Natsuko Sawaya – AFE Blog – MaiKhanda, Lilongwe, Malawi

Applied Field Experience (AFE) became Amazing Field Experience (still AFE)!

Searching for an AFE opportunity:

Spending two to three months in the field, between my first and the second-year of graduate school as a Rotary Peace Fellow, sounded like a great opportunity and I was eager to work in one of the fields below:

  •  Neonatal health, in a country which has a high neonatal mortality rate
  •  Neonatal and infant health, in conflicted areas
  •  Any project focused on Ebola orphans from the most recent Ebola epidemic in western Africa.

For me, a sense of peace that one has, always comes from childhood; family, community, education, friends, environment… The very first years of life are crucial for one’s future development.

 

Kangaroo Mother Care:

When I started to look for an opportunity, I came across a BBC documentary with a very shocking title, “Dead Mums Don’t Cry”. It was filmed about ten years ago and was about maternal mortality in Chad. I wanted to see what had changed since the filming of the documentary, as well as the current neonatal health situation. It took me a couple of months to get in touch with the doctor who was in the film. Unfortunately, she was not working in the same position anymore and could not take an intern. I kept searching and contacting various people and organizations, eventually I came up with an idea to go to the site where the Kangaroo Mother Care (KMC) method is implemented. From my previous field experiences, I had seen babies carried this way, but I had never researched the scientific evidence of the its effects.

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KMC drawings on the wall of a hospital in Lilongwe

Series of my AFE:

Kangaroo Mother Care (KMC) is a method of infant care where the baby is held skin-to-skin with the mother (or caregiver). Forty years have passed since this method was presented in Bogota by Colombian pediatrician Edgar Rey. Since then, the effectiveness of thermal control, improved breastfeeding, and bonding in all newborn infants has been firmly established as benefits of the KMC method. The implementation of KMC is also recommended by the World Health Organization (WHO). I believe KMC is an important tool for addressing neonatal mortality in places where adequate health services are limited, such as developing countries, conflicted areas and refugee camps.

 

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Kangaroo Mother Care (KMC)

IHI is a not-for-profit organization, leading innovative partnerships in pursuit of health care improvement worldwide. IHI gives technical guidance and program support to MaiKhanda Trust. IHI offers a variety of open school courses, related to quality improvement, which I took prior to my IHI internship. At IHI, I had briefings about the ongoing preterm projects that MaiKhanda conducts at health facilities in Malawi. I was also analyzing the monthly data they received from MaiKhanda. It was great that I could see the parent organization side prior to my field work, learning how they supported and communicated with MaiKhanda and what they expected in the field.At the end of my AFE opportunity hunting, I had established a very unique path, starting at the Institute for Healthcare Improvement (IHI) in Cambridge, Massachusetts (4 days). After IHI, I would participate in an intensive Kangaroo Care certification course in Ohio held by the United States Institute for Kangaroo Care (2 days). Then, off to Malawi, interning with MaiKhanda Trust, a Malawian non-governmental and nonprofit organization, working on the reduction of Maternal and Neonatal Mortality and Morbidity, both at the health facility and the community level in the country (2.5 months).

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Between 2000 and 2010, Malawi has reduced under-five mortality after the first month by 7.1% per year and neonatal mortality by 3.5%.[i] Although the neonatal mortality reduction is slower than the reduction of under-five, it is faster than the regional average, which is 1.5% per year. A comprehensive national health sector approach integrates newborn survival programs, which was initially focused at a facility level, but was lately extended to the community level. Implementing the KMC method was one of the initiatives for newborn care at the facility. In the Malawian national protocol for postnatal care of newborns, KMC is specifically for babies whose birth weight is less than 2000g. Hospitals where MaiKhanda works for quality improvement, have KMC rooms for mothers or caregivers. They can place babies in the kangaroo care position until the baby meets the criteria to be discharged. However, not all babies that weigh less than 2000g are admitted into the KMC rooms. The main task that I was given by IHI was to find out why those KMC eligible babies (with birth weights less than 2000g) were not admitted into KMC rooms. They also wanted to gather information about neonatal deaths. We also agreed to find out the reasons why the birth weights of all babies were not reported.

Upon my arrival to Malawi, I had meetings with MaiKhanda staff to plan my internship. Unfortunately, my time was too short to work at all the hospitals; therefore, I chose one facility, which was facing a huge challenge on KMC admissions. Every week from Tuesday to Friday, I was based in Kasungu, about 130 km to the north of the capital city Lilongwe. I have been observing at the maternity ward, following the babies, especially the ones below 2000g at birth, from their delivery till their discharge. I have been making a process map from my observation, which will enable both IHI and MaiKhanda to see the gaps and obstacles regarding the points that we focused on. Hopefully, those findings will be useful for them to think of ideas and quality improvement projects. When the MaiKhanda staff comes to the facility, I join the team for data collection as well as quality improvement meetings. My daily activity includes trying to encourage the mothers and caregivers of the KMC babies to understand the benefits of KMC and to continuously hold their babies in the kangaroo care position. I also visited villages with the MaiKhanda staff in Kasungu, to see some of their activities related to maternal and neonatal health. One of the aims is to mobilize communities for health and social change. They work closely with community health workers, local government, the Ministry of the Health and other partners, engaging the committee members from each community to inform the population on antenatal care, health facility delivery, hygiene, sanitation and HIV among others. It has been a wonderful opportunity to understand more about the mothers and the families that I see in the hospital.

In Malawi, and with Rotary:

I have about two weeks left and the process map is almost complete. Although I have been enjoying this rewarding internship here in Malawi, I also have to go through sad and tough realities; that newborns are losing their lives each week. Those deaths are mostly preventable, but not only by improving the quality of health care, but also by improving many other factors that I would need another opportunity to blog about. Each day, when I leave the hospital, I hope to see those most vulnerable ones the following day. Each day, when I arrive at the hospital, I hope not to hear or see any neonatal deaths… it’s too soon to go…

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In the KMC room (left) KMC demonstration by midwives/nurses (right)

 

When I go to a place for a short time, I always prefer staying with a host family. By being exposed deeply into their daily life, I can learn about their culture and their country. I contacted the Rotary Clubs in Malawi and Rotarian, Rachel Silungwe, kindly offered me to stay with her during my time in Lilongwe. Rachel is also a Rotary alumnus who had traveled to Indiana, USA, through the Rotary Group Study Exchange Program. We had a lot of rotary experiences to share. At work, both the MaiKhanda and the hospital staff are all Malawian and they embrace me with the essence of their culture every day. Malawians say that Malawi is the warm heart of Africa. People affectionately greet you and welcome you. Once they find out that I am Japanese, quite a few greet me in Japanese. Many of them had a Japanese teacher when they were at school and some have been to Japan on the Japanese International Cooperation Agency (JICA) training programs. In fact, the JICA has been sending volunteers to Malawi since 1971. Malawi is a peaceful and stable country despite the poverty, lifeline shortage, drought and other problems that the country faces. On the street, you see a lot of Japanese used cars with the former company logos. It reminds me of some Asian countries that I have I visited. But here, interestingly, I was asked by some Malawians to listen to their car when they turned the engine on. Initially, I was not sure what they meant, but later I figured out that the car navigation system was activated each time the car started and was giving them instructions in Japanese. Amusingly, I translated a couple of times what those car navigation ladies were saying to them.

 

Rotary connected me to other fellows; one Malawian Peace Fellow, Ian Saini, who studied in Thailand for 3 months in 2014, and an ex Rotary Youth Exchange Student, Laura Turrini, from Brazil who stayed in Japan for a year and a half when she was in high school. Surprisingly, she was in District 2760, the same in which I applied for both the Ambassadorial and Peace Fellow scholarships. She was introduced to me by the Past District Governor Ryusetsu Esaki, who was also one of her host families. Recently, Ian gave a speech at the Rotary Club of Lilongwe and Rachel kindly invited Laura and I to attend the meeting. Ian works for the Ministry of Agriculture and is also a Global Peace Index Ambassador at the Institute for Economics & Peace. Laura works for the Brazilian Embassy here but at the same time, she is writing her thesis for her master’s study about Dzaleka Refugee Camp in Malawi. Rachel works for the National Aids Commission. I am grateful to have met these active and inspiring Rotary alumni here in Malawi. I am also very happy to have had the chance to participate in the meetings of this very active Rotary Club of Lilongwe.

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Top right: (from the left) Rachel Silungwe (Rotarian/alumni) Ian Sinai (Rotary Peace Fellow) Hutch Mthinda (District Governor Nominee) Natsuko Laura Turrini (Alumni) Sophie Kalinde (Past President) Bottom left: Lake Malawi Bottom right: sunset in Kasungu

UNC Project:

You may or may not know that UNC has a great presence in Malawi, mostly in the medical and epidemiological field. In the capital city, Lilongwe, you can see “UNC Project” signs and you hear “UNC” quite often. At the hospital where I work in Kasungu, a Maternity Waiting Home was constructed under a UNC project. I heard about the project of waiting homes at one of the lectures at UNC but I did not know that the Kasungu District Hospital had one. It officially opened in April of this year. As a UNC student, I was curious to visit the site. Expectant mothers in their 8th and 9th month of pregnancy, who live far from health facilities or who are referred at antenatal care, stay there until they give birth. The chief midwife/nurse at the maternity waiting home told me that before mothers started to live here, there was just an open space. Expectant mothers were staying under the sun and the moon, without being visited for checkups and many had lost their lives, just outside the door to the maternity ward. Now, they receive antenatal care, treatment if needed, nutrition-cooking and sewing classes, daily physical exercises and can attend many healthy talk sessions. The midwives/nurses warmly accepted the idea of including the Kangaroo Mother Care topic in their health talks. They have toilets, showers and places to sleep under a roof; however, with more than 200 expectant mothers, there are just not enough rooms. There are huge tents and some extra rooms without beds, but usually, the ones who have no complications stay in these spaces. It is such an impressive scene that these expectant mothers dance and run with their very pregnant bellies. It is really, impressively beautiful and I believe, quite unique.

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Top left: morning run of the expectant mothers from the maternity waiting home Top right: learning how to sew Bottom center: cooking session

Thanks to many ongoing UNC projects, many Malawians know “UNC”. When I introduce myself, saying, “I am a UNC student”, many respond with a confused look. Many think it is a project’s name, some think it is part of the United Nations!

Starting from Cambridge in Massachusetts at IHI, my Applied Field Experience has been an Amazing Field Experience, full of laughter. I admire the hospital staff and Team MaiKhanda who dedicate themselves towards making their tomorrow better. As I have seen in different countries, music and dance are an important part of their life here. Seeing the smiling faces in those moments, feeling the united atmosphere surrounded by rhythms, I strongly believe that music can be a contributing factor to bring a peace among those, for any generation, who are sharing the rhythm with singing, dancing and smiling. I hope that babies coming into this world will be able to participate in these fun moments of life as they grow…

I did not mention much about Malawi itself, if you are interested in learning more, check out Malawi on the internet, please!

[i] E. Zimba, M. Kinne, F. Kachale et al. Newborn survival in Malawi : a decade of change and future implications, Health Policy and Planning 2012, 27:iii88-iii103; doi: 10.1093/heapol/czs043

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