Doi:10.1016/s0140-6736(06)69475-0

Articles
Women’s groups’ perceptions of maternal health issues in
rural Malawi
Mikey Rosato, Charles W Mwansambo, Peter N Kazembe, Tambosi Phiri, Queen S Soko, Sonia Lewycka, Beata E Kunyenge, Stefania Vergnano, David Osrin, Marie-Louise Newell, Anthony M de L Costello Lancet 2006; 368: 1180–88 Background Improvements in preventive and care-seeking behaviours to reduce maternal mortality in rural Africa
See Comment page 1139
depend on the knowledge and attitudes of women and communities. Surveys have indicated a poor awareness of
Centre for International Health
maternal health problems by individual women. We report the perceptions of women’s groups to such issues in the
and Development, Institute of
rural Mchinji district of Malawi.
Child Health, University College
London, UK (M Rosato MA, S
Methods Participatory women’s groups in the Mchinji district identifi ed maternal health problems (172 groups,
3171 women) and prioritised problems they considered most important (171 groups, 2833 women). In-depth qualitative
data was obtained through six focus-group discussions with the women’s groups, three with women’s group
A M de L Costello FRCP);
facilitators, and four interviews with facilitator supervisors.
Department of Paediatrics,
Kamuzu Central Hosptial,
Lilongwe, Malawi
Findings The maternal health problems most commonly identifi ed by more than half the groups were anaemia (87%),
malaria (80%), retained placenta (77%), obstructed labour (76%), malpresentation (71%), antepartum and postpartum
P N Kazembe FRCPC);
haemorrhage (70% each), and pre-eclampsia (56%). The fi ve problems prioritised as most important were anaemia
MaiMwana project, Mchinji,
(sum of rank score 304), malpresentation (295), retained placenta (277), obstructed labour (276). and postpartum
Malawi (T Phiri BSc, Q S Soko,
B E Kunyenge); and Africa
haemorrhage (275). HIV/AIDS and sepsis were identifi ed or prioritised much less because complexity and contextual
Centre for Health and
factors hindered their consideration.
Population Studies, University
of KwaZulu Natal, Somkbele,
Interpretation Rural Malawian women meeting in participatory groups showed a developed awareness of maternal
South Africa (M-L Newell PhD)
health problems and the concern and motivation to address them. Community mobilisation strategies, such as
women’s groups, might be eff ective at reducing maternal mortality because they can draw on the collective capacity in
communities to solve problems and make women’s voices heard by decision-makers.
[email protected]
Introduction
their issues or be listened to by policymakers or people in Malawi has one of the highest maternal mortality ratios local positions of power.13 Unsurprisingly, women’s (984 deaths per 100 000 livebirths) in the world.1,2 The risks concerns remain invisible to both policymakers and of pregnancy are indicated by the words used to describe a members of their own communities,10 and responsibility pregnant woman in the Chichewa language: either pakati for these issues falls to the individual women themselves.
(between life and death) or matenda (sick). In Malawi, Previous studies that have asked women about their behaviour at the village level can contribute to maternal perceptions of maternal health issues have generally mortality, for example, most births and deaths of pregnant focused at an individual level on the gaps and women happen at home,3 and some behaviours within the misconceptions in women’s knowledge, with the aim of community could hinder timely and appropriate developing and prescribing interventions for health care-seeking.4–6 education to change knowledge and behaviour.14–19 In this Community mobilisation interventions have been paper, we present the collective perceptions of groups of successful for improving neonatal health,7–9 but only one women in the rural Mchinji district of Malawi about the trial is known to have assessed the eff ect of community maternal health problems they face and the issues they mobilisation interventions on maternal mortality rates.9 feel are most important. Our article is not a presentation of This trial noted that participatory women’s groups in Nepal actual prevalences but of women’s group perceptions of substantially reduced neonatal and maternal mortality, but the issues they feel aff ect them. The implications of these maternal mortality was not a primary outcome of the trial fi ndings are discussed in relation to strategies to improve and the number of deaths was small. preventive and care-seeking behaviours and reduce The success of community mobilisation interventions to reduce maternal mortality depends on understanding
women’s perceptions of the health problems aff ecting Methods
them. This information can assist in creating more Setting
eff ective and acceptable interventions.10 However, culturally,
Malawi has a population of 11 million people, a gross issues surrounding pregnancy and childbirth are viewed national product per person of $190, a life expectancy for as strictly in the domain of women.11,12 Furthermore, rural women of 46 years,1 and is a poor country whose women are not often given opportunities to speak about development challenges are exacerbated by chronic food www.thelancet.com Vol 368 September 30, 2006
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Meeting 1 Group formation
Meeting 2 Identification of maternal problems
Meeting 3 Identification of neonatal problems
Meeting 4 Consulting the community
Meeting 5 Prioritising problems
Meeting 6 Identification of contributing factors
Meeting 7 Identification of preventative and
Meeting 8 Sharing discussions with men
Women’s group cycle
Meeting 9 Identification of strategies
Meeting 10 Identification of opportunities and
Meeting 11 Preparation for community meeting
Meeting 12 Sharing discussions with the whole community
Figure 1: The action cycle of the women’s group community
insecurity and HIV/AIDS. According to the Malawi interventions. Ethics approval for the trial was given by demographic and health survey for 2004, the total fertility the Malawi National Health Sciences Research Committee rate was 6·0 children per woman, female literacy was in January, 2003.
62%, infant mortality rate 76 per thousand, neonatal
mortality rate 27 per thousand livebirths, and perinatal Data collection
mortality rate 34 per thousand births.1 57% of women Quantitative data was obtained through the monitoring
had the delivery at a health facility and 56% were assisted
system of the women’s group intervention. The groups by a skilled attendant. The Mchinji district has a followed a participatory community-action cycle population of roughly 380 000 people and lies in the supported by trained local facilitators (fi gure 1). In this central region of Malawi. The main ethnic group is cycle, women meet and engage in discussions moving Chewa (90%), with smaller numbers of Ngoni, Senga, through four phases where they: identify and prioritise and Yao. At the start of this study, we obtained maternal and neonatal health problems; develop locally socioeconomic data for the 35 002 women of childbearing feasible and appropriate strategies to address them; age enrolled in our trial. Of these, 30% had no education, implement the strategies; and assess them. The basic 62% had primary education, and only 8% had secondary cycle is described in more detail elsewhere,7,20 although or higher. 24% were younger than 20 years, 41% were the MaiMwana cycle has been adapted to be more 20–29 years, 22% 30–39 years, and 13% 40–49 years. The district has one district hospital (a fi rst referral and Quantitative data for this paper was taken from two of secondary health facility), four rural community hospitals, these meetings—meeting two, where groups discussed seven health centres that provide maternity care, and and identifi ed all the maternal health problems that they three additional health centres that provide antenatal felt aff ected them (not solely those that lead to death; care. There are around 750 people per hospital bed.
fi gure 1), and meeting fi ve, where groups discussed and The MaiMwana project is a research and development prioritised the fi ve maternal or neonatal health problems initiative to improve maternal and newborn health they felt were most important in their community. The covering a total population of 156 784 in the Mchinji groups completed summary forms after these meetings district. One research component is a cluster randomised detailing the results of their discussions. These controlled trial to test the eff ect on mortality of a discussions, the problems identifi ed, and the fi ve participatory intervention through women’s groups with problems subsequently prioritised formed the catalyst an integrated process evaluation exploring the for the mobilisation of communities. Feasible strategies accessibility, appropriateness, and feasibility of the that made the best use of local resources were developed www.thelancet.com Vol 368 September 30, 2006
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and subsequently implemented by the women’s groups to address the top priorities. In subsequent cycles, the lower priority problems will be addressed.
In-depth qualitative data was also obtained through nine semi-structured focus-group discussions and four semi-structured interviews to provide detail and context to the quantitative data obtained by all groups. These methods explored several issues, including how and why problems were identifi ed or prioritised.
In meeting fi ve, the groups assessed the lists of maternal and neonatal health problems they had developed in meetings two, three, and four. The groups began with a discussion about the costs and benefi ts of prioritising and working on fi ve problems rather than trying to address all the problems identifi ed. Subsequently, the groups discussed and agreed a list of criteria they Figure 2: A MaiMwana women’s group discussing maternal health problems
would use to select the most important problems. All in the community
group members used these criteria to vote for the
maternal or neonatal health issue they felt was most identify problems and priorities themselves rather than
important in their community. Finally, the number of to lead them. Extensive observation of meetings supports
votes was converted into a rank and the top fi ve issues these expectations. Although in some instances the
were taken forward as those to be addressed by the group
facilitators were seen to involve women superfi cially, on
for the rest of the cycle. Tie-breaking votes were done if a the whole facilitators supported the women to take the draw made identifi cation of only fi ve priority problems lead in making decisions. For example, facilitators were
impossible. Although all groups used individual seen to only use the cards to clarify problems after their
member voting and subsequent ranking to identify the identifi cation by the groups.
priority problems, they used a range of diff erent
methods, which they themselves selected, to facilitate Study population
this process. Most groups used blind preference ranking,
3171 women and 2833 women, respectively, identifi ed all with members having one vote each (some groups used important maternal health issues (meeting two) and the same method but members could choose three or prioritised the fi ve maternal health problems they felt were fi ve problems each). Some groups, who identifi ed fewer most important (meeting fi ve). The women’s group problems overall, also used pair-wise ranking (a method intervention was implemented in 24 randomly-selected in which the importance of all problems were population clusters (mean population 3000 people) with systematically compared with every other problem). an average of nine groups per cluster. All women in these Because of the robustness and participatory nature of population clusters were eligible and had the opportunity the process, disagreements over fi nal ranks were rare. to attend the groups (fi gure 2). All women were invited by Disagreements were solved by reaching consensus facilitators or group members to attend either individually through facilitated discussion. Additionally, groups were or through community meetings. Women of childbearing encouraged to revisit their priority problems at any point age were particularly encouraged to attend. The women included in these discussions were predominantly of An important potential bias was the role the facilitators Chewa ethnicity and ranged in age from 15 to 78 years. might have had in inducing groups to report problems. Most women involved in identifying maternal health The facilitators were expected to be guides rather than problems also participated in prioritising the health leaders in the women’s groups. When selected, the problems, but a small proportion of women were only criteria for the facilitators included that they should involved in one or other of these activities because of come from the communities in which they would work changes in group membership.
and that they should be similar to the women who would Focus groups were done with six women’s groups to subsequently attend their groups. Also, facilitators were supplement the quantitative data. These groups were not health workers and, although they received extensive purposively sampled to represent the range of diversity of training in facilitation skills, they received only very characteristics across all 204 groups, such as socio-basic training in issues relating to maternal and neonatal economic status, ethnicity, intervention combination, health. They were also trained to use participatory tools urban-rural mix, and individual characteristics of local to stimulate discussion and picture cards depicting facilitators. 67 women took part in these discussions, and some of the major maternal and neonatal health ranged in age from 15 to 50 years. Of these women, 90% problems for clarifi cation. As a result, the facilitators were married, 39% had no education, 55% had some were expected to be able to guide women to actively primary education, and 6% had some secondary education. www.thelancet.com Vol 368 September 30, 2006
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Most respondents were of Chewa ethnicity (84%), Ngoni researcher who obtained the data and the translator ethnicity (14%), and Senga (2%) ethnicity, representing (both bilingual Chichewa-English speakers), and the the district profi le. All women in the focus groups had lead researcher (English speaker). This team made also participated in discussions to identify and prioritise decisions about the best terms to use. All data were maternal health problems. A further three focus groups subsequently transcribed and imported into MAXqda 2 were done with the 24 trained local facilitators running (VERBI Software version 2), where a system of codes the women’s groups. These respondents were all born in and memos was used by the lead researcher and the or were living in the communities in which they were researcher who obtained the data. As described working, all were women, 92% were Chewa and 8% were previously,21 this method sought to develop an analytical Senga, and ranged in age from 21 to 32 years. Additionally, framework based on the data by coding and highlighting 71% were married and all had some secondary-level pertinent excerpts that showed emerging themes. education. Finally, interviews were done with the four Subsequently, in an iterative process, the researchers MaiMwana staff supervising the local facilitators and the refi ned their analysis, ensuring that the themes built up running of the women’s groups. These respondents were cross-checked with other data within and then were all experienced in community development work, between transcripts, so that the validity of emerging all had secondary and some tertiary education, ranged in explanations was tested and improved. The qualitative age from 28 to 50 years, and three were female and one data was also used to interpret and contextualise the was male.
Results of quantitative and qualitative analyses have Data processing and analysis
been fed back to local facilitators and supervisors. To Data from the summary forms on the identifi cation and encourage groups to have the freedom to address their
prioritisation of maternal health issues were available own concerns rather than be swayed by those of other
for 172 and 171 women’s groups, respectively, of 204. groups, the results will be fed back to groups after the
The remaining 33 groups are still completing or have fi rst cycle of the intervention has been completed.
recently completed the meetings. 119 of the 172 groups
who identifi ed problems categorised issues by period, Role of the funding source
the remainder did not. Verbal consent from the groups The sponsor of the study had no role in study design,
was given for the data produced through the monitoring data collection, data analysis, data interpretation, or
system to be used to explore and assess the imple-
writing of the report. The corresponding author had full mentation of the groups. Some maternal health prob- access to all data in the study and had fi nal responsibility lems do not have a direct translation in Chichewa. for the decision to submit for publication. However, they are known and described by their most severe or obvious symptoms. As a result, problems were inferred from the symptoms identifi ed or the group’s In the meeting to discuss problem identifi cation, consensus about which maternal health problems the 172 groups identifi ed an average of 13 maternal health symptoms represented. A Malawian nurse and doctor problems per group (range 4–29). 78 diff erent maternal assisted in this inference process. After review for health problems were identifi ed, with varying degrees accuracy, consistency, and completeness, the data was of severity. The 119 groups who categorised problems entered into a Microsoft Access 2002 database, exported by period identifi ed an average of six in the antenatal to SPSS 11.0, and analysed with descriptive statistics to period, four intrapartum, and four postpartum. Some assess distributions and trends. Issues identifi ed were ranked on the basis of percentage of groups who identifi ed them during discussions. Women ranked Problem or symptoms identifi ed (literal translations
Problem inferred
problems higher when they felt them to be more from Chichewa)
important. To indicate this ranking in the aggregate score, problems were given a score by multiplying the number of groups who prioritised the problem by fi ve if the highest priority problem, four if the second highest, Failing to deliver and not enough room to pass and so on. These scores were subsequently added Coming fi rst with the hand/foot/face/cord and bad position together and used to rank the priority problems for maternal health (maximum possible score 171×5=855). Data from the focus groups and interviews were audio High blood pressure, swollen ankles, and blurred vision recorded after receiving verbal consent from 9 respondents. Data in Chichewa were translated into English by a bilingual speaker. To ensure conceptual, grammatical, and syntactical equivalence, translations Table 1: The ten maternal health problems most commonly identifi ed by women attending MaiMwana
women’s groups in Mchinji District across all periods (n=172)
were subsequently reviewed collaboratively by the www.thelancet.com Vol 368 September 30, 2006
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The most commonly identifi ed problem across all Problem or symptoms identifi ed (literal translations
Problem inferred
periods was anaemia, identifi ed by almost nine in ten from Chichewa)
groups (table 1). More than three-quarters of groups Antepartum (n=119)
identifi ed malaria, retained placenta, and obstructed labour. An almost equal proportion of groups (70%) identifi ed malpresentation, antepartum haemorrhage, and postpartum haemorrhage. Fewer groups identifi ed High blood pressure, swollen ankles, and blurred vision pre-eclampsia, miscarriage, and eclampsia. HIV/AIDS (31%) and sepsis (18%) were not in the top ten problems identifi ed. Almost all groups felt that they were in the best position to identify these problems because they knew them through their own experiences HIV/AIDS and sexually transmitted infections HIV/AIDS and sexually transmitted infections and those of their friends and relatives. As a result, most groups thought the process of identifi cation Coming fi rst with the hand/foot/face/cord and bad Intrapartum (n=119)
“The importance is that these problems are faced by us Failing to deliver and not enough room to pass alone…when discovering the problems we did not Coming fi rst with the hand/foot/face/cord and bad struggle because this was happening to us …we were remembering what we were experiencing and High blood pressure, swollen ankles, and blurred vision Focus group discussion–women’s group members Anaemia, malaria, and haemorrhage were by far the most commonly identifi ed maternal health problems in the antepartum period (table 2). In the intrapartum malpresentation, and haemorrhage. In the postpartum Postpartum (n=119)
period, haemorrhage and retained placenta were identifi ed as the predominant problems. In the prioritisation meeting, groups were encouraged to select, from their lists of maternal health problems identifi ed, the fi ve problems they felt were most important so that they could develop strategies to address them. Only limited data are currently available High blood pressure, swollen ankles, and blurred vision on these strategies, and preliminary analysis shows that HIV/AIDS and sexually transmitted infections the most common strategies discussed were: income- generating activities; accessing bednets; training traditional birth attendants; bicycle ambulances; and civic education. The groups themselves chose the criteria on which to judge importance. Severity and Table 2: The ten maternal health problems antepartum, intrapartum, and postpartum most commonly
identifi ed by women attending MaiMwana women’s groups in Mchinji District
commonness were most frequently used to establish the importance of a problem. Respondents defi ned a severe problem almost exclusively as one that leads to problems such as anaemia, malaria, and haemorrhage death, and a common problem as one that was were identifi ed as taking place in more than one experienced within their own community frequently, by period.
many women, and recently. Severity was considered to Women appreciated that identifi cation of problems carry more weight than commonness so that even rare was the essential fi rst step to improving prevention and problems could be prioritised if they were considered to management of the problems in the future.
“We have discovered these problems and when we learn “Severity is the most important thing…they choose these problems they should what?.they should vanish… severity above commonness because…it may be common because after discovering this problem we have realised but not kill many people but it can be severe and kills the way of life we should lead…after discovering this everyone who has it…they are prioritising to save lives problem we can know that to end it I should rush to rather than just trying to keep people healthy…if it is a hospital…I can avoid certain death if I deliver at the severe problem that can kill somebody then we need to Focus group discussion–women’s group members www.thelancet.com Vol 368 September 30, 2006
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24 diff erent problems were prioritised by 171 groups. Eclampsia (74) was prioritised by 13% of groups, The most important problem was anaemia, which scored pre-eclampsia (54) by 8% and HIV/AIDS (27) by 5%. 304 out of a possible 855 (fi gure 3), and ranked in the top Sepsis (12) was prioritised by only 2% of groups and fi ve maternal health problems in half the groups (47%). ranked twelfth. The respondents gave several reasons Anaemia was regarded as common, severe, and often why HIV/AIDS and sepsis were ranked so low. HIV/AIDS resulting in death. It was seen as a long-term illness that and sepsis were considered complex illnesses that lacked cult to treat and needed prompt action.
coherence in their symptoms or the problems they caused, which made distinguishing them from other “This issue of lacking blood [anaemia] it really takes a long time to treat and that is one way in which a person could die before they are cured…if there is little blood in the “It is unlike other problems…if you have malaria you body we could see that if an individual was to delay with know you have malaria…you have the symptoms but treatment or assistance…you could fi nd death faster” HIV/AIDS has many symptoms so it is diffi Focus group discussion–women’s group members Malpresentation (295) and retained placenta (277) were ranked in the top fi ve by 43% of groups. Malpresentation “The problem here is that HIV/AIDS is identifi ed by medical personnel…they themselves [community was considered to be very severe because there was members] cannot fi nd out that this problem is here almost a certainty that either the mother, the baby, or because the people haven’t been tested…of course we both, would die. Like anaemia, malpresentation was know that there is this problem but in our village nobody considered a common problem that many women has been tested so how can we prioritise it?” “One of the most contributing factors to maternal death in Mchinji is malpresentation…so people feel it is very severe…because most of them while they were There is still a taboo surrounding HIV/AIDS that prioritising they said once you are in that situation it is makes open discussion or prioritisation of the issue pakati–between life and death–its either you dying or the inappropriate within communities, despite the knowledge baby dying…and we have seen our friends going with and acceptance that the disease exists.
that problem so we really need to do something” Obstructed labour (276) was prioritised by 41% of groups, postpartum haemorrhage (275) by 40% of groups, Coming first with hand/foot/face/cord and bad position (malpresentation) and malaria (195) by 38%. Malaria, in addition to being severe and common, was felt to be important because it could be the cause of other problems such as anaemia Staying with the placenta (retained placenta) Failing to deliver and not enough room to pass (obstructed labour) “Because when a woman could suff er from malaria…she could be seen to have a weak body…maybe even lacking blood because the body could be hot all the time…this is Bleeding after birth (postpartum haemorrhage) why we chose malaria because everything comes from Focus group discussion–women’s group members 25% of groups prioritised antepartum haemorrhage Bleeding before birth (antepartum haemorrhage) (169). The cumulative score for antepartum and postpartum haemorrhage was 444, which ranked haemorrhage above all other problems. Antepartum and postpartum haemorrhage were prioritised for similar High blood pressure, swollen ankles, and blurred vision (pre-eclampsia) reasons to the other problems but were also perceived to cult for communities to manage locally without HIV/AIDS and sexually transmitted infections “It [haemorrhage] is mostly found in the village…it is very common…it has also the problem of control… Figure 3: Ten maternal health problems prioritised as most important by women attending MaiMwana
Focus group discussion–local facilitators women’s groups in Mchinji district
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“In some communities they are still closed…I think it is guided to assign instances of the co-occurrence of their lack of sensitisation and awareness of HIV/AIDS…they most severe or obvious symptoms as the clinical problem know the problem is there but they can’t air it…so it is these symptoms most commonly describe. The groups were guided to do this by the trained facilitator using the community…they cant accept it…but in this village the picture cards and the discussion tools. Since this process women are really serious about it because they said there have been mothers dying of HIV/AIDS related illnesses did not allow an in-depth exploration of exactly what the so I think we need to do something and we are keeping groups meant by each problem identifi ed, some problems orphans in our houses so really it is a problem” might have been over or under identifi ed and thus over or under prioritised. Since some maternal health problems do not have a direct translation in Chichewa, Additionally, HIV/AIDS was thought as a general misidentifi cation might also have taken place through problem that could aff ect anyone rather than a specifi c the process of inferring the problems identifi ed by the maternal health problem, and considered an untreatable groups from the Chichewa terms used to describe them. disease and therefore fruitless to address. Furthermore, although our experiences have highlighted that the problems raised and their prioritisation came “Why prioritise something that you can do nothing about…this problem doesn’t even have treatment so even predominantly from the women themselves, there is the if we are going to prioritise it how are we going to address potential that in a few cases the results might have been biased by the facilitator. Our sample was large but our study was done in one district in Malawi with a population Focus group discussion–women’s group members coming predominantly from one ethnicity. Furthermore, First priority ranking was diff erent from the cumulative women selected themselves to attend groups and this priority ranking described above. Malpresentation (16% might make the sample systematically diff erent from the of groups) and postpartum haemorrhage (15 %) were the general population in relation to certain demographic problems most commonly identifi ed as the fi rst priority, characteristics.
which indicated how severe and common these problems We would argue that the process by which women were judged. Fewer groups prioritised malaria as priority identify problems they perceive as important, and go on one, although the disease was most commonly ranked to develop strategies to deal with them, is intrinsically priority four and priority fi ve (8% in both cases). Women’s valuable, irrespective of whether or not they represent groups perceived malaria to be an important but routine the epidemiological pattern. Taking a more literal problem that was easy to identify, and quick and simple approach, however, what would be the eff ects at to treat even when there were delays in seeking population level if women addressed the problems they treatment.
have prioritised? No data are available for the prevalence of maternal health problems in community settings in “Malaria is a disease whereby you could go to hospital and receiving Fansidar [sulfadoxine-pyrimethanine]…at Malawi. The best data for comparison are from an this very moment you could feel better… as for malaria institutional review of direct and indirect causes of even when you could delay with treatment or assistance maternal deaths. The incidence data showed: postpartum sepsis caused 20% of institutional deaths; obstructed Focus group discussion–women’s group members labour caused 15%; anaemia 9%; HIV/AIDS 9%; post-partum haemorrhage 8%; meningitis 8%; complications Discussion
of abortion 7%; eclampsia and pre-eclampsia 5%; malaria Women’s groups in rural Malawi identifi ed and 4%; and retained placenta 3%.4 These data are similar to subsequently prioritised anaemia, malpresentation, women’s groups’ priorities, but, importantly, the two retained placenta, obstructed labour, postpartum datasets are not directly comparable. This paper presents haemorrhage, malaria, antepartum haemorrhage, and data from a community rather than an institutional eclampsia as their most important maternal problems. population and includes all problems, not only those that HIV/AIDS and sepsis were identifi ed and prioritised lead to maternal deaths. Furthermore, the data are for much less commonly. Groups regarded severity as perceptions rather than prevalence. These perceptions primary criteria and commonness as secondary criteria to were developed through consideration of a wide range of assess importance. This study shows that, through factors, only one of which is prevalence. collectively sharing experiences, groups of women can Women’s groups distinguished haemorrhage by the identify most maternal health problems, recognise how period in which it happened. Haemorrhage was in the important they are, and want to address them. top three most commonly identifi ed problems in all three The main limitation of this study was the process periods. Combining scores of antepartum and postpartum through which problems were identifi ed. Some clinical haemorrhage makes it by far the leading problem maternal health problems do not exist as a coherent idea identifi ed. Although a small proportion of this result of illness in the community but rather as disparate could be attributable to the misclassifi cation of normal symptoms. In many of these cases, women’s groups were bleeding particularly during and after birth, a systematic www.thelancet.com Vol 368 September 30, 2006
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review by WHO showed haemorrhage was the leading delay, a specifi city to mothers and pregnant women, and cause of maternal death in Africa (point estimate 34%, the potential to co-aff ect both mother and baby. Women range 13–44%).22 in groups thus consider themselves to be at high risk The most obvious underestimates by women’s groups from the problems and feel that the consequences can be of complications seem to be HIV/AIDS and sepsis. Data serious. These fi ndings suggest that, as well as raising from the summary forms show that few groups identifi ed awareness, women in groups have developed certain HIV/AIDS (9% antepartum and 14% postpartum) and attitudes that underpin the intention to change behaviour,28 sepsis (19% postpartum) as problems, and only HIV/AIDS and indeed expressed their motivations to move from was prioritised in the top ten most important problems identifi cation and prioritisation to addressing problems. (ranked tenth with a score of 27). In 2004, infection and Traditionally, health education interventions and those HIV/AIDS were in the top fi ve main direct and indirect at a health facility level have been the key elements of causes for maternal deaths in Malawi.4 Additionally, a most safe motherhood programmes, despite little hard paper reviewing causes of over 200 maternal deaths in evidence to suggest they are eff Queen’s Hospital in Blantyre showed that nearly communities.29 To improve preventive and care-seeking three-quarters of maternal deaths in a population behaviours, an increase in knowledge and a change in accessing a tertiary care hospital had an infection-related attitudes is necessary.28 The data for the perceptions of component.23 women’s groups presented here suggests that a great Assessment of the data reveals that the discrepancy is deal of this capacity already exists in communities. predominantly a function of the problems themselves Furthermore, whereas earlier studies suggest that women and the local context. HIV/AIDS and sepsis are considered as individuals do not have a comprehensive awareness of cult to identify and the problems that aff ect them,14,15 our study suggests that distinguish from other problems. For example, in Malawi this capacity can be accessed and channelled through all febrile illnesses such as sepsis, infection, and malaria women meeting and collectively discussing these issues. are commonly termed malungo.24,25 Even clinicians This process enables women to clearly identify their struggle to diagnose these problems without laboratory maternal health problems, recognise their importance, tests. In the case of HIV/AIDS, several focus groups and generate motivation to address them. Thus women’s stated that it was a problem that could aff ect anyone rather own perceptions of their problems could form a vital than specifi cally mothers. The local context exacerbates resource for communities and policymakers whether or these diffi culties because there still exists a reservation to not such information indicates epidemiological pre- discuss issues around HIV/AIDS in rural Malawi, and valence. In Africa, maternal health has had a low priority these group discussions were held early in the lifetime of with policymakers because of poor epidemiological data, the women’s groups. Only 15% of pregnant women in but also because of poor community involvement in Mchinji district have gone for voluntary counselling and decision-making about health priorities. Research in testing.26 Few people know their status, and thus Nepal has shown that women’s participation is potentially assessment of prevalence and the eff ect on maternal important9 in reducing mortality, but we must await the health is impossible. Furthermore, in Mchinji district fi ndings of our randomised controlled trial in Malawi to prevention of mother-to-child transmission of HIV see if maternal mortality rates at population level will be services and highly active antiretroviral treatment reduced by the mobilisation of communities through (HAART) are both only available in two out of 14 health women’s groups. Community mobilisation strategies facilities, and voluntary counselling and testing in only could be eff ective and effi six, so they are not accessible to much of the population. they would build on the capacity that already exists, and This situation explains why HIV/AIDS is judged tap into the collective knowledge and deeply felt concerns untreatable and why the groups felt there was little point of rural women. trying to address it. The availability of HAART is, however, Rural women in Malawi have a mature understanding changing rapidly. Another study showed that scalability of of their maternal health risks and problems. Women’s HAART is feasible and cost eff ective in similarly poor groups made careful judgments about maternal health communities of Malawi.27 priorities on the basis of both prevalence and severity. The diff erences between the frequency of identifi cation Their voices need to be heard by decision-makers, and and the prioritisation of problems bear some the participation of women in fi nding solutions to the
consideration. On the whole, the problems most huge risks of pregnancy in Africa is possibly the most
commonly identifi ed were also the highest priorities. In important part of the solution.
some cases—such as malaria—a common problem was Acknowledgments
thought to be less of a priority. We have already noted that
We thank the many individuals in Mchinji District without whom the priority depended on both frequency and perceived study would not have been possible. We particularly thank members of severity. Severity itself depended on several dimensions: all the women’s groups and members of communities in which the groups were running; the Chapanzi and Shangeni village women’s culty of treatment, particularly using group for consenting to have their photograph taken and used; the local resources, the potential for fatality in the event of MaiMwana offi ce and fi eld staff involved in running the intervention www.thelancet.com Vol 368 September 30, 2006
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and the process evaluation: Florida Banda, Sella Chigule, 10 Wong G, Li V, Burris M, Xiang Y. Seeking women’s voices: setting Robbins Chiuta, Hellina Mwimba, Catherine Banda, Matrida Banda, the context for women’s health interventions in two rural counties Patricia Banda, Tamala Banda, Coletta Brown, Juliet Chikumba, in Yunnan, China. Soc Sci Med 1995; 41: 1147–57.
Brenda Dakar, Deborah Iyilumbe, Ireen Julius, Martha Juma, 11 Boucher Chisale C. The gospel seed: culture and faith in Malawi as Falessi Kachaje, Hilda Kafukira, Christina Kalumphira, Jessy Kamiza, expressed in the Misso banner. KuNgoni Art Craft Centre, Mua Stella Katola, Beatrice Khungwa, Allena Kumanga, Kilinesi Lefani, Egnat Makande, Beatrice Mithi, Lizzie Mlimba, Stella Moyo, 12 van Breugel J W M. Chewa traditional religion. Kachere Monograph Sophia Phiri, Tinna Phiri, Krishaan Chinkhota, and Diana Mwaipaya; the Mchinji District Executive Committee, traditional leaders, the 13 MacCormack C. Planning and evaluating women’s participation in cers, and Haldon Njikho; Sarah Ball and Linda Deex; primary health care. Soc Sci Med 1992; 35: 831.
Stephen Wall, Research Director, Saving Newborn Lives Initiative, 14 Freda MC, Damur K, Merkatz I. What do pregnant women know Washington, Joseph de Graft Johnson, and members of the Saving about preventing preterm birth? J Obstet Gynecol Neonatal Nurs Newborn Lives mid-term evaluation team. The study was funded by the 1991; 20: 140–45.
Saving Newborn Lives Initiative and the Department for International 15 Hasan I J, Nisar N. Women’s perceptions regarding obstetric Development of the UK. The Department for International Development complications and care in a poor fi shing community in Karachi.
J Pak Med Assoc 2002; 52: 148–52.
accepts no responsibility for any information provided or views expressed. Saving Newborn Lives provided critical input to the protocol, 16 Kumbani L, McInerney P. The knowledge of obstetric complications among primigravidae in a rural health centre in the and valuable advice for the implementation of the project.
district of Blantyre, Malawi. Curationis 2002; 25: 43–54.
Confl ict of interest statement
17 Mubyazi G, Bloch P, Kamugisha M, Kitua A, Ijumba J. Intermittent We declare that we have no confl ict of interest. preventive treatment of malaria during pregnancy: a qualitative study of knowledge, attitudes and practices of district health Contributors
managers, antenatal care staff and pregnant women in Korogwe M Rosato designed the study and the data collection tools, collected District, North-Eastern Tanzania. Malaria Journal 2005; 4: 31–41.
interview data, did the quantitative and qualitative analysis, and wrote 18 Soltani M S, Sakouhi M, Belguith Z, Ben Salem K, Gacem H, the fi rst draft of the paper. Q Soko managed the collection of the Bchir A. Evaluation of mothers’ knowledge in pre- and postnatal quantitative data and B Kunyenge collected the focus group data and preventive care in the Tunisian Sahel. Sante Publique 1999; 11:
assisted in the qualitative analysis. S Lewycka, A Costello, D Osrin, and M-L Newell designed the main trial study. T Phiri managed the project, 19 Tadesse E, Muula A S. Knowledge and perceptions of antenatal C Mwansambo and P Kazembe were the directors, and M Rosato, women towards prevention of mother to child transmission of S Lewycka, and S Vergnano were technical advisers. All authors HIV/AIDS in Blantyre, Malawi. Cent Afr J Med 2004; 50: 29–32.
criticised drafts of the paper, and M Rosato and A Costello were 20 Morrison J, Tamang S, Mesko N, et al. Women’s health groups to responsible for subsequent collation of inputs and redrafting. improve perinatal care in rural Nepal. BMC Pregnancy Childbirth C Mwansambo and A Costello are guarantors for the paper.
2005; 5: 6.
21 Lofl and J, Lofl and L. Analyzing social settings: a guide to qualitative References
observation and analysis. Wadsworth, 1995.
ce Malawi, OCR Macro. Malawi demographic 22 Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PFA. WHO and health survey 2004. Calverton, Maryland: NSO and OCR Macro, analysis of causes of maternal death: a systematic review. Lancet 2006; 367: 1066–74.
AbouZahr C, Wardlaw T. Maternal mortality in 2000: estimates 23 Lema VM, Changole J, Kanyighe C, Malunga EV. Maternal mortality developed by WHO, UNICEF and UNFPA. Geneva: WHO, 2003.
at the Queen Elizabeth Central Teaching Hospital, Blantyre, Malawi. Waltensperger K. Cultural beliefs, societal attitudes, and household East Afr Med J 2005; 82: 1–2
practices related to the care of newborns. Save the Children, Saving 24 Helitzer-Allen DL, Kendall C, Wirima JJ. The role of ethnographic research in malaria control: an example from Malawi. McCoy D, Ashwood-Smith H, Ratsma E, Kemp J, Rowson M. Going Res Sociol Health Care 1993; 10: 269.
from bad to worse: Malawi’s maternal mortality. Lilongwe, Malawi: 25 Heggenhougen HK, Hackethal V, Vivek P. The behavioural and Task Force 4, UN Millennium Project, 2004.
social aspects of malaria and its control. UNDP, World Bank, and Erickson, N. What health care when? A literature review and fi eldwork study of low-caste women’s health care decision-making. 26 Mwansambo CW, Lewycka S, Kazembe P, et al. Equity of maternal health interventions in Mchinji district, Malawi. Oral presentation Thaddeus S, Maine D. Too far to walk: maternal mortality in at the Reproductive Health Conference, ‘As mothers die: who context. Soc Sci Med 1994; 38: 1091–10.
cares?’, May 4–5 2006, Lilongwe, Malawi.
Howard-Grabman L, Seone G, Davenport C. The Warmi Project: a 27 Ferradini L, Geannin A, Pinoges L, et al. Scaling up of highly active participatory approach to improve maternal and neonatal health: an anti-retroviral therapy in a rural district of Malawi: an eff ectiveness implementer’s manual. Westport: John Snow International assessment. Lancet 2006; 367: 1335–42.
Mothercare Project, Save the Children, 2002.
28 Fishbein M, Yzer C. Using theory to design eff ective health Bang A, Bang R, Baitule S, Reddy M, Deshmukh M. Eff ect of home behaviour interventions. Communication Theory 2003; 13: 164–83.
based neonatal care and management of sepsis on neonatal 29 Costello A, Osrin D, Manandhar D. Reducing maternal and mortality: fi eld trial in rural India. Lancet 1999; 354: 1955–61.
neonatal mortality in the poorest communities. BMJ 2004; 329:
Manandhar D, Osrin D, Shreshtha B, et al. Eff ect of a participatory intervention with women’s groups on birth outcomes
in Nepal: cluster-randomised controlled trial. Lancet 2004; 364:
970–79.
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