Delivery Care at Mangochi District Hospital, Malawi

Introduction: Maternal mortality is a significant disease burden in many countries. Despite global progress, it in unevenly spread with sub-Saharan Africa particularly lagging behind. The Sustainable Development Goal 3.1 aims for maternal mortality ratio (MMR) reduction to less than 70 maternal deaths per 100,00 live births, and all deliveries to be assisted by skilled birth attendants (SBA). The aim of this study was to identify key challenges in labour and delivery care in a low-income sub-Saharan setting.
\nMethods: The study was conducted in Mangochi District, Malawi. It included participant observation to better understand the setting of delivery care in the district, in particular at the new maternity wing at the Mangochi District Hospital (MDH) which was inaugurated in January 2019. The Health Management Information System (HMIS) in Malawi provided district level maternity care data for the years 2015-2019. Two additional datasets were created based on registration books in the labour ward and its surgical theatre at MDH. These include all delivery services at MDH from 19 February to 17 March 2020. Interviews were conducted with eight staff members at the maternity wing. The data were analysed in RStudio and the Mangochi Health Research Committee granted the study a permission.
\nResults: From 2015 to 2019, on average about two out of three deliveries in Mangochi District took place in health facilities; the Caesarean-section (C-section) rate was 4%. A quarter of the district’s institutional deliveries and nearly two thirds of the district’s C-sections took place at MDH. Institutional MMR in the district decreased from 162 to 64 per 100,000 live births in the period. MDH registers annually on average 34 maternal deaths. During the data collection period in 2020, 797 women received delivery care at MDH; 27 of the women had delivered before admission out of whom just less than one third delivered by SBA. All women who delivered at MDH were assisted during the delivery with SBA. Out of all admissions, 18% had obstetric complications and 6% received emergency obstetric care; about one in five of deliveries at MDH were C-sections. Nine out of 10 operations at the maternity wing were C-sections and 97% of the operations were emergencies. Overall, the staff were happy with the new facility, staffing had improved, and patients were better accommodated. However, having only one surgical theatre caused delays for C-sections. Further, lack of equipment was reported as well as deficient maintenance, especially for anaesthesia. Supply of drugs and single use items was also often reported as insufficient and unaccountable. Although teamwork was good and staffing had improved, there was still shortage of anaesthetists, Clinical Officers, and nurses.
\nConclusion: To decrease maternal mortality rate still further in Mangochi District, SBA needs to be improved with better and timely access to C-sections. While the new maternity wing at MDH was a quality improvement in delivery services, the option for a second theatre should be considered, coupled with improved maintenance, better staffing and stable supply of equipment and drugs to further decrease maternal mortality ratio in Mangochi District. These results may have implications for other similar settings.

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