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Introduction

Improvements in preventive and care-seeking behaviours to reduce maternal mortality in Malawi depend on the knowledge and attitudes of women and communities. Surveys have indicated a poor awareness of maternal health problems by individual women. Various barriers are identified to seeking care:
cultural beliefs about pregnancy and childbirth lack of knowledge about the complications of pregnancy and childbirth
gender-related imbalances in decision-making that add to the vulnerability of women
bad experiences with health care facilities, especially staff attitude.

Activities

Various activities will be implemented to improve awareness in the community concerning maternal health and empower women to access health care.

Activity 1.1 A baseline survey will be conducted

A baseline survey will be done at the start of the project using quantitative methods to get an understanding of maternal mortality and uptake of maternal health services and participative methods to understand community's perception of maternal health problems and required interventions.

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Activity 1.2 A selection of village health committee members will visit the Mangochi Safe Motherhood Project to learn about community responses to improve maternal health
                
The health area is divided in group village headman area's. A each group village headman area has approximately 5000 individuals. A village health committee with representation of the traditional authority (group village headman) is responsible for health in the population. Each group village headman area has two or three health surveillance assistants (HSA). The job description of the HSA includes disease surveillance, health promotion, antenatal and <5 care.

Village health committees have developed effective ways of dealing with maternal mortality. In the Mangochi Safe Motherhood Project (College of Medicine/Mangochi DHO) several committees succesfully impose a punishment on households where an unsafe delivery takes place.  Examples of punishment are a chicken or maize and stroke with practice of traditional governance. Village health committee action has further resulted in an improved design for bicycle ambulances and continued government support for the TBAs.

We will use the village health committee as entry point in the community for activity 1.2, 1.3, 1.4, 1.5, 2.3. The Health Surveillance Assistant will be the link between the program and the community.

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Activity 1.3 Establish thirty women's groups on a group village headman level

Women's groups  increase awareness of maternal health problems and the concern and motivation to address them (Mai Mwana Project, Mchinji district, Malawi, published M. Rosato, Lancet 2006 ). The groups draw on collective capacity to solve problems and can make women's voices heard by decision-makers. The women's group can be used as an entry point to address other reproductive health concerns: exclusive breastfeeding, prevention of mother-to-child transmission, family planning.

We plan to organise women's peer groups in each group village headman area. A training will be organised for peer group leaders. The training will be attended by 2 women and 1 female HSA for each group village headman area.  

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Activity 1.4 Every year an awareness campaign will be held in all thirty group village headman area's

Drama and song are popular ways of expression and are an accepted way to address issues that in direct communication may be sensitive. People often meet at the end of the day in a drama group or choir and competitions are a popular way of entertainment.

We plan to mobilise communities to discuss cultural beliefs and gender imbalances through annual awareness campaigns in each group village headman area. Drama and song will be used as well as health talks. The campaigns will be organised by Health Surveillance Assistants.

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Activity 1.5 A maternal mortality surveillance will be established

The actual event of a maternal death is an important moment to engage with the community. Secondly, decrease in maternal mortality is the key outcome of the Nathenje Safe Motherhood program. Unfortunately many maternal deaths in the community go unnoticed. Health surveillance assistants are supposed to keep a village register with vital events (birth and death) in their community. The quality of the data in these registers is generally poor through lack of supervision.

Key informant surveillance seems to be an effective and affordable solution to monitoring maternal mortality (Barnett S, 2008). Key informants in the community (often TBA's) identify maternal deaths in the communities. Identification is rewarded with a small incentive. In case of a maternal death a community nurse will visit the household where the death occurred and conduct a verbal autopsy to establish the cause of death.

All HSAs will be trained in keeping a village register and maternal mortality surveillance. A monitoring and evaluation officer (see activity 6.2) will employed to design the data collection procedure, set up an electronic database, data entry, data quality and analysis.

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Activity 1.6 Community based maternal death audits will be conducted after each maternal death

Currently maternal deaths in health facilities are followed up in the community by a clinician or a nurse. The cause of death is discussed during a meeting of the nursing and clinical staff in the hospital and during a three monthly meeting at the DHO.

In this project we will also do audits on maternal deaths that occur in the community. The audits will be presented by a community health nurse during a village meeting for discussion to create awareness on the cause of death and to give a cues for community action.

Back: Nkhoma Safe Motherhood Program - Overview