrician
5%
40%
0%
40%
0%
Clinical officer
89%
56%
54%
62%
76%
Registered Nurse 47%
47%
16%
30%
9%
Registered Nurse 80%
81%
82%
80%
73%
Midwife
Enrolled
37%
53%
26%
35%
15%
nurse/Nurse
technician
Enrolled Nurse 93%
87%
86%
85%
64%
Midwife/Nurse
Midwife Technician
Medical
80%
36%
22%
27%
12%
Assistant
Note 1: Facilities that did not provide answers are excluded from the calculation.
Removal
retained
products
MVA D&C
or
D&E
%
%
Procedures
of Assisted
Neonatal
vaginal
resuscitatio
delivery
n
Blood
transfusion
Caesarea
n delivery
%
%
%
%
43%
50%
64%
75%
60%
67%
49%
75%
32%
50%
58%
92%
18%
0%
56%
7%
35%
55%
0%
63%
0%
0%
27%
20%
70%
5%
69%
27%
80%
61%
9%
76%
27%
20%
38%
42%
76%
45%
0%
55%
0%
0%
3%
0%
6%
18%
41%
0%
45%
0%
50%
81%
72%
0%
14%
0%
7%
24%
16%
0%
77
HEALTH
(n=217)
Parenteral Drugs
CENTERS Faciliti Antibioti
es
cs
cadre
presen
t
Health worker cadre
%
%
Oxytoci
cs
Anticonvulsan
ts
Manual
removal
of
placenta
%
%
%
Removal
retained
products
MVA D&C
or
D&E
%
%
60%
0%
20%
0%
0%
0%
50%
17%
71%
Medical doctor
2%
60%
60%
40%
Obstetrician/Gyna 0%
0%
0%
0%
ecologist
General surgeon
0%
0%
0%
0%
Paediatrician
0%
0%
0%
0%
Clinical officer
13%
79%
57%
79%
Registered Nurse
3%
50%
50%
67%
Registered Nurse 8%
100%
94%
94%
Midwife
Enrolled
13%
71%
64%
71%
nurse/Nurse
technician
Enrolled
Nurse 84%
90%
90%
87%
Midwife/Nurse
Midwife Technician
Doctor/Clinical
officer/Nurse
Anaesthetist
Medical Assistant
76%
66%
59%
57%
Note 1. Facilities that did not provide answers are excluded.
Procedures
of Assisted
Neonatal
vaginal
resuscitatio
delivery
n
Blood
transfusion
Caesarea
n delivery
%
%
%
%
20%
0%
40%
0%
60%
0%
20%
0%
20%
0%
0%
0%
29%
0%
41%
0%
0%
11%
0%
0%
0%
0%
39%
0%
59%
0%
0%
57%
17%
94%
0%
0%
11%
17%
6%
0%
0%
0%
0%
0%
50%
4%
0%
18%
61%
4%
0%
55%
20%
0%
20%
79%
2%
0%
0%
0%
0%
0%
10%
46%
1%
0%
29%
11%
0%
78
To highlight who is providing the bulk of the services, the reader should examine the results
for one signal function at a time (the vertical columns). Thus, we see that in 32% of the
hospitals, medical doctors were reported to provide parenteral antibiotics. The primary
providers of parenteral antibiotics, however, were registered nurse/midwives (81%) and
enrolled nurse midwife/nurse midwife technician (87%). Similar percentages of hospitals
reported the administration of parenteral oxytocics by these two nurse cadres (82% and
86% respectively), and parenteral anticonvulsants (80% and 85% respectively).
For manual removal of placenta hospitals depended mostly on obstetrician/gynaecologist
(83%), clinical officers (76%), medical doctors (58%), registered nurse midwives (73%) and
enrolled nurse midwives/nurse midwife technicians (64%). For MVA, most hospitals
depended upon registered nurse midwives (41%), clinical officers (29%), medical doctors
(20%) and enrolled nurse midwives/nurse midwife technician (20%). D&C and D&E in
hospitals were mostly performed by obstetrician/gynaecologist (75%), medical doctors
(64%), clinical officers (63%) and general surgeons (55%). The cadres most frequently
reported by hospitals for assisted vaginal delivery were: registered nurse/midwives (59%),
medical doctors (40%) and clinical officers (39%).
To provide neonatal resuscitation hospitals reported enrolled nurse midwives (81%),
paediatricians (80%), registered nurse/midwives (76%) and obstetrician/gynaecologist (75%)
and clinical officer (61%). The very same cadres were reported by hospitals as providing
blood transfusions, after a doctor’s orders, in the following order of frequency: registered
nurse midwives (76%), enrolled nurse midwives (72%) and obstetrician/gynaecologist (50%).
To provide caesarean delivery, hospitals reported obstetrician/gynaecologists (92%),
medical doctors (58%), clinical officers (55%) and general surgeons (45%).
Health centres (the lower panel of Table 5.7) rarely reported that doctors of any type
provide the basic EmONC signal functions mainly because doctors are usually not available
in health centres. Instead health centres mentioned registered nurse/midwives and enrolled
nurse/midwives as the most frequent providers of parenteral drugs and also manual
removal of the placenta. However, health centres specified registered nurse/midwives,
clinical officers and enrolled nurse/midwives most frequently for the provision of MVA, D&C
or assisted vaginal delivery as well as neonatal resuscitation.
To be designated as a fully functioning EmONC facility all signal functions have to be
performed in the three months prior to the survey visit. Thus, which cadre provides the
signal function is less important as long as there is at least one person on staff duly
authorised and with the requisite skills. Figure 5.7 and Table 5.2A in the appendix serve as a
synthesis by showing the percentage of facilities that reported at least one cadre on staff
who can perform the signal function (with the addition of newborn blood transfusion), by
district. They suggest that hospitals were well staffed to perform the basic signal functions.
Seventy-two percent of hospitals had someone who could provide maternal blood
transfusion but only 51% had staff that could perform a blood transfusion on a newborn.
79
Figure 5.7: Percentage of facilities with at least one health worker who could perform the
signal function (including newborn blood transfusion)
Signal function performance
P
e
r
c
e
n
t
100
90
80
70
60
50
40
30
20
10
0
Hospital
Health centre
Table 5.2A in the appendix also shows that health centres were less well staffed than
hospitals to perform the basic signal functions. Fewer than 60% of health centres had health
workers who could provide manual removal of placenta, MVA, D&C or D&E or assisted
vaginal delivery.
Table 5.8 shows what cadres could perform other essential services such as normal and
breech delivery, family planning and PMTCT. Up to 70% of hospitals reported that registered
nurse/midwives performed normal delivery, but as many as 51% reported that clinical
officers did this task. Thirty-one percent and 64% of hospitals reported medical doctors and
registered nurse/midwives performing breech delivery respectively. Only about 63% of
hospitals reported that registered nurse/midwives were able to use a partograph to manage
labour but only 11% of enrolled nurse/midwives were able to do so. About 66% and 8% of
hospitals reported registered nurse/midwives and nurse/midwife technicians respectively
who could provide immediate newborn care. These same two cadres were reported as the
most likely staff to provide focused antenatal care, family planning (FP) counselling,
temporary contraceptive methods and PMTCT. Up to 41% of hospitals reported clinical
officers providing surgical FP methods but only 9% of all hospitals reported
obstetricians/gynaecologists provided this service. Up to 22% of facilities and 5% of facilities
reported medical doctors and surgeons providing surgical FP. None of the hospitals reported
staff that could provide uterotonic drugs by routes other than parenteral which is probably
a reference to the use of sublingual, vaginal or rectal misoprostol. Up to 5% of facilities
reported clinical officers providing anaesthesia. A smaller percentage of hospitals referred
to other professional health workers who could provide anaesthesia.
80
The cadre that heath centres were the most likely to report as providing all the listed
essential services was the enrolled nurse/midwife. At least 70% of health centres indicated
that they had enrolled nurse/midwives to provide normal delivery, immediate newborn
care, focused ANC, FP counselling and provision of temporary FP methods. Medical
assistants were also prominent as being able to provide these services.
81
Table 5.8: Percentage of hospitals and health centres that provide other essential services or procedures, by health worker cadre
HOSPITALS
(n=89)
Health
worker
cadre
Medical
doctor
Obst/Gynaecol
ogist
General
surgeon
Paediatrician
Clinical officer
Registered
Nurse
Registered
Nurse Midwife
Enrolled
nurse/Nurse
technician
Enrolled Nurse
Midwife/Nurse
Midwife
Technician
Medical
Assistant
Normal
delivery
Breech
deliver
y
Partogra
ph
manage
ment
Immediate
newborn
care
Focuse
d ANC
FP
counsel
ling
Temporary
FP
methods
Surgical
FP
methods
PMTCT
Uterotonic
drugs by
other
routes
Newborn
blood
transfusion
Provide
anaesthesia
%
%
%
%
%
%
%
%
%
%
%
%
18%
31%
16%
19%
8%
19%
13%
22%
22%
0
14%
0%
8%
10%
8%
10%
5%
7%
5%
9%
8%
0
5%
0%
2%
2%
0%
1%
2%
4%
2%
5%
1%
0
2%
1%
1%
51%
1%
1%
65%
2%
1%
46%
3%
2%
51%
2%
0%
19%
5%
2%
44%
21%
1%
35%
13%
1%
41%
1%
3%
54%
8%
0
0
0
5%
23%
12%
1%
5%
1%
70%
64%
63%
66%
58%
56%
40%
2%
60%
0
44%
1%
8%
5%
11%
8%
9%
19%
15%
1%
10%
0
12%
1%
80%
73%
75%
80%
74%
67%
51%
1%
74%
0
46%
1%
16%
8%
18%
18%
13%
26%
21%
0%
19%
0
8%
1%
Note 1. Facilities that did not provide answers are excluded.
82
HEALTH CENTERS
(n=210)
Health
worker
cadre
Medical
doctor
Obstetrician/G
ynaecologist
General
surgeon
Paediatrician
Clinical officer
Registered
Nurse
Registered
Nurse Midwife
Enrolled
nurse/Nurse
technician
Enrolled Nurse
Midwife/Nurse
Midwife
Technician
Medical
Assistant
Normal
delivery
Breech
deliver
y
%
Partogra
ph
manage
ment
%
Immediate
newborn
care
%
Focuse
d ANC
FP
counsel
ling
Temporary
FP
methods
Surgical
FP
methods
PMTCT
Newborn
blood
transfusion
Provide
anaesthesia
%
Uterotonic
drugs by
other
routes
%
%
%
%
%
%
%
%
0%
1%
1%
1%
0%
0%
0%
0%
1%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
7%
0%
0%
8%
0%
0%
7%
0%
0%
9%
0%
0%
4%
1%
0%
8%
0%
0%
5%
0%
0%
1%
0%
0%
6%
1%
0%
1%
0%
0%
1%
0%
0%
0%
0%
8%
6%
7%
7%
7%
6%
6%
0%
7%
0%
0%
0%
9%
8%
9%
10%
9%
7%
7%
0%
9%
0%
0%
0%
79%
69%
77%
77%
79%
74%
70%
1%
77%
5%
1%
0%
47%
28%
42%
46%
32%
44%
41%
1%
41%
3%
0%
0%
Note 1. Facilities that did not provide answers are excluded.
83
Table 5.3A in the appendix shows the percentage of facilities that had at least one health
worker who could perform the other essential services by district.
5.5 Ratios of health workers to expected births and the population
There are several accepted ways of determining how many midwives are needed to provide
skilled attendance to women in childbirth. One indicator is the ratio of midwives to 100 or
more expected births. Whether the figure used is 100, 150 or 175 depends on factors such
as density of the population. The more dispersed a population, the lower the number of
births. Another indicator looks at the ratio of midwives to a population of 5000. Usually this
population is further characterized by a crude birth rate of around 40/1000 population and
thus reflects 200 births. Fig. 5.8 and Table 5.4A in the appendix reflect the first indicator
(based on 100 expected births) and Table 5.5A in the appendix reflect the second indicator.
According to Fig. 5.8 and Table 5.4A in the appendix, only Likoma met the target of one
midwife for every 100 expected births. The districts with the least ratio of midwives to 100
expected births included Mangochi (0.12), Phalombe (0.17) and Kasungu (0.24). Figure 5.8
also shows the ratio of skilled birth attendants (SBA) to 100 expected births where a skilled
birth attendant is defined as an obstetrician/ gynecologist, medical doctor, clinical officer or
nurse/midwife, all of whom presumably have been trained in midwifery competencies. In
this case several districts exceeded the ratio of one SBA to 100 expected births: Mzimba,
Likoma, Zomba, Chiradzulu, Blantyre, Mwanza and Neno.
Table 5.5A in the appendix shows a similar set of relationships but in relation to a
population of 5,000. Patterns mirror Figure 5.8 but the target is less strict so that all districts
met the required target of midwives to a population of 5,000 except Kasungu, Salima,
Ntcheu, Mangochi, Nsanje and Phalombe. Similarly, all districts met the required target of
skilled birth attendants to a population of 5,000 except Kasungu and Mangochi.
Table 5.6A in the appendix displays the ratios of midwives, nurses, clinical officers, surgeons,
obstetricians/gynaecologists, paediatricians, medical doctors and medical assistants to a
population of 100,000. Except for midwives, internationally there has been little or no
consensus what the ratio of these cadres to the population should be. The smallest ratio
was shared by surgeons, paediatricians and obstetricians/gynaecologists and the largest was
the ratio of nurses to population.
84
Fig. 5.8: Ratio of midwives and skilled birth attendants to 100 expected births by district
Neno
Balaka
Phalombe
Nsanje
Chikwawa
Mulanje
Thyolo
Mwanza
Blantyre
Chiradzulu
Zomba
Machinga
Mangochi
Ntcheu
Dedza
Skilled birth attendants
Mchinji
Nurse/Midwives
Lilongwe
Salima
Dowa
Ntchisi
Nkhotakota
Kasungu
Likoma
Mzimba
Rumphi
Nkhata Bay
Karonga
Chitipa
0
0.5
1
1.5
2
2.5
3
Ratio
85
5.6 Recommendations
 Increase supply of skilled birth attendants through support for increased enrolment
into training institutions for uptake of nurses and clinicians; as well as the
development of a retention plan for providers already in service.
 Recruit and train 2-3 senior clinicians and midwifes per district to conduct EmONC
trainings in their districts
 Training must be prioritized for implementation in those districts that have had few
or no staff trained in EmONC.
 Human resources who can provide blood transfusions for mothers and newborns
appear to be the biggest gap in districts.
 Prioritize pre-service and in-service training on neonatal resuscitation for all skilled
birth attendants.
 Consideration should be given to bonding of skilled health workers for specific
number of years after graduation to prevent attrition.
86
Chapter 6: Availability of Drugs, Equipment and Supplies
This chapter presents data from Module 3 of the Needs Assessment tools. The main aim of
this chapter is to report on the availability of recommended drugs, equipment and supplies
required for the optimal delivery of EmONC services.
6.1 Management and stock outs of drugs
All hospitals and health centres (100%) reported having a supply of drugs or a pharmacy at
the time of the survey (Table 6.1A in the appendix presents data on the 92 hospitals and 217
health centres with a pharmacy (or a supply of drugs). Among these facilities, 95.6% of
hospitals and 97.3% of health centres had drug stock cards in place; however, 81.5% of the
hospitals and 79.3% of the health centres had up-to-date drug stock cards (Figure 6.1).
Figure 6.1: Status of drug stock cards
Status of drug stock cards
100
90
P
e
r
c
e
n
t
80
70
60
81.5
79.3
Stock card updated
50
Stock cards not updated
40
No stock cards
30
20
10
14.1
18
0
4.34
2.8
Hospitals
Health Centres
Sixty-one percent of hospitals and seventy-three percent of health centres reported that
government was their major supplier of medicines. Thirty-three percent of hospitals and
thirteen percent of health centres reported that the private pharmacy was their major
supplier of medicines where as seven percent of hospitals and thirteen percent of health
centres reported that the NGO and Mission were the major supplier of medicines (Table
6.1A in the appendix).
Government was the primary source for gloves, syringes and medical supplies in hospitals
(61%), followed by private pharmacy (36%) and NGO/Mission (3%). For Health centres, the
primary source for these commodities was Government (72%), followed by private
pharmacy (15%) and NGO/Mission (13%).
87
Government was the primary source for infection prevention supplies in hospitals (59%),
followed by private pharmacy (38%) and NGO/Mission (3%). For Health centres, the primary
source for these commodities was Government (75%), followed by private pharmacy (13%)
and NGO/Mission (12%).
Table 6.2A in the appendix presents different mechanisms for ordering drugs by facilities
with a supply of medicine and also by selected departments within health facilities. Among
all facilities with pharmacies 79% of hospitals and 85% of health centres order their drug
supplies regularly on a weekly, monthly or quarterly basis or when stocks reached re-order
levels (11%). Among all facilities, 67% of hospitals and 54% of health centres order their
drug supplies regularly on a weekly, monthly or quarterly basis. Data on the supply
mechanism in the labour & delivery rooms and maternity wards showed that hospitals and
health centres were similar in their ordering practices – 67% of hospitals and 55% of health
centres ordered their supplies same time each week, month or quarter or order whenever
stock reached the re-order level (7% of hospitals and 24% of health centres). Among
facilities with an operating theatre, i.e. hospitals, 76% of hospitals order supplies same time
each week, month or quarter while 10% of facilities order when their stocks run out and 8%
ordered whenever needed.
Table 6.3A in the appendix shows the main causes of delay in the delivery of supplies as
reported by staff in facilities with pharmacies or supplies of medicines. The most commonly
reported causes of delay of supplies in Government hospitals were ‘stock out at central
store’ (38%), ‘inadequate transport (20%), and ‘administrative difficulties’ (16%). While in
CHAM hospitals, the most common causes of delay were stock out at central level (30%) and
financial problems (20%). Similar causes of delay were reported by private hospitals
financial problems (31%) and stock out at central level (19%). For Government health
centres, the common causes of delay were administrative difficulties (35%), inadequate
transport (22%) and stock out at central level (22%). CHAM health centres reported
administrative difficulties (60%), financial problems (20%) and others (20%) that include
facility is new and staff didn’t know the reasons as common causes of delay. Private health
centres reported financial problems (36%), inadequate transport (19%) and stock out at
central level as common causes of delay.
Table 6.4A in the appendix reports on selected pharmacy-related items in hospitals and
health centres. Pharmacies ought to be accessible at all times – 24/7. Only 76% of hospitals
and 78% of health centres reported that their pharmacies (or drug supplies) were always
accessible. In most facilities, a ‘first-expiry-first-out’ system was in place (97%), mechanisms
were used to prevent the use of expired drugs (98%), and drugs were protected from
moisture, heat or infestation (98%). Almost all facility pharmacies had at least one
functioning electric/gas refrigerator - hospitals (96%) and health centres (91%) – and
required drugs were refrigerated in 98% of facilities. However, it is possible that many of
these facilities were reporting the presence of a refrigerator for the Expanded Program on
Immunization, which cannot be used to store other types of drugs. Only 5% of hospitals and
16% of health centres had at least 1 functioning solar refrigerator.
Table 6.5A in the appendix reports on percentage of facilities reporting on stock out of
ergometrine, magnesium sulphate, oxytocin, ketamine and atropine, at 1 month, 3 months,
88
6 months and 12 months by type of facility (among facilities with pharmacy/supply of
drugs).
Status of oxytocin
Figure 6.2 reports on the availability and stock out situation of oxytocin. Among reporting
hospitals, 3% reported never having oxytocin; whereas, 28% had stock out in the last 12
months and 69% had it available continuously in the last 12 months. At health centre level,
8% had never had oxytocin; 39% had stock out in last 12 months where as 53% had oxytocin
continuously in the last 12 months.
Figure 6.2 Stock out status of Oxytocin at hospitals and health centres
Stock out of Oxytocin
100
3
8
90
80
P
e
r
c
e
n
t
28
39
70
60
Never had Oxytocin
50
Stock out last 12 months
No stock out last 12 months
40
30
69
53
20
10
0
Hospital
Health Centre
Status of Ergometrine
Although oxytocin is the drug of choice for active management of the third stage of labour
(AMTSL), ergometrine can also be used for AMTSL. Furthermore, it is a critical drug for
emergency situations and should be available. Figure 6.3 shows that among reporting
hospitals, 39% reported never having ergometrine; whereas, 42% had stock out in last 12
months and 19% had it continuously available in the last 12 months. At health centre level,
54% had never had ergometrine; 36% had stock out in last 12 months where as 10% had
ergometrine continuously available in last 12 months.
89
Figure 6.3 Stock out status of Ergometrine at hospitals and health centres
Stock out of Ergometrine
100
90
80
P
e
r
c
e
n
t
39
54
70
60
Never had Ergometrine
50
40
Stock out last 12 months
42
30
36
No stock out last 12 months
20
10
19
0
Hospital
10
Health Centre
Status of Magnesium Sulphate
Magnesium sulphate (MgSO4) is the drug of choice for the management of preeclampsia/
eclampsia – a leading cause of maternal mortality in facilities in Malawi. Figure 6.4 shows
that among reporting hospitals, 9% reported never having magnesium sulphate; whereas,
34% had stock out in last 12 months and 57% had it continuously available in the last 12
months. At health centre level, 46% had never had magnesium sulphate; 26% had stock out
in last 12 months where as 28% had magnesium sulphate continuously available in last 12
months.
90
Figure 6.4 Stock out status of magnesium sulphate at hospitals and health centres
Stock out of magnesium sulphate
100
90
9
80
P
e
r
c
e
n
t
70
34
46
60
Never had magnesium sulphate
50
Stock out last 12 months
26
40
30
No stock out last 12 months
57
20
28
10
0
Hospital
Health Centre
Status of Ketamine
Table 6.5A in the appendix describes the stock out situation of two other emergency
medications: ketamine and atropine. Among reporting hospitals, 922% reported never
having ketamine; whereas, 12% had stock out in last 12 months and 66% had it continuously
available in the last 12 months. At health centre level, 96% had never ketamine; 1% had
stock out in last 12 months where as 3% had ketamine continuously in last 12 months (Fig.
6.5).
91
Figure 6.5 Stock out status of Ketamine at hospitals and health centres
Stock out of ketamine
100
90
22
80
P
e
r
c
e
n
t
70
12
60
Never had Ketamine
96
50
40
30
Stock out last 12 months
No stock out last 12 months
66
20
10
1
3
0
Hospital
Health Centre
Status of Atropine
Among reporting hospitals, 9% reported never having atropine; whereas, 10% had stock out
in last 12 months and 81% had it continuously available in the last 12 months. At health
centre level, 39% had never had atropine; 20% had stock out in last 12 months where as
41% had atropine continuously in last 12 months (Fig. 6.6).
Figure 6.6 Stock out status of atropine at hospitals and health centres
92
Stock out of atropine
100
90
9
10
39
80
P
e
r
c
e
n
t
70
60
Never had atropine
20
50
40
81
Stock out last 12 months
No stock out last 12 months
30
41
20
10
0
Hospital
Health Centre
6.2 Essential drugs
Table 6.6A in the appendix reports data on drug groups related to emergencies and signal
functions in hospitals and health centres. While drugs within a group may be
interchangeable, it is recognized that some drugs have specific clinical uses and may not be
substituted with drugs in the same group. Drugs are grouped by their usual EmONC use.
Almost all hospitals had at least one type of the selected groups of drugs – antibiotics,
anticonvulsants & sedatives, antihypertensives, oxytocics, and drugs used in emergencies.
At least one type of antibiotic was available in 99% of health centres and emergency drugs
were available in 98% of health centres.
For antibiotics, the main deficiencies in hospitals were procaine benzyl penicillin (available
in 4% of facilities), oral flucloxacillin (for newborn) (8%) and clindamycin (8%),
metronidazole injection (39%) and cloxacillin capsule (47%). All other antibiotics were found
in more than 50% of hospitals. Further investigation revealed that benzyl penicillin has been
discontinued because of the risk of thrombophlebitis. In health centres, the main
deficiencies were procaine penicillin (0%), oral flucloxacillin (for newborn) (1%), clindamycin
(1%), cefotaxime injection for newborn (1%), ampicillin injection (2%), metronidazole
injection (3%), cloxacillin capsule (3%) but according to the Malawi standard treatment
guidelines, none of these is a level 1 i.e. health centre drug.
All the 4 drugs in the anticonvulsants & sedatives group were found in all facilities. For
health centres, the major deficiencies were phenytoin (29%) and diazepam injection (37%).
For the antihypertensives group, all 4 drugs were found in at least 63% of hospitals but 3 of
the drugs were deficient in health centres i.e. nifedipine (6%), methyldopa (12%) and
hydralazine (14%). All four drugs in the oxytocic and prostaglandin group were found in all
facilities except syntometrine which was absent in health centres. Oxytocin was only
available in 13% and 12% of hospitals and health centres respectively. Misoprostol was
commonly found in hospitals (83%) and health centres (78%) and this is despite the fact that
93
Central Medical Stores has never stocked this drug in the last two years which raises
questions regarding the source of misoprostol.
A number of drugs used in emergencies were lacking at hospital level. Examples are
diphenhydramine found in 2% of hospitals; naloxone hydrochloride found in 5% of hospitals;
nitroglycerine found in 7% of hospitals; calcium gluconate found in 22% of hospitals and
digoxin found in 49% of hospitals.
Table 6.7A in the appendix reports on the availability of anaesthetic agents and other drugs
in hospitals and health centres with pharmacies or medicine supplies. Almost all (90 – 100%)
hospitals had at least one drug in each of the selected drug groups –anaesthetics,
analgesics, tocolytics, steroids, IV fluids, antimalarials, and antiretrovirals. Many members of
these drug groups may not be approved for use at the health centre level and this could
explain why many health centres did not have these drugs in stock. Combined ARVs for
mother were available in 43% of health centres and for baby in 31% of health centres.
Table 6.1 reports the percentage of health facilities that had in stock contraceptives and
other drugs. All contraceptive methods were found in health facilities. The least stocked
contraceptive method was IUCD (29% of hospitals and 4% of health centres) and female
condoms (47% of hospitals and 41% of health centres). At least 64% of all facilities had at
least three temporary methods of family planning in stock. The most commonly available
methods in both hospitals and health centres were injectables, combined oral
contraceptives (the pill) and implants. Hospitals were more likely than health centres to
have the three less commonly found methods of family planning. The high proportion of
facilities with at least three methods of family planning may be a reflection of the support
given to contraceptive availability by UN agencies and NGOs but no inquiry into
contraceptive source was made.
Table 6.1: Percentage of facilities that had contraceptives and other drugs, by type of facility
(among facilities with a pharmacy/supply of medicine)
Hospitals (n=91)
Health Centres Total (n=305)
(n=214)
Contraceptives (any)*
At least 3 temporary methods
3 month injectables
Combined oral contraceptives
Male Condoms
Implants
IUCDs
Female Condoms
%
77%
59%
67%
66%
41%
57%
29%
47%
%
85%
67%
69%
74%
54%
44%
4%
41%
%
83%
64%
68%
72%
50%
48%
11%
43%
Other drugs
Oral rehydration solution
95%
87%
89%
94
Gentian violet paint
77%
75%
76%
Magnesium trisillicate
73%
47%
54%
Tetanus toxoid
92%
93%
93%
Ferrous sulphate or fumerate
97%
92%
93%
Folic acid
68%
44%
51%
Anti-tetanus serum**
16%
5%
8%
Vitamin K (newborn)
58%
7%
22%
Nystatin (oral) (for newborn)
55%
32%
39%
Anti Rho (D) Immune Globulin
26%
2%
9%
Sodium citrate
2%
1%
1%
Heparin*
12%
1%
4%
*One hospital and three health centres did not respond and were excluded from the analysis.
Among the other drugs listed, the supply of haematinics and in particular folic acid appears
deficient in both hospitals and health centres (68% and 44% respectively). The same
comment can be made of tetanus toxoid, anti Rho (D) and vitamin K – drugs for prenatal
prevention of neonatal tetanus, postabortal/delivery care in Rh negative women and
newborn care, respectively. Only 58% of hospitals and 7% of health centres had vitamin K. It
is possible that fefol – the iron-folate combination drug – could have been available in
health facilities that did not have ferrous sulphate or folic acid but data collectors did not
specifically ask for fefol.
6.3 Guidelines, supplies and medical equipment in labour & delivery and maternity wards
Table 6.2 reports on the availability of selected clinical guidelines in maternity wards. The
most commonly available guidelines in all facilities were guidelines for management of
obstetric complications (88%), PMTCT (65%), and management of newborn complications
(64%). In general, health centres were less likely than hospitals to have the selected
guidelines; Post abortion care guidelines were available in only 46% of hospitals and 14% of
health centres.
Table 6.2: Percentage of facilities that have the indicated guidelines in the maternity ward1, by
type of facility
Guidelines or protocols
Hospitals2 Health
(n=92)
Centers2
(n=217)
%
%
Management of obstetric complications
96%
85%
Management of newborn complications
84%
55%
Immediate newborn care
74%
53%
Focused antenatal care
63%
47%
PMTCT (maternal and newborn dosing)
82%
58%
Infection prevention
75%
46%
Postabortion care
46%
14%
Family planning
49%
53%
1. For hospitals, the maternity area was likely to be a specific room and these
questions were related to the guidelines available in that specific room.
Health centres may not have had a specific room devoted for a maternity
Total
(n=309)
%
88%
64%
59%
52%
65%
55%
24%
52%
95
ward and these questions were therefore related to whether the facility, in
general, had the guidelines available.
2. Three Hospitals and eight Health Centres didn't respond to this question
Table 6.3 reports the percentage of hospitals and health centres with selected infection
prevention materials in the maternity area. The main deficiencies were with disinfectants
and antiseptics. Chlorhexidine was available in only 38% of hospitals and 30% of health
centres; cidex available in only 42% and 11% of hospitals and health centres respectively
and povidone iodine available in 46% and 52% of hospitals and health centres respectively.
Mayo stands were only available in 42% of facilities.
Table 6.3: Percentage of facilities that have the indicated materials for infection prevention in the
maternity area1, by type of facility
Hospitals (n=91)
Health Centres Total (n=301)
(n=210)
%
%
%
Basic Items
Soap
Antiseptics
Gloves
Heavy duty gloves
Non-sterile protective clothing
Decontamination container
Bleach or bleaching powder
Prepared disinfection solution
Regular trash bin
Covered contaminated waste trash bin
Puncture proof sharps container
Mayo stand to establish sterile field
93%
92%
98%
74%
90%
98%
96%
92%
95%
93%
87%
49%
93%
85%
100%
70%
85%
98%
93%
84%
93%
76%
94%
39%
93%
87%
99%
71%
86%
98%
94%
87%
93%
81%
92%
42%
Disinfectants and antiseptics
Ethanol
Chlorhexidine
Povidone iodine
Cidex
90%
38%
46%
42%
81%
35%
52%
11%
84%
36%
50%
21%
1. For hospitals, the maternity area is likely to be a specific room and these questions are related to
the infection prevention items available in that specific room. Health centres may not have a specific
room devoted for a maternity and these questions are therefore related to whether the facility, in
general, has the infection prevention items available.
96
Table 6.4 shows the percentage of facilities with newborn supplies, basic equipment and
resuscitation equipment in maternity wards of hospitals and health centres. Vital equipment
needed for newborn care such as radiant heater, incubators, phototherapy equipment and
apnea monitors were in short supply in both hospitals and health centres. Fifty six percent
of hospitals and twenty nine percent of health centres had a mucus extractor and around
eighty five percent and seventy six percent of facilities had ventilatory bag and infant face
masks respectively. All hospitals need this critical equipment for neonatal resuscitation.
Health centres are also expected to perform basic neonatal resuscitation but only 29% had
mucus extractors, 73% had face masks and 80% had ventilator bags. Only about 24% of
hospitals had infant laryngoscopes and 29% had endotracheal tubes. Health centres are not
expected to perform intubation therefore only 0-1% had these instruments.
Table 6.4: Percentage of facilities with basic and emergency newborn supplies and equipment in
the maternity area1, by type of facility
Hospitals
(n=91)
Health Centres Total
(n=210)
(n=301)
%
%
%
99%
11%
98%
9%
98%
10%
21%
8%
98%
79%
46%
42%
5%
35%
53%
53%
12%
1%
97%
21%
3%
3%
0%
0%
15%
19%
15%
3%
97%
39%
16%
15%
2%
11%
27%
29%
56%
84%
96%
87%
24%
29%
13%
90%
29%
73%
80%
40%
1%
0%
2%
56%
37%
76%
85%
54%
8%
9%
5%
67%
Supplies and equipment needed for newborn
Rectal thermometer for newborn
Low reading thermometer (32 or 35 degree C)
IV fluid (neonatal giving) set/umbilical catheter
Baby weighing scale
Neonatal resuscitating table
Incubator
Radiant warmer
Icterometer
Fluorescent tubes for phototherapy to treat jaundice
Apnoea monitor
Paladay / small cup for breast milk expression
Towels or cloth for newborn
Neonatal Resuscitation Pack
Mucus extractor
Infant face masks (sizes 0, 1, 2)
Ventilatory bag
Suction catheter 10, 12 Ch
Infant laryngoscope with spare bulb & batteries
Endotracheal tubes 3.5, 3.0
Disposable uncuffed tracheal tubes (sizes 2.0 to 3.5)
Suction apparatus: Foot – or electrically-operated
97
Mucus trap for suction
0%
0%
0%
1. For hospitals, the maternity area was likely to be a specific room and these questions were related
to the equipment and supplies available in that specific room. Health centres may not have had a
specific room devoted for a maternity and these questions were therefore related to whether the
facility, in general, had the equipment and supplies available.
Table 6.8A in the appendix presents data on the percentage of health facilities with basic
diagnostic equipment and supplies by type of facility. Diagnostics that were in short supply
included blood sugar testing sticks (found in 29% of hospitals and 7% of health centres),
uristix for measuring protein (found in 52% of hospitals and 13% of health centres) and
pulse oximeter (found in 20% of hospitals and 3% of health centres). 98% of hospitals and
97% of health centres had blank copies of the WHO modified partograph available.
However, it should be noted that a partograph is also printed on the antenatal card/labour
and delivery chart, but it is not used with any frequency. When partographs are used
appropriately they enable early detection of common maternal and foetal complications of
labour and delivery.
In Table 6.9A in the appendix, the percentage of facilities with cervical/perineal repair packs
and materials for other procedures in the maternity area are presented. Equipment for
episiotomy/perineal/vaginal/cervical repair, vacuum extraction, uterine evacuation and
manual vacuum aspiration were largely available in hospitals. However, the availability of
these important items in health centres was low as evidenced by the fact that 0% of health
centres had dressing instrument set, 1% had uterine evacuation set, 25% had
episiotomy/perineal/vaginal/cervical repair pack, 33% had MVA and vacuum extraction set.
Among gynaecological equipment, uterine sound and tenaculum were missing in health
centres (11% and 27% respectively).
Health centres are not supposed to perform forceps deliveries; vacuum extractor is the
instrument of first choice for assisted vaginal delivery and should be performed at the
health centre level. Only 33% of health centres had vacuum extractors. This lack of
equipment could explain the very low percentage of health centres that performed the
signal function of assisted vaginal delivery.
Almost all hospitals and health centres had delivery packs and most packs contained the
most important equipment. It is possible to improvise for the items that are most often
deficient. Long gloves are not routinely included in delivery packs. Gynaecological
equipment was available in most hospitals, but less likely to be available in health centres.
Table 6.10A in the appendix presents data on the availability of selected furnishings in the
maternity area of health facilities. Some striking deficiencies in health facilities include: only
33% of hospitals and 4% of health centres had oxygen cylinders and related apparatus; only
52% of hospitals and 42% of health centres had labour/delivery table with stirrups only 4%
of health centres provided meals to their patients (however, health centres generally do not
have kitchens). Empty beds for new patients were found in 88% of hospitals and 86% of
health centres; this may not be the case in all urbanized facilities.
98
Table 6.11A in the appendix reports data on the availability of autoclaves, sterilization
equipment and incinerators in the maternities of hospitals and health centres. Over 70% of
facilities had sterilization drums and functioning incinerators. Sterilizers and autoclaves are
used for preparing instruments and packs for re-use and they are interchangeable.
6.4 Operating theatre and equipment
In Table 6.12A in the appendix, the data on hospitals with operating theatres (OT) and the
availability of theatre equipment and supplies are presented. There were 62 (67%) hospitals
with operating theatres out of the 92 hospitals assessed. Operating theatres dedicated to
obstetric patients were found in 26% of the hospitals with OTs. In general, most hospital
theatres had most of the listed equipment and supplies. Table 6.12A in the appendix
presents data on the availability of anaesthetic equipment, craniotomy equipment and
supplies in hospitals with operating theatres. The main concern is that only 58% of
operating theatres had size 10 cuffed endotracheal tubes. Craniotomy equipment was not
readily available; only 31% of hospitals with operating theatres had decapitation hooks and
29% had craniotomy forceps. However, craniotomies are sometimes done using only
scissors and volsellum forceps.
6.5 Laboratory equipment and supplies for blood transfusion
Table 6.13A in the appendix presents data on equipment and supplies in health facilities
reporting that they had laboratories. Ninety percent of the hospitals and 16% of health
centres reported that they had a laboratory. However, most of the items in Table 6.13A in
the appendix, refer to equipment and supplies for blood transfusion and Table 3.3 showed
that none of the health centres provided blood transfusion in the three months before the
data collectors visited. For EmONC purposes, health centres are not expected to have blood
bank services; blood transfusion is considered a comprehensive EmONC signal function.
Eighty four percent of hospital laboratories and sixty three percent of health centre
laboratories had operating guidelines. Blood typing and cross-matching reagents were
available in 90% of hospital laboratories. Hepatitis B, hepatitis C, and syphilis testing kits
were found in 83%, 21% and 94% of hospital laboratories, respectively while HIV testing kits
were found in 96% of hospital laboratories and in 51% of health centre laboratories. Table
6.14A in the appendix provides additional data on the percentage of health facility
laboratories with selected equipment and supplies.
6.6 Recommendations




Improve supply chain management with a focus on the availability of key drugs in all
facilities such as oxytocin, magnesium sulphate, PMTCT drugs and testing kits and
anaesthetics.
Revise the essential drug list to enable health centres to perform all basic signal
functions especially with respect to the approval of the use of magnesium sulphate
and misoprostol in health centres.
Conduct supplies and logistics management training to ensure appropriateness and
sustainability of drug procurement and distribution in all rural hospitals and health
centres.
Ensure availability of health facility inventory registers and ensure that staff is
trained to keep them up-to date.
99


Compliance with the stock management guideline to refill when stock falls to third is
needed.
Maintain an emergency stock of key drugs (in operating theatres, labour wards and
maternity wards) in all facilities even where pharmacies are always open. The
emergency stock could then be refilled at re-order level.
100
Chapter 7: Performance of other MNH Services and procedures
In addition to the emergency signal functions many other essential services make up the
package of maternal and newborn care and those services are examined in this chapter. The
first table (Table 7.1) is based on the 309 facilities that answered these questions; the
remaining tables refer to the 299 facilities where deliveries took place in the 12 months
preceding the date that the data collectors visited the facility.
7.1 Overview of maternal and newborn services in all facilities
Focused antenatal care (FANC), Postnatal care, Diagnosis and treatment of STIs, PMTCT
and Family Planning
Nationally, nearly all facilities reported that they provided focused antenatal care (FANC),
postnatal care, diagnosis and treatment of STI and PMTCT. Only 85% of facilities provided
family planning services (Fig. 7.1 and Table 7.1). Provision of family planning services is
deficient in CHAM facilities. Only 50% of CHAM hospitals provide FP services, 20% of CHAM
rural hospitals and 60% of CHAM health centres. The reason for low uptake of FP planning
services in CHAM facilities may be due to policy issues. For district data, please refer to
Table 7.1A in the appendix.
Fig. 7.1: Percentage of surveyed facilities (national) providing selected services
120
P
e
r
c
e
n
t
100
98
97
96
95
85
80
60
40
20
23
19
19
8
0
101
Table 7.1: Percentage of surveyed facilities providing selected services by facility type and sector
Postnatal Obstetric
care
Surgery
National
Focused
Antenatal
care
%
98
Diagnosis & PMTCT
treatment
of STI
%
%
96
95
FP
%
19
General
Treatment
Anaesthesia and repair of
Ob fistula
%
%
19
8
%
97
Facility Type
Central Hospital
District Hospital
100
96
Other Hospitals
Govt
CHAM
Private
Total
number of
facilities
%
85
Cervical
cancer
screening
%
23
100
100
100
96
100
96
75
30
100
100
100
100
100
100
100
100
4
23
100
100
70
100
100
60
33
100
50
33
95
70
0
45
30
100
95
90
100
95
60
100
50
90
33
45
30
3
22
10
Rural Hospital
Govt
CHAM
Private
100
100
NA
100
100
NA
27
13
NA
20
13
NA
7
0
NA
93
87
NA
100
100
NA
100
20
NA
27
13
NA
15
15
NA
Health Centre
Govt
CHAM
Private
99
98
100
97
98
100
0
0
0
0
0
0
0
0
0
98
94
100
96
96
60
99
60
100
12
8
0
160
52
5
309
102
Provision of obstetric surgery and general anaesthesia (GA)
Nationally, only 19% of facilities provide these services. This may be a reflection of the fact
that only hospitals have the capacity to provide them. Almost all the central, district and
CHAM hospitals provide obstetric surgery and GA. The fact that 33% of other Government
hospitals do not provide obstetric surgery and GA is a reflection of the fact that Police and
Army hospitals do not provide these services. Only 13% of CHAM rural hospitals provide
these services while 27% and 20% of Government rural hospitals provide obstetric surgery
and GA respectively. For district data, please refer to Table 7.1A in the appendix.
Treatment and repair of obstetric fistula
Nationally, only 8% of facilities provide this service. This is a highly specialized area and only
obstetricians/gynaecologists, surgeons, trained medical doctors and clinical officers are able
to provide this service. One of the central hospitals (i.e. Mzuzu Central) does not have the
capacity to deliver this service. Only 30%, 45%, 30% and 7% of district, CHAM, private and
Government rural hospitals have the capacity to deliver this service. Therefore, many
women requiring this specialized service have to be referred to specialist centres to receive
adequate care. For district data, please refer to Table 7.1A in the appendix.
Cervical Cancer Screening
Nationally, only 23% of facilities provided this service (Table 7.1). It would appear that this
service is provided primarily through hospitals rather than health centres. Only 12% of
Government and 8% of CHAM health centres had capacity to deliver this service. While all
central and district hospitals had capacity to provide cervical cancer screening, only 45% of
CHAM hospitals could deliver this service. Likewise, only 30%, 33%, 27% and 13% of private,
Government other hospital, Government rural and CHAM rural hospitals had capacity to
deliver cervical cancer screening. For district data, please refer to Table 7.1A in the
appendix.
7.2 Length of stay for women after a normal delivery
Table 7.2A in the appendix shows the median length of stay in hours after normal delivery.
In both hospitals and health centres, staff reported that the median length of stay after
delivery was 24 hours. In Government facilities, the median stay was 24 hours, in CHAM
facilities 36 hours while in private facilities, it was 24 hours.
7.3 Provision of other essential services in facilities that provide delivery care
Figure 7.2 and Table 7.3A in the appendix reflect a number of procedures and services that
were asked about only in facilities that performed deliveries. The questions followed the
same format as the questions regarding the signal functions: staff was asked if the service
had been provided in the last 3 months, if not, why not? Figure 7.2 shows the percentage of
and health facilities that reported having not provided the different services in the last 3
months. Each entire bar reflects what percentage of hospitals did not provide the service.
The reasons for not having performed are shown in Table 7.3A in the appendix.
103
Fig. 7.2: Percent distribution of facilities that did not perform other essential services in
last 3 months
100
93
90
80
P
e
r
c
e
n
t
70
60
60
50
54
47
40
30
20
10
24
21
18
12
12
1
0
As shown in Fig. 7.2, craniotomy was least performed by health facilities but still 7% of all
facilities performed craniotomy. Currently, more modern procedures are preferred to
craniotomy so many facilities have seen this procedure being phased out. However, the
reasons for not having carried out craniotomy were policy issues (51%), training issues (28%)
and because the procedure was not indicated (28%).
Up to 60% of facilities did not perform episiotomy in the last 3 months largely because it
was not indicated (51%). A number of reasons were given for not having performed surgical
or permanent methods of family planning including policy issues (49%), training issues
(44%), lack of supplies, equipment or drugs (24%) and lack of human resources (17%). Only
53% of facilities provided care for premature or low birth weight babies.
7.4 Recommendations
 All government health centres should provide the following services: focused
antenatal care, normal delivery, a broad range of family planning choices, PMTCT,
newborn care, postnatal care and diagnosis and treatment of STIs. Policy issues
hindering uptake of FP methods in CHAM facilities may need to be addressed.
 All hospitals should provide obstetric surgery, anaesthesia, and cervical cancer
screening in addition to the services provided at health centres listed above.
104


Selected hospitals and certainly central hospitals should have capacity to provide
fistula repair.
Health facilities should provide adequate care for premature or low birth weight
babies
All pregnant mothers should have universal access to high quality PMTCT services
including provision of ART to mothers and newborns as clinically indicated.
105
Chapter 8: Case Reviews
8.1 Partograph reviews
The purpose of the partograph review was to assess the use and quality of the partograph
completion and labour management in the health facilities. According to the instructions to
the data collection team, if a facility used the WHO modified partograph the team would
select three partographs completed in the last month. If they used another type of
partograph, no assessment would be made. Although the data collectors were instructed to
complete three reviews from each eligible facility, three were not always completed. For
these case reviews and the two other case reviews, the cases are not a random sample but
are a convenience sample. Thus no extrapolation or weighting is possible.
Use of the partograph
Of the 299 health facilities with delivery services assessed in this survey, 293 facilities i.e.
98% reported using partograph. There was 100% usage of partographs in all hospitals except
private (60%), while 96% of health centres and 90% of CHAM health centres used them. Of
the 293 facilities that used a partograph, 84% of Government facilities and 77% of CHAM
facilities used the modified partograph. Up to 64% of private facilities used other type of
partograph. However, of the facilities using the WHO modified partograph, only 10% of
Government facilities and 17% of CHAM facilities had a protocol for labour management
(Table 8.1).
Table 8.1: Use of the partograph among all facilities, by type of facility
Govt
Used
partograph
%
100%
Of those that used
used modified
80%
used other
20%
type
Of those with
modified, have
management
protocol
17%
Hospitals
CHAM Privatefor profit
%
%
100%
60%
Health Centres
Govt
CHAM Private-for
profit
%
%
%
96%
90%
100%
All facilities surveyed
Govt
CHAM
Privatefor profit
%
%
%
97%
94%
73%
84%
16%
17%
83%
85%
15%
72%
28%
60%
40%
84%
16%
77%
23%
36%
64%
23%
0%
8%
12%
0%
10%
17%
0%
The quality of partograph completion
1. Availability of partographs for assessment
In this survey, the 205 facilities using the modified partograph produced partographs for
review – not every eligible facility produced 3 partographs. The 21 hospitals produced 54
partographs and the 129 health centres 344. Of the 398 partographs, only 180 (45%) had
106
the admission dilatation charted correctly on the partograph and could be used for further
analysis (see Table 8.4).
2. Frequency of recordings during labour
Tables 8.2 – 8.3 demonstrate how important standards are for recording observations
during labour in order to manage labour well. Foetal heart rate, temperature, blood
pressure, pulse, contractions, cervical dilatation and descent of head were all analyzed by
the number of hours women were in labour. Each question was phrased similarly, for
example, “How many times was the woman’s temperature checked and recorded between
admission and delivery (including admission and delivery)?” Number of hours in labour by
type of facility: Table 8.2 shows that overall, 48% of women stayed less than 6 hours in
labour, 43% of women in hospitals and 50% of women in health centres, suggesting that
women labour slightly longer in hospitals than in health centres. For those women who
stayed longer than 9 hours in labour this proportion was 11% and 6% for hospitals and
health centres, respectively.
Table 8.2: Percent distribution of women with partographs according to hours between first exam
and delivery, by type of facility
Hours between first
exam and delivery
0-2
3-5
6-8
9+
No information
Total
Women with
partographs in
hospital
%
25%
43%
20%
11%
0%
100%
Women with
partographs in
health centre
%
20%
50%
23%
6%
1%
100%
All facilities
%
21%
48%
22%
7%
1%
100%
Temperature: A woman’s temperature should be recorded every 2 hours. A total of 306
(37%) did not have their temperature recorded even once regardless of the number of
hours they were in labour in the facility (Table 8.3 for temperature and all subsequent
measurements).
Blood pressure: Partograph instructions recommend that maternal blood pressure be taken
every 4 hours. On the whole blood pressure recordings were taken regularly. However, 31%
of women had no blood pressure recorded.
Maternal pulse: Maternal pulse should be recorded every 30 minutes. It was not recorded
for 310 women (37%) during labour and the longer women were in labour, the less
frequently the pulse rate was recorded.
Foetal heart rate: The foetal heart rate should be recorded every half hour. A total of 282
women (34%) did not have foetal heart monitored. This is noteworthy in the context of
stillbirths with spontaneous vaginal deliveries (SVDs) on or left of the alert line – see Table
8.5.
107
Table 8.3: Number of women with partographs and how many times key measurements were
taken and recorded, by hours between first exam and delivery
Hours between first exam and delivery
0-2
3-5
6-8
9+
(n=178)
(n=403)
(n=186)
(n=62)
Total
(n=829)
Temperature
(standard)
0
1
2
3+
74
87
14
3
155
175
59
14
64
68
34
20
13
25
15
9
306
355
122
46
Blood pressure
(standard)
0
1
2
3+
57
82
31
7
129
141
90
43
59
47
32
48
11
18
12
21
256
288
165
119
Maternal pulse
(standard)
0
1
2
3
4+
72
75
23
7
1
150
135
63
25
30
68
35
27
21
35
20
13
12
7
10
310
258
125
60
76
279
124
34
547
Was foetal heart beat observed?
Yes
110
Were contractions assessed (standard)
Yes
130
300
136
36
602
Vaginal exams
(standard)
0
1
2
3+
14
24
235
130
0
9
24
153
0
1
5
56
16
67
395
350
2
33
131
11
Contractions: Contractions should be charted every half hour. A total of 227 women (27%)
had no contractions monitored during their labour. The longer the women were in labour in
the health facilities the less frequently contractions were recorded. Contractions together
with dilatation of the cervix and the descent of the head are critical to assessing progress of
labour and detecting any deviation from normal to prevent prolonged/obstructed labour.
108
Vaginal examinations to assess cervical dilatation: Since the recommendation is that vaginal
examinations should be carried out at least once every 4 hours during the first stage of
labour, the data in Table 8.3 show that despite this recommendation, 16 women (2%) did
not have vaginal examinations until delivery.
Table 8.4 shows that of the 180 women on the partograph whose progress could be
assessed, 63% delivered on or left of the alert line, 25% delivered between the alert and
action lines, which is the referral or transfer zone, and 11% delivered beyond the action line.
It is noteworthy that 64% of women delivered on or left of the alert line in health centres
compared to 61% in hospitals. Among women who were augmented, 13% used
augmentation on alert line, 26% used it between alert and action lines and 17% used it on or
beyond action line. Augmentation is not recommended in health centres and can be
dangerous unless there is a back-up for caesarean.
Table 8.4: Partograph assessment by progress of labour and augmentation, by type of
facility
First dilatation charted correctly on
alert line
Among those charted correctly,
delivered
on or left of alert line
between alert and action line
on or beyond action line
information not available
Women with
partographs in
Hospitals
%
93%
Women with
Partographs in
Health Centres
%
95%
Women with
Partographs in All
facilities
%
94%
61%
24%
15%
1%
64%
26%
10%
1%
63%
25%
11%
1%
22%
33%
33%
11%
7%
21%
7%
64%
13%
26%
17%
43%
used augmentation
Among those who used
augmentation
used on alert line
used between alert and action lines
used on or beyond action line
no information available
Table 8.5 shows the type of delivery and outcome by the progress of labour on the
partograph. Of the 828 women, 783 (95%) had an SVD, and 97% of these delivered during
normal active phase (on or left of alert line). The caesarean section rate was 1% among
these women. There were 3 stillbirths among 828 women on the partograph (<1%). Two of
these were delivered during normal active phase (on or left of alert line) and one was
delivered between alert and action line. Twenty-two women (3%) whose partographs were
assessed received augmentation, out of which 9 delivered on or left of alert line, 6 delivered
between alert and action line and 7 delivered on or beyond action line. Normally it is not
109
recommended to augment labour before the action line is reached unless there is a
pathology that makes deviation from the protocol necessary.
Table 8.5: Partograph assessment by progress of labour and type of delivery and foetal
outcome in all facilities
Components of
management
Total cases
Delivery type1
Caesarean
Vacuum
extraction
SVD
No
information
Augmented
labour
According to the partograph, the woman delivered
During normal
Between alert
On or beyond
active phase (on
and action line
action line
or left of alert
line)
n
%
n
%
n
%
524
63%
208
25%
92
11%
n
828
%
100%
1
2
0%
0%
3
2
1%
1%
8
2
9%
2%
12
6
1%
1%
507
13
97%
2%
198
5
95%
2%
78
4
85%
4%
783
22
95%
3%
9
41%
6
27%
7
32%
22
100%
64%
195
25%
82
11%
773
93%
21
3%
3
24
0%
3%
Outcome for the baby2
Normal live
496
birth
Live birth
12
with distress
Stillbirth
2
No
13
information
5
67%
1
6
4
33%
0
5
0%
Total
8.2 Caesarean delivery reviews
The objective of the caesarean delivery review was to understand the principal clinical
indications (causes) for caesareans and to evaluate some aspects of the quality of the
procedure and record keeping. According to the instructions to the data collectors, the
three most recent caesareans documented in the facility logbook/operating theatre logbook
were to be reviewed as long as they were no longer hospitalized and were performed in the
12 months prior to the interview date.
Characteristics of the women and outcomes
There were a total of 173 caesareans that were reviewed. Ninety-two were from
Government facilities, 66 from CHAM and 15 from private facilities. Fifty-three percent of
the women were between 20 and 29 years of age. The average age was 24 years and
average parity was 2. No woman died (Table 8.6).
110
Table 8.6: Percent distribution of women whose caesarean deliveries were reviewed
according to age, parity and condition after surgery
Characteristics
Age (in years) 1
<20
20-24
25-29
30-34
35-39
>40
Average age (in years) 1
Parity 2
0
1
2-3
4-5
>6
Average parity 2
Condition of the mother 3
Alive
Dead
%
21
31.1
22.2
18
7.2
0.6
24
14.2
26
37.3
14.8
7.7
2
100
0
1 Six cases had no information on age and were excluded from the analysis
2 Four cases had no information on parity and were excluded from the analysis
Indications, type of caesarean delivery, and partograph use
Table 8.7 shows several characteristics of the caesarean deliveries reviewed by sector.
Maternal indications accounted for 65% and foetal indications for 35%. Overall, the major
indications were: CPD/Prolonged labour (45%), and previous scar (13%), foetal distress (9%),
and breech with footling (7%). Previous scar as an indication played a bigger role among
women who delivered in the private for-profit sector (27%) than in government or CHAM
facilities.
111
Table 8.7: Percent distribution of women whose caesarean deliveries were reviewed according to
the indication for surgery, type of caesarean, and use of partograph among emergency caesareans,
by sector
All
facilities
Among all women whose caesareans
were reviewed
Indication for caesarean: 1
Maternal Indications
CPD/prolonged labour
Previous scar
APH*
Eclampsia/Severe preEclampsia
Failed induction
PROM
Multiple gestation
Foetal Indications:
Foetal distress
Breech with footling
Cord prolapse
Post term
Other*
Govt
%
(n=173)
%
(n=92)
Private
forprofit
%
(n-15)
45%
13%
3%
3%
42%
12%
5%
2%
33%
27%
0%
7%
52%
12%
0%
3%
1%
0%
0%
0%
0%
0%
0%
0%
0%
2%
0%
0%
9%
7%
6%
0%
7%
7%
9%
0%
20%
0%
0%
0%
13%
16%
13%
11%
9%
5%
0%
0%
8%
84%
60%
82%
1%
15%
33%
7%
3%
15%
(n=77)
(n=9)
(n=54)
70%
33%
87%
30%
67%
13%
Type of caesarean delivery
Emergency
Elective
No information
81%
5%
CHAM
%
(n=66)
14%
Among women whose caesarean
was an emergency 2
Partograph used
(n=140)
74%
Partograph not used
26%
* Other indications for both maternal and foetal indications
Of the 173 caesareans reviewed, 81% were emergencies, 5% were elective and for 14%
there was no information. Approximately 84% of all caesareans were considered
emergencies in Government facilities compared with 82% in CHAM and 60% in the private
112
for-profit sector. Among the women with emergency caesareans, 74% were managed with a
partograph. The partograph was most likely to be used at Government facilities.
Table 8.8 shows the type of caesarean (emergency or elective) and whether a partograph
was used according to the indication of the caesarean. Among the 23 women with a
previous scar, 5 had elective caesareans and 17 had an emergency section and there was no
information in one woman.
113
Table 8.8: Number of women whose caesarean deliveries were reviewed and their indications, by type of caesarean and whether the partograph was
used
Indication for
caesarean: 1
Govt
Total
CPD/prolonged
labour
Previous scar
Placenta
praevia/APH
Eclampsia/Severe
pre-eclampsia
Failed induction
PROM
Multiple gestation
Other
Foetal Indications:
Foetal distress
Breech
with
footling
Cord prolapse
Post term
Type of Caesarean
Elective
Emergency
CHAM
No. of caesareans
No information
CHAM
Privatefor Profit
Govt
Privatefor Profit
Govt
CHAM
Privatefor Profit
77
9
54
1
5
2
14
1
10
173
33
4
30
0
0
0
6
1
4
78
10
5
1
0
6
0
0
0
3
0
2
0
1
0
0
0
0
0
23
5
2
1
2
0
0
0
0
0
0
5
0
0
0
12
0
0
0
0
1
0
0
0
0
0
0
1
0
0
0
2
0
0
0
0
0
0
0
2
0
0
0
0
0
0
0
5
5
5
3
0
6
6
0
0
0
0
0
0
1
1
0
0
1
0
1
0
0
22
0
16
12
5
0
0
0
3
0
0
0
0
0
0
0
3
0
0
0
0
0
11
0
1. 12 cases did not report an indication for caesarean
2. 1 case did not report on partograph use
114
Characteristics of the caesarean delivery
Timing from diagnosis/decision for caesarean to actual surgery and duration of hospital stay
Figure 8.1 and Table 8.1A in the appendix show the lapse of time between the decision to
do the caesarean and surgery and the overall duration of the women’s hospital stay. Eight
percent of the women had surgery within 30 minutes of making the decision. The
recommended international standard is less than 30 minutes. Thirty-nine percent of the
women were delayed between half an hour and two hours. Two percent were delayed five
hours or more. These data are difficult to interpret since approximately 35% of the charts
reviewed did not have this information.
Nine percent of the women remained in the hospital for 3 days or less, 69% between four
and eight days. The average duration was 1.5 days. Duration varied depending on a number
of factors. Emergency caesareans were discharged after 8.1 days compared to elective
caesareans at 7.9 days. Women whose wounds were not infected were hospitalized twice as
long as women with infection (14 days vs. 8.2 days). This is surprising as one would expect
those with wounds infected to spend longer in hospital than those with wounds not
infected. Average time in the hospital also varied with indication.
Figure 8.1: Time lapse between the decision to perform a caesarean and actual surgery
30 minutes or less
8%
31 minutes to 1 hour
35%
21%
1-2 hours
2-3 hours
3-5 hours
2%
5%
18%
10%
5+ hours
No information
Foetal characteristics
The presence of meconium was reported for 21% of the charts reviewed (however, 65 of
the cases were missing this information) (Table 8.2A in the appendix). Where meconium
was detected, 75% progressed and delivered normal live births, 19% delivered live births
with distress and 6% delivered still births. Where meconium was not detected, 96%
progressed and delivered normal live births, 1% delivered live births with distress and 1%
delivered stillbirths. This is consistent with the fact that the presence of meconium was a
worse prognostic factor on newborn outcome.
115
At the last recording of the foetal heart rate, a normal rate was noted for 72% of women
and no heart beat was detected for 1% of the women. Where the foetal heart was normal,
90% of women progressed to deliver normal live births, 6% delivered live births with
distress, 1% delivered neonatal deaths and 3% delivered stillbirths. Where there was foetal
bradycardia, 83% of the women delivered normal live births where as 17% delivered live
births with distress. Where there was foetal tachycardia, 57% of the women delivered
normal live births, 29% delivered live births with distress and 14% delivered stillbirths. In
two cases, no foetal heart was detected and both of these turned out to be stillbirths.
Monitoring of foetal heart is therefore critical and integral part of good labour
management.
Finally, asphyxia and birth trauma were the leading causes of foetal and early neonatal
death. With improved intrapartum care, most of the deaths due to asphyxia and birth
trauma as well as very early infection could possibly be averted. According to Table 8.3A in
the appendix, foetal outcomes were poorest among women whose indications for a
caesarean were cord prolapse or foetal distress.
8.3 Maternal death reviews
The purpose of a review of maternal deaths was to identify factors that contribute to
institutional maternal deaths, and like the other reviews, they reveal aspects related to the
quality of patient management and record-keeping. Information was extracted from
registers and the patients’ records. Also, in line with the partograph and caesarean delivery
reviews, the data collectors were instructed to review the last three maternal deaths that
took place in the facility in the past year. If only one death occurred, then only one review
would be done. If only two deaths took place, then two deaths would be reviewed.
However, we should not equate a facility that did not complete at least one review with a
facility that did not have a maternal death in the past 12 months. In fact, the results from
the Facility Case Summary (Module 4) indicate that 101 facilities reported at least one
maternal death. Data collectors completed maternal death reviews in 89 facilities. The
teams of data collectors reported that although a maternal death had occurred, the facility
staff was not always able to locate the women’s records for review. A total of 153 deaths
were reviewed, thus some facilities reported fewer than 3 deaths.
Causes of maternal death
Of the 153 reviews, 142 (93%) took place in hospitals and 11 (7%) in health centres. Most
women (67%) died of direct causes, 25% of indirect causes and 8% had no information
regarding the cause of death (Table 8.9). Among the cases reviewed, the primary direct
causes of death were postpartum haemorrhage/retained placenta (33% of all maternal
deaths reviewed), sepsis (12%), ruptured uterus (7%) and severe pre-eclampsia/eclampsia
(7%). Abortion complications accounted for 5% of maternal deaths reviewed. Anaemia and
malaria together accounted for 13% of maternal deaths reviewed.
Proportionately, a larger percentage of women died of PPH/retained placenta in health
centres (45%) than in hospitals (32%), suggesting that they are able to reach lower level
facilities. Health centres should be ready to provide life-saving services. When the
distribution of causes of maternal death for the case reviews is compared with the all
116
maternal deaths documented during the 12 month period some differences stand out
suggesting that the reviews may not be representative of the larger number of maternal
deaths recorded.
Table 8.9: Percent distribution of women whose deaths were reviewed according to
primary cause of death, by facility type
Direct causes1
Deaths in
hospitals (n=142)
142
%
n
66%
94
Deaths in health
centres (n=11)
11
%
n
73%
8
All reviewed
deaths (n=153)
153
%
n
67%
102
PPH
Ruptured Uterus
Pre-eclampsia/Eclampsia
APH
Prolonged/Obstructed
labour
Bleeding
Sepsis
Abortion related
complications
32%
6%
8%
3%
1%
45
8
11
4
1
45%
18%
0%
9%
0%
5
2
0
1
0
33%
7%
7%
3%
1%
50
10
11
5
1
0%
13%
5%
0
18
7
0%
0%
0%
0
0
0
0%
12%
5%
0
18
7
Indirect causes
25%
35
27%
3
25%
38
Anaemia
Malaria
HIV
Others
10%
3%
4%
8%
14
4
6
11
9%
9%
0%
9%
1
1
0
1
10%
3%
4%
8%
15
5
6
12
No cause listed
9%
13
0%
0
8%
13
Total
100%
142
100%
11
100%
153
1
If the woman died due to direct and indirect causes, her death was classified as due to direct cause.
Relatively few women who died of indirect causes were reviewed. This may be because the
data collectors spent most of their time working in and around the maternity and
obstetric/gynaecological wards. It may not be surprising that the most recent deaths that
they located were due to direct causes. Proportionally, more indirect deaths were reviewed
in health centres than in hospitals (27% vs. 25%). Similarly, data collectors encountered a
greater proportion of deaths with an unspecified cause in hospitals than health centres (9%
vs. 0%).
Figure 8.3 and Table 8.4A in the appendix show the groupings of cause of death by when the
death occurred. Almost a fifth (18%) of all deaths occurred during pregnancy, 1% during
vaginal delivery, 5% during surgery and 69% after delivery. Deaths due to direct and indirect
causes were concentrated in the period after delivery.
117
Figure 8.2: Distribution of women whose deaths were reviewed according to time of
death
18%
During pregnancy
7%
During abortion
1%
During vaginal delivery
5%
During obstetric surgery
After delivery
69%
Characteristics of the women, their deliveries, and outcomes of the newborn
Close to 70% of the women who died were between the ages of 20 and 29 (Table 8.10).
Fifteen percent were under the age of 20 and 14% were 35 or older. Among women who
had a delivery, a fifth (21%) delivered at home or on the way to a facility while the other
three quarters (78%) delivered in a facility, most of whom delivered in a hospital (72%).
More than half of the women (53%) had spontaneous vaginal births, 2% were assisted with
vacuum extraction, while 36% had a caesarean. None of the women required a destructive
delivery or a laparotomy. Only 51% of the women had a live birth while 33% had a stillbirth.
118
Table 8.10: Percent distribution of women whose deaths were reviewed according to age,
location of the delivery, type of delivery and condition of newborn
Among maternal deaths
Age of woman1
<20
20-24
25-29
30-34
35-39
>40
Mean age (in years)
Among those with a delivery2
Location of delivery
At home
On the way to health centre
In a health centre
In a hospital
Other
Type of delivery 3
Vaginal
Assisted with extractor
Caesarean
Destructive delivery
Laparotomy
No information
%
(n = 149)
n
149
15%
24%
21%
26%
11%
3%
22
36
32
39
16
4
27
(n = 116)
116
18%
3%
6%
72%
2%
21
3
7
83
2
(n=115)
53%
2%
36%
0%
9%
1%
115
61
2
41
0
10
1
Condition of the newborn1
Normal live birth
Live with distress
Dead
One alive, one dead (twins)
No information
117
51%
5%
33%
2%
9%
60
6
39
2
10
Notes with details on newborn outcome
1
Four cases were did not report age and are excluded.
2
Three cases did not report on location of delivery and are excluded. 34 cases did not end up in a
delivery and are excluded
3
Three cases did not report on location of delivery and are excluded. 34 cases did not end up in a
delivery and are excluded
Factors related to averting maternal death
Table 8.5A in the appendix shows that about 3/4 of the women whose deaths were
reviewed were treated in facilities that were fully functioning as either a comprehensive or
119
basic EmONC facility. About half of the women were referred: 9% from a health post or
health extension worker, 71% from a health centre, and 12% from one hospital to another.
Three percent were reported to have been referred from a private facility.
The research team for the assessment knew that the information related to specific delays
that might have contributed to the death would not be readily available to them. The data
collectors were instructed to talk to the staff on duty to determine if anyone remembered
the case, recognizing the biases inherent in poor recall, as well as the subjectivity of their
memories. More than one response about the cause of delay was acceptable. Four out of
ten cases were thought to have been affected by delays in arriving at the health facility.
Another 34% were described as experiencing a delay in the transfer to the appropriate level
of care (approximately 45% were reportedly referred from lower level facilities). Sixteen
percent of the cases were thought to have experienced delays due to the lack of supplies,
25% due to absence or slowness of human resources, and 26% were due to delays in
reaching the correct diagnosis.
8.4 Recommendations
Partograph reviews
 The recording of essential components of labour progress and of maternal and foetal
conditions needs to be strengthened; otherwise the partograph cannot optimally
function as a managerial tool for the prevention and diagnosis of prolonged and
obstructed labour.
 Provide guidelines for referral based on the cervical dilatation moving between the
alert and action lines. These guidelines may vary according to the woman’s parity.
 Greater attention should be placed on the recording of the foetal heart rate during
both first and second stage of labour.
 Implement national standards for observation of a woman during labour and a
protocol for the management of labour with a partograph.
 Include application of labour management protocol in competencies of midwives.
 Develop criterion-based audits of partographs and outcomes.
 Make correct use of partograph a component of health workers’ performance
appraisals.
Caesarean delivery reviews
 A patient flow analysis would help identify the delays between the decision to do a
caesarean and actual surgery. Staff should work towards reducing this time.
 Evidence has shown that the use of the partograph to manage labour will result in
better outcomes for mother and baby by increasing the timeliness and
appropriateness of interventions, including a reduction in caesarean delivery. The
decision to implement partographic management of labour should be made at
national and district levels.
 Evidence-based guidelines should be developed or adapted regarding caesarean
delivery for intra-uterine foetal deaths, especially in light of the risk of postnatal
sepsis.
120


A substantial proportion of the very early neonatal deaths might have been
prevented with better labour management and immediate newborn care including
resuscitation. Fresh stillbirths could be reduced with improved intrapartum care,
especially with increased use of the partograph and careful monitoring of the foetal
heart in the second stage of labour.
Neonatal resuscitation needs to be the focus of pre-service training and refresher
courses. The distribution of equipment is urgent.
Maternal death reviews
 Very few maternal deaths due to indirect causes were reviewed. This is likely due to
difficulties in identifying these deaths and because data collectors were focusing on
the maternity and ob/gyn wards and services. In future studies, training of data
collectors must stress the difficulty of identifying maternal deaths, especially the
indirect deaths, and provide guidelines on where to locate the indirect deaths since
they are likely to occur outside of the obstetric or gynaecology wards.
 Several tables show deficiencies in the care provided by hospitals – among the
women who were referred, many were referred from one hospital to another, few
hospitals had blood banks, some were not fully functioning as EmONC facilities.
Hospitals must be upgraded to provide comprehensive newborn and obstetric care.
The concept of readiness should be reinforced and simulations to respond to
emergencies should be implemented to improve quality of care.
 Maternal death reviews/audits are considered good clinical practice and are
recommended at every facility where a death occurs. They should be conducted as
an educational process in a non-punitive way, so that health professionals can draw
lessons from the management of each case to improve the quality of care. Maternal
death audits and audits of near misses should be implemented soon in all facilities
providing deliveries.
 Staff appears willing to acknowledge that deficiencies exist in their work
environments as shown in the numbers of health workers who described delays
related to the lack of supplies, to the behaviour of human resources or their ability
to make the correct diagnosis. Maternal death reviews can be a powerful instrument
to promote accountability, but again this should happen in a constructive
environment.
 This review, like the partograph and caesarean reviews, demonstrated the difficulty
in accessing information in the medical records. Medical charts were chronically
incomplete. It is recommended that the accurate completion of medical charts be
given significant attention by management.
121
Chapter 9: Provider knowledge and competency for maternal and newborn
care
The assessment included one face-to-face interview with a provider in the maternity and
the criteria for selection were: 1) the person who had delivered the largest number of
babies in the past month, and 2) who was available to be interviewed at the time of the
visit. The purpose of the interview was to assess aspects of the providers’ knowledge and
competency related to maternal and newborn care. Questions were read aloud and
responses were spontaneous, with the data collectors using pre-coded categories to record
their answers. Prompting was limited to “anything else?”
After the interviewer explained the purpose of the interview and assured her/him that no
names would be recorded, if s/he consented to the interview, the data collector continued.
A total of 296 providers were interviewed and on average, each one attended to 23
deliveries in the past month (Table 9.1A in the appendix).
Most of the interviews were administered to enrolled nurse/midwives (81%), followed by
registered nurse/midwives (11%), then medical assistants (6%). Only two
obstetrician/gynaecologists were interviewed, two clinical officers, one registered nurse and
three enrolled nurses and because of the small numbers, they were excluded from analysis.
Enrolled nurse/midwives delivered on average more babies per month (25) than did
Registered nurse/midwives (20) or medical assistants (9).
All subsequent tables compare groups of health workers. Each question had multiple
“correct” answers but to facilitate the discussion of the results, average scores were
calculated, based on the sum of the responses that individuals provided. For example, Table
9.1 displays the scores to nine questions related to maternity care.
9.1 Pregnancy and delivery care
The first question asked about the components of focused antenatal care and up to six
answers were accepted (detect existing illnesses and manage complications, prevent illness
and promote health, teach danger signs, a minimum of four consultations, ensure a woman
has a birth preparedness plan, and promote breastfeeding). Registered nurse/midwives
were more knowledgeable with an average score of 4.09, followed by enrolled
nurse/midwives (average score of 3.45) and medical assistants (average score 3.39). The
second question related to the recognition of which women require a special care plan i.e.
high risk women, and eleven acceptable responses were possible. For this question, there
was average score of 4.7 for the registered nurse/midwives, 4.3 for the enrolled
nurse/midwives and 3.8 for the medical assistants. Table 9.2A in the appendix summarises
specific responses to knowledge of focussed antenatal care.
The next question related to recognition of labour and 4 possible responses were allowed.
For this question, medical assistants had least knowledge with an average score of 2.6,
enrolled nurse/midwives 3.0 and registered nurse/midwives 3.2. Table 9.2A in the appendix
summarises specific responses to knowledge of high risk women.
122
The pattern of average scores noted throughout table 9.1 is that registered nurses had
highest scores followed by enrolled nurses and medical assistants had least scores.
Table 9.1: Knowledge scores related to maternity care, by selected health worker cadre
Total
(n=293)
Registered
Enrolled
Medical
nurse/Midwife nurse
Assistant
midwife/
Nurse
midwife
technician
Knowledge of focused antenatal care
Average score (out of 6)
3.64
Knowledge of which pregnant women are at
risk
Average score (out of 11)
4.28
4.69
4.31
3.83
How do you know when a pregnant woman is
in labour?
Average score (out of 4)
2.92
3.19
3.00
2.56
What do you monitor when a woman is in
labour?
Average score (out of 9)
6.17
7.38
6.24
4.89
Where do you record this information?
Average score (out of 5)
1.4
1.52
1.29
1.39
What are the steps of AMTSL?
Average score (out of 5)
1.9
2.03
1.94
1.72
What do you look for when a woman arrives
with or develops heavy bleeding after birth?
Average score (out of 7)
3.7
4.32
3.70
3.06
What do you do when a woman arrives with
or develops heavy bleeding after birth?
Average score (out of 9)
4.64
5.47
4.77
3.67
3.9
4.94
3.97
2.89
What do you do when a woman has given
birth and retained the placenta?
Average score (out of 10)
4.09
3.45
3.39
The next question related to what they monitored when a woman is in labour and out of a
possible 9 responses, registered nurse/midwives scored on average 7.4, enrolled
nurse/midwives 6.2 and medical assistants had least knowledge scoring 4.9. All the cadres
performed poorly when it came where they would record information regarding labour
123
monitoring. Out of a possible 5 responses, registered nurse/midwives scored 1.5, enrolled
nurse/midwives 1.3 and medical assistants 1.4. This is the one question where medical
assistants outperformed the nurses. On active management of third stage of labour, all
cadres demonstrated limited knowledge as evidenced by the fact that out of 5 possible
responses, registered nurse/midwives scored 2, enrolled nurse/midwives 1.9 and medical
assistants 1.7. Table 9.3A in the appendix summarises specific responses from various
cadres on signs of labour, what to monitor, where to record information and steps of active
management of third stage of labour.
The last questions of this series related to postpartum haemorrhage (PPH): the signs of PPH
and how to treat PPH and retained placenta. For signs of PPH, out of 7 possible responses,
registered nurse/midwives scored 4.3, enrolled nurse/midwives 3.7 and medical assistants
3.1. Regarding what they would do when a woman arrived with or developed heavy
bleeding after birth, registered nurse/midwives scored 5.5 out of a possible 9 responses,
enrolled nurse/midwives 4.8 and medical assistants 3.7. There was limited knowledge
regarding what they would do when a woman who has given birth has a retained placenta.
Out of a possible 10 responses, registered nurse/midwife gave only 4.9, enrolled
nurse/midwives 4 while medical assistants gave 2.9. Table 9.4A in the appendix summarises
specific responses from various cadres on signs of PPH and how to treat PPH and retained
placenta.
The extremely low scores particularly in areas of identification of high risk women, where to
record information on monitoring of labour, steps of active management of third stage of
labour and signs and management of postpartum haemorrhage indicate a need for inservice refresher courses for these cadres.
9.2 Unsafe abortion and sexual violence
Tables 9.2 and 9.5A in the appendix look at a series of questions related to unsafe abortion
and sexual violence: “What are the complications of unsafe abortion?”, “What do you do for
a woman with an unsafe or incomplete abortion?”, What information do you give to women
after unsafe or incomplete abortion?” and lastly, “what do you do for the victim of sexual
violence?”.
124
Table 9.2: Knowledge scores related to abortion care and care for victims of sexual
violence, by health worker cadre
Total
(n=296)
What are the complications of unsafe
abortion?
Average score (out of 5)
2.84
Registered
nurse/Midwife
Enrolled
nurse
midwife/
Nurse
midwife
technician
Medical
Assistant
2.97
2.62
2.94
What do you do for a woman with an unsafe or incomplete abortion?
Average score (out of 9)
4.1
4.7
3.8
3.9
What information do you give to women after unsafe or incomplete abortion?
Average score (out of 6)
2.84
3.19
2.72
2.61
What do you do for the victim of rape?
Average score (out of 9)
2.89
3.61
3.37
3.61
The first question related to complications of unsafe abortion and there were 5 possible
responses. The health workers were able to mention 3 responses out of the 5 with
registered nurse/midwives scoring 3.0, enrolled nurse/midwives 2.6 while medical assistants
scored 2.9. When it came to what they would do for a woman with unsafe or incomplete
abortion, out of a possible 9 responses, 4-5 responses were given with registered
nurse/midwives scoring 4.7, enrolled nurse/midwives 3.8 while medical assistants scored
3.9. With regard to information given to women after unsafe or incomplete abortion, out of
a possible 6 responses, health care workers gave less than 50% of expected responses.
Registered nurse/midwives scored 3.2, enrolled nurse/midwives 2.7 while medical assistants
scored 2.6. The final question in this series related to what they would do for the victim of
rape and this was poorly answered as out of expected 9 responses, registered
nurse/midwives scored only 3.6, enrolled nurse/midwives 2.9 while medical assistants
scored 3.6.
From the foregoing, it is clear that the health workers interviewed demonstrated that they
had adequate knowledge on complications of unsafe abortion but their knowledge was
limited when it came to management of unsafe or incomplete abortion, information to be
given to women after unsafe or incomplete abortion and what to do for victims of rape.
These are areas that will need in-service refresher courses.
9.3 Newborn care
Tables 9.3 and 9.6A in the appendix contain critical questions about newborn care and
newborn morbidity, beginning with “What immediate care did you give the newborn you
last delivered?” For this particular question, the health care workers demonstrated limited
125
knowledge as they failed to give more than half of the possible responses with registered
nurse/midwives giving about 5 responses, enrolled nurse/midwives and medical assistants 4
responses.
Table 9.3: Knowledge scores related to newborn care and morbidity, by health worker
cadre
Total
(n=294)
Registered
nurse/Midwife
Enrolled nurse
midwife/
Nurse midwife
technician
The last time you delivered a baby, what immediate care did you give the newborn?
Medical
Assistant
Average score (out of 11)
4.4
4.88
4.25
4.06
Signs & symptoms of newborn
infection
Average score (out of 8)
3.38
3.59
3.21
3.33
Care for the infected newborn
Average score (out of 5)
2.21
2.47
2.10
2.06
Care for the low birth weight
newborn
Average score (out of 6)
2.64
3.00
2.49
2.44
The same applied to the next question which sought health care knowledge of signs and
symptoms of newborn infection for which they gave less than 50% of expected 8 possible
responses with registered nurse/midwives scoring 3.6, enrolled nurse/midwives 3.2 and
medical assistants 3.3. On care for infected newborn, there was also limited knowledge as
out of a possible 5 responses, registered nurse/midwives scored 2.5, enrolled
nurse/midwives 2.1 while medical assistants scored 2.1. The last question in this series was
on care for low birth weight newborn and out of a possible 6 responses, registered
nurse/midwives scored 3, enrolled nurse/midwives 2.5 and medical assistants 2.4. This
demonstrates therefore that these cadres need refresher in-service on newborn care.
9.4 Training and recent delivery of services
Table 9.4 is an overview of training topics and if a provider reported having been trained on
the topic, s/he was asked if s/he had provided the service in the last 3 months. The
components assessed are within the Integrated MNH training package that the
Reproductive Health Unit of the Ministry has developed. In general, medical assistants were
less likely than enrolled nurse/midwives or registered nurse/midwives to report having been
trained in many of the topics, such as the use of the partograph, manual removal of
placenta, the administration of magnesium sulphate, external and internal bimanual
126
compression of the uterus, and assisted vaginal delivery with a vacuum extractor. More
than 95% of the registered nurse/midwives received training in PMTCT while 92% of
enrolled nurse/midwives but only 72% of medical assistants had had this training. Almost all
nurse/midwives reported training in newborn resuscitation compared to 94% of medical
assistants. Among the providers who reported training, they were asked if they had
provided the service in the last 3 months – the most frequently reported services provided
were use of partograph (97.3%), do active management of third stage of labour (97.9%),
begin IV fluids (96.9%), check for anaemia (98.6%) and suture cervical tear (91.4%). The least
frequently reported were: use forceps (1%), perform dilatation and curettage (2.1%) and
suture cervical lacerations (4.1%).
9.5 Competency in newborn resuscitation
The measurement of competency of skills is a key aspect to assessing the quality of care.
Competency is often assessed by observing whether a provider carries out certain tasks
while engaged with a patient or with a model during the simulation of a task. Patient
observation was considered beyond the scope of this assessment; in its place the data
collector asked the respondent what s/he would do with regards to diagnosing and treating
birth asphyxia. Table 9.5 registers the average scores based on the full set of questions and
answers that can be seen in Table 9.7A in the appendix. Again only spontaneous answers
were registered. By design, the questions were restricted to providers who reported training
in newborn resuscitation. Approximately 100% of the nurse/midwives and 94% of the
medical assistants had received newborn resuscitation training with bag and mask and most
of them received training in their pre-service curriculum alone or in conjunction with inservice training (Table 9.7A in the appendix).
Registered nurse/midwives were able to describe how to diagnose birth asphyxia marginally
better than nurse/midwives and medical assistants (3.5 symptoms out of possible 4
mentioned vs. 3.0 and 2.5 respectively, Table 9.6). When it came to knowledge of
preliminary steps of neonatal resuscitation, medical assistants demonstrated least
knowledge as out of 8 responses, they scored 2.7 while enrolled nurse/midwife scored 3.8
and registered nurse/midwives scored 5.0. The next question related to what is involved in
neonatal resuscitation with bag and mask and out of a possible 5 responses, registered
nurse/midwives scored 3.8, enrolled nurse/midwives scored 2.96 while medical assistants
scored 2.59. Nurse/Midwives and medical assistants answered similarly to the question “If
the baby is breathing and there is no sign of respiratory difficulty, what do you do?” Each
group mentioned 2 out of the 3 correct responses (registered nurse/midwives scored 2.3
while enrolled nurse/midwives and medical assistants scored 1.8). Likewise, midwives and
nurses answered similarly to the question “If the baby does not begin to breathe, or if
breathing is < 30 per minute, what do you do?” Again, the answer least likely to be
mentioned by both groups was “explain to the mother what is happening.” Medical
assistants had least knowledge because out of possible 6 responses, they scored 1.24,
followed by enrolled nurse/midwives 1.34 and registered nurse/midwives 2.09. All these
responses demonstrate need for refresher or in-service training in newborn resuscitation.
127
Table 9.4: Percentage and number of providers who reported training in various services and percentage of those trained who provided the
service in the past 3 months, by health worker cadre
Total (n=292)
Trained
%
Provide focused antenatal
care
Use the partograph
Do active management of the
third stage of labour
Do manual removal of the
placenta
Begin IV fluids
Check for anaemia
Administer IM or IV
magnesium sulphate for the
treatment of severe preeclampsia or eclampsia
Do bimanual uterine
compression (external)
Do bimanual uterine
compression (internal)
Suture an episiotomy
Suture vaginal tear
Suture cervical lacerations
Perform vacuum extraction
Perform forceps delivery
Perform manual vacuum
Provided
(among
trained)
Number
%
Registered Nurse/Midwife
Enrolled Nurse/ Midwife
(n=32)
(n=242)
Trained
Provided
Trained
Provided
(among
(among
trained)
trained)
%
Number
%
%
Number
%
Medical Assistant (n=18)
Trained
%
Number
Provided
(among
trained)
%
84.6%
247
84.6%
96.9%
31
81.3% 83.5%
202
85.1%
77.8%
14
83.3%
97.9%
98.3%
286
287
97.3% 100.0%
97.9% 100.0%
32
32
100.0% 97.9%
100.0% 98.3%
237
238
97.9%
97.9%
94.4%
94.4%
17
17
83.3%
94.4%
77.7%
227
40.8%
93.8%
30
62.5% 76.0%
184
38.0%
72.2%
13
38.9%
99.7%
99.7%
83.6%
291
291
244
96.9% 100.0%
98.6% 100.0%
41.4% 100.0%
32
32
32
100.0% 99.6%
100.0% 99.6%
68.8% 82.6%
241
241
200
97.1%
98.8%
39.3%
100.0%
100.0%
66.7%
18
18
12
88.9%
94.4%
22.2%
80.8%
236
29.1%
90.6%
29
34.4% 80.2%
194
28.9%
72.2%
13
22.2%
69.5%
203
16.4%
87.5%
28
34.4% 68.2%
165
14.9%
55.6%
10
5.6%
99.0%
97.3%
18.5%
66.4%
11.0%
51.0%
289
284
54
194
32
149
73.3% 100.0%
91.4% 100.0%
4.1% 28.1%
19.5% 90.6%
1.0% 18.8%
18.5% 68.8%
32
32
9
29
6
22
241
235
40
154
24
116
72.3%
90.9%
3.7%
14.5%
1.2%
17.8%
88.9%
94.4%
27.8%
61.1%
11.1%
61.1%
16
17
5
11
2
11
50.0%
83.3%
5.6%
16.7%
0.0%
16.7%
93.8%
100.0%
6.3%
59.4%
0.0%
25.0%
99.6%
97.1%
16.5%
63.6%
9.9%
47.9%
128
Table 9.4: Percentage and number of providers who reported training in various services and percentage of those trained who provided the
service in the past 3 months, by health worker cadre
Total (n=292)
Trained
%
aspiration (MVA)
Perform a dilation and
curettage (D&C)
Administer antiretroviral
drugs for PMTCT
Counsel women about family
planning and contraception
Perform adult resuscitation
Resuscitate a newborn with
bag and mask
Provided
(among
trained)
Number
%
Registered Nurse/Midwife
Enrolled Nurse/ Midwife
(n=32)
(n=242)
Trained
Provided
Trained
Provided
(among
(among
trained)
trained)
%
Number
%
%
Number
%
7.9%
23
2.1%
15.6%
5
91.4%
267
88.4%
96.9%
97.3%
284
91.8%
99.3%
268
290
0.0%
Medical Assistant (n=18)
Trained
%
Number
Provided
(among
trained)
%
6.2%
15
2.5%
16.7%
3
0.0%
31
93.8% 92.1%
223
89.7%
72.2%
13
61.1%
88.0% 100.0%
32
84.4% 97.1%
235
88.4%
94.4%
17
88.9%
54.8% 96.9%
89.0% 100.0%
31
32
78.1% 90.9%
100.0% 99.6%
220
241
53.3%
89.7%
94.4%
94.4%
17
17
33.3%
61.1%
129
Table 9.5: Knowledge scores related to diagnosis and management of birth asphyxia
among midwives and nurses with either training or experience in neonatal resuscitation
Total
Registered Enrolled Medical
Nurse
Nurse Assistant
Midwives Midwife
n=296
n=32
n=242
n=18
How to diagnose birth asphyxia
Average score (out of 4)
3.0
3.50
3.02
2.47
Preliminary steps of neonatal resuscitation
Average score (out of 8)
3.82
5.00
3.77
2.69
If resuscitating with bag & mask, what do you do?
Average score (out of 5)
3.12
3.81
2.96
2.59
If baby is breathing and no respiratory difficulty, what
do you do?
Average score (out of 3)
1.97
2.3
1.8
1.82
If baby does not begin to breathe, or if breathing is <
30 per minute, what do you do?
Average score (out of 6)
1.57
2.09
1.34
1.29
9.6 Recommendations
 Improved implementation of FANC is urgent and early recognition of danger signs,
birth plans and the promotion of breastfeeding should be front and centre of FANC
given the low coverage of institutional births.
 The development of posters, wall charts, pocket books and other job aids should be
considered to assist with the education and advocacy of danger signs.
 Training and supportive supervision on the use of the partograph as a guide to
manage labour is urgently needed – other findings in the survey also point to this
need. Advocacy to “popularize” the partograph at pre-service training institutions
and facilities might lead to greater adoption.
 Simulations of how to recognize signs of PPH and how to treat it (as well as other
obstetric and newborn complications) would be a good quality improvement
exercise that could be led by internal staff or visiting supervisors.
 Key counselling messages for women with unsafe abortion appear to be incomplete;
women must learn when to expect a return to fertility and about opportunities for
social support if needed.
 Health providers need training on the management and prevention of complications
of sexual violence. The national protocols should be made available in all health
facilities.
 Essential newborn care should be addressed in both maternal and child health,
otherwise it may fall between the cracks. Pre-service and in-service training in
neonatal care is needed based on the Integrated Management of Pregnancy and
Childbirth (IMPAC) Managing Complications in Pregnancy and Childbirth: A guide for
130



midwives and doctors as well as Integrated Management of Neonatal and Child
Illness (IMNCI).
The training of nurses in midwifery skills should be strengthened in their pre-service
training.
Continuous supportive supervision and strengthening pre-service and on-site
training are needed.
Organize leadership training in order to develop a sense of accountability among
service providers and managers at all levels within the health system. The
introduction of clear job descriptions and clinical protocols should lead to safer
practices. Encouraging the practice of criterion-based audit can improve staff morale
and the quality of care, especially adherence to clinical guidelines and protocols.
131
Chapter 10: Discussion and Recommendations
With the results of this needs assessment, the opportunities to strengthen the Malawi
health system have increased and the challenge before us all is to use this information as
quickly and thoughtfully as possible to reduce maternal and newborn mortality and
morbidity. Although the focus of this report has been on EmONC, it is critical to remember
that the continuum of care from home to hospital is the desired outcome, with all essential
MNH services effectively and efficiently provided at all levels.
Chapter specific recommendations can be found at the end of each chapter. This final
chapter poses recommendations at a higher level, largely aimed at policy and
implementation.
Policy Level Recommendations
 The government has not yet met the UN minimum acceptable level of 5 EmONC
facilities per 500,000 population (at least one of which provides comprehensive
care). The government should revise their roadmap targets to first meet the UN
minimum recommendations. Upgrading of rural hospitals and overall strengthening
of health centres is required.
 Maternal death should become a notifiable event. All facilities should carry out
systematic death reviews. National guidelines for the clinical management of
obstetric and newborn complications should address this issue and improve health
providers’ accountability.
 Address the issue of human resources development, deployment and retention with
specific emphasis on rural areas.
 Review of the 2007 roadmap in view of the progress made so far and set new targets
to be achieved by 2015.
Program Implementation Recommendations
Training
 Pre-service training in maternal and newborn care should cover all basic EmONC
signal functions and other essential services, not just a subset. The government
should encourage donors to support capacity building of health worker cadres with a
strong set of integrated skills (basic EmONC signal functions, partograph, AMTSL,
PMTCT, etc.).
 The government may want to set a national standard for a training package for
EmONC that partners will follow. It is highly recommended that such training
programs use a team approach.
 Pre-service, in-service & continuing education: an EmONC training package needs to
be developed or adapted from existing materials to include a curriculum, Training of
Trainers (TOT), post training follow-up and supervision.
 Increase the capacity of nursing/midwifery institutions to match an increased intake
of nursing/midwifery students.
132
Improving Quality of Care
 National guidelines for the clinical management protocols for obstetric and newborn
complications are needed. Where guidelines exist, training, and supervision for
quality improvement should follow. Where they do not exist, they should be
distributed. Every facility needs a complete set of these guidelines in the form of
posters, wall charts, or complication specific charts that designate the appropriate
treatment at each level.
 Criterion-based audit (CBA) is an excellent, inexpensive intervention to improve the
adherence to protocols and clinical guidelines and to empower staff to make
improvements on their own in the quality of the care they provide. There should be
national and districts workshops to teach and implement CBAs.
 Every labour room in hospitals and health centres should be equipped with bag and
mask for newborn resuscitation and health workers trained to identify asphyxia in
newborns and how to resuscitate.
 The partograph should be a key component of essential MN services. Labour
management protocols should be in every facility that provides maternity services.
 Strengthen the integration of PMTCT into maternal and newborn care to increase
coverage and efficiency.
Strengthening the enabling environment
 The recommendations on establishment as outlined in 2007 functional review
should be implemented so there is the required number of health care workers in
health facilities.
 The Ministry of Health has the mandate to fill gaps in equipment and supplies.
Hospitals and health centres are not sufficiently stocked for what is needed for
EmONC; oxytocin, magnesium sulphate, and equipment such as MVA, vacuum
extractors and ambu bags and masks must be available all the time. The supply
management chain should be strengthened to ensure constant supplies.
 Each facility must have an emergency trolley/box for 24/7 responses to emergencies
(drugs, gloves, syringes, IV). This is particularly important for health centres.
 Record-keeping and documentation need improvement in all health facilities.
133
APPENDIX (TABLES)
Table 2.1A: Members of the country core team
NAME
ORGANISATION
1
Fannie Kachale
MOH (RHU)
2
Hans Katengeza
MOH (RHU)
3
Grace Mlava
UNICEF
4
Juliana Lunguzi
UNFPA
5
Harriet Chanza
WHO
6
Leslie Mgalula
WHO
7
Thokozani Sambakunsi
Consultant (data manager)
8
Edwin Libamba
Consultant (technical coordinator)
134
Table 2.2A: List of Technical experts who supported the 2010 needs assessment
NAME
ORGANISATION
1
Bonus Makanani
College of Medicine
2
Aaron Sosola
Pharmacy, Medicines & Poisons Board
3
Wilfold Mathiya
Pharmacy, Medicines & Poisons Board
4
Martha Kamanga
Kamuzu College of Nursing
5
Reggis Katsande
WHO (Regional Office)
6
Laura Harris
AMDD
7
Koye Oyerinde
AMDD
8
Wasihun Gobezie
AMDD
9
Aline Mukundwa
AMDD
10
Jose Rolando Figueroa
Unicef
11
Olive Makuwira
MOH (Nsanje District Hospital)
12
McDonald Msadala
MOH (South East Zone)
135
Table 2.3A: Survey Teams and Facilitators
TEAM NUMBER
TEAM MEMBERS
DISTRICTS
FACILITATOR
Blantyre
Juliana Lunguzi
Mrs. Serra Chanachi23
01
Dr. Rachel Chihana
Mr. Leonard Banda
02
Mrs. Dorothy Chanza
Chitipa
Dr. Tionge Khonje
Karonga
Hans Katengeza
Mrs. Rose Chisiza
03
Mrs. Judith Chirembo
Nsanje
Dr. Thembi Katangwe
Chikwawa
Grace Mlava
Mrs. Agnes Mtonga
04
Mrs. Maria Chikalipo
Mulanje
Dr. Tamara Phiri
Phalombe
Grace Mlava
Lilongwe (MINUS CHAM
HOSP)
Fannie Kachale
Mrs. Egglie Chirwa
Mrs. Hlalapi Kunkeyani
05
Dr. Chikumbutso Mpanga
Dr. Kondwani Katundu
06
07
23
Mrs. Florence Lungu
Rumphi
Dr. Ethwako Mlia
Mzimba North
Mrs. Thokozire Lipato
Embangweni hosp
Mrs. Christina Mbiza
Nkhata Bay
Dr. Patience Mapunda
Likoma
Mrs. Anna Mhango
Mzimba South (MINUS
Embangweni hosp)
Mrs. Rose Muheriwa
Ntchisi
Hans Katengeza
Hans Katengeza
Shaded name in yellow represent team leader
136
TEAM NUMBER
TEAM MEMBERS
DISTRICTS
FACILITATOR
08
Dr. Judith Mkwaila
Dowa
Fannie Kachale
Mrs. Ida Mzama
Lilongwe CHAM HOSP
Mrs. Betty Sakala
09
Dr. Yambanso
Makwelero
Kasungu
Harriet Chanza
Mchinji
Mrs. Evelyn Banda
10
Mrs. Susan Sundu
Chiradzulu
Mr. Semion Lijenje
Mwanza
Dr. Jayani Pathirani
Neno
Juliana Lunguzi
Mrs. Eliza Chodzaza
11
Dr. David Zolowere
Mangochi
Grace Mlava
Mr. Evans Kaunda
12
Mrs. Martha Kamanga
Zomba
Dr. Jenala Njirammadzi
Balaka
Edwin Libamba
Mr. McDonald Msadala
13
Mrs. Jayne Chisenga
Dedza
Dr. Noha Nyamulani
Salima
Harriet Chanza
Mr. Frank Mpotha
14
Mrs. Omba Lwanda
Nkhotakota
Dr. Chifundo Kajombo
Ntcheu
Harriet Chanza
Miss Olive Makuwira
Thyolo
Edwin Libamba
Dr. David Zgambo
Machinga
Mrs. Felesia Chawani
15
Mrs. Mary Jonazi
137
Table 2.4A: Data entry clerks
Name
1
Edna Bonga
2
John Nzeruzatha
3
Mwayi Phiri
4
Chinsinsi Mando
5
Royce Kaonga
6
Grace Katengeza
7
Semion Mononga
8
Chikondi Phiri
9
Beatrice Zamba
10
Fannie Chilalika
138
Table 3.1: Distribution of facilities according to EmONC status, by district
Hospitals
Comp
Partially
functioni
ng (C-2)
Not
functionin
g at all
(C0 - 6)
signal
functions)
National
n
42
n
24
23
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
Thyolo
1
1
1
0
4
0
1
0
1
3
1
5
1
2
1
4
1
2
2
3
1
1
0
1
1
2
3
1
2
2
0
1
0
5
1
0
0
0
0
0
0
0
0
1
1
3
0
3
0
0
0
1
0
0
0
2
3
0
1
0
0
5
0
3
0
1
Total
number of
hospitals
conducting
deliveries
Health centres
Basic Partially
functioni
ng (B-2)
Not
functionin
g at all (B0
- 4 signal
functions)
Total
number of
health
centres
conducting
deliveries
89
n
5
n
49
156
210
2
5
2
5
7
1
3
3
1
4
1
12
5
2
2
4
1
7
2
6
1
3
0
0
0
0
0
0
1
1
0
0
0
0
0
0
1
0
0
0
0
0
0
0
2
1
0
0
4
0
0
1
2
0
0
3
1
6
2
5
2
4
1
2
1
3
1
3
8
3
12
1
8
5
4
5
5
10
4
10
8
12
7
5
4
9
0
5
3
4
8
3
16
1
9
7
6
5
5
13
5
16
11
17
9
9
5
11
1
8
All Facilities
Comp Basic
n
42
1
1
1
0
4
0
1
0
1
3
1
5
1
2
1
4
1
2
2
3
1
1
n
5
Partially
functioni
ng
*C-2)+(B2)
n
73
0
0
0
0
0
0
1
1
0
0
0
0
0
0
1
0
0
0
0
0
0
0
2
2
1
2
7
1
2
3
2
1
0
8
2
6
2
5
2
4
1
2
1
4
Not
functionin
g at all (C06)+(B0 - 4)
signal
functions)
179
2
6
8
6
12
1
8
6
4
5
5
12
7
10
9
12
7
10
4
12
0
6
Total
number of
facilities
conducting
deliveries
299
5
9
10
8
23
2
12
10
7
9
6
25
10
18
13
21
10
16
7
17
2
11
139
Hospitals
Comp
Partially
functioni
ng (C-2)
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
Neno
n
2
2
0
1
1
0
n
0
1
2
0
0
1
Not
functionin
g at all
(C0 - 6)
signal
functions)
Total
number of
hospitals
conducting
deliveries
0
0
0
0
0
0
2
3
2
1
1
1
Health centres
Basic Partially
functioni
ng (B-2)
n
1
0
0
1
0
0
n
4
1
2
1
1
0
Not
functionin
g at all (B0
- 4 signal
functions)
Total
number of
health
centres
conducting
deliveries
5
6
6
4
2
4
10
7
8
6
3
4
All Facilities
Comp Basic
n
n
2
2
0
1
1
0
Partially
functioni
ng
*C-2)+(B2)
Not
functionin
g at all (C06)+(B0 - 4)
signal
functions)
Total
number of
facilities
conducting
deliveries
n
1
0
0
1
0
0
4
2
4
1
1
1
5
6
6
4
2
4
12
10
10
7
4
5
Partially functioning - lacking 1 or 2 signal functions
Not functioning - lacking more than 2 signal functions
140
Table 3.2A: Availability of EmONC facilities per 500,000 population by district and type (EmONC Indicator 1 & 2)
Population1,2
Basic and Comprehensive EmONC facilities
Comprehensive EmONC facilities
Recommended3 Actual
Actual2
Gap
Recommended3 Actual
Gap [exceeds
minimum]
n
n
n
n
n
n
n
National
13,077,160
131
47
52
79
26
42
-16
North
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
1,708,930
178,904
269,890
215,789
172,034
861,899
10,414
17
2
3
2
2
9
0
7
1
1
1
0
4
0
7
1
1
1
0
4
0
10
1
2
1
2
5
0
3
0
1
0
0
2
0
7
1
1
1
0
4
0
-4
-1
0
-1
0
-2
0
Central
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
5,510,195
627,467
303,659
224,872
558,470
337,895
1,905,282
456,516
624,445
471,589
55
6
3
2
6
3
19
5
6
5
18
2
1
1
3
1
5
1
2
2
21
3
2
1
3
1
5
1
2
3
34
3
1
1
3
2
14
4
4
2
11
1
1
0
1
1
4
1
1
1
15
1
0
1
3
1
5
1
2
1
-4
0
1
-1
-2
0
-1
0
-1
0
South
Mangochi
Machinga
5,858,035
797,061
490,579
59
8
5
22
4
1
24
4
1
35
4
4
12
2
1
10
4
1
2
-2
0
141
Population1,2
Zomba
Chiradzulu
Blantyre
Mwanza
Thyolo
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
Neno
667,953
288,546
1,001,984
92,947
587,053
521,391
313,129
434,648
238,103
317,324
107,317
Basic and Comprehensive EmONC facilities
Comprehensive EmONC facilities
Recommended3 Actual
Actual2
Gap
Recommended3 Actual
Gap [exceeds
minimum]
n
n
n
n
n
n
n
7
3
10
1
6
5
3
4
2
3
1
2
2
3
1
1
3
2
0
2
1
0
2
2
3
1
1
4
2
0
3
1
0
5
1
7
0
5
1
1
4
-1
2
1
1
1
2
0
1
1
1
1
0
1
0
2
2
3
1
1
2
2
0
1
1
0
-1
-1
-1
-1
0
-1
-1
1
-1
0
0
1. Source of Population Estimates: Malawi Housing & Population Census 2008
2. Weighted for Health Centre
3. WHO, UNFPA and UNICEF recommend as a minimum the ratio of 5 EmONC facilities per 500,000 where at least 1 is Comprehensive (Monitoring
emergency obstetric care: a handbook, 2009).
142
Table 3.3A: EmONC facilities, classified according to 3 months or 12 months, by district
% increase Comprehensive
when
EmONC facilities
considering
12 months 3
12
Months
Months
%
n
n
60%
42
53
% increase
when
considering
12 months
National
Basic
and
Comprehensive EmONC
facilities
3 Months
12
Months
n
n
52
75
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
Thyolo
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
Neno
1
1
1
0
4
0
2
1
1
3
1
5
1
2
2
4
1
2
2
3
1
1
3
2
0
2
1
0
0%
0%
0%
100%
50%
100%
0%
100%
0%
0%
0%
100%
200%
250%
0%
50%
0%
0%
0%
33%
100%
200%
33%
100%
200%
0%
0%
0%
0%
0%
0%
100%
25%
100%
0%
100%
0%
0%
0%
60%
0%
0%
0%
0%
0%
0%
0%
0%
0%
100%
0%
50%
200%
0%
0%
0%
1
1
1
1
6
1
2
2
1
3
1
10
3
7
2
6
1
2
2
4
2
3
4
4
2
2
1
0
1
1
1
0
4
0
1
0
1
3
1
5
1
2
1
4
1
2
2
3
1
1
2
2
0
1
1
0
1
1
1
1
5
1
1
1
1
3
1
8
1
2
1
4
1
2
2
3
1
2
2
3
2
1
1
0
%
26%
143
EMONC STATUS
SIGNAL FUNCTIONS PERFORMED IN THE LAST 3 MONTHS
PARENTERAL
OXYTOCICS
PARENTERAL
ANTICONVULSA
NTS
MANUAL
REMOVAL
PLACENTA
REMOVAL
RETAINED
PLACENTA
ASSISTED
VAGINAL
DELIVERY
NEWBORN
RESUSCITATION
WITH BAG &
MASK
CESAREAN
DELIVERY
BLOOD
TRANSFUSION
BALAKA
BALAKA
BALAKA
BALAKA DISTRICT HOSPITAL
COMFORT CLINIC
MBERA HEALTH CENTRE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
Yes
No
Yes
Yes
No
No
Yes
Yes
Yes
Yes
No
No
Yes
No
No
BALAKA
BLANTYRE
BLANTYRE
BLANTYRE
BLANTYRE
BLANTYRE
BLANTYRE
BLANTYRE
BLANTYRE
PHIMBI HEALTH CENTRE
BLANTYRE ADVENTIST HOSPITAL
CHABVALA HEALTH CENTRE
CHIKOWA HEALTH CENTRE
CHILEKA HEALTH CENTRE
CHIMEMBE HEALTH CENTRE
CHITAWIRA PRIVATE HOSPITAL
MADZIABANGO HEALTH CENTRE
MDEKA HEALTH CENTRE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
No
No
No
No
No
No
No
Yes
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
BLANTYRE
BLANTYRE
BLANTYRE
BLANTYRE
BLANTYRE
MLAMBE HOSPITAL
MPEMBA HEALTH CENTRE
MTENGOUMODZI PRIVATE HOSPITAL
MWAIWATHU PRIVATE HOSPITAL
NDIRANDE HEALTH CENTRE
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
No
Yes
No
Yes
Yes
No
BLANTYRE
BLANTYRE
BLANTYRE
BLANTYRE
CHIKHWAWA
QUEEN ELIZABETH CENTRAL HOSPITAL
SOUTH LUNZU HEALTH CENTRE
ST. VINCENT HEALTH CENTRE
ZINGWANGWA HEALTH CENTRE
CHAPANANGA HEALTH CENTRE
COMPREHENSIVE
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
PARTIALLY
FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
No
No
No
No
Yes
No
No
No
Yes
Yes
No
No
No
No
Yes
Yes
No
Yes
Yes
Yes
No
No
No
No
Yes
No
No
No
No
OF
FACILITY NAME
OF
DISTRICT
PARENTERAL
ANTIBIOTICS
Table 3.4A: List of facilities surveyed and signal functions performed in the last 3 months
144
CESAREAN
DELIVERY
BLOOD
TRANSFUSION
KASEYE RURAL HOSPITAL
NTHALIRE HEALTH CENTRE
NEWBORN
RESUSCITATION
WITH BAG &
MASK
CHITIPA
CHITIPA
ASSISTED
VAGINAL
DELIVERY
NDUNDE HEALTH CENTRE
NGULUDI HOSPITAL
NKALO HEALTH CENTRE
CHAMBO HEALTH CENTRE
CHITIPA DISTRICT HOSPITAL
IFUMBO HEALTH CENTRE
OF
CHIRADZULU
CHIRADZULU
CHIRADZULU
CHITIPA
CHITIPA
CHITIPA
REMOVAL
RETAINED
PLACENTA
ST MONTFORT MISSION HOSPITAL
CHIRADZULU DISTRICT HOSPITAL
MAUWA HEALTH CENTRE
NAMADZI HEALTH CENTRE
NAMITAMBO HEALTH CENTRE
OF
CHIKHWAWA
CHIRADZULU
CHIRADZULU
CHIRADZULU
CHIRADZULU
FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
COMPREHENSIVE
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
MANUAL
REMOVAL
PLACENTA
CHIKHWAWA DISTRICT HOSPITAL
DOLO HEALTH CENTRE
FEMA CLINIC
GAGA HEALTH CENTRE
MAPELERA HEALTH CENTRE
MFERA HEALTH CENTRE
MISOMALI HEALTH CENTRE
NGABU RURAL HOSPITAL
SIGNAL FUNCTIONS PERFORMED IN THE LAST 3 MONTHS
PARENTERAL
ANTICONVULSA
NTS
CHIKHWAWA
CHIKHWAWA
CHIKHWAWA
CHIKHWAWA
CHIKHWAWA
CHIKHWAWA
CHIKHWAWA
CHIKHWAWA
EMONC STATUS
PARENTERAL
OXYTOCICS
FACILITY NAME
PARENTERAL
ANTIBIOTICS
DISTRICT
Yes
No
No
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
No
No
No
Yes
No
No
No
No
No
No
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
Yes
No
Yes
No
No
Yes
Yes
No
Yes
No
No
Yes
Yes
No
Yes
No
No
Yes
No
Yes
Yes
No
Yes
Yes
Yes
No
Yes
No
No
Yes
No
No
Yes
No
No
Yes
No
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
Yes
Yes
No
Yes
Yes
No
No
No
No
145
EMONC STATUS
SIGNAL FUNCTIONS PERFORMED IN THE LAST 3 MONTHS
PARENTERAL
ANTIBIOTICS
PARENTERAL
OXYTOCICS
PARENTERAL
ANTICONVULSA
NTS
MANUAL
REMOVAL
PLACENTA
REMOVAL
RETAINED
PLACENTA
ASSISTED
VAGINAL
DELIVERY
NEWBORN
RESUSCITATION
WITH BAG &
MASK
CESAREAN
DELIVERY
BLOOD
TRANSFUSION
DEDZA
DEDZA
BEMBEKE HEALTH CENTRE
CHITOWO HEALTH CENTRE
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
No
No
Yes
Yes
No
No
No
No
DEDZA
DEDZA
DEDZA
DEDZA
DEDZA
DEDZA DISTRICT HOSPITAL
DZINDEVU HEALTH CENTRE
KAFERE HEALTH CENTRE
KANYEZI HEALTH CENTRE
KAPHUKA HEALTH CENTRE
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
No
No
No
Yes
Yes
No
No
No
Yes
Yes
No
No
No
No
Yes
No
No
No
No
DEDZA
KASINA HEALTH CENTRE
Yes
Yes
No
Yes
Yes
Yes
Yes
No
No
DEDZA
DEDZA
KAUNDU HEALTH CENTRE
LOBI HEALTH CENTRE
No
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
No
Yes
Yes
Yes
No
No
No
No
DEDZA
DEDZA
MATUMBA HEALTH CENTRE
MAYANI HEALTH CENTRE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
No
Yes
No
No
No
No
DEDZA
DEDZA
DEDZA
MPHATHI HEALTH CENTRE
MTAKATAKA HEALTH CENTRE
MTENDERE HEALTH CENTRE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
No
No
Yes
Yes
Yes
Yes
No
No
No
No
No
No
DEDZA
DEDZA
DEDZA
DOWA
DOWA
DOWA
MUA MISSION HOSPITAL
NAKALAZI HEALTH CENTRE
POLICE HEALTH CENTRE
CHAKHAZA HEALTH CENTRE
CHINKHWIRI HEALTH CENTRE
DOWA DISTRICT HOSPITAL
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
No
No
No
No
Yes
Yes
No
No
No
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
No
No
No
No
Yes
OF
FACILITY NAME
OF
DISTRICT
146
EMONC STATUS
SIGNAL FUNCTIONS PERFORMED IN THE LAST 3 MONTHS
PARENTERAL
ANTIBIOTICS
PARENTERAL
OXYTOCICS
PARENTERAL
ANTICONVULSA
NTS
MANUAL
REMOVAL
PLACENTA
REMOVAL
RETAINED
PLACENTA
ASSISTED
VAGINAL
DELIVERY
NEWBORN
RESUSCITATION
WITH BAG &
MASK
CESAREAN
DELIVERY
BLOOD
TRANSFUSION
DOWA
DOWA
DOWA
DZOOLE HEALTH CENTRE
MADISI MISSION HOSPITAL
MPONELA RURAL HOSPITAL
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
Yes
DOWA
DOWA
DOWA
KARONGA
KARONGA
MTENGOWANTHENGA HOSPITAL
MVERA ARMY HEALTH CENTRE
THONJE HEALTH CENTRE
ATUPELE COMMUNITY HOSPITAL
CHILUMBA RURAL HOSPITAL
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
No
No
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
No
No
Yes
No
No
No
No
KARONGA
KARONGA
KARONGA
KARONGA
IPONGA HEALTH CENTRE
KAPORO RURAL HOSPITAL
KARONGA DISTRICT HOSPITAL
KASOBA HEALTH CENTRE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
No
Yes
No
Yes
Yes
Yes
Yes
No
No
Yes
No
No
No
Yes
No
KARONGA
KARONGA
KARONGA
KASUNGU
KASUNGU
KASUNGU
KASUNGU
KASUNGU
KASUNGU
KASUNGU
KASUNGU
LUPEMBE HEALTH CENTRE
ST ANNE'S RURAL HOSPITAL
WILIRO HEALTH CENTRE
BUA HEALTH CENTRE
KALULUMA HEALTH CENTRE
KAMBONI HEALTH CENTRE
KAPELULA HEALTH CENTRE
KASUNGU DISTRICT HOSPITAL
KAWAMBA HEALTH CENTRE
KHOLA HEALTH CENTRE
LINYANGWA HEALTH CENTRE
NOT FUNCTIONING
COMPREHENSIVE
PARTIALLY
FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
BASIC
NOT FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
No
No
Yes
No
No
Yes
No
Yes
No
No
Yes
Yes
No
Yes
No
No
No
No
Yes
No
No
Yes
No
No
Yes
No
No
No
No
No
No
No
Yes
No
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
OF
FACILITY NAME
OF
DISTRICT
147
EMONC STATUS
SIGNAL FUNCTIONS PERFORMED IN THE LAST 3 MONTHS
PARENTERAL
ANTIBIOTICS
PARENTERAL
OXYTOCICS
PARENTERAL
ANTICONVULSA
NTS
MANUAL
REMOVAL
PLACENTA
REMOVAL
RETAINED
PLACENTA
ASSISTED
VAGINAL
DELIVERY
NEWBORN
RESUSCITATION
WITH BAG &
MASK
CESAREAN
DELIVERY
BLOOD
TRANSFUSION
KASUNGU
KASUNGU
MTUNTHAMA HEALTH CENTRE
NKHAMENYA RURAL HOSPITAL
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
No
Yes
Yes
Yes
No
No
No
Yes
KASUNGU
KASUNGU
SIMLEMBA HEALTH CENTRE
ST ANDREWS RURAL HOSPITAL
No
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
No
No
No
Yes
LIKOMA
LIKOMA
CHIZUMULU HEALTH CENTRE
ST PETERS HOSPITAL
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
No
No
No
Yes
No
Yes
No
Yes
LILONGWE
LILONGWE
LILONGWE
LILONGWE
LILONGWE
AREA 18 HEALTH CENTRE
BWAILA HOSPITAL
CHIWAMBA HEALTH CENTRE
CITY CENTRE CLINIC
DAEYANG LUKE MISSION HOSPITAL
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
No
Yes
No
Yes
No
No
Yes
No
Yes
Yes
No
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
Yes
No
No
Yes
LILONGWE
DAVID LIVINGSTONE CLINIC
Yes
Yes
Yes
Yes
No
No
Yes
No
No
LILONGWE
LILONGWE
LILONGWE
LILONGWE
LILONGWE
LILONGWE
DICKSON HEALTH CENTRE
KABUDULA RURAL HOSPITAL
KAMUZU BARRACKS HEALTH CENTRE
KAMUZU CENTRAL HOSPITAL
KANG'OMA HEALTH CENTRE
LIKUNI MISSION HOSPITAL
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
LILONGWE
LILONGWE
LILONGWE
LILONGWE
LILONGWE PRIVATE CLINIC
LUMBADZI HEALTH CENTRE
MALINGUNDE HEALTH CENTRE
MBANG'OMBE 2 HEALTH CENTRE
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
No
No
No
No
Yes
No
No
No
No
Yes
No
No
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
OF
FACILITY NAME
OF
DISTRICT
148
EMONC STATUS
SIGNAL FUNCTIONS PERFORMED IN THE LAST 3 MONTHS
PARENTERAL
ANTIBIOTICS
PARENTERAL
OXYTOCICS
PARENTERAL
ANTICONVULSA
NTS
MANUAL
REMOVAL
PLACENTA
REMOVAL
RETAINED
PLACENTA
ASSISTED
VAGINAL
DELIVERY
NEWBORN
RESUSCITATION
WITH BAG &
MASK
CESAREAN
DELIVERY
BLOOD
TRANSFUSION
LILONGWE
MITUNDU COMMUNITY HOSPITAL
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
LILONGWE
MLALE RURAL HOSPITAL
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
LILONGWE
MLOLERA WOMEN HEALTH CLINIC
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
LILONGWE
NAMBUMA MISSION HEALTH CENTRE
Yes
Yes
Yes
No
Yes
No
Yes
No
No
LILONGWE
NATHENJE HEALTH CENTRE
Yes
Yes
No
Yes
Yes
Yes
Yes
No
No
LILONGWE
LILONGWE
LILONGWE
LILONGWE
MACHINGA
MACHINGA
MACHINGA
MACHINGA
MACHINGA
MACHINGA
MACHINGA
MACHINGA
NKHALANGO PVT CLINIC
NKHOMA MISSION HOSPITAL
ST GABRIELS MISSION HOSPITAL
UKWE HEALTH CENTRE
CHIKWEO HEALTH CENTRE
MACHINGA DISTRICT HOSPITAL
MPIRI HEALTH CENTRE
MPOSA HEALTH CENTRE
NAMANDANJE HEALTH CENTRE
NAYUCHI HEALTH CENTRE
NGOKWE HEALTH CENTRE
NSANAMA HEALTH CENTRE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
Yes
Yes
No
No
Yes
No
No
Yes
No
No
Yes
No
Yes
Yes
No
No
Yes
No
No
No
No
No
No
No
Yes
Yes
No
No
Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
No
Yes
No
No
No
No
No
No
No
Yes
Yes
No
No
Yes
No
No
No
No
No
No
MACHINGA
NTAJA HEALTH CENTRE
Yes
Yes
Yes
Yes
No
No
Yes
No
No
MACHINGA
MANGOCHI
MANGOCHI
NTHOLOWA HEALTH CENTRE
CHIKOLE HEALTH CENTRE
CHILIPA HEALTH CENTRE
PARTIALLY
FUNCTIONING
PARTIALLY
FUNCTIONING
PARTIALLY
FUNCTIONING
PARTIALLY
FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
No
No
Yes
No
Yes
Yes
No
No
No
No
No
No
OF
FACILITY NAME
OF
DISTRICT
149
EMONC STATUS
SIGNAL FUNCTIONS PERFORMED IN THE LAST 3 MONTHS
PARENTERAL
ANTIBIOTICS
PARENTERAL
OXYTOCICS
PARENTERAL
ANTICONVULSA
NTS
MANUAL
REMOVAL
PLACENTA
REMOVAL
RETAINED
PLACENTA
ASSISTED
VAGINAL
DELIVERY
NEWBORN
RESUSCITATION
WITH BAG &
MASK
CESAREAN
DELIVERY
BLOOD
TRANSFUSION
MANGOCHI
KAPIRE HEALTH CENTRE
Yes
Yes
Yes
No
Yes
No
Yes
No
No
MANGOCHI
MANGOCHI
KATEMA HEALTH CENTRE
KOCHE HEALTH CENTRE
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
No
No
Yes
No
Yes
No
No
No
No
MANGOCHI
MANGOCHI
MANGOCHI
MANGOCHI
MANGOCHI
LUGOLA HEALTH CENTRE
LULANGA HEALTH CENTRE
LUNGWENA HEALTH CENTRE
LUWALIKA HEALTH CENTRE
MAKANJIRA HEALTH CENTRE
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
No
Yes
Yes
No
No
No
No
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
MANGOCHI
MANGOCHI
MANGOCHI
MANGOCHI
MANGOCHI
MALEMBO HEALTH CENTRE
MANGOCHI DISTRICT HOSPITAL
MKUMBA HEALTH CENTRE
MONKEY BAY RURAL HOSPITAL
MTIMABII HEALTH CENTRE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
Yes
No
Yes
Yes
No
Yes
No
Yes
No
No
Yes
No
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
No
Yes
No
No
Yes
No
Yes
No
MANGOCHI
MANGOCHI
MANGOCHI
MANGOCHI
MANGOCHI
MANGOCHI
MCHINJI
MCHINJI
MCHINJI
MCHINJI
MULIBWANJI RURAL HOSPITAL
NANGALAMU HEALTH CENTRE
NANKUMBA HEALTH CENTRE
NGAPANI HEALTH CENTRE
NKOPE HEALTH CENTRE
ST MARTIN HOSPITAL
CHIPUMI HEALTH CENTRE
GUILLEME RURAL HOSPITAL
KAIGWAZANGA HEALTH CENTRE
KAPIRI RURAL HOSPITAL
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
No
No
No
No
Yes
No
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
No
Yes
No
Yes
Yes
No
No
No
No
Yes
No
No
No
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
No
No
No
No
Yes
No
No
No
No
Yes
No
Yes
No
Yes
MCHINJI
KOCHILIRA RURAL HOSPITAL
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
COMPREHENSIVE
PARTIALLY
FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
Yes
Yes
No
Yes
Yes
Yes
Yes
No
No
OF
FACILITY NAME
OF
DISTRICT
150
EMONC STATUS
SIGNAL FUNCTIONS PERFORMED IN THE LAST 3 MONTHS
PARENTERAL
ANTIBIOTICS
PARENTERAL
OXYTOCICS
PARENTERAL
ANTICONVULSA
NTS
MANUAL
REMOVAL
PLACENTA
REMOVAL
RETAINED
PLACENTA
ASSISTED
VAGINAL
DELIVERY
NEWBORN
RESUSCITATION
WITH BAG &
MASK
CESAREAN
DELIVERY
BLOOD
TRANSFUSION
MCHINJI
MCHINJI
MCHINJI
LUDZI RURAL HOSPITAL
MCHINJI DISTRICT HOSPITAL
MIKUNDI HEALTH CENTRE
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
MCHINJI
MCHINJI
MULANJE
MULANJE
MKANDA HEALTH CENTRE
NKHWAZI HEALTH CENTRE
BONDO HEALTH CENTRE
CHINYAMA HEALTH CENTRE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
No
No
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
MULANJE
CHONDE HEALTH CENTRE
Yes
Yes
No
Yes
Yes
Yes
Yes
No
No
MULANJE
MULANJE
MULANJE
MULANJE
DZENJE HEALTH CENTRE
MBIZA HEALTH CENTRE
MILONDE HEALTH CENTRE
MPALA HEALTH CENTRE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
No
No
No
Yes
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
MULANJE
MULANJE
MULANJE
MULANJE
MULANJE DISTRICT HOSPITAL
MULANJE MISSION HOSPITAL
MULOMBA HEALTH CENTRE
NAMASALIMA HEALTH CENTRE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
No
No
MULANJE
MWANZA
MWANZA
NAMULENGA HEALTH CENTRE
MWANZA DISTRICT HOSPITAL
THAMBANI HEALTH CENTRE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
No
MZIMBA
MZIMBA
MZIMBA
MZIMBA
EKWENDENI MISSION HOSPITAL
EMBANGWENI MISSION HOSPITAL
EMFENI HEALTH CENTRE
ENDINDENI HEALTH CENTRE
NOT FUNCTIONING
COMPREHENSIVE
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
COMPREHENSIVE
COMPREHENSIVE
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
BASIC
COMPREHENSIVE
PARTIALLY
FUNCTIONING
COMPREHENSIVE
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
Yes
No
Yes
Yes
No
No
Yes
Yes
Yes
No
Yes
Yes
No
No
Yes
Yes
No
No
OF
FACILITY NAME
OF
DISTRICT
151
EMONC STATUS
SIGNAL FUNCTIONS PERFORMED IN THE LAST 3 MONTHS
PARENTERAL
ANTIBIOTICS
PARENTERAL
OXYTOCICS
PARENTERAL
ANTICONVULSA
NTS
MANUAL
REMOVAL
PLACENTA
REMOVAL
RETAINED
PLACENTA
ASSISTED
VAGINAL
DELIVERY
NEWBORN
RESUSCITATION
WITH BAG &
MASK
CESAREAN
DELIVERY
BLOOD
TRANSFUSION
MZIMBA
ENUKWENI HEALTH CENTRE
Yes
Yes
Yes
No
No
Yes
Yes
No
No
MZIMBA
JENDA HEALTH CENTRE
Yes
Yes
No
No
Yes
Yes
Yes
No
No
MZIMBA
MZIMBA
MZIMBA
MZIMBA
KABWAFU HEALTH CENTRE
KALIKUMBI HEALTH CENTRE
KAMTETEKA HEALTH CENTRE
KATETE RURAL HOSPITAL
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
No
No
Yes
No
Yes
No
Yes
No
No
No
Yes
No
No
No
No
Yes
Yes
No
Yes
No
No
No
No
No
No
No
Yes
MZIMBA
MZIMBA
MZIMBA
LUWAWA HEALTH CENTRE
MABIRI HEALTH CENTRE
MANYAMULA HEALTH CENTRE
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
No
Yes
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
MZIMBA
MZIMBA
MZIMBA
MZIMBA
MBALACHANDA HEALTH CENTRE
MHARAUNDA HEALTH CENTRE
MZALANGWE HEALTH CENTRE
MZAMBAZI RURAL HOSPITAL
Yes
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
No
Yes
No
Yes
Yes
No
No
Yes
No
No
No
Yes
Yes
No
No
Yes
No
No
No
No
No
No
No
Yes
MZIMBA
MZIMBA
MZIMBA
MZIMBA DISTRICT HOSPITAL
MZUZU CENTRAL HOSPITAL
MZUZU HEALTH CENTRE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
MZIMBA
ST JOHNS HOSPITAL
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
MZIMBA
MZIMBA
NENO
NENO
NENO
THUNDUWIKE HEALTH CENTRE
VIBANGALALA HEALTH CENTRE
CHIFUNGA HEALTH CENTRE
LISUNGWI HEALTH CENTRE
MAGALETA HEALTH CENTRE
PARTIALLY
FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
COMPREHENSIVE
COMPREHENSIVE
PARTIALLY
FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
No
No
No
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
OF
FACILITY NAME
OF
DISTRICT
152
EMONC STATUS
SIGNAL FUNCTIONS PERFORMED IN THE LAST 3 MONTHS
PARENTERAL
ANTIBIOTICS
PARENTERAL
OXYTOCICS
PARENTERAL
ANTICONVULSA
NTS
MANUAL
REMOVAL
PLACENTA
REMOVAL
RETAINED
PLACENTA
ASSISTED
VAGINAL
DELIVERY
NEWBORN
RESUSCITATION
WITH BAG &
MASK
CESAREAN
DELIVERY
BLOOD
TRANSFUSION
NENO
NENO
MATANDANI HEALTH CENTRE
NENO DISTRICT HOSPITAL
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
No
No
No
Yes
NKHATABAY
NKHATABAY
NKHATABAY
BULA HEALTH CENTRE
CHILAMBWE HEALTH CENTRE
CHINTHECHE RURAL HOSPITAL
Yes
No
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
No
No
Yes
No
No
No
No
No
Yes
No
No
No
No
No
Yes
NKHATABAY
NKHATABAY
NKHATABAY
NKHATABAY
NKHATABAY
NKHATABAY
NKHATABAY
NKHOTAKOTA
NKHOTAKOTA
NKHOTAKOTA
NKHOTAKOTA
CHITHEKA HEALTH CENTRE
KANDE HEALTH CENTRE
LWAZI HEALTH CENTRE
MPAMBA HEALTH CENTRE
MZENGA HEALTH CENTRE
NKHATABAY DISTRICT HOSPITAL
USISYA HEALTH CENTRE
CHIDIDI HEALTH CENTRE
DWAMBAZI RURAL HOSPITAL
LIWALADZI HEALTH CENTRE
MALOWA HEALTH CENTRE
No
Yes
No
No
Yes
Yes
No
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
No
Yes
No
Yes
No
Yes
Yes
No
No
No
No
No
Yes
No
No
No
No
Yes
No
Yes
No
No
No
Yes
No
No
No
Yes
No
No
No
No
No
No
Yes
No
No
Yes
No
No
No
No
No
No
Yes
Yes
No
No
Yes
No
Yes
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
NKHOTAKOTA
NKHOTAKOTA
NKHOTAKOTA
NKHOTAKOTA
MSENJERE HEALTH CENTRE
MWANSAMBO HEALTH CENTRE
NGALA HEALTH CENTRE
NKHOTAKOTA DISTRICT HOSPITAL
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
No
No
No
Yes
NKHOTAKOTA
NKHOTAKOTA
NKHUNGA HEALTH CENTRE
ST ANNES HOSPITAL
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
Yes
No
Yes
NSANJE
NSANJE
KALEMBA HEALTH CENTRE
MAKHANGA HEALTH CENTRE
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
BASIC
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
OF
FACILITY NAME
OF
DISTRICT
153
EMONC STATUS
SIGNAL FUNCTIONS PERFORMED IN THE LAST 3 MONTHS
PARENTERAL
ANTIBIOTICS
PARENTERAL
OXYTOCICS
PARENTERAL
ANTICONVULSA
NTS
MANUAL
REMOVAL
PLACENTA
REMOVAL
RETAINED
PLACENTA
ASSISTED
VAGINAL
DELIVERY
NEWBORN
RESUSCITATION
WITH BAG &
MASK
CESAREAN
DELIVERY
BLOOD
TRANSFUSION
NSANJE
NSANJE
MASENJERE HEALTH CENTRE
NDAMERA HEALTH CENTRE
Yes
Yes
Yes
Yes
No
No
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
No
NSANJE
NSANJE DISTRICT HOSPITAL
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
NSANJE
NSANJE
NYAMITHUTHU HEALTH CENTRE
PHOKERA HEALTH CENTRE
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
No
Yes
Yes
Yes
No
No
No
No
NSANJE
NSANJE
NSANJE
SANKHULANI HEALTH CENTRE
TENGANI HEALTH CENTRE
TRINITY MISSION HOSPITAL
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
No
Yes
No
No
Yes
Yes
No
Yes
No
No
Yes
No
No
Yes
NTCHEU
BILIRA HEALTH CENTRE
Yes
Yes
No
No
Yes
Yes
Yes
No
No
NTCHEU
NTCHEU
NTCHEU
NTCHEU
NTCHEU
NTCHEU
NTCHEU
NTCHEU
NTCHEU
NTCHEU
NTCHEU
NTCHEU
BIRIWIRI HEALTH CENTRE
BWANJE HEALTH CENTRE
CHIKANDE HEALTH CENTRE
KAPENI HEALTH CENTRE
KATSEKERA HEALTH CENTRE
LAKE VIEW HEALTH CENTRE
MLANGENI HEALTH CENTRE
NSIPE HEALTH CENTRE
NTCHEU DISTRICT HOSPITAL
NTONDA HEALTH CENTRE
ST TEREZA COMMUNITY HOSPITAL
TSANGANO HEALTH CENTRE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
No
Yes
No
No
No
Yes
No
No
No
No
No
No
Yes
Yes
No
No
No
Yes
No
No
Yes
No
No
No
No
Yes
No
No
No
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
No
Yes
No
NTCHISI
CHINGULUWE HEALTH CENTRE
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
BASIC
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
PARTIALLY
FUNCTIONING
Yes
Yes
Yes
Yes
No
No
Yes
No
No
OF
FACILITY NAME
OF
DISTRICT
154
EMONC STATUS
SIGNAL FUNCTIONS PERFORMED IN THE LAST 3 MONTHS
PARENTERAL
ANTIBIOTICS
PARENTERAL
OXYTOCICS
PARENTERAL
ANTICONVULSA
NTS
MANUAL
REMOVAL
PLACENTA
REMOVAL
RETAINED
PLACENTA
ASSISTED
VAGINAL
DELIVERY
NEWBORN
RESUSCITATION
WITH BAG &
MASK
CESAREAN
DELIVERY
BLOOD
TRANSFUSION
NTCHISI
KANSONGA HEALTH CENTRE
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
NTCHISI
NTCHISI
NTCHISI
NTCHISI
NTCHISI
PHALOMBE
PHALOMBE
PHALOMBE
PHALOMBE
PHALOMBE
PHALOMBE
KHUWI HEALTH CENTRE
MKHUZI HEALTH CENTRE
NTCHISI DISTRICT HOSPITAL
NTHONDO HEALTH CENTRE
NZANDU HEALTH CENTRE
CHIRINGA HEALTH CENTRE
CHITEKESA HEALTH CENTRE
HOLY FAMILY MISSION HOSPITAL
MPASA HEALTH CENTRE
MWANGA HEALTH CENTRE
NAMBAZO HEALTH CENTRE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
Yes
No
Yes
No
No
Yes
No
No
No
No
Yes
No
No
Yes
No
No
Yes
No
No
No
No
Yes
No
No
No
No
No
Yes
No
No
No
No
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
No
No
No
Yes
No
No
No
No
No
Yes
No
No
No
No
Yes
No
No
No
PHALOMBE
RUMPHI
RUMPHI
PHALOMBE HEALTH CENTRE
BOLERO RURAL HOSPITAL
DGM LIVINGSTONIA HOSPITAL
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes
No
No
Yes
No
No
Yes
RUMPHI
RUMPHI
RUMPHI
RUMPHI
RUMPHI
RUMPHI
KATOWO RURAL HOSPITAL
LUWICHI HEALTH CENTRE
MHUJU RURAL HOSPITAL
MPHOPA HEALTH CENTRE
MZOKOTO HEALTH CENTRE
RUMPHI DISTRICT HOSPITAL
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Yes
No
No
Yes
No
No
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
No
No
No
No
No
Yes
SALIMA
SALIMA
SALIMA
SALIMA
CHITALA HEALTH CENTRE
LIFELINE HEALTH CENTRE
MAKIONI HEALTH CENTRE
SALIMA DISTRICT HOSPITAL
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
BASIC
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
No
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
No
No
Yes
Yes
No
No
No
Yes
No
No
No
Yes
No
Yes
No
Yes
No
No
No
Yes
No
No
No
Yes
OF
FACILITY NAME
OF
DISTRICT
155
EMONC STATUS
SIGNAL FUNCTIONS PERFORMED IN THE LAST 3 MONTHS
PARENTERAL
ANTIBIOTICS
PARENTERAL
OXYTOCICS
PARENTERAL
ANTICONVULSA
NTS
MANUAL
REMOVAL
PLACENTA
REMOVAL
RETAINED
PLACENTA
ASSISTED
VAGINAL
DELIVERY
NEWBORN
RESUSCITATION
WITH BAG &
MASK
CESAREAN
DELIVERY
BLOOD
TRANSFUSION
SALIMA
SALIMA
THYOLO
THYOLO
THYOLO
THYOLO
THYOLO
THYOLO
SENGABAY BAPTIST HEALTH CENTRE
THAVITE HEALTH CENTRE
CHANGATA HEALTH CENTRE
CHIMALIRO HEALTH CENTRE
CHIMVU HEALTH CENTRE
CHINGAZI RURAL HOSPITAL
CHIPHO HEALTH CENTRE
KHONJENI HEALTH CENTRE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
No
No
Yes
No
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
THYOLO
MALAMULO HOSPITAL
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
THYOLO
MANGUNDA HEALTH CENTRE
Yes
Yes
Yes
Yes
No
No
Yes
No
No
THYOLO
MIKOLONGWE HEALTH CENTRE
Yes
Yes
No
Yes
No
Yes
Yes
No
No
THYOLO
THYOLO
THYOLO
ZOMBA
ZOMBA
MITENGO HEALTH CENTRE
THEKERANI RURAL HOSPITAL
THYOLO DISTRICT HOSPITAL
ARMY HOSPITAL
CHIPINI HEALTH CENTRE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
Yes
No
Yes
No
Yes
Yes
No
No
No
No
Yes
No
No
Yes
Yes
Yes
No
Yes
No
No
Yes
No
No
No
No
Yes
Yes
No
ZOMBA
ZOMBA
ZOMBA
CHISI ISLAND HEALTH CENTRE
DOMASI RURAL HOSPITAL
H PARKER SHARP HEALTH CENTRE
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
No
No
Yes
No
Yes
Yes
No
No
No
No
No
No
ZOMBA
LIKANGALA HEALTH CENTRE
Yes
Yes
Yes
Yes
No
No
Yes
No
No
ZOMBA
ZOMBA
MAKWAPALA HEALTH CENTRE
MATAWALE HEALTH CENTRE
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
PARTIALLY
FUNCTIONING
PARTIALLY
FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
PARTIALLY
FUNCTIONING
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
No
No
No
No
OF
FACILITY NAME
OF
DISTRICT
156
EMONC STATUS
SIGNAL FUNCTIONS PERFORMED IN THE LAST 3 MONTHS
PARENTERAL
ANTIBIOTICS
PARENTERAL
OXYTOCICS
PARENTERAL
ANTICONVULSA
NTS
MANUAL
REMOVAL
PLACENTA
REMOVAL
RETAINED
PLACENTA
ASSISTED
VAGINAL
DELIVERY
NEWBORN
RESUSCITATION
WITH BAG &
MASK
CESAREAN
DELIVERY
BLOOD
TRANSFUSION
ZOMBA
MATIYA HEALTH CENTRE
Yes
Yes
Yes
No
No
No
Yes
No
No
ZOMBA
ZOMBA
ZOMBA
ZOMBA
ZOMBA
ZOMBA
M'MAMBO HEALTH CENTRE
NGWELERO HEALTH CENTRE
PIRIMITI RURAL HOSPITAL
POLICE HOSPITAL
ST LUKES HOSPITAL
ZOMBA CENTRAL HOSPITAL
PARTIALLY
FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
NOT FUNCTIONING
COMPREHENSIVE
COMPREHENSIVE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
No
No
No
No
Yes
Yes
No
No
No
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
No
No
No
Yes
Yes
Yes
OF
FACILITY NAME
OF
DISTRICT
157
Table 3.5A: Percent distribution of health centres by number of signal functions missing by
sector and district
B0
B-1
B-2
B-3
B-4
B-5
B-6
Basic
National
%
14%
n
2
n
8
n
21
n
56
n
69
n
35
n
14
n
5
Number of
health
centres
conducting
deliveries
n
210
Sector
Govt
CHAM
Private
55%
40%
80%
85
20
4
103
34
4
119
42
4
136
43
5
27
14
3
139
46
4
143
46
4
4
1
0
155
50
5
0%
0%
13%
0%
6%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0
0
1
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
0
2
0
0
0
0
0
1
0
0
2
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
3
0
3
1
2
0
0
0
1
1
0
0
0
2
0
1
1
2
0
0
0
3
1
0
0
0
1
2
2
0
3
0
3
1
1
2
2
4
1
4
4
5
3
1
2
3
0
2
1
1
2
3
1
2
0
1
0
3
3
0
3
4
3
3
1
5
3
4
4
4
4
3
1
4
0
3
4
2
3
1
1
2
1
1
0
0
4
0
0
1
1
0
0
2
1
2
1
3
2
4
0
2
0
2
3
1
2
1
1
0
1
0
0
0
0
0
0
0
1
0
0
1
0
4
1
2
0
0
1
0
1
1
1
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
0
0
0
0
1
0
0
0
0
0
0
0
1
0
0
1
0
0
3
4
8
3
16
1
9
7
6
5
5
13
5
16
11
17
9
9
5
11
1
8
10
7
8
6
3
4
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
Thyolo
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
Neno
158
Table 3.6A: Percent distribution of hospitals by number of signal functions missing by
sector, facility type and district
C0
C-8
C-7
C-6
C-5
C-4
C-3
C-2
C-1
Compr
ehensi
ve
n
0
n
0
n
1
n
1
n
7
n
6
n
8
n
9
n
15
n
42
Number
of
hospital
s that
do
deliverie
s
N
89
Central Hospital
District Hospital
0
0
0
0
0
0
0
2
0
1
0
0
0
0
0
1
0
0
4
19
4
23
Other Hospitals
Govt
CHAM
Private
0
0
2
0
0
1
0
0
5
2
5
3
2
2
1
2
1
5
1
1
3
2
0
2
0
1
3
1
14
1
3
22
7
0
0
NA
0
0
NA
3
8
NA
6
4
NA
4
4
NA
6
7
NA
0
0
NA
12
13
NA
9
5
NA
2
1
NA
15
15
NA
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
1
0
0
0
0
0
0
1
0
0
3
0
0
0
1
1
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
2
0
1
0
0
2
0
1
0
0
0
0
0
0
0
1
3
0
0
0
0
0
0
1
0
0
1
1
1
2
0
1
0
0
1
0
1
1
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
2
0
0
0
4
0
0
0
0
0
0
0
0
0
1
1
1
0
4
0
1
0
1
3
1
5
1
2
1
4
1
2
2
3
1
2
5
2
5
7
1
3
3
1
4
1
12
5
2
2
4
1
7
2
6
1
National
Facility Type
Rural Hospital
Govt
CHAM
Private
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
159
Thyolo
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
Neno
C0
C-8
C-7
C-6
C-5
C-4
C-3
C-2
C-1
Compr
ehensi
ve
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
1
2
0
0
1
1
2
2
0
1
1
0
Number
of
hospital
s that
do
deliverie
s
3
2
3
2
1
1
1
Table 3.7A Percentage of facilities that administered parenteral oxytocics in the last 12
months, by type of oxytocic, type of facility and sector
Total number
of facilities
that
performed
deliveries
Percentage of
facilities that
administered
oxytocics in
last 12 months
National
n
299
Facility Type
Central Hospital
District Hospital
Among facilities that administered
parenteral oxytocics in the last 12 months,
percent that used:
Ergometrine
only
%
3%
Both
Other1
%
85%
Oxytocin
only
%
85%
%
7%
%
5%
4
23
75%
87%
75%
87%
0%
0%
25%
9%
0%
4%
Other Hospitals
Government
CHAM
Private
3
22
7
100%
100%
100%
100%
100%
100%
0%
0%
0%
0%
0%
0%
0%
0%
0%
Rural Hospital
Government
CHAM
Private
15
15
NA
93%
80%
NA
93%
80%
NA
0%
0%
NA
0%
20%
NA
7%
0%
NA
78%
98%
50%
78%
98%
50%
4%
2%
33%
10%
0%
0%
8%
0%
17%
Health Centre
Government
157
CHAM
48
Private
5
1. Other type used was syntometrine
160
Table 3.8A: Percentage of facilities that administered parenteral anticonvulsants in the
last 12 months, by type of medication, facility type and sector
Total
number of
facilities
surveyed
that
performed
deliveries
Percentage
of facilities
that
administered
anticonvulsa
nts in the last
12 months
National
n
299
Facility Type
Central Hospital
District Hospital
Among facilities that administered anticonvulsants
in the last 12 months, percent that used:
Magnesium
sulphate
only
Diazepam
only
Other
anticonv
ulsant
%
48%
Both
magnesium
sulphate
and
diazepam
%
22%
%
81%
%
30%
4
23
100%
100%
50%
57%
0%
9%
50%
35%
0%
0%
Other Hospitals
Government
CHAM
Private
3
22
7
100%
100%
57%
33%
45%
50%
33%
0%
0%
33%
55%
50%
0%
0%
0%
Rural Hospital
Government
CHAM
Private
15
15
NA
93%
87%
NA
43%
31%
NA
43%
62%
NA
14%
8%
NA
0%
0%
NA
Health Centre
Government
CHAM
Private
157
48
5
73%
88%
40%
24%
17%
0%
61%
64%
50%
15%
19%
0%
0%
0%
50%
%
0%
161
Table 3.9A: Percentage of facilities that removed retained products in the last 12 months,
by method, type of facility and sector
Total
number of
facilities
surveyed?
National
299
Total number
of facilities
that
removed
retained
products in
last 12
months
%
52%
Among those that removed retained products in last 12
months, percent that used:
Facility Type
Central Hospital
District Hospital
4
23
0%
9%
0%
9%
0%
0%
100%
61%
25%
4%
Other Hospitals
Government
CHAM
Private
3
22
7
0%
24%
0%
0%
24%
0%
0%
0%
0%
200%
33%
33%
0%
14%
17%
Rural Hospital
Government
CHAM
Private
15
15
NA
62%
27%
NA
62%
27%
NA
0%
0%
NA
31%
18%
NA
15%
0%
NA
Health Centre
Government
CHAM
Private
157
48
5
98%
89%
100%
98%
89%
100%
0%
0%
0%
0%
0%
0%
0%
0%
0%
Manual
vacuum
aspiration
only
Dilation &
curettage or
Dilation &
evacuation
only
Both manual
Misoprostol
vacuum
only
aspiration and
dilation &
curettage
%
52%
%
0%
%
27%
%
6%
162
Table 3.10A: Numeric and percent distribution of direct and indirect complications and
maternal deaths1
Total DIRECT complications/causes
APH
PPH/Retained placenta
Obstructed/ prolonged labour
Ruptured uterus
Postpartum sepsis
Severe pre-eclampsia / eclampsia
Complications of abortion
Ectopic pregnancy
Other direct obstetric complications
Women with Women with
complications complications
n
%
35,664
69%
2144
4%
4658
9%
10738
21%
737
1%
1373
3%
2798
5%
3295
6%
630
1%
9291
18%
Maternal
deaths
n
529
37
180
22
58
94
51
40
15
32
Total INDIRECT complications/causes
Malaria
HIV/AIDS - related
Anaemia
Other indirect causes
15,728
6328
6172
2240
988
217
31
58
66
62
25%
4%
7%
8%
7%
124
14%
870
100%
31%
12%
12%
4%
2%
Undefined cause
TOTAL
51,392
100%
Maternal
deaths
%
61%
4%
21%
3%
7%
11%
6%
5%
2%
4%
1. The data on number of complications and deaths is presented as it is in the surveyed facilities
163
Table 3.11A: Stillbirth and very early neonatal death rate in all facilities and in EmONC facilities, by district (EmONC Indicator 7)
All Facilities (surveyed)
Number of Number
institutional
of
deliveries
stillbirths
National
District
Balaka
Blantyre
Chikwawa
Chiradzulu
Chitipa
Dedza
Dowa
Karonga
Kasungu
Likoma
Lilongwe
Machinga
Mangochi
Mchinji
Mulanje
Mwanza
Mzimba
Neno
Nkhata Bay
Nkhotakota
Nsanje
289,551
5081
23264
10731
7565
4934
12888
11230
6251
11313
334
37722
16307
20404
10930
8626
3769
14724
1973
4167
6184
6813
5,972
90
307
161
136
104
257
219
234
316
10
821
319
587
211
284
71
334
17
179
124
71
EmONC Facilities (surveyed)
Number of Perinatal
Number of Number of Number of
very early mortality
institutional stillbirths
very early
neonatal
rate (per deliveries
neonatal
1
deaths
1000
deaths1
2
deliveries)
2,525
29.35
169,168
4,375
1,906
53
388
112
77
42
84
84
67
75
4
276
214
105
84
1
90
117
13
105
82
83
28.14
29.87
25.44
28.16
29.59
26.46
26.98
48.15
34.56
41.92
29.08
32.69
33.91
26.99
33.04
42.72
30.63
15.21
68.15
33.31
22.60
3111
11549
7890
3993
2884
5107
10013
3583
9224
281
28191
5127
11550
6176
4683
3769
10126
774
2875
5027
3170
69
206
134
100
77
145
193
194
264
7
703
171
442
92
237
71
270
11
157
103
21
43
362
80
63
41
38
81
46
63
0
262
129
40
36
0
90
102
9
94
61
11
Perinatal
mortality rate
(per
1000
deliveries)2
37.13
36.00
49.18
27.12
40.82
40.92
35.83
27.36
66.98
35.45
24.91
34.23
58.51
41.73
20.73
50.61
42.72
36.74
25.84
87.30
32.62
10.09
164
All Facilities (surveyed)
Number of Number
institutional
of
deliveries
stillbirths
Ntcheu
Ntchisi
Phalombe
Rumphi
Salima
Thyolo
Zomba
10724
5007
5613
5958
7558
13491
15990
97
96
169
100
141
157
360
EmONC Facilities (surveyed)
Number of Perinatal
Number of Number of Number of
very early mortality
institutional stillbirths
very early
neonatal
rate (per deliveries
neonatal
deaths1
1000
deaths1
2
deliveries)
2
9.23
6393
49
0
17
22.57
2117
49
6
0
30.11
876
92
0
61
27.02
2598
62
40
97
31.49
5072
99
91
110
19.79
6365
116
84
82
27.64
6644
241
34
Perinatal
mortality rate
(per
1000
deliveries)2
7.66
25.98
105.02
39.26
37.46
31.42
41.39
1. Very early neonatal death was defined as a death occurring within 24 hours after delivery
2. Perinatal mortality rate = (stillbirths + v. early neonatal deaths)/(number of deliveries)
165
Table 4.1A: Percentage of facilities with a functional mode of communication by district
Functioning public Total number of
in facilities
Functioning
Functioning cell telephone
vicinity
cell phone phone owned
owned
by individual
facility
National
On-site communication
Functioning
Functioning
Functioning
land telephone land
two-way
in maternity
telephone
radio
elsewhere in
facility
%
%
%
21
29
56
%
22
%
93
%
24
309
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
20
10
10
13
20
0
8
10
14
11
50
27
30
11
8
10
20
60
10
0
63
16
50
0
10
14
22
33
33
50
11
31
24
10
100
100
100
75
100
100
17
100
100
100
100
100
10
100
100
95
100
20
20
20
13
12
50
0
30
14
44
33
43
30
11
8
33
10
5
10
10
8
25
2
12
10
7
9
6
30
10
18
13
21
10
80
10
20
13
20
50
8
20
14
44
50
50
40
11
8
33
20
80
60
80
38
36
100
75
60
0
0
67
23
60
94
85
33
70
166
Zomba
Chiradzulu
Blantyre
Mwanza
Thyolo
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
Neno
On-site communication
Functioning
Functioning
Functioning
land telephone land
two-way
in maternity
telephone
radio
elsewhere in
facility
%
%
%
35
29
41
29
43
57
39
61
72
50
50
100
27
18
27
17
25
58
40
30
60
30
20
90
14
29
100
50
50
75
20
20
100
Functioning public Total number of
in facilities
Functioning
Functioning cell telephone
cell phone phone owned vicinity
owned
by individual
facility
%
41
29
11
0
0
8
10
60
0
0
20
%
100
100
100
100
100
100
100
100
100
100
100
%
18
57
33
50
18
8
20
30
14
25
40
17
7
18
2
11
12
10
10
7
4
5
167
168
Table 4.2A: Percentage of facilities with a functional mode of transport, by district
Motorized transport
Functioning Functioning Functioning
motor
motor
motor
vehicle
vehicle
cycle
ambulance
ambulance
National
%
44
%
23
%
14
At
least
one
functioning
mode of
motorized
transport
%
57
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
Thyolo
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
Neno
40
60
40
50
40
50
42
10
14
56
50
50
60
39
23
52
60
65
43
28
100
36
42
40
50
29
50
40
60
50
10
25
12
50
0
20
14
56
50
43
0
17
15
14
30
6
29
28
100
18
17
10
10
29
25
60
20
0
20
25
0
0
17
30
0
22
17
17
20
22
8
10
0
18
14
6
0
27
8
0
40
14
0
40
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
number of
Boat
Ambulance facilities
%
1
309
0
0
0
0
0
100
0
0
0
0
0
0
0
0
0
0
0
6
0
0
0
0
0
0
0
0
0
0
5
10
10
8
25
2
12
10
7
9
6
30
10
18
13
21
10
17
7
18
2
11
12
10
10
7
4
5
169
Table 4.3A: Percent distribution of facilities according to their system of waiving
maternity fees for poor women, by district
Have formal
system to
waive fees
National
%
12
Have
informal
system to
waive fees
%
6
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
Thyolo
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
Neno
20
10
0
0
16
0
8
0
0
0
17
10
10
6
31
19
30
18
14
0
0
18
17
20
20
0
25
0
20
10
10
0
4
0
17
10
0
11
0
20
10
6
0
0
10
6
0
0
0
0
0
10
0
0
0
0
Have no
system
Total
%
82
%
100
60
80
90
100
80
100
75
90
100
89
83
70
80
89
69
81
60
76
86
100
100
82
83
70
80
100
75
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
170
Table 5.1A: Percentage of hospitals and
weekends, by health worker cadre
Percent of
hospitals
with cadre
HOSPITALS (n=92)
present
Health worker cadre
Medical doctor
Obstetrician/Gynaecologist
General surgeon
Paediatrician
Clinical officer
Registered Nurse
Registered Nurse Midwife
Enrolled
nurse/Nurse
technician
Enrolled
Nurse
Midwife/Nurse
Midwife
Technician
Doctor/Clinical
officer/Nurse Anaesthetist
Medical Assistant
health centres with health workers present on-duty and on call during the week and during
Mon-Fri
daytime
OnOn
duty
call
%
%
Mon-Fri night
Onduty
%
On call
Total1
%
%
58%
13%
12%
5%
89%
47%
80%
37%
47%
10%
12%
8%
88%
29%
79%
24%
2%
3%
1%
1%
0%
0%
0%
0%
24%
1%
1%
0%
55%
9%
39%
17%
24%
12%
12%
9%
30%
6%
17%
0%
93%
99%
0%
98%
62%
3%
58%
0%
80%
Sat-Sun day
Sat-Sun night
Onduty
%
On
call
%
Total1
19
12
12
7
13
3
8
1
43%
0%
9%
0%
52%
21%
46%
53%
23%
92%
91%
0%
27%
9%
14%
0%
13
12
11
6
23
4
11
1
1%
2
87%
0%
1
0%
0%
0
0%
0%
0
47%
16%
13
39%
24%
19
Onduty
%
On
call
%
21
11
11
8
28
5
16
0
45%
8%
9%
0%
63%
28%
57%
50%
34%
92%
100%
120%
15%
7%
9%
0%
0%
1
86%
31%
34%
31
37%
21%
20
Total1
%
%
171
Percent of
HEALTH CENTERS/CLINICS health
(n=217)
centres with
cadre
present
Health worker cadre
Medical doctor
Obstetrician/Gynaecologist
General surgeon
Paediatrician
Clinical officer
Registered Nurse
Registered Nurse Midwife
Enrolled
nurse/Nurse
technician
Enrolled
Nurse
Midwife/Nurse
Midwife
Technician
Doctor/Clinical
officer/Nurse Anaesthetist
Medical Assistant
Mon-Fri
daytime
OnOn
duty
call
%
%
Mon-Fri night
Sat-Sun day
Onduty
%
On call
Total1
%
2%
0%
0%
0%
14%
3%
8%
13%
80%
0%
0%
0%
106%
100%
89%
90%
0%
0%
0%
0%
0%
0%
0%
0%
40%
0%
0%
0%
52%
67%
56%
79%
87%
103%
0%
0%
0%
78%
89%
Sat-Sun night
On
call
%
Total1
%
Onduty
%
0%
0%
0%
0%
48%
0%
17%
0%
0
0
0
0
16
1
4
1
60%
0%
0%
0%
61%
50%
67%
83%
77%
24%
46
0%
0%
0%
0%
57%
31%
53
On
call
%
Total1
%
Onduty
%
0%
0%
0%
0%
30%
0%
19%
0%
1
0
0
0
11
1
4
1
40%
0%
0%
0%
52%
17%
67%
79%
0%
0%
0%
0%
42%
0%
17%
0%
0
0
0
0
14
0
4
1
74%
14%
28
69%
20%
38
0%
0%
0%
0%
60%
23%
55%
25%
36
%
43
1. Columns may not sum to total due to rounding. Total columns may not equal the first column 'percent with cadre present' due to missing information.
172
Table 5.2A: Percentage of hospitals and health centres with at least one health worker who could perform signal functions by signal
function and district
Parenteral:
HOSPITALS
(n=92)
Antibiotic
s
Oxytocic
s
National
%
86
%
85
Anticonvulsant
s
%
87
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
Zomba
100%
60%
100%
100%
63%
0%
0%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
60%
100%
100%
63%
100%
0%
67%
100%
100%
100%
92%
100%
100%
100%
100%
100%
100%
100%
60%
100%
100%
63%
100%
0%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Manual
removal
of
placenta
Removal of
retained
products by:
MVA
D&C or
D&E
Assiste
d
vaginal
delivery
Neonatal
Resuscitatio
n
%
83
%
62
%
63
%
75
100%
60%
100%
100%
63%
100%
0%
100%
100%
100%
100%
85%
100%
100%
100%
100%
100%
86%
100%
40%
100%
80%
63%
100%
0%
100%
0%
75%
100%
46%
60%
100%
50%
100%
100%
29%
50%
0%
50%
40%
50%
100%
0%
67%
0%
75%
100%
85%
60%
100%
100%
100%
100%
29%
100%
40%
100%
80%
63%
100%
0%
100%
100%
100%
100%
77%
100%
100%
50%
100%
100%
57%
Blood transfusion
for:
Caesarea
n delivery
Total
number
of
hospital
s
Mothe
r
Newbor
n
%
82
%
72
%
51
%
55
92
100%
60%
100%
100%
50%
100%
0%
100%
100%
100%
100%
92%
100%
100%
100%
100%
0%
100%
50%
0%
100%
40%
63%
100%
0%
67%
100%
100%
100%
92%
80%
100%
100%
100%
100%
57%
50%
0%
100%
20%
50%
100%
0%
33%
0%
25%
100%
38%
20%
0%
100%
100%
100%
57%
50%
0%
50%
40%
38%
0%
0%
67%
100%
75%
100%
92%
20%
100%
50%
75%
100%
29%
2
5
2
5
8
1
3
3
1
4
1
13
5
2
2
4
1
7
173
Parenteral:
HOSPITALS
(n=92)
Chiradzulu
Blantyre
Mwanza
Thyolo
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
Neno
Antibiotic
s
Oxytocic
s
%
100%
86%
0%
100%
0%
100%
100%
100%
100%
100%
%
100%
86%
0%
100%
0%
100%
100%
100%
100%
100%
Anticonvulsant
s
%
100%
86%
0%
100%
0%
100%
100%
100%
100%
100%
Manual
removal
of
placenta
Removal of
retained
products by:
MVA
D&C or
D&E
Assiste
d
vaginal
delivery
Neonatal
Resuscitatio
n
%
100%
71%
0%
100%
0%
100%
100%
100%
100%
100%
%
100%
43%
0%
100%
0%
67%
100%
100%
100%
100%
%
100%
57%
0%
100%
0%
100%
100%
100%
100%
100%
Manual
removal
of
placenta
Removal of
retained
products by:
MVA
D&C or
D&E
%
57
%
21
100%
100%
Blood transfusion
for:
Caesarea
n delivery
Mothe
r
Newbor
n
%
50%
86%
0%
100%
0%
67%
100%
100%
100%
100%
%
100%
86%
0%
67%
0%
100%
100%
100%
100%
100%
%
100%
86%
0%
67%
0%
100%
100%
100%
100%
100%
Assiste
d
vaginal
delivery
Neonatal
Resuscitatio
n
Blood transfusion Caesarea
for:
n delivery
%
3
%
22
33%
67%
%
100%
86%
0%
67%
0%
100%
100%
100%
100%
100%
%
50%
71%
0%
67%
0%
100%
100%
100%
100%
0%
Total
number
of
hospital
s
2
7
1
3
2
3
2
1
1
1
HEALTH CENTRES (n=217)
Parenteral:
Antibiotic
s
National
%
85
Oxytocics Anticonvulsant
s
%
%
83
81
District
Chitipa
100%
100%
100%
Total
number
of
health
centres
Mothe
r
Newbor
n
%
73
%
0
%
0
%
0
217
100%
67%
67%
33%
3
174
Parenteral:
Antibiotic
s
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
Thyolo
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
%
20%
88%
100%
71%
0%
0%
100%
100%
100%
100%
94%
100%
81%
100%
100%
100%
90%
100%
91%
0%
100%
50%
100%
100%
100%
100%
Oxytocics Anticonvulsant
s
%
%
20%
20%
88%
75%
100%
100%
71%
71%
0%
0%
0%
0%
100%
100%
100%
100%
100%
100%
100%
100%
71%
82%
100%
100%
94%
81%
91%
100%
100%
100%
100%
100%
90%
90%
100%
100%
91%
82%
0%
0%
100%
100%
40%
40%
100%
86%
100%
63%
100%
83%
100%
100%
Manual
removal
of
placenta
Removal of
retained
products by:
MVA
D&C or
D&E
Assiste
d
vaginal
delivery
Neonatal
Resuscitatio
n
%
20%
38%
67%
41%
0%
0%
86%
67%
60%
20%
41%
40%
75%
64%
94%
33%
70%
60%
64%
0%
63%
30%
100%
88%
33%
100%
%
0%
25%
0%
24%
0%
0%
14%
17%
0%
0%
18%
20%
38%
36%
18%
22%
10%
20%
27%
0%
13%
10%
43%
13%
33%
33%
%
0%
38%
0%
24%
0%
0%
14%
0%
0%
0%
29%
40%
31%
45%
24%
0%
20%
20%
9%
0%
38%
10%
29%
38%
17%
67%
%
20%
63%
67%
59%
0%
0%
71%
100%
100%
40%
59%
100%
88%
100%
88%
89%
50%
60%
82%
0%
100%
50%
86%
100%
100%
100%
%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
6%
0%
0%
0%
12%
11%
0%
0%
0%
0%
0%
0%
0%
0%
17%
0%
Blood transfusion Caesarea
for:
n delivery
Mothe
r
Newbor
n
%
0%
0%
0%
0%
0%
0%
0%
17%
0%
0%
6%
0%
0%
0%
6%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
%
0%
0%
0%
0%
0%
0%
0%
17%
0%
0%
0%
0%
0%
0%
6%
0%
0%
0%
9%
0%
0%
0%
0%
0%
0%
0%
%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
6%
11%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
Total
number
of
health
centres
5
8
3
17
1
9
7
6
5
5
17
5
16
11
17
9
10
5
11
1
8
10
7
8
6
3
175
Parenteral:
Antibiotic
s
Neno
%
100%
Oxytocics Anticonvulsant
s
%
%
100%
100%
Manual
removal
of
placenta
Removal of
retained
products by:
MVA
D&C or
D&E
Assiste
d
vaginal
delivery
Neonatal
Resuscitatio
n
%
50%
%
25%
%
25%
%
100%
%
0%
Blood transfusion Caesarea
for:
n delivery
Mothe
r
Newbor
n
%
0%
%
0%
%
0%
Total
number
of
health
centres
4
Table 5.3A: Percentage of hospitals and health centres with at least one health worker who could perform other essential services or
procedure by service and district
HOSPITALS
(n=91)
Normal
delivery
Breech
delivery
Partograph
management
National
%
85%
%
82%
%
84%
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
100%
60%
100%
100%
63%
0%
0%
100%
100%
100%
100%
85%
100%
100%
60%
50%
100%
63%
0%
0%
100%
100%
100%
100%
85%
100%
100%
60%
100%
100%
63%
0%
0%
100%
100%
100%
100%
85%
100%
Focused
ANC
FP
counseling
Temporary
FP
methods
Surgical
FP
methods
PMTCT
Uterotonic
drugs by
other
routes
Provide
anaesthesia
Number
Hospitals
%
86%
%
81%
%
73%
%
58%
%
45%
%
82%
%
52%
%
8%
n
91
100%
60%
100%
100%
63%
0%
0%
100%
100%
100%
100%
92%
100%
100%
60%
100%
100%
63%
0%
0%
100%
100%
100%
100%
69%
100%
50%
40%
100%
100%
63%
0%
0%
100%
100%
75%
100%
62%
80%
50%
40%
100%
100%
38%
0%
0%
100%
100%
75%
100%
46%
20%
50%
0%
50%
40%
38%
0%
0%
67%
100%
50%
100%
46%
20%
100%
60%
100%
100%
63%
0%
0%
100%
100%
100%
100%
69%
100%
50%
0%
50%
100%
50%
0%
0%
33%
100%
75%
100%
92%
20%
50%
0%
0%
0%
13%
100%
0%
33%
0%
0%
0%
15%
0%
2
5
2
5
8
1
3
3
1
4
1
13
5
Immediate
newborn
care
176
of
Dedza
Ntcheu
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre1
Mwanza
Thyolo
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
Neno
100%
100%
100%
100%
100%
100%
100%
0%
100%
0%
100%
100%
100%
100%
100%
100%
100%
100%
100%
86%
100%
100%
0%
100%
0%
100%
100%
100%
100%
100%
100%
100%
100%
100%
86%
100%
100%
0%
100%
0%
100%
100%
100%
100%
100%
Normal
delivery
Breech
delivery
Partograph
management
National
%
84%
%
73%
%
84%
Immediate
newborn
care
%
85%
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba2
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
100%
20%
88%
100%
81%
0%
0%
100%
100%
100%
100%
20%
75%
67%
31%
0%
0%
86%
100%
100%
100%
20%
88%
100%
81%
0%
0%
100%
100%
100%
100%
20%
88%
100%
75%
0%
0%
100%
100%
100%
HEALTH
CENTERS
(n=217)
100%
100%
100%
100%
100%
100%
100%
0%
100%
0%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
83%
0%
100%
0%
100%
100%
100%
100%
100%
100%
50%
75%
100%
100%
50%
100%
0%
100%
0%
100%
100%
0%
100%
100%
50%
50%
75%
100%
86%
50%
67%
0%
100%
0%
67%
50%
0%
100%
100%
100%
50%
75%
100%
29%
50%
67%
0%
67%
0%
100%
50%
0%
100%
0%
100%
100%
100%
100%
100%
100%
100%
0%
100%
0%
100%
100%
100%
100%
100%
100%
0%
50%
100%
14%
100%
50%
0%
100%
0%
0%
100%
0%
0%
100%
50%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
2
2
4
1
7
2
6
1
3
2
3
2
1
1
1
Focused
ANC
FP
counseling
Temporary
FP
methods
Surgical
FP
methods
PMTCT
Provide
anesthesia
Number
health
centres
%
84%
%
79%
%
73%
%
2%
%
81%
Uterotonic
drugs by
other
routes
%
7%
%
0%
n
216
100%
20%
88%
100%
75%
0%
0%
100%
100%
100%
100%
20%
88%
100%
75%
0%
0%
100%
100%
100%
100%
20%
88%
100%
75%
0%
0%
100%
100%
100%
0%
0%
0%
0%
6%
0%
0%
0%
0%
0%
100%
20%
88%
100%
69%
0%
0%
100%
100%
100%
33%
0%
0%
67%
6%
0%
0%
29%
0%
20%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
3
5
8
3
16
1
9
7
6
5
177
of
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
Thyolo
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
Neno
100%
65%
100%
100%
100%
100%
100%
90%
100%
82%
0%
100%
40%
100%
100%
100%
100%
100%
100%
71%
100%
88%
100%
82%
100%
70%
60%
73%
0%
100%
20%
100%
100%
100%
67%
75%
100%
71%
100%
100%
100%
88%
100%
90%
80%
91%
0%
100%
50%
100%
100%
100%
100%
100%
100%
76%
100%
100%
100%
100%
100%
90%
100%
82%
0%
100%
50%
100%
100%
100%
100%
100%
100%
59%
100%
100%
100%
100%
100%
100%
80%
91%
0%
100%
50%
100%
100%
100%
100%
100%
100%
53%
100%
88%
91%
82%
67%
90%
100%
91%
0%
88%
50%
100%
100%
100%
100%
100%
100%
53%
100%
63%
82%
71%
67%
80%
100%
82%
0%
88%
40%
100%
88%
83%
67%
100%
0%
0%
20%
0%
0%
0%
0%
10%
0%
0%
0%
0%
10%
0%
0%
17%
0%
0%
100%
53%
100%
94%
100%
88%
100%
100%
100%
82%
0%
100%
50%
86%
100%
100%
100%
100%
0%
6%
0%
0%
0%
0%
22%
0%
0%
0%
0%
38%
0%
0%
0%
0%
33%
25%
0%
0%
0%
0%
0%
0%
0%
10%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
5
17
5
16
11
17
9
10
5
11
1
8
10
7
8
6
3
4
1. One Hospital did not respond to this question and was excluded from the analysis
2. One Health Centre did not respond to this question and was excluded from the analysis
178
Table 5.4A : Numbers and ratios of midwives and skilled birth attendants (SBA) to 100
expected births, by district
Nurse
Midwives
Skilled birth
attendants 1
Expected
births2
Ratio of nurse
midwives to 100
expected births3
Ratio of SBAs to
100 expected
births
653,858
0.50
0.76
8,945
13,495
10,789
8,602
43,095
521
31,373
15,183
11,244
27,924
16,895
95,264
22,826
31,222
23,579
39,853
24,529
33,398
14,427
50,099
4,647
29,353
26,070
21,732
11,905
15,656
15,866
5,366
0.41
0.52
0.42
0.62
0.72
1.73
0.24
0.65
0.53
0.42
0.27
0.60
0.43
0.40
0.37
0.12
0.42
0.72
0.78
0.88
0.88
0.40
0.42
0.34
0.58
0.17
0.39
0.90
0.76
0.91
0.73
0.95
1.02
2.50
0.39
0.88
0.82
0.60
0.43
0.98
0.60
0.58
0.52
0.26
0.55
1.08
1.11
1.14
1.53
0.60
0.62
0.53
0.94
0.33
0.61
1.40
(WITHOUT NURSES)
National
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
Thyolo
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
Neno
3,297
4,955
37
70
45
53
310
9
76
98
60
118
46
573
99
124
87
48
104
241
113
439
41
117
109
74
69
27
62
48
68
123
79
82
442
13
121
134
92
167
72
933
137
182
122
103
134
361
160
571
71
176
162
116
112
51
96
75
1 Defined as nurse/midwives, clinical officers, medical doctors, and
obstetricians/gynaecologists.
2. Based on 5% of total population
3. Based on a ratio of one midwife to 100 expected births (UNFPA
recommendation).
179
Table 5.5A: Numbers and ratios of midwives and skilled birth attendants (SBA) to 5,000
population, by district
Midwives
National
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
Thyolo
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
Neno
Total
number of
SBAs
3,297
4,955
37
70
45
53
310
9
76
98
60
118
46
573
99
124
87
48
104
241
113
439
41
117
109
74
69
27
62
48
68
123
79
82
442
13
121
134
92
167
72
933
137
182
122
103
134
361
160
571
71
176
162
116
112
51
96
75
Population1,2
Ratio of
midwives to
5,000
population3
13,077,160
178,904
269,890
215,789
172,034
861,899
10,414
627,467
303,659
224,872
558,470
337,895
1,905,282
456,516
624,445
471,589
797,061
490,579
667,953
288,546
1,001,984
92,947
587,053
521,391
313,129
434,648
238,103
317,324
107,317
Ratio of
SBAs to
5,000
population
1.26
1.89
1.03
1.30
1.04
1.54
1.80
4.32
0.61
1.61
1.33
1.06
0.68
1.50
1.08
0.99
0.92
0.30
1.06
1.80
1.96
2.19
2.21
1.00
1.05
1.18
0.79
0.57
0.98
2.24
1.90
2.28
1.83
2.38
2.56
6.24
0.96
2.21
2.05
1.50
1.07
2.45
1.50
1.46
1.29
0.65
1.37
2.70
2.77
2.85
3.82
1.50
1.55
1.85
1.29
1.07
1.51
3.49
1,2. Source of Population Estimates: [2008 Population and housing census]
3. Based on WHO recommendation of 1 midwife per 5000 population
180
Table 5.6A: Ratios of select cadres of health worker per 100,000 population, by district 1
Total
Population
Medical
doctor per
100,000
population
Obstetrician
Gynecologist
per 100,000
population
General
surgeon
per
100,000
populat
ion
Paediatrician
per 100,000
population
Clinical
officer
per
100,000
populatio
n
Registered
Nurse per
100,000
population
Registered
Nurse
Midwife
per
100,000
population
Enrolled
nurse/Nurse
technician
per 100,000
population
Enrolled Nurse
Midwife/Nurse
Midwife
Technician per
100,000
population
Medical
Assistant
per
100,000
population
National
13,077,160
1
0
0
0
7
1
4
1
26
4
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
178,904
269,890
215,789
172,034
861899
10,414
627,467
303,659
224,872
558,470
337,895
1905282
456,516
624,445
471,589
797,061
490,579
667953
288,546
1001984
92,947
1
1
0
1
1
10
0
1
1
0
0
4
1
1
0
0
0
1
1
2
4
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
9
7
9
8
11
19
5
6
5
4
3
12
3
5
4
3
3
12
9
7
12
4
2
4
0
3
0
1
3
2
1
3
1
1
1
3
1
1
1
1
0
9
2
2
3
3
6
10
2
4
2
3
2
5
2
1
2
4
2
8
4
7
4
2
0
0
0
1
0
1
1
1
1
2
0
1
0
0
9
1
0
0
1
2
22
27
22
31
36
77
12
33
27
23
18
30
20
22
21
3
22
33
39
43
42
8
12
6
8
4
10
2
5
8
6
5
2
5
4
3
4
2
5
6
2
16
181
Table 5.6A: Ratios of select cadres of health worker per 100,000 population, by district 1
Thyolo
Mulanje
Phalombe
Chikwawa
Nsanje
Balaka
Neno
Total
Population
Medical
doctor per
100,000
population
Obstetrician
Gynecologist
per 100,000
population
General
surgeon
per
100,000
populat
ion
Paediatrician
per 100,000
population
Clinical
officer
per
100,000
populatio
n
Registered
Nurse per
100,000
population
Registered
Nurse
Midwife
per
100,000
population
Enrolled
nurse/Nurse
technician
per 100,000
population
Enrolled Nurse
Midwife/Nurse
Midwife
Technician per
100,000
population
Medical
Assistant
per
100,000
population
587,053
521,391
313,129
434,648
238,103
317,324
107,317
1
0
1
0
1
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
5
6
6
4
5
7
14
1
1
1
2
0
1
0
2
3
3
2
3
3
7
0
0
0
1
0
1
0
22
21
23
17
14
24
44
4
4
7
6
5
4
12
1. per 100,000 population
182
Table 6.1A: Percentage of facilities with a supply of medicines with registers and sources
of drugs and supplies, by type of facility
Hospitals Health
Centres
Total
Among all facilities
Facility has pharmacy/supply of medicine
%
(n=92)
100%
%
(n=217)
100%
%
(n=309)
100%
Among facilities with a pharmacy/supply of medicine
Drug stock card exists1
Drug stock card exists and is up-to-date1
(n=92)
96%
82%
(n=217)
98%
80%
(n=309)
97%
80%
61%
33%
7%
73%
13%
13%
70%
19%
11%
61%
36%
3%
72%
15%
13%
69%
21%
10%
59%
38%
3%
75%
13%
12%
70%
21%
9%
Major source of medicine for facility
Government
Private pharmacy
NGO / Mission
Primary source for gloves, syringes and medical
supplies2
Government supplier
Private pharmacy
NGO / Mission
Primary source for infection prevention supplies1
Government supplier
Private pharmacy
NGO / Mission
1. Two health centres did not respond and are excluded
183
Table 6.2A: Percentage of facilities according to mechanisms for ordering drugs, by type of
facility
Hospitals
Among facilities with a pharmacy1
Drug supplies in the pharmacy are ordered
Same time (each week, month or quarter)
Order every 6 or 12 months
Order whenever stocks reach reorder level
Reorder when we run out
Among all facilities
Drug supplies in labour and delivery rooms are ordered1
Order same time each week/month/quarter
Order every 6 or 12 months
Order whenever stocks reach reorder level
Ordered on patient by patient basis
Daily basis
same time each week, when run out of drugs & on
patient by pa
Order whenever drugs run out and ordered on
patient by patient
No delivery services
Drug supplies in maternity/postnatal wards are
ordered2
Order same time each week/month/quarter
Order every 6 or 12 months
Order whenever stocks reach reorder level
Ordered on patient by patient basis
Daily basis
same time each week, when run out of drugs & on
patient by pa
Order whenever drugs run out and ordered on
patient by patient
Among facilities with an OT
Drug supplies in the OT are ordered
Order same time each week/month/quarter
Order whenever stocks reach reorder level
Reorder when we run out
Order whenever needed
Order same time each week/month/quarter & order
whenever needed
Health
Centres
%
(n=217)
Total
11%
10%
85%
0%
11%
4%
83%
0%
11%
6%
(n=88)
(n=207)
(n=295)
67%
10%
7%
5%
9%
1%
54%
14%
24%
2%
5%
0%
58%
13%
19%
3%
6%
0%
1%
0%
0%
5%
5%
5%
(n=88)
(n=207)
(n=295)
67%
9%
7%
7%
8%
1%
55%
15%
24%
2%
4%
0%
59%
13%
19%
3%
5%
0%
1%
0%
0%
(n=62)
(n=215)
(n=307)
76%
3%
10%
8%
3%
0%
0%
0%
0%
0%
76%
3%
10%
8%
3%
%
(n=92)
79%
%
(n=309)
Percentages not shown where denominator is less than 10.
184
1. Two health centres did not respond and are excluded.
2. Four Hospitals and 10 Health Centres did not respond and are excluded.
Table 6.3A: Percentage of facilities reporting most common cause of delay of delivery of
supplies, by type of facility/sector (among facilities with pharmacy/supply of medicine)
Most
cause of delay
Hospitals
common Government
(n=45)
Inadequate transport
Administrative
difficulties
Financial problems
Insufficient fuel
Insufficient staff
Stock out at the central
level
Other 1
CHAM
(n=36)
Private
for
profit
(n=10)
%
20%
16%
%
10%
0%
%
4%
20%
31%
0%
38%
0%
30%
22%
40%
Health Centres
Government CHAM
(n=158)
(n=47)
Private
for
profit
(n=5)
%
22%
35%
%
0
0.6
3%
19%
3%
1%
1%
22%
0.2
0
0
0
36%
0%
0%
15%
33%
17%
0.2
17%
8%
6%
%
19%
13%
1. 'Other' includes staff didn't know, pharmacy or facility was
new.
Table 6.4A: Percentage of facilities reporting on pharmacy-related items, by type of facility
(among facilities with a pharmacy/supply of drugs)
Hospitals
(n=92)
%
Pharmacy is accessible 24/7
"First-Expiry-First-Out" system in use1
Mechanism in place to ensure expired drugs are not
distributed
Drugs are protected from moisture, heat or infestation1
Required drugs are refrigerated1
Facility has at least 1 functioning electric / gas refrigerator
Facility has at least 1 functioning solar refrigerator1
Health
Centres
(n=215)
%
Total
(n=307)
%
76%
97%
97%
78%
97%
98%
77%
97%
98%
99%
98%
96%
5%
98%
98%
91%
16%
98%
98%
92%
13%
185
Table 6.5A: Percentage of facilities reporting on stock out of ergometrine, magnesium sulphate,
oxytocin, ketamine and atropine, by type of facility (among facilities with pharmacy/supply of
drugs)
Hospitals
(n=92)
n
%
n
Health
Centres/
Clinics
(n=215)
%
Total
(n=307)
n
%
Ergometrine
Stock out in last 12 months
Currently out of stock
Within last month
Within 3 months
Within 6 months
Within 12 months
Has never had Ergometrine in stock
92
92
92
92
92
92
92
42%
24%
2%
3%
8%
5%
39%
215
215
215
215
215
215
215
36%
16%
1%
6%
7%
5%
54%
307
307
307
307
307
307
307
38%
19%
2%
5%
7%
5%
50%
Magnesium Sulphate
Stock out in last 12 months
92
34%
26%
307
28%
Currently out of stock
92
12%
10%
307
11%
Within last month
92
8%
6%
307
6%
Within 3 months
92
8%
4%
307
5%
Within 6 months
92
3%
3%
307
3%
Within 12 months
92
3%
2%
307
3%
92
9%
21
5
21
5
21
5
21
5
21
5
21
5
21
5
46%
307
35%
92
28%
39%
307
36%
Currently out of stock
92
7%
15%
307
12%
Within last month
92
12%
13%
307
12%
Within 3 months
92
4%
7%
307
7%
Within 6 months
92
4%
2%
307
3%
Within 12 months
92
1%
2%
307
2%
Has never had oxytocin in stock
92
3%
21
5
21
5
21
5
21
5
21
5
21
5
21
5
8%
307
7%
Has never had magnesium sulphate
in stock
Oxytocin
Stock out in last 12 months
186
Hospitals
(n=92)
n
Ketamine
Stock out in last 12 months
%
n
92
12%
Currently out of stock
92
3%
Within last month
92
0%
Within 3 months
92
2%
Within 6 months
92
4%
Within 12 months
92
2%
Has never had ketamine in stock
92
22%
Stock out in last 12 months
92
10%
Currently out of stock
92
2%
Within last month
92
0%
Within 3 months
92
1%
Within 6 months
92
4%
Within 12 months
92
2%
92
9%
21
5
21
5
21
5
21
5
21
5
21
5
21
5
Health
Centres/
Clinics
(n=215)
%
1%
0%
0%
0%
0%
0%
96%
Total
(n=307)
n
30
7
30
7
30
7
30
7
30
7
30
7
30
7
%
4%
1%
0%
1%
2%
1%
74%
Atropine
Has never had atropine in stock
21
5
21
5
21
5
21
5
21
5
21
5
21
5
20%
8%
2%
4%
3%
3%
39%
30
7
30
7
30
7
30
7
30
7
30
7
30
7
17%
6%
1%
3%
4%
3%
30%
187
Table 6.6A: Percentage of facilities that have the drugs related to the signal functions and
emergencies, by type of facility (among facilities with pharmacy/supply of drugs)
Hospitals
(n=92)
Health
Centres
(n=217)
Total
(n=309)
Antibiotics (any)
Amoxycillin
Ampicillin (inj)
Benzyl Penicillin G
Cefotaxime inj (for newborn)
Cefriaxone (inj)
Chloramphenicol (inj)
Clindamycin
Cloxacillin capsule
Erythromicin
Gentamicin (inj)
Metronidazole (tablet)
Metronidazole (inj)
Oral Flucoxacillin (for newborn)
Procaine benzylpenicillin (procaine penicillin G)
Trimethoprim/Sulfamethoxalo (co-tromoxazole)
%
100%
75%
52%
96%
30%
72%
91%
8%
47%
86%
97%
77%
39%
8%
4%
96%
%
99%
12%
2%
88%
1%
5%
68%
1%
3%
67%
84%
5%
3%
1%
0%
87%
%
99%
31%
17%
90%
10%
25%
75%
3%
16%
72%
88%
27%
14%
3%
2%
89%
Anticonvulsants & Sedatives (any)
Diazepam (injection)
Phenobarbital (injection)
Magnesium sulfate
Phenytoin (Diphenythydantoin)
95%
72%
83%
75%
67%
90%
37%
61%
49%
29%
91%
48%
68%
57%
40%
Antihypertensives (any)*
Methyldopa
Hydralizine
Nifedipine
Propranolol
93%
64%
78%
65%
63%
73%
12%
14%
6%
58%
79%
27%
33%
24%
60%
Oxytocics (any)**
Ergometrine (inj)
Oxytocin
Syntometrine
Misoprostol
96%
17%
13%
21%
83%
90%
13%
12%
0%
78%
92%
14%
12%
6%
79%
Drugs used in emergencies (any)**
Adrenaline (Epinephrine)
Aminophylline
Atropine sulfate
Calcium Gluconate
Digoxin
Diphenhydramine
Ephedine
99%
82%
90%
85%
22%
49%
2%
17%
97%
47%
82%
53%
2%
1%
0%
3%
98%
57%
85%
62%
8%
16%
1%
7%
188
Frusemide
Hydrocortisone
Naloxone Hydrochloride
Nitroglycerine
Promethazine Hydrochloride
Hospitals
(n=92)
Health
Centres
(n=217)
Total
(n=309)
%
89%
52%
5%
7%
72%
%
63%
11%
0%
0%
60%
%
71%
23%
2%
2%
64%
** Two health centres didn't respond to this questions and are excluded from the analysis
Table 6.7A: Percentage of facilities that have anaesthetics and other drugs, by type of
facility (among facilities with pharmacy/supply of medicine)
Hospitals
(n=92)
Total
(n=309)
Anaesthetics (any)
Lignocaine / Lidocaine 2% or 1%
Ketamine Hdrochlride
Halothane
%
98%
91%
74%
56%
Health
Centres
(n=217)
%
80%
79%
4%
1%
Analgesics (any)
Acetylsalicylic acid
Indomethacin
Morphine Hydrochloride (inj)
Paracetamol
Pethidine Hydrochloride
99%
85%
58%
56%
91%
73%
88%
61%
28%
4%
77%
2%
91%
68%
37%
20%
81%
23%
Tocolytics (any)
Indomethacin
Nefidepine
76%
55%
65%
26%
23%
5%
41%
33%
23%
Steroids (any)
Prednisolone tablet
Dexamethasone
Betamethasone
87%
81%
66%
26%
31%
26%
10%
4%
48%
42%
26%
10%
IV Fluids (any)
Dextrose 5%
Glucose 50%
Normal saline
Ringer's Lactate
Half strength Darrows
98%
76%
54%
84%
91%
35%
95%
79%
49%
82%
87%
20%
96%
78%
50%
83%
89%
24%
%
100%
100%
100%
100%
189
Hospitals
(n=92)
Total
(n=309)
%
32%
Health
Centres
(n=217)
%
3%
Antimalarials (any)
Artemisium-based combination therapy
(ACT)
Sulphadoxine/Pyrimethamine
Quinine Dihydrochloride
98%
89%
97%
85%
97%
86%
96%
88%
88%
88%
90%
88%
Antiretrovirals (any)
Nevirapine - mother
Nevirapine - newborn
HIV Rapid testing kit
Post-HIV exposure prophylactic treatment
Combined ARV for mother
Combined ARV for newborn
97%
81%
67%
0%
76%
85%
62%
84%
73%
66%
0%
34%
43%
31%
88%
75%
66%
0%
46%
55%
40%
Haemaccel
%
11%
Table 6.8A: Percentage of facilities with basic diagnostics and supplies in the maternity
area1, by type of facility
Hospitals Health
(n=91)
Centres
(n=210)
%
%
Total
(n=301)
%
Diagnostics
Ultrasound
BP cuff
Stethoscope
Clinical oral thermometer
Uristix (dip stick for protein in urine)
Blood sugar testing sticks
Partographs (modified form)3
Pulse oximeter
51%
99%
97%
68%
52%
29%
98%
20%
4%
87%
94%
72%
13%
7%
97%
3%
18%
90%
95%
71%
25%
14%
97%
8%
Supplies
Kidney basins
Sponge bowls
Scissors
Needles and Syringes (10-20cc)
Syringes (1ml, 2ml, 5ml, 10ml)
Needles (23-25 gauge)
Suture needles/suture materials3
IV Infusion stand(s)
98%
87%
92%
91%
91%
73%
97%
96%
96%
70%
84%
78%
83%
53%
94%
80%
96%
75%
87%
82%
86%
59%
95%
85%
190
Hospitals Health
Total
(n=91)
Centres (n=301)
(n=210)
%
%
%
Urinary catheters
92%
69%
76%
IV cannulae
97%
95%
96%
Adult ventilator bag and mask
67%
27%
39%
Dressing forceps
84%
65%
71%
Surgeon’s handbrush w/ nylon bristles
22%
7%
11%
Watch or clock with second hand that can be easily seen
88%
72%
77%
Measuring tape
67%
53%
57%
Nasogastric tubes
82%
16%
36%
1. For hospitals, the maternity area was likely to be a specific room and these questions were related
to the equipment and supplies available in that specific room. Health centres may not have had a
specific room devoted for a maternity and these questions were therefore related to whether the
facility, in general, had the equipment and supplies available.
Table 6.9A: Percentage of facilities with items for cervical / perineal repair pack, delivery
set items, dressing instrument set items, and gynaecological equipment and equipment
for other procedures in the maternity area1, by type of facility
Episiotomy /Perineal /Vaginal / Cervical repair pack
Vacuum extraction / forceps delivery set
Uterine evacuation set
Manual vacuum aspiration set
Delivery Pack Set
Number of facilities with at least 1 complete delivery set
Number of complete delivery sets
Dressing Instrument Set
Gynaecological Equipment
SIMS or other type vaginal speculum
Cuscos or other type speculum, virgin size 75x17 mm
Cuscos or other type speculum, sm., heavy pattern 80x32mm
Sound, uterine Horrock’s graduated 305 mm s/s
Tenaculum
Scissors, straight, sharp 145 mm s/s
Hospitals Health
(n=91)
Centres
(n=209)
%
%
Total
(n=300)
53%
86%
59%
73%
96%
96%
25%
33%
1%
33%
88%
88%
33%
49%
19%
45%
90%
90%
78%
0%
24%
68%
45%
91%
41%
71%
89%
39%
42%
77%
11%
27%
70%
48%
43%
81%
20%
40%
76%
%
1. For hospitals, the maternity area was likely to be a specific room and these questions were related
to the items available in that specific room. Health centres may not have had a specific room
devoted to a maternity and these questions were therefore related to whether the facility, in general,
had the items available. Please note, however, that the MVA equipment for both hospitals and
health centres could have been located anywhere in the facility.
191
Table 6.10A: Percentage of facilities with selected furnishings and amenities in the
maternity area1, by type of facility
Hospitals
(n=91)
Health
Centres
(n=210)
Total
(n=301)
%
%
%
92%
87%
98%
96%
65%
71%
73%
98%
90%
62%
77%
77%
98%
91%
63%
33%
91%
90%
73%
52%
70%
4%
58%
57%
65%
42%
70%
13%
68%
67%
67%
45%
70%
Bed availability and storage3
Empty beds for next patients are available
Empty beds are clean and ready
Facility has any beds in storage
Facility has 1 - 5 beds in storage
Facility has > 5 beds in storage
88%
86%
54%
24%
76%
86%
89%
16%
68%
32%
86%
88%
17%
53%
47%
Miscellaneous Items
Food is provided to patients by facility
54%
4%
19%
Furnishings
Instrument trolley
Instrument tray
Beds
Blankets for cold weather
Water filter (or other means to make potable water
available to patients and staff)
Filled O2 cylinder with carrier + key to open valve
Wheelchair
Stretcher with trolley
Examination table
Labour/delivery table with stirrups
Labour/delivery table without stirrups
1. For hospitals, the maternity area was likely to be a specific room and these questions were related
to the items available in that specific room. Health centres may not have had a specific room
devoted to a maternity ward and these questions were therefore related to whether the facility, in
general, had the items available.
192
Table 6.11A: Percentage of facilities with autoclave, sterilization and incineration items in
the maternity area1, by type of facility
Hospitals Health
(n=91)
Centres
(n=208)
%
%
Total
(n=299)
%
Autoclave, Sterilization Equipment and Incineration
Separate autoclave room
58%
19%
31%
Autoclave (with temperature and pressure gauges)
59%
11%
25%
Hot air Sterilizer (dry oven)
13%
5%
8%
Steam Sterilizer
49%
25%
32%
Steam Instrument Sterilizer / Pressure Cooker
36%
61%
53%
(electric)
Sterilization drum
88%
63%
70%
Sterilization drum stand
33%
16%
21%
Functioning incinerator3
91%
67%
75%
1. For hospitals, the maternity area was likely to be a specific room and these questions were related
to the items available in that specific room. Health centres may not have had a specific room
devoted to a maternity ward and these questions were therefore related to whether the facility, in
general, had the items available.
Table 6.12A: Percentage of hospitals with an operating theatre (OT) and among those with
an OT, the percent with select equipment and supplies
Hospitals
%
Among all facilities
Facility has an operating theatre
n
91
62
Among facilities with an operating theatre
Facility has separate OT for obstetric patients
62
16
26%
62
62
62
62
62
62
62
100%
95%
98%
100%
95%
61%
87%
62
62
62
87%
98%
95%
Basic Items
Operating table
Light- adjustable, shadowless
Surgical drapes
Syringes 5ml
Syringes 10ml
Syringes 20ml
Needles 21, 22, 23
Obstetric laparotomy / cesarean delivery pack
Mini-laparotomy kit
Cesarean delivery kit
Obstetric laparotomy kit
68%
Anesthesia Equipment
193
Anesthetic face masks
Oropharyngeal airways
Laryngoscopes (with spare bulbs and batteries)1
Endotracheal tubes with cuffs (8 mm)
Endotracheal tubes with cuffs (10 mm)
Intubating forceps (Magill)
Endotracheal tube connectors: 15 mm plastic (connect
directly to breathing valve; three for each tube size)
Spinal needles (18-gauge to 25-gauge)
Suction aspirator (any)
Anaesthesia apparatus (draw-over system)
Oxygen cylinders with manometer and flowmeter
(low flow) tubes and connectors
Craniotomy Equipment
Decapitation hook Jardine’s s/s
Craniotomy forceps Brawn’s s/s
n
62
62
62
62
62
62
62
Hospitals
%
97%
95%
94%
89%
58%
87%
87%
62
62
62
62
82%
97%
92%
74%
62
62
31%
29%
Table 6.13A: Percentage of facilities with a laboratory and among those the percent with
equipment and supplies for blood transfusion, by type of facility
Hospitals
Health
Centres
Total
Among all facilities
Facility has a laboratory
%
(n=91)
90%
%
(n=213)
16%
%
(n=304)
38%
Among facilities with a laboratory
Facility has set of guidelines for laboratory
(n=82)
84%
(n=35)
63%
(n=117)
0%
83%
78%
78%
96%
51%
51%
98%
99%
96%
87%
28%
89%
13%
63%
59%
45%
6%
49%
40%
89%
11%
37%
86%
86%
60%
37%
6%
54%
26%
11%
29%
14%
60%
69%
67%
94%
39%
47%
94%
95%
85%
72%
21%
79%
17%
48%
50%
36%
Equipment & Supplies for Blood Transfusions
Refrigerator
Test tubes - small size
Test tubes - medium size1
Slides (microscope)
Compound microscope1
Microscope illuminator
Blood lancets
Cotton wool
Rack
8.5 g/l Sodium Chloride solution
20% Bovine albumin2
Centrifuge (electric)
Centrifuge (hand driven)
37o Water bath (or incubator)
Pipettes Volumetric - 1 ml
- 2 ml
194
Hospitals
%
- 3 ml
48%
- 5 ml
41%
- 10 ml
43%
- 20 ml
46%
Pipette holder of 10 pieces
49%
Blood typing and cross-matching reagents
90%
Blood collection bags
78%
Airway needle for GIVING blood
77%
Hepatitis B Test
83%
Hepatitis C Test
21%
HIV Rapid Test
96%
HIV Elisa Test
7%
Syphilis Test
94%
1. One health center did not respond and was excluded
2. One hospital did not respond and was excluded.
Health
Centres
Total
%
23%
11%
11%
6%
0%
14%
6%
6%
14%
3%
51%
3%
51%
%
40%
32%
33%
34%
34%
68%
56%
56%
62%
15%
83%
6%
81%
Table 6.14A: Percentage of facilities with laboratory supplies, by type of facility (among facilities
with a laboratory)
Microscope
Immersion oil
Glass rods
Sink or staining tank
Measuring cylinder (25 ml) polypropylene
Measuring cylinder (50 ml) polypropylene
Measuring cylinder (100 ml) polypropylene
Measuring cylinder (250 ml) polypropylene
Measuring cylinder (500 ml) polypropylene
Wash bottle containing buffered water
Interval timer clock with alarm
Rack for drying slides
Giemsa stain
Wright stain
May Grünwald stain
Methanol
Refrigerator
Glass containers
Counting chamber (Differential counter)
Pipette (5 ml)
Pipette (graduated, 1.0 ml)
Dropping pipette
Cover slips
Hospitals
(n=112)
Health
Centre
(n=628)
Total
(n=740)
%
98%
98%
43%
96%
45%
52%
71%
56%
62%
29%
74%
84%
30%
20%
7%
77%
89%
54%
80%
54%
63%
83%
91%
%
94%
94%
17%
89%
14%
17%
29%
29%
34%
11%
37%
60%
29%
6%
0%
51%
34%
20%
20%
26%
34%
57%
69%
%
97%
97%
35%
94%
36%
42%
58%
48%
54%
24%
63%
77%
30%
15%
5%
69%
73%
44%
62%
45%
55%
75%
85%
195
Petri dishes
Bowls, stainless steel, assorted sizes
Tork diluting solution
Tally counter
Haemoglobinometer
Microhaematocrit centrifuge (manual or electric)
Scale for reading results
Heparinized capillary tubes (75 mm x 1.5 mm)
Spirit lamp
Ethanol
Dip sticks (Coubec - 10 or URS-10)
Pyrex test-tubes
Test-tube holder
Beaker: 100 ml
Beaker: 250 ml
Beaker: 1000 ml
Ammonia
Lugol’s iodine solution1
CD 4 machine
Hospitals
(n=112)
Health
Centre
(n=628)
Total
(n=740)
%
52%
41%
49%
61%
80%
39%
35%
77%
71%
85%
83%
95%
95%
45%
43%
44%
33%
78%
46%
%
11%
20%
9%
20%
51%
14%
14%
23%
49%
34%
34%
71%
57%
26%
29%
31%
9%
17%
17%
%
40%
35%
37%
49%
72%
32%
29%
61%
64%
70%
68%
88%
84%
39%
38%
40%
26%
60%
38%
196
Table 7.1A: Percentage of facilities providing selected services by district
Postnatal Obstetric
care
Surgery
National
Focused
Antenatal
care
%
98
Treatment
Diagnosis & PMTCT
and repair of treatment of
Ob fistula
STI
%
%
%
8
96
95
FP
%
19
General
Ana
esthesia
%
19
%
97
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
Likoma
100
100
100
100
96
100
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
Thyolo
Total
number of
facilities
%
85
Cervical
cancer
screening
%
23
100
100
90
100
96
100
20
10
10
25
20
50
20
10
10
25
20
50
20
0
10
13
12
0
100
100
90
100
96
100
100
90
100
100
92
100
80
80
100
100
88
100
40
20
10
25
24
0
5
10
10
8
25
2
83
90
100
100
100
90
100
100
100
100
100
100
100
100
83
100
100
100
8
20
14
33
17
37
10
11
8
8
10
14
33
17
37
10
11
8
0
10
0
0
0
13
0
0
0
100
80
86
100
100
100
80
94
100
100
90
100
89
100
93
100
89
100
100
90
100
78
100
87
70
61
85
8
20
14
44
17
23
10
17
23
12
10
7
9
6
30
10
18
13
100
100
100
100
100
100
100
100
90
94
100
94
100
100
19
10
12
29
28
50
18
19
10
12
29
33
50
18
10
10
6
0
22
50
18
90
90
100
100
94
100
100
86
90
100
100
89
100
100
76
90
82
86
83
100
91
19
20
29
29
50
50
27
21
10
17
7
18
2
11
309
197
Table 7.1A: Percentage of facilities providing selected services by district
Mulanje
Chikwawa
Nsanje
Phalombe
Balaka
Neno
Focused
Antenatal
care
%
100
100
100
100
100
100
Postnatal Obstetric
care
Surgery
%
100
100
100
100
100
100
%
17
30
20
14
25
0
General
Ana
esthesia
%
17
30
20
14
25
0
Treatment
Diagnosis & PMTCT
and repair of treatment of
Ob fistula
STI
%
%
%
8
100
100
0
100
90
0
100
100
14
100
100
0
100
100
0
100
100
FP
%
92
80
80
71
75
100
Cervical
cancer
screening
%
17
10
10
14
25
40
Total
number of
facilities
12
10
10
7
4
5
198
Table 7.2A: Median length of stay (hrs) after normal delivery, by facility type/sector and district
deliveries
National
Government
number median
of
length
facilities of stay
(hrs)
206
24
CHAM
number median
of
length
facilities of stay
(hrs)
86
36
Private
number median
of
length
facilities of stay
(hrs)
12
24
Total
number median
of
length
facilities of stay
(hrs)
299
24
Facility Type
Central Hosp
District Hosp
Other Hosp
Rural Hosp
Health Centre
4
23
3
15
161
.
.
22
15
49
.
.
7
.
5
.
.
{24}
.
{24}
4
23
32
30
210
24
24
24
48
24
.
.
.
.
.
.
.
.
.
.
.
{48}
{24}
.
.
.
{48}
.
.
.
{36}
.
.
.
{24}
.
.
.
.
5
9
10
8
23
{48}
{48}
24
{30}
24
.
{24}
48
24
{48}
{48}
{48}
24
24
24
48
24
24
24
{24}
24
{36}
24
24
24
36
{24}
{24}
{24}
{24}
24
{24}
24
24
.
.
30
48
24
District
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
3
7
8
6
14
{48}
2
{36}
0
{48}
2
{36}
0
{24}
2
{18}
0
{24}
2
{42}
0
24
9
{48}
0
.
Likoma
1
{24}
1
{24}
0
Kasungu
10
{36}
2
48
0
Nkhotakota
7
{24}
3
{24}
0
Ntchisi
7
{48}
0
.
0
Dowa
7
{48}
2
{36}
0
Salima
2
{36}
3
{48}
1
Lilongwe
13
{24}
7
{48}
5
Mchinji
7
{24}
3
{48}
0
Dedza
11
24
7
{48}
0
Ntcheu
7
{48}
6
{48}
0
Mangochi
10
24
10
24
1
Machinga
6
{24}
4
{24}
0
Zomba
11
24
5
{24}
0
Chiradzulu
6
{24}
1
{24}
0
Blantyre
11
24
2
{36}
4
Mwanza
2
{36}
0
.
0
Thyolo
7
{24}
4
{36}
0
Mulanje
10
24
2
{24}
0
Chikwawa
8
{24}
1
{48}
1
Nsanje
8
{36}
2
{36}
0
Phalombe
5
{24}
2
{35}
0
Balaka
3
{24}
1
{24}
0
Neno
4
{24}
1
{48}
0
Note: Medians based on fewer than 10 observations appear in brackets { }.
2
12
10
7
9
6
25
10
18
13
21
10
16
7
17
2
11
12
10
10
7
4
5
199
200
Table 7.3A: Percentage of facilities that did not provide the service in last 3 months and reasons for not doing so
Extra care to premature or
LBW baby
Partograph
Episiotomy
Breech Delivery
Craniotomy
Rapid HIV testing in maternity
ward
ARV to mothers during
delivery
ARV to newborns in maternity
ward
Temporary FP Methods
Surgical / permanent FP
n
Percentage of facilities that responded that the service was not provided
in the last 3 months due to (multiple responses allowed):
availability of training
supplies/equip manage policy
no
other
human
issues
ment/drugs
ment
issues
indication reason
resources
issues
%
%
%
%
%
%
%
142
3%
4%
35%
3%
13%
15%
56%
2
178
62
277
72
100%
2%
2%
19%
18%
0%
1%
5%
28%
25%
0%
3%
2%
19%
39%
50%
6%
0%
10%
10%
0%
8%
6%
51%
3%
0%
51%
34%
28%
22%
50%
6%
65%
9%
15%
35
0%
20%
66%
0%
3%
20%
6%
35
0%
14%
69%
3%
0%
20%
6%
54
161
9%
17%
2%
44%
6%
24%
20%
11%
65%
49%
4%
1%
9%
9%
201
Table 8.1A: Percent distribution of time spent in facility prior to and following
caesarean delivery and mean duration of stay by type of caesarean, infection status
and indication (n=173)
n
Time lapse, diagnosis of caesarean to surgery
30 minutes or less
31 minutes to 1 hour
1 - 2 hours
2 - 3 hours
3 - 5 hours
5+ hours
No information
%
13
36
32
18
9
4
61
8%
21%
18%
10%
5%
2%
35%
Time that the woman remained in the hospital after the
caesarean
0 - 3 days
4 - 8 days
9 - 12 days
13+ days
No information
15
119
24
13
2
9%
69%
14%
8%
1%
Average time in hospital (in days)*
171
1.5 days
By type of cesarean1
Emergency caesarean
Elective caesarean
No information
140
8
25
8.1 days
7.9 days
-
By wound infection1
Wound infected
Wound not infected
8
152
8.2 days
14.0 days
78
23
5
5
1
0
0
22
8.5 days
6.9 days
6.4 days
6.9 days
7.0 days
0.0 days
0.0 days
12.3 days
16
12
11
0
8.5 days
6.4 days
6.5 days
0.0 days
By indication1
CPD/prolonged labour
Previous scar
APH
Eclampsia/Severe pre-eclampsia
Failed induction
PROM
Multiple gestation
Other
Foetal Indications:
Foetal distress
Breech with footling
Cord prolapse
Post term
* there was no information on number of days stayed in the hospital for
202
25 cases
203
Table 8.2A: Percent distribution of newborn outcomes after caesarean, by selected
characteristics
Characteristics
Total
Normal
live
births
(n=173)
(n=149)
(n=36)
36
72
65
Live births
with
distress
Neonatal
deaths
Stillbirths
LB and
death
(n=12)
(n=3)
(n=9)
(n=0)
(n=149)
75%
96%
82%
19%
1%
6%
(n=3)
0%
1%
3%
(n=9)
6%
1%
9%
(n=0)
-
(n=173)
124
12
7
3
2
(n=149
90%
83%
57%
100%
0%
(n=12)
6%
17%
29%
0%
0%
(n=3)
1%
0%
0%
0%
0%
(n=9)
3%
0%
14%
0%
100%
(n=0)
-
2
23
100%
78%
0%
4%
0%
9%
0%
9%
-
Newborn outcomes
Was meconium present?
Yes
No
No information
Last foetal heart rate
Normal
Bradycardia
Tachycardia
Irregular
No foetal heart rate
detected
Other
No information
Primary cause of foetal
death
Asphyxia and birth
trauma
Congenital abnormalities
Infection/pneumonia
Prematurity - related
Trauma
Other
Unknown / no
information
(absolute numbers)
5
1
4
-
0
0
0
1
4
2
1
1
4
1
-
204
Table 8.3A: Percentage of women whose caesareans were reviewed according to foetal
outcome, by indication for caesarean
Total
number of
caesareans
with
indication
N
78
23
5
5
Live
Births
88%
91%
100%
80%
8%
0%
0%
20%
1%
4%
0%
0%
3%
4%
0%
0%
0%
0%
0%
0%
1
0
0
100%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
22
82%
5%
5%
9%
0%
Foetal Indications:
Foetal distress
16
81%
Breech with footling
12
92%
Cord prolapse
11
64%
Post term
0
0%
* Other includes both maternal and foetal indications
19%
0%
9%
0%
0%
0%
0%
0%
0%
8%
27%
0%
0%
0%
0%
0%
CPD/prolonged labour
Previous scar
Placenta praevia/APH
Eclampsia/Severe preeclampsia
Failed induction
PROM
Multiple gestation
Other*
Live
Early
Stillbirths
Live
Births Neonatal
Birth(s)
with
Deaths
&
distress
Perinatal
Death(s)
205
Table 8.4A: Percentage distribution of women whose deaths were reviewed according to
time of death, by primary cause of death
During
During
pregnancy abortion
%
Time of death
During
During
After
vaginal obstetric delivery
delivery surgery
%
%
%
Total
number
of
deaths1
%
Total
number
of
deaths
n
Cause of death
%
Total
Direct causes1
18%
14%
7%
7%
1%
2%
5%
6%
69%
72%
100%
100%
153
102
PPH
Ruptured Uterus
Pre-eclampsia/Eclampsia
APH
Prolonged/Obstructed
labour
Bleeding
Sepsis
Abortion related
complications
6%
50%
27%
20%
0%
0%
0%
0%
0%
0%
2%
0%
0%
20%
0%
8%
0%
0%
20%
100%
84%
50%
73%
40%
0%
100%
100%
100%
100%
100%
50
10
11
5
1
0%
6%
14%
0%
11%
71%
0%
0%
0%
0%
0%
0%
0%
83%
14%
0%
100%
100%
0
18
7
Indirect causes
26%
11%
0%
3%
61%
100%
38
Anaemia
Malaria
HIV
Others
20%
60%
17%
25%
27%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
8%
53%
40%
83%
67%
100%
100%
100%
100%
15
5
6
12
No cause listed
31%
0%
0%
0%
69%
100%
13
Total
18%
7%
1%
5%
69%
100%
153
206
Table 8.5A: Percent distribution of women whose deaths were reviewed according to
EmONC classification of facility where she died, referral status, day of week death
occurred and factors contributing to the death
Among all women whose deaths were reviewed
EmONC classification
%
(n=153)
Comprehensive EmONC
Basic EmONC
Partially functioning
Non - EmONC
72%
1%
23%
4%
Referral status
Referred in
Not referred
No information
45%
53%
2%
Among those referred
Referred from:
Health post/community health worker
Health centre
Hospital
Private hospital/private clinic
Other
No information
Day of the week of death woman died 1
Weekday
Weekend
No information
Factors contributing to death2
Delay in arrival to health facility (%)
Delayed transfer to appropriate level of care (%)
Delay due to lack of supplies (%)
Delay due to absence or slowness of human
resources (%)
Delay in correct diagnosis
Notes with details on cause of death
1
Seven cases did not report the time of the
women's death and are excluded.
2
Multiple answers allowed
(n=69)
9%
71%
12%
3%
4%
1%
62%
31%
8%
41%
34%
16%
25%
26%
207
Table 9.1A: Percent distribution of health providers interviewed and mean number of
deliveries, by health cadre (n=296)
Providers Interviewed
Health worker cadre
Obstetrician
Medical doctor (general physician)
Clinical Officer
Registered nurse
Registered nurse/Midwife
Enrolled nurse/ Nurse technician
Enrolled nurse/ Nurse technician/
Midwife
Medical Assistants
Total
n
%
Mean number
of deliveries
attended in
past month
2
0
2
1
31
3
239
<1
0
<1
<1
11
1
81
41.5
0.0
3.0
15.0
19.6
30.3
24.8
18
296
6
100
9.3
23.3
208
Table 9.2A: Percentage of providers with knowledge of focused antenatal care practices and which
pregnant women are at risk, by health worker cadre
Total
(n=296)
Knowledge of focused antenatal care
Average score (out of 6)
Percent providing specific response:
Detect existing illnesses and manage
complications
Prevent illness and promote health
Teach danger signs
Minimum of 4 consultations
Ensure woman has birth plan
Promote breastfeeding
Knowledge of which pregnant women are
at risk
Average score (out of 8)
Percent providing specific response:
Previous caesarean
History of severe obstetric complications
5 or more deliveries
Previous stillbirth
Previous instrumental delivery
Previous neonatal death
<2 or >5 years between deliveries
Registered
Enrolled
Medical
nurse/Midwife nurse
Assistant
midwife/
Nurse
midwife
technician
3.51
%
4.09
%
3.45
%
3.39
%
59.7
75.0
57.7
61.1
86.5
55.7
74.7
46.3
28.4
87.5
62.5
87.5
56.3
40.6
87.6
54.1
74.8
44.6
26.4
77.8
66.7
55.6
44.4
33.3
4.33
%
4.69
%
4.31
%
3.83
%
71
29
100.0
24.4
11.2
20.1
78
19
62.5
34.4
9.4
28.1
70
31
60.3
23.2
12.0
18.8
61
17
55.6
22.2
0.0
16.7
209
Table 9.3A: Percentage of providers who know when a woman is in labour, what to
monitor, where to record information, and steps of active management of the third stage
of labour (AMTSL), by health worker cadre
Total
(n=296)
Registered
Enrolled
nurse/Midwife nurse
midwife/
Nurse
midwife
technician
Medical
Assistant
2.99
%
3.19
%
3.00
%
2.56
%
97
74
100
81
97
75
94
50
What do you monitor when a woman is
in labour?
Average score (out of 9)
Percent providing specific response:
6.3
%
7.4
%
6.2
%
4.9
%
Foetal heartbeat
Dilatation of the cervix
Maternal blood pressure
Uterine contractions
Maternal pulse
Maternal temperature
Descent of the head
Colour of amniotic fluid
Degree of moulding
92.6
72.2
90.9
84.5
75.0
82.1
68.8
36.5
26.2
93.8
87.5
96.9
96.9
87.5
87.5
90.6
53.1
43.8
93.4
69.7
91.7
84.7
75.2
83.9
66.4
36.4
25.8
88.9
83.3
72.2
66.7
55.6
50.0
61.1
5.6
5.6
Where do you record this information?
Average score (out of 5)
Percent providing specific response:
1.32
%
1.52
%
1.29
%
1.39
%
98
21
23
0
100
41
26
0
98
20
23
0
100
6
22
6
What are the steps of AMTSL?
Average score (out of 4)
Percent providing specific response:
1.9
%
2.0
%
1.9
%
1.7
%
Immediate oxytocin (1 to 2 min)
Immediate ergometrine (1 to 2 min)
Controlled cord traction
89
4.8
93
97
3.1
97
89
5.1
93
72
5.6
89
How do you know when a pregnant
woman is in labour?
Average score (out of 4)
Percent providing specific response:
Dilation of the cervix
Regular uterine contractions
Discharge of blood and mucus
Breaking of the waters/ruptured
membranes
Partograph
Clinical record
Piece of paper
Prenatal card
Partograph and clinical record
210
Total
(n=296)
Uterine massage
44
Registered
Enrolled
nurse/Midwife nurse
midwife/
Nurse
midwife
technician
53
43
Medical
Assistant
39
211
Table 9.4A: Percentage of providers who know the signs of postpartum haemorrhage
(PPH), how to treat PPH and retained placenta, by health worker cadre
Total
(n=296)
Registered
Enrolled
nurse/Midwife nurse
midwife/
Nurse
midwife
technician
Medical
Assistant
What do you look for when a woman arrives
with or develops heavy bleeding after birth?
Average score (out of 6)
Percent providing specific response:
3.72
%
4.32
%
3.70
%
3.06
%
Signs of shock
Signs of anaemia
Retained products or retained placenta
Amount of external blood
Damage to the genital tract
Whether uterus is contracted
71.9%
42.2%
41.2%
55.3%
68.5%
53.6%
77.4%
34.4%
34.4%
68.8%
81.3%
71.9%
70.2%
41.7%
42.1%
54.4%
67.2%
54.4%
88.9%
61.1%
38.9%
44.4%
61.1%
11.1%
What do you do when a woman arrives with or
develops heavy bleeding after birth?
Average score (out of 7)
Percent providing specific response:
4.77
%
5.47
%
4.77
%
3.67
%
Begin IV fluids
Give ergometrine or oxytocin (IV or IM)
Refer
Manually remove retained products
Examine woman for lacerations
Massage the fundus
Take blood for Hb and cross-matching
92.9%
83.1%
92.9%
33.2%
67.9%
52.5%
25.6%
93.8%
90.6%
93.8%
40.6%
90.6%
56.3%
56.3%
92.6%
82.6%
92.6%
31.5%
66.9%
55.2%
21.8%
94.4%
72.2%
94.4%
38.9%
44.4%
16.7%
11.1%
What do you do when a woman has given birth
and retained the placenta?
Average score (out of 10)
Percent providing specific response:
3.99
%
4.94
%
3.97
%
2.89
%
Manually remove placenta
Administer IV fluids
Give or repeat oxytocin
Refer
Monitor vital signs for shock and act
Apply controlled cord traction
Check that uterus is well contracted
Empty the bladder
Determine blood type and cross-match
Prepare surgical theatre
71.9%
73.6%
58.5%
66.1%
21.5%
24.1%
21.6%
39.9%
13.9%
10.7%
87.5%
90.6%
68.8%
34.4%
34.4%
34.4%
25.0%
68.8%
25.0%
22.6%
71.4%
72.3%
58.8%
69.7%
21.3%
24.6%
21.9%
38.3%
12.0%
9.7%
50.0%
66.7%
38.9%
83.3%
5.6%
5.6%
5.6%
16.7%
16.7%
0.0%
212
Table 9.5A: Percentage of providers who recognize complications of abortion, how to
intervene, and what to do for victims of sexual violence, by health worker cadre
Total
(n=296)
Registered
nurse/Mid
wife
Enrolled
Medical
nurse
Assistant
midwife/
Nurse
midwife
technician
2.97
%
2.62
%
2.94
%
Bleeding
69%
72%
Sepsis
93%
97%
Shock
Genital injuries
38%
53%
Abdominal injuries
What do you do for a woman with an unsafe or incomplete abortion?
Average score (out of 9)
3.9
4.7
Percent providing specific response:
%
%
68%
92%
72%
89%
34%
56%
3.8
%
3.9
%
55.8%
74.3%
81.0%
39.0%
23.7%
36.5%
35.3%
18.3%
18.4%
61.1%
88.9%
100.0%
27.8%
27.8%
33.3%
27.8%
11.1%
16.7%
What are the complications of unsafe abortion?
Average score (out of 4)
Percent providing specific response:
Start IV fluids
Start antibiotics
Refer
Assess vital signs
MVA
Vaginal exam
Assess vaginal bleeding
Evacuation with sharp curettage
Counsel
2.68
%
57.3%
76.6%
77.4%
39.7%
27.5%
36.6%
36.6%
23.5%
21.2%
64.5%
84.4%
40.6%
50.0%
53.1%
34.4%
50.0%
62.5%
40.6%
What information do you give to women after unsafe or incomplete abortion?
Average score (out of 6)
2.77
3.19
2.72
Percent providing specific response:
%
%
%
Family planning counseling and services
Consequences of unsafe abortion
Prevention of RTI/HIV
Referral for contraception
Return to fertility
Social support
82.4%
60.8%
24.2%
67.6%
35.7%
7.2%
What do you do for the victim of sexual violence?
Average score (out of 8)
3.03
Percent providing specific response:
%
Request urine and blood samples
Provide post-exposure prophylaxis for HIV
Provide emergency contraception
Help her complete the police report
Counsel her to report to police
Counsel for pregnancy prevention
26.5%
50.9%
55.1%
19.3%
29.6%
14.1%
2.61
%
90.6%
62.5%
40.6%
65.6%
43.8%
15.6%
81.0%
59.9%
21.3%
68.6%
36.7%
5.9%
88.9%
61.1%
33.3%
61.1%
11.1%
5.6%
3.61
%
2.89
%
3.61
%
22.6%
58.1%
71.0%
19.4%
32.3%
22.6%
26.5%
48.3%
53.1%
18.1%
27.3%
13.0%
22.2%
61.1%
55.6%
38.9%
55.6%
11.1%
213
Total
(n=296)
Counsel for pre- and post-HIV testing
73.6%
Registered
nurse/Mid
wife
80.6%
Enrolled
Medical
nurse
Assistant
midwife/
Nurse
midwife
technician
72.4%
77.8%
214
Table 9.6A: Percentage of providers who know steps of immediate newborn care, signs of
newborn complications and the appropriate responses, by health worker cadre
Total
(n=296)
Enrolled
nurse
midwife
/ Nurse
midwife
technici
an
The last time you delivered a baby, what immediate care did you give the newborn?
Average score (out of 10)
4.30
4.88
4.25
Percent providing specific response:
%
%
%
Clean the mouth, face and nose
Ensure the baby is breathing
Ensure the baby is dry
Observe for colour
Care for the umbilical cord
Provide prophylaxis for eyes
Weigh the baby
Thermal protection (skin to skin)
Begin breastfeeding within first hour
Signs & symptoms of newborn infection
Average score (out of 7)
Percent providing specific response:
Hypothermia or hyperthermia
Poor or no breastfeeding
Difficulty or fast breathing
Restlessness or irritability
Little muscle movement
Deep jaundice
Severe abdominal distension
Care for the infected newborn
Average score (out of 5)
Percent providing specific response:
Begin antibiotics
Refer
Continue to give breast milk
Keep airways open
Explain the situation to the mother
Care for the low birth weight newborn
Average score (out of 5)
Percent providing specific response:
Provide extra support to mother to
establish breastfeeding
Ensure thermal protection (skin to skin)
Registered
nurse/Midwife
Medical
Assistant
4.06
%
42.4%
44.4%
83.1%
33.7%
70.6%
17.1%
56.3%
87.5%
70.6%
50.0%
53.1%
84.4%
37.5%
75.0%
40.6%
53.1%
93.8%
75.0%
43.2%
42.7%
83.4%
32.9%
71.5%
13.4%
56.8%
87.6%
71.5%
16.7%
55.6%
88.9%
38.9%
55.6%
11.1%
61.1%
77.8%
55.6%
3.26
%
3.59
%
3.21
%
3.33
%
92.9%
68.9%
36.6%
61.0%
21.4%
26.6%
21.1%
96.9%
87.5%
34.4%
68.8%
31.3%
21.9%
18.8%
92.6%
65.7%
35.7%
61.0%
19.5%
26.8%
22.1%
88.9%
72.2%
44.4%
50.0%
27.8%
33.3%
16.7%
2.13
%
2.47
%
2.10
%
2.06
%
93.9%
51.2%
47.1%
3.1%
18.9%
96.9%
25.0%
65.6%
15.6%
43.8%
94.2%
53.6%
46.1%
1.7%
15.6%
88.9%
61.1%
33.3%
0.0%
22.2%
2.53
%
3.00
%
2.49
%
2.44
%
62.5%
78.1%
60.7%
61.1%
89.2%
96.9%
87.6%
94.4%
215
Total
(n=296)
Monitor ability to breastfeed
Ensure infection prevention
Monitor baby for first 24 hours
60.0%
17.3%
24.8%
Registered
nurse/Midwife
68.8%
31.3%
25.0%
Enrolled
nurse
midwife
/ Nurse
midwife
technici
an
59.3%
16.2%
25.8%
Medical
Assistant
61.1%
11.1%
16.7%
216
Table 9.7A: Place of training, diagnosis and management of birth asphyxia, among
midwives and nurses with either training or experience with neonatal resuscitation
Total
Registered
Nurse
Midwives
Enrolled
Nurse
Midwife
Medical
Assistant
296
%
32
%
242
%
18
%
15.0
25.5
59.2
0.3
100.0
16
25
59
0
100
15.4
23.2
61.0
0.4
100.0
5.9
47.1
47.1
0.0
100.0
3.04
%
3.50
%
3.02
%
2.47
%
87.1
71.8
55.3
89.8
96.9
81.3
78.1
93.8
86.3
71.8
52.9
90.9
82.4
52.9
41.2
70.6
Preliminary steps of neonatal resuscitation
Average score (out of 6)
Percent providing specific responses:
3.85
%
5.00
%
3.77
%
2.69
%
Place NB face up
Wrap baby, except for face & upper chest
Position baby's head so neck is extended
Aspirate mouth & then nose
Stimulate by rubbing feet
Explain process to mother
52.4
61.7
72.3
82.2
7.3
11.7
64.5
81.2
84.3
90.6
18.8
28.1
52.1
62.0
72.1
81.6
5.1
8.5
23.5
23.5
43.7
76.4
11.8
11.7
Average score (out of 5)
Percent providing specific responses:
3.04
%
3.81
%
2.96
%
2.59
%
Cover baby's chin, mouth & nose with mask
Ensure seal
Ventilate 1 or 2 times
Ventilate 40 times per min
Pause to determine whether breathing is
spontaneous
82.5
58.1
63.1
37.1
64.5
93.7
71.8
81.2
62.5
71.8
80.4
57.1
61.6
34.8
63.3
88.2
41.1
52.9
11.7
64.7
1.8
%
2.3
%
1.8
%
1.82
%
71.9
90.6
68.6
76.4
Number of providers
Where training in newborn resuscitation took
place
In-Service
Pre-service
Both
Other
Total
How to diagnose birth asphyxia
Average score (out of 4)
Percent providing specific responses:
Depressed breathing
Floppiness
Heart rate < 100 BPM
Central cyanosis
If resuscitating with bag & mask, what do you do?
If baby is breathing and no respiratory difficulty,
what do you do?
Average score (out of 3)
Percent providing specific responses:
Keep baby warm
217
Total
Immediate breastfeeding
Continue monitoring baby
If baby does not begin to breathe, or if breathing
is < 30 per minute, what do you do?
Average score (out of 5)
Percent providing specific responses:
Continue to ventilate
Administer O2
Assess need for special care
Explain to mother what is happening
66.7
46.2
Registered Enrolled
Nurse
Nurse
Midwives Midwife
81.3
64.7
53.1
46.4
Medical
Assistant
76.5
29.4
1.43
%
2.09
%
1.34
%
1.29
%
56.2
17.3
19.4
6.6
78.1
18.8
34.4
9.4
53.6
16.5
17.8
5.5
47.1
17.6
11.8
17.6
218