Meetings, the Malawian Way

Maybe some day I can host a volunteer meeting in Malawi without overthinking every detail, but this was just not the day.

When we do events for my main gig at Ohio State we have a real start and end time: at Tuesday’s community volunteer meeting people arrived any time between 11:55 and 2:30.

I wrote a detailed “agenda” (okay a script, it was a play-by-play script) that I’m pretty sure no one read, and I’m positive it wasn’t followed, and I didn’t need to understand Chichewa to know it.

At home, when you invite a bunch of people to come to a meeting and they are sitting in silence, just staring… waiting for something happen for minutes on end, something has gone seriously wrong. But here people are used to that. I was the high strung Mzungu trying to move things along for a few (30) minutes. Eventually I realized I needed to let my team do their thing. That we’d get our surveys completed to the best degree that we could, that everyone would get the snacks and transport money they needed, that everything would be fine. Even if people spent their whole afternoon with us, it would be okay.

And really it was. Sixty six volunteers attended! Three more than came to our meeting last year, meaning despite HSA turnover engagement has persisted and we are still able to call on our community reps when we need them. It was so nice to recognize names and faces, to see so many in the shirts I distributed last year, and to hear them offer insights in another open discussion. The surveys seemed to have given them a safe space to provide different feedback than what they said out loud.

Even if the responses are critical, the most important part was that our community reps came and gave honest feedback.

I’m still rummaging through the data and trying to formulate some lessons learned. One clear indicator is the measure of volunteer training: we asked if our volunteers have been given the information they need to fully understand their role in the surveillance. Seven responded “Neutral/Don’t Know” and the remaining 50+ said they Agreed or Strongly Agreed. A good sign for our training program and the HSAs’ work!

So another one of those necessary and exciting and exhausting meeting days has come and gone, and I’m happy to know that this outreach program has been successful enough to catch the attention of hospital leadership. The head clinicians have engaged with the group and asked to work with them for other outreach initiatives outside of this surveillance effort.

The stark difference between what’s inside the walls of the CLI campus and what is outside can be daunting–it’s an oasis inside of a dust bowl. Connections with the community bring that progress outside of the compound and it feels good AF to be a part of it.

Why Do Malawians Birth at Home?

Nearly 200 babies have been born in Child Legacy’s health center! Getting to check in on the CLI Facebook page brings me lots of pleasant surprises. There’s so much going on there, it’s amazing to see the speed of their growth in healthcare, agriculture and clean water access. The HSAs bring basic medical services out to the communities, and I spy a couple of my community volunteers in this photo!

Child Legacy mobile clinics. See more photos like this on their Facebook: https://www.facebook.com/childlegacyinternational/
A Child Legacy mobile clinic. See more photos on their Facebook page

Meanwhile, the research team has been dedicating a lot of time to the maternal and neonatal death audit over the last couple of weeks. It always feels good to see those 4 a.m. messages in my inbox.

Recently the team has followed up on four more neonatal deaths, held a community volunteers meeting, and gathered as a M&NDA committee, which has been in the works for many months but difficult to pull off with the turnover and other project work on their plates.

One of the most insightful pieces I’ve heard from the group is feedback on why women so often deliver at home. A significant proportion of the neonatal deaths we recorded occurred after a delivery outside of a hospital or other health facility. The research team asked the community for their insights, (which I LOVE–what better way to engage our volunteers than giving them a platform to provide their expertise and have a stake in the solution?). Here are the notes from that meeting:

We had to look at reasons why people don’t come to the hospital on time sometimes not even coming to the hospital when labor starts (these are the reasons which people can not confess themselves)

Then we observed that:

1. In a lot of women, it is just in their mind that to deliver at the hospital is no better than delivering at the TBA, nothing else.

2. Some women met cruel nurses in the hospitals and they don’t have a willing to go again to the hospital when they are in labor, TBA’s takes good care of them. (They gave some scenarios)

3. Unnecessary confidence. They are confident that they are much experienced with how labor goes and see going to the hospital as waste of time.

4. Other old women mislead young women, because they had 8 children all delivered at home or TBA without any problem, they discourage their children to go the facility for delivery and they want to conduct deliveries at home.

5. Laziness, other women are just lazy to act fast/on time, as a result others are even delivering in the bathroom outside the homes alone.

SO INTERESTING. So many opportunities for new research and continued work. I could unpack these notes alone for days.

I had to smile at the comment about ‘laziness’ — let’s be real. If I had to pay three day’s worth of my own pay, to ride over giant potholes on an ox cart for hours in active layer with no meds, I’d probably choose the person who birthed me and would come to me in my home.

It’s funny to consider how natural home birthing is kind of bourgeois in the West, where medicine is advanced enough to have skilled midwives who can handle a low-risk delivery pretty much anywhere. But Traditional Birth Attendants like those in Malawi are a different story. Finding a way to respect cultural practices and integrate safe medical practices (like standards around sterility) is vital in addressing this issue. And it needs addressed–in one neonatal death case, a TBA directed a mother to withhold from feeding her newborn because the baby was premature. Quite the opposite from what the child needed.

Birthing without a skilled labor attendant is one clear obstacle that we can definitely address in the Msundwe community. The question is how. I’m really looking forward to visiting with my team again in August to take the next step in improving care for these families. !

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.

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.

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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.

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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.

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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

Learning By Doing

Replace “being an adult,” with “leading a transcontinental practicum experience project” and this interweb gem has been my life.

Okay, not just Googling, but digging through journals and asking tons of questions. I’ve taken courses about public health in ‘developing countries’ but nothing on maternal health exclusively. So I’ve done a lot of learning by research and doing.

The elements of the project (so far) are the maternal/neonatal mortality audit form, a surveillance protocol, a database with data entry protocol, a volunteer training session and a volunteer manual.

My process for each piece is pretty much finding versions that have already been made (if/when that exists), comparing it to white papers and other peoples’ lessons learned for similar projects, aligning it with best practice guidelines by institutions like WHO or UNICEF, and researching Malawi-specific reports and maternal health projects from the area so I can make sure it’s relevant and appropriate.

I’ve gotten these far enough along to get the project off the ground so we can been able to take in cases (another neonatal death was reported last week). From here I’ll be refining them with experts on site at CLI. My time there overlaps with doctors from Baylor College of Medicine, including an OB-GYN who is living there currently. I’m also looking forward to working along side my practicum preceptor Gladson and other CLI research staff who can help me understand what needs to be done to make sure the tools fit in with the Malawian culture. Finding the right timing so we can respect the traditional mourning period, while getting our data close enough to the event for accurate reporting, is one item on that list.

Taking initiative to learn by doing + research has been difficult at times, but it’s been a huge growing opportunity for me and has been a great exercise for my brain. Now I’m looking forward to perfecting this system and making it run like a well-oiled surveillance machine!

Maternal Health in Malawi

Lets visit the numbers:

malawi MMR

The World Health Org has some awesome interactive visualizations of health data, showing maternal deaths per 100,000 live births.

Malawi is at 510.

In case you’re wondering, Is that a lot? Compare it to 28 in the U.S., or 6 in Switzerland.

This means that the risk of a woman in Malawi dying from a maternal-related cause during her lifetime is more than 18 times higher than the risk for a woman living in the U.S., and 85 times that for a Swiss woman.

Even compared to its neighboring countries, Malawi is still behind in maternal health care according to these parameters.

Numbers only carry as much meaning as they can be associated with real people and their stories.

On Tuesday I learned about our first deaths reported by our surveillance project. A mother who, for many reasons including lack of funds for transportation, delivered at home alone. She lost both of her twins within a week of their delivery. She was HIV positive but wasn’t taking the drugs because they made her very sick. Our HSA told her about the CLI clinic and she and her husband did come for a different therapy solution that might not cause so much nausea. We’re realizing it also has the potential to connect community members to the clinic’s resources.

The goal of my surveillance project is to document these circumstances under which mothers and their babies don’t survive. We’ll learn more about these twins’ deaths, but there are already so many obvious fixes to dramatically reduce the risk to mother and child. It is disheartening to identify these solutions after it’s too late. But getting data to illustrate these common obstacles to safe obstetric care will help plan for where new resources can make the most impact, identify training needs, and get facilities across the catchment area communicating with each other.

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For so many reasons 510 is more than just a number, and I’m feeling very privileged to be doing the tiniest something about it.

Next Stop: Malawi

Every Master of Public Health student  has to complete a practicum project. For mine, I knew I wanted to go abroad again, and the project requires me to work more hands-on in the health work than my Peru visit allowed.

mwafrica

In April of last year (yes, before my trip to Peru) the Child Legacy International team made a visit to Ohio State to talk about their wellness center and other services provided to rural Malawians. They shared their plans to open a new maternal ward and illustrated the need–Malawi has high maternal and infant mortality rates, even compared to their neighboring Sub-Saharan countries.

I got in touch with their Ohio State partner and asked how I could contribute to their work for my practicum. The stars aligned then, and their biggest need (that I could help with) happened to be related to maternal health. They needed a maternal death audit system to assesses their services and the care provided to mothers and their newborns throughout their catchment area of 20,000 people across 68 villages.

So it’s been a year working on and off (though more ‘on’ recently) to develop a surveillance system that can help us learn more about what happens when a mother dies from childbirth or when her neonate doesn’t survive. This data is collected routinely in western health facilities and used frequently to improve care practices and identify risks. Collecting and analyzing this information for the MWC catchment area will allow the quality of care to improve for their community as well.

I’m looking forward to sharing more with you as the project approaches and then will post stories from the field. I leave in early July for my 4-week trip.

Yes, You Can Help

plush uterus

I’m leaving for Peru in less than a week! If you’re still looking for ways to help, consider these:

Education materials on sexual and reproductive health
( in Spanish would be the most helpful )

  • educational boards of reproductive systems,
  • menstrual cycle visual aids,
  • pregnancy process materials,
  • demo kit of birth control methods, etc.judy blume book

Judy Blume’s “Are You There God? It’s Me Margaret” (in English and/or Spanish)

  • This book will  be used as an educational/discussion tool around menstruation for pre-teen and teen girls at Shilla primary and secondary school, and in the context of English classes. It allows for  participatory discussion about menstrual popular culture with an intercultural approach and in a fun context.

Kale seeds

  • for community organic garden and school garden

English Language Learning materials

  • to donate to the primary and secondary schools in Shilla

If you live in Columbus and want to donate something, let me know! I’ll pick them up from you this weekend.

and Cash, of course

Some of these are pretty specific so another option, for dwellers of Columbus or any city, is to donate money. Project needs will undoubtably arise once we are on site. Also, some things make sense to buy there, due to travel limitations, and also because learning materials obtained locally will have better cultural relevance to the learners than something we might bring over. Any donations collected will go straight to the community, not the volunteers’ expenses. So pitch in and help us boost our effectiveness.

Solpayki (thank you)!