From home births to hospitals: Trends in maternal health in rural central Malawi across economic development intervention and control areas

Background: We are evaluating an economic intervention combining Village Savings and Loan Associations (VSLA) and agricultural training to determine its impact on childbirth practices in Malawi, where maternal mortality is extremely high. Methods: In this five-year, mixed-methods quasi-experimental study, we are examining birth practices and barriers to delivery services in 900 households in rural central Malawi; 600 in the intervention area, 300 in the control area. Baseline and 18 month follow-up surveys were completed. Results: Eighteen months into the intervention, differences in birth practices between the intervention and control areas were not observed, although trends in both indicate movement toward institution-based births. Between baseline and follow-up, intervention households (101 births) and control households (50 births) delivered fewer babies at home (Intervention: 8.8% decrease, p=0.10; Control: 17.5% decrease; p=0.02); only change in control households was significant. Deliveries by traditional birth attendants (TBAs) decreased (Intervention: 10.7% decrease, p=0.03; Control: 9.3% decrease; p=0.26); only change in intervention households was significant. Attended births at health facilities increased significantly in both intervention and control areas (Intervention: 21.6% increase, p=0.001; Control: 26.7% increase; p=0.005). Barriers to service including lack of transportation and cost did not differ significantly between intervention and controls or between baseline and follow-up. Conclusions: Increased births in health facilities in control and intervention areas suggest the trend is independent of intervention participation. New policies banning TBAs and increased country-wide focus on maternal health offer potential explanations, but require further exploration. Our 36-month follow-up survey may reveal intervention effects requiring more time to manifest.