Women are essential to social and economic progress yet they shoulder some of the greatest burdens of preventable disease and death. According to the World Health Organization, 303,000 women died as a result of pregnancy and childbirth in 2015 alone, disproportionately in poorer regions of the world. These women often leave children without anyone to protect and care for them, which contributes to staggering under-5 mortality rates. In 2015, 5.9 million newborns and toddlers died.
Since a child’s health is so dependent on its mother’s health, Texas Children’s and Baylor College of Medicine collaborate with public and private partners in regions of greatest need to increase access to and improve delivery of women's health services. These wide-ranging obstetric and gynecological services include family planning, maternity care, and identification of preexisting conditions that may hamper a healthy delivery such as malnutrition, obstetric fistula, TB and HIV.
Texas Children’s offers community education on the benefits of smaller families, childhood nutrition and a host of other maternal and child health subjects.
Its clinical research leads to better outcomes for mothers and children worldwide.
In Malawi, the program helped found the country’s first OB/GYN residency program at the Malawi College of Medicine in Lilongwe. This included curriculum development, providing direct OB/GYN services to patients and training local healthcare providers. U.S.-based residents and fellows from Baylor College of Medicine rotate through the program in Malawi, which helps build their skills in a high-volume setting.
Texas Children’s OB/GYN staff work with multiple partners in China, Colombia, Malawi and Papua New Guinea. It also trains fellows interested in working in global women’s health.
Dr. Michael A. Belfort
Obstetrician & Gynecologist-in-Chief
Dr. Susan Ramin
Professor and Vice Chair for Education of Obstetrics & Gynecology
Associate Director, Global Women’s Health Fellowship
Dr. Jeffrey P. Wilkinson
Professor and Vice Chair for Global Health of Obstetrics & Gynecology
Director, Global Women’s Health Fellowship
Dr. Ronald H. Mataya
Adjunct Professor of Obstetrics & Gynecology
Dr. Joseph F. Sclafani
Associate Professor of Obstetrics & Gynecology
Global Women’s Health Division Director
The maternal mortality rate in Malawi is among the highest in the world at 675 per 100,000 live births, compared to the rate of 5 per 100,000 in the United States. The population of Malawi is just above 16 million and 53% live below the poverty line. In addition, there are only 2 physicians and 38 nurses per 100,000 people in Malawi. A 2010 assessment of emergency obstetric and neonatal care demonstrated that only 2% of all basic emergency obstetric and neonatal care sites and about 48% of the comprehensive emergency obstetric and newborn care sites are fully functional.
Texas Children's and Baylor have been working in Malawi through BIPAI since 2005. BIPAI owns and operates a Clinical Center of Excellence located on the grounds of Kamuzu Central Hospital (KCH), the main referral/tertiary hospital for the central region of Malawi. The hospital has 500 beds and serves approximately 5.5 million people annually. The Department of OB/GYN at KCH conducts approximately 3,000 deliveries per year. Texas Children’s Hospital and Baylor College of Medicine faculty were integral in the development of the first residency program in Obstetrics and Gynecology in Malawi. The first class of residents graduate from the program in 2017.
With one of the highest maternal and neonatal morbidity and mortality rates in the world, there was no formal OB/GYN residency training program in Malawi; and there were only 11 OB/GYNs in the entire country of 16 million people. Prior to the start of the residency training program, all postgraduate trainees in OB/GYN had to leave Malawi to obtain their specialty training. Texas Children's and Baylor Department of OB/GYN have partnered with the Government of Malawi, The University of Malawi College of Medicine, and other international partners to implement the first Malawian postgraduate training program in OB/GYN.
Texas Children's and Baylor have full-time US OB/GYN faculty based in Malawi. The Malawi-based Texas Children's and Baylor faculty support the implementation of the Malawi residency curriculum, provide direct obstetric and gynecologic care, teach and train local healthcare providers, and supervise U.S. OB/GYN residents and fellows rotating through the program. Our partners include the Malawi Ministry of Health, University of Malawi College of Medicine, Baylor College of Medicine Children’s Foundation - Malawi, University of North Carolina Department of Obstetrics & Gynecology, Government of Norway and the U.S. Centers for Disease Control & Prevention.
The program has three key goals:
Education: In partnership with the Government of Malawi, implement sustainable and scalable education programs to train Malawian and US healthcare providers in best practices in OB/GYN, including OB/GYN specialists, OB/GYN residents, clinical officers, medical students, midwives, nurses, and medical assistants.
Care and Treatment and Health System Strengthening (HSS): Increase access to quality OB/GYN care and support the improvement of maternal and child health service delivery within the Malawian healthcare system to ensure that women and children are able to live healthy and productive lives.
Research: Utilize research to gain knowledge of existing healthcare issues and guide implementation of collaborative research programs designed to improve maternal-child healthcare in Malawi.
Adverse birth outcomes related to the length of gestation (preterm birth) and fetal growth (SGA birth) are recognized as 2 of the most significant disorders in maternal-child health on a global scale. Worldwide, more than 20 million infants are born each year with low birth weight, with more than 95% of these being delivered in developing nations. Of the 4 million newborn deaths annually, nearly 1/3 (27%) are directly attributable to prematurity with another 36% secondary to prematurity-related infections (sepsis, pneumonia, gastrointestinal such as necrotizing entercolitis. Seventy-five percent of the 4 million deaths occur within the first week of life, with the vast majority occurring in the first 48 hours. In poor rural communities, infant mortality related to preterm and low birth rate exceeds that in urban communities, and is not solely attributed to limited access to secondary and tertiary care. The link between periodontal disease and risk of preterm and SGA birth is demonstrated.
Malawi is said to have the highest preterm birth rate in the world. Prior estimates suggest that 18-22% of all infants born in Malawi are born <37 weeks. Starting in 2011, Drs. Kjersti Aagaard and Judy Levison initiated work in Malawi with funding from USAID, the Gates Foundation, the Norwegian MOH, the World Bank, and Grand Challenges Canada. We have partnered with our colleagues in Malawi, and have made a number of important observations. First, our most recent in-depth data collection from the village to the city center suggests a likely clinically meaningful (26 to 34 weeks) preterm birth rate of 26.1%. Second, there is a high rate of poor oral health (periodontal disease and caries) which accompanies this high preterm birth rate. Third, the care providers and the people of Malawi are engaged and invested in understanding ways to prevent preterm birth.
We are currently engaged through our team of community health workers, nurses, and clinicians in efforts aimed at the primary prevention of preterm birth. Read more.
Obstetric fistula is a condition that occurs when the baby is too big to pass through the women’s birth canal and obstructed labor ensues. Without access to a timely cesarean delivery, prolonged obstructed labor usually leads to the death of the baby and eventually formation of a fistula or hole between the bladder and the vagina and/or the rectum and the vagina. This condition only occurs in parts of the world where resources are scarce and women do not have access to high quality obstetrics care. Dr. Wilkinson and his team are working with the Freedom from Fistula Foundation in Lilongwe on ground breaking clinical and research programs on obstetric fistula. They manage a database of over 1000 fistula patients and are looking at complex issues such as prevention of post-repair incontinence, vaginal reconstruction and urinary diversions in fistula patients.
In 2015 the risk of dying in childbirth in Malawi hovered at 634 maternal deaths per 100,000 live births, almost 25 times higher than in the United States. Over the past ten years efforts have been made to reduce Malawi’s mortality rate from maternal hemorrhage but have been largely unsuccessful. Baylor College of Medicine and Texas Children’s Hospital are collaborating with the American College of Obstetricians and Gynecologists (ACOG) to implement a one year program that trains health care workers on the prevention, rapid identification and prompt treatment of obstetric hemorrhage. The Alliance for Innovation in Maternal Health (AIM) program has had proven success in the United States, and will be adapted to the limited resources in Malawi to determine if the program can be successfully implemented in sub-Saharan Africa. The AIM program combines training in teamwork and communication skills with clinical training in the management of obstetric hemorrhage to improve emergency response times and avert maternal deaths when serious obstetric hemorrhage occurs.
Global Women’s Health Fellowship Program
As part of the Texas Children's / Baylor Department of Obstetrics and Gynecology’s commitment to women’s health, we offer a 2-year global women’s health fellowship to develop the global women’s health leaders of the future. It also serves as a platform to establish strong partnerships both locally and globally in countries that lack the infrastructure and/or organization to adequately address women’s health issues. Fellows will participate in the Baylor Clinical Scientist Training Program’s Clinical Research Course and the National School of Tropical Medicine Diploma Program. Fellows will conduct global health research under the tutelage of their Program Faculty. It is anticipated that fellows’ research will lead to publications and other scholarly activities. Read more.
OB/GYN Residency Training Program
Malawi has one of the highest maternal mortality rates in the world. The lack of skilled health professionals to care for complex obstetrical conditions is a major contributing factor. Until recently, there were no formal OB/GYN residency training programs in Malawi, requiring Malawian physicians to emigrate to other countries to receive specialist training in women’s health. In 2012 there were only 11 OB/GYNs in the entire country of 16 million people.
In 2013 Texas Children's Hospital and Baylor’s Department of OB/GYN partnered with the Government of Malawi, the University of Malawi College of Medicine and other international institutions to implement the first Malawian postgraduate training program in OB/GYN. Texas Children's Hospital and Baylor College of Medicine are committed to the mission of strengthening health care services by committing full-time US OB/GYN faculty at Kamuzu Central Hospital in Lilongwe, the capital city.
In addition to building the educational capacity of the Malawi residency program through bedside teaching and formal classroom education, they also provide direct patient care and treatment of extremely complex obstetrical and gynecological conditions. The faculty also supervise the training of visiting U.S. OB/GYN medical students, residents and Fellows. This bidirectional education provides an opportunity for American health care learners to be part of an international health care team that personally contributes to improving global health. They face the challenges of providing medical care in a low resource setting and treat a diverse array of medical conditions not typically seen in the United States.