Maternity in Malawi is a DIY gamble
Hospitals in Malawi are expecting pregnant women to supply their own delivery kits – including unsterilised plastic sheets used during childbirth – amid a growing public health crisis aggravated by a budget squeeze.
An amaBhungane investigation revealed the widespread use of private delivery kits, which are seen as exposing mothers and newborns to postnatal infection.
Postnatal sepsis accounts for between a third and half of neonatal deaths in Malawi.
The funding shortfalls facing hospitals and clinics have been worsened by a development aid embargo by major donors in reaction to the plundering of government funds in the Cashgate scandal.
Local media have reported that ambulance services have ground to a halt as hospitals cannot afford fuel. In another sign of strained finances, a major hospital in the northern rural area of Mzimba wrote to the health ministry complaining its October allocation has been halved.
An amaBhungane investigation of district health facilities in the Malawian districts of Zomba, Ntchisi, Rumphi, Chikwawa, Phalombe, Nsanje, Dedza, Chiradzulu, Salima and Balaka established that the use of home-made delivery kits is the norm.
According to one official interviewed, expectant women are asked at antenatal classes to bring to hospital a metre of black plastic sheeting, to cover the bed during delivery, a razor blade to cut the umbilical cord; cotton wraps, for bed sheets and to wrap the baby after birth; and thread to tie the umbilical cord.
The practice is particularly prevalent in rural health facilities and district hospitals. The situation is not clear in referral hospitals located in urban areas, such as Kamuzu and Queen Elizabeth central hospitals, which did not answer questions sent to them.
Still, women who have given birth at these hospitals told amaBhungane that they had used their own delivery kits.
All the district hospitals interviewed by amaBhungane indicated that they are experiencing financial problems due to underfunding.
None of them had a specific budget for bed linen, which was incorporated in the drug budget.
Driving the use of plastic sheeting is the shortage of high-volume laundry facilities.
Some districts said their primary health clinics lack the large laundries needed to handle the volumes of soiled linen, and cannot afford to transport it to larger facilities.
The health ministry denied the use of private delivery kits and condemned the practice, saying hospitals supply the necessary materials.
According to government figures, neonatal deaths account for 40% of all child deaths in Malawi.
An estimated 18 000 newborn babies die in the first month of life. Neonatal infection is one of the three leading causes of neonatal death, alongside preterm births and breathing difficulties.
The current maternal mortality rate is 600 per 100 000 live births, with infection and bleeding being the major causes of mortality at health facilities.
“If a woman goes to delivery without these things, health workers insult her and at times neglect her”
A health ministry action plan launched in July this year says that neonatal sepsis accounts for between 33% and 48% of newborn deaths and emphasises that simple cord care and clean practices can make a major difference.
The document notes that leading causes of neonatal mortality are not comprehensively addressed and there is no policy to tackle the issue.
Frank Banda, a spokesperson for Mzuzu Central Hospital in northern Malawi, agreed that the hospital is underfunded. But he insisted that “Mackintosh” – waterproof sheets for the temporary protection of beds – is always made available for the use of expectant women.
However, Liana Tembo, chairperson of Chipwaira Health Facility in southern Malawi, said it is the norm for expectant women to bring black plastic sheeting, sewing or knitting thread, a basin and gloves.
She said women buy gloves from other private health facilities for between R18 and R33, and that they buy the plastic sheeting from an open marketplace.
“If a woman goes to delivery without these things, health workers insult her and at times neglect her,” Tembo said.
Health workers at Nambazo Health Centre in Phalombe, southern Malawi, said there is an acute shortage of bed linen and the clinic’s maternity wing is worst affected.
“It’s a must to bring delivery kits. We don’t know where they get them from and there is mostly no time to vet their cleanliness since most women come in advanced labour,” said one worker, who asked not to be named.
She lamented: “I have worked at this facility for more than seven years, but there is nothing I can do to improve the situation. I’m only a junior without any influence.”
Owen Chataika, a spokesperson for Chiradzulu district health office, also in the southern region, said women are told to bring black plastic sheets as an alternative to mackintoshes. “We didn’t specifically budget for bed linen or [a] mackintosh. We may have to procure it through the drug budget, but this may be minimal.
“Our total budget this year is K206-million [over R5.1-million], down from last year’s K235-million [over R5.8-milllion],” he said.
Chataika said a shortage of bed linen at the hospital has greatly affected the maternity and Kangaroo Mother Care wards, leading to a high incidence of infection among mothers and babies.
He said 10 babies die monthly because of sepsis, prematurity and breathing problems.
Arnold Mdalira, speaking for the Dedza district health office in central Malawi, defended the use of home-made kits, saying that they prevent infection. “Plastic sheeting is suitable for holding blood and other fluids,” he said
A spokesperson for the Ntchisi district health office in the central region, Lovemore Kawayi, said that health facilities are supposed to have Mackintoshes, surgical blades and cord clamps, but in their absence, pregnant women are advised to bring their own kits.
A medical doctor who heads the Nsanje district health officer in the south, Alexander Chijuwa, said each primary health facility is required to have 10 beds but that the district is short of bed linen.
Chijuwa agreed that women bring their own kits, but said the practice is discouraged, as it goes against infection prevention policy.
Bwanalori Mwamlima, spokesperson for the Rumphi district health office, in the north of Malawi, confirmed that patients’ delivery kits were used in the district and agreed that they pose a health hazard.
Mwamlima said the hospital had 107 neonatal deaths between July last year and June this year, and that neonatal sepsis was one of the leading causes.
The health ministry’s deputy spokesperson, Adrian Chikumbe, denied that pregnant women are using own delivery kits at public health facilities. “There is no reason for this. These materials have to be sterilised in line with standard procedures and infection prevention practices according to World Health Organisation guidelines.”
Chikumbe was confident that Central Medical Stores Trust has enough bed linen, Mackintoshes and disposable items used in delivery kits. He said isolated shortages could occur possibly because of lapses in the supply chain.
He was sceptical that the use of home-made delivery kits has increased postnatal infection and infant deaths in hospitals, saying “this is a sweeping statement”.
“There could be many reasons. Infection can set in if sterile techniques are not followed or if delivery is performed in a dirty environment. Microorganisms can easily enter the birth canal or infect a newborn during delivery.”
Chikumbe said some government services might be affecting funding shortfalls, but that this has not yet affected maternal health services.
“This is one of our priority areas of health service delivery and we still have partners who are still supporting us in this endeavour.”
Central Medical Stores Trust public relations officer Hebert Chandilanga insisted there is enough bed linen and Mackintoshes.
“Health offices order linen and Mackintoshes in the same way that they order medicines and medical supplies,” he said. “We have a working arrangement where they have to send us orders by the 10th of every month and we start processing orders as soon as possible.”
Health ministry has to make do with less
Malawi’s finance ministry has confirmed that government belt-tightening is affecting health spending – but ministry sources also say district health offices are not spending what they have wisely.
About K77.4-billion (over R1.9-billion) was allocated to the health ministry in this year’s budget, compared to K65-billion last year.
Finance ministry spokesperson Nations Msowoya said the increase reflected rises in health costs, but the – like all other government departments – the health ministry could not be allocated the full funding it had requested.
However, a health ministry insider who wanted to remain anonymous complained that district health offices spent too much on locum allowances, meetings and fuel for “personal benefit”.
“It’s unfortunate – the health sector is our priority area, despite the squeezed budget, and the district health offices are advised to use the little they have sparingly.”
This year, an extra K55.6-billion was made available off-budget from donors. Off-budget allocations by donors began after the Cashgate scandal, involving corruption and fraud within then-president Joyce Banda’s government, broke in September 2013.
In the 2012-2013 budget, donor grants represented 140% of revenue raised from local sources.
In his 2015-2016 budget speech, Finance Minister Goodall Gondwe said the problem with off-budget support is that government has no role in deciding how it is used.
“Government can’t properly decide on expenditure priorities nor properly plan and time the delivery of goods and services in some critical areas such as delivery of drugs to health facilities,” he said.
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The M&G Centre for Investigative Journalism (amaBhungane) produced this story. All views are ours. See www.amabhungane.co.za for our stories, activities and funding sources.