Surveillance Findings So Far

MNM surveillance report Nov 2015_CoverWe’re about six months into surveillance, and have audited 16 deaths, 15 of which were neonatal. When these deaths occur, a community volunteer calls our research team and we wait at least 2 weeks for grieving. Then, our audit forms are completed through 1:1 interviews with family of the deceased and anyone who provided care during the delivery. Those audits are compiled in a database, where we can get a snapshot of dozens of factors that could influence maternal and neonatal mortality.

Patterns we’re seeing so far include:

  • Delivery occurring outside of a clinic
    • 10 cases
  • No skilled assistance
    • 14 cases
  • Lack of funding for transport or care reported in 3 interviews but possibly a more prominent issue
    • Average distance between home and nearest facility: 15 KM

An opportunity we identified was that mothers in all cases reported receiving antenatal care.

This interaction could serve as an opportunity to educate patients on the importance of delivery with skilled assistance, early warning signs of active labor, and how to get to a nearby facility.

And new questions arose:

  • Why do women deliver outside of the facility?
    • Culture?
    • Costs?
    • Delays in decision making?
  • What are our avenues for collecting this information?
    • Add a question to the audit
    • Ask mothers at CLI who have delivered at home
    • Ask the mother during her prenatal visit how she plans to choose the location of her delivery

It seems inevitable that new questions will evolve and present themselves as we redefine our bigger initial questions: Why is maternal mortality so high in this area? What can be done about it? How would these improvements be made? But we’re narrowing in on the problem in order to identify a solution. A solution that would be generated with the culture and resource context necessary for lasting change.

See the Full MNM surveillance report

Maintaining Community Engagement

When we hosted our first community volunteer meeting back in July one of the strongest pieces of feedback I received was “don’t disappear!” In communities that become subjects of multiple research projects and interventions like CLI’s, it’s important to work with intention to follow through, and illustrate the value these projects bring back–and not just to the PIs.

So, even though the next volunteer meeting occurred sooner than I had planned, I was still happy to hear that Monday’s gathering was well attended, and that our IDs are still being made and new volunteers recruited. The people in our catchment area move frequently, so we anticipated roll over in volunteers who moved out of the catchment area or into a village that was already represented by an existing surveillance volunteer.

Speaking of rollover… our star Health Surveillance Assistant, Lamulani, went off to university! He’s studying medicine and how can we not be excited for that? Luckily, the rest of the HSAs are stepping up and taking care of business. Frank, pictured, is working with fellow HSA Chrispine to continue cultivating this wonderful community dedicated to improving our knowledge about maternal and neonatal care in the MWC catchment area.

Wrapping Up

Turns out I had no problem staying busy for my time on site without the research team.
I got consultation from one of CLI’s resident obstetricians, who offered great feedback including the ever-looming “does the District Health Office know about this?” question. This, along with advice from my advisor, and 2014 conversations where I inquired about the need to involve the govt public health orgs, led to a field trip yesterday. After several stops at various DHO buildings and lots of help from a CLI surgeon/administrator, we had a parking lot meeting with Malawi’s Coordinator for Safe Motherhood. It actually left me feeling much more accomplished than the term ‘parking lot meeting’ implies.
 IMG_3098
I also found out that the CLI Maternal and Neonatal Mortality Committee I was proposing to be established already existed. !
And, that the Ministry of Health has, in fact, updated their maternal death audits recently. Which means changes for ours—but good ones, since the additions they made align with a portion of the information we included in ours.
Finally, I put together a ‘sustainability report’ that outlines what project management and resource alignment needs to happen to ensure that this whole thing doesn’t lose steam when I leave. This involved calculating what the project costs and how long my fundraising could sustain it.
Good news: The money I fundraised (plus some that I saved), is enough to support the maternal and neonatal mortality surveillance for 18 more months!
This is a significant amount of time. Long enough to plan for 12 and 18 month evaluations to see if the information collected is valuable enough to absorb the future costs into the regular expenses of the research program and continue with the surveillance. Since I’ll need to do a ‘final project’ to complete my MPH in a year, this could create a perfect opportunity for me to get some experience in public health program evaluation, which I’ve always had an interest in.
I spent my last day in the research office sending many emails of terrifying lengths, like a mom leaving for an extended vacation and needing to make sure you know how to set the alarm right and what to do in case you set it off anyway and also that the key to the shed for watering the garden (the half that needs watering, NOT the other half that gets all the rainwater from the gutters) is behind that lawn chair with the… you get the picture.
I’ve agreed to remain a resource for the team to be sure that the foundation for the system is strong. The CLI staff will take over all routine aspects of the system such as volunteer recruitment, training and kit distribution, case auditing and reporting.IMG_2816
It was a crazy last half of my visit, (especially with a safari weekend squeezed in the middle!) but I’m very proud of what I’m leaving the team with as I head back to the states. Thanks, again, to all of the moral and financial support from friends and family.
Zikomo kwambiri, and see you soon Ohio!

A Day in the Life

When I’m not running around like a crazy person preparing for a meeting like yesterday’s, here’s what a typical day at the office looks like:

Morning

Breakfast with my roommates, Araseli the CLI hospitality manager and sometimes other people on site.IMG_2722

Eggs with beautiful yokes and indulgent toast is the norm.

IMG_2746

For those who were wondering, my coffee solution is perfect and is a hit with others on site.

Breakfast is sometimes rushed so we can hop across the site and get to our morning meeting at the clinic.

IMG_2771

Clinic and research staff attend to give updates, ask for feedback on upcoming projects, and raise any issues. There’s usually also a presentation. We saw two last week about malaria diagnosis and treatment. I like how the doctors and ‘superior’ staff take time to share what they learn about new standards and best practices with the broader group. For example, they shared doses for children taking first-line malaria treatment with everyone, even though only a few of those present had authority to prescribe.

Last Friday we used this time to get feedback on the volunteer guide, and the project as a whole, from the clinic and research teams.

IMG_2772

After the morning meeting we go to the office. It’s simple, I’ll call it an ‘open workspace’ concept with lots of sun. Everyone works diligently, as a group or quietly on their own, until lunch.

Afternoon

Mzungus eat separate from the rest of the staff, which is kind of a bummer. We do benefit from more variety of the kinds of foods we eat, but “doing as the Malawians do” was more of what I expected. I can’t complain though; they just want us to be happy, and the food is great.

IMG_2737Sometimes we are served Malawian food; the main staple being nsima, a white cornmeal kind of dough that you mold in your hand and dip in whatever it’s served with. That is usually “relish” which reminds me of southern cooked greens at home; and then sometimes another version with some kind of peanut flour or paste in it. They call it “peanut butter” flavored.

Everyone in Malawi gets a 90 minute lunch break: it’s actually the law. So depending on the day I check in on things back at the home front (hi ODEE!), take care of things in my room (like cleaning the shoes I filled with dirt on the walk to the market last weekend) or practice some yoga. It’s super sunny, every day this time of year.

Our afternoon at work is our chance to communicate with people in the states so sometimes we do some of that. The other day it took 30 minutes, two computers, and several phones to connect for a conference call which was still off-and-on connectivity that often required transcription on the typing section of skype while my advisor Alison spoke on her end. It’s an exercise in patience.

IMG_2721Otherwise, we just do more of whatever we did in the morning. In the afternoon there are fewer people around, as some staff get assigned to work outside the clinic.

Evening

IMG_2760We’ve often come back to the room to find Midnight on one of our beds, which is just like home for me. I recently found out that this was ‘against the rules’ though, oops.

Sometimes we work out before dinner. I’m sharing the room with an agriculture volunteer (Mackenzie) and a student researcher (Julika) and the three of us have done circuit training and running. Malawians, of course, think it’s funny that we exercise. I’m glad we can provide them some entertainment while we get some of that extra energy out from all the eating we do.

Sometimes after dinner we play games like bananagrams or puzzles. Usually we make calls home, do some reading and go to bed early. Like, lights out by 9.

That’s a (week)day in the life for me. It’s a nice routine with some wonderful people and a lot shorter to-do list than at home. I’m learning how to multitask effectively–loading a web page can take dozens of minutes and downloading a device driver has proven to take an hour or two. But with all the progress we’ve made already, I’m feeling confident about having a comprehensive system in place by the time I head home.

Zikomo kwambiri (thanks much)!

Lucy