Creating a health system that cares for everyone: Malawi and respectful maternal care

Rosemary Miyove Bilesi still remembers the grueling demands of her work as midwife early in her career in Dedza District hospital in southern Malawi, near the border with Mozambique.

“I was passionate about being a midwife. I wanted to be a part of the team that cared for women and their newborns. But then you entered the labor ward and you barely sat down for eight hours,” said Bilesi, who today serves as Chief Reproductive Health Officer for Malawi’s Ministry of Health. “There would be six or eight women in labor at the same time and only one or maybe two midwives. It was stressful physically and mentally. Sometimes it was frustrating as we did not have the right equipment. And in addition to caring for patients and their newborns, I also had to manage the ward.”

Such staffing shortages weren’t unusual.

“In Malawi at that time, there were reports from some midwives that they didn’t have time to go to the bathroom during their shift,” said Elena Ateva, who worked with the White Ribbon Alliance on the issue of maternal and newborn health. “In some facilities, there was just one midwife who had to be on call 24/7.”

In fact, said Ateva, who is now Deputy Director of Heat, Health and Gender, with Atlantic Council's Adrienne Arsht- Rockefeller Foundation Resilience Center, such shortages were impacting the quality of maternal and newborn care and discouraging women from delivering in health facilities far beyond Malawi. International surveys of midwives have consistently found an acute shortage of midwives globally. In 2010, the international nonprofit Save the Children warned that a shortage of 350,000 midwives globally  was a "significant barrier to…prevent[ing] maternal, newborn and child deaths.”

The tipping point came in 2010 with a landmark USAID report by Diana Bowser and Kathleen Hill documenting examples of neglect, disrespect, and abuse of women in labor, often as a result of overburdened staff struggling to keep women and their newborns safe amid limited resources.

The report quoted providers and patients and cited incidents from South Africa to Brazil that illuminated how abuse and neglect of women in labor had been normalized. Bowser and Hill concluded that "disrespect and abuse may sometimes act as more powerful deterrent to skilled birth care utilization than other more commonly recognized deterrents such as geographic and financial obstacles.”

In Malawi and many other countries, the report proved a catalyst for remarkable national conversations about women’s rights, power in the medical system, and the treatment of women in labor. That conversation continues to this day.

This article outlines how Malawi responded to the crisis in the care of women and is part of a series on respectful maternal care by Exemplars News.

Over roughly a decade, Malawi implemented reforms that have helped improve the quality of care for women, nearly eliminated the gap in access to skilled birth attendants between the poorest and richest communities and urban and rural communities, and helped the country cut is maternal mortality ratio to 439 per 100,000 live births in 2016 from 675 in 2010. “This has strengthened the health system as a whole,” said Ateva.

Malawi’s journey from poor treatment and poor outcomes – as recently as 2006 nearly half of women gave birth without the benefit of a midwife or other skilled birth attendant – to a country that has succeeded in providing nearly all women, regardless of income or location, access to skilled birth attendants, is one that may be instructive for health leaders seeking to make similar gains.

Bilesi highlighted a few key pillars of the government’s strategy. They include both demand and supply side reforms.

The supply side reforms started a decade ago when the government adopted the Respectful Maternity Care Charter, which documents the rights of women and responsibilities of health workers. The Ministry of Health and nursing and midwifery training institutions, with support from the White Ribbon Alliance, translated the document into Malawi’s national language, Chichewa, and updated their curricula to align with it.

The government began heavily investing in training more midwives to address the shortage. The WHO recommends one midwife for every 175 people. In Malawi in 2016, a national survey had found “a critical shortage of midwives” – one midwife for every 5,058 people.

In 2018, the government accepted and promoted a manual for maternal care developed by the Association of Malawi midwives. The manual includes checklists to guide midwives and help ensure respectful, confidential care.

The government also launched, with support from the Association of Malawian Midwives, the “10,000 happy birthdays” campaign aimed at improving the training of midwives to control bleeding and stabilize women during and after childbirth and equip midwives with the skills needed to address common neonatal breathing challenges. The program aimed to improve the skills of midwives and inform the training of new midwives across the country. The government also launched performance-based financing which, research has indicated, improved the quality of childbirth care.

And, most recently, in 2021, the Malawian Ministry of Health officially endorsed and adopted the updated Respectful Maternity Care (RMC) Charter: The Universal Rights of Women and Newborns, which sets an international standard for the rights and services women and newborns should receive when seeking care. It was one of the first countries to do so.

The demand side reforms were aimed, in part, at making sure that women recognized the benefits of skilled birth attendants and knew about their health needs and rights. To achieve this goal, the government trained its 3,000 Health Extension Workers to educate women on the importance of prenatal care and skilled birth attendants.

Lastly, to make giving birth in a health facility more accessible and further reduce pressure on the staff of government facilities, the government established a public-private partnership with the Christian Health Association of Malawi, which runs 184 healthcare facilities around the country. Women who live near a Christian Health Association facility can elect to deliver their child in that facility, with the government covering the cost of their care. “So, they don’t have to trek to a government owned facility,” explained Bilesi, adding that the goal of these reforms was to build “a system that takes care of everyone,” including both midwife and patient.

The impact was swift and substantial and can be seen, said Bilesi, in the increasing numbers of women who give birth in health facilities.

In 2010, 73% of births in Malawi occurred in a health facility. By 2020, the percentage had reached 91%. Even rural women endeavor to give birth in a health facility, said Bilesi. While globally, 90% of urban births and 70% of rural births are attended by skilled health personnel, in Malawi access to skilled birth attendants is about equal for both urban and rural women – crucial for a country where 80% of the population is rural.