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“I AM TIRED, BUT WE REALLY TRY.” PERSPECTIVES OF MIDWIVES ON QUALITY OF MATERNAL HEALTH CARE PROVISION IN QUEEN ELIZABETH CENTRAL HOSPITAL, BLANTYRE (MALAWI).

MASTER’S THESIS - MEDICAL ANTHROPOLOGY AND SOCIOLOGY | L. QUADVLIEG


“I AM TIRED, BUT WE REALLY TRY.” HOW MIDWIVES CARE FOR MATERNAL HEALTH IN QUEEN ELIZABETH CENTRAL HOSPITAL IN BLANTYRE (MALAWI).

Thesis submitted to the University of Amsterdam, Graduate School of Social Sciences, in partial fulfilment of the requirements for the degree of Master of Science in Medical Anthropology and Sociology, December 23rd 2010. By Linda Quadvlieg Feedback is welcome at l.quadvlieg@gmail.com. University of Amsterdam ID: 5771617

Supervision: Dr. W. Koster, University of Amsterdam Second reader: Prof. Dr. J.D.M. van der Geest, University of Amsterdam Local Supervisor: Dr. A. Malata, Kamuzu College of Nursing


Acknowledgments

To be able to conduct a study in Malawi on quality of care from midwives perspectives was a very interesting and rewarding experience, and the writing a challenging endeavour. It is not original but certainly true for me: I discovered that in qualitative research and writing, one learns not only about the subject but also about oneself. I would like to thank the many people that have supported me throughout this time of learning. First I would like to thank Winny Koster, my supervisor. Your contacts with Address Malata at the Kamuzu College of Nursing in Malawi made it possible for me to engage in a study that completely matches my interests. Thank you for your assistance and your enduring patience. For an orientation on the subject, I would like to thank Jose Utrera (Cordaid), Frans Hamer and Anong Boonchuey (ICCO) for sharing their insights with me. Their information and the people José Utrera introduced me to in Malawi were very valuable. Linda Kalilani (College of Medicine) was one of the people to whom José introduced me. I would like to thank her for opening doors for me at Centre for Reproductive Health. Then I would like to thank Address Malata, my local supervisor, and Elizabeth Chodzaza for supervision in Blantyre. Thank you for making my time in Malawi a great learning experience and taking me in at your campus. I am also grateful to Jeanette van Oss from the Billy Riordan Memorial Clinic for introducing me to the field of health care provision in Malawi. Your courage, resoluteness and down-to-earth approach to your work as a physician in rural Malawi were inspirations to me. I would also like to thank Nazar, Clever, Joy, Miriam and Douglas for making “Coffee Cottage” my home away from home. Thank you for your friendship in Malawi: Kari, David, Paul, Yulian and Willem. Thank you for helping with the transcription of the interviews Marisa, Tinu and Ire. Thanks for commenting on earlier drafts Floor, Marieke, Jessica and Leanne; and for correcting my English David, Lucy, Bill, Elke but most of all Kari. Thank you very much Floor for your motivating words, and my parents for keeping your faith. Hessel, your support means the world to me. Thanks for always standing by me. Finally I would like to say thank you to all the respondents and the people present at the focus group discussion, especially the midwives at Queen Elizabeth. Thank you for your participation in the interviews, sharing your thoughts and feelings and allowing me in your space at the hospital. It is really you who have made this study and this thesis possible. You have my thesis in your hands. I hope this study contributes to putting midwives’ concerns about improving the quality of maternal care high on the agenda in Malawi. This is of great importance if we are to increase the health seeking behaviour of women during delivery because, just like L. A. Kamwendo, former president of the Association of Malawian Midwives (AMAMI), I believe that: A satisfied midwife is going to provide quality care.

Linda Quadvlieg, Rotterdam, December 2010

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Table of contents Acknowledgments........................................................................................................................................... ii Table of contents ............................................................................................................................................ iii List of figures and pictures ............................................................................................................................ v List of abbreviations and acronyms......................................................................................................... vi Map of Malawi................................................................................................................................................. vii Chapter 1: Introduction................................................................................................................................. 2

Literature review of context.................................................................................................................. 2 Obstetric or midwifery care? ....................................................................................................................... 2 Nurse or midwife? ............................................................................................................................................ 3 Maternal mortality - a global picture........................................................................................................ 4 Skilled attendants at birth in Malawi ....................................................................................................... 4 Barriers to accessing quality obstetric care .......................................................................................... 5 Politics, economic development and government health expenditure...................................... 8 Health status and health care provision in Malawi ............................................................................ 9

The missing perspective of midwives ............................................................................................. 12

Chapter 2: Theoretical considerations .................................................................................................. 13

Theoretical assumptions ...................................................................................................................... 13

Hospital ethnography ................................................................................................................................ .. 14 The multi-level perspective....................................................................................................................... 15

Theoretical concepts .............................................................................................................................. 17

Coping and survival ...................................................................................................................................... 17 The professional midwife as a holistic person .................................................................................. 18

Study questions ........................................................................................................................................ 19

Chapter 3: Methodology and study setting........................................................................................... 21

Access to the field and time of the study ........................................................................................ 22 Study design and research methods ................................................................................................ 22

Self-administered questionnaire with QECH’s midwives ............................................................. 23 In-depth interviews: 13 midwives from the maternity wing ...................................................... 24 Stakeholder interviews ............................................................................................................................... 26 Documentary sources ................................................................................................................................ .. 27 Participants feedback session: focus group discussion ................................................................. 28

Data management and analysis ......................................................................................................... 28 Ethical considerations ........................................................................................................................... 30 Reflections and limitations .................................................................................................................. 30

Chapter 4: Be(com)ing a midwife: a struggle or an easy career?................................................. 34

Choosing nursing and job-satisfaction ............................................................................................ 34

Reasons to join: “helping the poor and sick"...................................................................................... 34 Reasons to stay: “you achieve something when you save lives” ................................................ 36 Working in an urban referral hospital................................................................................................ .. 37

Coping with low salaries and great responsibilities .................................................................. 39

The salary.......................................................................................................................................................... 39 Expectations and expenditures: building a house, caring for dependants ............................ 41 Transport .......................................................................................................................................................... 42

Personal characteristics, attitudes and coping ............................................................................ 43

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Fear of contracting HIV and attitudes towards HIV positive patients ....................................... vi Emotion-focused coping and religion ................................................................................................ ... 45 Personal factors: personality and responding to overwhelming demands........................... 45 Gender and personal and interpersonal care .................................................................................... 47

Conclusion .................................................................................................................................................. 48

Chapter 5: Formal and informal education: ideals and practice.................................................. 49

Nursing and midwifery education .................................................................................................... 50

Courses, cadres and possible career paths.......................................................................................... 50 Education of the Gogo Chatinkha Maternity Wing........................................................................... 51 “I want to upgrade” and the hierarchy of knowledge..................................................................... 51

The ideal midwife and daily practice............................................................................................... 52

The ideal midwife .......................................................................................................................................... 52 Daily practice, routines and informal knowledge ............................................................................ 53 Lack of follow up and supervision in the clinical area ................................................................... 54

In-service education: “we have to be up to date”........................................................................ 56

Importance of in-service training ........................................................................................................... 56 Selection for courses: “they are fond of taking only Matrons”.................................................... 56 Sharing knowledge and needs assessment: “they just want to go for the money” ............ 57

Conclusion .................................................................................................................................................. 58

Chapter 6: The work environment: care provision in underequiped and understaffed wards.................................................................................................................................................................. 62

Facilities and essential items at the work environment........................................................... 63

Perceived availability of medicine.......................................................................................................... 63 Perceived availability of equipment ...................................................................................................... 65 Perceived availability of other materials and supplies.................................................................. 66 Facilities at the ward .................................................................................................................................... 68

“We sacrifice”: human resources in the government hospital............................................... 68

Ward coverage ................................................................................................................................................ 68 Consequences for daily practice: frustration and improvisation .............................................. 69 Government’s response: the Locum system and the consequences......................................... 70

Conclusion: Improvisation as a consequence of dealing with shortages........................... 72

Chapter 7: Discussion and conclusion: how to support midwives in helping women deliver safely................................................................................................................................................... 74

Survival, coping and the midwife as a holistic person .............................................................. 75 Multi-level approach to quality of care ........................................................................................... 77 Recommendations................................................................................................................................... 80

References........................................................................................................................................................ 82 Summary........................................................................................................................................................... 87 Appendixes ...................................................................................................................................................... 88 Appendix A. Characteristics of study populations............................................................................. 88 Appendix B. Questionnaire midwives all wards ................................................................................ 89 Appendix C. Interview guide midwives ................................................................................................. 95 Appendix D. Interview guide stakeholders.......................................................................................... 97 Appendix E. Focus Group Discussion guide ......................................................................................... 98

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List of figures and pictures Figure 1. Total number of midwives on roster by response ................................................................. 23 Figure 2. A nurses’ prayer ..................................................................................................................... 36 Figure 3. Main mode of transport used by 31 midwives from questionnaire ...................................... 43 Figure 4. Highest attained training of 31 midwives in questionnaire ................................................... 51 Figure 5. Number of courses or workshops followed by 31 midwives in questionnaire...................... 57 Table 1. Satisfaction with salary by 31 midwives in questionnaire ...................................................... 39 Table 2. Salary locum shifts .................................................................................................................. 40 Table 3. Perceived sufficiency and adequacy of work environment characteristics ............................ 64 Picture 1. Hall at maternity wing .......................................................................................................... 32 Picture 2. After the FGD in the COM medical annex ............................................................................ 32 Picture 3. Left: Pamplets in several offices ........................................................................................... 33 Picture 4. Above: Midwife and midwifery student in sisters' office ..................................................... 33 Picture 5. Below: Blantyre market ........................................................................................................ 33 Picture 6. Midwife of the month pamphlets ........................................................................................ 60 Picture 7. At the entrance of KCN Blantyre Campus............................................................................. 60 Picture 8. At the parking lot of KCN Blantyre Campus .......................................................................... 61 Picture 9. Holy Family Mission Hospital in Phalombe........................................................................... 61 Picture 10.Chitenjes .............................................................................................................................. 65 Picture 11. Stock of delivery packs at QECH Labour ward .................................................................... 65 Picture 12. Documentation room at Labour ward ................................................................................ 65

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List of abbreviations and acronyms ANC HIV/AIDS AMAMI ARV BEMOC CEMOC COM COT CHAM DFID EHRP EMOC ENM FGD FIGO HR ICM IDI(s) KCN K MDG MDHS MMR MOH NMCM NMT NSO NGO NMT Obs&Gyn PNC QECH RH RNM SAP SIC(s) SSI(s) SWAp TBA UNFPA UvA WHO

Antenatal Care Human Immunodeficiency Virus / Acquired Immunodeficiency Syndrome Association of Malawian Midwives Anti Retroviral Drug Basic Emergency Obstetric Care Comprehensive Emergency Obstetric Care College of Medicine Chathinkha Operation Theatre Christian Health Association of Malawi Department for International Development (UK) Emergency Human Resources Program Emergency Obstetric Care Enrolled Nurse-Midwife Focus Group Discussion International Federation of Gynaecology and Obstetrics Human Resources International Confederation of Midwives In-Depth Interview(s) Kamuzu College of Nursing Malawian Kwacha, Malawi’s national currency Millennium Development Goal Malawi Demographic and Health Survey Maternal Mortality Ratio Ministry of Health (Malawi) Nurses and Midwives Council of Malawi Nurse-Midwife Technician National Statistical Office Non-Governmental Organization Nurse-Midwife Technician Obstetrics & Gynaecology Postnatal Care Queen Elizabeth Central Hospital Reproductive Health Registered Nurse-Midwife Structural Adjustment Program Sister(s) in Charge Semi-Structured Interviews Sector Wide Approach program Traditional Birth Attendant United Nations Population Fund Universiteit van Amsterdam [University of Amsterdam] World Health Organization vi


Map of Malawi

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Chapter 1: Introduction and context: midwifery in Malawi There are some patients who feel that we are not really caring for them. While actually, as I said, it’s a very busy ward, and there are so many patients who need to be taken care of. Then there comes a very sick patient, and you turn to that patient and then some patients think you are favoring them. They don’t know what you are doing; they don’t know that the other patient is more priority to you than they are. So they feel they are not being taken care of. So when they come ask you, when you try to explain them, they don’t listen. So they talk a lot, you know, amongst themselves. So instead of maybe explaining them, you just shout at them, you just tell them: ‘you don’t know what you are saying’. And then you get so harsh on them, you get so hard on them. Another example is in Labour ward, you are expecting good results in delivery, but she [the woman in labour] is not performing well. So you try harsh words on her, like if you don’t deliver now, your baby is going to die, all sort of words. They feel they are being shouted at, they are being insulted, when basically you are trying to help them, but then they just don’t understand. . . It’s just a different way of speaking to them. Some will say you are shouting at them when you’re not. Some do [shout], yeah. I can’t really blame them all, but some nurses it’s just their attitudes, they are just not good with patients.

Above you find a fragment of an interview with Chimemwe (aged 23), who works in the Obstetrics and Gynaecology ward, at the Queen Elizabeth Central Hospital (QECH). According to general Western-based ideas of the ideal nurse, a nurse is a kind, caring, knowledgeable, efficient, precise and orderly person, and usually a woman. According to the young, recently graduated midwife who was quoted above, it seems that the reality does not always match this ideal. Chimemwe says midwives may get overwhelmed by the workload which results in tiredness and possibly agitation something others may call a “bad attitude” or “inappropriate behaviour”. Women who are hospitalized in the Gogo Chatinkha Banda Maternity Wing (from now on referred to as the maternity wing) are there for assistance during labour or because they have other reproductive health (RH) care needs. This thesis concerns the quality of care given to these patients, and how the midwives working at the maternity wing perceive the quality of care. It also concerns the lives of the midwives and their experiences. They have to face the resource poor hospital setting and an overwhelming number of patients every day; how they cope with the demand of providing optimal care within the circumstances is also described. This study is of importance because there is increasing criticism of the midwives’ performance in local newspapers, and there are various reports that the quality of care is not up to standard (Kongnyuy et al. 2009; Leigh et al. 2006 & Seljeskog et al. 2006, Simutowe 2007; Kandiero & Simutowe 2007; Namadzunda 2010; Anonymous 2007a; Anonymous 2007b). The good reputation of midwives in Malawi is being challenged by these critical reports, especially the rare but appalling cases on which the media tend to dwell. Due to difficult working conditions, many midwives have decided to leave the government to work in NGOs or private hospitals, or have even sought a different profession (Palmer 2006:31). With this high shortage of midwives, it is important to know what motivates them to join the profession and to continue striving for optimal maternal care, and so to reduce the maternal morbidity and mortality. In Malawi, the maternal mortality ratio (MMR) is among the highest of Sub-Saharan Africa and the world. It has fallen from 1,120 per 100,000 live births in 2000 (National Statistical Office [NSO] 2005:247) to 807 per 100,000 live births in the period 2000-2006 (NSO & UNICEF 2008:268). Despite the decrease in maternal mortality, too many women still die from avoidable causes. One of 1


the strategies to reduce MMR is by ensuring the presence of skilled attendants at birth. This presumes that access to skilled attendants during delivery will lead to better health outcomes. An important question, however, is what role does the skilled attendant (in this study the midwife) play in the delivery of good maternal care? In the aforementioned quote, Chimemwe says that in some cases she feels midwives do not have correct attitudes towards patients, but also that patients fail to understand the pressure created by having to work in such adverse conditions. In a developing country such as Malawi, the resources needed to provide midwifery care are far from optimal, which influences the quality of care provided. Furthermore, with the high prevalence of HIV/AIDS and the high number of people living in extreme poverty, life in Malawi in general is characterized by extreme difficulties. This affects midwives´ private lives as well. My personal interest in the motivations of health workers started during my fieldwork in Guatemala for my Bachelor’s thesis in Interdisciplinary Social Science at the University of Utrecht. While studying the reasons the local population gave for seeking or not seeking different forms of health care, I became intrigued with the motivations and experiences of health workers in developing countries. Before entering the University of Utrecht I studied one year of Nursing at the University of Applied Sciences of Arnhem and Nijmegen, where I became acquainted with the nursing profession. In Guatemala, I wondered what it would be like for nurses to provide care in such adverse conditions, and what quality of care entails in a developing country. I also wondered how health workers keep faith in their practice when they cannot fulfil the promises of the ideals which prevail in globalized nursing and medicine. It is central in this study to look at the personal, socio-cultural and economic context of midwifery care providers in Malawi. This global profession is embedded in and shaped by this local context, which influences the abilities of midwives to provide quality midwifery care. In the next paragraphs I will give some definitions and explore the factors that may influence the quality of midwifery care in Malawi by describing the setting and the wider context of the topic. I will continue in Chapter two with an explanation of the theoretical concepts which shaped the study and analysis. In Chapter three I describe the study populations and the research methods and reflect on how these were implemented. Chapter four to six form the empirical body of the thesis. In Chapter four, I will explain what attracted midwives to the profession in the first place, and how their personal, economic and socio-cultural background influences their care provision. In Chapter five a description is given of how midwives perceive their pre- and in-service training, and how this prepares midwives to work at the wards. In Chapter six, the work environment is described. Issues like the availability of medicine and equipment, human resources (HR) management and motivations are looked at from the perspectives of the midwives. In the final Chapter, I will discuss the findings and give recommendations for improvement on the basis of these findings.

Literature review of context Obstetric or midwifery care? The terms “obstetric”, “maternal” and “midwifery care” are often used interchangeably in the literature and refer to “health care provision for women during pregnancy, childbirth, and the postpartum period (from childbirth up to 42 days after childbirth)”. In some definitions, maternal health services also include family planning and pre-conception care. In a joint statement by the WHO, FIGO and ICM on the critical role of the skilled birth attendant in making pregnancy safer, the

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terms “obstetric” and “midwifery” are avoided (2004). The authors define a skilled birth attendant as followed: An accredited health professional – such as a midwife, doctor or nurse - who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns. (WHO 2004:1).

In this study, the terms obstetric care and midwifery care are seen as synonyms. I will refer more often to midwifery care than to obstetric care, since midwives usually provide midwifery care, which is care in uncomplicated deliveries. “Obstetric” refers to care rendered by medical assistants, clinical officers and physicians when deliveries are complicated, usually in district hospitals and referral hospitals (tertiary line). However, obstetric care is also provided by midwives who are trained to perform obstetric tasks such as a vacuum extraction. For convenience I will follow the convention of using the term “obstetric” when discussing literature about emergency obstetric care. However, for the title and study question I have chosen to use “midwifery” care, because this term stands closer to what midwives are professionally providing: care to women during (uncomplicated) pregnancy, childbirth and the postpartum period. Nurse or midwife? In 1975, the Malawi Head of State directed that all nurses with a diploma or certificate in nursing are also required to have knowledge of midwifery skills, so they can serve the population best when deployed in rural areas (KCN syllabus 2009). Before this, it was only compulsory for nurses to take a post-basic year of training in midwifery if they wanted to work at the Labour ward. By 1982, 80 percent of all nurses also graduated as midwives (Sagawa 1982: 26). Currently, the majority of the nurses are also midwives, hence the words “nurse midwives”, “nurse/midwives” and “nursemidwives” found in several publications (see a.o. Kamwendo 1999:301 and Kafulafula et al. 2005). However, some publications still use “nurses” while also meaning “midwives” (Grigulis et al. 2009 and Palmer 2006) or simply “midwives” (Kongnyuy et al. 2008; 2009a; Leigh et al. 2008). Throughout this thesis I will use the term “midwives”, because all nurses in the Labour ward have completed their midwifery certificate. More specifically, I will refer to three different cadres of midwives: Enrolled Nurse Midwives (ENMs), Nurse Midwives Technicians (NMTs) and Registered Nurse Midwives (RNMs). ENMs were trained according to a program that no longer exists, in one of the nine Mission Schools run by the Christian Health Association of Malawi (CHAM) and several other schools. Currently, nine Mission Schools and the School of Nursing (in Zomba) offer three year programs to train the now existing equivalent of the enrolled cadre: NMTs. The respondents sometimes used the name NMT interchangeably with the enrolled cadre. None of them was able to explain what has changed in the curriculum, and since when. However, those who call themselves ENM are aged 30 years and above while younger graduates from the same institutions refer to themselves as NMTs. The third cadre is that of the Registered Nurse Midwife (RNM). There are two types of RNMs: those with a bachelor’s degree and those with a diploma. RNMs with a bachelor’s degree are trained at Kamuzu College of Nursing (KCN) or Mzuzu University for three years in general nursing, followed by a post-basic year in midwifery (a few years ago the general nursing program was four years). The diploma RNMs are trained for 2 years, after their NMT program, at KCN or Malawi College of Health Sciences (MCHS). These two nursing colleges offer similar diploma 3


programs and have recently begun collaborating. In brief explanation, the RNMs who had their training at MCHS have a diploma, while RNs from KCN can have either a diploma or a degree depending on the program they followed. A more detailed description of the cadres including entry requirements will be provided in Chapter five. Finally I want to point out that “midwife” means “with woman” (KCN syllabus 2009). This means the word “midwife” is not gender-specific, though the majority of midwives are, indeed, female. However, when walking around the KCN campus in Blantyre it becomes apparent that the overall majority of the students are male, which may indicate that more male midwives than female midwives will graduate in 2010. However, in this context the midwife will be referred to as “she” unless when I am talking about my only male midwife respondent, Tiyanjane, for no other reasons than that it will simplify my writing. Maternal mortality - a global picture Worldwide 535,900 women died in 2005 of complications during pregnancy or childbirth (Hogan et al. 2010). Less than 1 percent of pregnancy-related deaths occur in developed countries. SubSaharan Africa and Southern Asia account for 89 percent of all maternal deaths, equally divided over both continents. The life-time risk1 of maternal death is 1 in 18 in Malawi (UNdata 2009). This number stands in contrast to the average in developing countries (life-time risk of 1 in 76) and the Eastern and Southern African average of 1 in 29. The difference is especially great considering that the average for industrialized countries is 1 in 8,000 (ibid). Both within and between countries, maternal mortality is one of the health indicators that shows the greatest gap between the rich and the poor (UN 2009). Since 1987, several safe motherhood initiatives have called for more focus and awareness from health workers, policymakers, politicians and international donors on maternal health issues (Rosenfield & Maine 1985; Maine & Rosenfield 1999; Rosenfield et al. 2006; Hogan et al. 2010). The focus on maternal health was sharpened in 2000 when the reduction of maternal mortality was made one of the eight goals for development in the United Nations Millennium Declaration (Millennium Development Goal [MDG] 5). MDG 5 has two targets: to reduce the maternal mortality ratio by 75 percent between 1995 and 2015, and to achieve universal access to RH by 2015. Since most of the maternal deaths worldwide occur during childbirth and the immediate postpartum period, safe motherhood initiatives argue that access to skilled attendants during pregnancy and childbirth, and to emergency care in the event of complications are the keys to MMR reduction (Freedman et al. 2007: 1384; Ronsmans et al. 2006: 1189). One of the indicators to measure progress towards MDG 5 is skilled attendants: the target is that by 2015, 90 percent of all deliveries should be in presence of a skilled attendant (World Health Organization [WHO]; International Federation of Gynecology and Obstetrics [FIGO] & International Confederation of Midwives [ICM] 2004). However, MDG 5 has shown the least progress of all MDGs worldwide (UN 2009). Skilled attendants at birth in Malawi In the Malawi Demographic and Health Survey (MDHS), a sample of 11,698 women (aged 15-49) from all 28 districts in the country were asked about all live births that occurred in the five years preceding the study (NSO 2006:4,6,133). This study found that the coverage of obstetric care services is high for antenatal care (ANC), very low during delivery, and low for postnatal care (NSO 1

Life-time risk: the estimated risk of an individual woman dying from pregnancy or childbirth during her lifetime, based on maternal mortality and the fertility rate in the country (WHO 2004).

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2005: 134,135, 142). The coverage of ANC services by skilled attendants seems high at 93 percent, but if women are to benefit from ANC services, the visits should be well-timed and the care provided should be of sufficient quality (2005:134). The MDHS found that only 57 percent met the need to go four times, and only 8 percent made a first visit before the recommended fourth month of pregnancy (ibid: 135). The late first visit, the low number of visits and the limited content of ANC given indicates that many women miss out on the intended benefits (NSO 2005: 163). Only 56.1 percent of all deliveries occur in the presence of a skilled attendant: 50.1 percent by midwives and 6.0 percent by doctors or clinical officers. In the other cases, women delivered alone or in the presence of a traditional birth attendant (TBA), a relative, a friend or others (NSO 2005: 142). According to the MDHS authors, PNC is an important component of obstetric and neonatal care, especially with respect to the prevention and management of complications. PNC is recommended for all women from the moment after the birth of the baby and placenta to 42 days after delivery (NSO 2005: 145). Only 31 percent received PNC, of which 10 percent received PNC after delivery in the presence of a skilled attendant, and 21 percent received care within two days after delivery, upon arrival in a health facility. According to the MDHS, the results indicate that the utilization of obstetric care services is low, in particular during delivery and during the PN period. For all three types of obstetric care, utilization is more common for women residing in urban areas, with higher levels of education and from a higher wealth quintile. Thus, these numbers are an overestimation of the utilization of maternal health care services in rural areas. Nationwide, 42 percent of the women use free government-run facilities, and only 15 percent makes use of private facilities such as Christian Heath Association Malawi (CHAM) administered mission hospitals and other private or NGO clinics (NSO 2005:141). Age is not related to the utilization of ANC, but for care during delivery, women younger than 34 years are more likely to seek skilled attendants in a hospital or clinic. For PNC, older women are more likely to seek care (NSO 2005: 133, 140, 145). The authors of the MDHS argue that strategies should therefore focus on pull factors for health facility care or bringing skilled care to the home (NSO 2005: 145). In this study, the focus lies on the first strategy: pull factors from the health facility for PN and delivery care. Barriers to accessing quality obstetric care The following quote is an excerpt of a speech Dr. Taulo (obstetrician QECH) gave during a conference, organized by the College of Medicine (COM) (University of Malawi) and the Centre for Reproductive Health: In the hospital, we oftentimes blame the patients for presenting late with their medical problems. But we also have a responsibility in the hospital, which we do not always manage to comply to. We have to be on top of the patients complaints; we do not always give the patients the attention they are supposed to get. (Conference “Research for Action: Promoting Maternal and Newborn health� 2009)

It illustrates that delay in providing care to save mothers’ lives can be caused by a patient presenting late, but also by the health care system, due to inadequate management of complications. Thaddeus & Maine (1994) conducted a comprehensive literature review on the reasons for delay in utilization and receiving adequate obstetric care, which leads to high maternal mortality levels. They divided the reasons in three categories of delay: (1) delay in the decision to seek care, (2) delay in arrival at 5


the health facility and (3) delay in the provision of adequate care. Factors that influence delay in actual (timely) provision of adequate care at the institution, can be related to the referral system; availability of supplies, equipment and trained personnel; and competence of available personnel (Thaddeus & Maine 1994: 1103-1104). According to Campbell et al. (2000), increasing attention is being paid to patients’ subjective experiences of care provision in quality of care assessments. Patients’ perceptions of the quality of care, influences the first delay. Campbell et al. explain quality of care is characterized by access and effectiveness, and effectiveness should be met in both clinical care and interpersonal care. Clinical care refers to the bio-medically oriented care which health workers provide, while interpersonal care describes the interaction between health care providers and their clients (ibid: 1613). Quality of care can thus be assessed from the perspective of the receiver, and directed towards measuring clinical care, which can be done according to (inter)nationally defined RH indicators. Several studies have been done in Malawi, which addressed both the quality of clinical and interpersonal obstetric care. I will first discuss review what studies have been found regarding the quality of clinical obstetric care, followed by interpersonal aspects of care. Clinical care In order to measure clinical care and progress towards MDG5, facilities in Malawi are screened in several studies on their ability to provide the so-called Emergency Obstetric Care (EMOC) signal functions and UN process indicators. In Malawi, health clinics and district hospitals provide Basic Emergency Obstetric Care (BEMOC), and referral hospitals in Malawi (such as QECH) provide Comprehensive Emergency Obstetric Care (CEMOC) is provided. The signal functions (that is, what should be provided) for BEMOC facilities are the following: 1) Availability of injectable oxytoxic drugs 2) Availability of injectable antibiotics 3) Availability of injectable anticonvulsants 4) Manual removal of placenta 5) Removal of retained products (for example manual vacuum aspiration) 6) Assisted vaginal delivery (for example vacuum extraction (Source: Kongnyuy et al. 2009)

CEMOC facilities should be able to provide all six BEMOC signal functions plus blood transfusion (7) and caesarian section (8). The UN process indicators are for example the population-based caesarean section rate, the proportion of all births in EMOC facilities and the case fatality rate (proportion of women admitted with obstetric complications who die), for which the UN gives recommended levels. Several studies assessed obstetric care facilities in Malawi (Konnyuy et al. 2009; 2009a; Leigh et al. 2006). Kongnyuy et al. (2009) assessed all obstetric care facilities in three selected districts in the Central Region in Malawi and found that only one in 60 rural health facilities was able to provide all six BEMOC signal functions. Of the 13 hospitals which were assessed, only nine were operational, meaning that these nine facilities met all BEMOC and CEMOC signal functions. None of the four remaining hospitals could even provide all six BEMOC signal functions. Leigh et al. (2006) found in their random sample of 25 percent of health facilities that more than half (56 percent) of all hospitals could provide all CEMOC functions, but 35 percent are missing at least two of the eight signal functions (2006:108). They conclude that the most important reason for failure to provide 6


signal functions three to six (removal of retained products, and assisted vaginal delivery and manual removal of placenta), is that there was no health personnel authorized to carry out such procedures. One of the UN process indicators used in both studies was case fatality rate, which was found to be too high compared to the UN recommended level (<1 percent): 2 percent in Kongnyuy et al. (2009) and 3.4 percent in Leigh et al. (2006). The authors state that it is not surprising that utilization of maternity services is below expectations when the continuous availability of skilled attendants at birth cannot be ensured (Kongnyuy et al. 2009). Several health worker factors were found in a study of the causes or contributing factors of 43 maternal deaths which occurred in nine hospitals in three different districts of Malawi, in another study by Kongnyuy et al. (2009a). The major factors were: inadequate resuscitation (69.8 percent), lack of obstetric life-saving skills (60.5 percent), inadequate monitoring (55.8 percent), initial assessment incomplete (46.5 percent) and delay in starting treatment (46.5 percent). Other category three delays found in this study was the lack of blood for transfusion (20.9 percent) (Kongnyuy et al. 2009a: 17). These three studies stress the importance of knowledge and skills of the health workers, who have to be trained in life-saving skills and in provision of the signal functions in order to work effectively. Interpersonal care Interpersonal care includes: “the management of the social and psychological interaction between client and practicioner” (Donabedian 1980 in Campbell et al. 2000:1613). Skills which are needed for quality interpersonal care are according to Donabedian: communication, building a relationship of trust, understanding and empathy with the patient, humanism, sensitivity, responsiveness, explanation and discussion about symptoms and involvement of clients in decisions about their management (ibid). Quality in interpersonal care can be measured according to these characteristics (Campbell et al. 2000:1613). An illustration of the bad reputation of the health care is the following, which is an excerpt from a newspaper article from the Nation (10 October 2006), which is together with the Daily times one of the two most popular national newspapers: Phalombe decries maternal deaths Health officials in Phalombe have decried the escalating continued maternal deaths in the district, saying they can be avoided. Speaking during a consultative meeting with traditional birth attendants (TBAs), medical officers, religious and traditional leaders . . . Acting district health officer Tommy Mthepheya said it was sad the problem persists despite plans put in place at district level to stop deaths of mothers during and after delivery . . . Mthepheya said most of the deaths are due to delays in ferrying expectant mothers to hospital, complications during delivery and HIV/AIDS. He called on traditional leaders and TBAs to always refer women to hospital in time if deaths of maternal deaths are to drop. But senior chief Mkhumba of the district said the deaths must not be blamed on TBAs alone, but health officers as well, saying their behaviour forces women to stay away from hospital and seek help locally. ‘How do you expect women to go to your hospitals when you call them names, scorn them and abandon them to deliver on their own?’ charged Mkhumba. The chief said government must rebuild its image to that of a caring entity first before it complains that women are delivering at home. [emphasis added]

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Senior Chief Mkhumba complains about the attitudes of health workers, which prevents women to seek care from skilled attendants. In a Ministry of Health (MOH) study which took place in 166 health facilities in four districts they found six reasons which contributed to the category three delay: unrealistic demands on the mothers (e.g. asking them items in preparation for the new baby), lack of technically competent staff, clinic being closed at night, bad attitudes of health staff (shouting and beating of patients), negligence during labour and delivery, shortage of drugs and mistreatment of the ambulance driver (MOH 2005). Another study about the barriers pregnant women in Malawi experience in gaining access to care, found that the first and a major barrier is suboptimal quality of care including communication, attitudes and cooperation within the health care system (Seljeskog et al. 2006:66). Other factors such as cultural barriers (traditional views of pregnancy and perception of danger signs) and unsatisfactory availability in terms of distance and cost were also found (ibid: 72-73). The authors stressed that sub-optimal care is not only caused by a lack of staff, equipment and drugs, but also by poor interpersonal skills and attitudes. Therefore “an enhanced awareness of the rural pregnant women's psychological vulnerability and insecurity” is necessary. According to Seljeskog et al., health workers need to be better educated and trained on how to include this in their practice: In rural Malawi, a more individualised professional maternity care is needed, that takes into account the particular woman's needs, preferences and insecurity, and that meets her as the service-minded institution it is meant to be. (Seljeskog et al. 2006: 74)

The authors also pointed out that having a guardian present during labour could help to improve the quality of care from the patients’ perspective (2006: 74). This point was also discussed at the Conference “Research for action: promoting Maternal and Newborn health” (2009). In Malawi, hospitalized patients are accompanied by another adult who takes care of them during their stay. These adults are called guardians, who cook for the patient and wash their clothes, and if necessary wash the patient. They usually stay outside the hospital in basic guardian shelters if they do not live close enough to travel back and forth daily. At the conference a study was presented which revealed that satisfaction levels about delivery care provision in QECH were higher among women who were allowed to bring a guardian during delivery, who were previously prohibited to enter Labour ward (Conference 2009). These guardians could serve as “advocates” for the patients during labour which could benefit the care. In summary we can conclude that the quality of clinical and interpersonal care is found to be poor: specifically in terms of availability and readiness to assist of the staff, and the capacity and skills to deal with obstetric complications (see Kongnyuy et al. 2009, Leigh et al. 2006, Palmer 2006; Seljeskog et al. 2006). To place these findings in the wider political and economic context I will now give a short summary of how the rule and economic choices of Banda and Muluzi (under pressure of international donors and governments) has influenced the health care system. Thereafter I will describe the impact of these developments on the health care infrastructure and access to health care, as well as the health status of the people of Malawi. Politics, economic development and government health expenditure This paragraph is mainly based upon the first chapter of the book from Van den borne (2005), who draws upon reports and studies to describe how Malawi developed from a British colony, into the multiparty democracy that it is now. She summarizes that, Malawi came under the rule of Kamuzu 8


Hastings Banda directly after gaining independence from the British in 1964. He declared himself “president for life” and ruled under the ethos of “Unity, Loyalty, Obedience and Discipline” (Lwanda 1996: 24 in 2005: 32). The income of the country relied on the export of products such as tobacco, sugar, coffee, cotton, pulses, groundnuts and macadamia nuts, grown at large-scale specialized estates (Mkandawire et al. 1990: 35 in 2005:33). Although the first 15 years of Banda’s time in office, the economy grew strongly, he did not diversify the country’s economy and failed to improve national development and increase social welfare (Lwanda 1996 & Kaluwa et al. 1992:1,4,12 in 2005:33). Rural poverty was not alleviated and peasants remained “heavily dependent on good land, good rains and good harvest to survive” (Mkandawire et al. 1990:38 & Lwanda 1996:15,23 in 2005:33). Under Banda the country began to borrow heavily. According to Motala and Tørres, the country has achieved little economic progress since 1970 (Motala and Tørres 2000:29 in 2005:35). Under pressure of many donors who refused to provide any financial and technical support unless Malawi would implement the World Bank’s Structural Agreement Program (SAP) the country was forced to adopt this macroeconomic stabilization program (Van den borne 2005:34). This affected the people in the country negatively: “Jobs became scarce, wages fell, purchasing power diminished, the cost of living rose and socioeconomic and health indicators worsened” leaving especially the low-income urban households suffering significantly (Roe 1992:6 in 2005:34). The SAP had significant consequences for the health sector, because the government was forced to decrease its per capita expenditure on health. The expenditure is still low at US$ 20 per capita per year (WHO 2008) as compared to the average of US$ 26 in other countries with a GNP per capita under US$ 1,200 (Jha et al. 2002:2037). Coupled with a high population growth rate (the population grew from 4 to 8.2 million between 1964 and 1988) and one million Mozambican refugees, the health care system was overstretched by 1993-1994 (Ngalande-Banda & Walt 1995). Despite the negative consequences, the World Bank’s concept has not been abandoned and still undermines the socio-economic and political structure of countries like Malawi (Van den borne 2005:35). Under all the international economic and political pressure, president Banda held a referendum in 1993 in which people voted for a multi-party democracy. A year later, Muluzu from the United Democratic Front (UDF) won the presidential election. He implemented a parliament with three main political parties and a bill of rights. But despite the hopes of the population that a democratic government would bring about a better future, their problems worsened: the rich became richer and the poor became poorer. In 2002, the UDF government adopted the World Bank’s strategy to eradicate poverty: the Poverty Reduction Strategy Paper, whose acronym was popularly said to stand for “the Poor Remain Substantially Poor” program (Van den borne 2005). Health status and health care provision in Malawi There are a lot of things which are happening that are interfering with the quality of care that our patients should receive.

Lennie Kamwendo, former president Association of Malawian Midwives (AMAMI) According to the WHO, Malawi is one of the poorest countries in the world, facing the “triple threats” of HIV/AIDS, food insecurity and poor infrastructure (WHO 2008). Life-expectancy fell from 52 years in 1992 to 41 in 2004, largely due to the HIV/AIDS epidemic (ibid). The prevalence of HIV/AIDS in Malawi is among the highest in the world, and is estimated by the MDHS to be 12 percent for adults aged 15-49, and peaks at age 30-34 with 19 percent (NSO 2005:225). 9


Heterosexual contact is the principal mode of HIV transmission, while mother-to-child transmission (MTCT) accounts for about 25 percent of all new HIV infections (ibid: 225). Food insecurity has increased due to the high cost of fertilizer, which, coupled with irregular rains from 2002 to 2005, has made Malawi dependent on imported maize from South Africa (NSO 2005:2). Over half of the population of around 13 million (based upon the 12,884,000 estimated population in 2005 (UN Population Division in WHO 2008)) is food insecure, and 65.3 percent of the population is unable to meet their daily consumption need (Palmer 2006:28). Almost half of all children under five years (48 percent) are stunted. The underweight parameter is around 22 percent and more than 50 percent of all children under five are malnourished (WHO 2008). According to the MDHS, malnutrition remains one of the major public health and developmental problems which threatens child and maternal health and development. Deficiency-rates of vitamin A, iron/folate and iodine leading to chronic malnutrition have been high and have remained unchanged for decades (NSO 2005: 163). Malawi’s health care system consists of formal and non-formal health care providers. The formal health care in Malawi is provided by government facilities and private facilities, under which the Christian Health Association of Malawi (CHAM) falls (Leigh et al. 2008). The 28 districts in Malawi have four central (tertiary) hospitals, of which QECH with its 1250 beds, is the biggest (QE statistical office 2009). The other referral hospitals are in Zomba, Lilongwe and Mzuzu. Then there are two psychiatric hospitals, 22 government district hospitals and 46 CHAM and private hospitals. In government hospitals, no user fees have to be paid, only when one chooses to be admitted at a paying ward. In CHAM facilities, payment for services is since recently no longer needed, through the Service Level Agreement (SLA). With this policy, an essential health package is delivered through CHAM facilities where the government has no or low coverage. CHAM can bill the services provided at the government. In practice, this means patients need to visit the District Health Officer first to receive a permit for ‘free care’ at CHAM. Without this permit, they have to pay for the services as usual, unless it is an emergency (personal communication accountant CHAM hospital). Besides hospitals, 374 health centres plus smaller health posts and dispensaries provide diverse forms of health care (Leigh et al. 2008: 108; Palmer 2006:28). Other than these formal health care facilities, traditional healers, TBAs and grocery store owners (as providers of drugs such as Panadol, the local name for paracetamol) are also important non-formal health care providers (Tolhurst et al. 2008: 95). These non-formal health providers are said to be especially important among communities where there are a number of barriers to accessing formal health services (Nhlema et al. 2004 in Tolhurst et al. 2008: 95). No numbers on coverage were given. Palmer says the health care infrastructure in Malawi is reasonably well-developed with its many health care facilities, but “in overwhelmingly poor condition” (Palmer 2006:28). The author illustrates this with an example of a MOH study, saying the buildings are there (397 health centres), but the majority (243) had no operational water source or operational communications system (radio or telephone) (244); and about half had no operational electricity (204). The poor condition of the health care system is not only due to the poor state of the infrastructure, but also due to an enormous shortage of staff. The HR levels in the health sector have declined since the mid-1990s, while the demand for services kept growing, particularly given population growth and high levels of HIV and AIDS (Palmer 2006:26). In 2004 an official MOH report stated that the health sector is “facing a major, persistent and deepening crisis with respect to HR” (Ministry of Health 2004, cited in ibid). Staffing levels are low in Malawi even compared to other African countries, with only one physician and 26 nurses per 100,000 population (Palmer 2006: 29). The vacancy rate for nursing and 10


midwifery posts in the government service is as high as 77 percent (Grigulis et al. 2009: 1196). Dorothy Ngoma, president of the NONM said the following about the shortage in an interview I conducted (2009): So if currently, in the whole country in government we have about 4,000 nurses. With a 76 percent vacancy rate probably it means you just do times three isn’t it? Yeah. So we should have had 12.000, according to government resources. Not according to need but according to the budget and what Malawi can afford because it is a poor country. So according to Malawi it can afford to pay 12.000 nurses. . . But because the nurse-midwives are not there, Malawi only has 4.000 in post, this is approximately the 30 % so a 100 % is 12.000 isn’t it? So we are short by 8.000. That doesn’t necessarily mean that 12,000 would equate as to Norway or Britain or whatever . . . How good do you think the quality of care is? Because the quality I said, starts with the numbers.

Ngoma is saying the staff shortage is one of the leading factors negatively influencing the quality of care. Palmer gives three major reasons for the human resource crisis: poverty, HIV/AIDS related absence and poor retention (2006: 30-31). First, the Malawian government could not maintain the costs of training and employing enough health sector staff to meet the growing demand, which also had to do with the low expenditure per capita on health due to SAP (2006:30). Second, HIV/AIDS causes direct losses of health staff by their increased risk of infection and illness and death due to infection. A study by Harries et al. found an annual death rate of 2 percent (Palmer 2006:31). Also, HIV/AIDS indirectly lowers staffing levels by instilling fear of infection (Palmer 2006:30-31 and Mondiwa & Hauck 2007:218), and by causing loss of staff time due to funeral attendance and illness of others in their family or community for whom they have to care (Palmer 2006: 30-31). In this study, one midwife reported she was sick “on and off”. She possibly meant that she is HIV positive and could therefore not be present the same number of working hours as before. Third, poor retention is a consequence of low levels of job-satisfaction in the public health sector. For several reasons, an NMCM estimated 1,200 qualified nurses living in Malawi decided to move out of the public sector to work in private institutions or NGOs, or to switch to other less stressful professions (Palmer 2006:31). Additionally, a significant proportion of nurses migrated to other countries (Grigulis et al. 2009:1195-1196). From 2000 to 2006, almost 400 nurses emigrated, mainly to the UK (Palmer 2006:31). According to Seljeskog et al. (2006), low job-satisfaction also influences midwives’ coping strategies. The authors quote the Malawian Obstetric Quality of Care Assessment (2003), which found that 60% of the health workers in Malawi are dissatisfied with their salaries, accommodation or other aspects of their working conditions (Seljeskog et al. 2006:71). Additionally, they propose midwives possibly experience fatigue and helplessness, because of a working situation with little supervision, poor feedback and few prospects of improvement in the future (2006: 71). Palmer also mentions these three reasons for low job-satisfaction and adds that difficult working conditions; lack of essential drugs, supplies and equipment; limited career opportunities; high and uneven workloads and inequitable access to training; inadequate housing and the lack of a clear deployment policy all contribute to midwives’ low morale and frustration in Malawi (Palmer 2006: 31). The UK Department for International Development (DFID) and the joint United Nations program on HIV/AIDS (UNAIDS) have agreed that a comprehensive approach, as opposed to piecemeal donor support (vertical approaches and uncoordinated initiatives), should be implemented as the “Emergency Human Resource Program” (EHRP) (Palmer 2006:28). This is a six11


year program (2005-2010), aiming to expand the training capacity of health workers, improve retention and re-engage personnel to rural and government health facilities (O’Neil et al. 2010:1). An example of an intervention to improve retention is the implementation of a bonding system, which requires nurses and midwives who graduate to remain in duty for two years after graduation at a government (60 percent of all graduated) or CHAM facility (40 percent). The direct costs of this relief program were US$95,587,010, of which the three largest donors were the Government of Malawi, the Global Fund to Fight Aids, Tuberculosis and Malaria, and DFID. Numerous other organizations contributed with technical and financial support through a collaboration network called the Sector Wide Approach program (SWAp) (O’Neil et al. 2010:3,9).

The missing perspective of midwives What is striking in the studies on utilization and quality of care, is that health worker accounts are not examined (in Kongnyuy et al. 2009; Leigh et al. 2008) or only minimally paid attention to (in Seljeskog et al. 2006). By studying health care provision only by making an assessments of the clinical care, using a fixed (inter)national list of indicators; and looking at the interpersonal care only from patients’ perspectives, factors related to health workers’ motivations remain invisible. The studies from Seljeskog et al. (2006), Kongnyuy et al. (2009) and Leigh et al. (2006) conclude their results with the statement that service providers suffer an “attitude problem”. This refers mainly to skills of interpersonal care, although Kongnyuy et al. (2009) also stated that health workers did not possess the right clinical skills: the technical (midwifery) skills to do for example manual vacuum aspiration. This study aims to seek insight into health workers perspectives on quality of care. It has become clear from the literature review that a lack of material, economic and infrastructural resources have a negative impact on the utilization and quality of clinical provision of care. According to Kongnyuy et al. (2009) it is assumable that these conditions also contribute to a low staff morale and client-unfriendly behaviour. It is unknown however what midwives themselves think of the quality of care as it is provided by them, and whether they agree with the presumed low quality of interpersonal care as suggested in public and scientific reports and papers. Before one can come with interventions aimed to improve quality of care and increase health care utilization, it is important to know how midwives perceive the quality of care and investigate their motivation to work on the improvement of quality care. This study will explore what role midwives think they have in quality of midwifery care, and how quality of midwifery care can be improved, while recognizing that both financial and material resources are scarce. This is of importance in order to improve both the reputation of care services and the management and diagnosis of obstetric complications. Thaddeus and Maine stressed that adequate obstetric (or midwifery) care provision will contribute to reducing maternal mortality both indirectly and directly. Indirectly, because it provides evidence on how to increase the level of utilization, and directly through an improvement of obstetric care provision itself. In the next chapter I will turn to the theoretical framework that was used to shape the study and the study questions.

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Chapter 2: Theoretical considerations In qualitative research it is very important to determine very precisely on forehand what the starting point is. (Mol 2008).

In this chapter I will discuss the difference between critical and clinical medical anthropology and explain which three theoretical assumptions have guided this study. This framework will help to analyze in what way macro level factors influence midwifery care provision in Malawi. In the second part of this chapter I will discuss the theoretical concepts that were used to gain insight into issues at the micro level of interaction and midwives’ daily practice.

Theoretical assumptions Good classifies four different theoretical frameworks, which can help in developing a framework which leads to a “genuinely anthropological account” of illness and the nature of medical knowledge (1994: 37). By discussing these frameworks briefly, I will clarify the difference between clinical and critical anthropology, and how I came to what I call critical clinically applied anthropology, thereby following Wright and Johnson in Baer (1990: 1011). The first framework Good describes is called the empiricist tradition, in which culture is seen as adaptation and the individual as someone making rational and voluntary choices. The second tradition is called cognitive anthropology and investigates how language and culture structure perception.2 Critiques towards studies within these traditions are that these studies provide no more than “common-sense” explanations and conventional knowledge about the individual in society (ibid: 47). They would explain too little about the societies being studied: “cognitive anthropology remains curiously innocent of social theory” (Keesing 1987: 387 in Good 1994:52). So if we want to study midwives’ perspectives from an anthropological point of view, the epistemology (culture as adaptation and culture as a shaper of perception) these frameworks offer us are not sufficient. These critiques led to a third approach which Good (1994) calls the meaningcentered tradition. The premise of studies in this tradition is that categories (such as sickness and health) are not natural but cultural. In Young’s words, disease has its ontological grounding in the order of meaning and human understanding (Young 1976 in Good 1994: 53). Ideas on sickness and health (or health care) are not based upon natural categories, but on the local meaning which is given to it. These categories are, according to studies in this framework, only knowable by interpretative activities (ibid: 53), which means that social scientists should aim to interpret a culture from its own internal point of view, thus, that of the respondents themselves (Fay 1996: 133). Studies which are conducted according to these premises are also called interpretative medical anthropology and clinical anthropology. Clinical medical anthropology can also be described as anthropology in health - a practice discipline with applied rather than theoretical (Baer 1990:1012; Tripp-Reimer 1980:21). Before I turn to an explanation of the fourth framework Good describes, critical anthropology, or anthropology of health, I will explain how the assumptions of the meaningcentred tradition have shaped this study. I will do so by using a relatively new form of research in medical anthropology, which is described by Van der Geest and Finkler (2004) as hospital ethnography. 2

For a more thorough and nuanced description of the frameworks and its critiques see Good (1994:24-64).

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Hospital ethnography Van der Geest and Finkler propose two important premises on which hospital ethnography is based, and the social and cultural world of hospitals can be studied. The first premise is the following: Contrary to a commonly held notion that hospitals are nearly identical clones of a global medical model, anthropologists are beginning to describe and interpret the variety of hospital cultures in different countries. Medical views and technical facilities may vary considerably leading to different diagnostic and therapeutic traditions. (2004: 1996)

According to Van der Geest and Finkler, hospitals and biomedicine have for a long time been seen as institutions and systems which are universal, or seen as a “more or less monolithic enterprise” (2004: 1995). They explain that medical anthropological studies, and those of medical pluralism in particular, often oppose biomedicine with traditional healing systems. The implicit idea which forms the basis of these studies is that the biomedical system is a coherent system of rules and practices performed worldwide, regardless of their setting (2004: 1995). By acknowledging that these rules and practices vary, they become an interesting object of study. According to this premise, midwives’ ideas on quality of care can be studied, as a feature of local hospital culture. The first premise of hospital ethnography makes it possible to investigate local medical views and technical facilities and how these have shaped diagnostic and therapeutic traditions (2004:1996). This premise is the first assumption on which this study on midwives’ perspectives is based. The second premise the authors propose, which is related to the first, is the following: “Biomedicine, and the hospital as its foremost institution, is a domain where the core values and beliefs of a culture come into view...Hospitals both reflect and reinforce dominant social and cultural processes of a given society.” (2004:1996). Van der Geest and Finkler quote Lock here to explain further that “the study of health, illness and medicine provides us with one of the most revealing mirrors of the relationship between individuals, society and culture” (2004:1996). So according to the authors, it is in situations and processes of illness where “people’s true values, convictions and moral rules become most clearly visible” (2004:1996). Therefore, hospital ethnography has theoretical relevance (it reveals information about Malawi culture and society in which the hospital is embedded), as well as a practical relevance (by providing insight into why midwives act the way they act and insight into what constitutes adequate interventions). The analysis of power relations and power inequalities are important aspects of the second premise in hospital ethnography, and central in anthropology of health. They have also shaped this study. At the basis of this study, however, is the development of concrete recommendations. As such, this study is not aided by relying on such an analysis. A researcher’s interpretation of the reality of the midwives would distract us from the actual midwives’ perspectives, which should be the central perspectives. It is clear that in a critical and clinical anthropological study, accounts of individual health care providers need to be combined with macro-level processes such as national and international politics and economy. The focus however should be on the institutional level, because of the applied objective. Therefore I have chosen in this study to take on the approach suggested by Press (1990), and Van der Geest et al. (1990): a multi-level perspective.

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The multi-level perspective In an attempt to bridge the gap between a clinical and a critical anthropology and to combine applied and critical objectives, Press (1990) proposes a multi-level or multi-element approach consisting of five levels. After summing up a very long list of factors, Press states that to come to an understanding in which all levels and factors have explanatory value is very complex, because it “increases the noise” in our data (ibid: 2003). The principle that everything in the research context can be relevant and could be taken into account is in line with what Gellner and Hirsh describe as “methodological holism”, a central feature of ethnography (2001:7). But Hirsch and Gellner (2001:8) make clear that one can break through the “noise” by focusing on what respondents deem most important. According to them, a focus should be found by spending time with respondents, through effort and empathy, and by being open to respondents’ concerns. These directions have guided this study and the analysis of the data. Van der Geest et al. proposed a somewhat simpler multi-level perspective, and give clear suggestions for a focus: research can be limited to the role of health workers within the object of study (1990: 1031). The authors distinguish the following levels, with examples given from the organizations and people relevant in this study: 1) The international level – international organizations and bilateral or multilateral partners, e.g. WHO, UNICEF, UNFPA, ICM and FIGO. 2) The national level – e.g. the state, Ministry of Health, National Organization of NurseMidwives (NONM), Association of Malawian Midwives (AMAMI), Nurses and Midwives Council of Malawi (NMCM) 3) The local level – health workers in a clinic or hospital, e.g. cleaners, ward clerks, midwives, matrons and physicians. 4) The population – patients and the local community, e.g. friends, relatives and guardians of patients; people living around the hospital; friends, relatives and acquaintances of midwives. In this study the focus will be on the local level, the midwives in the hospital environment. But according to the multi-level perspective, their experiences have to be seen in the broader context of national and international policy and the issues at stake for the population. These are the so-called vertical linkages. The nature of the linkages between these levels should be studied in order to define what takes place at a specific level. A linkage can be defined as political power but also as cultural values: opinions and customs which could descend from elites to larger groups of society (top to bottom), but could also come from the bottom up. These linkages are important because “what is carried around does not remain the same during its journey. The meanings of concepts, words and institutions change as they move from one level to the other” (Van der Geest et al. 1990: 1026). By studying the linkages between different levels, discrepancies in meaning can be revealed. These can provide very useful information if one wants to come to feasible recommendations for improvement. Maternal health might also have different meanings at different levels of social organization (vertically), in different sectors like rural and urban or private, between government and mission (horizontally) and through time (temporally). The multi-level perspective proposes that the researcher looks at these horizontal, vertical and temporal linkages. This temporal linkage approach has been used by Sciortino, who found that “too often social phenomena have been presented as being in an eternal present, preventing a deeper understanding of the changes which have 15


occurred” (Sciortino 1992:7). This was also argued by Press (1990), who said that the historical context of the profession and local health facility should be taken as a factor of influence on the patient-provider interaction. Thus, in a critical clinical medical anthropological account, we should look at all these kinds of linkages if we want to make sense of the local reality we study. In this study, the focus is on the quality of midwifery care according to midwives in QECH, and what it means for them to work at the maternity ward and to provide this care. The interpretation of the interviews and observations are guided by this multi-level perspective. The theoretical framework is based upon three different assumptions. The first two are the two premises of hospital ethnography and the third assumption is that the reality does not exist in isolation of vertical (level of social organization), horizontal (multiple causal sub-elements such as economy, politics, religion but also private/government/mission hospitals and traditional/modern medicine) and historical (professionalization of nursing) contexts. These three assumptions make this study different from other studies on health providers’ performances, for three reasons. Firstly, it is different because the health worker is viewed as a holistic and social person, rather than as a professional who takes on the same activities and values worldwide (acknowledging horizontal linkages). This will be further explained when I discuss the concept “the professional midwife as a holistic person”, drawing on Martin’s work on Ugandan nurses (2006). Secondly, it sees the biomedical institution as a place in which the core values and beliefs of a culture and society are present (acknowledging vertical linkages). And thirdly, it looks at the daily midwifery practice of midwives in the context of national and international policy (vertical linkages), and historical processes (temporal linkages). With this study, I will aim to provide an emic description of what it means to work on quality of midwifery care as a midwife in Malawi. An emic perspective “describes behaviour and understandings in terms meaningful (consciously or unconsciously) to the actor” (Kinsman 2008:12). This is different from an etic account, in which behaviour is described in terms meaningful to the observer. This description will lead to policy recommendations which are sensitive to the midwives, who are “the vehicle” for maternal health policy. I thereby take on a constructivist and critical approach, in which I see the meaning of providing midwifery care as locally constructed, and influenced by global and societal as well as historical processes.

Theoretical concepts As we have seen in the literature review, midwives and other health workers are often blamed by patients and health care managers for providing care of poor quality (in Kongnyuy et al. 2009, Leigh et al. 2006 & Seljeskog et al. 2006). However, Martin said “to speak of anomie of dysfunction is a description, not an explanation” (2006:26). Thus, to blame midwives of “bad attitudes”, “rudeness”, “indifference”, “poor motivation” and “negligence” does not assist us in understanding the issues at stake for midwives. In order to come to an understanding of care provision by midwives, we must focus our attention on the experiences of midwives in their daily practice. According to social and anthropological theory, every form of behaviour can be seen as a type of agency. Agency is an often used concept in the social sciences with many different meanings, and is broadly defined as “an individual making active choices” (Gammeltoft in Koster 2003:24). In this thesis coping is used to describe the agency midwives employ in their work environment. Here, I will identify which definitions of coping and survival has structured this thesis.

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Coping and survival Coping is defined as “the thoughts and behaviours used to manage the internal and external demands of situations which are appraised as stressful” (Folkman & Moskowitz 2004 and Taylor & Stanton 2007 in Taylor 2009:181). Coping is a concept mainly used in psychological studies. It is a dynamic process, a series of transactions between a person and the environment. It is thus not a one-time action but a set of responses taking place over time. Emotional reactions are also a part of the coping process. The definition of coping includes many actions and reactions, both behavioural and intra-psychic, as responses to a stressor (Folkman & Moskowitz 2004 in Taylor 2009). For example, anger can be seen as an outcome of a stressful event as well as a way of dealing with a stressor (Meursing 1997). “Survival” is the empirical theme Martin (2006) uses throughout her dissertation about nursing practice and professional formation in Uganda. In this study Martin shows how nurses deal with the contradictions between professional ideals and the reality of working in a resource-poor health-care system and the local values of education and kinship. Survival refers to “the creative ability to get by in the face of overwhelming difficulties. These terms evoke the economic struggle that the majority of Ugandans feel caught up in.” (Martin 2006: 19). Survival is the same term Van den borne uses in her study on female sex workers in Malawi, referring to the many challenges Malawians face in a “highly competitive and uncertain environment without a national security system” (2005:41). According to Martin, it means that people are not doing as well as they would like to or had aspired to, but through efforts they are trying to create an acceptable situation for themselves (2006: 19). The daily life of a midwife with its many challenges can thus be seen as a coping process. There are many different coping styles and these depend, among other factors, on the appraisal of the stressor and the resources available. The first step in coping with a stressor is to make a primary appraisal and to see whether this stressor poses a threat to the individual. In this study the stressor can be a difficult patient, but also the nearing of a physician or a matron by whom a midwife feels threatened because of possible critique. However, it could also be the absence of something or someone, like sterile wound dressing packs or a colleague who was supposed to report for duty and has not. The second step in coping with a stressor is the secondary appraisal, when the available resources and the potential coping strategies to gain immediate control over the stressor will be assessed (Folkman & Lazarus 1991 in Meursing 1997). This secondary appraisal determines the coping style that is used. If the individual thinks there are enough resources available to deal with the stressor, she is likely to use problem-focused coping. This is defined as “the attempt to do something constructive about the stressful conditions that are harming, threatening or challenging an individual” (Taylor 2009: 182). This type of coping is found to be beneficial when individuals can do something about the stressor, for example, when work-related problems can be solved by seeking information or help from another person (ibid: 182). In cases in which the stressor “simply has to be accepted” or when the individual thinks their resources cannot be increased to deal with the stressor in the future, it is likely that emotionfocused coping will be used. The latter involves efforts to regulate emotions experienced because of the stressful event, which can take on several forms. Examples are ruminating, denial of the stressor and emotional-approach coping. Emotional-approach coping involves “clarifying, focusing on, and working through the emotions experienced in conjunction with a stressor” (Stanton, Danoff-Burg, Cameron & Ellis 1994 in Taylor 2009:181). This latter form of coping has found to be beneficial in many stressful situations, as for managing stressors of daily life. 17


Emotion-focused coping can also take on the form of avoidance coping which is defined as “strategies which focus attention away from the stressor itself or one’s psychological/somatic reactions to the stressor” (Meursing 1997:46). Examples of avoidance-coping are cognitive coping (avoiding of thinking about the stressor), behavioural coping (not taking steps which you know are required to deal with the consequences of the stressor) or emotional coping (by joking about the stressor) (Meursing 1997:46-47). Emotion-approach coping is differentiated from emotional avoidance coping, because in the former, one works with the emotion to confront a stressor and deal with it. In this study, the concept of coping is used to describe the way midwives deal with what they define as stressful situations, and how they balance professional and personal demands and needs. I will not only look at the coping strategy that is used (emotion or problem-focused strategies), but also why certain forms of coping are used, and what, according to the midwives, is the effect on their environment and the quality of care. To describe midwives behaviour in terms of coping helps in finding a possible lack of resources to deal with the stressor effectively. Increased resources could alter their appraisal and possibly lead to a shift from avoidance coping strategies (if any) to problem-focused coping, with the goal to improve the quality of care. Using the concept coping can lead to practical advice and recommendations, therefore it was used to fill in the theoretical framework of this study (that of the multi-level perspective). Before turning to the next chapter about the study methods used, the final concept is explained: that of the professional midwife as a holistic person. The professional midwife as a holistic person Criticism of the behaviour of nurses arises from the idea that nurses are not doing what they are supposed to do, or that they are not acting professionally. It is important therefore, to conceptualize what it means to be “professional” and what behaviour suits professional nurses. Through time, nursing has established itself increasingly as a profession, while others persist in call it a “semiprofession”. As an example, I will quote Martin (2006: 9): If we consider the basic characteristics proposed by the taxonomic approach - an independent knowledge base, monopoly over education, professional autonomy, altruism etcetera - nursing fails in two respects: it has no independent knowledge base, but is grounded in medicine; and nurses do not have full autonomy over their professional practice, but are more subject to administrative control. On the other hand, the nursing community partially organizes and regulates nursing education, supervises the service and lays claims to the altruism.

It is relevant to mention this debate because it has had an impact on the way nursing developed itself over the last forty years, throughout the world. This debate still leads to discussions on what is required to call one-self a professional nurse, and what tasks suit nurses’ daily activities. In this regard, the debate has also contributed to the development of what Martin calls “an increasing academism”: One strategy in this quest to establish a knowledge base and a range of competences independent of medicine has been to launch nursing education at university level. This trend has resulted in greater specialization, rigorous admission criteria and an emphasis on education results and advanced administrative competences. (Martin 2006:9).

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So the debate on what qualifies as a profession has implications for the status and educational requirements of midwives. Throughout this thesis I will regard nursing as a profession, because it is my intention to provide an emic description of what it means to be a midwife, and midwives generally refer to themselves as professionals. Having said this, it is now important to explain how professions can be studied within an ethnographic approach. Martin distils three premises on which studies of the professions until recently have been based: first, professions consist of universally comparable units; second, professions are merged with the institutions in which professional practice is authorized; and third, the professional is an institutional figure rather than a whole person (Martin 2006: 11). These premises are an “echo of a Weberian ideal-type bureaucracy that promoted the complete separation of public functions and private lives”. Bureaucratic practice is characterized by clear cut procedures that are authorless and impartial (2006:11). Since the 1970s medical anthropologists introduced the notion of culture into studies of health and illness and included the life-worlds of patients as significant for understanding health systems and practices (Kleinman 1980). While they have acknowledged the notion of culture in the life-worlds of patients, they have rarely applied this to health providers working in the field of medicine. Very little research has been done on how medical professions in non-Western countries are shaped by their political, economic and socio-cultural context. Examples of exceptions that I know of are the studies of Zaman (2005), who studied the staff of an orthopaedic ward in Bangladesh, and Sciortino (1995) who looked at the role expansion of nurses in rural central Java, Indonesia. The aim in this study is thus to step away from the idea that health workers are doing their jobs in an environment which should ideally “remain unaffected by personal interests and sociocultural forces like kinship-based priorities, status negotiations etc” (Andersen 2004: 2003). The midwife at work is thus not only a professional, but also has other identities that play a role at the work place. This refers to the horizontal linkages from the multi-level perspective. All these different identities contain different agentive possibilities, or in other words: possibilities for coping with the demands of private life as well as those in the work environment.

Study questions After combining the formerly discussed theory and literature, the following broad and specific study questions were formulated: Broad: What are midwives’ perspectives on the multilevel factors which influence the quality of care they give in QECH to patients and their guardians, and how do they cope in adverse conditions? Specific: 1) Which personal, economic and socio-cultural background factors inhibit or facilitate midwives in providing quality midwifery care? 2) How does the midwives’ educational training influence their provision of quality midwifery care? 3) How do factors related to the work environment of midwives influence their midwifery care provision? 19


4) What are according to midwives feasible recommendations for interventions aimed at enabling midwives to provide a better quality of midwifery care? In the broad study question I have included not only care towards patients but also their guardians, since they are thought to have a positive influence on quality of midwifery care when they are allowed to accompany labouring women. What the broad study question points out is that the multi-level perspective is used as a framework, while looking at daily practices of midwives as a form of coping and agency. This daily practice is shaped by the personal and socio-cultural context, the work environment (as a bureaucratic organization) and the historical and political background in which these practices are embedded. The specific study questions were formulated after carefully considering factors that were found to be of importance in the literature review. In Chapters four, five and six, the answers to these study questions will be discussed. Education was not explicitly addressed in the literature review, but certainly plays an important role in the acquisition of competencies and skills needed to perform adequate clinical care (such as the obstetric signal functions) and quality interpersonal care. In Chapter five, a discussion on the midwife as a professional will also take place. The fourth study question, which is about recommendations, will be discussed in the conclusion.

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Chapter 3: Methodology and study setting When pregnant women are ill or have contractions but are not yet ready to give birth, they are admitted to the ANC ward. The ANC ward forms one block with the Obstetrics and Gynaecology (Obs&Gyn) ward. The main halls are connected to each other in an L-shape, where if you walk straight from the ANC ward down you get to the main hall which is connected to the Labour ward on the right side. In the Obs&Gyn ward, women in the hallway wait to be screened for cervical cancer, to be assessed by a doctor after rape, or to find out whether their obstetric fistula can be repaired. The Labour ward is found behind closed doors with a sign saying ‘no visitors allowed’. The ward consists of two parallel halls, with rooms in the centre and at both sides. Women on the left side of the hall, the non-paying area, deliver their babies in large wards where beds are separated by curtains. In the rooms on the right side of the hall, the paying-side, women get food provided from the hospital kitchen, have a bit more privacy and slightly better facilities. When I visited a midwife who was in labour herself, on the paying side, I observed that her infusion bag was attached to the latch of a window in the absence of a drip stand. When you follow the main hall down from ANC ward, leaving Labour ward at your right side, you end at a T-junction. A left turn at the T-junction takes you to the Chathinkha Operating Theatre (COT) on the right side and the PNC ward at the end of the hall on the right side. At COT I once saw four patients sitting on a bench in the hall, waiting for their curettage. They told me they had had a miscarriage. From around the corner in the hall of COT, you could hear three other women moaning while recovering on their beds from their CS and the anaesthetics. There were three ORs of which only two were in use; it remained unclear to me why the third was not in use. Women who have delivered at the Labour ward or in COT are brought to the PNC ward afterwards. Here women are monitored so haemorrhage or postpartum sepsis can be diagnosed early, or to wait until CS stitches are removed. The PNC ward is as big as the AN and Obs&Gyn ward together, consisting of one block with the two sub wards PN1 and PN2, with each their own sister’s office. If you take a right turn at the T-junction, coming from Labour ward, you leave maternity wing, but find a ‘lost’ small paying delivery ward called 1A, before finding the connecting corridor to the other wards. In 1A, women who can afford to pay extra are admitted to a private room where they can stay from the time of their admission for care during labour until PNC is administered (unless they need a CS). Throughout their stay they are attended to by one of the three different midwives that are deployed at this ward. When leaving the maternity wing, one can also exit the hall through a door that connects you via an outdoor path to the AN clinic. In this outpatient department, AN checks are done. Patients take a seat in one of the 30 wooden benches in the centre of the building, and are called inside the AN counselling rooms according to a tight schedule, found in the tidy and structured sister’s office. The AN clinic appeared far more orderly than the other wards. Some of the rooms in the building were occupied by Johns Hopkins University researchers, who also had a well-equipped and furnished office in the Labour ward. A Malawian midwife working there showed me around and told me they were doing various research projects on HIV. (Diary notes, 25 August 2011)

At these seven wards in the maternity wing (Labour, AN, PN1, PN2, COT, Obs&Gyn and 1A), almost a thousand patients (QE Statistical Office 2009) are admitted monthly to receive maternal health care. I conducted my study in these seven wards, and added the AN clinic, as they also provide midwifery care. The PNC wards are counted as two wards because, although they collaborate, they have a separate schedule and separate sisters’ offices. In this chapter I will explain the study methods used. 21


I will first give some more information about the setting and describe how access to the field was gained. Subsequently, the study design, research methods and study populations will be explained. Finally, I will explain how the data was analyzed, share my ethical considerations and point out the limitations of this study.

Access to the field and time of the study The study was conducted in QECH which is located in Blantyre. Blantyre is the capital of Blantyre district and the administrative city of the Southern Region (see map page vii). This particular hospital was chosen by convenience sampling. QECH has a higher number of midwives than district hospitals (60 in the maternity wing), ostensibly making it easier to find the ten midwives to target. The study was started 14 June 2009 after approval from the College of Medicine’s Research and Ethics Commission and from the Head Matron of QECH, Mrs. T. Soko. After that, a KCN lecturer introduced me to the matrons of the maternity wing so I could ask their permission. At this reception area where the matrons’ office was based, there was a counter, a little tuck shop where I often bought refreshments given in appreciation to the interviewees, several offices, and the Blantyre chapter of the National Organization for Nurses and Midwives (NONM). There are benches for visitors to wait, and this area was also used as a place to discuss issues when a meeting outgrew the capacity of the conference room. The KCN lecturer introduced me to the sisters in charge (SICs) and then the midwives, one by one. However, not all SICs were present at that time, so at some wards I introduced myself later that week. At all introductions and during my visits at the wards I explained the study objectives and which themes would be addressed. The study was done over a period of approximately two months, starting halfway through June 2009 and ending with the focus group discussion on 19 August 2009.

Study design and research methods This study is exploratory and descriptive. The study is exploratory because the aim is to gain insight into midwives’ views on coping possibilities and structural limitations in their provision of quality care. Until recently, these topics have rarely been investigated. The study is descriptive in the sense that the results provide a description of how midwives experience their care provision in one particular hospital. The aim of this study is not to generalize results to a larger population, but to gain insight into a phenomenon (here, quality of care) and how this phenomenon is interpreted by the selected group. Because the aim is to gain an in-depth understanding, a qualitative approach was chosen. Indepth interviews (IDIs) were held with 13 midwives who were the key informants, selected through convenience and purposive sampling. To complement the qualitative research methods and in order to get a general overview of opinions and backgrounds from all midwives at the maternity wing, a self-administered questionnaire was held with 31 midwives. Furthermore, interviews were conducted with 12 other stakeholders, and at the end of the study period a focus group discussion (FDG) was held in the form of a feedback session. Additionally, existing documents were consulted for background information that could only be accessed locally. For each of the study methods I will describe the study population, how sampling was done, which themes were addressed, and explain how problems were overcome. Finally, attention will be given to how the data was analyzed, ethical considerations and limitations of this study.

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Self-administered questionnaire with QECH’s midwives The first study population consists of 31 midwives employed at the QECH maternity wing who filled out the self-administered questionnaire. Convenience, non-probability sampling was used: all 51 midwives at the seven selected wards could participate. The themes addressed were background variables like age, education, working experience, household composition, marital status, transport used, and financial situation. Additionally, questions about job satisfaction were included (see Appendix B). The purpose of this method was to gather information on general opinions and demographic characteristics to make it easier to select “typical” cases for the IDIs. In my efforts to disturb midwives as Figure 1. Total number of midwives on roster little as possible, I initially gave 51 questionnaires by response to the SICs and asked them to distribute the forms to the individual midwives. Midwives could fill out the forms in a time and place convenient for them, after which they could return them to me by 10 July, two and a half weeks later. It became clear from the low initial response (only eight were turned in by 10 July) that the method I used to recruit respondents was not suitable: the SICs did not always pass the message to their fellow midwives. However, by the end of the study, 31 midwives had participated (Figure 1). In general, I got the questionnaires back from midwives who were interested in the research objectives and who felt it was good to let others know how they felt about working as a midwife. The midwives who did not fill out the forms gave the following reasons: they were absent, they lost the forms, they gave their forms to someone who claimed not to have it, or because they weren’t interested in the study. While some were absent temporarily, others were out for a longer period of time, such as for a long holiday or maternity leave and were, therefore, hard to reach. Due to the initial low response, I decided to take a different approach to the recruitment of respondents. I sought advice on more effective methods from the matrons and several people at KCN. One of the maternity wing matrons explained that midwives do not always see the benefits of research, but also that their non-cooperation is “part of the attitude problem we have with the midwives in our country”. I also became inspired by the wall poster I found in two offices that read: “Sometimes, the only way to get things done in time is to use a little bit of force” (Picture 4). I did not want to use literal “force”, but tried a more pro-active approach: I spent my lunch hour several days in a row at the sisters’ office in the same ward, and lobbied for midwives’ cooperation in the completion of questionnaires (see Picture 2). By doing so, I aimed to establish rapport and convince them to participate (see also Box 1 about rapport in the IDIs). It was time-consuming and challenging to speak to everyone personally, especially considering that breaks are short and there are only one to two full-timers on the ward simultaneously (except for the Labour ward where about six were present during a regular day shift). In the majority of the cases this method proved more successful, such as in the Obs&Gyn ward, where initially only one midwife had filled in the form. At the end of the week I spent in their ward, they all handed in their forms. When midwives seemed agitated by 23


my ongoing presence or said they did not want to participate, I did not approach them anymore. It was important for me to follow the key principle in ethical practice: to respect human autonomy (Cassell 1980 in Green & Thorogood 2004:65). While this might result in less data, participants need to feel they have the ability to refuse or withdraw from the study at any time. In-depth interviews: 13 midwives from the maternity wing The second population is a selection of 13 midwives from the maternity wing, with whom 20 interviews were conducted. Seven midwives were interviewed once, five midwives twice, and one midwife was interviewed three times. Inclusion criteria were that (1) they were willing to participate in one to three IDIs (written consent), (2) they had worked at the QECH in the Maternity Wing for at least six months at the time of the study. Since more than ten respondents were found willing to participate, midwives were selected based upon variation in age, education, experience, job satisfaction, household composition and the ward in which they were employed. I thus started with convenience sampling and later used purposive sampling: additional midwives were selected as “typical” (representative, not only strong and distinct opinions) and “contrasting” cases, according to these background variables (Hardon 2001:267-268), in a grounded theory approach. This means that participants are recruited until saturation in the data is achieved, at which point ongoing analysis is not producing any new insights relevant to the emergent theory (Straus & Corbin 1990 in Green & Thorogood 2004:102-103). For example, some midwives from Labour ward said that working there was more hectic than at COT, so I included a COT midwife to find out how she felt about the pressure of work. Recruiting respondents was done in the same way as previously described for recruiting questionnaire respondents. At least one to two hours were spent each day at one of the seven wards, trying to build rapport and recruit more informants (see Box 1). Box 1. Building rapport: establishing a relationship of trust to encourage disclosure While transcribing the recorded interviews, it was painful to review those interviews during which I failed to build rapport, as they were always characterized by cursory answers. Occasionally this made me more nervous, resulting in the rapid deterioration of interview technique and prompting me to ask leading questions or questions that could be answered with a simple ‘yes’ or ‘no’. In these interviews midwives did not try their best to make me comfortable in their environment either. They were obviously busy, walking in and out of the office, calling in patients, writing in the patient files - I often felt that I should not be waiting there, taking time away from their patients when I was fully aware they were understaffed. Sometimes we chatted, sometimes I was ignored, and sometimes I could make myself useful by helping with simple tasks like folding gauzes. In order to not feel uncomfortable, I took my notebook with me to write out notes or to write down observations. I tried as often as possible to visit wards during lunch hours to avoid taking their time away from patients, but I sometimes felt they were annoyed by my presence during their lunch break. They often spoke in Chichewa, while I waited up to 14 minutes to get their attention. I wanted something from them, so I had to wait before being attended, just like the patients. Once, I did have a nice conversation instantly, but it turned out that this midwife wanted to sell me religious books from her church. It seemed that I was not the only person trying to establish rapport before getting down to business.

Themes that were addressed in the IDIs were related to the factors of influence as described in Chapter one: reasons for choosing this career, job-satisfaction, satisfaction with their income, daily activities at the ward, working experience, education and refresher courses, perceived quality 24


of care, recommendations for improvement, housing and secondary benefits. An interview guide was used as a flexible instrument (Appendix C), which was initially based upon findings of other studies, but was later supplemented by additional topics. The fact that some questions were added later in the study also means I have not asked all respondents the same questions. I attempted to keep the conversations as “natural” as possible and tried to introduce topics in a non-leading manner. I probed issues that midwives came up with themselves. Contrary to my expectations, recruiting midwives for interviews was easier then recruiting them for the questionnaires. Midwives were more willing to make time to talk about their experiences than to fill out a questionnaire. However, I did not manage to get the targeted two to three interviews per midwife; the majority was only interviewed once. I recruited 13 midwives instead of the targeted 10 midwives to get more information on topics that needed further exploration. The reason midwives gave for not wanting to give additional interviews is that they found it too time consuming, and said everything I ought to know was already discussed. They elaborated mainly about their work experiences, and although I wanted to find out about their home situation they did not see this as an issue which influenced their work, and thus regarded it as irrelevant. This means saturation was achieved after the second and sometimes first interviews, from an emic point of view. The study location might have also influenced this: all interviews (except for one with Wyness) were held in the hospital which elicits biomedical thinking and answers to questions that are meant to be answered holistically. In some cases, I think the reason some interviews were short and midwives were not interested also had to do with difficulties in building rapport. However, some midwives really enjoyed talking about the issues and, although they hesitated in the beginning, they were quite eager to have another interview (with one midwife I even had two one-and-a-half-hour interviews). In short, both the lack of available time and saturation were reasons the number of interviews per midwife was lower than proposed. In the majority of the cases (nine midwives) written consent was obtained. Due to the spontaneous planning of interviews with four midwives (for which I did not bring consent forms), I obtained verbal informed consent from them. Characteristics interviews with midwives The mean length of the interviews was 50 minutes and took place in rooms at the ward or in the sisters’ office. While they were only scheduled and conducted when the workload allowed, it was still a challenge not to be disturbed during the interviews. Seven IDIs took 35 minutes or less, usually because midwives felt it was too busy in the ward to be able to stay away any longer, or because they were called away by colleagues or patients who needed assistance. But five IDIs lasted 75 to 90 minutes. We usually planned the interview one or two days ahead of time, but whether or not the interview could take place as planned depended on the midwife’s judgment of the situation in the ward. Sometimes I could conduct an interview immediately. When interviews were planned, I got interviewees scones from the bakery and refreshments (Fanta Passion or Pineapple) from the tuck shop. I could only manage a drink and some biscuits for unplanned interviews. I will proceed with an introductory description of the participants, who are divided into three age groups. The ages of two midwives were unknown, and estimated based upon their graduation year and number of years of experience. Six of the 13 midwives are younger midwives with less work experience, aged between 23 and 33. The eldest in this group is Theresa, who only recently graduated as a NMT and is thus also seen as a younger/less experienced midwife. The younger midwives are eager to learn and 25


expressed more enthusiasm and idealism towards their profession. They looked “fresher” and were more willing to make time for me than the older midwives, probably fuelled by their curiosity and possibly because I was of their age. Four midwives are married and live with their husband and children; one of those four gave birth to her firstborn during the study (Jenny). Many of the midwives with whom I spoke were also living with their sisters- or brothers-in-law. Chimemwe (aged 23) lives with her parents. Male midwife Tiyanjane, had “someone” in mind to marry, and is saving for the wedding, which he says costs a lot of money. In the second age group are two midwives both SICs - with a moderate amount of experience, employed at the labour ward (Gift) and paying ward 1A (Violet). Gift is 35 years old and Violet is 36 years of age. They are both married and have children, and are eager to go on workshops and courses to learn more so they can use their knowledge in their jobs. In the third age group are the remaining five midwives, aged between 50 and 67. Four are widowed; they are Martha (aged 67) from ANC ward, Tiyamike (aged 52) who is SIC at PNC ward, Judy (aged 55) who is SIC at Labour ward (working many hours overtime when Gift left for training in Lilongwe); and Sabrina (aged 50) from COT. The fifth older midwife is Beatrice (aged 54), who is married to a civil servant who works at the Ministry of Housing and Land. Three of them expressed a desire to retire from this hectic and stressful job, while two (Sabrina and Judy) thought it was tiresome but felt strong and still wanted to be there for their patients. They enjoyed their jobs and expressed no plans or wishes to retire anytime soon. The majority of the midwives interviewed are NMTs (six), four are ENMs and three are RNMs. The three RNMs are also SICs: Tiyamike, Gift and Violet. There is one more SIC, Judy, an ENM who is in her third year in the Labour ward but has plenty of working experience in other wards at QECH. The other ENMs are Sabrina, Martha and Beatrice. The younger midwives are the NMT, of which the majority graduated from mission schools in a diversity of regions before coming to Blantyre to work in QE (Jenny, Chisangalalo, Wyness and Chimemwe). Theresa was trained at MCHS and Tiyanjane is currently in training at KCN to become a RNM. For additional details on the midwives who participated in the IDIs see Appendix A (Table A.1). Stakeholder interviews The third study population consists of “stakeholders”. Although the focus of this study is on midwives’ perspectives, these stakeholders were interviewed to get a better understanding of the context. Twelve semi-structured interviews (SSIs) were conducted with 12 stakeholders (Appendix A, Table A.2). The inclusion criterion was that they had a view on the context of the topic of study due to their position and/or work experience. Verbal consent was given by all participants for the SSIs and for audio taping. The majority of SSIs were arranged via snowball sampling. Themes that were addressed were topics related to their perceptions of the quality of midwifery care in general in Malawi, and in QE if applicable. More or less the same topics addressed in the IDIs with midwives were brought up, but they were adapted to be relevant to the specific interviewee (Appendix D). Green and Thorogood (2004:93) state that often, interviews with policy makers or managers in health care (which they call “elite” interviews) are more difficult to arrange than interviews with “regular” respondents. In this study this was not the case - recruiting stakeholders was relatively easier than recruiting midwives. This was possibly because they are both more available and more interested in cooperation, because of the topic of the study and because they were happy to make a contribution to research. Additionally, the National Organization for Nurses and Midwives (NONM) and the Association of Malawian Midwives (AMAMI) find it important to have had their say on this

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topic. The interviews were usually held at the offices of the stakeholders, with a mean duration of 50 minutes, within a range of 15 to 75 minutes. The stakeholders interviewed in their offices in Blantyre and Lilongwe were Bonus Makanani (Head of Obstetrics QECH), Sabrina Chirwa (KCN lecturer), Dorothy Ngoma (Executive Director NONM), Fanny Kachale (Deputy Director MOH RH Unit), Martha Mondiwa (Registrar MNMC), Juliani Lunguzi (Office Director UNFPA). Additionally, I interviewed Lennie Kamwendo (former president and present member of AMAMI) in a cybercafé in Blantyre, Sabrina Sesay (matron of Holy Family Mission Hospital) at her home, a staff house on the hospital grounds, and Obrin Sangala (accountant in Holy Family Mission Hospital) in his office in the rural area Phalombe, in Mulanje district (see Picture 12). I intended to include an interview with personnel from a rural health facility, so I was happy to be able to interview Obrin and Sabrina in Phalombe, both of whom I had previously met at a meeting with Cordaid in the Netherlands. The SSIs with them contributed a view on the differences between rural and urban perceptions of quality of care. All stakeholders talked with more passion about the subject than the midwives themselves did, possibly because they have their institutions to represent. Elite interviewees often reflect only the viewpoints of the organizations they represent, which are in many cases just as easy to get through reports or written documents (Green & Thorogood 2004:93). This was definitely the case at the MOH and the UNFPA. But with other stakeholders I did get relatively new and different accounts on issues, some of which contradicted those gathered in interviews with midwives. For example, midwives in general said that they work very hard and that they provide the best care they can within the circumstances. They do not say the quality of care is good, but neither do they say it is unacceptable to them. But according to a KCN lecturer, the Head of Obstetrics, and the AMAMI representative, there are many midwives with unacceptable attitudes and very poor skills who set a bad example for others and are detrimental to the health of patients and the image of nursing as a profession (they also stressed there are many very good midwives). These three stakeholders expressed firmly that they are sure midwives could provide better care with the resources they currently have. Their statements and ideas about quality of care in nursing, helped to inform the interview guides for the midwife IDIs. Therefore, the perspectives of these stakeholders were valuable for shaping this study, although the emic accounts of the midwives are central. Documentary sources The documentary sources used in this study are reports and locally published articles and studies on topics related to midwifery care provision, job-related satisfaction, and the reasons for (poor) retention of midwives. These were found by using the KCN library computers, which have access to electronic databases including more local scientific magazines than accessible from the Netherlands. Additional reports and data were also found through other individuals, such as the statistician of the QECH and researchers I met in and around QEC; and by looking through an un-catalogued library cabinet for interesting reports and articles. Additionally, the library had posters and folders from nursing organizations with educational messages (for example on nurses’ rights). The library also had the two major newspapers (the Daily Times and the Nation), which I occasionally screened for the above-mentioned topics. I soon found out that these papers could also be consulted on the internet, and made an article search back to the year 2005 using the keywords “nurse”, “midwife”, “maternity”, “care”, “QECH”, “Gogo Chathinkha”, “midwives”, “maternal”, and “health care” I consulted documents on the KCN website relating to the subjects midwives study in the different training programs. I also found a syllabus on the history of midwifery in Malawi which was used in 27


the literature review. Other sources of data that gave me a general idea of “what was going on at the ward” are the folders, pamphlets, notes, posters, protocols and signs which were found everywhere in the halls and offices of the wards at the maternity wing and the NONM chapter inside this wing. Participants feedback session: focus group discussion The last study population consists of a diversity of people: foreign medical electives, health and nurse researchers, KCN lecturers, three midwives from the IDIs, Master in Midwifery students and others. An overwhelming 27 people took part in the FDG held on 18 August. Sampling was done through an invitation letter to all participating wards at the maternity wing, and by inviting specific significant others personally. These “significant others” were midwives and stakeholders who participated in the IDIs and SSIs, and SICs and matrons at the maternity wing. The FDG served both to inform interested parties about the preliminary findings of the study and as a study method: people were asked to give their opinion about the findings and supplement the retrieved data with their ideas on five ambiguous topics. Important issues found in the interviews were summarized, and both commonly offered and contradictory opinions were included. From this overview, five emerging themes where identified (see Appendix E). At the FGD, a presentation of these preliminary findings was given (10 minutes), followed by a discussion of these findings in two separate groups (one hour), a plenary session (30 minutes) and a wrap up (5 minutes) followed by a drink (15 minutes). Convenience sampling was used because the two-fold goal of the meeting (both giving information and retrieving data) made it impossible to use purposive sampling. The number of respondents was higher than expected: only five people confirmed, others told me they might come if the workload would let them. It is usual in group interviews such as this FGD to over-recruit by about 25 percent, although caution is required because invited people can also invite others (Green & Thorogood 2004: 123). The number of participants was not known beforehand, for the same reasons interviews could sometimes not take place. Since I had become familiar with the “ad-hocism” in the facility, a term used by Martin (2006) to describe the unpredictability of the course of day in the hospital in Uganda, I prepared for 24 participants. To overcome the problem that in a group conversation of over ten people, only the more dominant opinions are heard, the group was split up in two subgroups for the main discussion. In order to have both groups facilitated, I asked my acting supervisor KCN Lecturer Elizabeth Chodzaza to facilitate this second group, while I facilitated the other subgroup. I also facilitated the plenary session of the FGD. When the FDG started, only four participants were present, but twenty minutes later 14 people were present. During the discussion even more people entered. Unfortunately, the reorganization of the chairs and people entering during the FGD disrupted the conversation and the audio file. As disruptive as this was, I found it important to give people the chance to be present at this dissemination of findings.

Data management and analysis The results of the questionnaires were put in a matrix in SPSS, and used to illustrate qualitative statements of the midwives in interviews. All of the IDIs with the midwives were recorded (except for one, Violet from 1A, who did not want to be audio-taped) and mostly fully transcribed. Some parts were summarized, where the issues discussed were irrelevant to the study. The stakeholder interviews were mostly fully recorded and transcribed, but the transcription has been done by others. From interviews that were not transcribed, notes were taken and also put into Word. I coded 28


all interviews myself both inductively (derived by themes emerging from the data) and deductively (derived from themes found in literature) on the hard copies of the written interviews. Documentary resources were analyzed by coding them like the interviews, and were used as empirical material “speaking” for the different levels of organization within the multi-level perspective. The FGD audiotape was not transcribed due to its bad quality, but written notes taken during the session were complemented with what could be understood from the tape, and put in Microsoft Word. The data gathered in the FDG is not given the same weight as the midwife IDIs, but did contribute to the rigor of the study. The FGD facilitated triangulation of the findings, but is taken more as a stakeholder-source than as a midwife account, as there were only three midwives present and there is probably a bias towards socially desirable answers. In addition to these sources of data, notes were taken from informal conversations on related topics and written down as field notes. Observations made in the wards and descriptions of the wards were also written down as field notes. To reflect on my role as a researcher and my bias towards the topic of study I kept a diary. In Box 2 an example is given of how important it was to be open and not fall back on personal normative ideas about how care should be given and what counts as infection prevention and what does not. For the interpretation of my data, I used thematic content analysis, which involves summarizing and classifying data within a thematic framework. According to Richie and Spencer, this type of analysis is very useful for generating policy-oriented findings, as it preserves individuals’ accounts throughout the analysis (Green

Box 2. Prejudices on Malawian practices Before entering the field, I stated I would be careful with judging Malawian medical practice, and that I would reflect on my own ideas about how nurses should treat patients (Quadvlieg, 2008). It was important not to give midwives the idea that treatment or nurse-patient contact were not optimal according to my perspective. This was not always easy, because when things surprise you, a surprised response often follows. The example here will show how these prejudices tended to guide my reaction to interviewees: Linda: And if you treat the infected patients what do you do then? Interviewee: We dress the wound and we use brown sugar. Linda: Brown sugar?! For what? Interviewee: For putting on the wound. Linda: Oh really?! Interviewee: Yes, because brown sugar eats the infection which makes the puss bacteria. Linda: Oh yes? Interviewee: Yes and it helps and it is really effective. When it is clean and ready, we stop it. And its granulation starts. My first response was “how can sugar ever be an effective way for preventing further infection?” Back in the Netherlands, I told a Dutch friend and nurse, who said he was equally surprised about the fact they poured honey on infected wounds at the wards of an Indonesian hospital where he worked. He started to look for scientific articles on the topic, and found that honey and sugar are excellent substances for curing wounds. Besides having antimicrobial properties, sugar and honey also leave wounds with smaller scars (Topham 2002). Pieper and Caliri (2003) found in their meta-analysis that sugar or sugar paste can be very effective for reducing odor, reducing wound endema, inhibiting bacterial growth, stimulation of granulation and reduction of pain during the changing of the dressing. According to these authors, using sugar is not that weird after all. Using sugar instead of expensive solutions for wound cleaning and treatment is a good choice for economic reasons: sugar is one of Malawi’s major export products and is, therefore, cheaply available.

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and Thorogood 2004:184). I took four steps in the process of analysis. First, I familiarized myself with the data by listening and transcribing the audio files, reading the transcripts and re-reading field notes. Second, I developed a coding scheme for thematic analysis: the themes that I found in the data, such as “improvisation”, “helping the poor and sick”, “locum system” and “petroda” became the labels for codes. Additionally, but to a limited extent, I analyzed the data following theoretical themes, such as “emotion-focused coping” and “gender prescriptions”. Third, I applied codes to the whole data set in a systematic way, using the same codes, which is called indexing. Finally, I rearranged the data in charts, putting the findings or accounts of midwives in four tables (personal, work-related, education-related and socio-cultural) organized according to the derived themes.

Ethical considerations Good interviewers build a sense of rapport, and encourage interviewees to tell personal and detailed stories about themselves. They are, in short, experts at exploiting and mining individuals for data. For this to be done ethically, it has to be done with respect for the interviewee as an individual, rather than merely a carrier of “good data”. (Green & Thorogood 2004:62)

My primary goal when I left my work-space to visit the wards was to retrieve data. I sat down in the sisters’ offices and tried to get the midwives attention, or “catch” interesting details when making observations. On the other hand, I tried as much as possible to not disturb midwives who were busy with patients. If they were busy, I asked them when would be the best time to come back. In consultation with my local supervisor, it was determined that conducting the interviews during work time was appropriate as long as the midwives themselves could decide the day and time, and were always given the opportunity to cancel the interview. This happened quite often, and made getting the interviews a rather time consuming business: just to walk from the campus to the ward, buy them a scone and drink as an appreciation, and find the interviewee took more than half an hour. Since interviews were cancelled often, little time was left for analysis and transcribing in the field. Still, I deemed it very important to give midwives the space to plan the interviews at a time convenient for them. I had to adapt to the “ad-hocism” which characterized the daily routines at the ward: I never knew when it would be possible to have some of the midwives’ spare time for an interview.

Reflections and limitations An important limitation of this study is that it aims to provide an emic perspective on midwifery practice in Malawi, but, unavoidably, this thesis is a product of who I am. The presentation of the midwives in this thesis in an interpretation of what I think they meant in the interviews I conducted. Observations and interpretations of the Malawian (hospital) surroundings and the behaviour of the midwives are influenced by my background as a western, white, young woman, who received a oneyear nursing training and is finishing her training as a social scientist. It is not possible to “turn off” this background, so it is necessary to reflect on it, which I have done in this chapter by giving insights into my experiences and thoughts while being in the field. My background also means the interviews were conducted in a language that was not my native language. Neither was it the native language of the midwives interviewed. Through spending time in Malawi, I found that the meaning of their English was sometimes different than mine, leading to confusion. An example is “too much”, which does not always mean it exceeds the limit, but can also mean “a lot” or “very” (such as: “Mangochi is 30


too much far”). This example illustrates the difficulty in doing interviews in a cross-cultural setting, let alone getting an idea of differences by means of non-verbal expression and emotions. It brings about challenges in the interpretation of observations and audiotapes. What is represented here is an outcome of ongoing comparative analysis and interpretation of what I initially heard and saw and what I thought about after spending more time in Malawi, and it is as accurate as I could do it. It is not likely that all midwives will see themselves completely in these findings. If I had had more time to get to know the wards’ internal system and midwives’ private lives better, other things may have come to light. However, this presentation is also a presentation of what they shared with me in the interviews, so it is likely that the central themes apply to all of them and are crucial issues for them. Furthermore, I attempted to overcome the bias of giving only socially desirable answers by aiming to get more than one interview per midwife and by establishing rapport before doing the interview through informal conversations. Another possible bias in this study is that I have mainly included female midwives, although an increasing proportion of RNM graduates are men. Issues raised in informal conversations and in the interview with my only male respondent indicate that being a male midwife is experienced as different from being a female midwife. Unfortunately there was not enough time to investigate this further; the fact that there was no full-time male midwife employed at the maternity wing did not help in this respect. A more important limitation is that QECH is a unique hospital, since it is an urban referral hospital and the biggest in Malawi. A disadvantage of selecting QECH is that some of the problems found in the literature (low utilization, scarce resources, low quality of care) are mainly problems belonging to rural areas. The coverage of care during delivery in Blantyre is the highest of all 28 districts, namely 78.6 percent (NSO 2005:142). Therefore, the issues found in this study might not all be relevant for midwives working in rural areas and smaller district hospitals. Nevertheless, the problems of substandard quality of obstetric care in Malawi are found to be widespread; they exist in urban hospitals as well as in rural areas (Kongnyuy et al. 2008). Also, I have paid attention to this in the interviews by discussing issues that play a role according to midwives in rural areas, and whether they would (not) like to be deployed in rural areas. The final limitation I would like to point out is that all findings are based upon what midwives reported; no systematic observations were made. I did make observations while being at the sisters’ offices and walking around the maternity wing. Although observations inside the wards and while midwives were at work would have increased my understanding of what their work entails, I was not allowed to do so. The College of Medicine Research and Ethics Committee did not deem this necessary for these study questions, and also had to keep the patients’ integrity in mind.

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Picture 1. Hall at maternity wing

The hall goes from the PNC wards to other wards, COT is through the door at the left side; reception area, Labour ward, ANC and Obs&Gyn ward are found when you take a right turn at the end; and a passage to 1A, the AN clinic and the rest of QE is straight ahead.

Picture 2. After the FGD in the COM medical annex

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Picture 3. Left: Pamplets in several offices Picture 4. Above: Midwife and midwifery student in sisters' office Picture 5. Below: Blantyre market

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Chapter 4: Be(com)ing a midwife: a struggle or an easy career? We really need a researcher to come up with evidence that reflects the reality on the ground. The government should understand that these nurses and midwives after working in such abhorring conditions have a home, and family members to support. They have a life to enjoy just like everyone else. Sometimes it’s not just about the pay check. It’s a lot more than just a “calling”! These people love their country; they are our everyday heroes, giving hope to the hopeless. And most importantly they are humans, with their personal dreams and aspirations too! (Informal conversation Billy, Malawian architect with “special interest to health and health care”)

Most midwives stated that their home situation did not influence their work. The above quote is not from a health worker. I expected health workers to speak this passionate about their concerns and difficulties combining their private and professional lives. In the first instance, everybody expressed that the major reason for not delivering the care they would like to give, is related to staff shortages, and not to personal problems or a personal situation. This leaves little room for further discussing personal factors and their influences on care provision. Although midwives were very moderate in their expressions of discontent, there were some issues that were repeatedly mentioned and thus important to them. I will describe the influence of the midwives’ personal, economic and sociocultural background on quality of care provision. The first topic discussed is the motivation of midwives to join the profession, and how satisfied they are now, as a midwife in QECH. This is relevant according to the temporal linkage within the multilevel perspective, because it shows their concerns in care provision through time. The second topic is financial responsibilities. Midwives were very discontent with their salaries, and I will elaborate the background of this discontent and how they think about recent policies that tried to address this problem. I will also discuss their major expenditures and coping styles with the low income. The last issue that will be considered personal is how midwives cope emotionally and practically with the shortage and the high workload. Midwives were asked what they think of the reports of “bad attitudes” in the media and in scientific publications. They used the word “mistakes” to refer to these reports and accounts, examples of these “mistakes” included: forgetting to follow a “doctor’s order”, shouting at patients, rudeness, negligence and slapping women in labour. I will discuss how midwives talked about these issues and how they cope with difficulties.

Choosing nursing and job-satisfaction Reasons to join: “helping the poor and sick” The foremost reason midwives reported why they wanted to “join the profession” is because they wanted to help other people. Several reasons were mentioned for why nursing/midwifery is regarded as a good profession, of which helping sick and poor people was the main reason they gave. The interviewees expressed this in statements such as: “I wanted to help my fellow Malawians”, and “I wanted to take care of the many sick people in my country”. Many midwives say it just feels good to be able to do something for others, to help others and to save someone’s life. Sabrina (aged 50) works at COT ward and says:

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After secondary school I thought, I have to go to nursing school so I can continue that care [which I was given when I was sick]. I feel it is life saving, it’s good to save someone’s life. It just felt good to save those people as we are doing now.

Midwives also said the status which comes with the job was attractive. They often referred to the moment they first encountered midwives due to their own hospital stay or during a visit to someone in the hospital, as the two midwives Jenny (aged 25) and Chisangalalo (aged 30) from Labour ward did: Jenny: I was inspired by my aunt, she is a matron… I was in the hospital with my mother and I was admiring the nurses putting on their work uniforms and my aunt being a matron. That’s what inspired me. And now I enjoy it, at last! Chisangalalo: “I was just admiring nurses. So I just wanted to become like them. When I was nine years old I was sick. . . I was admiring those people, when they help someone who is sick. They help her and she gets better. So I thought this is good work. I just wanted to help people who are helpless.”

Two other midwives said they admired midwives and nurses “with their white uniforms and the white caps”. The admiration was both directed to the work of the nurses and to their symbolic uniforms with corresponding accessories. This admiration was often mentioned as an additional reason to the “helping the sick and poor” discourse, but one can see from Chisangalalo’s statement that these reasons are often combined. Gift, a 35 year old SIC at the Labour ward, said she admired the dedication in the work of nurses, using the words “dedication” and “sacrifice” to point out that she does the best she can for her patients. Besides these vocational reasons, which were mentioned by all midwives, some also gave more pragmatic reasons for choosing a nursing career. Pragmatic reasons were only mentioned by two midwives, Martha (aged 67) and Theresa (aged 33), but it is likely they play a significant role in the choice for a nursing career, as I will argue here. Vocation was mentioned by all interviewees; however nursing or midwifery was not the first choice for all. Martha illustrated that it was just a matter of chance whether she would pursue a nursing career or one in teaching. She wrote two application letters to different schools. An invitational letter from a nursing mission school came first, and after studying for half a year, she received an offer for a diploma course in teaching. Although she had preferred to be a teacher, she decided it was too late to change. Like Martha, there were three other midwives who said they also thought about becoming a teacher. Nursing and teaching are both typical careers for young girls who want to go to college. For Theresa (aged 33), working part-time at the AN clinic, nursing was not the first choice either. She studied Business Administration at Chancellor College before, but her parents and husband thought she would have problems finding a job when she was older. According to them, companies only want to employ good looking young girls and Theresa said they were probably right. She did not mind switching to nursing school because she was aware of the better job-security as there would always be a demand for nurses. Nevertheless, after some years of working experience, she would like to go back to school to study for a career in research in public health. Job security is very important in times of economic hardship, so a career is attractive to people in that respect. Furthermore, midwives said they could earn a greater salary with international agencies and private clinics. Four out of the five midwives below the age of 35 saw their jobs at the government hospital as a springboard to better paid jobs (Jenny, Theresa, Tiyanjane and Chimemwe). The majority however said that they were not interested in a career at 35


international NGOs, but were content with the benefits of working for the government, such as the pension after retirement, free secondary school courses, free upgrading courses at KCN or MCHS, and flexible sick and maternity leave policies. Therefore, according to the majority there certainly are extrinsic factors which play a role in their choice for nursing as a career (job security and the relatively easy/cheap career path), additional to the intrinsic motivation they all put forward (that of the joy it brings to help the suffering fellow Malawians). Other reasons are one given by Martha, male nurse Tiyanjane, and Wyness. Martha feels nursing is a way of being closer to God, she says she “wants to do the work that Jesus did, nursing is part of spiritual work”. Although many participants were religious, and the relationship between Christianity and nursing was evident on posters (see Figure 2. A nurses’ prayer Figure 2), few midwives said their choice for nursing was related to their religion. Tiyanjane (aged 30) said he NURSES PRAYER first wanted to have a “medical career”, but wanted to “As I care for and comfort my patients aid patients 24 hours instead of seeing them for short today, periods only, like physicians do. Additionally, he Be there with me, O’Lord I pray. preferred midwifery over other specialties in nursing (e.g. pediatrics and theater nursing), because he would Make my works kind, be relatively autonomous from doctors. Wyness (aged For it means so much for my patients. 29), said she wanted to do something with the science subjects (Physical Science and Biology), because she In my hands place your healing touch. was good at them and she enjoyed them. Tiyanjane and And let your love shine through my Wyness both stressed the medical and curing side of hands.” nursing, as opposed to the feminine side of nursing which beholds the caring aspect. This caring aspect was (Prayer printed on a sheet and pinned to the present in the majority of discourses midwives walls in several wards in the sisters’ office and employed about the interesting, or satisfying parts of matrons’ office) their profession. Reasons to stay: “you achieve something when you save lives” The main reason for choosing to become a nurse (helping poor and sick people) is also the main reason for the midwives’ job-satisfaction now, even in the face of difficult work conditions. Beatrice (aged 54) explains she is unhappy about the poor remuneration for the many working hours, night shifts and the heavy workload. However, she really likes her work, and she would not want to move out of the sector or retire soon despite her tiredness and age, as she would miss it too much. Some midwives gave examples in which they have saved lives and thereby explaining what satisfies them in their nursing/midwifery career. They stressed that they have the knowledge and experience which is needed in order to make good decisions, to save people and help them adequately. This knowledge and skills do not only help them to make good decisions at work, but also at home, such as Beatrice says: My father wouldn’t have been here anymore if I wouldn’t have taken him to the hospital. I also saved a baby, when we were going to the hospital in the car I resuscitated the baby on the way. My goal is to help people and I am good at it.

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Some midwives said that if they were at home or in a village visiting family, they were often consulted by sick people. In emergencies they could also help, which gives them a good feeling. To work as a midwife instead of a nurse, is seen as particularly special and rewarding, because the lives of two people are at stake. The following quote illustrates what working as a midwife means for newly graduated Chisangalalo who just started at the Labour ward: It's nice because when you see someone in pain you can help that patient. She can shout at you, or say this and that, but when you help that patient with love, they deliver. You become excited when you look at that. It's like you have achieved something. You have given someone life and a live baby as well. So it's exciting to work in Labour ward.

Chisangalolo also says that patients can be rude but it is your task to help them through, which was also mentioned by Debby, a midwife from UK who did her internship in Malawi. She said: They will all become tired and they will all refuse to push at a certain moment and that is not different here from in the UK. But that is when you are there, you become kind of like a cheerleader. That is your job, you have to encourage those women and pull them through.

The pride and joy of being a midwife for both the Malawian and the UK midwife is to assist women to through delivery, with a positive outcome for both the woman and her child. There was a difference though in how Debby and some midwives talked about encouraging women in labour. Some midwives had a more firm view on labour, and said women need the pain because it gives them strength for the delivery. Other midwives (both Malawian as well as Debby from UK) adopted a more compassionate approach towards the women in labour. What remains the same for all midwives however is that their special task of asisting the mother and baby through the delivery, and the rewarding feeling they get when they succeed, is what satisfies them in their job. The midwives’ feeling that they could make a difference was repeated as the reason why they like their job so much. This can be seen as the satisfaction midwives get for their altruistic reasons to choose nursing, which is “simply” and “only” because they have an urge to help others and improve their health. So the realty of their job agrees with the pre-conceived ideas they had about it: they get to help people who are sick, poor and helpless. Working in an urban referral hospital In addition to the nature of the work, working in an urban referral hospital as QECH gives midwives job-satisfaction. Although they experienced heavier workload in a government referral hospital than in rural clinics, there are several advantages. First of all, working in a referral hospital brings intellectual challenges, because district hospitals in the surrounding area refer their complicated cases to them. They are the “last resort” patients: “We have to do it here, when they are referred to us we have to think of something to do”, says Chisangalalo from Labour ward. In “the Queen” (as midwives refer to their work place), everything happens which cannot be done elsewhere in the region. Four midwives said they therefore have more learning opportunities in the Queen than they would have in rural areas. Gift, SIC at the Labour ward, explained that midwives in QECH see a lot of interesting cases and therefore have more knowledge than those working in the rural areas. This also had to do with the QE’s equipment and supplies: four midwives said they have the scans and medicine to do more complicated diagnosis and treatments. Chisangalalo gave an example of a 37


woman who came from St. Joseph’s district hospital. They had opened her up there because something was wrong with her uterus. They found it was ruptured unnoticed some time ago and had become necrotic, leading to peritonitis. They had to close her up and refer her to QE because they could not perform the needed hysterectomy there. Additionally, the QECH is only one out of the four referral hospitals in Malawi which has an MRI scanner. Two midwives said working in QECH gives them job-satisfaction because the poorest and sickest people are treated in government hospitals, which is even more rewarding than “just” helping any sick person, referring to richer patients in private hospitals. They explained that in a private clinic or hospital people need to pay for the services. Especially the private for-profit clinics are very expensive and can only be afforded by wealthier Malawians, expats, volunteers and travellers. Thus in (non-paying wards at) government hospitals the very poor and very sick patients are treated; they get the chance to help those who need it the most. This was not giving everyone job-satisfaction however. Wyness said she worked at General Surgical Ward for a few years and did not like it because the majority of the patients were very sick. They came to QE very late in the stage of their illnesses, and many people died at that ward. She liked it better in Obs&Gyn ward where she works now, where except for terminal cervical cancer patients, not many people die. Working in QECH also means living in one of the biggest cities in Malawi, which according to the interviewed midwives has several advantages over living in a rural area: closeness to husband’s work, more business opportunities, closeness to high school and nursing schools (for both their children as themselves), and shorter distance to their social network of relatives and friends. Disadvantages of living in a rural area are related to the poor housing: often there is no running water and electricity and staff houses often only have one bedroom, which makes it too small to receive visitors or family to stay. According to the respondents and stakeholders these disadvantages are mainly associated with rural areas. A matron at Holy Mission Family Hospital added that some areas are very hard to reach, so it is hard to go to town by bus to do shopping and visit family and boyfriends, especially in the rainy season when the roads are bad. Dorothy Ngoma, the Executive Director of NONM, added that in cities there is a better assortment and quality of vegetables and other commodities and luxuries; additionally there is entertainment. Despite these disadvantages in the rural area, most of the midwives answered it would be no problem to move there, on the condition that their husbands would be posted there too. The main reason why midwives said they worked in the QE was because their husbands were working in Blantyre, and according to Matron 1, “following husband” is usually an accepted reason at the nursing headquarters in Lilongwe, when one wants to “escape” the place where they are deployed. However, several midwives indicated that there are socio-cultural and professional objections to being posted in a rural area, and home area in particular. Tiyanjane and Theresa said fear of reprimands and witchcraft of the community are common cultural objections for being posted in a rural area. Theresa (the former Business administration student and part-timer at the AN clinic), said there were recently reports in the media about a snake in a nurse’s home, and two deaths in her family the two following days. The village would oppose the presence of that nurse because she had made some mistakes with patients. According to Theresa, this example does not stand alone, and happens mainly in rural areas. The few midwives who were asked about this said these incidents indeed happen; hostile communities lead to fear among them to be placed in such a community. Tiyanjane said it is the responsibility of the midwife to be kind and patient, saying that a hostile community is only the result of an incorrect attitude towards the midwife. “Therefore I am learning different languages so I can communicate with the patients”, he says. Gift and Chimemwe 38


said they would not like to be posted in their home regions, because they would be overwhelmed by demands for services from relatives and friends. They explained they want to give equal care to everyone, but it is culturally inappropriate to ignore requests for assistance from people you know, especially when they are part of your extended family.

Coping with low salaries and great responsibilities The salary All midwives in the IDIs complained about their salaries being too low, it was a very important issue for them. In the questionnaire, midwives were asked whether they were satisfied with their salary. None of the respondents indicated they were satisfied or really satisfied with their income: 64.5 percent responded that they were “very unhappy” and the remaining 35.5 percent felt merely “unhappy” (Table 1). Midwives said they think this is the primary reason why nurses “run away” from the government hospital as a work place in search of greener pastures and why wards continue to be understaffed. The actual monthly salary for ENM and NMT in QECH, including allowances and after tax deductions, lies somewhere between Malawian Kwacha (K) 20,000 and K30,000 (between €98.18 and €147.27). This is based upon the responses of four ENM and NMT in the IDIs, aged 20 to 50. Matron 1 says salaries start at K20,000, while SIC (who are often RNMs) earn something between K30,000 and K50,000 (between €147.27 and €245.45). She adds that these SIC positions should ideally be for RNM, but since these are scarce, ENM and NMT often fill these posts (although they receive lower salaries, generally less than K30.000). Table 1. Satisfaction with salary by 31 midwives in questionnaire

Salary

Not at all satisfactory 64.5%

Not really satisfactory 35.5%

Satisfactory 0%

Absolutely satisfactory 0%

Don’t know / no answer 0%

According to Palmer (2006), the government addressed the problem of the low salaries by giving salary top-ups. In 2005, all health workers in government and CHAM facilities received a top up of 52 percent (ibid: 34). From 2006 to 2009, the midwives’ salaries increased another 20 percent annually, and an additional 15 percent in 2010 (interview Mission hospital accountant). Anders explains that due to inflation, the wages of civil servants (and thus health workers) were actually continually eroding starting in 1982: “in 1992 the real value of basic salaries was about 50 percent below the levels of 1982” (World Bank 1994: 37-39 in Anders 2006). According to Anders, this trend has intensified due to currency devaluations and high inflation rates since 1994. Midwives in this study also said that these top ups had not improved their situation, as this quote from an interview with Sabrina illustrates: They [the government] said for this year they will give us, what is it, 15 percent? While it used to be 20 percent. So they are going down instead of going up. You know, things are very expensive and they are reducing the percentage. I think this is not on [not fair].

Sabrina says things are very expensive. Other midwives said the prices of food and other goods have gone up drastically, therefore, none of the top ups had a real improvement on their purchasing 39


power. In an informal conversation at the AN clinic, a midwife complained that the government is taking a large amount of the top ups back through tax deductions, something she found very unfair. A satisfactory salary would according to one midwife be at least one with a 20 percent topup, three said it should be doubled and two thought it should be quadrupled. Loans were also mentioned as a good incentive by two midwives, referring to what CHAM facilities do for their midwives. According to Anders, a contributing factor to the growing discontent about civil servants’ decreasing purchasing power also had to do with the fact that colleagues with the same qualifications, performing the same job at donor agencies and NGO, received a salary several times higher (website 2006). Although many midwives in this study mentioned that colleagues employed in NGOs and private institutions earn much bigger salaries, the majority did not think the salaries should be equal. They explained that NGOs and private institutions demand more of their personnel, and do not provide the benefits (such as opportunities currently offered in government hospitals. Additionally, Gift says they are stricter in NGOs, “you always have to be there and they see to it that you will, even when your child is sick at home”. Many midwives explained that financial difficulties force them into different coping strategies. Some work overtime; others seek additional employment or business to supplement their wages. This was especially true for widows and women with many children or dependents. Sabrina (aged 50) also complained about the salary. She earns K29,000 (€142.36) per month, including allowances and after deductions. She has four children of her own and two other children in her care who are children from her brother and her sister. She says it is difficult to get by, but explained that “doing locum” and doing petroda (working two shifts after each other) helps. Doing petroda gets its name from the petrol station Petroda which is open 24 hours. By working extra hours, midwives can get paid through the locum system, as part of the government’s EHRP, whose aim is to relieve midwives at busy or poorly staffed wards. Through this system the management of government hospitals can attract midwives to take shifts on a Table 2. Salary locum shifts part-time basis, and pay full-timers for the Weekdays Weekends overtime they make when they work extra shifts (Mo-Fri) (Sa-Su) on their days off. The majority of the midwives Day shift K1,200 (€5.89) K1,400 (€6.87) said they “come for locum” to “go and help Night shift K1,600 (€7.85) K1,800 (€8.84) themselves”, because they say they need and warm meal and warm meal something to survive. They say they are forced to (source: personal communication Matron 2) go on locum to supplement their low wages with the additional income (see Table 2). Another strategy within the EHRP to get more health workers was to call back 340 retired nurses and re-employ them for three years. After those years, they would receive a certain amount of money on top of their normal salary. Three midwives who were working on this contract said they heard the lump sum would be lower than promised. Beatrice said she would stay in service until the NONM succeeded in negotiating a better amount. Tiyamike and Martha said it was not right that they did not receive their money: the contract ended in June 2009. Martha said she really wanted to retire because she is sick quite often, but that she wanted to make sure she got her money first, because without she cannot survive. A Daily Times article in April 2010 revealed that by then they still had not received their money (Somba 2010).

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Expectations and expenditures: building a house, caring for dependants Many midwives said they want to invest their salaries in building a house so they do not have to pay rent the rest of their lives and accomplish something. This is mentioned by some as being very important to them. For instance Beatrice says “I have worked very hard my whole life, but I didn’t build my own house.” Several midwives said it is difficult for them to meet the expectations of paying for their children’s education, and three midwives said they want to have built a house by the time they are old. This was especially true for the four widows. Those who are married said their husbands had an income which contributes to their financial situation. In Violet’s case, her husband paid for their own children’s school fees while she pays for their transport to school. She gave a bit of her salary to her extended family so their children could also go to school. Jenny, who just gave birth to her first baby, said she is not worried about increasing expenditures; she says she will just take extra night shifts after her maternity leave. Together with her husband’s salary, they will earn enough to get by. Several midwives were taking care of other children besides their own. The results of the questionnaire revealed that 15 midwives lived with family members outside their nuclear family. So among the questionnaire respondents it was common to share the household with nephews and brothers and sisters (in-law). Midwives in this study are living in or around Blantyre. This central location also makes their houses an attractive place for family to stay (temporarily). The additional members of the household might depend on the midwife’s salary as well, but when they are employed they might also contribute to the household budget. What is certain, however, is that many midwives in the IDIs feel their salaries do not suffice in feeding the children in their care. Caring for dependents is normal in Malawi. The MDHS shows that it is common for children not to live with their two biological parents: out of the 31,981 children who were included in the study, only 58 percent live with both biological parents. The remainder are living with their mother only (19 percent), their father only (3 percent) or with neither of their biological parents (20 percent) (NSO 2005:11). Judy, who is widowed, 55 years old and has four children of her own, said the following about taking care of others’ children: First I always said, I won’t care for other women’s children. Yes, the mother has to take care of her own children. I also have to take care of my own children. And how can I take care of other children, I am a widow and I already have four of my own! But then I saw many people are also taking care of my children when I am at work, so why should I not take care of other children? We should care for each other. … My husband’s sister brought me her daughter who was sick but she was cured. After three years she is still with me because her mother never came back again to help me. She doesn’t treat her daughter well, so I thought, I will take care of her and I will send this girl to school.

Although the girl was originally sent to Judy for a temporary stay, Judy decided to take her in and send her to school, because her mother did not return to help her. She says she did not feel she should take care of other children in principle, but thought it was not in line with what she ought to do. Besides this girl, she also took two other children in her care, making her a widow with seven children to educate and take care of. One important coping task of Judy and many other midwives is to financially care for their dependents. This leads to working overtime to gain extra income through locum.

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Tiyamike, aged 52 and taking care of six children, said something similar about locum and her responsibilities since her husband died. When she was asked if she can support her family she replied: With difficulties, I can but with difficulties . . . That’s why we come for locum. We are off duty. We are supposed to rest but we come here to work. Or some find another private hospital, they go and work. To get something, so that we can survive . . . When I am supposed to get off on Saturday and Sunday, I do come, for locum. “Let me go and help myself.” So that means I will only be off one day, which is not enough, not enough for my body to rest. But I need money, let me go, maybe I will get something later . . . [My children] don’t like it, because they say I will get tired [and say] “instead of staying home to rest you are going”.

In these two cases it becomes clear that the personal situation might influence the quality of care indirectly, because midwives say they are “forced” to work many hours overtime on locum, leading to fatigue and less concentration at work. When I asked Tiyamike if all her children went to school she replied with “yes, I love them all”, implying that if you cannot send your children to school you are not taking your responsibilities for your children seriously, and you do not love them or care for them the way you should. Beatrice (aged 54), mother of four children, says she also needs to receive some extra money to supplement her meagre salary and that of her husband who works for the government, in the Ministry of Lands, Housing and Urban Development. She states: With the little money I get, what else could I do? We have to do something [extra work] to have something [extra money], to improve our living standard. But it is really tiresome. Because most of the times I am not at home, I’m always in the hospital. All the time I’m in hospital, I can’t look after my kids well, they’re always asking, why can’t you just rest? But we want to eat food all the time and we want our daughters to go to good schools.

So Beatrice also says the extra locum money helps her in sending her children to good schools and in having enough to eat at home, but also because she wants to improve her living standard. Later in the interview however, she adds that it is not only her personal situation which makes overtime necessary, work-related factors also play a role in this, which will be discussed in Chapter 6. Transport One of the things mentioned in the IDIs which costs a lot of money is transport. The majority of the questionnaire respondents (64.4 percent) travel by bus (Figure 3), costing them K600 (€2.95) to K3,000 (€14.63) per week (mean expenditure K986 or €4.88 per week). It takes them between 18 minutes and two hours to arrive at work, with the mean average travel time of 45 minutes. One regular distance mini-bus drive costs K60 (€0.29), and it is common for one to live at least two buses away from QECH. Unreliability of the busses due to their irregular times often leads to late arrival at work. As a result, fewer midwives are at the ward at any one time, forcing others to stay longer than their shift requires. The trip duration and irregularity of busses depends on where one lives, which means personal circumstances (where one lives) indirectly influence the work situation. Several midwives said they often walked instead of boarding a bus, to save money. The results of the questionnaire did not suggest this was true for the majority because reported that 42


their main form of transport Figure 3. Main form of transport used by 31 midwives from was by foot. Two midwives questionnaire usually went by bus and foot, and by bus, foot or car/truck (Figure 3). Two midwives from the IDIs complained that additional walking when they cannot board the bus made them very tired. Especially when they work many hours, their legs and feet become very tired and painful. Beatrice joked, “If you would put all the short distances we walk here daily together, it will bring you as far as Zomba!” She also said that she often needs to take Panadol (paracetamol) at the ward, to be able to stay on her feet. Midwives explained that despite this, they would rather walk to work and save the money because then they can afford something to eat. Indirectly the quality of care might suffer because of their tiredness: midwives with lower budgets might be more tired due to the need for them to walk instead of boarding busses and due to the financial need to work more overtime. There were also some midwives who came to work by car, which shows the diversity within the group. The expenses for bus rides are so high that it takes up a large amount of their monthly income. For part-timers who only get paid for the days they come to work on locum, this means they are paying for their transport months before they receive their money. This has been causing problems during the time of the study (June to August 2009), because the locum salaries had not been paid since March. This made it very unattractive (if not financially impossible) for part-time midwives go for locum. Midwives often expressed they would rather find other businesses or work part-time in private hospitals where they are paid immediately instead of months later. Gift, SIC at the Labour ward, says all the part-timers have stopped coming on locum, so they only have the full– timers left. Midwives who have lived in rural areas (such as Violet) say that living in a staff house or in student hostels provided by CHAM made life much easier: living close to the workplace saves time and money. The monetary benefits are felt in both transportation savings and in the money freed up by the ability to prepare one’s own meals rather than always buying lunch at work or “surviving on tea and bread”.

Personal characteristics, attitudes and coping Fear of contracting HIV and attitudes towards HIV positive patients Midwives in this study said they did fear contracting HIV, but see this risk as a normal and controllable part of their job. The question posed about this fear was regarded as irrelevant. They often answered that they cannot treat HIV positive patients different from other patients. The following example comes from an interview with Jenny (25 years, Labour ward): 43


Linda: I have read that people working as a nurse or midwife are often afraid to get HIV/AIDS and that's why they maybe leave the sector. Are you afraid to contract HIV or is that an issue here? Jenny: Of course! That's why there are protective measures if you are helping patients. You have to wear gloves and have to take care when you are handling sharp objects like needles, razor blades. Linda: But are you afraid of it? Jenny: [laughs] Yeah, yes. But it doesn't mean that if the patient is positive we should not help. We are [helping them], we are supposed to help the patient despite being positive or negative. And you are helping them.

At the root of what she is saying is the belief that all patients should be helped equally, which is part of the nursing ethics. Whether a patient is HIV positive or not should be irrelevant. The answer is always that they should not be afraid and that they should treat HIV positive patients equally. But she does say she is afraid to contract it. Still she and other midwives stressed that they feel they can control the risk by following the instructions on how to protect themselves (with gum boots, glasses, aprons and plastic aprons on top of that). Because of these precautions they feel there is no reason to be afraid. A medical student from the UK said about her Malawian colleagues’ fear of AIDS: “The fact that patients have HIV/AIDS doesn’t seem to be an issue here. So many patients have it, that it has become normal. It’s not a big deal. I think in our country there is more fear for a HIV positive patient.” It is not clear if it is really not a big deal or if health workers are silent about their fears, and take on a role that reflects their professional ethics: treat everyone equally. According to a NONM employee, the stigma on HIV/AIDS is especially high amongst health workers. In an informal conversation she explained that this is because as health personnel they “should know better”. She said fear of being discriminated at work makes it difficult for midwives who are HIV positive to disclose this at work: Sometimes they don’t get sent to workshops or courses because they are positive. Colleagues wouldn’t want to drink from the same cup, they will be calling them names and they will be reluctant to work with nurses who are HIV positive. They think HIV positive nurses are weak, they are sick, so they will not be of much help when they are put on a shift together. And often they are weak. We don’t get the nutritional support like in the UK, and they suffer from a lot of opportunistic infections.

She explains that if midwives have contracted HIV and want to be tested or treated they usually have to spend their time and money to travel to a different clinic to keep their status secret. According to the NONM employee, these practical considerations keep midwives from letting themselves be tested. Dorothy Ngoma reported that they know that 400 of the 5,000 nurses in the country are HIV positive. She says the real number of HIV positive midwives is probably much higher because it is very likely to be underreported. There are no percentages that I know of on how many midwives and nurses are HIV positive, but Palmer quoted a study by Harries et al. who found that HIV/AIDS causes an annual loss to death of 2 percent among hospital health workers (2006:31). Based upon what midwives say about HIV/AIDS in the workplace, it would appear that their fears do not fundamentally affect their motivation to provide good care to their patients.

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Midwives not only see the disease in their patients daily, they may have to deal with it in their personal lives as well. Because they are midwives, their family or friends might request their services to care for infected individuals (Matron 1). One midwife started to cry during her interview because she lost her 40 year-old son to HIV/AIDS a few years ago. None of the other midwives said that one of their family members contracted the disease, and no one revealed that they were living with HIV/AIDS. There was one interviewee however, who I suspect was HIV-positive. She mentioned twice that she was sick ‘on and off’, which according to Van den Borne (2005: 300) is a common way for HIV-positive people to describe their health. She also said she wished she had become a teacher instead of a midwife, because then she would then probably not be sick. The consequence of her being sick on and off is that they are often missing one of the full-timers at the already understaffed ward. Emotion-focused coping and religion While talking about “mistakes” one type of response was humour. Midwives very often laughed while talking about mistakes or examples of corruption. Some examples are: Gift, SIC Labour ward: Yes, sometimes we eat the food from the patients [laughs]. The midwives divide the food for the patients at the paying ward and then eat the rest [laughs]. That’s what we do. Midwife Obs&Gyn ward (informal conversation): We are only four today [laughs]. The parttime [locum] nurses didn’t show up today, because they haven’t been paid any salary. [laughs]

The giggling when talking about issues which were hard to deal according to them with is an emotion-focused strategy. After asking how they felt about these events, they would turn their discourse into a rather stoic or resigned response. They say they have been working under these conditions for a long time, and that it has actually become a little better since the locum system was instituted. But they do not see hope for changing the situation, so they so need to be sad or frustrated about it: it is just the way it is. The next utterance came from Matron 2, and is a good example of how this resignation is also expressed by the midwives: “I have shut my ears for this, I don’t want to hear it anymore, because I am tired of all this. I will retire soon and take care of my chickens.” She was already retired but she is one of the midwives who were asked to return by the government in 2006 as a response to the Human Resource Crisis. She doesn’t know when she will retire but she says she has had enough of all the problems in the hospital and wants to retire to start a small chicken farm. Sometimes midwives would just laugh about the topic, sometimes they expressed their concerns and worries, and in two cases they said they prayed to God to overcome stressful situations. Personal factors: personality and responding to overwhelming demands When midwives were asked why they think some colleagues shout or are rude towards patients, they gave two explanations. First, because the person in question is just born different; she or he is simply short-tempered or prone to get angry very easily. It had to do with their character, poor upbringing or, as Violet stated, it might be because something has happened in their youth. Beatrice said you find these people anywhere, “just like in every other profession”. According to this explanation, midwives with bad attitudes are not lacking a good educational training, but are just 45


accustomed to dealing with frustration in this fashion. Jill, a medical elective from the UK who was working in the labour ward, said she saw firm views of some midwives towards women in labour and in pain, but said that the attitudes are more related to the personalities of the midwives than to education, experience or age. She said she saw that some are really compassionate while others ignore patients’ cries. The second explanation was that some people have many problems themselves (in their private life), and therefore cannot deal with difficulties in the workplace in a constructive manner. Beatrice (aged 54) from PNC ward said: Another thing [why some midwives have bad attitudes] is poverty. When you have nothing at home, you don’t even want to work, it’s very frustrating when a person comes with a problem, and you are already frustrated you will shout.

Beatrice and other respondents said that midwives still shout at patients and their guardians, but that these days it is not as common because of the locum system, which according to her improves their financial situation and it helps at the workplace because there is more staff now. She also said that when she is dealing with a difficult patient she tries to think of the patient as her mother or sister, who deserves the same love and care as she would give to them. This is actually an emotionalapproach coping style - she is drawing upon her motivation to care for people and uses her feelings for loved ones to improve her mood and care for a difficult patient. Although many said it has become better, there were also a lot of accounts from midwives that they are dealing with a lot of demands, both privately and at their workplace. They expressed feelings of tiredness and painful legs and backs because of the hard work with no rest. In this light, midwives themselves did not express critiques on the nursing/midwifery practice at their wards: they say they are really trying but this is all they can do. An Australian nurse said she saw exhaustion in the nurses she worked with at the pediatric ward. According to her, it was as if the nurses had ‘given up trying to make a difference’. She said she felt like giving basic care is already such a challenge that it is exceptional for a midwife to want to do just the little bit extra for a patient that would turn “basic nursing” into “taking care”. She says she once got other nurses to help her in making beds and doing bed baths, but usually midwives prefer a slower pace in which extra efforts have no space. The way midwives talked about situations which were “difficult to handle” was different from the way Dorothy Ngoma talked about them. As a unionist and the director of the National Organisation for Midwives (NONM), she clearly feels strongly about midwives’ rights. During her interview, she was very energized and full of arguments crafted to convince me that the current situation is unacceptable and that measures should be taken. She is well known in the country for her strong advocacy for more midwives and improved working conditions. Midwives themselves did not talk about the circumstances at their workplace in such a self-conscious and empowered manner. They did feel that the quality of care was not as good as it could be, but they didn’t seem to feel that it was their responsibility to stand up against this situation. It seemed to them to be “just the way it is”. According to Matron 2 this is actually one of the problems: that the midwives don’t care about trying to do a good job. She said very bluntly that she is really fed up with the attitudes of some midwives; they lack discipline, they are not on the job at the scheduled times and they are not doing the assigned work. For example they are often found resting at the office when there are 46


patients who haven’t been washed or beds that haven’t been made. Critical accounts of the attitudes of midwives were mainly given by two stakeholders: Lennie Akamwendo (representative from AMAMI) and a KCN Lecturer; and by two midwives: a part-timer (Theresa) and someone in training at KCN (Tiyanjane) who is working at the Maternity Wing as a part-timer. The two stakeholders said that there are many very good midwives, but these are being overshadowed by the many examples of the “not so good midwives”. Tiyanjane said that he feels midwives often just relax in their office when there are students doing their practicals, letting the students do the work without supervising them. Also, Theresa says she does not like the attitudes of midwives who do not want to learn from others unless they benefit from it. Gender and personal and interpersonal care With some stakeholders and one male midwife “gender” as a factor influencing interpersonal care was discussed. Seljeskog et al. (2008) found that some patients preferred male midwives in the Labour ward because they were kinder; I asked several respondents what they thought about the differences in male and female midwives’ attitudes. Tiyanjane indeed said that male midwives are more understanding and caring and female midwives often talk to patients in a harsh way. The explanation for this was according to him twofold. First, men are better in handling pressure, because they are brought up with “hard jobs and hard duties”, and the spirit to always stand strong. He says some female midwives are also strong, but he says many are afraid and it is often too much for them - many just cannot bear it. Therefore, he says, women would appraise situations differently than men, feeling that their resources are exceeded sooner than man. Men with their typical masculine qualities are raised to take on active coping strategies while women would avoid stressful situations. Second, he says women may have additional pressure at home, making it more difficult for them than for men: I assume it is because the pressure of work. They are tired, and also maybe the pressure of their husband, maybe they had quarrels, they come to work. And sometimes they empty the anger to their patients, things like those. Male midwives are controllers in the house, so most of the problems are solved by them. There are not a lot of men who can transfer anger to other people. So that’s why maybe female midwives have these problems.

Men do not have these additional problems. They do not need to worry about their personal home situation because they control everything and do not carry the same responsibilities women have in the household. Judy and Sabrina indeed expressed that they often felt bad about working while their children were at home alone without the support of their mother cooking for them and raising them well (“it is not only money that I need to give them”). An additional explanation given by another midwife and in an informal conversation is that men have never gone through labour and never will; therefore they are more humble and caring towards women in labour. Female midwives are, according to them, much harder on women who scream out in pain or complain about their labour. Two female midwives said it is not good and not allowed for women to cry during labour, because all mothers have been through this, she is not alone, and crying does not help. Crying will only make them weaker or bring them closer to giving up. These midwives said that there are times when you have to shout at women or speak firmly to them to get them to follow instructions to deliver safely. This could also be seen as a personality factor, but others also said in informal conversations these attitudes are related to gender. 47


Conclusion Midwives say they wanted to join the profession because they want to take care of sick people, contribute to the development of the nation, because of the job security and relatively cheap way to get an education, and for religious reasons. Only two midwives provided answers related to the curing aspect of nursing: because it is a medical career (Tiyanjane) and because it makes use of science subjects (Wyness). The reason they gave for being satisfied with their job is that they think it is rewarding to save and care for people, both personally and professionally. So the work coincided with their prior ideas. It is important to note that the interviews were conducted with midwives who have already worked for at least several years, so answers to the question “Why did you want to become a nurse?” were possibly subject to a recall bias. Still, midwives and stakeholders say that a midwife’s motivation is for entering the profession influences their attitudes towards patients. They do not always really have the passion to care for the sick and the poor, and have the dedication in them. According to midwives, those who do not have this passion might “run away” from government hospitals to better paid jobs in private hospitals or to administrative duties at NGOs. According to critical stakeholders (KCN lecturer and AMAMI representative), those who do not have the passion cannot deal with the pressure and will have apathetic attitudes towards quality of interpersonal care. They will care only for the money, rest in their office often, and be working long days (or several days on petroda) which do not benefit the patients. Midwives think their colleagues who work overtime are not there for personal financial gain but are “forced into it”. SIC Gift illustrates this by explaining that: People just work so many hours to fill the gap that the salaries cannot fill. It’s not good, but people are forced just because the responsibilities that they have. A lot of midwives who work here are widows, or are single parents and have to pay school fees or whatever so they rather stay in the hospital and go home twice a week to make money. [laughs]

This means that financial difficulties at home, whether because of the number of children or because of the lack of a secondary income, influence the number of additional locum shifts midwives take. Midwives admit this can be very tiring, but say they are strong, and are trying to give the best care they can. They say that they do, indeed, give adequate interpersonal care, but that there are always a few midwives who have a character or a personal situation that might lead to a less caring and less kind attitude towards patients. Emotional and cognitive approach strategies that are used are humor, praying to God for extra strength, or thinking of one’s feelings for their own sister or mother. In the next chapter I will describe the educational background of the midwives at the maternity wing and how the ideals learned in training relate to the actual work done. I will describe how midwives perceived their pre-service training and what they think of in-service training, i.e. seminars, workshops and courses.

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Chapter 5: Formal and informal education: ideals and practice After passing the busy hospital entrance where 20 to 30 people are daily trying to sell their papers, bananas, bread, cookies, candy, phone credit and mandazi (deep fried batter), you pass the morgue and the guardian shelter. The noise and activities die as soon as you take a left turn, into a street along the hospital walls, leading to the entrance of the Kamuzu College of Nursing (KCN). Two guards welcome me: “Muli bwanji [how are you]?” as I enter the gate, and so does the gardener watering the grass and gardens. A red dirt road leads to the unpaved parking area, where about six to ten cars and land cruisers are parked, belonging to the administrative staff and teachers. On the left side of the parking area, about six classrooms are built in a U-shape around a small square where nursing students follow their theory classes. One week, students moved the furniture to this square to have group discussions, which demanded more space than the classrooms could offer. The student restrooms are simple, there is no lock on the door, one of the toilet seats was broken and usually there is no toilet paper. At the right side of the dirt road and parking area, there are three buildings, lying parallel to each other with polished concrete paths in between, and a channel on all sides for the water drainage in the rainy season. In one of the buildings the offices are found from the vice-principal and her secretary, and the registrar and his secretary. The center building consists of classrooms; a few (junior) teachers’ offices and a store room. The offices are simple, some decorated with calendars and posters from President Mutharika Bingu. Several offices rely on electricity for light, because they have no windows. These offices have been constructed by walls of boards placed in former classrooms. In the storeroom there are some dusty textbooks and rubber boots, to use for students to protect themselves from fluids during their practicals at Labour ward. In the third building more classrooms, a library, and offices of senior lecturers are found. In the library, four computers can be used free of charge, but the use of internet became a paid service while I was there: K60 per 30 minutes (€0.30). Very often though, there was no internet, which could take hours up to days. One time the internet and power was down for four days to the frustration of the nurse tutors and students in MSc in Midwifery, who could hardly work in the absence of internet and their computers. The library is half used for computers and working space, and the other half is occupied with six four meter long book cabinets, where hundreds of book are organized into several thematic areas in nursing: from neonatology to public health and from nursing ethics to theatre nursing. The student hostels are not far from the nursing campus, and can be reached by a concrete path going from the morgue, the laundry and the hospital kitchen to the wards and then the outpatient departments. Next to the Moyo clinic, where malnourished children are being cared for, the KCN hostels are found. The degree students are based here, while students in upgrading courses are staying in houses nearby the hospital where they have their own kitchens. It is in this space where student nurses learn to become a midwife, and tutors teach what needs to be known before you can call yourself a Registered Nurse Midwife. (Fieldwork notes, 15 July 2010)

What is described here is the Blantyre satellite campus of the Kamuzu College of Nursing (KCN), which opened over ten years ago (personal communication KCN lecturer). The main campus of KCN is based in the capital Lilongwe, overlooking the referral hospital of the Central Region: Kamuzu Central Hospital. The Blantyre campus of KCN is currently used for degree students in their third year of training and several other (upgrading) courses. The majority of midwives included in this study are 49


trained in Mission Schools, not in the educational environment described above. This description gives the reader an idea of what the teaching environment of the highest level of nursing education looks like. The KCN campus looks very simple compared to the COM campus, a few 100 meters further along the road. Here there are separate buildings for every specialism; each with several stories, there is an athletic arena and a well furnished canteen where food is served. Then there is a separate library, there are colourful gardens, well kept grass fields between the buildings and a paved road connecting the buildings. The COM campus also contains a research section. Still, with an output of 100 midwives per year, the KCN outnumber the output of the COM, who train 60 per year (Dovlo 2004). Looking at the training institutions, one can see a bias towards the COM in the budget for the educational environment of these two professions. In response to the critical shortage of midwives, policy makers (government and international donor organizations together) have agreed that more nurses and midwives need to be trained urgently (Palmer 2006). The KCN Blantyre campus did not look like it had the capacity to double the intake, let alone tripling or quadrupling it. KCN would need to seriously improve the infrastructure in terms of classroom and dormitory expansions according to Dorothy Ngoma from NONM. But sufficient infrastructure alone is not a guarantee for (quality) training of midwives according to a KCN lecturer. In this chapter, the question is raised what good education is and what could or should be improved according to the respondents. First, the different cadres and training opportunities will be explained. Second, I will discuss what the characteristics of a good midwife are, both ideally and within the circumstances the midwives have to deal with daily. Finally, I will discuss in-service education, which plays an important part in sustaining and improving quality of care, through an investment in skills and knowledge improvement for those already working in the field.

Nursing and midwifery education Courses, cadres and possible career paths I explained in chapter one that if NMTs want to upgrade to a diploma RNM, they can follow a two year upgrading program at the MCHS or at KCN. The entry requirements for this program are an ordinary pass in Mathematics and four credits (score of 75% or higher): in Biology, Physical Sciences, English and one in any other subject. But many midwives wanted to be a degree RNM. They could go from NMT to degree RNM via two routes, the “Mature entry” program or the “Generic” program. The first “Mature Entry” option is a two year program in which one can enrol after completion of the formerly mentioned upgrading program and two years of work experience as a diploma RNM. The midwives in this study did not prefer this route though, because it takes many years. In an informal conversation, the father of an NMT told me his daughter wants to go for her degree, but if she wants to go for this “Mature Entry” program she would need two years of working experience before she can enter. He said he was worried that by then she would already be married and pregnant. Two respondents indeed got pregnant during their NMT training and had to drop-out of school, but they re-enrolled a later year to finish their study. The second of the two routes is preferred by the majority: qualifying for the four years “Generic Program” at KCN to get their bachelor’s degree at once. This requires higher grades in high school: six credits in Physical Science, Biology, Mathematics, English and two other subjects. Additionally, they need an acceptable score in the University Entry Exam. NMT are saying that this is one of the reasons they are so happy with their job in the government hospital: the government pays for these high school fees, so they can obtain their credits in the subjects they still need. 50


Additionally, while keeping their normal salary, they get afternoons off to attend school. Both midwives aiming to enter the upgrading course and midwives who want to enter the Generic Program benefit from this educational incentive. The curricula have changed several times during the past decade of which one example is that of the Enrolled Nurse Midwife (ENM), who is no longer trained. Another recent change is the collaboration between MCHS Blantyre and KCN. Due to agreements on curricula, midwives who have attained their diploma at MCHS Blantyre (not at Mission Schools, MCHS in Lilongwe or Zomba Nursing School) can enter straight into the two year “Mature Entry” course to obtain their bachelor’s degree. This saves midwives four years: two years of study for an upgrading and two years of the required work experience; so it is a great improvement for midwives who want to “go up”. Now I turn to the educational training the respondents followed. Education of the Gogo Chatinkha Maternity Wing Figure of the questionnaire.4 shows the attained education of the midwives of the questionnaire. As seen the majority of midwives (NMT) has just recently graduated. They are young and do not have a lot of experience. The 23 ENMs en NMTs who are trained in a lower cadre are in the majority. Out of the 13 midwives in the IDI’s, two are Figure 4. Highest attained training of 31 midwives in RNMs: Gift and Violet, who are SICs in questionnaire the Labour ward and ward 1A. One of the remaining 11 is enrolled in a KCN course for a diploma, this is Tiyanjane. The other ten interviewees are five NMT trained by Mission Schools and five ENM. The respondents in the interviews all agree that the system of different cadres is complicated, and that career possibilities and entry requirements are not clear-cut. The NMT however all say they want to upgrade to be a RNM, and preferably want to a university degree so they are “in the Bachelor’s order”. “I want to upgrade” and the hierarchy of knowledge All midwives, except for the ones who are about to retire, say they want to upgrade. The several reasons are mentioned why midwives want to upgrade, can be divided into four main arguments. The first is that they wanted to learn more about why they had needed to do things in a particular way, so they wanted to be taught the theory behind their practice. The majority claims that after their training, they would come back to work at the ward, because they say that background knowledge is needed to advance practice at ward level (Evidence-Based Practice). They would eventually possibly want to become a SIC when they are a RNM, or want to get other managerial positions in government hospitals. The second reason is that with a diploma and even more so with a degree, midwives say they have better career opportunities than with a certificate only. The career opportunities are even better if one gets a specialization after their degree. Going from NMT to a degree RNM is a long way, 51


but through their employer (the government hospital) they can seize the opportunity to obtain their credits in high school; and after that apply for the “Direct Entry” program. Tiyanjane and Theresa say they want to improve their education because they get better chances to get a (better paid) job in projects from NGO’s, for example for the UNFPA or the NAC (National Aids Commission) which are both big employers for midwives in the country. The third reason, given by Chimemwe (with a NMT certificate) was not directed to career or salary enhancement but purely based upon professional security. Chimemwe did not necessarily have an interest in becoming a matron or ward manager, but said there were rumours that the NMT certificate will not be of value anymore in the future. She could not tell me where the rumours came from, but she thought the government and hospitals sooner or later would not accept her certificate. The fourth reason is that a RNM diploma allows midwives to do vacuum extractions and breech deliveries which are essential CEMOC functions. Three NMTs said this would really make their care easier, because when they obtain these skills and the authority to perform these, they would no longer need to “run around” looking to find other RNMs or physicians to look after a patient. They would become more independent and it would save time. Stakeholders (from MOH, the NMCM and a KCN lecturer) as well as a Mission School lecturer explained that upgrading the skills of NMT can make a huge difference in rural areas where these CEMOC functions are needed as well, RNMs are scarce and timely referral is difficult. For this reason, the Ministry of Health and the NMCM have decided to train NMT in these CEMOC functions as well (personal communication Mission School lecturer). Not many midwives at the ward were aware of this, and generally said they wanted to upgrade anyway when they have the chance. It is clear that it has become relatively easy for young midwives to reach their dreams and aspirations to be “in the bachelor’s order”, now government is paying school fees so students can enter high school and University. It also became clear that higher formal education was regarded as very important in midwifery, where evidence based practice is becoming increasingly important. One SIC said improved knowledge also helped when debating with doctors, about an appropriate treatment for patients.

The ideal midwife and daily practice The ideal midwife When you walk through the hospital corridors, numerous portraits are decorating the walls with the under script “midwife of the month”, and “midwife of the year” (Picture 6). Such an appointment should lead to more awareness of good behaviour, and a midwife of the month should set the example of others at the ward. In an informal conversation, Matron 2 told me about the selection of the midwife of the month: Nice midwives are extremely rare. Midwives who are really listening to patients’ problems; those are the midwives we are looking for. It is not good to select a best midwife every month. She must really be meeting the criteria (informal conversation Matron 2).

According to Matron 2, it is important that she really is a role model, but explains that the best among good midwives might not always be good enough. Also, she says sometimes “good ones have already been rewarded the past couple of months” which makes the selection difficult. In agreement 52


with the QECH Management Committee and the SICs, they decided to come up with criteria for the midwife of the year, to whom an award would be granted. The following aspects need to be scored on a five point scale: Punctuality, attitude towards work/willingness, reliability, organized, initiative, knowledge of work, leadership, decision making, use of time, interpersonal relations and neatness (hair and overall appearance). (Guideline sheet “Nurse of the month”)

When I asked the midwives at the ward (six in total) what they found important in good nursing, they replied with: kindness to patients (five midwives); complete observation and examination of patients (two midwives); following doctors’ orders like administering drugs and doing tests (two midwives); take care of the patients like bed bathing the patient, clean the bed and clean the environment (three midwives), ask for help when things are beyond your practice (one midwife), should do as Florence Nightingale did (one midwife). Although the majority mentioned good nursing is related to interpersonal care (kindness to patients), in their discourses more attention is given to the actual tasks a midwife should fulfil, so to clinical care aspects. Midwives gave me reasons why they could not always fulfil or meet the requirements they had mentioned, for example by saying that if a patient has a guardian; they would ask the guardians to wash the patients when it is busy. The workload and shortage of staff was often used as a reason why midwives could not adhere to their own set ideals. Compared to the ideals set by the Management Committee, managerial (use of time, organized) and theoretical aspects (knowledge and decision making) are missing. Daily practice, routines and informal knowledge The following issue about punctuality serves as an example of where ideals are acknowledged, but at the same time there is understanding among the midwives for not adhering to the ideal. When I asked them about their schedule, they said the nurses on nightshift often had to stay in longer because the dayshift was late. When I asked Jenny whether this was a problem, she said she did not mind, since “most of us are commuting, so we come from far.” Also Violet, SIC at the paying ward, said she has troubles being at work in time due to the unreliability of the minibuses. Gift, SIC at the Labour ward says that people are not taking this rule very strict. As a solution, Matron 2 said they were thinking about a clocking system, this would especially be good to discipline those who are late quite often, such as some locum nurses. I asked Gift (RNM) if she thinks this would help: Gift: It will. It’s just a matter of discussing, disciplining where possible. Linda: Is it difficult to discussing this? Or do you do it all the time? Gift: We do discuss, but people have got their own social problems, like “I’m taking an exam at school” and whatever, things like that. We try.

She is thus saying that it is important to stress rules and remind midwives of the ideals, but she also says she understands peoples’ social problems or other concerns like education. According to some stakeholders (lecturer KCN and Lennie Kamwendo) it is high time that hospital management “put its foot down” and demands better performance and better attitudes. What is also claimed by Matron 2 and several other stakeholders and participants at the FDG, is that there are not enough leaders or role models at the ward, while they are very important at this time. “Nurses have really relaxed,” a KCN lecturer says, “and it is time for them to do a better job”. What would this better job be then? And who should be these role models? 53


According to Matron 2 they need RNMs at the ward, because: She has the capability of applying theory into practice, learned that they should work and not be just comfortable with the situation. A good RNM will be a committed midwife, of which you can expect higher quality, she is a manager and an organizer of supplies and staff, is a trainer and also evaluates services to the patients. She is there for the patients, act as an advocate for patients in relation with doctors and offers totality patient care.

The Matron says she prefers RNMs above NMTs because of her managerial skills and because she will resist the situation: she will not just be comfortable and will be an advocate for her patient. RNMs have competencies and technical skills NMT do not have. The Matron says NMTs are also working very hard, but says it is very necessary to have at least one RN at every ward because they can operate at another level and can set an example. Many NMT expressed indeed they sometimes miss the supervision and support of older and more experienced midwives, which will be discussed in the next paragraph. What becomes clear when looking at these examples is that learning does not only have a theoretical aspect. It is not only a matter of applying rules and regulations (with punishments for those who do not adhere to the rules). Nursing also is a social process. The stakeholders and also some NMTs (3) stress the importance of learning from role models and RNMs who need to restore discipline and manage the ward better. These examples also show that the ideals as they are given are difficult to maintain at the ward. The knowledge base on which midwifes build their expertise, comprises according to Martin of two different kinds of knowledge: informal and formal knowledge (2006: 90). The Matron and other two stakeholders quoted above represent the importance of formal knowledge, which is needed in order to maintain the professional ideals. Formal knowledge refers to both the right technical skills as well as the appropriate attitudes. The SIC acknowledges that she needs to remind midwives of these ideals, but that there are also other issues at stake, so she feels she cannot expect midwives to do everything according to these ideals. The midwives themselves (especially the younger ones) are saying that with the shortage it is simply impossible to care for all the patients the way they would like to. They have to step away from their professional ideals make themselves acquainted with the informal knowledge which shapes the daily practice at the ward. It is the informal knowledge and skills midwives need to attain when they enter the wards. In this process, midwives are learning to cope with the constraints they encounter, which is more a social process than applying a clear-cut guideline. This is precisely where they (and several stakeholders) say their education is lacking: strong role models who teach the right informal knowledge, or coping possibilities. Lack of follow up and supervision in the clinical area Due to an increase in intake of students, the lack of teachers is becoming bigger. In order to ensure quality of education, classroom teachers have tried to follow students up in their clinical area. This has become more difficult now the student-teacher ratio has grown bigger, according to Dorothy Ngoma (NONM) and Rebecca Ngalanda (KCN lecturer). The problem is that because of the lack of staff at the wards, experienced midwives do not have the time to supervise and guide students in their practicals. Tiyanjane, a student in an upgrading course at KCN, says some midwives who are on duty have a poor motivation to teach nurse students, and just take them as if they are their helpers. 54


The midwives are according to him just doing administrative tasks, or “are just sitting in their office”, while the students are at the wards practicing skills for which they actually need supervision. One midwife said she had time for an interview, because she had seven students at the ward who could attend the patients. I could not tell the difference between students’ levels of education, and I was not aware of the tasks they were due to perform, but it appeared to me as an illustration of what Tiyanjane had said. Another example comes from Matron 1 who said that the quality of care in QECH is not as bad as elsewhere because they are compensated with the students who come from different colleges. She says the quality of care would be much worse without students filling the gaps, and stresses that it is not a permanent solution and students are always working under supervision. This example underscores that the surroundings in which midwifery students need to familiarize themselves with the informal knowledge or local context of their nursing theory is everything but conducive. None of the midwives said their education was of poor quality, however, they did express that their education did not prepare them well for today’s nursing practice and that they lack practical knowledge. Finally, the last example on the importance of clinical teaching in quality of education comes from the Head of Obstetrics. This is not about midwives but about medical students, but it applies to midwives as well. Medical students get trained in ethics, medical ethics, how to deal with patients, how to talk to patients, then they can learn that. You know the problem is when it comes to something you learn is putting that into practice then there is a difference. Because the other aspect of training is what they see, and unfortunately over the years, health workers were not particularly kind to patients, so you find in some cases patients being shouted at or even in particular cases being slapped, being physically hit by health workers. And if somebody in training watches that, observes that, then they will pick up those bad habits. So it is something that you can teach in a classroom, but also in practice. How you conduct yourself in the presence of students, in the interaction with patients. They will pick up what they see. If you are rude to patients they are going to be rude as well, if you are nice to patients they are going to be nice as well. So yes, it is a little bit of both. Teaching formal classes in the classroom but also practicing that on the wards and allowing patients to watch you do that.

In a study on the Improved Health Training Education in Malawian Nursing Schools, commissioned by the Norwegian Organization for Development Cooperation, it was found that in nine mission schools and MCHS, the number of tutors has only increased by 26 percent on average, while the student numbers increased by 119 percent (Martinez et al. 2008:21). It is very likely that this affected the quality of care, as stated by the trainers and principals they interviewed. However, students of these colleges said they think the quality of training had improved, while many complained about the limited availability of tutors.3 This was similar to what is found in this study. Recently graduated midwives in this study say they were overall satisfied with their training, but still say they want to gain more practical knowledge and want to upgrade.

3

Many also complained about the lack of books, lack of equipment in the skills lab and the shortage of computers.

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In-service education: “we have to be up to date” Importance of in-service training The following excerpt is again from the Head of Obstetrics, but was also expressed by many midwives when talking about in-service training: Oh yeah, every ones knowledge should be improved, it’s quite obvious. When you are in training you learn certain aspects of medicine. But as you know medicine is in a changing environment, it’s very pragmatic. I mean what might be applicable today might not be applicable in the next few months or next few weeks. So someone who has been trained in the eighties or nineties, they need to be keep up with the changes of medicine. So you need the particular in-service training to improve people’s knowledge. There’s no doubt about it. That even goes for medical officers. You know medical officers themselves develop themselves, they read round, they attend seminars, meeting workshops and that’s all part of improving some ones knowledge

In-service training is according to midwives as well not only important in addition to what is learned in pre-service training. It is a necessity, and typical for the field of medicine, especially when it comes to HIV/AIDS treatment. As an example, midwives often referred to the field of HIV/AIDS, where regimes on ARV change regularly and one needs to be kept updated. In most of the wards there were sheets saying what to do to Prevent Mother to Child Transmission (PMTCT) with details on dosage and kind of medications should be given during pregnancy, during labour, after delivery and to the baby until weeks after being born. Not all midwives had (extensive) training in PMTCT, ARV treatment and Voluntary Testing and Counselling. The burden of HIV/AIDS and PMTCT is very concrete for the midwives at this wing, when the less experienced or trained midwives have to find colleagues who are authorized and trained in doing PMTCT and counselling. At the same time it demands a lot of the few midwives who actually had the training. It was also very often stated that when midwives actually mastered these procedures (from others at the ward), things could just have changed the other month. Besides courses on HIV/AIDS, midwives mentioned they would like to know more about conditions and procedures which are specific for their ward. For a midwife in the operation theatre this would be on surgical procedures or theatre nursing, while in the gynaecology ward they are saying they would like to do a course on post-abortion care and cervical cancer. A NMT in Labour ward says she would really like to have a course in preeclampsia patients; an EMOC course (see page 6) is also popular among midwives in the Labour ward. Selection for courses: “they are fond of taking only Matrons” There is a general notice among all midwives (apart from the SICs) that there is no equity regarding who is picked for in-service training. Midwives feel the same candidates are picked all the time. Figure 5 does not necessarily support that idea, but it does not refute it either. As seen, there were two midwives who have followed seven courses in the past five years. One of them indeed is a SIC, but the other one is a “regular” midwife working at a ward.

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Favouritism is also denied by the matrons and SICs. This does not mean this does not exist, it is a sensitive subject. Matrons said that most of the times she would ask the SIC who keeps a list who has not been on training the past few months or year. A SIC said the same. The previously mentioned mid-term review on Improved Health Training Education in Malawian nursing schools, commissioned by Norwegian Organization for Development Cooperation, also found that: “Selection was dependent on whether one had gone for any workshop before or not. In general, most Principals were unable to explain how they assessed training needs for their staff or how decisions were made who should go for available training.” (Martinez et al. 2008:24). According to Martinez et al., there was a lack of systematic efforts to develop staff capacities based on their needs and institutional requirements (ibid). One organization which organizes workshops is NONM. An example a NONM representative gave me is that to be eligible for a course organized by NONM, you need to be “a committed member” of the organization. This means that you have to be at least paying your yearly contribution of K500 per year. Furthermore you have to have done “something outstanding” for the organization. These criteria might be picked up by people at the ward as unfair. Figure 5. Number of courses or workshops followed by 31 midwives in questionnaire

Sharing knowledge and needs assessment: “They just want to go for the money” All midwives say that they are satisfied with the training they had, but that they need extra courses to refresh and, to keep them sharp, and know more. The knowledge improvement may be an important reason, but there were also many stakeholders and midwives who confirmed that another important drive to go for training and workshops is the money. A KCN Lecturer says the following about monetary incentives for workshops: If you want to conduct a workshop, people [midwives] will only come to the workshop if they know that they will get some allowances. It’s not on [fair]. If you are going to a workshop to gain knowledge, you know that you are coming back to use that knowledge to improve the quality of care. Then you are going to achieve something. But if they are there to get the money, they will come back and you are at ground zero. . . They go out because through that, they get a lot of money, but when they come back, do they really use the knowledge they gain to improve the care? . . . People should learn that they are going to workshops to learn and come back and implement that knowledge. If there is any monetary incentive or something else it should be secondary. It should not be the primary reason. It started like the past ten years; that is what has been happening the past few years. Which is a very very very bad attitude, I don’t like it.

The motivation to go on refresher courses might be mainly the monetary incentives; which is “not on” according to this KCN Lecturer. Lennie Kamwendo from AMAMI felt the same about this issue and added that it is not only morally inappropriate as some would call it, it is also a waste of HR, 57


because the knowledge or skills that have been aquired, are not implemented at the institution where the midwife or matron is based. On this matter, the accountant of an CHAM hospital does not agree: Beside the salary midwives also get paid a lot of money with workshops. For example a two week NGO course, they pay a lot of money. It is unfortunate that some will go for the sake of going, but of course it will benefit in their personal growth. They do learn. So I don’t agree that it is not good that organizers of courses give money [to make participants come].

Maybe the individuals do learn from their courses, but it will benefit only the patients who are in her care. I discussed this issue in the FGD, after midwife Theresa said that it is not only a fault of the ones coming back from a course, but also the responsibility of the midwives who did not get picked to go for the course. She gives the example of a colleague at her ward who came back from a two week course. Her colleagues were jealous that she was sent and probably got a big amount of money, besides having had a nice break. Theresa stated that midwives who did not go should be open to learn from the ones who went for the course, and ask her to update them. She says the midwives did not seem motivated to take on tasks which they have not been trained for even if it is not complicated or “no big thing”. Another reason this knowledge is not shared is not mentioned by any of the respondents, but comes from Martinez et al. (2008: 24). This applied to nurse lecturers who learned about new ways of teaching (e.g. Problem Based Learning). The lecturers were determined to improve their quality of training, but failed to do so due to poor documentation of the activities; a lack of follow up by the trainers; and no supervision on how to apply the learned principles to their own institution. The Head of Obstetrics says that although any training is always useful, it is important to make a need assessment before people are trained. He does stress the importance on training even for people who have been around for a long time, because “every now and then one needs to sit down and just be inspired by new skills and new knowledge, and stimulated to read a little bit more”. This needs assessment could ensure that what midwives are learning is directly improving the quality of care at the area they are working at, by giving focused training for staff development.

Conclusion In this chapter is has become clear that midwives have not experienced their training to be of poor quality. Interestingly however, is that all NMT want to upgrade to become a RNM. This might have to do with the fact that increased levels of education lead to upward social and economic mobility, but it could also mean that they do not feel competent and confident enough to perform their nursing tasks. To acquire this feeling of competence and confidence, younger midwives say they need more practical knowledge, and older midwives say they need to be kept up to date of new nursing theories and protocols. They actually say they need both more formal and more informal knowledge. This formal knowledge helps midwives to keep faith in the ideals in nursing practice. Once they start learning in the clinical area, they are confronted with practices which are far from these ideals. This mainly has to do with the impoverished work environment, but also with the lack of supervision and good examples at ward level. Midwives in QECH have to cope with a very demanding work environment, which requires managerial skills next to technical nursing skills. These could be attained through in-service trainings. In-service training is seen as a very necessary means of updating midwives with the latest ARV 58


treatment regimes; and make midwives more familiar with the skills and knowledge their ward requires. According to some however, the motivation of midwives to attend educative meetings are often not to upgrade their technical skills and knowledge, but to get the monetary incentives. For midwives, attending a course is a nice breakaway, it may lead to career enhancement and the money is a very welcome extra. This makes courses highly popular and sometimes leads to jealousy among colleagues, who have the feeling that the selection process is not fair. Furthermore, midwives think knowledge should be shared more with those who did not attend the training, and colleagues are not always open to learn from people who attended courses.

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Picture 6. Midwife of the month pamphlets

Picture 7. At the entrance of KCN Blantyre Campus

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Picture 8. At the parking lot of KCN Blantyre Campus

Today there are only few cars parked, under the shed at the right side of the parking lot.

Picture 9. Holy Family Mission Hospital in Phalombe.

One of the CHAM Mission Schools where NMT and ENM are trained (ENM Sabrina was trained here in 1986). Mulanje massif is visible in the background.

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Chapter 6: The work environment: care provision in underequiped and understaffed wards “When the Queen Elizabeth opened in the sixties by president Banda, it was a place of promise, a place of high technology and a model for progress and modernity”, says my Malawian host. “But now”, he says, “It is just a remainder of what once was a beautiful place. They are dealing with severe shortages, the place is old and poorly maintained and its reputation is not as good as it has been. Although I heard it is getting better”. What I saw on my first days when I was introduced to my field was not quite what I expected. First of all it was very cold. There was no central heating and only a few sisters’ offices had a small electric heater to make the room temperature a bit more comfortable. I didn’t want to imagine how cold the rest of the ward was, where patients are recovering from CSs or severely infected wombs due to incomplete abortions. I spotted some leakages in the PNC ward corridor and some steam was coming out of a pipeline in the hall of the Labour ward, filling the ward with a strange scent. Everywhere on the wall I find “do’s” and “don’ts” written in Chichewa, for patients and guardians in the corridors and for the personnel in the sisters’ office. The long corridors are cleaned by ward attendants, recognizable because of their rubber boots and green clothing. The old mops they use with black and torn streaks seem to spread the dirt and dust around rather than cleaning it. Only the strong chlorine scent gives you the idea that their work must be effective against the spreading of infections. The paint on the walls is old and the curled corners of the ‘midwife of the month’ pamphlets frame the fading images of faces and names of the very same midwives I see at the wards (Picture 6). Within the wards I find the midwives shuffling through the sisters’ office, one even limping because her feet hurt. When I come in they are always busy, speaking Chichewa with colleagues, laughing and joking with each other or with me in English. Patients who come in with questions are often not responded to immediately, but eventually they answer them with a raised voice. Patients often kneel halfway down, one hand folded into the other as an expression of respect and gratitude, before they are greeted and are permitted to ask their question. The sisters’ office serves both as a lunch room and a patient consultation room at the same time. In some wards they are used to remove or insert canulas, take blood or measure blood pressure and temperature. Midwives are oftentimes at this office, but are usually busy with administration or patients who entered with questions or for procedures that needed to be done. Some midwives have unkempt hair, and many are wearing worn out shoes. The uniforms did look well taken care of, but only some of them wear sweaters while everyone felt (including me) very cold. Some complained about not having received uniform sweaters. (Field notes, 3-10 July 2009)

This was one of my first observations, as a Dutch student in medical anthropology and a former nursing student with a one month internship in a Dutch hospital environment. I was very much aware that I would see major differences, but I did not expect to see such a poorly maintained work environment at the biggest central hospital in Malawi. However, I do not think the environment was as poor at every other ward, and compared to other buildings in Blantyre, the QECH had allure. The hospital was spacious and had many windows which allow plenty of light to come in. Furthermore it seemed organized, with different wards, a separate Family Planning clinic and an Emergency ward at the entrance. Services like laundry and the kitchen area for patient meals were found at the back. Here yellow sheets with the letters “MOH” (Ministry of Health) decorated the gardens, which were separated from the Kamuzu College of Nursing by a sturdy-looking fence. Around the whole hospital and college campus a red bricked wall cut off the medical world with the outside world. Along this 62


wall in the outside world, “businessmen” (and -women) were selling banana’s, candy, airtime for cell phones, newspapers, local breads and other small goods such as mwanzas (deep fried batter which taste like Dutch oliebollen) The hospital did not only look like a building of past glory, but also like a vibrant centre of social and economic activity. The faces of the people who worked in this centre, however, told a different story. I observed agitation and fatigue in most of the midwives, as well as in the faces of the matrons, ward attendants and security most of the time. To be clear on this matter there were certainly those who were always smiling and “fresh” looking as well, but this was more the exception than the rule. In the joint statement by the WHO, the International Confederation of Midwives (ICM) and the International Confederation of Gynaecology and Obstetrics (FIGO), it is argued that an enabling environment is crucial in order for skilled attendants to provide the local and national quality standards of care (WHO 2004). In this chapter I will illustrate how the midwives themselves experience this very work environment, specifically how they think their work environment influences their ability to work on quality care. The chapter is divided into a section on the facilities and supplies at the work environment, a second section on the staff shortage and the consequences of this shortage, a third that covers interpersonal relations at work and finally the last part which covers remaining issues like secondary benefits and other motivational factors.

Facilities and essential items at the work environment The aforementioned joint statement by WHO, ICM and FIGO highlights nine criteria required to qualify a work environment as “enabling”, enough for a skilled birth attendant to work effectively. The authors state that an enabling environment is tantamount to a well functioning health system. One of the nine criteria is the availability of all essential items, which are further defined as essential drugs, supplies and equipment. Furthermore mechanisms should be in place to replenish drugs and supplies and to maintain equipment. In this study, I have looked at how midwives perceived the availability of medicine, supplies and equipment. One midwife (Tiyamike) and a PhD Senior Nursing Officer also brought up issues related to the absence and importance of certain facilities, and how the presence of these could enable them in an effective and pleasant work environment, while this was not a topic incorporated in the semi-structured interview guide. The joint statement also includes a criterion of facilities and infrastructure which should be available together with established procedures for maintaining the enabling environment. In chronological order, the perceptions of midwives on the availability of medicine, equipment, and supplies will be described here. Finally, some remarks about the infrastructure will be made. Perceived availability of medicine Some midwives said in the interviews that drugs are usually available, and that the availability of drugs has improved. Eight midwives were asked whether they thought the medicine stock is adequate. Tiyamike (aged 52), SIC responsible for ordering drugs at the pharmacy, says she makes sure there is always enough. Another SIC, Violet (aged 36), tells me she is responsible for ordering PMTCT medicine for the whole maternity wing, and says she communicates well with the pharmacy to make sure the stocks are delivered in time. Chimemwe and Beatrice also agree that there is enough medicine. Beatrice (54) stresses that the availability has greatly improved, and that a previous lack of medicine had proven to be bad for the quality of care. According to a KCN lecturer, wards only run out of stock when an incorrect number of medicines are ordered, not because they are not available in the pharmacy. 63


Gift (aged 35) says things have really improved since January (2009), but that certain medicines still run out of stock occasionally. Three other midwives said running out of stock is a serious and current problem for the quality of care (Tiyanjane, Wyness and Chisangalo). Wyness (aged 29) from Obs&Gyn ward says that she sometimes tries to administer a drug prescribed by a doctor but then finds the drug has run out of stock at the ward. Furthermore, the results of the questionnaire point out that only one fourth of the 31 participants (25.8 percent) think the medicine stock is “sufficient”. More than half at 51.6 percent thinks the medicine stock is “not really sufficient”, and 19.4 percent thinks the medicine stock is “not sufficient at all”. Clearly, there is disagreement among midwives on the adequacy of the medicine stock, with some feeling it has improved and others thinking it is still not sufficient (see Table 3). Table 3. Perceived sufficiency and adequacy of work environment characteristics by 31 midwives in questionnaire Not sufficient

Sufficient

Availability medicine Availability equipment Availability other supplies

Not sufficient at all 19.4% 29.0% 19.4%

51.6% 67.7% 67.7%

25.8% 3.2% 12.9%

Not adequate

Adequate

Staffing level

Not adequate at all 87.1%

12.9%

0%

Often too heavy

Rarely too heavy

Workload

Always too heavy 41.9%

29.0%

19.4%

Absolutely sufficient 0% 0% 0%

Don’t know

Absolutely adequate 0%

Don’t know

Never too heavy 6.5%

Don’t know

3.2% 0% 0%

0%

3.2%

The topic was also discussed with a UK elective (Claire) and an AMAMI representative. Claire said she was unpleasantly surprised about the lack of magnesium sulphate and calcium, which, according to her, were inexpensive, easy to find, and essential at the maternity wing. Magnesium sulphate is given to women with preeclampsia, used to temporarily stabilize the mother by lowering blood pressure and diminishing protein loss via the kidneys, in order to prolong the pregnancy to the benefit of the foetus.4 Calcium supplementation can also lead to a decrease in severe pre-eclamptic complications (Villar et al. 2006). To Claire it was shocking that a maternity wing from a referral hospital does not have enough calcium tablets and magnesium sulphate in stock: “What they prescribe when calcium is out of stock is a glass of milk!”. Milk contains calcium, but she said she questions the effectiveness because it is not clear how much milk must be taken in order to reduce the symptoms of preeclampsia. Another example of ineffective care due to the unavailability of medicine is presented by Lennie Kamwendo. She says that some time ago, many women had to undergo CSs because there was no oxytocin available in QECH to induce labour for women who were over 42 weeks of pregnancy. Women were therefore undergoing unnecessary surgery just because of the unavailability of the drug oxytocin. Kamwendo had lobbied as a member of the AMAMI and succeeded in mobilizing the private sector to donate oxytocin. According to her, this example is not representative for the whole nation, as far as she knew it had only happened in the QE, but says 4

Preeclampsia can lead to eclampsia and is one of the main direct causes of maternal mortality. The most effective “treatment” of eclampsia or advanced preeclampsia is abortion or delivery. When this happens before 37 weeks gestation the baby is called “premature” (personal communication H. Nijenhuis, paediatric).

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there are more examples of low quality of care due to a lack of drugs. An example is the temporary unavailability of local anaesthesia so women need to be sutured without pain relief. Perceived availability of equipment There is less satisfaction about the availability of equipment than with the availability of medicine. In the questionnaire 29,0 percent of the midwives think the availability of equipment in the ward is “not sufficient at all”; 67.0 percent thinks the wards’ supplies in terms of equipment is “not really sufficient” and only 3.2 percent thinks the ward has sufficient equipment (see Table 3). Three examples of the implications of a lack of equipment will be given from the IDIs with the midwives. The first comes from midwife Wyness (aged 29) from Obs&Gyn ward. She said they lacked thermometers when students had their practicals, saying some students take them away. She says she is not sure students steal them or accidently leave them in their pockets. Two others said that when students come for practicals it is difficult to use the blood pressure machine and thermometers because they are in use all the time by the students. One blood pressure machine was dysfunctional at Obs&Gyn ward and had been taken away for repair; therefore they had to share one machine with the ANC ward. This is difficult with so many patients, Wyness said, because she is not able check the vital signs as often as she would like to, since the equipment for measurement is always occupied. Tiyanjane (aged 30) makes a similar point, saying that there is a lack of staff but if the HR would be increased in terms of more staff, the number of equipment such as blood pressure machines should also be increased. He says that “with a lot of midwives but no resources we are still not doing good things”. The second example comes from Chimemwe (aged 23), who is also from Obs&Gyn ward and says that the care can be improved with more oxygen machines: Chimemwe: In Obs&Gyn we only have one, if we have three or four patients who need oxytherapy it won’t be possible because we can only use the machine on one patient. So the others will suffer. Linda: Can you borrow oxygen machines from other wards? Chimemwe: Yeah we could borrow, but that’s really not fair because what if the other ward needs it, then we have to give it back and then the patients will suffer. Linda: And other examples, is equipment a really big issue here for quality of care you think? Chimemwe: Not really. I wouldn’t say that. We do try, yeah we really try.

Interestingly, she says that by “really trying”, the lack of equipment is not a big issue for the quality of care. She does say patients are suffering when more than one oxygen distributor is needed. A similar kind of response is given by midwives as an answer to the question “How is the quality of care in QECH compared to other hospitals in Malawi?” They respond saying that it is relatively good, because they try really hard with the resources they have available. However, when asked which resources are missing, they can all mention several things, with HR as a first priority (in terms of staff numbers and experienced midwives or RNMs). The third example comes from Sabrina from COT. She says that they need “a machine” so they can read the foetal heartbeat, instead of having to check it with the foetoscope. When they think there is foetal distress it is hard to monitor the foetus with only a foetoscope, so they need to rush to make a scan. She is saying that foetal distress can be detected more easily with a machine. This means unnecessary CS can be prevented (she comments: “can you imagine someone having a scar just because of removing a dead foetus?”). When the foetus has died it is better for the patient 65


to deliver vaginally. On the other hand, when foetal distress is detected early an emergency CS could save the baby. Perceived availability of other materials and supplies Both stakeholders and midwives were saying the stock of other supplies such as sheets, gloves and mattresses has greatly improved since the beginning of the new millennium, when the situation was really poor. Although the situation has improved, 67.7 percent of the midwives in the questionnaire think it is “not really sufficient” and 19.4 percent thinks it is “not sufficient at all”. The percentage of midwives who think the availability of supplies is “sufficient” is with 12.9 percent much higher than the perceived adequacy for equipment (3.2 percent), but lower than the perceived adequacy of the availability of sufficient medicine (25.0 percent) (see Table 3). It was only asked explicitly in some IDIs whether midwives thought additional supplies were missing in order for them to do their work well. Some (like Chimemwe, 23) replied that everything was there in this category. It was attempted to let midwives themselves come up with items which, in their eyes, were missing, but no questions were asked about items which were mentioned by others. Although the majority said that things have really improved, in several IDIs midwives gave examples of a lack of supplies leading to compromised care. The examples given are about sheets, by Tiyanjane and Sabrina; about dressing packs by Beatrice; and finally about delivery packs by Wyness. An example of an often mentioned item that is still “on the low side” are sheets. The main reason that sheets are lacking is because there aren’t too many, but is related to the cleaning process too. According to the protocol, all sheets have to be soaked in chlorine for ten minutes and then rinsed by salted water. After that they can be brought to laundry to be washed, and dried in the gardens. The first problem is that the sheets become fragile in the process, and tear easily. According to Tiyanjane, this could be much less if sheets would only be soaked for 10 minutes, “but the problem is midwives take of dirty linen and just add it to the bucket until they are finished, which means that the first sheet might be in there for hours!”. He explains that although there is a problem with the staff level and this is easier, this is also a matter of attitude, because “you can also wait with soaking until you have gathered everything so the sheets can last longer”. The second problem is the drying. Since it is cold season now, the sheets take a long time to dry which makes the turnover much slower. So a lot of patients are lying at Picture 10.Chitenjes the plastic covered mattresses without sheets, because there are none temporarily. So in the cold season, midwives and matrons said it happens more often that patients are just lying on the mattresses without sheets, because there are none temporarily.5 When I had an interview inside the ANC ward we sat down on one of the beds. Some women were sitting at the beds at the other side of the ward and they were not sitting on sheets but on colourful chitenjes: big pieces of textile with designs Malawi women use to wear as leg length skirts or to tie their babies with at their backs (see Picture 10). It was unclear however if this was because no sheets were handed out or because they were just the guardians or visitors of the patients. Sabrina (COT) also said they need more drapes 5

I was not able to observe this. I was usually only present in the corridors and the sister’s offices, not at the wards rooms where the patient beds were. I had one interview at the ANC ward once because other rooms were occupied and the ANC ward was almost empty that day.

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(textiles used for covering the patient in surgery), because they get torn quickly due to the cleaning process with chlorine. So she also mentioned the use of chlorine as a reason for the quick deterioration of the cloths. At COT ward, Sabrina (aged 50) said she was missing gowns (worn by the personnel) and gum boots they wear to protect themselves for infection. She says the gowns are just like the drapes torn and very old, it is good in general to replace things and work with things that are newer according to her. Beatrice (aged 54) said they still run out of dressing packs every day, which makes her work hard: she will just have to leave on dressings she had planned to change, and refresh it the next day sometimes or when the dressing packs have been sterilized again. After a few weeks I asked Beatrice again if they were still short of dressing packs, she replied that they are there now; they are really trying, but that they are still short in general so they still need more improvement. Wyness (aged 29) explained me some differences between the places she had worked. She said that when she was in Liwonde, the hospital was really well equipped with materials and medicine, and that she therefore liked this workplace the most. She thought this hospital was well equipped because it was the home region of the former president Bakili Muluzi at the time. When I asked her about her time in Mulanje, where she followed her training for the Certificate in Midwifery she said this was great, but she said it was difficult sometimes because they lacked delivery equipment, and therefore had to improvise. Bandages soaked in spirit (to sterilize them) were used in absence of cord clamps, and as a substitute for scissors to cut the cord they used slides (piece of glass they use to investigate blood samples to diagnose malaria in the laboratory). A delivery pack should have to clamping scissors, a pair of regular scissors and in addition one needs two towels, for wiping and covering the baby (see Picture 11). A more serious consequence of the absence of the right materials was a case told by Theresa (AN clinic). She said a theatre midwife was complaining of sutures, which were not of quality and broke easily. One COT midwife also told me about a shortage of sutures, but did not tell me the following story: The suture they were using [for the womb] was not strong enough, it was breaking. They want the government to buy strong sutures. The [patient] who was sutured went to the ward. Then after one day she was complaining of pain and that she had a pain in her abdomen. After reviewing her and she was taken back to the theatre, they discovered that the uterus was ruptured. And there were some necrotic tissues so they removed the uterus. These are things that can be avoided. So we find that she’s got only one child and the problem was caused by the hospital. Should they suture her with the right sutures, she wouldn’t have had a gaping wound. They wouldn’t have removed her uterus. She’s got only one child now, so she is affected psychologically, [she will think] “they removed my womb so how can I have maybe two or three children?” So some others things like sutures, the management, I think they should take a look at those things because they say the budget has passed it so why are they not buying us the right materials? The patient is suffering because of hospital; the removal of the uterus was because of the hospital.

In the next paragraph improvisations like these will be further elaborated on, but this quote shows that improvising has played a big role in her daily practice in Mulanje, where supplies were scarce at the time she was stationed there.

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Facilities at the ward Some midwives complained about the general facilities in the wards. Tiyamike (aged 52) said it would help in keeping the sisters’ office tidy if they would have cabinets for their personal belongings. She also said they needed a good sofa at their ward to sit on during night duty; now they have to sit on wooden chairs all night. Also some midwives told me it was very cold in the cold season, and said they would really like to have a heater. Only some sisters’ offices had a heater (which worked) (such as the small one visible at the table in Picture 9). Then there was Beatrice (aged 54), who said the government should provide them with shoes (which were promised but not given according to her), and a proper winter uniform with a sweater. In the FGD there was a Malawian nursing PhD student who said hospital is the house of the midwife: she is there more often than she is at home. Therefore, she says, it is very important to keep it clean, tidy and well maintained. It should be an environment in which people feel pleasant to work in.

“We sacrifice”: human resources in the government hospital At the top of the list of sub criteria the WHO, ICM and FIGO mention in their joint statement on skilled attendance at birth, it says: “sufficient skilled attendants with all the necessary skills (including where required skilled attendants with additional skills) should be deployed where they are needed” (WHO 2004). At the first word alone, “sufficient”, the situation in Malawi does not meet the criteria: there is a 76 percent vacancy rate (Dorothy Ngoma, NONM). According to Ngoma, there are not even enough midwives for giving basic care. She states that the care is not adequate, before we could even start talking about quality of care. She says: “So we talk of maternal health: it’s way, way out. Not even close to say it is reasonable because it is not.” She also stresses the importance of the numbers, a basic number of midwives and other health workers is needed. At the introduction of this thesis, a quote from Chimemwe shows the implications of the shortage of staff: midwives feel they have to go from priority to priority without being able to give patients the attention which is needed to help patient in a respectful manner. In this section I will illustrate how midwives experience the consequences of understaffing. First I will give some statistics about the ward coverage and how midwives perceive the need for additional staff, both in quantity as in quality. Finally I will turn to the unintended effects of the locum system launched by the government to ease local and exceptional shortages. Ward coverage It is heavy at Queens, because we are short of staff. What can we do; nowhere to go (midwife Martha, aged 67, ANC ward).

Several midwives complained about the extremely low midwife/patient ratio, which they saw as the biggest inhibiting factor for giving quality care. Chimemwe from Obs&Gyn ward was talking about occasions when there is one midwife to 50 patients. Tiyamike (PNC ward) was talking about 60 patients to two or three midwives. In night shifts and at busy days at the PNC ward one midwife can be covering 100 patients on her own according to Beatrice, because she would have to cover both sides of the PNC ward. Tiyanjane says that one may find a whole ward covered by just two midwives; with a midwife/patient ratio of 1:25. The AN, PN and Obs&Gyn ward can have about 60-70 patients (the Labour ward will be discussed separately). These 60-70 patients do not necessarily correspond with the number of beds, because the hospital becomes very congested in the rainy season, when many people fall ill (informal conversation several midwives). Some women may have to be 68


hospitalized at mattresses on the floor in the case all beds are occupied. But on other days it might be less busy; one day there were only three patients at the ANC ward. Outside the rainy season, other events may lead to overcrowding of the ward, such as when the COM was offering free obstetric fistula repairs and were “recruiting” patients from surrounding areas. Two midwives from the Obs&Gyn ward told me this led to a very hectic and busy week at the ward. From what I observed, the AN, PN and Obs&Gyn wards were covered by two up to six midwives. It happened twice that I found one midwife covering the whole ward in a day shift, because others were “away to the bank”, “accompanying relatives in the hospital” or called in sick (at PNC ward). Of what I heard from Beatrice and Martha, it happened regularly that they had to cover the wards alone during night shifts. Especially these two older midwives (aged 54 and 67) complained about the regular basis on which they had to do nightshifts now, while before (“when they were young”) there was more staff and they only had night shifts once a month. Now it is about once a week or three times a month (Martha). For Martha from ANC ward, it is the busy night shifts that make the work heavy for her. She said there are three full-timers on the roster (to cover all shifts), and saying that with an additional three full timers it would be much better. At the Labour ward, it is a different story all together. The minimum of midwives on the roster should be 12-14, so they can rotate shifts. At the time of this study, there were only six, who have to be divided over seven day and seven night shifts a week. They need the extra part-timers who are coming on locum desperately to assist them, but the number of locum midwives had decreased during the last two months. Chisangalalo (aged 30) said the following about the staff shortage: In our ward, at the paying side, we have 14 beds. We have to be about four midwives [at the paying side], maybe each taking care of four patients, which would be better. She will be concentrating on those four patients. But we have got few midwives. One is staying on the paying side and intensive care unit [covering 18 patients if full], the other one is on admission, another one is in theatre and maybe just two midwives are on the main ward. Like one would take care of eight patients, it would be different than when one would take care for four patients only.

In total, there are 30 beds at the Labour ward. She is means that they sometimes have to cover eight patients at once, who are about to deliver a baby, suffering complications (since they are mainly referrals from other clinics and district hospitals), or have just delivered and need close monitoring for haemorrhages. Violet from the paying ward (1A) says there might be more midwives in government hospitals, but the workload is much heavier because patients are coming from all the districts around. She compared this with her experiences in a district hospital, where she had more opportunities to go for workshops because the ward coverage was better. The results of the questionnaire also point out that the staffing level is least adequate, compared to availability of equipment and even the salaries. Only three (12.1 percent) out of the 31 respondents thinks it is “not adequate”, the other 27 respondents scored the staffing level as “not adequate at all” (87.1 percent) (see Table 3). Consequences for daily practice: frustration and improvisation According to many midwives, the low staffing level is very detrimental to the quality of care. Martha (aged 67) from ANC ward says when it is busy, they only do emergency things, tasks that are really 69


necessary. Tiyanjane (aged 30) says this shortage leads to exhaustion because of all the improvising, and lists a few daily improvisations at QE: If you want to take a blood sample you need a tone kit so that the blood can be retracted, but it’s not there so instead you use a glove. Or if you want to take specimen to the lab, you find that there is no tray to carry the specimen, so you use a box, for example a glove box, which is not very safe. And in direct patient care, you want to give your patient a warm bath. If you want to boil water, you find that there are no kettles to boil water. So you have to go to the kitchen to take water. That’s another improvisation. For dressings you can find that we would just put on a gauze and just wrap it with plaster. But if it’s a big wound you would need to secure it with a bandage. . . So instead of giving quality care you are just trying to get things moving. This puts you off, because is not what you have been taught at school.

Tiyanjane is one of the few midwives who says he is really demotivated because the imperfect situation at the ward, which is probably related to the fact he is in an upgrading course at KCN now, familiarizing himself with the ideals. When Chisangalalo was asked what she found a difficult situation at work, she answered she finds it difficult when there are few midwives and many complicated cases: “So that's a challenge. You keep on running up and down, not sure of what to do. You see this patient needs your care, and this patient needs your care. You don't know what to do.” In her case the shortage led to worries and feelings of insecurity about how to prioritize. Martha (aged 67), says one of the consequences of the shortage of staff is that it is hard to get all the things done that doctors want. Looking back on midwives’ answers to the question what good care is, many midwives also stressed the importance of following doctors’ orders. Gift explains what happens because of the shortage, and how the shortages lead to tiredness and psychological stress and therefore poor quality of care: For those that are coming from the health centres, they work during the day in their health centres and they come here during the night. So they come here tired and they may need to rest and leave the patients unattended sometimes. And sometimes even our own midwifes from the Labour ward, they would work day [shift] and continue in the night or else they work during night shift and they continue during the day. This happens mostly during the weekends just because of the shortage. It’s not healthy because you are tired. Psychologically it’s not good. Maybe you end up shouting at patients. [laughs]. . . Because when someone is tired and she wants to rest a patient is calling and she shouts: “No you shouldn’t call me, I have attended to you!” Et cetera.

It is not difficult to imagine how these staff shortages influence the peace of mind of midwives and their job-satisfaction. Government’s response: the Locum system and the consequences Sabrina, aged 50, four children and two orphans in her care, COT ward: “I am working now but I am also doing the night [laughing]. It’s hard, but, you have to work. I need money, so [laughs] I need money and we also need to cover the ward. And tomorrow, I will also be on day shift.”

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The locum system has made some real improvements with the staff shortage according to Lennie Kamwendo (AMAMI) and Matron 2. Also midwives appreciated the extra help from the part-timers, and felt it has improved the ward coverage at least a bit. However, the locum system also had undesirable consequences according to both parties, especially when the government did not pay locum salaries. Four negative consequences will be discussed here. Firstly, while the goal was to relieve midwifes, it has oftentimes only made midwifes more tired. “What happens is that the majority of midwives will on their two off days, not be going home from work, but coming to work for two days extra”, Lennie Kamwendo says. According to all respondents it occurs often that midwives have worked at the same ward or at another clinic on day duty and then continue to the maternity wing to work on night shift. In Chapter three the reasons for doing petroda were also explained. When I asked midwives what they thought of this they all responded in the same way: “of course it’s not good, health wise, but we need the money”. Sabrina (aged 50, COT) said: “we will just continue until we get sick, then we will need to rest.” This shows that midwives were primarily concerned about their own health, than about the quality of care they provide. When I asked them about the consequences for the quality of care, they replied it could have a negative influence, because they might not be able to remember all their tasks or to concentrate on their work. The second problem with the system is that the overtime incentive makes it easier for superiors to convince midwives to come and work during their spare time. It is not always the deliberate choice of midwives to work overtime and come “just for the money”; sometimes there is just simply no experienced midwife present to supervise the others. Midwives also work overtime because they realize they “cannot leave the ward, they have to be there for the patients” (Beatrice, PNC ward), and “cannot leave the ones who come from other clinics with little experience at QE to do the work without supervision” (Judy, SIC at Labour ward). Third, the system has become under pressure now the locum salaries have not been paid for the past three months (since April 2009). Part-timers could not afford the bus fare to get to their work, and began searching for other job opportunities. As a consequence, the full-timers cannot count on the part-timers anymore. One midwife said that when part-timers (and even she herself) are on the locum schedule you can just come “you can manage to come”. For locum shifts that were not adhered to or for several petroda shifts taken in a row, midwives were not held accountable for by anyone. The reason why midwives are not being held accountable for the long working hours is according to Judy (SIC labour ward, aged 55) partly because matrons and SICs need these midwives to cover the ward. At the Labour ward, part-timers have overall stopped to come when the locum salaries were not given. The hospital management says they have to get the locum salaries from headquarters before they can pay. The main problem is not that part-timers stopped coming in to work when the hospital was no longer able to turn out locum salaries. The main problem is not that part-timers do not want to come to work on locum, but that they need their income to feed their children and pay for the transport. Transport costs are higher than the part-time midwives’ income, so coming to work is no longer cost-efficient. Wyness (aged 29, Obs&Gyn ward) said they never know whether part-timers who are supposed to come on locum will show up and at what time. This sometimes means they are overwhelmingly busy because the part-timers are not there. Fourth and finally, there is no control over who actually came to work on locum and how they functioned. According to stakeholders (KCN lecturer, AMAMI representative and Matron 1 and 2), the supervision and administration is poor: there is little control over whether people actually showed up and there are rumours among these stakeholders that some midwives who are on the 71


roster but did not come still get paid for their locum services. According to a KCN lecturer and an AMAMI representative there are also midwives who come into the hospital for their night shifts to deliberately go to sleep. This was not confirmed by midwives, with one acceptation: at the COT. Sabrina said that at this ward you can just go to sleep in a chair with your head on the table, and wake up when needed, for example when an emergency CS comes in. She says at Labour ward you had to be really strong, but some can just do petroda without losing concentration. She was referring to a friend of hers (Judy), who had worked almost the entire week including night shifts as a SIC, because the other SIC was on a three week course on Emergency Obstetric Care in the capital. Judy said she was very tired but the matrons asked her to help out and she did it for sake of the patients and her inexperienced young colleagues at Labour ward. Lennie Kamwendo and Matron 2 said the locum system has for these reasons only made midwives more overworked, which was also confirmed by the participants in the FDG. Lennie Kamwendo would even go as far saying that since there are no nurse (and midwife) leaders or strong managers to make sure the locum system is not abused, it is better to abolish the system until those conditions are present. Midwives who are on locum should not be able to work on petroda that often, and be held accountable for doing so. According to her, it should be the SIC who should be checking who are coming for locum shifts it in the first place, and the matrons that should double check. In her perspective, even though there is a shortage: There is a movement that is lobbying for it [abolishment]. Because at the end of the day, midwives are suffering, they are overworking and patients are suffering. Because nobody is going to look after a patient if they have been working for 24 hours. So it's not working. And I'm one of them who would want to see it abolished. Not the way it is happening now, it is not working.

Matron 2 however, says she knows it is very common midwives work on petroda, but she says she really needs them to cover the ward (adding to that the midwives also want to come, because they need the money, referring to point two).

Conclusion: Improvisation as a consequence of dealing with shortages How can you give quality care if you are taking care of five women in labour? (Judy, aged 55, Labour ward)

In this final chapter, the availability of resources has been discussed. Clearly, both according to midwives and according to stakeholders, the situation in QECH is not the enabling environment as described by the WHO, FIGO and ICM. The work environment was not measured as to which of the nine points QE scored worse or best, but from the questionnaire findings point out to one aspect in particular: the staffing level. In interviews however, midwives also indicated that equipment was often lacking, leading to the need to improvise with the materials which are available. But when midwives are asked what influenced the care the most, it is the staffing level. This influences clinical care, because according to them there is not enough time to do the vital checks and fulfil the medical tasks they are required to do. On a closer look, it also influences the interpersonal care, because midwives say they are tired and become frustrated, and therefore say might become agitated towards patients at times.

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Picture 11. Stock of delivery packs at QECH Labour ward

The stock of sterile delivery packs, wrapped in sterile cloths, is seen at the right on the shelf.

Picture 12. Documentation room at Labour ward

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Chapter 7. Discussion and conclusion: how to support midwives in helping women deliver safely. Mechanisms for retention of staff and promoting a professional culture of self-discipline are crucial for the provision of quality care. (Kamwendo, L.A. & Bullough C. 2005: 41)

In my thesis I have given insight into what working at the maternity wing in “the Queen” means for midwives and what they see as priorities for improving the quality of care. In the literature review we found that midwives do not always have the right attitude: for various reasons their work motivation could be low. I explained in chapter four that midwives in this study become motivated from the good feeling it gives them to help poor and sick people. This is the reason they joined the profession, and keeps them in their jobs when they are working at the wards. Another reason midwives were happy with their job is that the government gives them the opportunity to study and be promoted in their careers while working. If midwives desire, they can re-enrol in high school to obtain credits they need to enter a degree program or passes when they choose to advance. These programs graduate degree RNMs and diploma RNMs, and could lead to promotion to a managerial position such as SIC. Education was regarded as very important among all participants, but these formal educational incentives were only used by the younger midwives in this study. Older midwives said they were too old to go to school, but they were eager to learn more in in-service trainings and workshops. The educational opportunities and positive feelings they get from caring for other people motivates all midwives in Queen Elizabeth. Their altruism and urge to do good not only leads to job satisfaction, but is also the reason they work overtime, on locum or petroda - they do not want to leave their patients alone. Another reason older midwives work overtime is that they do not want to leave the un-experienced and less trained NMT alone at the ward, which would affect patient care negatively. The intrinsic motivation to care for other people is an important drive for midwives in aiming to give the best care they can within the circumstances. On the other hand, midwives also mentioned aspects of their work which made them less motivated to strive for giving quality care. Midwives said they felt they were not taken seriously, as evidenced by the low salaries paid in the government hospital. They think the low salary is the reason midwives “run away” from government institutions and seek jobs in private hospitals or NGOs for research. The low salary presents serious challenges for “survival” at home in terms of food, education for their children, good housing, and options for retirement. Midwives in this study, especially the older ones and the ones with more dependents, felt forced to work overtime and on petroda for additional income to be able to survive financially. Staying to cover the staff shortage is thus not the only reason midwives work overtime. The low salary and the staff shortage are the two main issues that influenced the quality of care according to midwives, who also stated they were sure the staffing level would increase if the salaries were improved. The low salary not only influences retention, it also influences their motivation to report on time and work to improve quality of care: “we earn little, we work little”. Other factors that influence the quality of care negatively according to the midwives are, in order of importance, the shortage of functional equipment, the shortage of supplies (such as sutures, dressing packs, delivery packs, patient gowns and sheets), and the shortage of medicine. The supply of medicine has seen some real improvements, but is still insufficient according to the respondents. Additionally, the workload is experienced as “always” or “often too heavy to handle” for the majority of the midwives (41.9 and 29.0 percent respectively), leading to poor quality of care.

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Interestingly, all midwives found their pre-service training sufficient in quality and length, but saw in-service training and courses as equally important in the improvement of quality of care. Some midwives said they had difficulties finding a way to “improvise”. In school they were taught the ideals, but found it impossible to achieve these ideals because of the constraints they find at work. Some younger midwives said these constraints were not only the real barriers such as the lack of the bare necessities or the shortage of staff, but also barriers of routines and informal (accepted) knowledge. This is reinforced by older midwives who expect conformance to routines but do not always invite discussion. One example is that midwives could try to bed-bathe and talk more with the patients when the ward is less busy, but these tasks are still often left to guardians while midwives take advantage of the lull to enjoy a longer break. Therefore, some practices that were done out of sheer necessity to improvise have become convention, and the standards of good care are changed into standards of attainable care. Still, many midwives said they wanted to learn more about the standards and said they needed more theory, which could be done either in upgrading or degree courses or in courses and in-service trainings. This desire to learn more and be apprised of the latest standards was especially true for ward-specific care and in PMTCT and ARV treatment. Several midwives indicated that they feel the selection of participants for courses and workshops does not happen fairly. Some midwives reported that they could not really say whether the quality of care was up-to-standard, as they are not sure how their particular circumstances and improvisations may change what the standard is. Additionally, they feel they are still giving better quality of care than is given in rural areas. This also affected how they talked about quality of care, which I will explain by placing the findings in the context of the theoretical framework proposed in chapter two. I will discuss the coping employed by the midwives in this study and, after that, place the findings in the multi-level perspective. Then I will turn to the implications of these findings in terms of policy recommendations and recommendations at the institution.

Survival, coping and the midwife as a holistic person When midwives in this study were asked how they were doing, they often said: “I am tired, but surviving.” Before I entered the field I was reluctant to use the concepts “coping” and “survival”, because I thought I that might pre-emptively define the experiences of midwives, implying they see their work as stressful. After the interviews, I found “coping” was a very suitable term, because many midwives found their work “hectic” and the workload “hard to handle”. They also reported they found it difficult to survive on such a low salary and suffered under the weight of their responsibilities to earn a good income and care for their children. Coping and survival turned out to be very useful concepts because they allow interviewees to define situations they experience as stressful (primary appraisal in the coping process), so using these concepts does not define their situation. The second step in coping, the secondary appraisal, is when the individual assesses the available resources to cope with a stressor, and determines the coping strategy used (Folkman & Lazarus 1991 in Meursing 1997). The main issues midwives in this study experienced as difficult to cope with in their personal lives and at their work place evolved around three themes: coping financially, giving care in understaffed wards and balancing the demands of the workplace with personal and private demands. The first issue, coping financially, refers to the difficulty midwives experience in making ends meet at home. They want to send their children (including children of others in their care) to good schools, to have “something to eat” and to be able to afford proper housing, preferably in their own possession by the time they retire. A male midwife reported he needed to save money for his 75


wedding and for settling down with his future wife. Coping strategies are going for locum at the maternity wing (especially on weekends and during the nights, as these shifts pay more), and doing petroda, resulting in workshifts that last up to 32 hours. When the locum salaries were withheld, another coping strategy of some midwives was working at other hospitals in Blantyre, because there, salaries are paid directly after each workday. Their need for personal survival and the delay in payment of locum salaries combined with the unreliability of part-time midwives has resulted in uneven ward coverage. Other consequences of working overtime are that midwives become tired, concentrate less and eventually become sick because they are overworked. Also, midwives working at wards other than those in which they regularly work are not always familiar with routines and procedures. In order to relieve the pain in their feet, legs and backs from the many work hours, they take Panadol, but this problem-focused strategy only works temporarily. Eventually they say they may become sick and have to stay home to rest. These coping strategies are chosen because they are the best options midwives have for personal survival. The second issue midwives experience as difficult is giving care in understaffed wards. This is the most important barrier in the provision of quality care, and causes labouring women to deliver unattended or only attended for a limited time. On busy days it inhibits midwives’ ability to do vital checks quarter-hourly, run necessary tests for diagnosis, inform patients thoroughly, give bed-baths, keep the environment clean at all times, and so on. It also sometimes results in small mistakes, such as forgetting to administer drugs or blood at indicated times because there are too many tasks to be completed. Problem-focused strategies used on busy days are, for example, giving simple tasks to students if they are present, letting guardians be responsible for caring tasks, and prioritizing daily activities. Midwives are aware that these strategies do not result in the quality of care they had aspired to give when they joined the profession: they call these strategies “improvisation”, indicating they are a creative solution to dealing with deficiencies. They know these improvisations do not address the problem adequately, and therefore often also resorted to emotion-focused strategies. In some cases, humour was used to relativize issues. Midwives also used cognitive avoidance coping: they said they tried not to think about it too often, especially the older midwives. In many cases they just shrugged and had rather stoic or resigned attitudes towards topics such as the staff shortage and low salaries. Meursing (1997:288) described this emotion-focused coping strategy as fatalistic acceptance: midwives often said “it is just the way it is and there is nothing we can do about it” or similar statements. As interviews proceeded, midwives (especially the younger midwives) also expressed their concerns and said they were worried about the staff shortage and poor quality of care, but their initial responses and the attitudes observed at the wards displayed fatalism. An example of fatalistic acceptance is midwives sitting around the office when they could be doing more than the absolute minimum by giving patients bed-baths, chatting with them and teaching students at the wards (reported by a student and a lecturer). The third issue or coping task is related to the concept of the professional midwife as a holistic person with identities other than that of just a midwife. Midwives are also mothers and members of extended families, for which they have both financial and practical responsibilities: they have to take care of their children and dependent relatives, which is experienced as even more of a burden when family members are sick. Midwives and nurses are culturally obligated to take care of and help sick relatives, and this can either prevent them from going to work or require that they spend time during their shift attending to their family. The patients’ health is thus not the only concern of midwives - they have to balance the demands of the workplace with those of the private domain and maintain a positive self-image. This brings challenges in emotional coping. Second-hand 76


reports from stakeholders and midwives made clear that these demands can be overwhelming and lead to frustration. When this frustration is projected on to the patient, the outcome can be shouting or other inappropriate behaviours. The coping strategy chosen (becoming frustrated and angry or becoming fatalistic or using humour) is related to midwives’ personal histories and characters, age, personal situations (in terms of demands at home and income of partner) and gender (chapter four). Although survival has a somewhat dramatic connotation, the situation of midwives can definitely be described as such using the definitions of Martin (2006:19) and Van den borne (2005:41). Their daily activities are characterised by economic struggle and attempts to deal with the overwhelming difficulties they encounter in creative ways. Through these efforts they are trying to create an acceptable situation, but they are not doing as well as they had aspired to do. Midwives in this study, especially the widows and those with husbands having a lower income, are trying to survive both professionally and personally. This results in their perception of the quality of care as: “not really good, but we are trying,” and the idea that they are doing well within the circumstances. Although some stakeholders said the care is far from adequate, midwives described the care given as somehow acceptable within the circumstances they find themselves.

Multi-level approach to quality of care As explained in chapter two, when looking from a multi-level perspective, one looks at the meaning of a concept, here quality of care, at different vertical and horizontal levels, and through time. In this perspective, quality of care does not remain the same when it travels through different levels (Van der Geest et al. 1990:1026). The respondents, with their diversity in professional position and age, revealed that quality of care indeed had different significations for different people, in different settings and through time. Temporal linkages can be described as the way values or political power change through time. We saw in this study that older midwives referred to past times in which everything was much better. It remained unclear whether this was 20 or 30 years ago, but clearly in those times there was not such a high staff shortage as there has been for the last ten years, and they also had better supplies. Palmer mentions three processes underlying the human resource crises: poverty, HIV/AIDS and poor retention. Midwives, as opposed to stakeholders such as Dorothy Ngoma, did not mention HIV/AIDS as such an important contributor to staff shortages. They mainly talked about the consequences of the rise of the HIV/AIDS epidemic, in terms of changing patient care, which requires time consuming ‘voluntary testing and counselling’ at the ward. The pandemic is not reported as a factor of much influence for the staff shortage, especially when compared with factors such as the salary and work conditions. Midwives discussed HIV/AIDS mainly as a new or “modern disease” they had to or wanted to learn about. They did experience HIV/AIDS as a professional burden. It complicated the care and thus the workload, but it did not play a role in their private lives, influencing their role as a professional midwife. This might have to do with what was discussed in chapter three as well: their answers were usually bio-medically related since they did not see their private situation as relevant when discussing quality of care. Midwives did explain how quality of care changed through time due to the pandemic: the disease requires increased knowledge and interpersonal skills (counselling) and more time if one wants to provide good care. Another temporal linkage is how QECH changed from a place of promise to a place characterized by decay, if not in the care given due to the staff shortage then at least in maintenance. It is still known as a place where the care is better than in rural areas, but its 77


reputation is stained by negative accounts in the media. Older midwives look back at the forgone times with nostalgia. Because of the better supplies and better ward coverage, the care was much better, and their work was less complicated: “life was easy back then”. Before turning to a discussion on the (absence of) vertical linkages, I turn to discuss another change observed through time, but within the career span of the same midwife: how they perceive quality of care through their career. Younger midwives with less work experience, questioned the quality of care more than older midwives. They expressed concerns about how they should balance their ideals with the need to improvise and how to combine the formal knowledge learnt in class with the informal knowledge used by older midwives at the wards. Older midwives, especially the ones that would rather retire, and who work “on a contract” (i.e. those who were called back after their retirement), express they had lost their ideals along the way. They feel they are doing the best they can within the circumstances, and that they have given up hoping for better circumstances, saying that unless they are provided with better material and more staff, this is all they can do. They see the quality of care in the context of what they have seen throughout time, and say it has been like this for a long time now. Still, they expressed that they certainly have seen improvements in the ward coverage and thus the quality of care, since the locum system and other incentives (such as the salary top-ups and opportunities to re-enrol in high school courses) were implemented. Another factor that changed the workload dramatically and was mentioned by the older midwives, was the coming of HIV/AIDS. Testing and counselling patients and explaining the correct dosage of the PMTCT drugs to women, costs the authorized midwives a lot of time. Vertical linkages in this study can be seen as how quality of care is conceptualized at different levels, and how internationally and nationally defined quality of midwifery care relates to the definitions at the local setting. The midwives in this study can be seen as the vehicle or the linkage, through which policies are being implemented. The younger midwives, especially students in a KCN or MCHS (upgrading) course form a vertical linkage between the national level and the institutional level. They learn the formal knowledge taught at schools and are closest to definitions or standards of quality of care as formulated at the national level. They become confronted with the institutional level where what is done does not match the ideals they were taught to strive for. This is discouraging them from striving for better care. This also has to do with the obligation they feel to respect the orders of higher ranking and more experienced midwives, although with the coming of democracy since 1994 this natural respect for superiors and the elderly has become less self-evident. However, the macro-societal process of democratization has according to Lennie Kamwendo and a KCN lecturer not always been to the benefit of quality care, it also contributes to disenchantment with the profession and poor attitudes because of midwives’ awareness of their rights. According to them, some midwives are focusing on their rights (such as a proper salary and a conducive work environment), while giving less attention to patients’ rights. The democratization process was mainly by stakeholders defined as an important issue influencing midwives’ attitudes. Unfortunately, since it was only found to be an issue in a later stadium of the study, it was not possible to ask midwives about their ideas on this matter. In the FGD midwives and other respondents agreed this was a relevant issue when discussing quality care: an awareness of both patients’ and nurses’ rights could lead to improvement in care, but the focus in the FGD was more on patients’ rights than on midwives’ rights, while in interviews it was the other way around. The democratization as a macrosocietal process thus influences hospital life, but needs further investigation, as it was not a topic discussed thoroughly with the midwives. It is an important topic, however, in light of the professionalization of nursing and midwifery and the value of education in the bureaucratic 78


institution of the hospital. In contrast, a topic that is very often brought up by midwives is the locum system. The locum system is a good example of how meanings and intentions change as they move from one level to the other. The locum system did not have the effect it was originally intended to have. The locum system was supposed to relieve midwives, by making it attractive for midwives to work a bit extra and receive a salary for these overtime hours. Mobilization of existing HR was the goal. However, both stakeholders (from AMAMI, NONM and KCN) and midwives agreed that working overtime did not always benefit the quality of care. Midwives have become tired and overworked because of abuse of the locum system. The locum rates were used for personal financial survival, even though the quality of care is affected by midwives resultant fatigue and poor concentration. Ward managers have used the locum system to convince midwives to stay and cover the ward. Because of the payment, it is easier to convince midwives to work overtime. The fact that the hospital did not pay the locum salary for several months led to additional problems, especially at the labour ward where they did not have enough full-timers on the roster. The motivation to work on locum diminished when it was discovered that payments stalled months ago. Midwives working their normal hours could not depend on locum-scheduled colleagues, reporting for duty was taken as voluntary. The locum policy was not well implemented or reinforced at the institutional level, with two results: fatigue and exhaustion for midwives who worked too many hours; and unreliability and instability of ward coverage due to the unpredictability of locum workers. This demonstrates something, which was also pointed out by Quarles van Ufford (in Sciortino 1995: 287), that we need to be aware of the extent to which “agents of policy implementation”, here midwives, have the power to “modify, transform or even neutralize the policy intentions imposed from above”. The motivation of midwives who come for locum in night duty is different than those of the policy makers. They want to survive financially and cannot leave patients alone, while policy makers want to improve the quality of care through ward coverage. But if these midwives are too tired to motivate themselves to do vital checks and provide care, you might find them sleeping at the wards. Furthermore, Dorothy Ngoma (from NONM) pointed out that midwives who are not used to work in the Labour ward but are formally employed at a health clinic or other wards, may not know about the routines at the ward and the tasks that need to be done. Ward coverage does not necessarily result in better quality of care. In Ngoma’s words, “midwives are not just bodies you can put at any ward!” The horizontal linkages are the connections between the private and public sector or the link between the midwife as a professional and her other identities. I have already discussed some of the personal versus professional issues in the coping section, so I will focus on the difference between public and private here. This final example will support my argument that midwives indeed need to work on a culture of self-discipline and critical reflection, referring to the quote at the beginning of this chapter. Midwives expressed that it is unfair that their colleagues in private institutions get salaries so much higher than what is earned in government facilities and want to be remunerated for their work equally. On the other hand, they report working in government institutions does have certain benefits over working in a private institution. One example is the free high school education and the possibilities to upgrade from NMT to RNM. Midwives also stated that the government is not as strict an employer as a private institution: statements such as “the government is more like a family” were often made. Midwives expressed the assumptions that personnel in the private sector are held more accountable for their professional behaviour. I suggest this does not only have to do

79


with the higher salaries but also with stricter supervision, and the more serious consequences of absence. These findings are translated in the following recommendations.

Recommendations The health crisis in Africa requires unprecedented mobilization of resources, and the human resources for health must form an essential part of this mobilization (Dovlo 2004:7).

It has become clear that circumstances which inhibit provision of good quality care are not caused only by a lack of material and human resources. A multi-level approach is needed: both a cultural change in the institutions is needed to increase midwives’ feelings of self-efficacy and possibilities for coping, as well as action at the national level to address structural barriers. According to several stakeholders, quality of care can only be improved if the number of staff is improved. That is the most essential outcome of this study, and should be of highest priority according to midwives themselves as well (see Table 1 and Table 3), which means national interventions should be focused on the shortages of staff. The literature already suggested this should be highest priority. With the six year EHRP implemented in 2005, a good start has been made by the government to address the staff shortages. The three key components of this program are salary top-ups, measures to improve the capacity of training institutions and recruitment of expatriate volunteers for filling posts in short term (Palmer 2006). However, more can be done to improve the situation at institutional level. Based upon findings of this study and the FGD I want to propose other ways to improve the quality of care. The findings point out that more staff alone will not necessarily improve the care. There will still be those midwives “who are just relaxing” and who have a fatalistic attitude. Things can be improved with the resources there are as well: midwives could do a better job. Everyone agreed on this matter in the FGD. Training and sensitizing in interpersonal care and supportive leadership are necessary. Training could also motivate midwives who their superiors and the government is not taking them serious. Other incentives should be put in place as well to retain the midwives who have been trained. If the government is serious about reducing maternal mortality and retaining midwives, they have to be serious about their incentives. The statistician of QECH explained this using the following words: “It is just as important to close the leakage of the bucket down the bottom, as to fill the bucket with more water at the top.” It is as the picture on the cover of this thesis suggests: train and retain nurse-midwives, and treat them well. These suggestions will improve job satisfaction and the interpersonal quality of care, which could lead to an improvement of the reputation of the profession and hopefully the care-seeking behaviour of women during delivery and in the postnatal period. Interventions at the national level should be direct towards the training of more midwives should be trained, both RNM and NMT. Where possible, training institutions should supervise students in the clinical area, to relieve the full-timers (midwives) working at the wards from these task. Of course, increasing the enrolment of students should go hand in hand with increasing the number of tutors, so the quality of education is not reduced. Hospital managers could improve the retention at the work environment through salaries by paying more attention to ensure an enabling, conducive work environment: medicine, supplies and overall “neatness” (maintenance) will influence satisfaction and retention positively. The matrons explained that the hospital was not responsible for the delay in payment of the locum salaries, since this had to come from the nursing headquarters in Lilongwe. However, the consequences for the ward coverage were very serious. Therefore it would be good to look into whether a structure could 80


be made to “reserve” an amount of money so salaries can always be paid. The locum salaries and the top-ups should be sustainable and enduring: an impasse in the salary payments can lead to temporary staffing crises because without salary, part-timers stay away. Additionally, the locum system needs to be regulated by SICs and matrons at institutional level: more supervision on how many hours midwives are working on locum. There should be a restriction to the hours midwives are weekly working. Futhermore, hospital managers and matrons could see if they can collaborate more with AMAMI, NONM and NMCM, who can help strengthen leadership and reflection at the ward. Training in leadership and managerial skills should be given to RNs and NMT so they can become role models. Better rewards (in terms of salary) for NMT who are fulfilling RNMs jobs and diploma RNMs who are on ward management and matron posts should also be provided, to prevent them from “running away” to more interesting jobs at NGOs, other health institutions and other sectors. At ward level, not only better maintenance of the environment (painted walls and repairs of leakages) could lead to more job-satisfaction and better retention, but also the provision of a fridge and a microwave at each ward so they can prepare their own lunch. A fridge and microwave make it possible for midwives to carry their food with them to work and prepare simple meals, so they do not have to “survive on bread and tea”. Finally, supportive supervision by SICs, Matrons is needed, and better communication with the physicians, who need to collaborate more and involve midwives in decisions. This is needed both at the ward level in the form of feedback in a supportive manner, “good examples” should be rewarded; positive feedback should be given in meetings. In these meeting reflection and openness about practice, concerns and “mistakes” should be stimulated. These meetings could take on the form of (relatively) simple self-organized trainings, for which midwives do not get monetary incentives so that the hospital does not have to invest too much money in it. Supportive supervision also entails that matrons and SICs should aim to provide more transparency on the election process of midwives going into workshops and trainings. It is important to develop feedback mechanisms so midwives can train themselves, and their colleagues through regular meetings, based upon their personal or ward specific needs. The implications for the findings of the study should be mainly seen as relevant for the QECH and possibly other referral hospitals. This thesis does not give an exhaustive collection of factors which are of influence, but an overview of those factors that emerged as most relevant for midwives. I am certain the issues discussed also play a role in other facilities, but especially in hospitals similar as QECH. In remote district hospitals and smaller clinics, the findings will be of less relevance. But after having read this thesis, you have become aware of what makes midwives so tired. Midwives are “our daily heroes” according to Billy in Chapter 4, but sometimes are relaxing too much according to Chimemwe in Chapter 1. But if we do not answer to their cries, and listen to their concerns, the staffing level and quality of care are not likely to be improved.

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Summary The maternal mortality ratio (MMR) in Malawi is high compared to other countries in Sub-Saharan Africa. One of the targets to reduce the MMR is to increase the current percentage of women that delivers in presence of a skilled attendant, now at 56.1 percent (WHO, ICM & FIGO 2004; NSO 2005:142). Quality midwifery care is needed to attract the population to deliver in a health facility, and in order to timely diagnose and manage obstetric complications at health facilities (Thaddeus & Maine 1994). The quality of obstetric care in Malawi is found to be substandard: barriers to the provision of quality care because are a lack of drugs and supplies; poor infrastructure; lack of supportive supervision; low staffing level; inadequate knowledge and technical skills of staff; poor interpersonal care and a high workload. (Kongnyuy et al. 2009, Leigh et al. 2008, NSO 2005, NSO & UNICEF 2005, Seljeskog et al. 2008). This study focuses on midwives’ perspectives on quality of care in Malawi, as it is important to gain insight into how they cope with providing midwifery care in adverse conditions. Macro-level (socio-economic and cultural processes) as well as micro-level (e.g. interpersonal issues, emotions and salary) factors are thought to influence diagnostic and therapeutic traditions. The research question is “What are midwives’ perspectives on the multilevel factors which influence the quality of care they give in QECH to patients and their guardians, and how do they cope in adverse conditions?” The study was performed in the Queen Elizabeth Central Hospital (QECH) in Blantyre in collaboration with the Kamuzu College of Nursing (KCN). Research methods used are: (1) a selfadministered questionnaire among all midwives at the maternity ward, (2) twenty in-depth interviews with 13 midwives, (3) 13 in-depth interviews with 12 stakeholders in the field, (4) a FDG as a feedback session, and (5) locally available data such as unpublished reports and studies and newspapers. Consent was asked verbally and in writing from the participating midwives for both the questionnaire and the interviews. Themes which were addressed in the data collection methods are: midwives’ demographics, background, motivation to become a midwife, job-satisfaction, perceived sufficiency of medicines, equipment and supplies, satisfaction with salary, influence of private life on work, professional training and their recommendations for improvement. The results of the study indicated that midwives experience difficulties in coping with shortage of staff, high workload, low salaries and insufficiency of working equipment. This leads to frustration among the midwives. Coping strategies employed were mainly emotion-focused: joking and laughing about the situation, being angry or annoyed and resignation. Generally, younger midwives also expressed concerns and worries, and find it difficult to provide care in an environment characterized by improvisations. Older midwives usually try not to think about difficulties, and had a stoic and resigned attitude. To cope with the financial consequences of the low salary, many midwives work on locum (take extra shifts), leading to fatigue. Some work on locum to assist colleagues due to shortage, others come because they need the additional income to survive. Among midwives and stakeholders there was agreement that the attitudes towards patient care of some midwives are detrimental to the quality of care, while the majority of midwives are really good. The findings indicate that midwives need to be taken seriously in terms of improvement of their work situation: more staff is needed and higher salaries. On the other hand, midwives need to take responsibility for their own (lack of) skills and (inappropriate) attitudes and need to invest in quality of care. Self-organized trainings and regular (staff) meetings could help in creating a sphere of trust and reflection. 87


Appendixes Appendix A. Characteristics of study populations Table A.1. Overview background of 13 midwives in IDIs Names (pseudonyms) Jenny

Ward Labour ward

Age 25 [20-30]

Position NMT

Number of IDIs 2

Duration (min) 60; 30

Beatrice

PNC ward 1

54

ENM

3

45; 30; 35

Chisangalalo

Labour ward

30

NMT

1

50

Martha

ANC ward

67

ENM

2

18; 36

Tiyamike

PNC ward 2

52

RNM

1

50

Wyness

Obs&Gyn ward

29

NMT

2

60; 80

Gift

SIC 1 Labour ward

35 [30-40]

RNM

1

60

Theresa

AN clinic

33

NMT

2

90; 90

Violet

Paying ward 1A

36

RNM

2

25; 30

Tiyanjane

Student KCN

30

NMT*

1

75

Judy

SIC 2 Labour ward

55

ENM

1

60

Chimemwe

Obs&Gyn ward

23

NMT

1

45

Sabrina

COT ward

50

ENM 6 NMT; 4 ENM; 3 RN

1

80

20

Total 17h28min Mean 52 min

13 n/m

8 different wards

mean age 40 (range 23-67)

nd

*respondent is NMT but in his 2 year of training to be RN.

Table A.2. Overview 12 stakeholders Names Matron 1

Position Matron QECH

Duration 1 hour

Claire (pseudonym)

Elective UK

30 min

Bonus Makanane

Head of Obstetrics & Gyn.

30 min

Sabrina Chirwa

Lecturer KCN

1 hour 15min

Dorothy Ngoma

Executive Director NONM

35 min

Fanny Kachale

Deputy Director MOH RH Unit

50min

Martha Mondiwa

Registrar MNMC

1 hour

Lennie Kamwendo

AMAMI representative

1 hour 15 min

Juliani Lunguzi

Office Director UNFPA

15 min

Obrin Sangala

Accountant CHAM hospital

1 hour

Sabrina Sesay

Matron CHAM hospital

1 hour

Matron 2

Matron QECH 2

46 min

Total

Total 9h56min Mean 50 min

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Appendix B. Questionnaire midwives all wards UNIVERSITY OF AMSTE RDAM (AMSTERDAM, NE THERLA ND S) KAMUZU COLLEGE OF NURSI NG (LILONGW E) Project Title: Midwives’ perspectives on their midwifery care provision Principal Investigator: BSc. L. Quadvlieg Local Supervisor: Dr. A. Malata Supported by: University of Amsterdam Supervisor: Dr. W. Koster “Moni (hello) ... [name respondent]. Muli bwanji (how are you)? My name is Linda Quadvlieg and I would like to ask you about yourself and about your job satisfaction. I am a student in Medical Anthropology at the University of Amsterdam, and this study is part of my Master’s program. There is no direct benefit to you when you participate in this study, but I hope this study will be useful for policymakers to improve your work environment and educational training in the future, and thereby your abilities to improve the quality of midwifery care. It will take about 30 minutes to finish all the questions of this questionnaire. Both personal and professional questions will be asked. I would very much appreciate it if you would like to fill it in and leave it at the box at the matron’s office. Whatever information you provide will be kept strictly confidential and will not be shown to other persons. If you want to, you can choose not to answer individual questions and you can always withdraw without negative consequences. However, I hope you will participate since your views are important for this study.” Name: Date: The first questions are general questions about your work at the QECH and your professional training as a midwife. 1

What is your current position at the Maternity Wing: □ Midwives Technicians □ Registered Midwives □ Other:___________________________________________(if applicable)

2

How long have you been working in that position at the QECH? _______________months

3

At which ward are you working currently? _____________________

4

What is the highest level of education you have completed? □ □ □ □ □ □ □ □

5

Bachelor of Science in Nursing (Generic) Bachelor of Science in Nursing (Post Basic) Bachelor of Science in Advanced Midwifery Diploma in Nursing/Midwifery (Upgrading) University Certificate in Midwifery Master of Science in Nursing Other__________________________________________(please specify) Don’t know

Have you followed any other courses/workshops/seminars in the past five years, which were not a part of your schooling mentioned at 4? □ Yes, (please specify what this extra education was about (title or subject) □ No 1___________________________________5_____________________________________ 2___________________________________6_____________________________________ 3___________________________________7_____________________________________ 4___________________________________8_____________________________________

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Now we turn to some questions about the infrastructure of the QECH Maternity Wing as your work environment. 6

What do you think of the sufficiency of the ward’s supplies in terms of adequate equipment and how this enables you to provide the quality of midwifery care you would like to give? □ □ □ □ □

7

Not at all sufficient Not really sufficient It is sufficient It is absolutely sufficient Don’t know

What do you think of the ward’s sufficiency in supplies of medicine and how it enables you to provide the quality of midwifery care you would like to give? □ Not at all sufficient □ Not really sufficient □ It is sufficient □ It is absolutely sufficient □ Don’t know

8

What do you think of the ward’s sufficiency of supplies (such as sheets, gloves etc.) to enable you to provide the quality of care you would like to give? □ Not at all sufficient □ Not really sufficient □ It is sufficient □ It is absolutely sufficient □ Don’t know

9

What is the adequacy of the staffing level at the ward you work on? □ Not at all adequate □ Not really adequate □ It is adequate □ It is absolutely adequate □ Don’t know

10 Are there times you feel like the workload is too heavy to handle? □ Never □ Rarely □ Often □ Always □ Don’t know 11 Do you feel the hospital’s transport facilities for transferral, if necessary, are adequate? □ No, not at all adequate □ No, not really □ Yes, it is adequate □ Yes, it is absolutely adequate □ Don’t know Now I would like to ask you some questions about your religious affiliation and your ethnicity. 12 Do you consider yourself as belonging to any particular religion or denomination? □ Yes □ No If yes go to 13, if no go to 14.

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13 If yes, which one? □ Catholic □ Church of Central African Presbyterians (CCAP) □ Anglican □ Seventh Day Adventist/Baptist □ Other Christian denomination:_____________________(please specify if applicable) □ Muslim □ Other non-Christian religions______________________(please specify if applicable) 14 To what ethnic group or tribe do you belong? □ □ □ □ □ □ □ □ □

Chewa Tumbuka Lomwe Tonga Yao Sena Nkonde Ngoni Other: ___________________________________________(please specify)

Now I would like you to answer some questions about yourself and others in your household. 15 Including yourself, how many people – including children – are living regularly as members of your household at this moment? _____________people. 16 Are you the head of the household? □ Yes □ No □ Don’t know If no, go to 17, if yes/don’t know, go to 18. 17 What is your relation to the head of the household? __________________________________________ 18 What is your year of birth? The year 19_____________. 19 What is your marital status? □ Single □ Married □ Divorced □ Widow □ Don’t know/no answer 20 What is the age and what is the relationship to the head of the household of everyone living in your household, including yourself and the head of the household (e.g. wife, head of the household, daughter/son, son in law/daughter in law, parent in law (m/f), brother/sister, co-wife, other relative, other non-relative)? Place the type of relationship of the person to the head of the household and put their date of birth between brackets behind the name of the relationship, starting with the youngest. Example: 1. head of household m (1965), 2. wife (1962), 3. son (1998), 4. daughter (1995), 5. daughter (1993).

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Write down from oldest to youngest: 1___________________________________6_____________________________________ 2___________________________________7_____________________________________ 3___________________________________8_____________________________________ 4___________________________________9_____________________________________ 5___________________________________10____________________________________ Put f for female and m for male behind the name of the relationship in case it is not clear (e.g. head of household/parent/foster). 21 Where do you live now (name of area if in Blantyre/town or village)? ______________________________________________________________________ 22 Is that in a city, a town or on the countryside? □ City □ Town □ Countryside 23 How long in travel time is this approximately from your work? _________________minutes. 24 What is the mode of transport you use on average to get to your workplace? □ By foot □ By bicycle □ By car or truck □ By motorcycle or motor scooter □ By bus □ Other________________________(please specify) 25 What are the money costs for transport to go to your work per week? ______Malawian kwacha. 26 How long have you been living in (present place of residence)?______________months 27 How would you describe the area where have you have lived most of the time until you were 12 years old? □ City □ Town □ Countryside 28 How would you describe the area where you lived most of you life just before you moved to where you live now? □ City □ Town □ Countryside 29 Are you happy with the place where you work and live now? □ Not happy at all □ Not very happy □ Pretty happy □ Very happy □ Don’t know

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6

30 How involved are you in the community/area you live? □ Very involved □ Pretty involved □ Not very involved □ Not involved at all □ Don’t know 31 If you would describe yourself in relation to others in the community/area you live, would you see yourself as an appreciated/important person? □ Very appreciated/important □ Pretty appreciated/important □ Not very appreciated/important □ Not appreciated/important at all □ Don’t know 32 In general, do you feel your relatives are supportive of the place you work and live now? □ Not supportive at all □ Not very supportive □ Neutral □ Pretty supportive □ Very supportive □ Don’t know 33 Has anyone within the household in the past 12 months been very sick? With very sick, I mean that he or she was too sick to work or carry out normal activities around the house for at least three months the past 12 months. □ Yes,namely_________________________________________________________________________

□ □

________________________________________________________(mention relationship to head of household and age, mention all if more than one) No Don’t know

If yes go to 34, if no go to 35. 34 Do your duties to take care for sick members of your household have a negative effect on your abilities to carry out your duties at work, according to your own ideas? □ Yes, it had a great…. □ Yes, it had somewhat …. □ Neutral □ No, it did not have a…. □ No, it did not at all have a….. …negative effect on my abilities to carry out my duties at work. □ Don’t know 35 How much is the pressure you feel from, if any, tasks you have in and around your house like washing, cooking, cleaning et cetera? I am not referring to duties which are directed to generate extra income. □ Not much pressure at all □ Not so much pressure □ Not difficult, not easy □ Pretty much pressure □ Very much pressure □ Don’t know

6

Do you feel connected with…/do you meet people socially (not due to work) .

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36 On average the past month, do you think the time demanded for activities in and around your household like washing, cooking, cleaning et cetera have a negative effect on your abilities to carry out your duties in a good manner at work, according to your own ideas? □ Yes, it had a great…. □ Yes, it had a somewhat …. □ Neutral □ No, it did not have a…. □ No, it did not at all have a….. …negative effect on my abilities to carry out my duties at work in a good manner. □ Don’t know 37 Are you the only one in your household who generates income for your household? □ Yes □ No (please specify who else generates income/ supports respondent sister/brother/husband/son/daughter/non-relative)

financially

e.g.

1___________________________________4_____________________________________ 2___________________________________5_____________________________________ 3___________________________________6_____________________________________ □

Don’t know

38 On average, how much of your household’s expenditures do your earnings at the QECH and if any, others mentioned at 37, pay for? □ □ □ □ □ □

Almost none Less than half About half More than half All None, this income is all saved

39 Are you satisfied with the salary you receive at the QECH? □ No, not at all □ No, not really □ Yes I am satisfied □ Yes I am very satisfied □ Don’t know I would like to ask you a final question now. Would you be interested in participating in three to five interviews. In these interviews all the issues mentioned here will be discussed more in-depth. □ No □ Yes you can approach me later. This is the end of the questionnaire. Thank you very much for your time.

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Appendix C. Interview guide midwives UNIVERSITY OF AMSTE RDAM (AMSTERDAM, NE THERLA ND S) KAMUZU COLLEGE OF NURSI NG (LILONGW E) Project Title: Midwives’ perspectives on their midwifery care provision Principal Investigator: BSc. L. Quadvlieg Local Supervisor: Dr. A. Malata Supported by: University of Amsterdam Supervisor: Dr. W. Koster Moni. ….[name respondent] (Hello….), Muli bwanji (How are you)? My name is Linda Quadvlieg and I would like to ask you about yourself and about your perspective on quality of midwifery care provision. I am a student in Medical Anthropology at the University of Amsterdam, and this study is part of my Master’s program. There is no direct benefit to you when you participate in this study, but I hope this study will be useful for policymakers. This is your chance for you to have a voice on how nurse/midwives’ work environment and educational training can be improved. It is your chance of sharing your ideas, frustrations, thoughts and advices with policymakers, in order to improve nurse/midwives retention, job satisfaction, and ultimately quality of midwifery care. This interview will take about 1 hour. It will be audio taped. Whatever information you provide will be kept strictly confidential and will not be shown to or heard by other persons. If you want to, you can choose not to answer individual questions and you can always withdraw without any further consequences. If you wish to turn of the audio recorder at any time I will always adhere to your request. However, I hope that you will participate since your views are important for this study. I would also like to ask you to please feel open to share your thoughts with me, all your ideas are important. At this time, do you have any questions about the survey? May I begin the interview now? INTERVIEW NUMBER: RESPONDENT’S NUMBER:

Date

The first questions are about your work at the QECH and your professional training as a midwife. Can you tell me how a regular day at the maternity wing looks like? What is the difference between a midwife technician and registered midwives? For how long have you been a midwife? [experience, change profession over years] Why did you want to become a midwife? [religion, vocation] Can you tell me something about your expectations of your work as a midwife before you started to work? In what other hospitals do you have working experience, can you describe the differences in the midwifery care provision? What kind of daily activities do you have as a midwife on the maternity wing in the QECH? How many hours per week do you work at the maternity wing? How consistent is the training you had at school with the actual work you do? How relevant do you think your training was for the work you do at the maternity wing? Is there anything you would really like have had on a training/something that you missed in your schooling which would help you in your daily work? Do you attend refresher courses or seminars? Do you think it would be useful/ Do you think it is useful? (on what conditions where/when/what about) What do you think about the extent to which you discuss patients and care for patients and their families with your colleagues? Do you feel supported by your colleagues? How important is that feeling for you? Do you feel supported by your superiors? How important is that feeling for you? In the past week, has there been an example of a situation that you found difficult to handle? (what did you do, how did you handle it) What do you think of the quality of midwifery care that is provided by midwives at the maternity wing in the QECH?

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What do you think of the locum system, how does it inhibit or facilitate better quality care provision? What do you think is important in quality of midwifery care? What would be your recommendations which could enable midwives to provide a better quality of obstetric care? The next questions are about your personal life. I would like know if you think your personal life and background influences your work and in what way. Can you describe the place and area where you live? Can describe the people with who you live? Do you feel supported in your work by these people? How important is it for you that people in your private life support you in your job? What are important things for you in your living area and house? When and why did you decide to become a midwife? [in case appropriate to ask this question] HIV/AIDS is a major problem in Malawi’s people’s health. It is said that a lot of health workers choose to do other work because they are afraid to contract HIV/AIDS during their working activities. Have you or your friends/family ever felt scared you would contract HIV/AIDS at work? Do you think your belief in ….[fill in religion from questionnaire] plays a role on the way you see you work? How do you feel about working and living in a rural area? Do you have any other income-generating activities next to your work at the QECH? (If yes, what do you do) As a final subject, I would like to discuss your satisfaction with your present job. How do you feel now about your job as a midwife? How do you feel about your salary? How important are secondary benefits to you? How satisfying are the secondary benefits provided at the QECH to you? How important is housing offered by the hospital for you? What kind of secondary benefits would really help you in your home situation so you can carry out your activities in the hospital without worries? How satisfied are you with your current position? How satisfied are you with your present career opportunities? How satisfied are you with your working conditions? Are you satisfied with your present location/workstation? Please explain. Having discussed all this, do you think there is anything else you said before, that could enable midwives to provide a better quality of obstetric care? Do you have anything else you would like to add to the interview? Do you have any questions? I would like to thank you very much for your time. I will see you at the next interview. If any questions in the meantime come up to you, don’t hesitate to call me.

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Appendix D. Interview guide stakeholders UNIVERSITY OF AMSTERDAM (AMSTERDAM, NETHERLANDS) KAMUZU COLLEGE OF NURSING ( LILONGWE) Project Title: Nurse-midwives’ perspectives on their midwifery care provision Principal Investigator: BSc. L. Quadvlieg Local Supervisor: Dr. A. Malata Supported by: University of Amsterdam Supervisor: Dr. W. Koster

Moni. ….[name respondent] (Hello….), Muli bwanji (How are you)? My name is Linda Quadvlieg and I would like to talk to you about your views on midwifery care for patients and their families as provided by nurse-midwives at the maternity wing of the QECH. I am a student in Medical Anthropology at the University of Amsterdam, and this study is part of my Master’s program. There is no direct benefit to you when you participate in this study, but I hope this study will be useful for policymakers to improve the work environment and educational training of midwives in the future, and thereby job satisfaction, retention and improvement of the quality of midwifery care. This interview will take about 1 hour. It will be audio taped. Whatever information you provide will be kept strictly confidential and will not be shown to or heard by other persons. If you want to, you can choose not to answer individual questions and you can always withdraw without any further consequences. If you wish to turn of the audio recorder at any time I will always adhere to your request. However, I hope you will participate since your views are important for this study. I would also like to ask you to please feel open to share your thoughts with me, all your ideas are important. At this time, do you have any questions about the questionnaire? May I begin the interview now? INTERVIEW NUMBER: RESPONDENT’S NUMBER:

Date

[The same topics (if applicable) as mentioned in appendix C will be discussed, but then framed as for example: “what do you think of midwives’ housing facilities as secondary benefits at the QECH?”] And the following questions: 1. In general, what do you think of the quality of midwifery care at the maternity wing as provided by nursemidwives? 2. What is happening at the ward that should according to you be a priority in order to deliver a better quality of midwifery care? 3. How do you think nurse-midwives can be trained better in order to enable them with the theoretical/background knowledge and skills to provide a better quality of care? 4. What changes at the infrastructure at the maternity wing could according to you lead to a better delivery of midwifery care? (e.g. referral system, maternity management system, adequacy of equipment, adequacy supplies an drugs stock, radio/communication system) 5. What do you think can be done at the level of human resources at the work environment (e.g. skill-mix, balance care duties vs admin duties, interpersonal factors, influence staff shortages) 6. What is important in good quality of midwifery care according to your own perception?

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Appendix E. Focus Group Discussion guide The FDG is organized at the medical annex of the maternity wing. It is a conference room with beamer facilities where up to 60 people can be seated. It is a quiet place where we will not be interrupted, because it was booked beforehand. Preparations The president of the FDG will be the investigator: Linda Quadvlieg. Organize materials for: • For after the FGD (refreshments: coke and fanta passion and orange, cookies/small snacks) • presentation (beamer for power point, chairs set up in a circle) • discussion (markers & flip board) • consent form and contact details in case dissemination of findings desired • two audio tape recorders (incl spare batteries) 10 min Introduction Name, welcome, thanks for coming Who I am (UvA, masters, why here – Address Malata & Winny Koster) Introduction FDG attendants Explain set up meeting: (introduction, explanation study & objectives, discussion emergent findings, wrap up) Intro of the study (nurse-midwives perspectives on quality of midwifery care, why this study) Objectives of study Questions about the study? Explain discussion: no right or wrong answers, disagree OK Confidentiality (me and also in-between group members) Information and consent form pass around Questions on form? Please sign. Audio record (because cannot remember by heart) Take notes (in case tape recording is of bad quality) Please do interrupt me when you have questions for clarification during presentation. Any questions now? 40 minutes Discussing emergent findings Emerging theme 1: Staffing shortage & the locum system • The locum system, helpful or harmful? • How can the locum system be improved? • Recommendations to retain and get back (registered) nurses in the public health sector? • Recommendations which do not cost a lot. Emerging theme 2: Poor nursing/”bad attitudes” • “Rotten apple in the barrel” or widespread problem? Since rise of democracy? Or eighties? • Are you aware of patients’ rights and nurses’ rights, and do these get shape in daily practice at QECH? • How can nurses with “bad attitudes” be motivated to improve their care provision (courses on ethics/responsibilities)? Emerging theme 3: Supportive supervision and leadership • What is important in supervision and nurse leaders according to you? • Is quantity of personnel prerequisite for quality improvement or can much be done by “setting the right example” and good management of scarce resources? • How can tired and/or unmotivated midwives be motivated and supported? Emerging theme 4: Knowledge: pre-service training • Have midwives learned how to do the right thing?

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• •

Do EN and NMT feel comfortable and are they able to provide quality care in case no RN is around and complicated cases show? How is the quality of RN and NMT training perceived, what can be improved?

Emerging theme 5: Knowledge: in-service training • Are there enough guidelines/protocols available and known at the ward to lead good practice? • Is it desirable to let midwives who have come back from training teach other nurses? • How should the importance of in-service training be balanced with the shortage of staff? 10 minutes Summarize points raised. Ask if there is anything else participants want to add or share. Ask if there are any questions. Give e-mail address in case anyone wants to contact or comment later. Thank participants.

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"I am tired, but we really try." Perspectives of midwives on quality of midwifery care in Malawi.