Piloting a psychosocial intervention for perinatal depression, the Thinking Healthy Programme-Peer delivered (THPP), in a primary care setting in Lilongwe District, Malawi.

Despite the evidence for the effectiveness of psychosocial interventions for perinatal depression, their uptake is low in Low- and Middle-Income Countries. Reasons for this include the lack of contextually adapted interventions and mental health specialists to deliver them. This study aimed to test the acceptability and feasibility of a psychosocial intervention for perinatal depression, the Thinking Healthy Programme-Peer Delivered, adapted for use in rural Malawi. A multi-method evaluation of feasibility and acceptability of the intervention was conducted using a one-group pretest-posttest quasi-experimental design and an exploratory qualitative study. Pre-post intervention change in depression scores (paired t-test) and recruitment, retention and session adherence rates were calculated. Qualitative data were collected through 29 in-depth interviews (22 mothers and 7 peer volunteers) and 1 Focus Group Discussion (18 mothers). Thematic analysis approach was used to analyse qualitative data. Seven (7) out of 8 peer volunteers were successfully trained to deliver the intervention. A total of 31 pregnant women with Edinburgh Postnatal Depression Scale (EPDS) score ≥12 were offered intervention, of whom 24 were enrolled (recruitment rate 77.4%). Out of these 24 women, 22 completed the intervention (retention rate 91.6%). Mean difference between pre- and post-test EPDS scores one week after 8th session was 7.59 (95% CI 4.98 to 10.19), p<0.001. Qualitative evaluation showed that the intervention was acceptable despite some challenges including stigma and issues around incentivization of peer volunteers. The Thinking Healthy Programme-Peer Delivered, adapted for use in Malawi, was feasible to deliver and acceptable to its target population. The intervention may be useful in management of perinatal depression in primary care settings in Malawi. However, definitive trials are needed to evaluate its effectiveness.

Clinical Competency During Undergraduate Midwifery Training in Malawi: A Concept Analysis.

Background: The purpose of midwifery education is to produce clinically competent midwives. However, clinical training in Malawi faces multiple challenges, and the concept of Clinical Competency (CC) has not been analysed in this context. This article analyses CC during undergraduate midwifery training in Malawi to elucidate its attributes, antecedents, consequences, and empirical referents. Methods: A literature search was performed on data bases, Google Scholar, PubMed, and CINAHL, using the following terms: clinical competency, midwifery competency, nursing competency, nursing and midwifery competency. Published articles were retrieved and clinical competency analysis was guided by Walker and Avant's strategy. Results: CC attributes were knowledge, skills, attitudes, performance level, professionalism, and entrustable professional activity. Antecedents included motivation, role models, learning environment and personal traits. The consequences of CC include confidence, client safety, and quality of care. CC can be measured through a combination of four strategies: observing a student practising it in clinical area, simulation or Objective Structured Clinical Examination (OSCE), application through written essays or case presentations, and knowledge-based assessment. Conclusion: CC is a multidimensional concept and its definition and defining attributes are contextual. Similarly, clinical competencies are a major determinant of educational decisions such as curriculum nucleus, length of clinical placement, teaching strategies, and student assessment methods. However, CC and its attributes have not been fully utilised in Malawi, especially in clinical teaching and student clinical assessments. There is a need to adequately prepare midwifery educators, clinical staff, and students to deliver quality clinical competencies consistent with competency-based education. Adoption of different assessment strategies and development of valid and reliable tools is necessary to comprehensively measure CC among midwifery students in Malawi.

Adapting group care to the postpartum period using a human-centered design approach in Malawi.

BACKGROUND: Responsive and resilient strategies to reduce high rates of maternal and infant mortality and clinician shortages are needed in low- and middle-income countries (LMICs). Malawi has some of the highest maternal and infant mortality rates globally. Group healthcare is a service delivery model that integrates these strategies. Although primarily implemented during the prenatal period, its potential for improving both maternal and infant health outcomes during the postpartum period has not been realized. The purpose of this study was to adapt and co-design the prototype for an evidence-based group care model for the postpartum period using a human-centered design approach with key stakeholders in Malawi. METHODS: We completed steps of a framework guiding the use of human-centered design: 1) define the problem and assemble a team; 2) gather information through evidence and inspiration; 3) synthesize; and 4) intervention design: guiding principles and ideation. Qualitative methods were used to complete steps 2-4. In-depth interviews (n = 24), and incubator sessions (n = 6) that employed free listing, pile sorting and ranking were completed with key stakeholders. Data analysis consisted of content analysis of interviews and framework analysis for incubator sessions to produce the integrated group postpartum and well-child care model prototype. The fifth step is detailed in a separate paper. RESULTS: All stakeholders reported a desire to participate in and offer group care in the postpartum period. Stakeholders worked collaboratively to co-create the prototype that included a curriculum of health promotion topics and interactive activities and the service delivery structure. Health promotion topic priorities were hygiene, breastfeeding, family planning, nutrition, and mental health. The recommended schedule included 6 sessions corresponding with the child vaccination schedule over the 12-month postpartum period. CONCLUSIONS: Using a human-centered design approach to adapt an evidence-based group care model in an LMIC, specifically Malawi, is feasible and acceptable to key stakeholders and resulted in a prototype curriculum and practical strategies for clinic implementation.

The H-HOPE behavioral intervention plus Kangaroo Mother Care increases mother-preterm infant responsivity in Malawi: a prospective cohort comparison.

BACKGROUND: Early behavioral intervention to promote development is recommended as the standard of care for preterm infants, yet is not provided in Malawi. One such intervention is H-HOPE (Hospital to Home: Optimizing the Premature Infant's Environment). In US studies, H-HOPE increased mother-preterm infant responsivity at 6-weeks corrected age (CA). Kangaroo Mother Care (KMC) improves infant survival and is the standard of care for preterm infants in Malawi. This is the first study to examine whether H-HOPE is feasible and promotes mother-preterm infant responsivity in Malawi, and the first to examine the impact of H-HOPE when KMC is the standard of care. METHOD: This pilot was conducted in a KMC unit using a prospective cohort comparison design. Because the unit is an open room without privacy, random assignment would have led to contamination of the control cohort. H-HOPE includes participatory guidance for mothers and Massage + , a 15 min multisensory session provided by mothers twice daily. H-HOPE began when infants were clinically stable and at least 32 weeks postmenstrual age. Mothers participated if they were physically stable and willing to return for follow-up. Mother-preterm infant dyads were video-recorded during a play session at 6-weeks CA. Responsivity was measured using the Dyadic Mutuality Code (DMC). RESULTS: The final sample included 60 H-HOPE + KMC and 59 KMC only mother-preterm infant dyads. Controlling for significant maternal and infant characteristics, the H-HOPE + KMC dyads were over 11 times more likely to have higher responsivity than those in the KMC only dyads (AOR = 11.51, CI = 4.56, 29.04). The only other factor related to higher responsivity was vaginal vs. Caesarian delivery (AOR = 5.44, CI = .096, 30.96). CONCLUSION: This study demonstrated that H-HOPE can be provided in Malawi. Mother-infant dyads receiving both H-HOPE and KMC had higher responsivity at 6-weeks CA than those receiving KMC only. H-HOPE was taught by nurses in this study, however the nursing shortage in Malawi makes H-HOPE delivery by nurses challenging. Training patient attendants in the KMC unit is a cost-effective alternative. H-HOPE as the standard of care offers benefits to preterm infants and mothers that KMC alone does not provide.

Improving breastfeeding support through the implementation of the Baby-Friendly Hospital and Community Initiatives: a scoping review.

BACKGROUND: Improved breastfeeding practices have the potential to save the lives of over 823,000 children under 5 years old globally every year. The Baby-Friendly Hospital Initiative (BFHI) is a global campaign by the World Health Organization and the United Nations Children's Fund, which promotes best practice to support breastfeeding in maternity services. The Baby-Friendly Community Initiative (BFCI) grew out of step 10, with a focus on community-based implementation. The aim of this scoping review is to map and examine the evidence relating to the implementation of BFHI and BFCI globally. METHODS: This scoping review was conducted according to the Joanna Briggs Institute methodology for scoping reviews. Inclusion criteria followed the Population, Concepts, Contexts approach. All articles were screened by two reviewers, using Covidence software. Data were charted according to: country, study design, setting, study population, BFHI steps, study aim and objectives, description of intervention, summary of results, barriers and enablers to implementation, evidence gaps, and recommendations. Qualitative and quantitative descriptive analyses were undertaken. RESULTS: A total of 278 articles were included in the review. Patterns identified were: i) national policy and health systems: effective and visible national leadership is needed, demonstrated with legislation, funding and policy; ii) hospital policy is crucial, especially in becoming breastfeeding friendly and neonatal care settings iii) implementation of specific steps; iv) the BFCI is implemented in only a few countries and government resources are needed to scale it; v) health worker breastfeeding knowledge and training needs strengthening to ensure long term changes in practice; vi) educational programmes for pregnant and postpartum women are essential for sustained exclusive breastfeeding. Evidence gaps include study design issues and need to improve the quality of breastfeeding data and to perform prevalence and longitudinal studies. CONCLUSION: At a national level, political support for BFHI implementation supports expansion of Baby-Friendly Hospitals. Ongoing quality assurance is essential, as is systematic (re)assessment of BFHI designated hospitals. Baby Friendly Hospitals should provide breastfeeding support that favours long-term healthcare relationships across the perinatal period. These results can help to support and further enable the effective implementation of BFHI and BFCI globally.

Evaluation of implementation outcomes of an integrated group postpartum and well-child care model at clinics in Malawi.

BACKGROUND: Persistently elevated rates of maternal and infant mortality and morbidities in Malawi indicate the need for increased quality of maternal and well-child care services. The first-year postpartum sets the stage for long-term health for the childbearing parent and infant. Integrated group postpartum and well-child care may improve maternal and infant health outcomes. The purpose of this study was to examine implementation outcomes for this model of care. METHODS: We used mixed methods to examine implementation outcomes of integrated group postpartum and well-child care. We piloted sessions at three clinics in Blantyre District, Malawi. During each session we evaluated fidelity using a structured observation checklist. At the end of each session, we administered three surveys to health care workers and women participants, the Acceptability of Intervention Measure, the Intervention Appropriateness Measure, and the Feasibility of Intervention Measure. Focus groups were conducted to gain greater understanding of people's experience with and evaluation of the model. RESULTS: Forty-one women with their infants participated in group sessions. Nineteen health care workers across the three clinics co-facilitated group sessions, 9 midwives and 10 health surveillance assistants. Each of the 6 sessions was tested once at each clinic for a total of 18 pilot sessions. Both women and health care workers reported group postpartum and well-child care was highly acceptable, appropriate, and feasible across clinics. Fidelity to the group care model was high. During each session as part of structured observation the research team noted common health issues, the most common one among women was high blood pressure and among infants was flu-like symptoms. The most common services received within the group space was family planning and infant vaccinations. Women reported gaining knowledge from health promotion group discussions and activities. There were some challenges implementing group sessions. CONCLUSION: We found that clinics in Blantyre District, Malawi were able to implement group postpartum and well-child care with fidelity and that it was highly acceptable, appropriate, and feasible to women and health care workers. Due to these promising results, we recommend future research examine the effectiveness of the model on maternal and child health outcomes.

Evaluation of implementation outcomes of an integrated group postpartum and well-child care model at clinics in Malawi.

Background Persistently elevated rates of maternal and infant mortality and morbidities in Malawi indicate the need for increased quality of maternal and well-child care services. The first-year postpartum sets the stage for long-term health for the childbearing parent and infant. Integrated group postpartum and well-child care may improve maternal and infant health outcomes. The purpose of this study was to examine implementation outcomes for this model of care. Methods We used mixed methods to examine implementation outcomes of integrated group postpartum and well-child care. We piloted sessions at three clinics in Blantyre District, Malawi. During each session we evaluated fidelity using a structured observation checklist. At the end of each session, we administered three surveys to health care workers and women participants, the Acceptability of Intervention Measure, the Intervention Appropriateness Measure, and the Feasibility of Intervention Measure. Focus groups were conducted to gain greater understanding of people’s experience with and evaluation of the model. Results Forty-one women with their infants participated in group sessions. Nineteen health care workers across the three clinics co-facilitated group sessions, 9 midwives and 10 health surveillance assistants. Each of the 6 sessions was tested once at each clinic for a total of 18 pilot sessions. Both women and health care workers reported group postpartum and well-child care was highly acceptable, appropriate, and feasible across clinics. Fidelity to the group care model was high. During each session as part of structured observation the research team noted common health issues, the most common one among women was high blood pressure and among infants was flu-like symptoms. The most common services received within the group space was family planning and infant vaccinations. Women reported gaining knowledge from health promotion group discussions and activities. There were some challenges implementing group sessions. Conclusion We found that clinics in Blantyre District, Malawi were able to implement group postpartum and well-child care with fidelity and that it was highly acceptable, appropriate, and feasible to women and health care workers. Due to these promising results, we recommend future research examine the effectiveness of the model on maternal and child health outcomes.

Experiential Training Workshops for Group Antenatal Care in Malawi.

The positive effects of the CenteringPregnancy group antenatal care (ANC) model on perinatal outcomes in the United States has led to its adaptation and implementation in many low- and middle-income countries. Facilitative discussions are a core component of this group ANC model. Facilitator training lays a critical foundation for delivery of this paradigm-shifting model as practitioners learn to adapt their approach to health education from didactive to facilitative. However, there is little rigorous research focused on best practices for training group health care facilitators and none that is guided by a theoretical framework. Kolb's experiential learning theory offers a theoretical framework to guide the development of training workshops that allow trainees to experience, reflect on, and practice the facilitation skills needed to deliver this evidence-based intervention. This article describes an experiential learning-based training workshop that was implemented as part of an ongoing effectiveness-implementation trial of a Centering-based group ANC model in Blantyre District, Malawi. We provide a blueprint for conducting group ANC facilitator trainings that, in addition to imparting knowledge, effectively builds confidence and buy-in to this paradigm-changing approach to ANC delivery. This blueprint can be adapted for use in designing and implementing group health care across settings in the United States and globally.

The Role of Family Members in Providing Support For Malawian Women With Preterm Infants During Infant Hospitalization.

Purpose: Family support is essential for women with preterm infants during hospitalization. In low-income countries, the additional burden of infant care due to shortages in nursing staff necessitates that family members (guardians) be physically present to care for woman and the infant. The purpose of this study was to explore the types of support that Malawian women of preterm infants need during hospitalization. Methods: This descriptive qualitative study was conducted at a tertiary level hospital in southern Malawi. We recruited 15 women with preterm infants during hospitalization and conducted in-depth interviews. Data was audio-recorded, transcribed, and analyzed using NVivo. Results: The postpartum women participating this study preferred females and members of the maternal side of their family for guardians. Participants' support needs included physical, financial, emotional, and spiritual support. Barriers such as financial constraints and the lack of accommodations for guardians had left the participants without support persons physically present to help them.

Exploring the cultural appropriateness of a psychosocial intervention, the Thinking Healthy Programme-Peer delivered (THPP), for perinatal depression in Lilongwe, Malawi.

Background: Perinatal depression is a common and disabling mental health problem in Malawi and other Low- and middle-income countries. There is evidence for effective psychosocial interventions for perinatal depression, but no such intervention has been developed for use in Malawi. The broad aim of this study was to explore the cultural appropriateness of a psychosocial intervention for perinatal depression called the Thinking Healthy Programme-Peer delivered for adaptation and use in Lilongwe, Malawi. Methods: A qualitative exploratory design was used. Data were collected through conducting five Focus Group Discussions, involving thirty-eight purposefully selected participants including pregnant women, community volunteers and their supervisors, the Health Surveillance Assistants and maternal health care workers at implementation and policy level following observations of video recorded role plays of the Thinking Healthy Programme-Peer delivered sessions in theatre testing. A content analysis approach was used to analyse data. Results: Six main themes were generated regarding the appropriateness of the content and delivery of the Thinking Healthy Programme-Peer delivered intervention, including: 1) Focus of the intervention; 2) Cultural appropriateness of the content; 3) Language used; 4) Context; 5) Provider of the intervention; and 6) Flexibility in the delivery of the intervention. The Thinking Healthy Programme-Peer delivered intervention was deemed appropriate for the target population, though with recommendations to: review illustrations to enhance clarity, use culturally appropriate stories and idioms, use daily spoken language, and adapt the number and duration of sessions to meet the needs of individual clients. Conclusions: These findings highlight important areas to inform adaptation of the Thinking Healthy Programme-Peer delivered and add to the growing evidence of cultural adaptation of psychosocial interventions for perinatal depression.

Challenges experienced by newly qualified nurse-midwives transitioning to practice in selected midwifery settings in northern Malawi.

BACKGROUND: Literature shows that newly qualified nurse-midwives face challenges integrating into the workforce during their transition period from education to practice. However, little is known about the needs and challenges of Malawian nurse-midwives during their transition from education to practice. The aim of the study was to explore the transition experiences of newly qualified nurse-midwives working in selected midwifery units in Northern Malawi. METHODOLOGY: A qualitative descriptive approach was used. Data were collected through in-depth interviews using semi-structured interview guides from a purposive sample of 19 participants (13 newly qualified nurse-midwives and 6 key informants). The researchers developed two interview guides; one for the newly qualified nurse-midwives and another one for the key informants. The interview guides had questions related to newly qualified nurse-midwives experiences of transitioning to practice and the support they received. Participants were from three selected hospitals in the Northern part of Malawi that have maternity units. Data were analysed manually using thematic analysis. FINDINGS: Five themes related to challenges faced by newly qualified nurse-midwives during their transition to practice in midwifery units emerged from the thematic analysis of the data. These included (1) Theory-practice gap, (2) Lack of confidence and skills, (3) Inadequate resources, (4) Transition support system, and (5) Workplace conflict. CONCLUSION: Newly qualified nurse-midwives in Malawi encounter many challenges while transitioning from education to practice. The study findings underscore the need to develop a national framework support system that could not only help newly qualified midwives adjust positively to their new role but also create more opportunities for learning and developing and strengthening a collaborative partnership between colleges and hospitals.

Acceptability and feasibility of a screening protocol for antenatal depression (SPADe) in Blantyre District, Malawi.

BACKGROUND: Depression is one of the most common perinatal mental health problems that affect pregnant women. Antenatal depression can adversely affect the well-being of the pregnant woman and her foetus. Depression is rarely detected by midwives due to the unavailability of relevant screening instruments in Malawi. A Screening Protocol for Antenatal Depression (SPADe) was developed and recommended for possible use to screen for depression in antenatal clinics in the country. The acceptability and feasibility of using the SPADe protocol to screen for depression has not been established. The aim of this study was to assess the acceptability and feasibility of screening for depression by midwives using SPADe in antenatal clinics in Blantyre district. METHODS: This study used a quantitative survey design to collect data among 60 midwives in three antenatal clinics in primary care settings. All inclusive sampling of all 60 midwives were used. The Structured Assessment of FEasibility and Ottawa Acceptability of Decision Rules Instruments were used to collect the data. Descriptive statistics and Chi square tests were used to analyse the data. RESULTS: This study found that it was feasible to implement SPADe and the following enablers for screening depression had the highest ratings: the SPADe is applicable to pregnant women (M = 3.9, sd = 0.4); the intended goal of the SPADe matches the prioritised goals of Malawi Ministry of Health (M = 3.9, sd = 0.5); and the SPADe is likely to be effective (M = 3.8, sd = 0.6). On the other hand, barriers for implementing the SPADe were: the need for specific training to deliver the SPADe (M = 3.7, sd = 0.7); ongoing support and supervision (M = 3.5, sd = 0.8); and additional resources (M = 3.0, sd = 0.9). This study also found that the implementation of the SPADe was acceptable to respondents. The overall mean score for respondents on acceptability of screening antenatal depression using SPADe was found to be high (M = 4.6, sd = 0.6). However the differences in the respondents' mean scores on acceptability of screening for depression in antenatal clinics using SPADe in relation to their demographic characteristics were not significant (p > .05). CONCLUSION: This study suggests that midwives feel that it is feasible and acceptable for them to implement the SPADe in antenatal clinics with ongoing training, support and clinical supervision.

What are the mechanisms and contexts by which care groups achieve social and behavioural change in low- and middle-income countries? Group motivation findings from a realist synthesis.

OBJECTIVE: Infant and under-five mortality rates in low- and middle-income countries (LMIC) can be reduced by encouraging behaviours such as sleeping under insecticide-treated bed nets, exclusive breast-feeding for the first 6 months, regular handwashing, etc. Community-based volunteer or peer-to-peer mechanisms are cost-effective ways of promoting these lifesaving practices. However, the sustainability and reach of community-based behaviour change promotion remains a challenge. Our inquiry focuses on the utilisation, by non-governmental organisations (NGO), of Care Groups, a peer-to-peer behaviour change intervention. We asked: What are the mechanisms and contexts by which Care Groups achieve social and behavioural change in nutrition, health and other sectors? DESIGN: Realist synthesis reviewing forty-two texts that contained empirical evidence about Care Group interventions. SETTING: LMIC. PARTICIPANTS: We held consultations with a research reference group, which included Care Group and nutrition experts, and Care Group - implementing NGO staff in Malawi. RESULTS: Different types of motivation drive the establishment and the sustainability of peer group interventions. A certain amount of motivation was derived from the resources provided by the NGO establishing the Care Groups. Subsequently, both volunteers and neighbourhood group members were motivated by the group dynamics and mutual support, as well as support from the wider community. Finally, volunteers and group members alike became self-motivated by their experience of being involved in group activities. CONCLUSIONS: When designing and implementing community-based behaviour change interventions, awareness of the multi-directional nature of the motivating drivers that are experienced by peer- or community group members is important, to optimise these groups' reach and sustainability.

Experiences of Malawian Mothers During Their Infants' Hospitalization.

BACKGROUND: Hospitalization of a newborn infant is stressful for all mothers. Hospitals in Malawi have limited nursing staff and support, so mothers are the primary care providers for their hospitalized infants. Few studies have explored the experience of these mothers as both care providers and mothers. PURPOSE: The purpose of this study was to explore the experiences of mothers during the hospitalization of the infant. The goal was to increase knowledge of their primary concerns about the hospital stay. METHODS: This was a descriptive qualitative study conducted at Queen Elizabeth Central Hospital in Malawi. Mothers were interviewed prior to their infant's discharge. We used the directed content analysis approach to analyze our data. RESULTS: Twenty mothers of preterm or full-term infants were interviewed. The primary concerns were perinatal experiences, the infant's condition and care including breastfeeding, support from family members, and support and care from healthcare providers. Additionally, mothers of preterm infants were concerned about the burdens of kangaroo mother care. IMPLICATION FOR PRACTICE: In hospitals that provide limited nursing support to mothers and their infants, it is important to identify a support system for the mother and provide mothers with information on infant care. IMPLICATIONS FOR RESEARCH: Future research should identify specific supports and resources in the community and hospital settings that are associated with positive hospital experiences.

A randomized group antenatal care pilot showed increased partner communication and partner HIV testing during pregnancy in Malawi and Tanzania.

BACKGROUND: HIV testing at antenatal care (ANC) is critical to achieving zero new infections in sub-Saharan Africa. Although most women are tested at ANC, they remain at risk for HIV exposure and transmission to their infant when their partners are not tested. This study evaluates how an HIV-enhanced and Centering-based group ANC model-Group ANC+ that uses interactive learning to practice partner communication is associated with improvements in partner HIV testing during pregnancy. METHODS: A randomized pilot study conducted in Malawi and Tanzania found multiple positive outcomes for pregnant women (n = 218) assigned to Group ANC+ versus individual ANC. This analysis adds previously unpublished results for two late pregnancy outcomes: communication with partner about three reproductive health topics (safer sex, HIV testing, and family planning) and partner HIV testing since the first antenatal care visit. Multivariate logistic regression models were used to assess the effect of type of ANC on partner communication and partner testing. We also conducted a mediation analysis to assess whether partner communication mediated the effect of type of care on partner HIV testing. RESULTS: Nearly 70% of women in Group ANC+ reported communicating about reproductive health with their partner, compared to 45% of women in individual ANC. After controlling for significant covariates, women in group ANC were twice as likely as those in individual ANC to report that their partner got an HIV test (OR 1.99; 95% CI: 1.08, 3.66). The positive effect of the Group ANC + model on partner HIV testing was fully mediated by increased partner communication. CONCLUSIONS: HIV prevention was included in group ANC health promotion without compromising services and coverage of standard ANC topics, demonstrating that local high-priority health promotion needs can be integrated into ANC using a Group ANC+. These findings provide evidence that greater partner communication can promote healthy reproductive behaviors, including HIV prevention. Additional research is needed to understand the processes by which group ANC allowed women to discuss sensitive topics with partners and how these communications led to partner HIV testing.

Culture's Place in Quality of Care in a Resource-Constrained Health System: Comparison Between Three Malawi Districts.

Public health scholars describe "culture of quality" in terms of desired values, attitudes, and practices, but this literature rarely includes explicitly stated theories of culture formation. In this article, we apply Fredrik Barth's transactional model to demonstrate how taking a theory-centered approach can help to identify what would be necessary to foster "cultures of quality" outlined in the public health literature. We draw on data from a study of the Republic of Malawi's Performance and Quality Improvement for Reproductive Health initiative. These data were generated in 2017-2018 through a 6-month organizational ethnography in three facilities selected to represent a range of districts with differing social and economic contexts. Our analysis revealed facility-level organizational cultures in which staff valued providing care, but responded to structural constraints by normalizing divergence from quality-of-care protocols. These findings indicate that sustaining a quality-oriented organizational culture requires addressing underlying conditions that generate routine experiences and practices.

Improving breastfeeding support through the implementation of the baby friendly hospital and community initiatives: a scoping review protocol.

Background: Improved breastfeeding practices have the potential to save the lives of over 823,000 children under 5 years old globally every year. Exclusively breastfeeding infants for the first six months would lead to the largest infant mortality reduction. The Baby-Friendly Hospital Initiative (BFHI) is a global campaign by the World Health Organization and the United Nations Children's Fund (UNICEF), which promotes best practice to support breastfeeding in maternity services. The Baby-Friendly Community Initiative (BFCI) is an extension of the BHFI's 10 th step of the Ten Steps to Successful Breastfeeding and of the BFHI overall. Its focus is on community-based breastfeeding supports for women. There have been no known attempts to synthesise the overall body of evidence on the BFHI in recent years, and no synthesis of empirical research on the BFCI. This scoping review asks the question: what is known about the implementation of the BFHI and the BFCI globally? Methods and analysis: This scoping review will be conducted according to the Joanna Briggs Institute methodology for scoping reviews. Inclusion criteria will follow the Population, Concepts, Contexts approach. A data charting form will be developed and applied to all the included studies. Qualitative and quantitative descriptive analysis will be undertaken. In order to address equity of access to the BFHI/BFCI, the Levesque et al. (2013) access to health care framework will be used as a lens to analyse the charted data in relation to this aspect of the review. An already established group of stakeholders with experience of infant feeding policy and implementation in Malawi will be consulted, to obtain expert views on the findings of the scoping review. Conclusion: This review will establish gaps in current evidence which will inform areas for future research in relation to this global initiative.

The Challenges of Precepting Undergraduate Nursing Students in Malawi.

PURPOSE: Malawi trains registered nurses as clinical preceptors to facilitate quality clinical teaching to nursing students. The concept of preceptorship is new in Malawi, and as such data about its contribution and challenges are scanty. It is for this reason that this study was undertaken to explore the challenges that preceptors face as they teach students. METHODS: This exploratory-descriptive qualitative study was conducted at Malawi's four major referral hospitals utilised by nursing training institutions as clinical sites. A sample of 12 participants was purposively selected to provide data regarding challenges encountered during preceptorship activities. In-depth interviews were conducted in order to collect data on challenges experienced by these facilitators. The data were later categorised and analysed into themes. RESULTS: From the analysed data, three key themes emerged including preceptorship as time-consuming, lack of support from faculty members and lack of teamwork among preceptors. CONCLUSION: The study concluded that preceptors face several challenges that affect the quality of clinical teaching. The study recommends that there should be an improvement in the working relationship among those involved in clinical teaching to enhance clinical learning experiences among student nurses. It also recommends that more registered nurses should be trained as preceptors to improve the student-preceptor ratio.

Protocol for assessing feasibility, acceptability and fidelity of screening for antenatal depression (FAFSAD) by midwives in Blantyre District, Malawi.

BACKGROUND: Depression is often underdiagnosed by treating health professionals. This is a situation in Malawi where there is no routine screening of depression at antenatal clinics. Recently, a Screening Protocol for Antenatal Depression (SPADe) that can be used by midwives to screen for antenatal depression was developed in Blantyre District. SPADe proposes multistage screening of antenatal depression by midwives which may enable early detection and treatment of pregnant women with depression. Proper treatment of antenatal depression can assist in achieving Sustainable Development Goals (SDGs). However, utilisation of SPADe in clinical practice to screening for depression in antenatal clinics has not been established yet. Therefore, the primary aim of this study is to assess feasibility of screening for depression by midwives using SPADe in antenatal clinics in Blantyre District. The secondary aim was to assess acceptability and fidelity of screening for depression by midwives using SPADe in antenatal clinics in Blantyre District. METHODS: This will be a feasibility study which will consist of scientific investigations that will support movement of evidence-based, effective health care approach, SPADe, from the clinical knowledge base into routine use. This study will consist three phases: phase 1 will introduce SPADe in antenatal clinics in Blantyre District where screening of depression is almost none existent; phase 2 will implement screening of depression using SPADe in antenatal clinics in Blantyre District; and phase 3 will evaluate the screening of antenatal depression using SPADe to establish its feasibility, acceptability and fidelity in antenatal clinics in Blantyre District. DISCUSSION: This study will establish and document feasibility, acceptability and fidelity of screening for depression by midwives using SPADe in antenatal clinics in Blantyre District. It is expected that midwives will develop more confidence in detecting and dealing with antenatal depression. Consequently, there will be increased numbers of pregnant women detected with depression by midwives and increased accessibility to mental health care by pregnant women in antenatal clinics.

Determinants of maternal near-miss cases at two selected central hospitals in Malawi.

Background: Maternal near-miss cases occur in larger numbers than maternal deaths hence they require comprehensive analysis when studied. However, there is scarcity of information on determinants of maternal near-miss cases in Malawi. Therefore, this study aimed at establishing the determinants of maternal near-miss cases at two selected central hospitals in Malawi. Methods: This was a case control study that utilized a quantitative approach. A random sample of 458 case files comprising maternal near-miss cases (161) and non-cases (297) was drawn using a ratio of 1:1.8. Data were analyzed using Stata 14 to generate descriptive statistics, Chi Square values to describe the data and determine associations among variables and logistic regression was conducted to determine the determinants of maternal near-miss. Results: We found significant differences between demographic characteristics (marital status, occupation, admission mode, means of transport and age) of maternal near-miss cases and the non-cases (P<0.05). Age and mode of birth were found to be significantly associated (P<0. 05) with maternal near-miss. Women aged 31-35 years were 3.14 times more likely to experience maternal near-miss [OR=3.14, 95% CI: 1.09, 9.02, p=0.03] compared to those aged less than 20 years. Furthermore, emergency caesarean [OR=4.08, 95% CI: 2.34, 7.09, p=0.001] and laparotomy for uterine rupture [OR=83.49, 95% CI: 10.49, 664.55, P=0.001] were significantly associated with maternal near-miss. Conclusion: Among pregnant women, health workers need to pay close attention to factors such as age and mode of birth for them to implement targeted maternal health services in order to reduce incidence of maternal near-miss cases.