In the last couple of posts, I’ve written about clinical decision making and the way that physicians at Queens make day to day decisions about individual patient care. That’s something that I’ve noticed during the time I’ve spent in the wards, but in the CPAP office, I’ve also noticed how increasing availability of information leads to better ideas and outcomes for programs like the CPAP implementation project.

Last week, Tanya and I spent a lot of time in Chatinkha Nursery, the equivalent to the neonatal intensive care unit, working on a project to create a system of identifying jaundiced babies. While we were there, Florence, one of the CPAP nurses that has been with the project since 2012 when it began, mentioned that she had been thinking more about the CPAP Coordinator Meeting which she had attended with us as a CPAP mentor.

Since the CPAP project is based out of Queens, the hospital doesn’t have an official coordinator position, but most people would agree that Florence is the unofficial coordinator here. She had wanted to present the Chatinkha CPAP data at the meeting, but she didn’t currently have a way of compiling her data in a simple, straightforward way. So with that information in mind, I’ve been working on creating an Excel template for her where she can input patient totals by diagnoses and outcomes to automatically generate survival rates and trend graphs looking at several aspects of CPAP care.

Each month, inputting the totals from her handwritten log book will take her between 5-10 minutes, and the monthly summary will give her a graphical representation of how Chatinkha is performing when it comes to CPAP and oxygen patients. In addition, at the end of the year, the template takes the numbers from each month and generates a yearly report to show trends across a longer block of time. The summaries are geared towards giving Florence and other coordinators the information with which to critically evaluate their nursery’s CPAP performance and make changes or continue successful practices accordingly.

As Alfred and Norman repeatedly stressed at the Coordinator Meeting, data is a powerful tool for advocates of neonatal care. Hopefully, this template can be a sustainable tool for CPAP coordinators to document the strengths and weaknesses of their implementation efforts, not only to identify areas for improvement but to identify which strategies have worked best for bettering patient outcomes in the long term.

As I mentioned in my previous post, there are two major types of information gaps that doctors here face during clinical decision making. I already wrote about the lack of reliable patient histories, but lack of diagnostic and monitoring technologies also places a significant burden on doctors and nurses at Queens.

To use another example from the maternity ward, Tanya and I were observing in the High Dependency Unit (HDU), which is essentially the equivalent to the maternity ward’s intensive care unit. There was a woman on the ward who had been in the hospital for 15 days post-delivery, and she was so ill that she was unable to consume food without a feeding tube. She had been having this issue for the duration of her stay, so even though her vitals had stabilized, she was still lethargic and unable to continue improving and gaining strength.

There happened to be a British doctor visiting the ward that day who brought a small creatinine and lactate measuring device with him, so clinicians were able to actually quantify how severely malnourished she had become. With this new knowledge, they realized the urgency of developing and following a new treatment plan that included removing her feeding tube and transitioning her back to solid, more nutrient rich foods within 12-24 hours. However, this entire decision was spurred by using this expensive monitoring device brought in for a two week stay with the British physician. With the device, it was easy to see what the next logical treatment step was for this woman, and they could also monitor her creatinine and lactate levels every 4-6 hours to evaluate whether or not the treatment was working. Without the device, the process would look a lot more like a guess and check method, and the severity of the condition could have been discovered much later in the process.

In a way, situations like this one require Malawian physicians to have an incredibly adept ability to analyze what little information they have at their fingertips to make the best decision for their patient, but it also places significantly more mental and emotional burdens on them. For example, while the Malawian doctors were excited and grateful that they had the chance to use this monitoring device to better understand how to care for their patient, there is of course an element of frustration in knowing that when the visiting physician leaves, the device leaves as well. It’s difficult to continually have these experiences with high-tech, expensive devices that are incredibly helpful but also incredibly out of reach for Malawi’s current healthcare system.

This is just one area where the need for low-cost, well-designed diagnostic and monitoring technology becomes so clearly apparent. While Malawian doctors do the best they can with limited resources, seeing these instances is a constant reminder that there is still a long way to go in medical technology development, and it is important to keep low-resource settings at the forefront of our minds as so many great advances are made in medicine.

Throughout our time in the maternity ward and in the Pediatric Department morning meetings, one issue that often arises is the lack of information doctors have for clinical decision making. This lack of information comes in two forms: first, doctors often don’t have a reliable patient history with which to make a diagnosis, and second, the wards lack access to technologies like glucometers or ultrasounds to feel completely confident in treatment choices and monitoring. While patient care always involves a degree of uncertainty, Western doctors are lucky in the sense that they have so much information at their fingertips.

However, these two types of information gaps represent fairly different needs. A lack of well-recorded patient history demonstrates a need for a public health related intervention at the local level, while a lack of diagnostic and monitoring equipment demonstrates a need for accessible, low-cost technologies that can be sustainably manufactured, purchased, and maintained.

For example, while we were working in the maternity ward with Dr. Kommwa on pre-eclampsia observations, he pointed out the need for stronger antenatal care programs in the communities. Each mother in the Labor and Delivery ward comes into Queens with her Health Passport, the equivalent to her medical chart or electronic medical record in the U.S. Patients keep these passports with them from birth to track anything from vaccines to major medical procedures. In theory, this is a great tracking system, but looking at the passports also reveals major gaps in availability of preventative monitoring and treatment, particularly during pregnancy. In this instance, Dr. Kommwa showed us each patient’s antenatal care page, and a mother with more than two antenatal visits was extremely unusual. Compare this number to expectant mothers in the U.S. who see their obstetrician every 3-4 weeks during pregnancy, and you already begin to see the potential for much higher numbers of high-risk pregnancies going unmonitored. In the case of pre-eclamptics, blood-pressure monitoring is critical for reducing risk to both mother and baby. Early identification of the condition can drastically improve outcomes, but without consistent antenatal care, it’s impossible to know who needs treatment and to what extent until they arrive at Queens already in labor.

In addition, a lack of patient history also complicates things like the decision to induce. Oftentimes, the estimation for gestational age of the baby can be off by almost 3-4 weeks. To know gestational age, you must know the date of the mother’s last menstrual period, but again, this information can be pretty tough to recall 8-9 months after the fact. Without having a recording of this date, memory is the next best option. As you can imagine, doctors would make different decisions on how to treat a 35 week mother as compared to a 39 week mother, particularly when deciding whether or not to induce. Something as simple as an accurate gestational age estimate would have a significant impact on how doctors in the Labor and Delivery ward make decisions.

Health Passports are an incredibly useful and well-designed method for tracking individual patient data, but in order to reach their full potential, the passports must actually have a chance to be used. The gaps in passport usage reveal upstream factors at play that public health interventions such as community-level antenatal care could address. Not only would these types of programs provide better care and lead to safer pregnancies for mothers, but they would have the double effect of improving labor and delivery by providing physicians with a more complete understanding of the patient upon arrival at the hospital.

These are just some of the many examples of the ways that lack of patient information affects diagnosis, and I’ll discuss the second type of information gap in treatment choices and monitoring in my next blog.

Last week was full of travel! On Wednesday, we had the opportunity to head to Lilongwe for the annual CPAP Coordinator Peer Review Meeting where each of the twenty-eight hospital coordinators come together to present their hospital’s previous year of data collection, CPAP successes and challenges, and action plans for the coming year. This meeting was a great chance for us to see yet another side of program planning and implementation: How can we assess success and failure in a way that leads to progress and sustainable planning for the future use of CPAP in Malawi?

We were able to see a lot of motivated coordinators, but the major challenges that each of them face will require hard work in the coming year. Despite regular trainings for hospital staff, CPAP coordinators struggle to keep trained nurses in the maternity and neonatal wards due to frequent staff rotations by management. A lack of trained staff on the wards then leads to a lack of confidence in putting patients on CPAP, so patients put on CPAP steadily decline as trained nurses rotate out. Keeping trained staff available requires strong advocacy and lobbying by hospital coordinators as they work with management to prioritize improving neonatal care.

Several hospitals also struggled to collect ample amounts of data due to already short-staffed nurseries, and the 4-hour monitoring requirements for patients on CPAP increase workload on the already overwhelmed nurses. In some cases, hospital coordinators reported having as many as 70 babies in a nursery staffed by just a single nurse. In a project where data is one of the most powerful tools for proving CPAP’s effectiveness, it becomes critical to understand the barriers to collecting and recording that data. In this sense, the meeting was incredibly helpful, as it allowed a forum for coordinators to come together to see how other districts were performing, which data collection strategies were showing success, and discuss ideas for further improvement. The exchange of ideas and enthusiasm was exciting to watch as each hospital drafted an action plan for the next three months at the end of the meeting.

The peer-review style of discussion was a great way to increase both enthusiasm and accountability for each hospital coordinator. By presenting his or her hospital’s progress to the group, each coordinator was able to critically evaluate his or her work and identify areas of success as well as areas of improvement. There were also nine coordinators from Phase III hospitals in attendance, and Phase III hospitals are gearing up for CPAP installation in August. This meeting gave them a chance to learn from their Phase I and Phase II colleagues on how to mitigate challenges from the outset, and the meeting fostered discussion between these newer CPAP hospitals and hospitals that have been operating with CPAP for some time now. The energy from the Phase III coordinators also added a unique element to the meeting, and it will be exciting to see how their implementation plans move forward in August upon installation!

Spotty access to wifi has actually turned into one of the best things about our time at home in the evenings. It’s given all of us more time to reflect on and discuss our experiences from the day, and we’re also able to get tons of great reading in. One of the books we’ve been passing around is The Bright Continent: Breaking Rules and Making Change in Modern Africa by Dayo Olopade, and it has given me an entirely new insight into how countries in Africa have been creating innovative market opportunities and economic growth in recent decades. It also delves into the dynamics of aid-based economics and the way that this approach can often be detrimental to the homegrown businesses and markets that are already in place.

One of Olopade’s main focuses in the book comes from the concept of kanju, the creative solutions that are common in resource-limited settings across many African countries. Tanya wrote a great blog on the kanju and several of the examples we’ve already seen of it here at Queens and in Blantyre, so definitely check out her post here to get a better idea of it!

The most interesting example I’ve seen of kanju, however, was during the maternal mortality meeting that I also spoke about in my last post. Hypothermia is always a huge concern for infants, and in delivery conditions that are not thermally regulated, helping babies maintain body temperature is a challenge that begins immediately after birth. While a technology design could theoretically fill this need, the amount of time that it would take to move from design through testing and development could span any number of years. In the meantime, however, babies still need help thermoregulating, and doctors and nurses are continually looking for interim solutions. A 2012 study at a South African hospital showed significantly improved outcomes for babies swaddled in a plastic bag after birth, and these babies had reduced incidence of complications from hypothermia. A single plastic bag at a grocery store costs 35MKW on average (~0.09 USD), and in bulk, that cost would likely shrink even further. The bags are an example of a readily available, low-cost resource that clinicians and nurses at Queens are able to use without having to wait for a technology to fill the existing gap.

This is just one example of how the hospital staff continually identifies creative, practical solutions to the challenges they face every day, and I’m interested to see how they begin to implement the idea in the delivery suite here and track its progress before next month’s meeting.

Once a month, clinicians from Pediatrics and Maternity come together to discuss both specific cases and general coordinated care between the two wards. Maternal and child health are intricately linked, and the more communication and collaboration that occurs between these two departments, the better the outcomes for both mother and child. Tanya, Sarah and I were able to attend this monthly maternal mortality meeting, and one of the central discussions involved making the decision whether or not to induce labor in high risk pregnancies.

Worldwide, rates of cesarean section births usually hover around 15%. However, at Queens, 29% of births were performed by C-section in 2014. This unusually high rate of C-section births points to two major concerns that guided the discussion – first, why are so many C-sections necessary at Queens, and second, how does this influx impact long-term maternal and child outcomes here?

On any given day, the delivery suite at Queens ebbs and flows between the calm of just two or three mothers in labor to the chaos of sixteen or seventeen (more than half of whom are likely high-risk deliveries). Especially for pre-eclamptics or younger mothers whose hips have not developed fully, C-sections offer immediate intervention when fetal distress puts both mother and baby at risk. Queens sees incredibly high numbers of these types of cases, and one theory that came up during the meeting was the fact that prenatal care in district health clinics rarely provides adequate preventative monitoring for mothers due to both personnel and equipment constraints. Oftentimes, expectant mothers don’t seek prenatal care due to the time it takes to travel to the clinic and wait to be seen- a significant economic productivity drain for a population that can hardly afford it. This lack of prenatal preventative care could therefore be a major cause of high numbers of deliveries requiring C-section interventions at Queens.

As for the second question, it’s difficult to tell how significant of an impact that these interventions have on maternal and child health outcomes due to a lack of long-term data on the topic at Queens. Surgical operations alone increase risk of infection and sepsis for the mother as she heals post-operatively at the hospital and in the following weeks at home. As mothers recover from the procedure, any complications she experiences can make kangaroo mother care (helping with infant thermoregulation) or breastfeeding difficult. So from birth, babies born by C-section are already potentially at a disadvantage.

But perhaps one of the most interesting threads of conversation on the topic came from the decision on whether to induce labor, perform a C-section, or postpone intervention. At this point, several of the expatriate physicians brought up the fact that the mother rarely, if ever, actually gets to participate in this discussion. Growing up in the American healthcare system, I’ve experienced physician-patient interaction where information exchange and patient agency in decision making are held as central components of treatment plans; however, in what I’ve observed, the doctor-patient relationship at Queens takes on a different focus. Patients almost always default to the physician’s first decision on all treatment plans without requesting that doctors take the time to explain and discuss different options. This difference has been a striking example of how medicine is rarely as culturally neutral as it appears, and the debate on whether patient preference should factor into clinical decisions shows how the exchange of ideas and standards from expatriate doctors has influenced Malawian physicians’ opinions on what the practice of medicine should look like.

For me, informing patients on the risks and benefits of various options and providing patients with a choice seems like the natural course, but this discussion also helped me recognize that my opinion is very much a result of the healthcare system in which I’ve been raised. For a Malawian mother in labor, her preferences for her doctor-patient relationship could be drastically different. For someone used to a system where physicians make most treatment decisions with little patient input, a sudden discussion about her options could indicate to her that the doctor doesn’t feel confident in making a choice; it would be foolish of me to assume that she would want the same experience as me without involving her in the conversation. So while I think that the idea of patient agency in decision making sounds like an exciting discussion for physicians to be having, it also points me back to the importance of conversations with the patients themselves when shifting the concept of the ideal doctor-patient relationship. Regardless of technological advances or cultural exchange of ideas, medicine at its core will always focus on treating and healing the patient, and patient-centered care requires a careful understanding of the specific patient population itself to best treat and heal.

As I briefly mentioned in my post about the Poly interns, we were excited to meet with the Physical Assets Management (PAM) engineers to better understand their role in the hospital system as well as to see if there was a potential for collaboration between the PAM office and the Poly. In the process, I learned much more about the challenges PAM engineers face on a daily basis as they try to repair and maintain all of the equipment across Queens and 6 surrounding district hospitals.

Walking into PAM is a bit of an overwhelming scene. Outside their warehouse sit 9 or 10 hospital bed frames broken and awaiting repair. Upon entering the building, we were greeted with hundreds of boxes of donated neck collars that the hospital had no space or use for, so they had been sent to PAM for storage indefinitely.

Boxes of 4,000 soft neck collars fill the entryway to PAM. These collars were donated from India in 2011, but PAM was the only spot that had enough space to store them while the hospital tried to identify a use for them.

Suction pumps, ventilators, heat lamps, and autoclaves in need of servicing fill the warehouse shelves, and an army of nonfunctioning oxygen concentrators cover about a fifth of the floor space:

We met with one of the head engineers in the office, and he gave us a tour of the workspace. Since we were with the Poly interns, this tour was incredibly helpful for better understanding the common breaks that PAM sees in the hospital’s most-used equipment.

For example, Queens already runs on a limited supply of suction pumps due to lack of availability, but these machines are also subject to frequent breaks because they lack an alarm system to alert nurses that the container is filled with fluids and must be emptied. The machine then continues to suction, the container overflows, and the fluids flood the motor. For a nurse whose attention must be split across patients and procedures, something as simple as an audible alert when the container is reaching its capacity could be the difference that avoids the machine needing 2-month repair stint at PAM. In addition, a shut-off mechanism could provide a fail-safe in case the nurse is unable to attend to the overfilled container in time. These types of design ideas gave the Poly interns great material with which to start a design project that would fill a real-world need at Queens, not only helping clinicians get more out of their machines, but also reducing some of the repair load that falls on PAM.

Francis, Christina, and Sarah look on as Joseph explains how radiant warmers in the nursery use temperature to regulate a baby’s body temperature. If the probe malfunctions and misreads ambient temperature, the warmer can under or overheat the infant. 

In an ideal world, PAM would be able to perform quarterly checks on all hospital equipment both at Queens and at the 6 district hospitals it services. However, these checks would take 4-5 staff members about 3-4 days per hospital, per quarter. In terms of funding and staff availability, these standards are oftentimes impossible, so the challenge then becomes how to get the most out of preventative maintenance by the in-hospital maintenance departments.

Another approach could be more useful instruction for clinicians and nurses on day-to-day care for the machines. While engineers must have an in-depth knowledge of a technology, the user requires a much more basic understanding of key points to extend viability and proper functioning of a device. For example, understanding that running an autoclave (used to sterilize surgical or other procedural equipment between patients) without water covering the heating element can permanently ruin the heating element is one instance where user knowledge prolongs the lifetime of a machine and keeps PAM from having to perform a costly, time-intensive repair.

An autoclave with a damaged heating element sits in PAM for the foreseeable future until they are able to acquire a replacement element from the procurement office.

So while the procurement of repair parts and availability of trained engineers present very real constraints for PAM, having an understanding of the upstream causes of machine breakdown can provide options that in the long run can work within these limitations to increase PAM’s ability to serve Queens and its surrounding district hospitals.

These past few weeks have definitely given me a greater appreciation for the importance of project implementation and management, especially in the context of the CPAP Study. This week in particular, we had three different CPAP trainings going on. We had one for graduate students at the Kamuzu College of Nursing, one for district hospital coordinators hosted here at Queens, and one for nurses during a CPAP installation visit at Thyolo District Hospital.

Here’s a brief overview of what a training looks like:

• Introduction to CPAP as a treatment option
• Explanation of conditions appropriate for CPAP treatment
• Description and outcomes of the pilot study at Queens
• An explanation of assembly and cleaning of the machine
• Instruction on how to place a baby on CPAP
• Instructions on monitoring care, tracking progress, and weaning babies from CPAP when treatment is complete
• Explanation of the current study procedures and data that should be obtained during treatment
• Suggestions for talking to mothers about the benefits of CPAP treatment

The training itself is a mix of classroom instruction and observational periods on the wards, and the classroom portion combines presentations and videos with practical, hands-on experience with the CPAP machine.

Tanya and I helped prepare the training for district hospital coordinators here at Queens, and we had seven participants from five different hospitals attending. The hospitals included Machinga District Hospital, Thyolo District Hospital, Chiradzulu District Hospital, and Mulange District Hospital, marked on the map below:

District hospital coordinators are critical to effective CPAP implementation. District hospitals are much smaller than central hospitals like Queens, so oftentimes these hospitals are even more short-staffed and pressed for resources. By training coordinators, each hospital then has its own CPAP expert to be able to conduct further staff and clinician training when they return home to their district. All of the coordinators were engaged in the material, and it was neat to see how the simplicity of the bCPAP design makes it an approachable and exciting machine to learn about and train with.

Hospital coordinators during the instructional and practical training sessions.

However, no matter how simple or intuitive a design, this training also showed me that no machine can be successful without a full-force effort from a wide range of community members, nurses, clinicians, and policymakers. The amount of resources that go into planning, executing, and evaluating training shows that the quality of these trainings have been fundamental to the CPAP’s success thus far. The enthusiasm and effectiveness of the facilitator, pediatrician, and nurse running the program today were a powerful reminder that improving outcomes for patients comes from the dedicated professionals who commit to constant development and educational opportunities as much as it comes from the technology innovation itself.

Nurse Florence and Dr. Mzikamanda look on as trainers demonstrate how to select the appropriately sized tubing for infants on CPAP.

One of the really neat things about this internship actually comes from Sarah, Emily, and Catherine’s internship at the Polytechnic University of Malawi(affectionately known as the Poly), which is right next door to the hospital. The Poly is starting a biomedical engineering program in the fall, and Sarah, Emily, and Catherine are collaborating with current faculty and students there this summer to work on ideas for design project ideas and prototyping frameworks for the new curriculum. (Check out their blogs linked above if you’re interested in more of their day-to-day work!)

It’s been great working in Queens and getting to know the staff members, nurses, and clinicians here, but the collaboration with the Poly gives all five of us from Rice a unique chance to better understand and experience Malawi from the perspective of college-aged students living in Blantyre. Christina, Andrew, Charles, and Francis are all rising fifth-year engineering students in mechanical and electrical engineering. This opportunity for cultural exchange has been so helpful for learning more about Malawian life on several levels.

Last week, we had them all over to our house to do an American-Malawian exchange meal, and the menu was quite extensive! On the Malawian side, it included nsima, the staple starch here; a mixed vegetable dish of fresh tomatoes and rape greens; green beans cooked with carrots and tomatoes; and of course, Nali, a Malawian hot sauce also known as “Africa’s hottest peri-peri sauce”. On the American side, it included peanut-butter (and/or Nutella) banana pancakes with baked apples and cinnamon. We might have been a bit ambitious on the amount of dishes, but between the nine of us, there wasn’t much left at the end of the night!

But the exchange goes much further beyond just a meal shared here or there- the exchange of ideas and engineering expertise has been incredibly fruitful as well. For example, Tanya and I prepared the Incubaby project prior to leaving Houston, but our electronic components weren’t performing the way we wanted them to by the time we departed. However, after just one afternoon at the Poly, Christina, Andrew, Charles, Francis, and Sarah were able to make great progress with the troubleshooting. And not only did they have great technical expertise in helping us with the electronic components, but they had thoughtful feedback on how realistic the design and materials would be for use in Malawian hospitals.

Perhaps what is most exciting about the energy and enthusiasm of the Poly students is the potential for a longer-term collaboration with Queens in which students can contribute their engineering experience to hospital technology development and maintenance while gaining valuable practical experience outside of the classroom. There is a department at Queens called Physical Assets Management (PAM) that deals with repairing and maintaining all hospital equipment at Queens and at 6 surrounding district hospitals. The nine of us actually have a meeting set up with PAM later today, so we’re really looking forward to exploring the potential of a more involved PAM-Poly relationship in the near future. I’ll be sure and give an update on how the meeting goes in a later post!

This past week, we were able to spend a good amount of time getting to know our way around the maternity ward and the delivery suite at Queens, and in doing so, I gained a bit more insight into the intricacies of the Malawian healthcare system at large.

The nurse’s station in the Delivery Suite.

One of the technologies in development at Rice, AutoSyP, is preparing to start clinical trials in July. AutoSyP is an infusion pump that can deliver medications to a patient at a constant flow rate over an extended period of time. Infusion pumps not only improve accuracy and consistency of flow but also relieve overworked nurses from having to be available to administer a medication for the entire duration of the treatment.

One of the two infusion pumps currently available in the High Dependency Unit of the Delivery Suite.

In order to prepare the clinical trial protocol, it’s important to understand how nurses currently administer medications that must be delivered to the patient over a specific time period of several minutes or hours. One example of a procedure that fits this description is magnesium sulfate (MgSO4) delivery to pre-eclamptic or eclamptic expectant mothers in the maternity ward. Pre-eclampsia is a characterized by swelling, high blood pressure, and protein in the urine, leading to a high risk of seizures during labor and delivery and placing both mother and child in danger. However, MgSO4 acts to stabilize the mother, and it must be administered constantly from the time the condition is identified to 6 hours after delivery. The goal is therefore to understand how nurses currently manage MgSO4 administration and to create a protocol that integrates as easily as possible into the existing system.

Through these observations and conversations with nurses and physicians, I learned a few things about the Malawian healthcare system in the process:

The reality of a procedure is often different from the textbook description of a procedure. We had read about the two different types of MgSO4 administration techniques, one of which uses an IV drip and one of which uses intramuscular injections, but when we went in to observe the procedure, what we found was a mix of the two techniques. Limited supplies meant 60mL syringes were scarce and infusion pumps were often unavailable. Therefore, while the loading dose was administered by a nurse through an IV (this takes only 10-15 minutes of flow rate control), the maintenance dose had to be administered intramuscularly every four hours. An IV drip of the maintenance dose would have required constant flow control, and without a nurse continuously at the bedside, this control is not possible.

An example of some of the syringes available to nurses.

There are often variations in methods for a procedure across the nursing staff. It is often hard to locate the references for these textbook procedures, and it becomes even harder to locate a protocol when the reality of the treatment is a blend of multiple techniques. There was an official reference on the procedure that was located after about 10 minutes of flipping through a book in the main office of the delivery suite, but there were limited resources for nurses on the floor of the ward itself, so many times the procedure could look significantly different depending on which nurse was administering the treatment.

Policy decisions can sometimes prioritize ease of care over patient comfort. One of the main reasons nurses were using a mix of these two protocols was actually due to something far beyond their control, and one of the obstetricians explained this reason to us. In 2014, Malawi held its first tripartite elections to vote for local government, members of parliament, and the president in one single election. Peter Mutharika won the election over the incumbent Joyce Banda, and this shift in presidential administration was felt across government ministries – particularly the Ministry of Health. Specifically, political affiliations with pharmaceutical companies led to changes in the way that the government procured MgSO4: The concentrations changed from 1g MgSO4 diluted in 2mL to 2g MgSO4 in 10mL. Now, instead of receiving intramuscular injections of 10mL, patients must receive 2.5 times that, 25mL, in order to have a full maintenance dose. Imagine being injected with 25mL of fluid every four hours- that’s a large amount that causes patients extreme discomfort and soreness. However, because it’s easier for the government to procure and intramuscular injections are faster for nurses to administer, it becomes standard of care for MgSO4 administration.

One of the MgSO4 vials used in a maintenance dose. A full maintenance dose would be 2.5 of these vials.

It takes significant time and effort to shift a system towards a new method, but if implemented well, AutoSyP could not only simplify a day to day task for nurses but also lead to more customized, comfortably delivered care for mothers. Observing the system surrounding this aspect of maternity care allowed me to see how both hospital procedures on a micro-level and policy procedures on a macro-level can directly impact patient care. Providing nurses with a viable alternative that integrates into their routine would benefit both parties, so I’m excited to see how AutoSyP is received next month!