Working lives of maternity healthcare workers in Malawi: an ethnography to identify ways to improve care

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Study Justification:
– Maternal mortality in East Africa, including Malawi, remains high despite previous efforts to reduce it.
– Improving the quality of maternal healthcare is crucial to further reduce maternal mortality.
– The study aims to identify ways to enhance the working lives of maternity healthcare workers to improve clinical care.
Study Highlights:
– The study conducted a 1-year ethnographic study in 3 district-level hospitals in Malawi.
– Data were collected through observations and discussions with staff, focusing on the interrelationships among staff.
– The findings revealed that the Malawian healthcare system is underresourced, hindering the provision of high-quality care.
– Staff rotations and poorly managed processes for labeling drugs were identified as barriers to providing optimal care.
– Hierarchical relationships and a desire for career advancement also influenced the quality of care provided.
Study Recommendations:
– Focus on improving the working culture, relationships, and environment to enhance the working lives of maternity staff.
– Address the underresourced healthcare system by improving infrastructure and providing necessary equipment.
– Streamline staff rotations and improve processes for labeling drugs to ensure efficient and effective care delivery.
– Provide opportunities for career advancement and benefits to motivate staff and retain them within the healthcare system.
Key Role Players:
– Malawian Government: Responsible for implementing policies and allocating resources to improve maternal healthcare.
– District Health Officers: Provide local support and assist with obtaining ethical approval and access to hospital wards.
– Research Team: Includes psychology, maternal health, and nursing/midwifery experts who analyze data and provide guidance.
– Healthcare Workers: Collaborate with researchers, share insights, and contribute to the development of recommendations.
Cost Items for Planning Recommendations:
– Infrastructure Improvement: Budget for renovating and upgrading healthcare facilities.
– Equipment Procurement: Allocate funds for purchasing medical equipment and supplies.
– Training and Capacity Building: Invest in training programs to enhance the skills of healthcare workers.
– Career Advancement and Benefits: Budget for incentives and benefits to motivate and retain staff.
– Research and Evaluation: Allocate resources for ongoing monitoring and evaluation of the implemented improvements.
Please note that the provided cost items are general categories and not actual cost estimates. The specific cost details would depend on the context and scope of the improvement initiatives.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is strong, but there are some areas for improvement. The study design is clearly described, and data collection methods are explained. The findings are presented and supported by examples from the data. However, the abstract could be improved by providing more specific details about the results and their implications. Additionally, it would be helpful to include information about the sample size and demographics of the healthcare workers involved in the study. To enhance the evidence, the abstract could also mention any limitations of the study and suggest potential areas for future research.

BACKGROUND: Maternal mortality in East Africa is high with a maternal mortality rate of 428 per 100,000 live births. Malawi, whilst comparing favourably to East Africa as a whole, continues to have a high maternal mortality rate (349 per 100,000 live births) despite it being reduced by 53% since 2000. To make further improvements in maternal healthcare, initiatives must be carefully targeted and evaluated to achieve maximum influence. The Malawian Government is committed to improving maternal health; however, to achieve this goal, the quality of care must be high. Furthermore, such a goal requires enough staff with appropriate training. There are not enough midwives in Malawi; therefore, focusing on staff working lives has the potential to improve care and retain staff within the system. OBJECTIVE: This study aimed to identify ways in which working lives of maternity healthcare workers could be enhanced to improve clinical care. STUDY DESIGN: We conducted a 1-year ethnographic study of 3 district-level hospitals in Malawi. Data were collected through observations and discussions with staff and analyzed iteratively. The ethnography focused on the interrelationships among staff as these relationships seemed most important to working lives. The field jottings were transcribed into electronic documents and analyzed using NVivo. The findings were discussed and developed with the research team, participants, and other researchers and healthcare workers in Malawi. To understand the data, we developed a conceptual model, “the social order of the hospital,” using Bourdieu’s work on political sociology. The social order was composed of the social structure of the hospital (hierarchy), rules of the hospital (how staff in different staff groups behaved), and precedent (following the example of those before them). RESULTS: We used the social order to consider the different core areas that emerged from the data: processes, clinical care, relationships, and context. The Malawian system is underresourced with staff unable to provide high-quality care because of the lack of infrastructure and equipment. However, some processes hinder them on national and local level, for example staff rotations and poorly managed processes for labeling drugs. The staff are aware of the clinical care they should provide; however, they sometimes do not provide such care because they are working with the predefined system and they do not want to disrupt it. Within all of this, there are hierarchical relationships and a desire to move to the next level of the system to ensure a better life with more benefits and less direct clinical work. These elements interact to keep care at its most basic as disruption to the “usual” way of doing things is challenging and creates more work. CONCLUSION: To improve the working lives of the Malawian maternity staff, it is necessary to focus on improving the working culture, relationships, and environment. This may help the next generation of Malawian maternity staff to be happier at work and to better provide respectful, comprehensive, high-quality care to women.

The study was conducted in community, district, and referral hospitals close to Lilongwe, the capital city of Malawi. The characteristics of the hospitals are described in the Table. Characteristics of Study Sites Observational data were collected by the first author (A.M.) working 4 to 8 weeks in the field at a time for 12 months (July 2015 to July 2016, a total of 7 months of observations). During field visits, jottings were made as aide-memoire, and these were used to produce more detailed, freehand, electronic notes (in Microsoft Word) immediately on leaving the field.10,11 The staff were observed in their daily tasks and their interactions with patients, colleagues, and managers on the wards. This was supplemented by discussions with the staff about their working lives. During the ethnography, the first author (A.M.) was increasingly struck by how the interactions of the staff seemed to underpin the functioning of the hospital and therefore focused on these more complex relationships, as they seemed to reveal and allow a deeper understanding of the working environment than the interactions of the staff with their physical surroundings. The district health officers assisted with obtaining local ethical approval by writing letters of support. Furthermore, their permission guaranteed access to the wards for observations. The first author (A.M.) was viewed by local staff as a foreigner, which initially affected their interactions. As time progressed, and familiarity developed, the staff became more open about themselves and their working lives. Neither data gathering nor analysis is a neutral activity.12 As a British obstetric trainee, the first author (A.M.) had up-to-date clinical knowledge and training in obstetrics in high-income settings. However, because delivering care would have been incongruous with the environment where there were no or few doctors, a conscious decision was taken not to practice clinically; to facilitate this, A.M. did not obtain a Malawian medical license. However, because of practicing in a high-income setting, the first author (A.M.) had prior beliefs about how maternity care should be practiced. Therefore, efforts were made to understand and attenuate this effect by developing diverse collaborations and discussing ideas with participants and other researchers and health workers in Malawi. The project team consisted of M.L., a reader in psychology, who assisted with the data analysis. J.H., a maternal health specialist, who has worked in Malawi, guided the process and practicalities. C.M. runs a research nongovernmental organization in Malawi, and he provided practical support. A.Ma. is a professor of nursing and midwifery in Malawi. She provided access to the field and detailed discussions about the interpretation of working lives. A.C., a professor of gynecology, provided a clinical perspective. This iterative process enabled the development of emergent themes and guided data collection.10,13 NVivo (version 10 (2014); QSR International Pty Ltd, Australia.) supported this process.14 We developed patterns, clustered concepts,13 and compared cases within the themes and within and between sites and then related each theme to the others.12 We discussed how they related to the conceptual basis for the analysis: the social order of the hospital. We developed a conceptual framework, based on Bourdieu’s political sociology,15, 16, 17, 18 to underpin our analysis. Many of the concepts have been supported in previous ethnographies based in Malawi.19, 20, 21 The social order was created by the “social structure of the hospital” and a “set of rules,” which governed the workplace and meant that mHCWs followed the “precedent” of those that came before them. Box 1 explains this further. The social structure of the hospital: Malawi’s hospitals, like it’s society, are hierarchical. This is defined by a person’s social, cultural, and economic capital.14 As has been observed in Malawi previously,18, 19, 20 access to capital was associated with higher status and a sense of entitlement. The hospital had its own hierarchy, manifesting as deference to superiors who had more power to decide who got what and when, further bolstering their power. Rules of the Hospital: There seemed to be a set of rules that governed the workplace. Bourdieu17 argued that our social world is made up of “fields,” where “agents” form identifiable groups. These different “fields” recognized each other and struggled for power. We saw staff groups as “fields” and individual staff as the “agents.” Within these fields, there were rules that governed membership to the group.15 These unwritten rules dictated the hierarchical situation in which staff interacted with each other and the patients. Precedent: seemed to dictate how the staff worked. Bourdieu believed that a particular reaction cannot be predicted, but there is limited diversity of possible reactions. There was no conscious determination of these behaviors, but within groups, actions were relatively homogenous.14 We saw members of different staff groups drawing on a distinctive repertoire of clinical and interpersonal behaviors. These likely resulted from observing those before them and cemented their membership to their “field.” The “social structure,” “rules,” and “precedent” interacted to form the “social order of the hospital.” It was clear that these concepts were intimately linked and that they affected each other. Therefore, we drew on the social order of the hospital to illuminate how the staff interacted and behaved at work. Alt-text: Unlabelled box Ethical approval was obtained from the University of Malawi College of Medicine Research Ethics Committee on February 27, 2015 (approval number P.09/14/1635-) and the University of Birmingham on October 30, 2014 (ERN_14-0878). The clinical managers of each hospital provided consent for the inclusion of their maternity unit in the study. Individual staff members were provided with information and could opt not to be observed at work by individually informing the study team, individual consent was not obtained, and patients received information from the staff and posters.

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The study conducted in Malawi focused on identifying ways to improve the working lives of maternity healthcare workers in order to enhance clinical care and access to maternal health. The study utilized an ethnographic approach, observing and discussing with staff members in three district-level hospitals in Malawi.

The findings of the study highlighted several recommendations to improve access to maternal health:

1. Improve working culture, relationships, and environment: The study emphasized the importance of creating a positive working culture, fostering supportive relationships among staff members, and improving the working environment. This can be achieved through strategies such as providing regular training and professional development opportunities, promoting teamwork and collaboration, ensuring adequate staffing levels, and creating a safe and comfortable working environment.

2. Address infrastructure and equipment limitations: The study identified that the lack of infrastructure and equipment hinders healthcare workers from providing high-quality care. To improve access to maternal health, it is essential to address these limitations by investing in the necessary infrastructure, such as well-equipped maternity wards and operating theaters, and providing healthcare workers with the appropriate tools and equipment to deliver quality care.

3. Streamline processes and improve management: The study highlighted that certain processes, such as staff rotations and poorly managed drug labeling, hindered healthcare workers from delivering optimal care. To overcome these challenges, it is important to streamline processes and improve management systems. This can be achieved through the implementation of standardized protocols and guidelines, efficient scheduling and staffing practices, and effective management of drug supplies and inventory.

4. Empower healthcare workers and promote professional growth: The study revealed a desire among healthcare workers to move up the hierarchical system to improve their working lives. To retain skilled healthcare workers and ensure their job satisfaction, it is crucial to empower them by providing opportunities for career advancement, recognizing their contributions, and offering competitive compensation and benefits. Additionally, fostering a supportive and inclusive work environment that values the input and expertise of healthcare workers can contribute to their professional growth and overall job satisfaction.

By implementing these recommendations, it is expected that access to maternal health will be improved in Malawi, leading to better quality care for women and reduced maternal mortality rates.
AI Innovations Description
Based on the study conducted in Malawi, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Improve working culture, relationships, and environment: To enhance the working lives of maternity healthcare workers, it is crucial to focus on creating a positive working culture, fostering supportive relationships among staff members, and improving the working environment. This can be achieved through various strategies such as providing regular training and professional development opportunities, promoting teamwork and collaboration, ensuring adequate staffing levels, and creating a safe and comfortable working environment.

2. Address infrastructure and equipment limitations: The study identified that the lack of infrastructure and equipment hinders healthcare workers from providing high-quality care. To improve access to maternal health, it is essential to address these limitations by investing in the necessary infrastructure, such as well-equipped maternity wards and operating theaters, and providing healthcare workers with the appropriate tools and equipment to deliver quality care.

3. Streamline processes and improve management: The study highlighted that certain processes, such as staff rotations and poorly managed drug labeling, hindered healthcare workers from delivering optimal care. To overcome these challenges, it is important to streamline processes and improve management systems. This can be achieved through the implementation of standardized protocols and guidelines, efficient scheduling and staffing practices, and effective management of drug supplies and inventory.

4. Empower healthcare workers and promote professional growth: The study revealed a desire among healthcare workers to move up the hierarchical system to improve their working lives. To retain skilled healthcare workers and ensure their job satisfaction, it is crucial to empower them by providing opportunities for career advancement, recognizing their contributions, and offering competitive compensation and benefits. Additionally, fostering a supportive and inclusive work environment that values the input and expertise of healthcare workers can contribute to their professional growth and overall job satisfaction.

By implementing these recommendations, it is expected that access to maternal health will be improved in Malawi, leading to better quality care for women and reduced maternal mortality rates.
AI Innovations Methodology
To simulate the impact of the main recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify key indicators that reflect access to maternal health, such as the number of women receiving prenatal care, the number of skilled birth attendants present during deliveries, and the maternal mortality rate. These indicators will serve as the basis for measuring the impact of the recommendations.

2. Baseline data collection: Collect baseline data on the identified indicators before implementing the recommendations. This will provide a starting point for comparison and help assess the current state of access to maternal health.

3. Implementation of recommendations: Implement the recommendations outlined in the abstract, including improving working culture, addressing infrastructure and equipment limitations, streamlining processes, and empowering healthcare workers. Ensure that these recommendations are implemented consistently across the selected healthcare facilities.

4. Data collection during implementation: Continuously collect data on the identified indicators during the implementation phase. This can be done through routine data collection systems, surveys, interviews, and observations. The data should capture changes in access to maternal health as a result of the implemented recommendations.

5. Data analysis: Analyze the collected data to determine the impact of the recommendations on access to maternal health. Compare the baseline data with the data collected during implementation to identify any changes or improvements. Use statistical methods to assess the significance of the observed changes.

6. Evaluation and interpretation: Evaluate the results of the data analysis and interpret the findings. Assess whether the implemented recommendations have led to improvements in access to maternal health. Consider any limitations or challenges encountered during the implementation phase that may have influenced the results.

7. Recommendations and next steps: Based on the evaluation and interpretation of the results, provide recommendations for further improvements or modifications to the implemented recommendations. Identify areas that require additional attention or interventions to sustain and enhance the positive impact on access to maternal health.

By following this methodology, it will be possible to simulate the impact of the main recommendations outlined in the abstract on improving access to maternal health in Malawi. The findings can inform future interventions and policies aimed at reducing maternal mortality and improving the overall quality of maternal healthcare services.

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