Malawian Midwife Works to Improve Quality of Care for Mothers and Newborns

Elimase Kamanga is a mother, a midwife for more than 15 years, and the Senior Technical Advisor for Maternal and Newborn Health for the USAID-funded Organized Network of Services for Everyone’s (ONSE) Health Activity, led by MSH. Chisomo Mdalla, ONSE’s Chief Communications and Knowledge Exchange Officer, talked with Kamanga about her work to improve the quality of care for mothers and newborns in Malawi. This interview was edited for length and clarity.

Elimase, can you tell us about how you got to where you are today?

It’s quite a long story. I grew up in a very poor family in a village near Kasungu, here in Malawi. But my mom still encouraged me to go to school. Even though I would go to school without shoes, without enough books, maybe even on an empty stomach, I still rose up to go to secondary school. I was also privileged to be selected by the government to go to the University of Malawi’s Kamuzu College of Nursing.

After university, I joined the ministry of health in 2003, working mostly in the Maternity Department. I was a fast-rising nurse midwife in terms of promotions. I really love midwifery. I really love reproductive health. So I decided to go back to school and do my master’s degree in reproductive health. I joined MSH in January. This marks my fifth month with this beautiful organization. I feel proud that I am at this stage at this moment.

How has your experience and education as a midwife shaped how you approach your work?

Now I have more than 15 years’ work experience as a midwife. Studying about Florence Nightingale, someone who dedicated her time when she was not even afraid of losing her life for the service of others, has shaped me. I’ve always been gentle, not harsh; always understanding, and this is all part of the training that I’ve gone through.

During my career, I started having my own babies. That’s when I felt no woman should lose a pregnancy. No woman should deliver a stillbirth. Every woman, every family, needs to have their children live and grow.

What needs to be addressed urgently to improve the health of mothers and newborns?

I believe in Malawi – we have a very good environment in terms of policies, guidelines, documents, standards. We are privileged that a lot of women in the communities are coming to deliver and seek care in the health facilities, which is a very big challenge in most countries. We have over 95 percent of women attending at least one antenatal care visit during their pregnancy. We have over 90 percent of women delivering in health facilities. But why is it that the women keep on dying? It is about improving quality.

Some 439 women per 100,000 live births are dying in my country, and 27 per 1,000 live birth newborns are dying, while people are coming to us in the health facility. So what ONSE, what we, are working on – and it’s also the priority of the Malawi government –  is the quality of care given to people coming to us.

What are you doing to improve quality of care?

I work with the Ministry of Health, especially the Reproductive Health Directorate. I also work with 11 districts, where we have Maternal and Newborn Health Mentors, working directly with the ministry of health to build capacity in terms of implementing interventions, how the ministry should provide supervision so that health providers have the right skills to manage women in labor.

All of us are working together at improving maternal and newborn health outcomes. We look at facility-level health data and when we see that there are gaps, we provide technical support to districts. Our main model for capacity-building in the district is mentorship, moving out of the traditional, classroom-based training, which hasn’t been effective. It’s not that health providers don’t know what do, but they don’t feel confident they have the skills to perform the interventions they are trained in. ONSE’s approach is interactive – mentors provide skills-based coaching and supportive supervision directly to the midwives and other health providers.

When you say that we need to improve the quality of care, what do you mean exactly?

Whatever we do when a woman comes in for antenatal care or for delivery should lead to positive outcomes. If I’m a midwife, I’m monitoring a woman in the labor and delivery ward. She has been in my hands for six hours of labor. I’m supposed to check her blood pressure every hour. But if I’m not doing that, the woman can end up having pre-eclampsia, which I could have detected early and managed sooner. If I’m not monitoring the fetal heart rate, I may end up with a stillbirth. These are the things we can prevent. If you practice handwashing the way you’re supposed to, you will prevent sepsis, a leading cause of maternal death. If I do each intervention according to standards, like handwashing, I can avert more maternal and perinatal deaths.

What unique role do midwives play in improving the health of women and families?

As it is, the midwife is the person who will first meet a pregnant woman when she comes through the facility. She’s the one who makes necessary referrals. She’s the one who gives the right guidance. She’s the one who knows who else can help this woman.

The midwife takes time with this woman, with this family, with this adolescent. She listens to them, provides respectful maternity care. That way, she will be able to understand the challenges, the hidden challenges, that people have and know how she can help them.

How can we better support midwives to do this important work?

My best advice is that we need to invest in midwives. So I think the approach ONSE has is something that can really produce results. Our role is to improve the quality of care so that indeed, a high proportion of skilled delivery attendance in our facilities really translates to positive outcomes for mothers and babies. The number of women dying should be going down, the number of newborns dying should be going down.

I am very sure, having been a midwife for more than 15 years, that midwives need to be given the necessary resources and a good working environment, so that they can exercise what they’re best at. We can support the governments in every country where we are working to help midwives really be what they’re intended to be. As we talk about improving the health outcomes of women, newborns, adolescents, children, we should not forget the midwives. Midwives can bring great change.