The document outlines the agenda for a Health Links Forum meeting on the 7th of February 2013 in Scotland, which includes presentations and discussions on maternal health links between Scotland and Malawi, including topics like the Scotland-Malawi maternal health partnership, maternal health research at the International Institute for Health and Development, screening for diabetes in pregnant women in Malawi, and projects by organizations like VSO Scotland and the Scotland Malawi Anaesthesia program.

1. Health Links Forum Meeting 5
7th February 2013

2. Health Links Forum Meeting 5
7th February 2013
2.15pm: Welcome
2.20pm: Joyce Banda video
2.25pm: TED Blog
2.40pm: Scotland-Malawi maternal health links Part 1
3.15pm: Tea and coffee break
3.30pm: Scotland-Malawi maternal health links Part 2
4.00pm: Discussion groups: Addressing the challenges and finding solutions
4.45pm Brief plenary
4.55pm The way forwards
5.00pm Close

4. Health Links Forum Meeting 5
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http://www.nyasatimes.com/m
alawi/2013/01/11/joyce-banda-
discusses-safe-motherhood-in-
malawi/

5. St Andrews-Malawi Partnership

6. 1st SGIDF-funded project.
• Partnership between the Medical School at St Andrews and
the only medical school in Malawi, the College of Medicine.
• St Andrews collaborated with College of Medicine (COM) to
assist the College with a major review of the undergraduate
medical curriculum.
• The changes were identified and driven by the need to
modernize the curriculum content and its delivery, and
significantly increase the number of medical students in
training.
• As a result of two joint conferences in Blantyre, the COM
implemented a new 21st century curriculum in January 2009.
• The COM has now reached the point of admitting 100
medical students per year up from 40-50 before this project
started.

7. 2nd SGIDF-funded project.
• We will extend the curriculum review to the Allied Health
Sciences programmes in the COM.
• Extend the curriculum review to the Diploma for Clinical
Medicine in the COHS in Lilongwe, liaising with other
projects pertaining to the clinical training of these students
• Development of an Honours B.Sc. in Biomedical Science at
COM to give a new science degree programme
• Working with the library at the COM to improve the
efficiency in resource utilisation.
• Encourage the existing partnerships between Malawian
undergraduates and those at St Andrews.

8. 2nd SGIDF-Funded Grant
• Work with the Department of Community Health to develop
a postgraduate Masters in Global Health at the COM.
• Extend current IT and LT support available to other local
degree programmes and out to other campuses.
• The LT team will work with the Malawian systems developers
to consolidate and extend the online curriculum
management system currently used by the COM to all its
programmes.
• Purchase of 50 PCs and monitors for Lilongwe computer
classroom. Purchase of desktop PC software licences for
each.
8

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10. School of Health,
Nursing & Midwifery
The Development of a
Multi-Professional
Skills Lab in Blantyre
Malawi

11. Campus Locations
Paisley Campus
Ayr Campus
Dumfries Campus
Hamilton Campus
N

12. Four Campus Equity

13. Alison Mc Lachlan 12th
December 2006

14. International Development Projects
• Three year Grant Award Scottish Government
(2006-9)
1. Educational development of acute care
skills / transfer of CS technology (IDF SM9)
2. Development of a support programme for
newly-qualified practitioners (IDF SM10)
3. Consultancy for 4 year BSc in Nursing /
Midwifery (KCN)

16. Lilongwe – Kamuzu College of Nursing
and Malawi College of Health Sciences

17. Current International Development
Project
• Project M53
‘Development of a multi-professional skills lab at
Blantyre Malawi’
• Partners:
College of Medicine
Kamuzu College of Nursing
Malawi College of Health Sciences
• Methodology:
‘Train the Trainers’
Live Video Link -SMOTS
(Scotia Medical Observation & Training System)

18. Blantyre
College of Medicine
Multi-Professional Skills Lab

21. Kamuzu College of Nursing
Leadership & Management
Programme

23. Outcomes
• Clinical Simulation established-4 Nursing Skills
Labs across Lilongwe, Blantyre and Zomba
Regions
• 1 Multi-Professional Skills Lab, Blantyre -
establishment of inter-professional education
• Future live video link from Blanytre to
Scotland –huge possibilities L & T
• Enhanced curriculum design and clinical
simulation embedded in curricula (pre/post
graduate/CPD)

24. Thank you for listening
Zikomo Kwambiri

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26. VSO Scotland
Maternal Health Projects in
Malawi

27. THET project: Bringing together midwives and
nurses to improve maternal health in Malawi
through volunteerism and partnerships
Aim: The project will:
Develop a strong, long term Recruit volunteer tutors and
volunteering programme that advisers to contribute to scaling
transfers skills between UK up the number of highly skilled
and qualified nurses and
and Malawian health
midwives in Malawi
professionals, leading to the
immediate and long term Increase recognition of value of
international volunteering
improvement in quality of
amongst UK Health professionals,
maternal health services for as a valuable part of their
poor and rural women in medical career – support from
Malawi RCN, RCM in UK

28. THET activities
Volunteers: and
•21 nurse/midwifery tutors 6 HR/ Management information
•2 midwives/nurses as CPD advisers
facilitators working in the Ministry of Health to
•2 Malawian Diaspora nurses or improve the quality of HR
midwives Management information systems
•6 Organisational Development
Advisers Project partner - the Nurses and
working in 7 nurse training Midwives Council of Malawi will
institutions: support the CPD programme
Kamuzu, St John’s, Nkhoma, St
Lukes, Trinity, Malamulo, Mulanje

29. Ntcheu Integrated Maternal Health
Project – Scottish Government funded
Aim The project will:
To improve the skills of clinical Increase the retention of
staff – specifically midwives – to qualified nurses and midwives
promote maternal services and providing ‘on the job’ support to
improve knowledge and health the Continuous Professional
seeking behaviour of Development Facilitator and 25
communities in Ntcheu (Ganya nurse/midwives across 11 health
and Njolomole Traditional facilities
authorities) Support Safe Motherhood
Groups which raise awareness of
maternal health risks and
services

30. Ntcheu Integrated Maternal Health
Project, 2
Volunteers: Partner agencies:
Two nurse/midwife volunteers Peri-natal Care project (PNC)within
volunteering for 2 years Ministry of Health – will co-ordinate Safe
Motherhood groups
Two Malawian Diaspora Theatre for a Change – will use popular
volunteers, volunteering for 3 theatre to promote safe motherhood
months Parent and Child Health initiative
(PACHI) – linked with University College
London Centre for International Health
Volunteers will provide ‘on the & Development – will monitor and
job’ support and structured CPD evaluate project impact
activities for local nurses and MIND – Scottish based Malawian
midwives diaspora NGO – will recruit Malawian
midwives and disseminate info in
Scotland

31. Fiona Forsyth
0131 243 2781
Fiona.forsyth@vso.org.uk

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41. Supporting Midwives in Rural Africa
A model for retention in the Malawi
CMT programme

42. Project scope
Aim : to strengthen and evaluate the training and
support of midwives in rural Malawi
Objectives
 Develop capacity for clinical teaching by providing
training and teaching/learning materials
 Develop model of mentorship for CMTs
 Support review and updating of curriculum
 Increase health systems support for rural midwifery
 Embed midwives in communities
 Evaluate the impact of CMT programme

43. Challenges for maternal health
Retention of midwives in rural areas
Mentoring and supervision
Continuing professional development/career path
Environment of care
Referral
Providing acceptable care

44. Challenges for project team
Communications
Employing a project officer
Accessing funds
Accessing sites
Demonstrating impact

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Tea and coffee served at the back of
the hall

46. Scotland Malawi Anaesthesia
With thanks to:
• Instructors
Founder: • SMMDP
Dr Catriona Connolly • ALSG
• SSA
• SICS
Ninewells Hospital,Dundee • RCOA
• OAA
• AAGBI
Malawi lead: • NHS Tayside, NHS Lanarkshire
• Colleagues who collect equipment
Mr Cyril Goddia • Medical physics Ninewells
• Fundraisers and donors
Anaesthetic Clinical Officer • Avian graphics, Dundee
• ASCO shipping, Aberdeen
• Senergy Oil, Aberdeen
• Malawi CHS

47. Overview
• Link established 2005
• Education: 43 courses including 2 train-the-trainers- ACOs from
throughout Malawi
• Critical care/ obstetric and paed emergencies and trauma/transport of
critically ill/advanced life support/Communication(SBAR)
• Sustainability: Developed Local faculty
• Equipment- reconditioned “condemned”
• Support from ministry- establish HDUs
• New project on multi-disciplinary training in obstetric emergencies

48. Monitoring and Evaluation
• Feedback from course participants
• Pre- and post- course tests of knowledge
• Supervision of local faculty teaching
• Data from hospitals following HDU provision

49. Dedza hospital data
Pre-HDU 2011
Transfers to central 80% 6%( 9/148)
Hospital
Maternal deaths per 3-4 1-2
month
Balaka Hospital data
Pre- HJDU 2011
Maternal deaths per month 3-4 2

50. Mangochi (8,300 deliveries)-2 HDUs
4 bedded maternity and 2-bedded general HDU
2006 2011
HDU admissions per 0 300
annum
sepsis 27 530 -i.e. x19
abortion 450 650- i.e. x1.4
eclampsia 48 112 – i.e. x2.3
Referrals to Zomba 30% of previous
Central Hospital years
In-hospital annual
maternal mortality 120 60

51. Effect of Scotland Malawi Anaesthesia
courses
Pre- 2006 Post course
• No critical care at district • Critical care provided in
hospitals district-Transfer numbers
• Many deaths during transfer of decreased by up to 74%
unaccompanied critically ill to
• Of those treated locally-
central hospitals
survival rate is 70-80%
• Poor communication from
referring hospital • Transfers are conducted safely-
proper resus, personnel and
communication
Maternal deaths decreased by 50% in the 3 centres
collecting data

52. Current Challenges
In Malawi
1. Essential equipment and drugs
2. Per Diems
3. Taxes on equipment entering the country
In Scotland:
 Administration of grants-
NHS act is interpreted as prohibiting accounts dept from administering grant
unless the project is of direct benefit to the people of Scotland
 Leave from NHS departments to deliver teaching.

53. Aspirations for SMP support
With Malawi government:
1. Encourage discussion on per-diems at Malawi ministry of Health –
including all NGOs
2. Negotiate on taxes applicable on donations entering the country
With Scottish Government:
1. Discuss Scottish Government commitment through the NHS- specifically-
Effect on Scottish waiting lists of additional leave by hospital doctors. Should
we include locum and “on-costs” in our grant applications
1. Discuss Scottish Government position on Scottish NHS accounts
departments administering grants.

54. Health Links Forum Meeting 5
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55. Dina McLellan
7th February 2013

56.  May 2005 – Scottish Franchise ALSO UK (self
financed)
 November 2005 – Scotland signed co-
operation agreement with Malawi:
 Contribute to the improvement of maternal
health by supporting the increase in the
number of trained midwives and facilitating
the exchange of knowledge and skills
required for dealing with obstetric and
gynaecological emergencies

58.  3 year funding 2005/2008
 Extended 2009/2010
 Sorenson, B L., Advanced Life Support in Obstetrics (ALSO) and post-
partum haemorrhage: a prospective intervention study in Tanzania., Acta
Obstetricia et Gynecologica Scandinavica, Volume 90, Issue 6, Page 609-
614, June 2011
 Adaptable
 Incorporated local needs
 Development of one day course
 BLSO

59.  1238 - 2 day ALSO
 151 – one day emergency
skills training / BLSO
 >40 instructors
 ALSO Malawi – Advisory
Faculty
 BEmOC

60.  Build on past success
 Utilise extensive instructor resource
 Avoid duplication of effort / conflict
 Ongoing co-operation and communication
between MOH/RHU

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62. Maternal health research
at IIHD
Dr. B de Kok bdekok@qmu.ac.uk
Source pictures: GuardianUK, UNICEF

63. IIHD Maternal Health Projects
Project 1. Loss in childbearing in Malawi: How
interpretations of responsibility, blame and entitlement
to care may affect maternal health care.
Dr. B. de Kok, 1 year research project. Funder: ISRF
Project 2. The changing role of Traditional Birth
Attendants in maternal health in Malawi : An
exploration of stakeholders’ perceptions
Isa Uny, 3 year doctoral research project
• Both qualitative studies, both just started.

64. Partnerships for maternal health
• Malawian partners:
– Centre for Social Research, Zomba.
– KCN (Address Malata)
– clinical officer, community member
– Challenges –unknown; too early !
• SMP:
– Learning, avoiding duplication
– Universities; critical reflection, deeper analysis of
‘nebulous’ aspects

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66. Screening for diabetes in
pregnant women in Malawi
A simple way to improve maternal
and neo-natal health

67. What is gestational diabetes?

68. Gestational diabetes.
• Diabetes mellitus which is detected for the
first time during pregnancy.
• May be undiagnosed diabetes.
• May be diabetes that develops during
pregnancy and then ‘disappears’ shortly after
the birth of the baby. In Scotland, mother is
tested 6 weeks after delivery.

69. Gestational Diabetes.
• If diabetes in the mother does ‘disappear’ after
the birth of the baby it is likely to be present in
future pregnancies and the mother has an
increased risk of developing diabetes later in life.
• *Women with a history of GDM have a 60%
chance of developing diabetes (usually type 2)
within the subsequent 20 years and this risk is
increased by obesity. For this reason they should -
-- have an annual fasting glucose measurement
performed.
* NHS GGC Guidelines

70. Diabetes.
• Pregnancy causes changes in glucose levels in
the mother.
• Increasing glucose levels in the mother
increases supply to the fetus hence enhanced
growth of the fetus.
• Gestational diabetes may develop – if not
controlled, mother and offspring at risk.
• Type 1 and Type 2 mothers and their offspring
are at similar risk if diabetes uncontrolled.

71. Risks to the fetus:
• Developmental malformations
• Increased insulin secretion
• Accelerated growth

73. Risks to the neonate:
• Reduced glucose levels in the blood of the
neonate
• Impaired production of lung surfactant –
increases risk of respiratory distress syndrome

74. Risks to mother:
• Miscarriage
• Pre-eclampsia
• Premature labour
• Polyhydramnios

75. What should be done.
• Pregnant women with diabetes should be
offered dietary advice and blood glucose
monitoring.
• They should be treated with glucose lowering
therapy
(Sign 116)

76. Anecdotal evidence.
• Information from three former students of
GCU who are DSNs and have visited Malawi.
• Women and their offspring are dying or
suffering needlessly because gestational and
other types of diabetes are not detected.

77. What we want to do.
• Produce and distribute posters to raise awareness
of diabetes.
• Send a small team of experts to Malawi
(pharmacist, physiologist, nutritionist, midwife
and diabetes nurse specialist) to train and
educate health workers on the problems caused
by diabetes.
• Note: we are in contact with (and have the
support of) a medic who is in Malawi and is a
diabetes expert.

78. What do we want to do? (continued)
• Bring a number of interested health workers
from Malawi to GCU so they can attend
postgraduate education in diabetes care and
management and attend relevant clinics in
Scotland.
• In due course these health workers can
educate and train other health workers in
Malawi.

79. What can you do?
• Please contact Jane Nally
(J.E.Nally@gcu.ac.uk) if you are able to help in
gathering evidence or offer experience that
can help us to apply for funding for this
initiative.

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81. SMP Health Links Forum
Tamara Mhura
St Augustine Church
07th February, 2013
www.waverleycare.org

82. Who we are
Voluntary organisation
Delivering prevention, care &
support services across Scotland
for people living with HIV and
Hepatitis C
Includes an African Health Project
www.waverleycare.org 90

83. What we do in Malawi
Raise awareness
Encourage
Deliver maternal behavioural change
health programmes
Deliver campaigns Improve access to
& Study circles health services
www.waverleycare.org
91

84. Maternal Health
Early attendance at antenatal clinics
Urge husbands to accompany wives
HIV testing
Family planning
PMTCT
www.waverleycare.org 92

85. Success stories
EHAPs PMTCT statistics
More husbands attending clinics with
their wives
Study Circles & peer education
www.waverleycare.org 93

86. Challenges
Only 56% of women in MLW give birth at health
clinics; reduces to 50% in Mzimba
Mzimba has few clinics which are scattered &
hard to reach
Unfriendly/ unsympathetic health professionals
Lack of facilities for guardians
Harmful cultural beliefs/practices
www.waverleycare.org 94

87. Lament of a husband whose wife and
baby son died in childbirth
When I see a nurse
“Me, when I see a nurse, I see cruelty. When I
see a nurse I see a witch,
www.waverleycare.org 95

88. Contact me:
Tamara Mhura, Waverley Care
Tamara.mhura@waverleycare.org
www.waverleycare.org 96

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91. Input from MaSP Health
Group Members
Ms Grace Goti Tahuna Soko,
Deputy College Principal, Holy Family College of Nursing
Dr Alexander Chijuwa,
District Health Officer, Phalombe District Health Office
Mr Steve Musopole,
Principal Architect, Malawi Polytechnic
Dr Mulina Nyirenda
Adult Emergency and Trauma Centre, Queen Elizabeth Central
Hospital, (Ninewells Hospital),
Mr Fyneck Kufeani,
Electrical Engineer, Malawi Polytechnic, (UWS)
Mr Webster Kadazi Chitsulo
Secretary, Kuthandiza Osayenda Disability Outreach, (Global
Concerns Trust)

92. Contributing factors to
improved maternal health in
Malawi
• Waiting antenatal wards, and an increase in
number of rural maternal clinics
• Community-based health: HSAs, community
leaders, etc
• Training of community midwives
• Safe Motherhood Initiative
• Up-skilling technicians where no registered nurse
or midwife available
• Training of traditional birth attendants

93. Main challenges towards
improving MH in Malawi
• Lack of resources: skilled personel,
equipment, medication and finances
• Inadequate infrastructure: access, facilities
(electricity) and space
• Socio-cultural attitudes: limited community
participation, family planning
• Information transfer and illiteracy

94. A Scottish contribution?
• Infrastructure: building district
hospitals, maternity units, training
centres
• Equipment: ambulances
• Education: campaigns in schools
and in the community
• Training: training and retaining
health professionals

95. Summary of recommendations from 2011 SMP Report:
Malawi-led: Projects have to be developed in response to requests from Malawi. Teaching
programmes should be adaptable to different cadres – doctors, nurses, midwives and clinical
officers – and should support policies which foster good working relationships between the
different professional categories.
Good stewardship: Making sure that funds are correctly used and accounted for.
Sustainable: Training trainers is essential and ensuring local ownership of the programme. If
equipment is available for sending make sure there is a need for it and that it can be serviced
locally.
Coordinated: Good collaboration between groups in Scotland is important to avoid replication of
effort but it is also important to establish that there is not duplication or overlap in Malawi.
Capacity-building in Malawi: In addition to the benefit in terms of trainees working in their own
country or region partnerships need to ensure that clinical experience gained was locally
relevant.
Exit strategy: Writing yourselves out of the script!
Manage expectations: There is a need to clarify the commitment of Scottish staff going to
Malawi on medium-term assignments (anxiety about losing out on National Insurance and
superannuation payments).

96. Health Links Forum Action • Further discuss on challenge of per
diem culture (SMP event?)
Points • Promoting inter-disciplinary
• MOU with NHS
approaches
• NHS administration of funding
• Supporting leadership
• Enabling Malawi-led ideas:
management initiatives in Malawi
working with MaSP to coordinate
• Up-skilling
efforts from Malawi
• SMP training on financial
management (Q3/Q4)
• Discussion among SMP members
on impact of devaluation on
partner projects in Malawi
• Important of
education/relationship to
maternal health

97. Health Links Forum Meeting 5
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