Influences of health facility type for delivery and experience of cesarean section on maternal and newborn postnatal care between birth and facility discharge in Malawi.

BACKGROUND: A number of studies in the past have looked at determinants of postnatal care. However, many of them do not distinguish between postnatal care (PNC) before discharge and after discharge for women delivering at health facilities. Conceptually and practically, factors associated with PNC before discharge and after discharge should be different. This study examines key factors for maternal and newborn PNC before discharge. METHODS: Data from the 2015-16 Malawi Demographic and Health Survey were used for the study. Three categorical endogenous variables examined in the study were whether or not mothers received a postnatal check between birth and facility discharge, whether or not newborns received a postnatal check between birth and facility discharge and whether or not women delivered by cesarean section. Delivery by cesarean section was considered as a mediator in the model. The main predictor of interest was type of health facility where women delivered. Other exogenous variables included were women's age at most recent birth, number of antenatal visits, women's education, household wealth, parity, newborn size, region of the country and residence. Simultaneous equation modeling was used to examine the associations of interest. RESULTS: 47% of the mothers and 68% of the newborns had PNC before facility discharge. The total and direct effects of delivering in private hospitals on maternal and newborn PNC before facility discharge were significantly higher than the effects of delivering in government hospitals. The total effects of delivering in government health centers or health posts on maternal and newborn PNC before facility discharge were significantly lower than the effects of delivering in government hospitals. Delivering by cesarean section compared to delivering vaginally was positively associated with maternal and newborn PNC before facility discharge. CONCLUSION: It is important that all women and newborns receive PNC before they are discharged from the facility regardless of whether or not they had a complication. The same standard of quality PNC should be provided equitably across all types and affiliations of health facilities.

A Comparison of Breastfeeding Exclusivity and Duration Rates Between Immediate Postpartum Levonorgestrel Versus Etonogestrel Implant Users: A Prospective Cohort Study.

OBJECTIVE: This study compares breastfeeding outcomes after immediate postpartum initiation of single-rod etonogestrel (ENG) versus two-rod levonorgestrel (LNG) contraceptive implants. Outcomes assessed include the following: (1) breastfeeding continuation through 24 months after delivery and (2) exclusive breastfeeding until 6 months after delivery, at Kasungu District Hospital, Malawi. METHODS: We used Kaplan-Meier survival analysis to compare breastfeeding continuation through 24 months and exclusive breastfeeding through 6 months after delivery for ENG versus LNG implant users. We described infant feeding practices up to 6 months after delivery. RESULTS: We analyzed 140 women: 28 (20%) ENG and 112 (80%) LNG impalnt users. Eighty-seven percent (n = 122) of women completed the 24-month study visit. Twenty-four months breastfeeding continuation proportions were 54.2% (95% confidence interval [CI] = 32.7-71.4) and 74.7% (95% CI = 64.9-82.2) for ENG and LNG implant users, respectively (p = 0.10). Breastfeeding continuation was high in both groups at 21 months: 100% and 93.2% (95% CI = 86.2-96.7) for ENG and LNG implant users, respectively (p = 0.18). Seventy-one percent (20/28, 95% CI = 51.0-84.6) of ENG and 72% (78/108, 95% CI = 62.4-79.7) of LNG implant users exclusively breastfed their infants until 6 months postpartum (p = 0.89). CONCLUSIONS: Continuation of breastfeeding until 24 months and exclusive breastfeeding until 6 months were high among users of both types of progestin implant initiated immediately postpartum and similar to proportions among the general population of postpartum women in the Central region of Malawi.

Evaluation of a maternity waiting home and community education program in two districts of Malawi.

BACKGROUND: The implementation of Maternity Waiting Homes (MWHs) is a strategy to bring vulnerable women close to a health facility towards the end of their pregnancies. To date, while MWHs are a popular strategy, there is limited evidence on the role that MWHs play in reaching women most in need. This paper contributes to this topic by examining whether two program-supported MWHs in Malawi are reaching women in need and if there are changes in women reached over time. METHODS: Two rounds of exit interviews (2015 and 2017) were conducted with women within 3 months of delivery and included both MWH users and non-MWH users. These exit interviews included questions on sociodemographic factors, obstetric risk factors and use of health services. Bivariate statistics were used to compare MWH users and non-MWH users at baseline and endline and over time. Multivariable logistic regression was used to determine what factors were associated with MWH use, and Poisson regression was used to study factors associated with HIV knowledge. Descriptive data from discharge surveys were used to examine satisfaction with the MWH structure and environment over time. RESULTS: Primiparous women were more likely to use a MWH compared to women of parity 2 (p < 0.05). Women who were told they were at risk of a complication were more likely to use a MWH compared to those who were not told they were at risk (p < 0.05). There were also significant findings for wealth and time to a facility, with poorer women and those who lived further from a facility being more likely to use a MWH. Attendance at a community event was associated with greater knowledge of HIV (p < 0.05). CONCLUSIONS: MWHs have a role to play in efforts to improve maternal health and reduce maternal mortality. Education provided within the MWHs and through community outreach can improve knowledge of important health topics. Malawi and other low and middle income countries must ensure that health facilities affiliated with the MWHs offer high quality services.

Task shifting levonorgestrel implant insertion to community midwife assistants in Malawi: results from a non-inferiority evaluation.

BACKGROUND: In 2013, Malawi began task shifting long acting reversible contraception (LARC) insertion from Nurse Midwife Technicians (NMTs), who undergo 3 years of training, to Community Midwife Assistants (CMAs), who undergo 18 months of training. However, there is no evidence on whether CMAs have the same competency as NMTs for LARC insertion. Therefore, we describe a non-inferiority evaluation to determine whether CMAs are non-inferior to NMTs for the insertion of levonorgestrel (LNG) contraceptive implants in Malawi. METHODS: One CMA and one matched NMT from 31 health centers across Malawi were selected for training in Malawi's 1-week LARC insertion course in October 2016, and 31 CMAs and 30 NMTs completed the training. After the course, two Family Planning Master Trainers visited the nurses' health centers over a 5-month period and used the Malawi LNG implant insertion checklist to evaluate the first five LNG implant insertions that each nurse performed during the monitoring visit. A non- inferiority margin of 10% was used to compare mean implant scores between CMAs and NMTs. RESULTS: We were able to fully evaluate 29 CMAs and 29 NMTs with the LNG implant insertion checklist. The CMAs and NMTs had mean scores of 90.2% and 89.7%, respectively, which were non-inferior (mean difference - 0.5%; 95% CI -3.4%, 2.4%), even when adjusted for the number of years post-graduation and the number of LNG implants inserted pre-training, during training, and since training (mean difference 1.3%; 95% CI -2.2%, 4.8%). CONCLUSIONS: CMAs were non-inferior to NMTs with LNG implant insertion, and both cadres were generally observed to be competent with their insertions after completing their follow-up evaluations. During the evaluations, we generally saw an increase in scores with each insertion. Therefore, for both cadres, it is important to establish continued mentorship and evaluation for LARC insertion after the initial training.

Two-year contraceptive continuation rates among immediate postpartum implant users at a district hospital in Malawi: a prospective cohort study.

OBJECTIVE: To compare 2-year continuation rates in Malawian women undergoing immediate postpartum insertion of the levonorgestrel implant or etonorgestrel implant. STUDY DESIGN: We followed 159 women who underwent immediate postpartum levonorgestrel implant or etonorgestrel implant insertion at Kasungu District Hospital for up to 2 years. RESULTS: We analyzed continuation data on 145 (92.4%) implant users. The 2-year continuation rates were 93.4 (95% CI 86.5-96.8) for levonorgestrel implant and 96.3 (95% CI: 76.5-99.5) for etonorgestrel implant (p=.268). CONCLUSIONS: Immediate postpartum implant insertion of both the levonorgestrel and etonorgestrel implant had high continuation rates at 2 years in Malawian women. IMPLICATIONS: Immediate postpartum implant insertion of both the levonorgestrel and etonorgestrel implant had continuation rates of over 90% at 2 years among our population of Malawian women. Both implants should be offered routinely to eligible and interested women prior to hospital discharge after delivery.

Effect of family planning interventions on couple years of protection in Malawi.

OBJECTIVE: The primary objective was to assess the effect of family planning interventions at two health facilities in Malawi on couple years of protection (CYP). METHODS: A prospective quasi-experimental design was used to compare CYP and uptake of long-acting reversible contraception (LARC) between two intervention facilities (Area 25 Health Center and Kasungu District Hospital) and two nonintervention facilities (Mkanda Health Center and Dowa District Hospital). The interventions included community mobilization and demand generation for family planning, and training and mentoring of providers in LARC insertion. Monthly data were collected from 1 year prior to intervention implementation until 2 years thereafter. RESULTS: From the pre-intervention year to the second post-intervention year, CYP increased by 175.1% at Area 25, whereas it decreased by 33.8% at Mkanda. At Kasungu and Dowa, CYP increased by 90.7% and 64.4%, respectively. Uptake of LARC increased by 12.2% at Area 25 r, 6.2% at Kasungu, and 2.9% at Dowa, but decreased by 3.8% at Mkanda. CONCLUSIONS: The interventions led to an increase in CYP and LARC uptake. Future family planning programs should sensitize communities about family planning and train providers to provide all contraceptives so that women can make informed decisions and use the contraceptive of their choice.

Contraceptive uptake after training community health workers in couples counseling: A cluster randomized trial.

BACKGROUND: Young women in Malawi face many challenges in accessing family planning (FP), including distance to the health facility and partner disapproval. Our primary objective was to assess if training HSAs in couples counseling would increase modern FP uptake among young women. METHODS: In this cluster randomized controlled trial, 30 HSAs from Lilongwe, Malawi received training in FP. The HSAs were then randomized 1:1 to receive or not receive additional training in couples counseling. All HSAs were asked to provide FP counseling to women in their communities and record their contraceptive uptake over 6 months. Sexually-active women <30 years of age who had never used a modern FP method were included in this analysis. Generalized estimating equations with an exchangeable correlation matrix to account for clustering by HSA were used to estimate risk differences (RDs) and 95% confidence intervals (CIs). RESULTS: 430 (53%) young women were counseled by the 15 HSAs who received couples counseling training, and 378 (47%) were counseled by the 15 HSAs who did not. 115 (26%) from the couples counseling group had male partners present during their first visit, compared to only 6 (2%) from the other group (RD: 0.21, 95% CI: 0.09 to 0.33, p<0.01). Nearly all (99.5%) initiated a modern FP method, with no difference between groups (p = 0.09). Women in the couples counseling group were 8% more likely to receive male condoms (RD: 0.08, 95% CI: -7% to 23%, p = 0.28) and 8% more likely to receive dual methods (RD: 0.08, 95% CI: -0.065, 0.232, p = 0.274). CONCLUSION: Training HSAs in FP led to high modern FP uptake among young women who had never used FP. Couples counseling training increased male involvement with a trend towards higher male condom uptake.

Reaching vulnerable women through maternity waiting homes in Malawi.

OBJECTIVE: To determine whether two maternity waiting homes (MWHs) supported by the Safe Motherhood Initiative are reaching vulnerable women during the early phase of their implementation. METHODS: A cross-sectional interview-based study was conducted among women who attended two centers in Malawi with attached MWHs (Area 25 Health Centre, Lilongwe; and Kasungu District Hospital, Kasungu). Between April and June 2015, exit interviews were conducted among MWH users and non-users. RESULTS: Compared with non-users, MWH users at Area 25 were significantly more likely to report a prior spontaneous abortion (10/46 [21.7%] vs 5/95 [5.3%]; P=0.006) and to be in the lowest wealth quintile (4/87 [4.6%] vs 0/150; P=0.029). Although not significant, a greater percentage of MWH users at Kasungu District Hospital than non-users had a prior stillbirth (6/84 [7.1%] vs 0/77) or spontaneous abortion (3/84 [3.6%] vs 2/77 [2.6%]), and were in the lowest wealth quintile (15/175 [8.6%] vs 5/141 [3.5%]). MWH users at Kasungu lived further from the hospital than did non-MWH users, although the difference was not significant (mean 6.81±9.1 km vs 4.05±7.42 km; P=0.067). CONCLUSION: MWHs offer a promising strategy to reduce maternal mortality in Malawi and other low-income countries.