Developing a new public health cadre to meet the demands of midwifery care in Malawi.

Current healthcare planning and delivery in Malawi is guided by the Ministry of Health's Health sector strategic plan (Hssp): 'moving towards equity and quality' (2011-2016).1 this plan followed a sector wide programme of work between 2004 and 2010 intended to inform the implementation of interventions in the health sector.2 During this period, an essential Health package (eHp) was agreed and delivered free of charge to Malawians, including those interventions which can prevent and treat diseases and conditions affecting the majority of the population, especially poorer people. Good progress has been made since 2004 in reducing the unacceptably high rates of maternal and neonatal mortality, where infant mortality has reduced from 76 to 66 per 1000 live births between 2004 and 2010, and estimated maternal mortality has fallen from 984 to 675 per 100,000 live births.3the Community Midwife Assistant (CMA) initiative supports implementation of the national sexual and reproductive Health and rights strategy contained within the country's Hssp. it has high- level, political support from the presidential initiative on safe Motherhood and Maternal Health (pisMH), and despite the recent election of a new president, the creation of this new cadre is likely to continue. the global context is an increasing move towards task shifting (defined as delegating tasks to existing or new cadres with either less training or narrowly tailored training) in low income countries. the primary objective of task shifting is to increase the number of healthcare services provided at a given quality and cost.4,5Rationale foR the CMa initiativetwo of the four strategic outcomes from the current Hssp are to increase healthcare coverage and to strengthen health systems, particularly by addressing the 'Human resources for Health' crisis.2 increasing women's access to high-quality maternity care is the most effective way of reducing deaths among women and babies, and this is essential to Malawi's efforts to achieve Millennium Development Goal 5 - the improvement of maternal health, specifically through reduction of the maternal mortality ratio. However, building system capacity in rural areas (where 80% of the Malawian population live) is challenging, particularly in recruiting and retaining clinical staff. typically, traditional birth attendants, who have no formal training, provide maternity care in villages to women who prefer not to attend formal health services or are unable to do so due to multiple barriers, such as cost, transport and cultural constraints. the CMA initiative aims to replace traditional birth attendants with a more skilled workforce working in these underserved areas who are better connected into the wider public health system and supported to deliver high-quality care.DevelopMent of CMasA pilot has been completed in six districts selected purposively on the basis of remoteness and high levels of maternal mortality. CMAs are recruited by the District Management team and must hold a secondary school Certificate, be female and prepared to sign a commitment to work in their home community for five years post training. CMAs undergo an 18-month training programme at a nursing and Midwifery College using a syllabus set by the nursing and Midwifery Council of Malawi, and a core curriculum that has now been standardised across all colleges. …