UNC to improve safe motherhood effort in Malawi

With an $8-million grant from the Bill and Melinda Gates Foundation, UNC Project-Malawi will reduce maternal and neonatal morbidity and mortality in Malawi by strengthening President Joyce Banda’s Maternal Health and Safe Motherhood Initiative. The effort builds on UNC’s more than two-decade commitment to research, training, and care in the nation.

by Zach Read - zread@unch.unc.edu

As part of the Gates Foundation grant, UNC, in collaboration with Malawian health care workers, will seek to improve safe motherhood in several ways. Due to the shortage of trained clinicians and the small number of facilities capable of treating high-risk pregnancies, UNC will construct two maternity waiting homes that will serve as models for the development of similar homes across Malawi. These homes will place high-risk women closer to medical facilities in the months before delivery.

“The problem with maternal mortality is generally that the woman doesn’t have access to proper emergency obstetric care, is unable to reach the facility in time, or once she reaches the facility, there is limited capacity to deal with the problem,” said UNC Project-Malawi doctor Jeff Wilkinson, MD, associate professor of gynecology at UNC and leader of the project. “So the idea of a maternity waiting home is that a woman who lives remote from a health care facility or is deemed to be high-risk in pregnancy will come to the home early and either await onset of labor or in some cases be scheduled for an elective Cesarean delivery, if needed.”

Wilkinson’s work in emergency obstetrics has saved hundreds of women from the devastating impacts that can result from childbirth complications, including obstetric fistula and death. UNC OB-GYN faculty member John Thorp, who two years ago helped establish the department’s presence in UNC Project-Malawi, believes that, if done properly, maternity waiting homes can play an important role in the improvement of safe motherhood in Malawi.

“If a woman is in a very rural area of Wautaga County (N.C.), she can look out her window on a beautiful day and see for 15 miles, uninterrupted by civilization,” said Thorp. “But at the same time, if she identifies the need, she can drive eight miles into Boone and get a Cesarean-section within an hour. That infrastructure does not exist in Malawi.”

Not all maternity waiting homes successfully help women with high-risk pregnancies. Some do not provide adequate food or space for women who arrive months before delivery—they simply exchange the problems found in rural villages for a new set of problems in the maternity homes. UNC will ensure that the homes contain proper access to medical care and do not present new health issues for patients. UNC also plans to provide education within the maternity waiting homes by making educators available so that the women benefit from the time they spend at the facility before delivery. Post-delivery education may be offered as well.

“One of the somewhat novel things we’re going to try is to see if the women can return after delivery to get more education on family planning, care of the newborn baby, and general postpartum care,” said Wilkinson. “And so some of the limitations—or the perceived limitations—of maternity waiting homes in the past will hopefully be addressed by having education at the homes; a safe, clean place with food; and the ability to come to the home after delivery to get more education and be prepared to go home with a newborn.”

These maternity waiting homes will serve as a model for development of the facilities throughout the country. President Joyce Banda has set the goal of constructing 130 such facilities nationwide. But UNC’s work as part of the grant will not be complete with the building of maternity waiting homes. UNC has set additional goals of funding the training of 300 community midwives, training all levels of maternity health care providers, and enhancing its recently initiated OB-GYN resident training program. As of today, the lone medical school in Malawi does not offer OB-GYN training, and only 8 or 9 trained Malawian OB-GYNs live in the country.

“Within five years or so we hope to have another 30 or more OB-GYNs trained and ready to assume posts with the government and with district hospitals throughout Malawi,” said Wilkinson.

Thorp thinks that Malawians trained as OB-GYNs will be more likely to live and work in Malawi if they receive training in the country.

“Because no one can get trained to do OB-GYN work in the country, they go abroad, and once they’ve been abroad, they’re less likely to return,” said Thorp. “Once you live in Charlotte, you probably won’t move back to Rocky Mount. Once you’ve been trained in South Africa or London, you tend not to go back. I think that’s partly because of the poverty, but I think it’s also because people are in a developmental stage in their life—they get married and start a family, they put down roots. My hope is that by having the residency in the country and by giving those people a chance to get trained, we can start a pipeline that will deliver clinicians who will stay in country and who will provide leadership.”

Another key to the expanded UNC effort in Malawi is to engage traditional chiefs and local communities more effectively and improve education about issues concerning maternal health.

“The challenges of working in Malawi run the gamut,” acknowledged Wilkinson. “There are challenges of language and of culture, which is why it’s so important to engage Malawians in the effort. So our team is largely made up of Malawian staff who are able to communicate effectively and have experience in community engagement.”

The relationship between UNC Project-Malawi and local Malawians is strong, and Wilkinson is optimistic that Malawians today are more prepared than ever for the sort of change in maternal and newborn health care and education that the project promises.

“There’s a very high degree of openness on the part of community leaders to consider these topics, which in the past may not have been the case, because they’re sensitive topics that traditionally had some taboo associated with them,” said Wilkinson. “But it seems as if that dynamic is changing, and most community leaders are very willing to be a part of this effort and are interested in seeing their communities—and women in their communities—live healthier lives.”

UNC hopes that, taken together, the integration of maternity waiting homes, the training of maternal health-care providers at all levels, and the engagement of local communities and traditional chiefs will serve as a model for improving safe motherhood not only in local communities in Malawi but also throughout the region and perhaps the world.

According to John Thorp, such an effort would not be possible if not for the doctors who have been willing to live full-time in Malawi to produce on-the-ground change.

“UNC is so fortunate to have people like Jeff Wilkinson, Mina Hosseinipour, Jeff Stringer, and Jennifer Tang—doctors willing to live there,” said Thorp. “I think we’re at the very beginning of a real improvement in women’s health, and something that will advance health in that country along the lines that the antiretrovirals and the understanding of HIV have done. I don’t mean that arrogantly, but I think we’re poised at UNC to lead that effort.”

Irving Hoffman, PA, MPH, at the UNC Institute for Global Health & Infectious Diseases, helped establish UNC’s presence in Malawi some 20 years ago. He has witnessed the program’s growth from its early focus on the relationship between STIs and HIV prevention; more recently to TB, malaria, and other traditional sexually transmitted diseases; and ultimately to the surgery and OB-GYN work that is now part of the effort.

“In the last 10 years, investigators interested in global health and surgery and in OB-GYN and pediatrics have joined our faculty on the ground, and in Obstetrics & Gynecology that’s been especially gratifying because they’ve ‘talked with their feet,’” said Hoffman. “That’s often what it takes to be able to put yourself in a position to get grants like this.”

John Thorp also gives credit to the support given by the UNC administration, reaching all the way to former chancellor Holden Thorp, who visited Malawi two years ago. He believes that the Gates Foundation saw the commitment from UNC doctors and administrators as improving the chances of success on the ground; the Gates Foundation, John Thorp believes, understood that UNC would stand by Malawi.

In the days before his departure for Washington University in St. Louis, Chancellor Thorp expressed his reverence for the work being done in Malawi and its importance to UNC.

“It’s hard to think of a project that encompasses as many of the things we care about as the Project-Malawi,” said the former chancellor. “The science that is done there is remarkable and has influenced health care in lots of different ways, the care that we provide to the people there is transformational for them, and our students and faculty who get to go there have experiences that change their worldview and make them more interested and engaged in the problems facing the world.”