Development of Malawi project
～From August 2022～
After in-depth discussions with the Malawian Ministry of Health in August 2022, I visited Malawi in September. The following Malawi project were approved by the Ministry of Health Council on 7 September.
A Myanmar mobile phone-based medical information and consultation system project was also approved.
Background and objective
Malawi has a very high maternal mortality rate. In order to reduce this maternal mortality rate, we are planning to introduce to Malawi the remote maternal abdominal echography system (SPAQ), which has been developed and introduced in the Democratic Republic of the Congo. The project has already been approved by the Council of the Ministry of Health of Malawi on 7 September 2022, as well as receiving a request to commence activities. The full cooperation and support of the Malawi Ministry of Health and the Association of Obstetricians and Gynecologists of Malawi has already been obtained. We signed an MOU with the Government of Malawi through the Malawi Ministry of Health in October 2023. The objective of this project is to develop human resources. It will foster human resources who can independently and self-reliantly operate the remote maternal abdominal echography system within Malawi.
Discussion and approval by the Malawi Ministry of the Health Council on 7 September 2022
Malawi Project as human resource development
Workshop instruction is provided to midwives and abdominal echoes are performed by midwives at each medical facility. If there are problems, medical consultations can be provided with the obstetrician at the centre hospital while sharing the echo screen via mobile phone. The advantage of this system is that one obstetrician can cover a wide area for health check-ups with the help of midwives.
Probes are connected to the mobile phone
Malawi has 0.019 doctors per 1,000 people [1], which is one 126th of Japan's 2.4 doctors per 1,000 people [2] and very few doctors. In Malawi, where the number of doctors is low, this is a very effective system. The probe is connected to a mobile phone, so there is no need for a large machine. The system is portable and can be used for echographic checkups in villages where there are no doctors.
Remote maternal abdominal echography system: SPAQ
The remote maternal abdominal echography system was developed by the innovative company SOIK in the DRC. Digital antenatal check-ups using SPAQ were conducted in seven medical facilities in Kwango Province, DRC, for 1,014 pregnant women over a three-month period from December 2021 to March 2022, with a 99% satisfaction rate among pregnant women, a 74% increase in the number of antenatal check-ups and a 42% increase in medical facility income. In addition, 79 abnormalities were found, including ectopic pregnancy and pre-eclampsia, and 28 pregnant women were saved.
As a result, SOIK has signed a public-private partnership agreement with the DRC Ministry of Health and plans to roll out SPAQ check-ups to 3.6 million pregnant women annually. The project is also positioned as a pilot study for the full-scale introduction of SPAQ in Malawi. First, two primary health facilities and one secondary health facility in the peri-urban area will be selected, which would be located in Lilongwe, the capital city, with the cooperation of the Lilongwe City Health Department. The midwives' training course will last eight days. A total of six midwives, two from each of the three health facilities, will participate in the workshop.
Remote maternal abdominal echography system: SPAQ
1) High maternal mortality rate; 70 times higher than in Japan and 5 times higher than the UN SDGs target
The maternal mortality rate in Japan is 5 per 100,000 [3], whereas the maternal mortality rate in Malawi is 349/100,000 [3], 70 times higher. Incidentally, the Sustainable Development Goals (SDGs) set a target of less than 70/100,000 [4]. Echo-abdominal examinations of pregnant women can detect ectopic pregnancies and other problems at an early stage, and are expected to reduce the maternal mortality rate. Incidentally, the infant mortality rate is also 29 per 1000 live births, 16.1 times higher than the Japanese rate of 1.89 per 1000 live births [5].
This is a case of ectopic pregnancy in a rural area of the DRC that was in practice detected by this system. The patient was urgently referred to the state hospital. If she had not undrgone echo-examination, the pregnant woman would have died due to massive hemorrhage.
2) Difficulty in contacting medical facilities or receiving medical care
In September and October, I visited rural areas in Zambia and the DRC, where it is common for pregnant women to walk several hours just to be examined at a local village clinic (health post: no doctor). 3 hours is normal, and some health posts require a 12-hour walk. In Zambia, it took three hours to walk to a clinic without a doctor, and half a day by public bus to get from the clinic to a state hospital with a doctor, and in some cases the bus only had one service early in the morning. The difficulty in contacting medical facilities is beyond our imagination, partly due to poor road conditions. The system allows nurses/midwives to carry echo kits in their bags and visit clinics without a doctor. Even if midwives/nurses only visit doctorless clinics in the villages once a week to perform abdominal echoes on pregnant women in the area, it would greatly reduce the travelling effort for pregnant women.
DRC : Health posts
It takes several hours by car from the health post to the clinic where the doctor is available.
During the rainy season, the roads are muddy and in poor condition.
Health posts: no doctor present
Pregnant women's abdominal Echography during health post visits
According to the Health Sector Strategic Plan II 2017-2022 issued by the Government of Malawi, in 2016, 90% of the population lived within an 8 km radius of a health facility (i.e. within a two-hour walk; author's note), but in rural and hard-to-reach areas, 56% of women have difficulties in accessing medical care in case of illness due to long distances [6]. Only 24% of all health facilities have functioning ambulances. Vehicle maintenance is poor, especially in remote areas with poor road conditions [7].
Rural Amburance (DRC)
3) Lack of mothers' knowledge of pregnancy
Malawi's adult literacy rate (15 years and above) is 62.14% [8] and mothers' knowledge of pregnancy is inadequate because, as mentioned above, the number of doctors is one 126th of that in Japan. If obstetricians were available, they could prevent maternal deaths by judging from abnormal blood pressure, anaemia and oedema, but ordinary mothers do not have this medical knowledge. If midwives and volunteers in each region are provided with this medical knowledge during the training sessions of this system, and if they are given early check-ups, maternal deaths can be reduced.
Three reasons to introduce the SPAQ system
Cooperation of the Malawi Ministry of Health and the Association of Obstetricians and Gynecologists of Malawi:
The project is described as a pilot study for future introduction into the Malawian Government and has already received the full cooperation of the Malawi Ministry of Health, the Capital Lilongwe Department of Health and the Association of Obstetricians and Gynecologists of Malawi.
1
The selection of designated medical facilities (selection of three medical facilities in the periphery of one city) has also already received the cooperation of the Department of Health in Lilongwe, the capital city.
2
The implementation of medical activities (echography and diagnosis) will be carried out by a team of obstetricians, midwives and nurses in Malawi, and we will not carry out direct medical activities within this project. What we do is develop human resources to operate this system.
【References and reference websites】
1. World Health Organization 2010
2. Organisation for Economic Co-operation and Development Health Statistics 2019
3. World Health Organization 2017
4. United Nations Summit 2015
5. WorldBank.org 2017
6. National Statistical Office (NSO) [Malawi] and ICF.
Malawi Demographic and Health Survey 2015-2016. Zomba, Malawi 2017
7. Service Provision Assessment - MoH 2014e
8. knoema.com 2015