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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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