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Background The prevalence of teenage pregnancies in Malawi is 29%. About 25% of those are married while 30% are unmarried adolescents (15–19 years old) who use contraceptives. Data on contraceptive use has focused on older adolescents (15–19 years old) leaving out the young adolescents (10–14 years old). This study assessed factors that influence contraceptive decision-making and use among young adolescents aged 10–14 years. Methods This was a qualitative study that used the Theory of Reasoned Action (TRA) model to understand the processes that influence contraceptive decision-making among young adolescents (10–14 years old) in urban Lilongwe. The study was conducted in six youth health-friendly service centers and 12 youth clubs. Two focus group discussions and 26 in-depth interviews were conducted among sexually active in and out of school young adolescents and key informants. The results are organized into themes identified during the analysis. Results Results showed that contraceptive decision-making is influenced by social factors (individual, interpersonal, society) and adolescents’ perceptions regarding hormonal contraceptives. There is also a disconnect between Education and Adolescent Sexual and Reproductive Health policies. Conclusion The findings suggest that interventions that scale up contraceptive use need male and female involvement in decision making. Addressing myths around contraceptives, and harmonization of Education and Sexual and Reproductive Health policies in the country would motivate adolescents to use contraceptives., Plain language summary There is limited data on modern family planning method use of young adolescents aged 10–14 years compared to older adolescents aged 15–19 years. The study assessed factors that influence modern family planning method decision-making and use among young adolescents aged 10–14 years. The Theory of Reasoned Action model was applied to understand the processes that influence modern family planning method decision-making and use among young adolescents. The study was conducted in 6 youth health-friendly services clinics and 12 youth clubs where adolescents access contraceptives. We conducted 2 focus group discussions and 26 in-depth interviews. The study involved sexually active, in and out of school young adolescents and influential decision-makers in reproductive health. The results are presented in a narrative format using themes identified during analysis in line with study objectives. The study discovered that modern family planning method decision-making is influenced by social factors; hormonal side effects of modern family planning methods and improper linkage between Sexual and Reproductive Health Rights and Education policies. The findings suggest the need to empower girls in decision-making. Address myths surrounding modern family planning methods. Then harmonize Sexual and Reproductive Health Rights and Education Policies in the country.

ObjectivesTo assess temporal shifts in HIV risk factors among adolescent girls (AG, aged 15–19 years) and young women (YW, aged 20–24 years) in Kenya, Malawi and Zambia.DesignProspective cohorts with two time points (Kenya: 2016/2017, 2018; Malawi: 2017, 2018; Zambia: 2016/2017, 2018)SettingCommunity-based programming.Participants1247 AG (Kenya: 389, Malawi: 371, Zambia: 487) and 1628 YW (Kenya: 347, Malawi: 883, Zambia: 398)InterventionDetermined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS), a multisectoral approach to reduce AGYW’s HIV vulnerability by delivering a package of tailored, multilayered activities and services.Primary and secondary outcome measures: HIV testing, sexually transmitted infection (STI) symptom experience, number of sexual partners, condom use (consistently, at last sex), transactional sex, experience of physical violence (from intimate partners) and sexual violence (from intimate partners and strangers/non-partners).ResultsChanges in HIV-related risk behaviours among DREAMS participants varied by age group and country. Among AG, HIV testing increased (Kenya and Zambia) and sexual violence from partners (in Kenya and Malawi) and non-partners (in Malawi) decreased. Among YW, HIV testing increased and STI experience decreased in Malawi; consistent condom use decreased in Kenya; transactional sex increased in Kenya and Zambia; and physical violence (in Malawi) and sexual violence from partners (in Kenya and Malawi) and non-partners (all three countries) decreased over time.ConclusionsImprovements in HIV testing and reductions in experiences of sexual violence were coupled with variable shifts in HIV-related risk behaviours among DREAMS participants in Kenya, Malawi and Zambia. Additional consideration of AGYW’s risk circumstances during key life transitions may be needed to address the risk heterogeneity among AG and YW across different contexts.

ObjectivesDisrespectful care, which remains prevalent in low and middle-income countries (LMICs), acts as a barrier to women accessing skilled birth attendance, compromising care when services are available. Building on what was positive in facilities, we aimed to explore lay and healthcare providers’ experience of respectful care to inform future interventions.SettingFive maternity facilities in Mwanza Tanzania and Lilongwe Malawi.Participants94 participants in Malawi (N=46) and Tanzania (N=48) including 24 women birthing live baby within the previous 12 months; 22 family members and 48 healthcare providers who regularly provided maternity care in the included facilitiesDesignThe study was guided by Appreciative Inquiry (AI). Semistructured, one-to-one interviews were conducted between January and December 2019. Interviews were audio-recorded, translated where necessary, transcribed verbatim, and analysed using the framework approach.ResultsFour main themes describing participants positive experience and their vision of respectful care were identified: (1) empathic healthcare provider–woman interactions including friendly welcome and courteous language, well-timed appropriate care and information sharing, (2) an enabling environment, characterised by improvement of physical environment, the use of screens, curtains and wall partitions for privacy, availability of equipment and provision of incentives to staff, (3) supportive leadership demonstrated by the commitment of the government and facility leaders to provision of respectful care, ensuring availability of guidelines and policies, supportive supervision, reflective discussion and paying staff salaries timely, (4) providers’ attitudes and behaviours characterised by professional values through readiness, compassionate communication and commitment.ConclusionThe positive experiences of service users, families and healthcare providers provided insight into key drivers of respectful care in facilities in Tanzania and Malawi. Interventions targeting improved environment and privacy, healthcare provider communication and developing positive leadership structures in facilities could provide the basis for sustained improvement in respectful and dignified maternal and newborn care in LMICs.

Background: Maternal mortality and morbidity rates remain high in sub-Saharan Africa, yet with appropriate management, these rates could be reduced significantly. Midwifery training to improve the management of women during intrapartum period is often lacking, calling for innovative training methods in midwifery clinical care. Aims: To develop and evaluate a game, aimed at the prevention and management of the main causes of maternal morbidity and mortality. Methods: In collaboration with the Lugina Africa Midwives Research Network (LAMRN), the authors developed an educational board game and field tested the final version in Kenya, Tanzania and Malawi with midwives (n=56) and student midwives (n=32). Findings: Qualitative and quantitative evaluation demonstrated that the game was well liked for its ease of use, acceptable appearance and relevance to practice. Conclusions: The board game, named ‘Crisis’, has potential to influence practice; however, further research is required to assess its ability to improve outcomes.

Background In 2013, the World Health Organisation (WHO) recommended Option B+ as a strategy to prevent mother-to-child transmission (PMTCT) of HIV. In option B+ , lifelong antiretroviral therapy (ART) is offered to all HIV positive pregnant and breastfeeding women to reduce MTCT rate to less than or equal to 5%. Its success depends on retaining women on ART during pregnancy, delivery and breast-feeding period. There is limited data on early retention on ART among pregnant women in Zimbabwe. We therefore assessed early retention among women on Option B + from antenatal care (ANC) until 6 months post ANC booking and at delivery in Bulawayo city and Mazowe rural district of Zimbabwe. Methods We collected data for pregnant women booking for ANC between January and March 2018, comparing early retention among ART naïve women and those already on ART. The two cohorts were followed up for 6 months post ANC booking, and this was done in two districts. Data were collected from routine tools used at facility level which include ANC, delivery and ART registers. The Kaplan-Meier survival analysis was used to estimate retention probabilities at 1, 3 and 6 months post-delivery and for retention at delivery proportions were used. Poisson regression was used to investigate factors associated with non-retention at 6 months post ANC booking. Results A total of 388 women were included in the study with median age of 29 years (IQR: 25–34). Two-thirds booked in their second trimester. Retention at 3 and 6 months post ANC booking was 84% (95% CI 80–88) and 73% (95% CI 69–78) respectively. At delivery 81% (95% CI 76–84) were retained in care, 18% lost-to-follow-up and 1% transferred out. In this study we did not find marital status, gestation age, facility location, ART status at ANC booking, to be associated with loss to follow-up. Conclusion In this study, we found low retention at 3, 6 months and delivery, a threat to elimination of Mother-to-child Transmission of HIV in Zimbabwe. Our findings emphasize the need for enhanced interventions to improve early retention such as post-test counselling, patient tracing and visit reminders.

INTRODUCTION: Zimbabwe has a high burden of HIV (i.e., estimated 1.3 million HIV-infected and 13.8% HIV incidence in 2017). In 2017 the country developed and implemented a pilot of HIV case surveillance (CS) based on the 2017 World Health Organisation (WHO) person-centred HIV patient monitoring (PM) and case surveillance guidelines. At the end of the pilot phase an evaluation was conducted to inform further steps. METHODS: The pilot was conducted in two districts (i.e., Umzingwane in Matabeleland South Province and Mutare in Manicaland Province) from August 2017 to December 2018. A mixed-methods cross-sectional study of stakeholders and health facility staff was used to assess the design and operations, performance, usefulness, sustainability, and scalability of the CS system. A total of 13 stakeholders responded to an online questionnaire, while 33 health facility respondents were interviewed in 11 health facilities in the two districts. RESULTS: The HIV CS system was adequately designed for Zimbabwe´s context, integrated within existing health information systems at the facility level. However, the training was minimal, and an opportunity to train the data entry clerks in data analysis was missed. The system performed well in terms of surveillance and informatics attributes. However, viral load test results return was a significant problem. CONCLUSION: The HIV CS system was found useful at the health facility level and should be rolled out in a phased manner, beginning in Manicaland and Matabeleland South provinces. An electronic link needs to be made between the health facilities and the laboratory to reduce viral load test results delays.

Background Early adolescence is an important period to lay the foundation for positive sexual health development that can overcome sexual and reproductive health (SRH) challenges faced by very young adolescents (VYAs) as they reach puberty and sexual debut. In this study, we explored the following questions: first, what are the experiences of VYA girls on DREAMS’ Go Girl club participation? Second, how does club participation influence the VYAs SRH knowledge to reduce their risk for HIV and negative sexual health outcomes? Methods This was a qualitative study in which twenty-three in-depth interviews were conducted with VYA girls aged 12–14 years. These girls were enrolled in girl-only clubs in two rural southern districts in Malawi. The clubs were a part of larger comprehensive HIV prevention project called DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) which provided an evidence-based core package of interventions to VYAs to prevent HIV. Interventions included improved access to key health services, education support, social skills, asset building, and economic strengthening. Narrative inquiry was used to generate first-hand accounts of the girls’ experiences with club participation. Thematic analysis was used to generate themes from the transcribed stories. Results Six main themes were generated: 1) reasons for joining the clubs with desire to learn about SRH as a motivation for joining the clubs.; 2) influence on gender norms and roles whereby participants described a change of gender roles and norms at home; 3) influence on child abuse practices whereby participants reported a decline in child abusive practices at home;4) influence on life skills and social networks whereby participants described learning about networking; 5) support to go back to school whereby out-of-school girls described how economic empowerment of their guardians facilitated their return to school; and 6) influence of clubs on SRH knowledge acquisition and behaviours whereby participants described acquiring knowledge on sexual health issues. Conclusion Girls-only HIV and SRH programs coupled with economic empowerment for their families can be effective in keeping VYA girls in school and improving SRH knowledge and health seeking behavior.

Introduction\ud Despite improvements in prevention of mother‐to‐child transmission (PMTCT) of HIV outcomes, there remain unacceptably high numbers of mother‐to‐child transmissions (MTCT) of HIV. Programmes and research collect multiple sources of PMTCT data, yet this data is rarely integrated in a systematic way. We conducted a data integration exercise to evaluate the Zimbabwe national PMTCT programme and derive lessons for strengthening implementation and documentation.\ud \ud Methods\ud We used data from four sources: research, Ministry of Health and Child Care (MOHCC) programme, Implementer – Organization for Public Health Interventions and Development, and modelling. Research data came from serial population representative cross‐sectional surveys that evaluated the national PMTCT programme in 2012, 2014 and 2017/2018. MOHCC and Organization for Public Health Interventions and Development collected data with similar indicators for the period 2018 to 2019. Modelling data from 2017/18 UNAIDS Spectrum was used. We systematically integrated data from the different sources to explore PMTCT programme performance at each step of the cascade. We also conducted spatial analysis to identify hotspots of MTCT.\ud \ud Results\ud We developed cascades for HIV‐positive and negative‐mothers, and HIV exposed and infected infants to 24 months post‐partum. Most data were available on HIV positive mothers. Few data were available 6‐8 weeks post‐delivery for HIV exposed/infected infants and none were available post‐delivery for HIV‐negative mothers. The different data sources largely concurred. Antenatal care (ANC) registration was high, although women often presented late. There was variable implementation of PMTCT services, MTCT hotspots were identified. Factors positively associated with MTCT included delayed ANC registration and mobility (use of more than one health facility) during pregnancy/breastfeeding. There was reduced MTCT among women whose partners accompanied them to ANC, and infants receiving antiretroviral prophylaxis. Notably, the largest contribution to MTCT was from postnatal women who had previously tested negative (12/25 in survey data, 17.6% estimated by Spectrum modelling). Data integration enabled formulation of interventions to improve programmes.\ud \ud Conclusions\ud Data integration was feasible and identified gaps in programme implementation/documentation leading to corrective interventions. Incident infections among mothers are the largest contributors to MTCT: there is need to strengthen the prevention cascade among HIV‐negative women.

Parental participation is one of the cornerstones of paediatric practice. Evidence from the literature has shown that effective parental participation depends on parents’ preparedness, adequate communication between parents and nurses, and the negotiation process. However, little is known about the perception of these parents regarding their participation in the care of their hospitalised children. The aim of the study was to explore the perceptions of parents regarding their participation in the care of their children who were hospitalised at a government hospital in Malawi. A descriptive qualitative study was carried out using a semi-structured interview guide to collect data from 20 parents in the paediatric department. Thematic analysis was done guided by Colaizzi’s method. Three main themes emerged from the data and these were lack of role negotiation by healthcare workers, inadequate role preparation for parents, and parents’ perceptions of the care they provided to their hospitalised children. The study findings showed that parents view their participation in the care of hospitalised children as appropriate, important and satisfying. However, gaps exist in the way they participate in the care of their hospitalised children due to inadequate role negotiation and role preparation for parents and inadequate information from nurses. The researchers recommend that management should develop protocols and guidelines for the implementation of parental participation in the care of hospitalised children to promote best practices and quality children’s care.

ObjectivePeer education is an intervention within the voluntary medical male circumcision (VMMC)–adolescent sexual reproductive health (ASRH) linkages project in Bulawayo and Mount Darwin, Zimbabwe since 2016. Little is known if results extend beyond increasing knowledge. We therefore assessed the extent of and factors affecting referral by peer educators and receipt of HIV testing services (HTS), contraception, management of sexually transmitted infections (STIs) and VMMC services by young people (10–24 years) counselled.DesignA cohort study involving all young people counselled by 95 peer educators during October–December 2018, through secondary analysis of routinely collected data.SettingAll ASRH and VMMC sites in Mt Darwin and Bulawayo.ParticipantsAll young people counselled by 95 peer educators.Outcome measuresCensor date for assessing receipt of services was 31 January 2019. Factors (clients’ age, gender, marital and schooling status, counselling type, location, and peer educators’ age and gender) affecting non-referral and non-receipt of services (dependent variables) were assessed by log-binomial regression. Adjusted relative risks (aRRs) were calculated.ResultsOf the 3370 counselled (66% men), 65% were referred for at least one service. 58% of men were referred for VMMC. Other services had 5%–13% referrals. Non-referral for HTS decreased with clients’ age (aRR: ~0.9) but was higher among group-counselled (aRR: 1.16). Counselling by men (aRR: 0.77) and rural location (aRR: 0.61) reduced risks of non-referral for VMMC, while age increased it (aRR ≥1.59). Receipt of services was high (64%–80%) except for STI referrals (39%). Group counselling and rural location (aRR: ~0.52) and male peer educators (aRR: 0.76) reduced the risk of non-receipt of VMMC. Rural location increased the risk of non-receipt of contraception (aRR: 3.18) while marriage reduced it (aRR: 0.20).ConclusionWe found varying levels of referral ranging from 5.1% (STIs) to 58.3% (VMMC) but high levels of receipt of services. Type of counselling, peer educators’ gender and location affected receipt of services. We recommend qualitative approaches to further understand reasons for non-referrals and non-receipt of services.

This was a cross-sectional study describing HIV testing uptake and ART initiation for pregnant women and HIV-exposed infants after one-off clinical mentorship training in 2013 for nurses in 56 peripheral health-facilities, Zimbabwe. Between 2014-2018, 92% of 106411 pregnant women were HIV tested and 98% of HIV-positive women initiated antiretroviral therapy (ART). There were 15846 HIV-exposed infants, of whom 96% had dried blood spots collected for virologic diagnosis and 51% of those diagnosed HIV-positive initiated ART. In conclusion, this one-off clinical mentorship training in 2013 was associated with consistently high HIV testing and ART initiation in pregnant women and their children.

Background Majority of maternal and new-born deaths occur within 28 hours and one week after birth. These can be prevented by well-educated midwives. Confidence in postnatal and newborn care skills depend on the quality of midwifery education. Objective To assess confidence and its associated factors for basic postnatal and new-born care skills of final year midwifery students , from seven African countries. Methods A multi-country cross-sectional study where final year midwifery students answered a questionnaire consisting of basic skills of postnatal and newborn care listed by the International Confederation of Midwives. The postnatal care area had 16 and newborn care area had 19 skill statements. The 16 skills of postnatal care were grouped into three domains through principle component analysis (PCA); Basic postnatal care; postnatal complications and educating parents and documentation. The 19 skills under the newborn care area were grouped into three domains; Basic care and care for newborn complications; Support parents for newborn care; and Care for newborns of HIV positive mothers and documentation. Results In total 1408 midwifery students from seven Sub-Saharan countries participated in the study namely; Kenya, Malawi, Tanzania, Uganda, Zambia, Zimbabwe, and Somaliland Overall high confidence for all domains under Post Natal Care ranged from 30%-50% and for Newborn care from 39-55%. High confidence for postnatal skills was not found to be associated with any background variables (Age, sex, type and level of educational programme). High confidence for newborn care was associated with being female students, those aged 26-35 years, students from the direct entry programmes and those enrolled in diploma programmes. Conclusions Almost half of the study participants expressed lack of confidence for skills under postnatal and newborn care. No association was found between high confidence for domains of postnatal care and background variables. High confidence was associated with being a female, between 26-35 years of age, from direct entry or diploma programmes for newborn care area. The results of the study indicate gaps in midwifery education. Countries could use the ICM list of competencies to develop country specific standards for midwifery education. However, actual competence remains to be measured.

Background: Inadequate pain management is a problem in hospitalized children. Objectives: To explore knowledge and attitudes of nurses in management of pain in children. Methods: A descriptive design using qualitative methods was used to conduct the study. 17 nurses with prior pain management training were interviewed using a semi-structured interview guide. Ethical approval was obtained from College of Medicine Research and Ethics Committee. Data were analysed using thematic content analysis. Results: Nurses had some knowledge of pain assessment methods, treatment and use of morphine. Gaps, however, existed on how to use pain assessment scales, analgesics to use at each step of the WHO analgesic ladder, and how to effectively use morphine for pain relief. Although most nurses had positive attitudes towards children’s pain and use of morphine, negative attitudes were evident in some nurses regarding administration of morphine to neonates or acutely ill children. Conclusion and Implications: The study has revealed knowledge and attitude gaps which may reflect deficiencies in the pain education nurses received, non-availability of pain scales and lack of support for nurses to link theory with practice. Nurse leaders are challenged to provide repeated comprehensive education for nurses on pain assessment and management. Furthermore, user friendly pain scales should be developed, and nurses educated and demonstrated on their use. In addition, opportunities for supportive supervision with nurses in the clinical setting should be created for linkage of theory and practice.

An intervention focused on children, adolescents, and young adults living with HIV using a cadre of dedicated peers—community adolescent treatment supporters—led to improvements along the HIV care cascade among their household contacts and sexual partners., Background: Africaid Zvandiri, in partnership with the Ministry of Health and Child Care (MOHCC) in Zimbabwe, implemented a comprehensive, peer-led program, focused on children, adolescents, and young adults living with HIV aged 0–24 years. The peers, known as community adolescent treatment supporters (CATS), are people living with HIV (PLHIV) aged 18–24 years who are trained and mentored to support their peers throughout the HIV care continuum through support groups, home visits, phone call reminders, and messages. We report the HIV care continuum outcomes (HIV testing uptake, antiretroviral therapy [ART] uptake, retention, and viral suppression) in a cohort of household contacts and sexual partners (aged younger than 25 years) of index children, adolescents, and young adults living with HIV identified by CATS from October 2017 to September 2018 in 24 districts of Zimbabwe. Methods: This was a retrospective cohort study involving analysis of routine program data, extracted from electronic databases consisting of data on contacts of index PLHIV and ART outcomes. We used April 30, 2019, as the censor date for all analyses. Results: A total of 15,223 household contacts and sexual partners with unknown HIV status (linked to 9,353 index PLHIV) were identified and referred for HIV testing. Of these, 12,114 (79.6%) were tested and 1,193 (9.8%) were HIV-positive. Of the latter, 1,153 (96.6%) were initiated on ART with 99% starting on the day of diagnosis. Of those on ART, 1,151 (99.8%) were alive on ART at 6 months and 2 (0.2%) died. A total of 1,044 (91%) children, adolescents, and young people living with HIV underwent viral load testing at 6 months or later, of whom 1,037 (99.3%) were virally suppressed (

BackgroundGlobally, ten percent of new HIV infections are among children and most of these children acquire infection through mother-to-child transmission. To prevent this, lifelong ART among pregnant and breast feeding (PBF) women living with HIV, irrespective of the WHO clinical stage, was adopted (option B+). There is limited cohort-wise assessment of VL testing among women on 'option B+'.ObjectiveAmong a pregnancy cohort on antiretroviral therapy in public hospitals and clinics of Mazowe district, Zimbabwe (2017), to determine the i) proportion undergoing VL testing anytime up to six months post child birth and associated factors; ii) turnaround time (TAT) from sending the specimen to results receipt and VL suppression among those undergoing VL testing.MethodsThis was a cohort study involving secondary programme data. Modified Poisson regression using robust variance estimates was used to determine the independent predictors of VL testing.ResultsOf 1112 women, 354 (31.8%, 95% CI: 29.2-34.6) underwent VL testing: 113 (31.9%) during pregnancy, 124 (35%) within six months of child birth and for 117 (33.1%), testing period was unknown. Of 354, VL suppression was seen in 334 (94.4%) and 13 out of 20 with VL non-suppression underwent repeat VL testing. Among those with available dates (125/354), the median TAT was 93 days (IQR 19.3-255). Of 1112, VL results were available between 32 weeks and child birth in 31 (2.8%) women. When compared to hospitals, women registered for antenatal care in clinics were 36% less likely to undergo VL testing [aRR: 0.64 (95% CI: 0.53, 0.76)].ConclusionAmong women on option B+, the uptake of HIV VL testing was low with unacceptably long TAT. VL suppression among those tested was satisfactory. There is an urgent need to prioritize VL testing among PBF women and to consider use of point of care machines. There is a critical need to strengthen the recording and local utilisation of routine clinic data in order to successfully monitor progress of healthcare services provided.

BackgroundDomestic violence against pregnant women exists in Malawi but its magnitude and types were, until recently published data, unknown due to scanty published data on the subject. This study aimed at identifying types of abuse women experience during pregnancy. MethodsThe study design was cross-sectional descriptive quantitative using a random sample of 292 pregnant women attending an antenatal clinic at Nsanje District Hospital, southern region of Malawi. A structured questionnaire was administered to each pregnant woman that consented to participate. Data was analyzed using SPSS software version 16. Descriptive statistics were computed for demographic data and type of violence. ResultsThe findings indicate that a majority (59%) of women experienced more abuse during pregnancy, compared to 12.5% prior to current pregnancy. The women were psychologically (29%), sexually (28%) and physically (14%) abused during pregnancy. There was a significant association (P0.05) was found between domestic violence and other demographic variables; age, low education level and low income. ConclusionThe pregnancy period is not a joyful time for all women. The study found high levels of psychological, sexual and physical domestic abuse among pregnant women. We advocate for community awareness creation on domestic violence, strengthening victim support units and One-Stop centres, and training health workers to screen for and counsel victims during antenatal care.

In low-income settings, partner engagement in HIV testing during pregnancy is well recognised, but uptake remains low. To understand why men fail to engage, seventy-three interviews were conducted with women (n=23), men (n=37), and community stakeholders (n=17) in Malawi and Kenya. Data were collected through individual, in-depth interviews. Transcribed data were analysed thematically. Male engagement was verbally supported. However, definitions of ‘engagement’ varied; women wanted a shared experience, whereas men wanted to offer practical and financial support. Women and stakeholders supported couples-testing, but some men thought separate testing was preferable. Barriers to couples testing were strongly linked to barriers to antenatal engagement, with some direct fear of HIV-testing itself. The major themes identified included diverse definitions of male engagement, cultural norms, poor communication and environmental discomfort – all of which were underpinned by hegemonic masculinity. Couples-testing will only increase when strategies to improve reproductive healthcare are implemented and men’s health is given proper consideration within the process. As social norms constitute a barrier, community-based interventions are likely to be most effective. A multi-pronged approach could include advocacy through social media and community forums, the provision of tailored information, the presence of positive role models and a welcoming environment.

Background The World Health Organisation has recommended that healthcare workers, teachers and community leaders work with parents to support children living with HIV. The aim of this study was to assess the perceptions and experiences of primary caregivers and other care providers such as healthcare workers, teachers, and community leaders regarding their involvement, practice and challenges of HIV disclosure to children aged between 6 and 12 years living with HIV in Malawi. Methods Twelve focus group discussions and 19 one-on-one interviews involving a total of 106 participants were conducted in all three administrative regions of Malawi. The interviews and focus group discussions explored perceptions and experiences regarding involvement, practice and challenges of disclosure of HIV status to children. Data were analysed using thematic analysis. Results Primary caregivers, healthcare workers, teachers, and community leaders all reported that the disclosure of HIV status to children was not well coordinated because each of the groups of participants was working in isolation instead of working as a team. A “working together” model emerged from the data analysis where participants expressed the need for them to work as a team in order to promote safe and effective HIV status disclosure through talking about HIV, sharing responsibility and open communication. Participants reported that by working together, the team members would ensure that the prevalence of HIV disclosure to young children increases and that there would be a reduction in any negative impact of disclosure. Conclusion Global resources are required to better support children living with HIV and their families. Healthcare workers and teachers would benefit greatly from training in working together with families living with HIV and, specifically, training in the disclosure process. Resources, in the form of books and other educational materials, would help them explain HIV and its effective management to children and families.

The rate of disclosure of HIV status to children living with HIV in sub-Saharan Africa remains low despite the World Health Organisation's recommendation that children should be told about their HIV status by the age of 12 years. Authors of previous studies have identified lack of disclosure materials as the main barrier to disclosure of HIV status. This study aimed to assess the need and acceptability of a series of age-appropriate children story books intended to help with informing children about their HIV status. Questionnaires, interviews, and focus group discussions were used to collect data from caregivers, healthcare workers, and school teachers, adolescents living with HIV, and community leaders across the three administrative regions of Malawi. Information about the need and acceptability of the story books and the sociodemographic characteristics of the participants was collected using reliable instruments. Quantitative data were tabulated while thematic analysis was used to analyse qualitative data. Almost 600 participants responded to the survey questionnaire, and 19 interviews and 12 focus groups were conducted with 106 participants. Ninety-eight per cent of participants supported the idea of developing the proposed series of story books and reported that they would use the books once they are developed. Most of the participants expressed that the books will help to improve their knowledge and understanding of HIV disclosure, increase their confidence on how to disclose and help to provide consistent information about HIV disclosure to children.The results of this study show a high acceptability rate of the story books. The process of HIV disclosure to children is a very complex issue that will require the development of guidelines and materials that are rigorously evaluated prior to dissemination.

Background In 2011 the World Health Organisation recommended that children with a diagnosis of HIV be gradually informed about their HIV status between the ages of 6 and 12 years. However, to date, literature has focused mainly on primary caregiver and child experiences with HIV disclosure, little is known about healthcare workers’ perspectives and practices of HIV status disclosure to children. The aim of this study was to assess healthcare workers’ perspectives and practices regarding the disclosure of HIV status to children aged between 6 and 12 years in Malawi. Methods A cross-sectional survey was used to collect data from 168 healthcare providers working in antiretroviral clinics in all government District and Tertiary Hospitals in Malawi. Participants were asked questions regarding their knowledge, practice, and barriers to HIV disclosure. Data were analysed using binary logistic regression. Results Almost all healthcare workers (98%) reported that it was important to disclose HIV status to children. A significant proportion (37%) reported that they had never disclosed HIV status to a child and about half estimated that the rate of HIV disclosure at their facility was 25% or less. The main barriers to disclosure were lack of training on disclosure (85%) and lack of a standard tool for disclosure (84%). Female healthcare workers (aOR) 2.4; 95% CI: 1.1–5.5) and lack of training on disclosure (aOR 7.7; 95% CI: 3.4–10.7) were independently associated with never having disclosed HIV status to a child. Conclusions This study highlights the need for providing appropriate training in HIV disclosure for healthcare workers and the provision of standardised disclosure materials. Electronic supplementary material The online version of this article (10.1186/s12913-018-3354-9) contains supplementary material, which is available to authorized users.

The World Health Organisation (WHO) recommends that children living with HIV should be informed about their HIV status within the ages of 6 to 12 years using age-appropriate resources. The aim of this study was to assess the socio-demographic, clinical and psychosocial factors associated with primary caregivers' decisions to disclose HIV to children living with HIV aged 6 to 12 years in Malawi. A cross-sectional study of 429 primary caregivers of children living with HIV were systematically recruited from all regions of the country. Information on HIV disclosure, family and child socio-demographic characteristics, child clinical characteristics, and child and family psychosocial characteristics was collected using validated instruments. Logistic regression was used to analyse data. The prevalence of non-disclosure of HIV status to children was 64 per cent. Concerns about the child's inability to cope with the news (29%), a lack of knowledge on how to disclose HIV status (19%), and fear of stigma and discrimination (17%) were the main reasons for non-disclosure. On multivariate analysis, the odds of non-disclosure were higher among primary caregivers who were farmers (aOR 3.0; 95% CI: 1.1-8.4), in younger children (6-8 years) (aOR 4.1; 95% CI: 2.3-7.4), in children who were in WHO HIV clinical stage one (aOR 3.8; 95% CI: 1.4-10.2), and in children who were not asking why they were taking ARVs (aOR 2.9; 95% CI: 1.8-4.8). On the other hand, nondisclosure of HIV status was less likely in underweight children (aOR 0.6; 95% CI: 0.3-0.9). Many children living with HIV in Malawi are unaware of their HIV status. Non-disclosure is associated with a number of clinical and demographic characteristics. The findings highlight the need to provide guidance and support to primary caregivers to help them to effectively disclose HIV status to their children.

HIV transmission is most likely to occur during the first few months after infection, yet few cases are identified during this period. Using a population-based cohort of young Malawian women, we identify the distinct symptomology and health-seeking behavior marking early HIV infection by comparing it with periods of seronegativity and chronic infection. During early HIV infection, women are more likely to report malaria-like symptoms and visit clinics for malaria care. In malaria-endemic contexts, where acute HIV symptoms are commonly mistaken for malaria, early diagnostic HIV testing and counseling should be integrated into health care settings where people commonly seek treatment for malaria.

Male involvement in maternal and child health has been promoted since the 1994 International Conference on Population and Development in Cairo. Literature from high-resource settings demonstrates the benefits of involving males in maternal and child health including improvement in maternal mental health, increased assistance from partners and reduced stay in hospital; however, little is known about the situation in low-income countries. This paper aims to provide a descriptive review of qualitative studies on experiences of men who supported their partners during labour and birth in low-resource settings. Themes identified from the literature include: unpreparedness, pleasant but frightening experience, loss of interest in wife and lack of privacy. Further good quality studies should be performed in addition to the need for adequate preparation of men for involvement during labour and birth.

Malawi has a high total fertility rate of 5.7 per woman and Jadelle implant may be an ideal option for couples who want to practice family planning. Jadelle is a long term contraceptive which is inserted just under the skin of a woman’s upper, inner arm by a nurse or midwife and prevents a woman from getting pregnant for a period of five years. But the use of Jadelle for family planning depends on perceptions of couples. The purpose of this study was to explore the perceptions of couples who choose Jadelle as their family planning method at a Central Hospital in Blantyre district. This study used a descriptive qualitative design. A purposive sample of 5 couples was used. Ethical clearance was granted by relevant authorities. Data was analysed through content analysis. The findings showed that the following nine themes emerged from the qualitative data: 1) men and women perspectives about mode of action of Jadelle; 2) knowledge about effectiveness and efficacy of Jadelle among men and women; 3) sources of information about Jadelle; 4) information given to Jadelle users by providers; 5) benefits of Jadelle; 6) challenges associated with Jadelle; 7) myths associated with Jadelle; 8) attitudes of providers of Jadelle and 9) role played by men regarding use of Jadelle. In conclusion, this study found that both men and women generally lacked knowledge of Jadelle. Men play a vital role when couples are choosing contraceptives. Every opportunity should be utilised at antenatal, postnatal and family planning clinics to teach individuals about family planning. This may allow women and men to make informed choices about the use of Jadelle.

Background In Malawi, abortion is legal only if performed to save a woman’s life; other attempts to procure an abortion are punishable by 7–14 years imprisonment. Most induced abortions in Malawi are performed under unsafe conditions, contributing to Malawi’s high maternal mortality ratio. Malawians are currently debating whether to provide additional exceptions under which an abortion may be legally obtained. An estimated 67,300 induced abortions occurred in Malawi in 2009 (equivalent to 23 abortions per 1,000 women aged 15–44), but changes since 2009, including dramatic increases in contraceptive prevalence, may have impacted abortion rates. Methods We conducted a nationally representative survey of health facilities to estimate the number of cases of post-abortion care, as well as a survey of knowledgeable informants to estimate the probability of needing and obtaining post-abortion care following induced abortion. These data were combined with national population and fertility data to determine current estimates of induced abortion and unintended pregnancy in Malawi using the Abortion Incidence Complications Methodology. Results We estimate that approximately 141,044 (95% CI: 121,161–160,928) induced abortions occurred in Malawi in 2015, translating to a national rate of 38 abortions per 1,000 women aged 15–49 (95% CI: 32 to 43); which varied by geographical zone (range: 28–61). We estimate that 53% of pregnancies in Malawi are unintended, and that 30% of unintended pregnancies end in abortion. Given the challenges of estimating induced abortion, and the assumptions required for calculation, results should be viewed as approximate estimates, rather than exact measures. Conclusions The estimated abortion rate in 2015 is higher than in 2009 (potentially due to methodological differences), but similar to recent estimates from nearby countries including Tanzania (36), Uganda (39), and regional estimates in Eastern and Southern Africa (34–35). Over half of pregnancies in Malawi are unintended. Our findings should inform ongoing efforts to reduce maternal morbidity and mortality and to improve public health in Malawi.

Population health needs in developing countries are great and countries are scaling up health professional education to meet these needs. Marginalized populations, in particular, are vulnerable to poor health and health care. This paper presents a culturally appropriate diversity training program delivered to Global Health Fellows who are educators and leaders in health professions in Malawi and Zambia. The purpose of this interprofessional education experience was to promote culturally competent and humble care for marginalized populations.

This study examined factors that determine utilization of postpartum family planning services at Ntchisi District Hospital in Malawi. The study design was descriptive and utilized quantitative methods of data collection and analysis. A random sample of 383 postpartum women was interviewed using a structured questionnaire. Data were analysed using SPSS version 16.0. Chi-square tests were used to establish relationships between utilization of Post Partum Family Planning services and demographic variables. Knowledge about family planning services was almost universal at 94.3% among the women. About 75% of the women were using the contraceptives within the first year after delivery however they started taking the contraceptives after they had already resumed sex. There was a significant association (P < 0.05) between utilization of post partum family planning services and the following: clarity of family planning information given, level of education, period for resuming sex, husband’s approval of family planning method, counselling on fertility intention, duration of lactation amenorrhoea, maternal age and parity. There is therefore a need to promote these factors to increase uptake of postpartum services.

This study explored beliefs and actual practices of young women on utilization of Prevention of Mother to Child Transmission (PMTCT) of HIV services in Balaka district of Southern Malawi. The study design wascross sectional which utilized qualitative data collection and analysis methods. In-depth interviews were conducted on 12 young mothers of 15 to 24 years old. The respondents were drawn from 6 health centres in the district during their visits to either the under-five clinic, HIV and AIDS support groups or HIV follow up clinics. Data were analyzed using thematic analysis approach. Overall the respondents had positive beliefs on utilization of PMTCT services. They believed that adherence to PMTCT guidelines such as condom use, taking of Nevirapine (NVP) and exclusive breastfeeding protected the baby from contracting the virus. Nevertheless, all respondents believed that HIV testing was mandatory and that early weaning caused malnutrition and death of babies. Actual practice was very low. Very few young mothers breastfed exclusively, weaned their babies abruptly and took NVP as recommended. Not all positive beliefs translated into positive behavior. Lack of male support, inability of the midwives to provide comprehensive care to HIV infected mothers and their infants, and fear of stigma and discrimination were other factors that hindered utilization of PMTCT services. Culture was also a major barrier because traditionally babies are expected to be breastfed and supplements are fed to babies too. Therefore, there is a need to mobilize communities on PMTCT of HIV. Education programmes in HIV should emphasize behavior change interventions and should focus on both men and women and significant others. There is also need to intensify monitoring and evaluation of health workers’ activities to ensure that beliefs translate into positive behavior.

This study was conducted to assess quality of postnatal care that midwives provide to women seeking postnatal services in health facilities in Dedza district, the central region ofMalawi. The study design was descriptive cross sectional and utilized quantitative data collection and analysis method to determine structural, process and outcome components of postnatal care in two facilities that offer emergency obstetric and neonatal care and five that offer basic emergency obstetric and neonatal care. All 60 midwives who were providing postnatal care during the time of study in the district were interviewed using a structured questionnaire. In addition, the midwives actual practice was observed and compared to a standard checklist on postnatal care practice which was developed by the Malawi Ministry of Health. Data were analyzed using SPSS version 16.0. Results show that structure for providing postnatal counseling services was inappropriate and inadequate. Furthermore, the contents of postnatal services were below reproductive health standards because the clients were neither monitored nor examined physically on discharge. On average, all the seven facilities scored 48% on postnatal services rendered which is far below the recommended 80% according to the Reproductive Health Standards. There is a need to provide basic infrastructure in all the basic emergency obstetric and neonatal care facilities. In addition, refresher training courses for midwives in maternal and neonatal health with emphasis on postnatal care are recommended. There is also a need to restructure the maternal and neonatal health departments in the facilities so that the postnatal care units become stand-alone priority sites to improve the quality of the postnatal care services rendered.

Background Malawi continues to experience critical shortages of key health technical cadres that can adequately respond to Malawi’s disease burden. Difficult working conditions contribute to low morale and frustration among health care workers. We aimed to understand how obstetric care staff perceive their working relationships with managers. Methods A qualitative exploratory study was conducted in health facilities in Malawi between October and December 2008. Critical Incident Analysis interviews were done in government district hospitals, faith-based health facilities, and a sample of health centres’ providing emergency obstetric care. A total of 84 service providers were interviewed. Data were analyzed using NVivo 8 software. Results Poor leadership styles affected working relationships between obstetric care staff and their managers. Main concerns were managers’ lack of support for staff welfare and staff performance, lack of mentorship for new staff and junior colleagues, as well as inadequate supportive supervision. All this led to frustrations, diminished motivation, lack of interest in their job and withdrawal from work, including staff seriously considering leaving their post. Conclusions Positive working relationships between obstetric care staff and their managers are essential for promoting staff motivation and positive work performance. However, this study revealed that staff were demotivated and undermined by transactional leadership styles and behavior, evidenced by management by exception and lack of feedback or recognition. A shift to transformational leadership in nurse-manager relationships is essential to establish good working relationships with staff. Improved providers’ job satisfaction and staff retentionare crucial to the provision of high quality care and will also ensure efficiency in health care delivery in Malawi. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1694-x) contains supplementary material, which is available to authorized users.

PURPOSE:To determine knowledge and practices of young women on utilization of prevention of mother-to-child transmission (PMTCT) of HIVservices.DESIGN:A cross-section descriptive study that used quantitative and qualitative data analysis methodologies.FINDINGS:Knowledge of PMTCT of HIV among respondents was universal. All respondents (100%,N= 184) stated that utilization of PMTCT services reduces transmission of HIV from mother to child. Respondents knew that HIV transmission can be reduced with exclusive breastfeeding (93%,n= 172), abrupt weaning at 6 months (44%,n= 81), taking single-dose nevirapine (SD-NVP; 43%,n= 79), and giving NVP to the baby (65%,n= 120). Very few respondents (4%,n= 7) stated that avoiding pregnancy is one way of preventing HIV transmission and that a mother who is HIV positive who has received SD-NVP or antiretroviral (ARV) therapy can still deliver a baby who is HIV positive. Actual practice was very low; only 14% breastfed exclusively and only 3% weaned their babies abruptly. Although all the 184 mothers were given NVP to take at onset of labor, very few respondents (22%) took NVP as recommended. Although it was recommended that all babies take NVP at birth and within 72 hr of birth, only 58% of the babies received NVP as recommended and only 3% of the women avoided pregnancy.CONCLUSION:There was a big discrepancy between knowledge and practice of PMTCT services. Culture was the major barrier because traditionally, babies are expected to be breastfed and supplements are fed to babies, too. Most mothers did not adhere to the taking of NVP at onset of labor. Therefore, there is a need to mobilize communities on PMTCT of HIV. The HIV education programmes should emphasize behavior-change interventions and should focus on both men and women, their partners, and significant others. There is also need to intensify monitoring and evaluation of health workers’ activities to ensure that knowledge is put into practice.

This study aimed to determine the factors that influence the use of prevention of mother to child transmission of HIV (PMTCT) services among young HIV-positive adults in the Balaka district of Malawi. A questionnaire was given to 184 HIV-positive young mothers aged 15–24 years who met the inclusion criteria and who consented to the study. The participants were selected from six health centres in the Balaka district during their visits to the under 5 clinic, HIV and AIDS support groups and HIV follow up clinic. Results showed that the participants’ knowledge of mandatory HIV testing, stigma and discrimination, and poverty influenced their use of PMTCT services. There is a need to mobilise the communities to promote PMTCT awareness and reduce stigma and discrimination towards HIV-positive mothers. Monitoring and evaluation activities and in-service education for health workers is also recommended to promote utilisation of PMTCT services in the district.

Cervical cancer is a curable disease if diagnosed early. However, many women in Malawi seek treatment when the disease has reached inoperable stage. This study was conducted to explore factors that contribute to delay in seeking early diagnosis and treatment of cervical cancer among women in Malawi. The study was exploratory and utilized qualitative data collection and analysis method. In-depth interviews were conducted using a semi-structured interview guide on a purposive sample of 24 women who were diagnosed of cervical cancer at the gynaecological wards of Zomba and Queen Elizabeth Central Hospitals in Malawi between July and September, 2011. Thematic content analysis was used to analyze the qualitative data. Two major themes (individual and health facility) emerged from the participants’ narratives as factors that contributed to their delay in seeking early diagnosis and treatment. The individual factors included; limited knowledge on symptoms and signs and limited financial resources. The health facilities factors included; limited accessibility and unavailability of cancer screening facilities in the health centres. Results show that there is a need to strengthen the screening of cervical cancer among women in the country. In addition, there is a need to create community awareness on the signs and symptoms of cervical cancer and the merits of seeking early diagnosis and treatment.

This report describes the effects of a peer-group intervention on Malawian urban hospital workers’ HIV-related personal knowledge, attitudes, and behaviors. More than 850 clinical and nonclinical hospital workers received the intervention. Evaluation used independent surveys of a sample of workers at baseline (N = 366) and postintervention (N = 561). Compared with the baseline survey, after the intervention, workers had higher knowledge of HIV transmission and prevention; more positive attitudes including more hope, less stigmatization of persons with HIV, more positive attitudes toward HIV testing and condom use, and higher self-efficacy for practicing safer sex and for community prevention; more reported recent personal HIV tests, more discussion of safer sex with partners, and more reported community HIV prevention activities. However, health workers’ risky sexual behaviors did not differ at baseline and postintervention. The intervention should be strengthened to support more sexual risk reduction and be made available to all health workers in Malawi.

Objectives Zimbabwe has started to scale up Option B+ for the prevention of mother-to-child transmission of HIV, but there is little published information about uptake or retention in care. This study determined the number and proportion of pregnant and lactating women in rural districts diagnosed with HIV infection and started on Option B+ along with six-month antiretroviral treatment (ART) outcomes. Methods This was a retrospective record review of women presenting to antenatal care or maternal and child health services at 34 health facilities in Chikomba and Gutu rural districts, Zimbabwe, between January and March 2014. Results A total of 2728 women presented to care of whom 2598 were eligible for HIV testing: 76% presented to antenatal care, 20% during labour and delivery and 4% while breastfeeding. Of 2097 (81%) HIV-tested women, 7% were HIV positive. Lower HIV testing uptake was found with increasing parity, late presentation to antenatal care, health centre attendance and in women tested during labour. Ninety-one per cent of the HIV-positive women were started on Option B+. Six-month ART retention in care, including transfers, was 83%. Loss to follow-up was the main cause of attrition. Increasing age and gravida status ≥2 were associated with higher six-month attrition. Conclusion The uptake of HIV testing and Option B+ is high in women attending antenatal and post-natal clinics in rural Zimbabwe, suggesting that the strategy is feasible for national scale-up in the country.

Introduction Male involvement (MI) is vital for the uptake of Prevention of Mother to Child Transmission (PMTCT) of Human Immunodeficiency Virus (HIV) interventions. Partner notification (PN) is among the strategies identified for MI in PMTCT services. The purpose of this randomized controlled trial was to evaluate the efficacy of an invitation card to the male partners as a strategy for MI in PMTCT services by comparing the proportion of pregnant women that were accompanied by their partners between the intervention and the non-intervention study groups. Methods Pregnant women attending antenatal care without a male partner at South Lunzu and Mpemba health centres in Blantyre, Malawi, were enrolled in the study from June to December 2013. In an intention-to-treat analysis, we compared all participants that were randomized in the invitation card group with the standard of care (SoC) group. Risk ratios (RR) with 95% confidence intervals (CI) were computed to assess the efficacy of the invitation card. Results Of the 462 randomized women, 65/230 (28.26%) of the women in the invitation card group reported to the antenatal care clinic with their partners compared to 44/232 (18.97%) women in the SoC group. In an unadjusted intention-to-treat analysis women in the invitation card group were 50% more likely to be accompanied by their male partners than those in the SoC group RR: 1.49 (95% CI: 1.06-2.09); p = 0.02. Our random effects analysis showed that there was no clustering by site of recruitment with an inter cluster correlation coefficient (ICC) of 1.98x 10-3, (95% CI: 1.78 x10-7 - 0.96 x 10-1); p =0.403. Conclusion An invitation card significantly increased the proportion of women who were accompanied by their male partners for the PMTCT services. An invitation card is a feasible strategy for MI in PMTCT.

In rural sub-Saharan Africa, most care for patients with AIDS is provided at home by relatives. Caring for those with AIDS is assumed to be a substantial burden, but little is known from the perspectives of those who provide the care. In this paper we use interviews with caregivers, supplemented with survey data from a larger study in rural Malawi, to investigate this issue. We focus on the caregivers' diagnoses of the illness of their patients, the type and duration of the care they provided, the support they received from relatives and other members of the community, and the extent to which caregiving was experienced as an emotional, physical, and financial burden. Although none of the caregivers knew of a formal diagnosis and few explicitly named their relative's disease as AIDS, most appeared to suspect it. They described the illness using the typical symptoms of AIDS as they are locally understood and sometimes related the illness to their patient's sexual history. The care, typically given by close female relatives of the patient, was limited to the care that would be given to anyone who was seriously ill. What was striking, however, was the compassion of the caregivers and the attempts they made to provide the best care possible in their circumstances. For most caregivers, kin and members of the community provided social, moral, and physical support, as well as modest financial assistance. Caregiving was physically and emotionally demanding and confined the caregivers to their home, but most caregivers did not consider caregiving a problem primarily because the patients were close relatives. The financial impact of caregiving was typically modest because the caregivers had very little income and few possessions to sell.