Documenti di Didattica
Documenti di Professioni
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Naor Bar-Zeev
Melissa Gladstone
Esther Kungwimba
Bagrey Ngwira
Queen Dube
Sarah Bar-Zeev
28 October 2013
Blantyre, Malawi
Cite this work as: Bar-Zeev N, Gladstone M, Kungwimba E, Ngwira B, Dube Q, Bar-Zeev S. Situational Analysis of Newborn Health in
Malawi 2013, Reproductive Health Unit Malawi Ministry of Health, Save the Children, SSDI, UNICEF, WHO; Blantyre 2013.
TABLE OF CONTENTS:
TABLE OF CONTENTS:.......................................................................................................................................
Executive summary...........................................................................................................................................
Acknowledgements .........................................................................................................................................
Acronyms..........................................................................................................................................................
Definitions........................................................................................................................................................
List of Figures....................................................................................................................................................
List of Tables...................................................................................................................................................
Quick Facts: What is known about newborn mortality? ................................................................................
CHAPTER 1: INTRODUCTION - The state of Malawis newborns.....................................................................
CHAPTER 2: LITERATURE REVIEW ..................................................................................................................
CHAPTER 3: METHODOLOGY..........................................................................................................................
CHAPTER 4: KEY FINDINGS AND DISCUSSION.................................................................................................
CONCLUSION .................................................................................................................................................
CHAPTER 5 RECOMMENDATIONS...................................................................................................................
CHAPTER 6: GUIDELINES ON OPERATIONAL USE OF ANTENATAL CORTICOSTEROIDS AND TOCOLYTICS
IN THE MANAGEMENT OF PRETERM LABOUR................................................................................................
Appendices.....................................................................................................................................................
References....................................................................................................................................................
Executive summary
Malawi is among the few countries in Africa that is on track to achieve Millennium Development
Goal (MDG) number 4 (reduce child mortality by 2/3 by 2015). Neonatal mortality, which is very
high (31/1,000 live births), accounts for over 40% of under five mortality and this has an effect on
further progress of the MDG 4. The major causes of neonatal mortality include sepsis, prematurity
and asphyxia, all of which are preventable.
In July 2013 a situational analysis of newborn health in Malawi and the national response to it was
undertaken. The situational analysis synthesises the prevailing causes of newborn mortality,
relevant current policies and programmes in Malawi, and the availability of interventions with
proven efficacy for reducing newborn mortality, as well as highlights areas for immediate action.
Whilst there are a number of interventions and strategies for reducing newborn mortality
implemented across Malawi, their effectiveness is often limited because of health seeking
behaviour, a lack of guidelines for health care providers, quality of care at the health facility,
availability of skilled staff and inconsistent supplies of drugs, equipment and resources needed for
the delivery of life saving interventions.
The following recommendations are made:
1. Community sensitization around preterm birth and neonatal infections
2. Engage communities in early birth preparedness and encourage the use of maternity
waiting homes, planning for birth at a health facility and emergency transport
3. Reduce the economic burden of a hospital stay on women and their families for preterm or
sick newborns requiring inpatient care
4. Improve health facility infrastructure and supplies: Ensure every district and referral
hospital has a neonatal unit, functional Kangaroo Mother care Unit, equipment and
continuous supplies of essential drugs and supplies
5. Investment in maintenance of emergency transport at district level and strengthening of
referral mechanisms between communities and health facilities
6. Improve the quality and coverage of antenatal care: screening and management of urinary
tract infections, sexually transmitted infections, high blood pressure and proteinuria, HIV,
IPTp (Intermittent Preventive Therapy during pregnancy) tetanus toxoid, early antenatal
nutritional packages iron/folate and micronutrient supplementation for
mothers/adolescent girls, counselling on danger signs and essential newborn care
practices.
7. Improve the coverage and quality of facility based early postnatal care:
8. Improve the coverage and quality of early facility based postnatal care: Ensure
implementation of evidence based and essential newborn care practices to protect against
infection and hypothermia (skin to skin contact, drying, hat and blanket, delayed cord
clamping, early breastfeeding initiation)
9. Introduction of chlorhexidine for cord care for institutional deliveries
10. Increase coverage and continuous availability of antenatal corticosteroids and tocolytics
and antibiotics for preterm labour
11. Provide regular supportive supervision, mentoring and competency based training and
assessments in emergency obstetric and newborn care and case management of newborn
illness for pre-service students and all health care providers working with mothers and
newborns
12. Review the content and quality of pre-service curriculum for the recognition and
management of preterm labour, birth and care of the preterm infant
13. Engagement of regulatory boards (nursing and medical) to establish competencies in
emergency obstetric and newborn care as part of annual re-registration requirements for
health care providers working with mothers and babies
14. Dissemination of management and referral guidelines for preterm labour and care of
preterm or sick newborns
Acknowledgements
We are grateful to all the individuals who have contributed to this Situational Analysis of
Newborn Care in Malawi. Our sincere appreciation goes to the District Medical Officers,
District Nursing Officers in Mulanje, Mchinji, Karonga and Blantyre who helped with the
selection of health facilities, mobilisation of stakeholders for interviews and facilitated data
collection in the various districts; and to Safe Motherhood Coordinators in all districts for
sharing their experiences and collected data.
Special thanks to the team of researchers undertaking the assessments for this report Francis Mtwele, Charles Ngwira, Samuel Simfukwe, Patwell Sulumba, Wilson Phiri, Daniel
Mushani, Glory Chaguma, Sarah Chikafa, Isaac Filikiri, Chimwemwe Mtonya, Samuel
Makwakwa, Chifuniro Bisweck, Inly Mvula, Matilda Lali, Hanna Potani, Memory Katchuka,
Steven Maluza, William Malombe, Juliana Majawa, Matthews Mwalapa, Justin Barnet. In
particular Gilbert Kachamba and Mahebere Chirambo facilitated the focus group discussions
in Blantyre and Mulanje and provided transcription and analysis of this data. Agnes Madimbo,
Angela Kadulira, Nomsa Sapao and Gloria Chirombo worked together with the consultancy
team to collect data from the districts. We thank Clement Trapence for his skill in database
design and data management.
Also our sincere thanks go to all the health care providers, community members, mothers of
preterm infants and other stakeholders who took the time to participate in interviews and
focus group discussions. Your experiences and insight are extremely valuable and your
dedication towards improving maternal and newborn health care in Malawi is inspiring.
Naor Bar-Zeev
Melissa Gladstone
Esther Kungwimba
Bagrey Ngwira
Queen Dube
Sarah Bar-Zeev
Acronyms
AIDS
ANC
BEmOC
CEmOC
DHMT
DHO
EHP
EmONC
FGD
HBB
HIV
IMR
IPTp
IUGR
KMC
LBW
MDG
MOH
PMTCT
QECH
QOC
SP
SWAp
UNICEF
WHO
Definitions
Abortion/Miscarriage
Adolescence
Birth asphyxia
Child mortality
Infant mortality
Low Birth Weight
Maternal mortality
Neonatal mortality
Neonate/Newborn
Post neonatal infant mortality
Preterm/Premature
Stillbirth
Under-5 mortality
Figures
Figure 1: Cause of deaths worldwide
Figure 2: High mortality countries
Figure 3a: National progress towards Millennium Development Goal 4 for newborn and child
survival from 1990
Figure 3b:Neonatal mortality trends from 1990
Figure 4: Estimated causes of mortality around the year 2010 for around 18,000 neonatal deaths
Figure 5: Growth rate of births per region
Figure 6: Report of trends and correlates of contraceptive use among married women in malawi
Figure 7: Place of birth
Figure 8: Proportion of preterm births in the 4 study districts
Figure 9: Gestational age at birth and place of birth
Figure 10: Birth weight by place of birth
Figure 11: Gestational age of preterm babies by birth outcome
Figure 12: Birth weight by birth outcome
Figure 13: Gestational age of preterm babies by category
Figure 14: Birth weight of live born outborn babies by referral status
Figure 15: Gestational age at birth of live born outborn babies by referral status
Figure 16: Gestational age of preterm babies by place of birth
Figure 17: Gestational age of preterm babies by in/out of hospital births across districts
Figure 18: Gestational age of preterms by district
Figure 19: Gestational age of preterm babies by age category
Figure 20: Birth weight of preterm babies by district
Figure 21: Number of ANC visits during pregnancy by category
Figure 22: Quality of ANC indicators
Figure 23: BP checked at every ANC visit
Figure 24: Quality ANC indicators: Blantyre
Figure 25: Quality ANC indicators: Mchinji
Figure 26: Quality ANC indicators: Karonga
Figure 27: Quality ANC indicators: Mulanje
Figure 28: Uninterrupted availability of antenatal equipment in all districts during the last 3 months
Figure 29: Uninterrupted availability of intrapartum drugs/equipment in all districts during the last 3
months
Figure 30: Uninterrupted availability of labour ward equipment for newborns in all districts during
the last 3 months
Figure 31: Uninterrupted availability of neonatal equipment in all districts during the last 3 months
Figure 32: Uninterrupted availability of neonatal drugs in all districts during the last 3 months
Figure 33: Quality of care provided to preterm infants during the 1 st 24 hours of admission to
9
neonatal nursery
Figure 34: Quality of care provided to preterm infants in the 1st 24 hours of neonatal nursery
admission for respiratory distress syndrome
Figure 35: Quality of care provided to preterm infants in the 1st 24 hours of neonatal nursery
admission for hypothermia/sepsis
10
Tables
Table 1 Table of key interventions with evidence to reducing neonatal mortality and morbidity
Table 2 Table of essential antenatal care as recommended by WHO
Table 3: Regions, districts and health facilities visited in the situational analysis
Table 4: Data collection methods
Table 5: Adjusted logistic model of the odds of death
Table 6: Availability of ambulances in emergency
Table 7: Uninterrupted supply of services, drugs and equipment for ANC
Table 8: Uninterrupted supply of services, drugs and equipment for intrapartum care
Table 9: Uninterrupted supply of services, drugs and equipment for postnatal newborn care
Table 10: Uninterrupted supply of services, drugs and equipment for postnatal maternal care
Table 11: Availability of newborn interventions across Malawi
11
Malawi is a densely populated country of 15.9 million people situated in South Central
Africa2.
The Gross National Income per Capital is $320 with 50% of the population living below
the stated poverty line3.
82% of the rural population have access to water3
Nearly 50% of women have less than five years primary school education. For men
this is 37%4 .
Malawis population growth rate is 3.1% per annum, and 46% of the population are
younger than 15 years5.
Total fertility rate in Malawi remains high at 6 births per woman. Adolescent
motherhood in Malawi occurs in 177 per 1000 adolescent females5 this is the highest
rate in the region.
Life expectancy is 47 years (lowest in African region)5 with males at 51 years and
females 44 years.
Malawi is one of two low income countries in sub-Saharan Africa on track to meet
MDG4 (Reduce child mortality by 2/3 by 2015)6.
Maternal mortality is falling at a rate of 6% per year5.
Neonatal mortality in Malawi accounts for 40% of all under-5 mortality. Preterm birth
occurs in up to 20% of all births in some districts in Malawi; Low Birth Weight occurs in
14% of births in the country4
Stillbirths occur in 24 per1000 births in Malawi. The global average stillbirth rate is 19
per 10007
12
Figure 1: Causes of deaths worldwide adapted from Child Health Epidemiological Reference
Group. In Committing to Child Survival A promise renewed 8.
13
Malawi has made significant progress in achieving MDG 4 and is on track to having cut child death
rates by 2/3 by 2015. Malawi has achieved a 64% decline in under-5 mortality since 1990, and is
ranked 7th in the world for this achievement, among high mortality countries.
Figure 2: High mortality countries (countries with an under-five mortality rate of 40 or more
deaths per 1,000 live births in 2011) with the greatest percentage declines in under five mortality
rates since 1990 from Committing to Child Survival A promise renewed adapted from Child
Info. Org.
14
This situational analysis provides a descriptive overview of the current situation of newborn health
in Malawi. It synthesises the prevailing causes of newborn mortality, relevant current policies and
programmes in Malawi, and the availability of interventions with proven efficacy for reducing
newborn mortality, as well as highlights areas for immediate action.
15
Figure 3 (a): National progress towards Millennium Development Goal 4 for newborn and child survival
from 1990 (Data from DHS NSO Malawi and Macro International Inc. 1994, NSO Malawi and ORC Macro
2001, NSO Malawi and ORC Macro 2005, NSO Malawi and ICP Macro 2011, Malawi Multiple Indicator
Cluster Survey (MICS) NSO Malawi and UNICEF 2008. From Zimba 2013.
16
Most of this progress is due to reducing under five mortality after the first month (post neonatal
mortality) with reduction rates of 7.1% per year 5. Maternal mortality is also falling at a rate of
approximately 6% per year. Despite these advances, neonatal mortality still accounts for
approximately 40% of under 5 mortality and progress is slower at a rate of 3.5% per year 9. The
regional average rate of reduction in neonatal mortality is 1.5% per year 5.
Figure 3(b): Neonatal mortality trends from 1990 Data source National progress towards Millennium
Development Goal 4 for newborn and child survival from 1990 (Data from DHS NSO Malawi and Macro
International Inc. 1994, NSO Malawi and ORC Macro 2001, NSO Malawi and ORC Macro 2005, NSO Malawi
and ICP Macro 2011, Malawi Multiple Indicator Cluster Survey (MICS) NSO Malawi and UNICEF 2008. From
Zimba 20139
17
Figure 4: Estimated causes of mortality around the year 2010 for around 18,000 neonatal deaths
Data Source: Malawi specific mortality estimates (Liu et al 2012)12
Birth Asphyxia
The definition of birth asphyxia is often confused in the literature. It has been defined as
conditions of birth capable of interfering with oxygen supply or perfusion (sentinel events) and
in some studies, with the more specific definition of the presence of a diagnosis of hypoxic ischemic
encephalopathy with abnormal neurologic signs in the newborn infant, including neonatal seizures.
For the purposes of some of the larger surveys, the definition has simply been the failure to initiate
or sustain spontaneous breathing at birth. Birth asphyxia accounts for approximately 20% of the
18
over 3 million neonatal deaths which occur worldwide15. Among children surviving birth asphyxia,
a sizable proportion will go on to develop learning difficulties, cerebral palsy and other
developmental difficulties. Approximately 6-10% of newborns do not initiate normal spontaneous
breathing16. Providing resuscitation at birth is proven to decrease neonatal mortality, yet
appropriate neonatal resuscitation is lacking worldwide17. Perinatal asphyxia is directly linked to
the quality of care during childbirth and can be averted by good quality obstetric care18. There are
limited data on the prevalence of birth asphyxia in Malawi, however the 2006 Multiple Indicator
Cluster Survey claims birth asphyxia accounts for 22% of all neonatal deaths in Malawi19.
A study in Ntcheu district found that midwives were not reliably able to identify clinical signs of
birth asphyxia and were not skilled in providing neonatal resuscitation. The study also found that
resuscitation equipment and supplies were not adequate 20. The ETATMBA project has sought to
address some of these issues21. This is a study which is looking at the impact of training non physician clinicians in Malawi on maternal and perinatal mortality. It has done this through enhancing
training and appropriate technologies for mothers and babies. This is an 18 month programme of
skills training in specific obstetric, neonatal and leadership skills delivered over three week long intensive training modules with follow-up in the workplace and then a six month in service training
period to apply enhanced teaching, training and clinical audit. The training programme addresses
the major causes of maternal and perinatal mortality, how to teach and research as well as leadership skills.
Helping Babies Breathe (HBB) is another education program designed to teach resuscitation skills to
health care providers in low resource settings with the goal of having a minimum of one person
who is competent in neonatal resuscitation at every birth. An emergency obstetric care assessment
in Malawi identified that fewer than 33% of health care providers had a satisfactory level of newborn resuscitation knowledge and skills. The HBB programme commenced in Malawi in 2011 and is
being rolled with the support of USAID, Save the Children, Johnson and Johnson and other patners
together with the Ministry of Health. In October 2012, 1,254 skill birth providers had received the
HBB training and this is being scaled up across the country (Little G. National HBB implementation
in Malawi is moving forward. Healthy Newborn Network 2012).
In Malawi, 14% of newborns are born low birth weight though prevalence varies by district 19. It is
particularly high in Salima (17%), Dedza (16%) and Phalombe (15%) districts. Research in Malawi
shows that LBW is associated with maternal HIV infection, malaria in pregnancy and poor maternal
nutritional status 25. According to the WHO, the birth weight is the single most best predictor of
survival and of normal growth and development26.
Recording birth weight is an expected standard of practice, but it is frequently not recorded in
Malawi. According to the 2006 MICS 48% of babies in Malawi are weighed at birth with variations
in regions. 62% of infants in the Northern Region are weighed at birth and 45% in the Central
Region. In Rhumpi District, 79% of babies were weighed at birth and in Mangochi only 34% of
babies were weighed at birth. Those born in urban areas, to educated mothers, those in the highest
wealth quintile and those with a skilled birth attendant were more likely to be weighed 19.
Preterm birth
Rates of preterm birth are rising globally 27. Premature infants are much more likely to die 28 and
have a much greater risk of serious health problems including cerebral palsy, intellectual disability,
chronic lung disease and vision and hearing problems 28. Risks for preterm birth include adolescent
mother, primiparity, anemia, poor nutritional and micronutrient status of the mother and short
stature, maternal malaria and other infectious diseases such as urinary tract infection, bacterial
vaginosis, sexually transmissible infections like syphilis and HIV 28,29. Processes leading to preterm
delivery may start early in the antenatal period30.
20
Multiple pregnancy:
A study at Queen Elizabeth Central Hospital (QECH) found that 58% of early neonatal deaths in
hospital occur among infants of gestational age of 20-37 weeks at birth. Sixty-two percent of
mothers whose babies died preterm had experience a previous preterm infant deatht 41
demonstrating the need to identify and monitor these women more carefully throughout
pregnancy and the postnatal period. Multiple gestation births in Malawi are also more likely to lead
to complications with only 38% of multiple gestation infants surviving 42. It is estimated that
multiple gestation births in Malawi may add to up to 5.5% of perinatal, 1.2% of post-perinatal and
11.5% of maternal deaths in the population.
Infection
22
Syphilis
Syphilis is a risk factor for preterm birth and can also cause congenital syphilis. Screening and timely
treatment of syphilis are proven to decrease neonatal mortality. Prevalence of syphilis in pregnancy
is high in Malawi. The National HIV and Syphilis sero-surveys conducted in 2010 found a prevalence
rate for syphilis of 1.2%53. This rate is unchanged since 2007 but is much lower than it was in the
1990s and mid 2000s. The highest prevalence (7.6%) is in Mulanje with the lowest rates in the
northern region (0.5%). Studies in Malawi have shown that mothers with active syphilis were 11
times more likely to have stillbirths (OR 10.9), 18 times more likely to have a macerated stillbirth,
almost 5 times likely to experience early and late neonatal deaths (OR 4.86) and had more than
double the risk of post-neonatal infant death (OR 2.24) 54. Identifying and treating syphilis is a
priority in Malawi.
Malaria
Each year approximately 125 million pregnant women are at risk of placental malaria (PM) and
nearly 25% of all pregnancies in sub-Saharan Africa are complicated by PM at delivery 55. Placental
malaria has profound maternal and fetal health consequences including increased risk of anemia,
preterm birth, fetal growth restriction and delivery of low birth weight infants. The well-recognised
consequences of P. falciparum infection during pregnancy include maternal anaemia, premature
birth and foetal growth restriction resulting in low birth weight and higher perinatal morbidity and
mortality}. These effects are most severe in first and second pregnancies. Additional consequence
of placental malaria that are now receiving much more attention are the effect of in utero exposure
to malaria on neurocognitive development and the potential long-term effect on susceptibility to
malaria infection in early childhood.
There have been many studies in Malawi that have looked at the association of in-utero malaria on
outcomes in pregnancy and in the neonatal period. Evidence is amassing as to the positive effect of
treatment with antimalarials during the in-utero period as well as the clear indications for the use
of bed nets for all but particularly for young children and pregnant women61-68.
HIV
National HIV prevalence has decreased since the mid 1990s. Prevalence of HIV in pregnant women
attending antenatal care has declined from 16.9% in 2001 to 10.6% in 2010 as can be seen in Figure
1.2 below. Prevalence is higher among women than men (12.9% vs. 8.1%) 5. Recent studies from
Karonga show that HIV status of the mother did not affect neonatal mortality but was associated
with higher mortality in older children10. Post neonatal mortality was shown to be much higher in
children of HIV infected mothers (RR of 7.3) and remain higher even beyond the fifth year of life (RR
of 3.7)10.
23
The recent BAN studies have demonstrated that initiation of antenatal prophylaxis as early as
possible has a greater effect on HIV transmission than postnatal prophylaxis 69. These studies have
shown that once breastfeeding has reported to have stopped, HIV transmission still seems to occur .
This recent evidence has shown that it is still beneficial to continue antiretrovirals even after
cessation of breastfeeding. Indeed Malawi has recently implemented Option B +, in which all HIVinfected pregnant and breastfeeding women are commenced on lifelong triple antiretroviral
therapy with the focus of PMTCT programs being HIV-free survival and opportunity to ensure that
essential newborn care and other neonatal strategies help improve survival. Evaluation of the
impact of the Option B+ programme is under way at the Karonga Prevention Study in Chilumba 70.
24
Table 1: Table of key interventions with evidence to reducing neonatal morbidity and mortality.
From Darmstadt et al Lancet 200549.
25
The WHO has highlighted a number of interventions for antenatal care, which should be followed
(Table 2). Screening and treatment of sexually transmitted diseases such as syphilis and detection
and management of pregnancy complications such as hypertensive disorders during the antenatal
period are effective interventions known to reduce the risk of stillbirth (McClure EM, Saleem S, Pasha O,
Goldenberg RL. Stillbirth in developing countries: a review of causes, risk factors and prevention strategies. Journal Maternal Fetal Neonatal
Mediciine; 2009: 183-90).
Contraceptive use
Sub-Saharan Africa is the only region of the globe where the number of births and the under-15
population are set to substantially increase this century with sub-Saharan Africa being the single
region with the greatest number of children under 18. Between 2010 and 2025, the child
population of sub-Saharan Africa is projected to rise by 130 million with one in three children in the
world will be born in Sub-Saharan Africa by 2050. 100 years previous to this, the ratio would have
been one in ten71.
Figure 5: Growth rate in births per Region. You D & Anthony D, Generation 2025 and beyond.
UNICEF Occasional Paper 1,2012 71 Papers
27
Contraceptive use in Malawi has increased in the last ten years in Malawi. HSAs are now approved
to provide injectable contraceptives with an increase in modern contraceptive use from 28.1% of
unmet need to 42% in 2010 (in all women Figure 2 showing that in Married Women). Injectable
methods account for 26% of contraceptive methods 72. In 2011 the unmet need for family planning
was estimated at 36% of women73
Figure 6: Report of trends and correlates of contraceptive use among married women in Malawi:
Evidence from 2000-2010 Malawi DHS73.
28
In Malawi, 17.7% of adolescent girls have given birth, this is the highest rate in the African region) 5.
Birth during adolescence is associated with preterm premature birth and a higher rate of
complications, so preventing unintended pregnancies by improving contraception in the adolescent
period as well as promoting birth spacing and planned pregnancies is important 74-76. Some
programmes have shown that if education is promoted for longer in adolescence along with
parenting programmes, that rates of adolescent pregnancy will fall dramatically. Furthermore, it is
clear that optimised vaccination programmes for children as well as adolescents will decrease the
risk of infectious diseases during pregnancy (Rubella, TB).
Disclosure of pregnancy in adolescent and unmarried mothers may be an issue due to the stigma
involved. Furthermore, multiparous women in Malawi may not be attending due to conflicting
expectations on time. Many women in Malawi reported coming to health facilities in the first
trimester and not disclosing pregnancy a significant factor in terms of being provided with
pharmaceuticals which may be harmful to the unborn child. Furthermore, many women described
how clinics were often fixed and this inflexibility with limited health care staff in these clinics added
to their inability to attend clinics when expected.
30
The currently recommended intervention in Malawi is the use of insecticide treated bed nets,
treatment with Sulfadoxine-Pyrimethamine (SP) at each routine antenatal care visit starting in the
second trimester and treatment of infection as well as treatment with folate along with SP to
prevent neural tube defects. Intermittent Prevention of Malaria in pregnancy has increased
dramatically by 26% (NSO Malawi and ORC Macro 2001 and 2011). However, current evidence
suggests that the effectiveness of IPTp-SP in eastern and southern Africa is waning. A recent
analysis of the effectiveness of IPTp-SP between 1996 and 2006 in Malawi, showed that the impact
of IPTp reduced dramatically since 2002, and has reached levels where it is no longer protective.
These findings in Malawi are of grave concern and are consistent with recent observations from
northern Tanzania86. Preliminary results of a currently on going observational study assessing the
efficacy of IPTp-SP in HIV seronegative women has shown the prevalence of placental malaria
standing at 1 in 3 women (Linda Kalilani, personal communication), further emphasising the
desperate situation malaria control in pregnancy faces, and the need for an alternative strategy.
In areas with high SP resistance where IPTp-SP is failing, the alternative options are limited to either
replacing SP with other drugs for IPTp, or considering alternative strategies to replace IPTp. In
addition, it has been noted that the transmission of malaria is declining in many parts of Africa,
including southern Malawi, and is likely to decline further with the provision of funds for malaria
control and elimination initiatives 87. This will also result in reductions in the number of women at
risk for malaria infection during pregnancy, reducing the potential impact and cost-effectiveness of
presumptive approaches such as IPTp.
There is increasing interest in using screening approaches for the control of malaria in pregnancy.
One strategy that has been proposed is Intermittent screening and treatment in pregnancy (ISTp)
which involves screening for malaria as part of focused antenatal care using appropriate diagnostics
and treating parasiteamic women with long acting Artemisinin-based Combination Therapies (ACTs)
to clear the existing infections, while providing additional post-treatment prophylaxis for 3 to 6
weeks. The screening ensures that only parasiteamic women receive treatment, whereas women
without evidence of malaria i.e. lower risk groups such as the multigravidae or women protected by
ITNs are not unnecessarily exposed to antimalarial drugs.
neonatal mortality rates in Malawi with distance away from care. Despite the fact that better
geographic access and a higher level of care were associated with more frequent facility delivery,
there was no association with lower neonatal mortality. This may be a telling fact that quality of
care for mothers and newborns at health centres is still poor 89. A qualitative study has also
demonstrated how although women in Malawi would like to be well received in health facilities,
they are not critical of care and do not have high expectations. They have no idea about the
standard of care but do want to be treated with kindness and dignity 90.
Recent audits of sites in Malawi and their ability to provide CEOC (Comprehensive Emergency
Obstetric Care) or BEOC (Basic Emergency Obstetric Care) have been interesting. In Malawi, 8/8
(100%) hospitals expected, provided CEOC (meeting the UN requirements) but only 2/31 (6%) of the
facilities expected provided BEOC (52% antibiotics, 97% oxytocin, 45% anticonvulsants, 32% manual
removal of placenta and removal of retained products, 13% assisted delivery, 18% neonatal
resuscitation). Rates of neonatal resuscitation were only slightly higher than the rate of 0.1 per
500,000 in 200091-93. There is an expected population need for EOC based on 15% of all births
anticipated. Caesarean section rates in Malawi were found to be 3.6% up from 1.6% in 2000
(minimum recommended level of 5%) with case fatality rates at 1.9% 94. There have previously been
concerns about the high mortality rates associated with caesarean section rates in Malawi and the
fact that these have increased over the years. Concerns have been raised in to the need for
improved training in anaesthetics, wider use of spinal anaesthesia and improved surveillance and
resuscitation in postoperative wards95.
Poor record keeping has also been previously described in many centres, particularly with regards
to recognition and recording of women with obstetric complications and or the procedures carried
out to manage such patients91. Data on the number of women with EOC complications are not
routinely collected in most labour ward registry books. This affects the estimates of the met need
for EOC and case fatality rates.
Neonatal units
There are very few neonatal units in Malawi and therefore services working to improve outcomes
through neonatal care are limited. There has however been recent interest in the use of low cost
nCPAP machines in tertiary neonatal units in Malawi. This is still in its infancy and no larger trials
have yet been conducted101.
Breast feeding
There is a growing body of evidence showing the significant impact of early initiation of
breastfeeding, preferably within the first hour of birth in reducing neonatal mortality 8. Reasons for
this include providing colostrum to infants to improve immunity, keeping the baby warm through
skin to skin contact, preventing infection through providing only breastmilk and the provision that
breastmilk provides in terms of nutrients for optimal growth.
In Malawi, up to 71% of mothers exclusively breast feed for 1 st six months (2005-2011)5. Rates of
initiation of breast feeding and exclusive breast feeding have increased dramatically since 2001 5. A
recent cluster randomised trial in Mchinji area demonstrated that volunteer peer counselling could
33
improve uptake of postnatal care as well as HIV testing and exclusive breastfeeding compared to
clusters without that peer counselling
Postnatal care
Healthy home behaviours in the postnatal period have been encouraged in some settings in
Malawi. Rates of post natal care at home (within the first two days of life and the number of babies
weighed at birth) in Malawi have increased over the past ten years 5. Levels are still low and need to
be encouraged.
Immunisation rates in Malawi are very high with rates up to 97% for DTP3, Hep B3, Hib and Measles
in 1 year olds along with a 99% rate for BCG vaccination 5. Polio coverage is at 86% and provision of2
doses of Tetanus toxoid vaccine has also increased.
A cluster RCT in central Malawi demonstrated that volunteer peer counselling could improve
uptake of postnatal care as well as HIV testing and exclusive breastfeeding compared to clusters
without that peer counselling. This was compared to womens groups. This study demonstrated
that the clusters with womens group interventions on their own had the lowest uptake of
antenatal and postnatal care and HIV testing and higher perceived maternal problems. These
studies demonstrated that both interventions improved exclusive breastfeeding but after
stratification, the effect only significantly increased in those areas with a womens group
intervention. In these womens groups, there were certain neonatal problems which were
considered more important by the women. This included neonatal sepsis, ear and eye infections,
being born in the amniotic sac or wrapped in the umbilical cord and asphyxia, tetanus, diarrhoea,
malaria, pneumonia, jaundice, prematurity, malnutrition and hypothermia 103. Within the womens
group and counselling interventions there were lower frequencies of perceived maternal and
neonatal problems with earlier wrapping and initiation of breastfeeding. The infant mortality rate
(IMR) fell by 36% in areas where volunteer peer counsellors advised mothers about feeding and
infant care and overall infant morbidity by 42%.
Care for Low Birth Weight (LBW) babies/Kanagroo Mother Care (KMC)
A number of studies have promoted the use of KMC as an effective safe and cheap method of
saving lives of low birth weight or premature infants 104. Some studies have shown that KMC may
prevent up to half of all deaths in babies weighing less than 2000g therefore being an effective way
of improving infant survival and improving MDG4105. Malawi started implementing KMC in 1999
and developed national guidelines in 2005 106. A scale up process has occurred and there are now
over 121 health care facilities that are supposed to provide KMC services 107. Despite this, reports
have highlighted the many issues that still exist relating to implementation of programmes. Many
34
units still do not have clear guidelines, proper documentation of practices, good feeding and
weighing policies and many do not encourage the amount of skin to skin contact which is
recommended for good KMC. Discharge policies are often followed well, but follow up in the
community is entirely dependent on whether an HSA in the area had been trained in KMC. Only
some facilities have a written implementation plan on continued training on KMC 107.
demonstrated how 33 of the 55 EHP interventions were found to be potentially cost effective
(<$150/DALY)85. Maternity care was found to be half of what was required and there did not seem
to be a great emphasis on maternity care within the EHP.
Spending on health
Malawi spends $65 per capita total expenditure on health (14.2% of total government expenditure)
with external resources for health make up 63.8% of the total expenditure on health 5.
Human resources
In Malawi, there are 0.2 physicians per 10,000 population and 2.8/10,000 nursing or midwifery
personnel to population ratio with 0.2/10,000 dentists and 0.2/10,000 pharmacists. Malawi has 13
hospital beds per 10,000 population5. There are approximately 8 paediatricians and 16
obstetricians in the country. These levels are exceedingly far below WHO recommended standards
for developing countries of 1 doctor per 5,000 population and 1 Nurse per 1,000 population Health
worker density per 10,000 population (2008) 3.0. Whilst the number of medical doctors and
pharmacists in Malawi is scarce, pharmacy technicians are providing most of the pharmacy services
at district level and clinical officers providing the majority of medical services.
during pregnancy and three postnatal visits within the first week after birth as well as to engage in
community mobilisation activities encouraging care-seeking throughout pregnancy, childbirth and
the postnatal period52. The home visits are supposed to focus on antenatal care, skilled birth
attendance and early hygiene, breastfeeding and identification and care seeking for danger signs.
Small babies should receive extra visits and be referred for KMC. There should be linkage with
facility based health workers orientated also in CBMNC enabling access to essential maternal and
newborn care including care at birth, resuscitation and KMC. A study by Zimba from 2011,
demonstrated that 17 of 28 districts were implementing the CBMNC package with more than 1700
HSAs trained but a Save the Children household survey in 3 pilot districts (Dowa, Thyolo and
Chitipa) demonstrated that coverage of HSA home visits during pregnancy was only 36% with only
20% of women receiving a home visit within the first week after birth. Difficulties with this
programme seem to be to related to balancing the demands placed on HSAs who have many
commitments in terms of care of both adults and children in the community 110.
38
Conclusions
Despite the improvements in rates of child mortality in Malawi, improvements in neonatal mortality
are lagging. In Malawi the majority of deaths in the neonatal period can be attributed to three main
causes: birth asphyxia, low birth weight/ prematurity and infection.
Information regarding the underlying causes of birth asphyxia in Malawi are lacking, however it is
proven that improved emergency neonatal care and resuscitation can improve survival and long
term outcomes. Further research into the causes and linkages of birth asphyxia would be incredibly
beneficial for Malawi. Sustained and embedded mandatory training programmes where all staff
dealing with neonatal emergencies are trained and where accountability is seen to be important
will make a difference to outcomes. Furthermore, leadership and capacity building with regards to
neonatal resuscitation will help build confidence and improve emergency neonatal care in all
settings.
Knowing the risk factors for preterm birth and low birth weight allows for the design of targeted
interventions. For example, providing nutritional support and micronutrients such as folic acid and
iron (or multivitamins) in the antenatal period, encouraging more regular antenatal clinic
attendance for all mothers but particularly primiparous mothers and those who have had previous
premature births and programmatic delivery of intermittent treatment for malaria should be
ensured. The quality and effectiveness of these interventions should be evaluated through
investment in ongoing supportive supervision and programmatic monitoring so that challenges to
implementation are identified and addressed.
Finally, we know that infections contribute greatly to the large number of neonatal deaths in
Malawi. This can be directly through causing sepsis or pneumonia or HIV or through the effects on
maternal health causing preterm birth or low birth weight. Sexually transmissible infections
(syphilis, HIV and other infections) as well as malaria during pregnancy will both contribute to this
immensely in Malawian settings. Investment in the resources required for achieving high coverage
of antenatal screening for and treatment of sexually transmissible infections is needed.
Intermittent treatment of malaria during pregnancy should be rolled out to national scale.
Infections for which existing interventions may be ineffective or inappropriate in the Malawi
context (such as screening and treatment of colonisation with group B streptococcus) but is still the
subject of preventive research, for example through prioritising vaccine trials against pathogens
causing disease in mothers and newborns in Malawi (for example Group B streptococcus,
Streptococcus pneumoniae, influenza). Furthermore, further training and policies surrounding how
health care workers work to identify early signs of neonatal sepsis and treat or refer for services
should be considered through Community IMCI and the new Community Neonatal and Maternal
Care packages. Scope for this is at present limited and ways and means of sustainably scaling up
these programmes need to continue to be considered.
39
CHAPTER 3: METHODOLOGY
Design
This situational analysis was conducted using a mixed method approach. It incorporated a literature
review, health facility assessments, a retrospective cohort study on preterm birth outcomes based
on routinely collected data at the health facility, evaluation of the quality of antenatal care and
quality of care (QOC) delivered to preterm infants in the 1 st 24 hours of life, key stakeholder
interviews and structured questionnaires, focus group discussions (FGDs) and interviews with
mothers of preterm infants (see Table 3).
Literature review
The literature review includes published and unpublished data relating to neonatal morbidity and
mortality in Malawi from 1990 to the present. We undertook a search of published literature using
the following databases: Pubmed, Scopus, Ovid SP, CINAHL and Embase using the MeSH terms
neonatal OR premature AND Malawi. This was supplemented by snowballing techniques
where literature cited from those articles were also sought if felt relevant. Grey literature included
that from the Ministry of Health, official government and agency websites as well as any other key
informant literature relating to newborn care and health in Malawi. Many studies specifically were
looking at maternal child transmission of HIV and maternal malaria and treatment options but there
were also a number of studies looking specifically at prematurity and its outcomes.
Table 3: Regions, districts and health facilities visited in the situational analysis
Region
District
Southern
Blantyre
South Eastern
Mulanje
Central
Mchinji
Northern
Karonga
In-depth individual Interviews and focus group discussion were undertaken in Chichewa and English
with a range of health care providers and community member to gain an understanding and insight
into newborn health issues in Malawi, with a focus on preterm birth. We also sought to confirm the
participants understanding and acceptability of antenatal corticosteroids and tocoloytics for
preterm labour. Experienced qualitative researchers facilitated Focus Group discussions.
In-depth interviews were also conducted with mothers of in patient pre-term infants to identify
care seeking behaviours and decision-making practices around preterm labour, understanding and
acceptability of antenatal corticosteroids and preterm birth. Purposive sampling was used to
identify and recruit all participants. In addition, Safe Motherhood Coordinators from each district
were invited to complete a structured questionnaire designed to elicit district level data on local
newborn health interventions, programs and key newborn health indicators. Twenty-seven Safe
Motherhood Coordinators were sent questionnaires and 16 responses were received.
All data were collected during June 2013. The data collection teams were comprised of members of
the consultancy group (midwives, paediatricians and a sub-speciality medical doctor) together with
41
additional neonatal nurses, other midwives and doctors who received training in the use of the data
collection tools prior to the commencement of data collection.
Table 4: Data collection methods
Data collection methods
Sample
Facilities included
Health facility
assessment
Purposefully selected
hospitals and health centres
across 4 surveyed districts
(n=19)
Retrospective cohort
study on preterm birth
outcomes using routinely
collected data in facility
maternity register
In-depth individual
interviews
In-depth individual
interviews
Structured
questionnaires to assess
the availability of
essential newborn care
facilities at district level
Community members
(n=40)
42
Data analysis
Medical record data were entered into a Redcap database and cleaned and analysed descriptively
using STATA 12.1 (Statcorp, College Station, Texas). Interviews and FGDs were recorded with the
participants consent and transcribed verbatim. Pseudonyms were used to preserve anonymity. The
transcribed material was analysed by qualitative researchers. The transcriptions were examined to
identify issues and themes in the data and codes were assigned to units of meaning apparent in
each paragraph or sentence. Data were then merged into higher-level categories and core themes
selected. Frequencies of responses within the core themes were subsequently identified.
Qualitative and quantitative data sources were used to corroborate our findings around the issue of
newborn health in Malawi.
The findings are quoted throughout this report with the questionnaires and topic guides included as
Appendices 1-6.
43
Place of birth
The vast majority of persons presenting to a health facility had a birth in a facility. With the large
majority being born in hospital. However, it is important to recognise that home births or births in
traditional facilities may be less likely to present to a health facility, especially if the baby is still born
or dies soon after birth. Capturing such births and their outcome is outside the scope of this work,
but is a process actively underway in Mchinji (Mai Mwana Project) and in Kasungu & Salima (Mai
Khanda Project, PACHI).
44
P la c e o f b ir t h
H o s p it a l
H e a lt h C e n t r e
I n t r a n s it
Hom e
N o t re c o rd e d
O th e r
n=2695
P r o p o r t io n o f p r e t e r m s b o r n in e a c h lo c a t io n
P e r c e n t b o r n i n e a c h l o c a t io n
100
80
H om e
H e a lt h C e n t r e
H o s p it a l
I n t r a n s it
O th e r
N o t re c o rd e d
60
40
20
B la n t y r e
K a ro n g a
M c h in ji
M u la n je
babies tend to be referred) or hypothesising an association between place of birth and antenatal
care attendance, may reflect a protective effect of better antenatal care on birth weight. There was
no association between place of birth and gestational age at birth.
G e s t a t io n a l a g e a t b ir t h b y p la c e o f b ir t h
Hom e
H e a lt h C e n t r e
H o s p it a l
I n t r a n s it
O th e r
N o t re c o rd e d
25
30
35
G e s t a t io n a l a g e ( w e e k s )
40
45
B ir t h w e ig h t b y p la c e o f b ir t h
Hom e
H e a lt h C e n t r e
H o s p it a l
I n t r a n s it
O th e r
N o t re c o rd e d
1 ,0 0 0
2 ,0 0 0
3 ,0 0 0
B ir t h W e ig h t ( g r a m s )
4 ,0 0 0
5 ,0 0 0
G e s t a t io n a l a g e a t b ir t h o f p r e - t e r m s b y b ir t h o u t c o m e
A liv e
S t illb ir t h f r e s h
S t illb ir t h m a c e r a t e d
D ie d b e f o r e d is c h a r g e
N o t re c o rd e d
20
25
30
G e s t a t io n a l a g e ( w e e k s )
47
35
B ir t h w e ig h t b y b ir t h o u t c o m e
A liv e
S t illb ir t h f r e s h
S t illb ir t h m a c e r a t e d
D ie d b e f o r e d is c h a r g e
N o t re c o rd e d
1 ,0 0 0
2 ,0 0 0
3 ,0 0 0
B ir t h W e ig h t ( g r a m s )
4 ,0 0 0
G e s t a t io n a l a g e o f p r e m s b y c a t e g o r y
1
P r o p o r t io n
.8
.6
.4
.2
S u r v iv e d t o d is c h a r g e
D ie d b e f o r e d is c h a r g e
<28 w eeks
2 8 to < 3 2 w e e k s
3 2 to < 3 7 w e e k s
5 ,0 0 0
weeks.
Referral behaviour before birth is unclear, but hospital pre-term births had a greater proportion of
very pre-term births than out of hospital births but this was mainly seen in Blantyre and Mchinji. An
investigation into the reasons for high numbers of preterm births in these districts is needed.
In-depth interviews with mothers of preterm infants identified that mothers were aware of signs of
preterm labour and were keen to access health care as soon as possible however, delays in care
seeking were often attributed to the womens need to obtain permission for accessing health care
from a mother in law or husband and then once at the health facility, further delays in actually
receiving care.
We reviewed partographs of 46 women who had given birth to a preterm infant to assess cervical
dilation on first examination or admission at the health facility. Close to 80% of women, the
majority of who were multiparous were recorded to have a cervical dilation of 9cm or were fully
dilated. This has significant implications for future scale up of antenatal corticosteroids and
tocolytics, as women need to present much earlier in preterm labour to receive timely care and
obtain maximum benefit from the drugs and for appropriate referral to a higher-level facility if
needed.
One woman noted: I got there (to the health centre) fast as I could because I knew it was not right
my pains were too early. I was 6 or 7 months and had some small bleeding. When I got there, no
one to look after me and I just kept having pains for a long time, then the nurse said get on the bed
and then I just had my babyit was in hospital for many weeks.
50
B ir t h w e ig h t o f liv e b o r n o u t b o r n s b y r e f e r r a l s t a t u s
R e fe rre d o n w a rd
N o t re fe rre d
N o t re c o rd e d
1 ,0 0 0
2 ,0 0 0
3 ,0 0 0
B ir t h W e ig h t ( g r a m s )
4 ,0 0 0
Figure 14: Birth weight of live born outborn babies by referral status
51
5 ,0 0 0
G e s t a t io n a l a g e a t b ir t h o f liv e b o r n o u t b o r n s b y r e f e r r a l s t a t u s
R e fe rre d o n w a rd
N o t re fe rre d
N o t re c o rd e d
25
30
35
G e s t a t io n a l a g e ( w e e k s )
40
45
Figure 15: Gestational age at birth of live born outborn babies by referral status
52
G e s t a t io n a l a g e o f p r e m s b y c a t e g o r y
B o r n in h o s p it a l
B o r n o u t o f h o s p it a l
P r o p o r t io n
.8
.6
.4
.2
<28 w eeks
2 8 to < 3 2 w e e k s
3 2 to < 3 7 w e e k s
G r a p h s b y B o rn o u t o f h o s p ita l
G e s t a t io n a l a g e o f p r e m s b y in / o u t o f h o s p it a l b ir t h
1
P r o p o r tio n
.8
.6
.4
.2
0
in
out
B la n t y r e
in
out
K a ro n g a
in
out
M c h in ji
in
out
M u la n je
<28 w eeks
2 8 to < 3 2 w e e k s
3 2 to < 3 7 w e e k s
Figure 17: Gestational age of preterm babies by in/out of hospital births across districts
53
District comparisons
Gestation and birth weight by district
Compared to Blantyre, Karonga and Mchinji (but not Mulanje) had higher gestational age on
average 1.6 (95% CI: 1.3 to 1.8) and 1.7 (95% CI: 1.4 to 2.0) weeks respectively, p<0.001 for both
districts. Compared to Blantyre all 3 other districts had higher mean birth weight. For Karonga,
Mchinji and Mulanje respectively 964.3 (95% CI: 915.2 to 1013.4), 94.7 (95% CI: 40.6 to 148.8) and
143.1(95% CI: 71.0to 215.2); p<0.001 for all districts. Restricting the analysis to babies born in
hospitals the association still hold and the differences are of even greater magnitude; and for
gestational age include a significant difference for Mulanje also (not shown). When comparing
Blantyre to all three other districts combined, the mean difference in birthweight is 547.5 gram
lower and 1.4 weeks younger in Blantyre, p<0.001. The reporting of estimated gestational age at
birth seems different in Karonga, with a greater proportion of babies reported as being 36 weeks.
Many of these babies had birth weight consistent with being term, and it seems likely that there is
an overestimation of prevalence of preterm birth in that district.
The reason for younger gestation and lower birth weight in Blantyre is uncertain, but may reflect a
referral bias, since facilities for more intensive care of preterms and low birth weight babies are
available in Blantyre, it is possible more of these babies are either referred from primary health
services or that parents self refer in such circumstances in Blantyre, but that such children are not
recognised or brought as often for care in other districts. There are plausible biological reasons why
in a densely populated urban setting preterm birth and low birth weight would be more frequent,
for example during intensive influenza outbreaks.
54
G e s t a t io n a l a g e o f p r e t e r m s b y d is t r ic t
F re q u e n c y
50 100 150 200
B la n t y r e
F re q u e n c y
200 400 600 800
K a ro n g a
20
25
30
35
G e s t a t io n a l a g e ( w e e k s )
40
20
25
30
35
G e s ta t io n a l a g e ( w e e k s )
M c h in ji
F re q u e n c y
50
100
F re q u e n c y
20 40 60
80
150
M u la n je
20
25
30
35
G e s t a t io n a l a g e ( w e e k s )
40
20
25
30
35
G e s ta t io n a l a g e ( w e e k s )
D a t a s h o w h e a p in g is e v id e n t a t e v e n n u m b e r s
K a r o n g a lik e ly fa ls e o v e r r e p r e s e n t a ti o n o f '3 6 ' w e e k s
G e s t a t io n a l a g e o f p r e m s b y c a t e g o r y
1
P r o p o r t io n
.8
.6
.4
.2
B la n t y r e
40
K a ro n g a
M c h in ji
<28 w eeks
2 8 to < 3 2 w e e k s
3 2 to < 3 7 w e e k s
55
M u la n je
40
B ir t h w e ig h t o f p r e t e r m s b y d is t r ic t
B la n ty re
F re q u e n c y
50
100
F re q u e n c y
20 40 60
80
150
K a ro n g a
M u l a n je
M c h in ji
F re q u e n c y
20
40
F re q u e n c y
20 40 60
80
60
56
The increased mortality in Mchinji is more marked when restricted to children born outside of
hospital (5.3% mortality), particularly for those born in health centres and in transit. Mchinji also
has a higher proportion of hospital births (Figure). The finding of higher mortality in outborns with
greater proportion of hospital birth may reflect a that the fewer infants being referred in Mchinji
tend to be sicker but may also reflect differences in quality of care at health centre and hospital
level. It may also suggest that referral systems are more challenging in Mchinji. These complexities
require adjustment by multivariate logistic methods (see below).
Stillbirth by district
Stillbirths occurred in 40/770 (5.2%) births in Blantyre, 19/992 (1.9%) in Karonga, 33/660 (5.0%) in
Mchinji and 17/269 (6.3%) in Mulanje. Compared with Blantyre only Karonga had significantly lower
stillbirth rate (OR 0.36 95% CI: 0.2 to 0.6, p<0.001). This may reflect differences in recording of still
borns in the maternal register.
There was no significant association in still birth rate by hospital or facility delivery. Still birth was
not associated with a difference in gestational age but low birth weight was more common among
still births, low birth rate occurred in 102/109 (93.6%) still births and in 1773/2586 (68.6%) live
births, p<0.001. These differences are consistent when restricted either to fresh or to macerated
stillbirths.
Fresh stillbirths are more often due to difficulties in second stage of labour, and severe foetal
asphyxia. However, these data suggest a higher rate of low birth weight even in fresh stillbirths.
Multivariate analysis
An adjusted logistic model of the odds of death that includes birth weight, gestational age, district,
facility birth and transit birth
Table 5: Adjusted logistic model of the odds of death
Parameter
OR (95%CI), p-value
p-value
p<0.001
gestational age
p=0.98
district
p<0.001
p=0.005
facility birth
p=0.86
Born in transit
p=0.021
In all adjustments, birth weight remains a significantly associated with mortality, but once adjusted
for birth weight gestational age is no longer significant. For each 100gm increase in birth weight
57
mortality reduces by 21%. After adjustment for place of birth and proportion born in transit and
gestational age and birth weight, Karonga (almost 6-fold) and Mchinji (2.5-fold) both have higher in
hospital mortality. Being born in transit (e.g. on the road) is associated with an almost 5 fold
increase in mortality, even adjusting for gestational age, birth weight and district.
The association between birth weight and mortality is well known. However, it should be stated
that there is some debate in the literature about whether interventions that improve birth weight
alone result also in reduced mortality. However, many interventions directly have an impact on
both these outcomes.
These data are based on maternal register data and do not provide information on quality of care
received at different facilities. We now turn to analysis of quality of care based on antenatal and
newborn care audits.
QUALITY OF ANTENTAL CARE
Use of antenatal care services
Three hundred and sixty one antenatal records contained within the health passports were
retrospectively audited in the facilities outlined in Table 1. Data on ANC attendance and on
completion of key interventions required to provide a high standard of care were collected. Women
who did not attend antenatal care at all were excluded. Among women who had attended ANC
care, the most frequent number of visits by the end of pregnancy was 3, many women had only 2
visits, and some women had 4 or more visits. Mean number of visits was 2.9 (SD 1.2). This reflects
the high use of health services during pregnancy and womens willingness to engage with the
health system.
58
N u m b e r o f A N C v is it s d u r in g p r e g n a n c y b y c a t e g o r y
1
P r o p o r t io n
.8
1 A N C v is it
2 A N C v is it s
3 A N C v is it s
4 A N C v is it s
5 + A N C v is it s
.6
.4
.2
H C H os
HC Hos
HC Hos
H C H os
B la n t y r e
K a ro n g a
M c h in ji
M u la n je
Q u a lit y A N C a r e in d ic a t o r s : A ll d is t r ic t s
0 .9 1
0 .5 5
G A r e c o r d e d a t 1 s t v is it
E D C re c o rd e d
S F H re c o rd e d
H b re c o rd e d
I r o n p r e s c r ib e d
W e ig h t r e c o r d e d a ll v is it s
H IV te s t d o n e
S P g iv e n
B P d o n e e v e r y v is it
S y p h ilis s c r e e n in g
B a c t e r u r ia s c r e e n in g
0 .8 3
0 .2 9
0 .9 2
0 .9 1
0 .8 8
0 .7 6
0 .4 5
0 .1 4
0 .0 2
.2
.4
.6
P r o p o r t io n
60
.8
B P c h e c k e d a t e a c h v is it
b y n u m b e r o f v is it s w o m a n h a d
P e r c e n t h a v in g B P a t e v e r y v is it
100
80
60
40
20
i e W o m a n b y 2 n d v is it h a d 2 B P s in p r e g n a n c y , b y 3 r d v is it h a d 3 B P s in p r e g n a n c y , e t c
Q u a lit y A N C a r e in d ic a t o r s : B la n t y r e
0 .6 5
0 .5 2
G A r e c o r d e d a t 1 s t v is it
E D C re c o rd e d
S F H re c o rd e d
H b re c o rd e d
I r o n p r e s c r ib e d
W e ig h t r e c o r d e d a ll v is it s
H IV te s t d o n e
S P g iv e n
B P d o n e e v e r y v is it
S y p h ilis s c r e e n in g
B a c t e r u r ia s c r e e n in g
0 .8 0
0 .4 1
0 .8 8
0 .9 6
0 .8 2
0 .7 2
0 .5 1
0 .2 9
0 .0 4
.2
.4
.6
P r o p o r t io n
61
.8
Q u a lit y A N C a r e in d ic a t o r s : M c h in ji
0 .9 1
G A r e c o r d e d a t 1 s t v is it
E D C re c o rd e d
S F H re c o rd e d
H b re c o rd e d
I r o n p r e s c r ib e d
W e ig h t r e c o r d e d a ll v is it s
H IV te s t d o n e
S P g iv e n
B P d o n e e v e r y v is it
S y p h ilis s c r e e n in g
B a c t e r u r ia s c r e e n in g
0 .6 0
0 .7 0
0 .3 4
1 .0 0
0 .8 4
0 .8 3
0 .9 7
0 .6 9
0 .0 6
0 .0 3
.2
.4
.6
P r o p o r t io n
.8
Q u a l it y A N C a r e in d ic a t o r s : K a r o n g a
0 .9 8
0 .5 7
G A r e c o r d e d a t 1 s t v is it
E D C re c o rd e d
S F H re c o rd e d
H b re c o rd e d
I r o n p r e s c r ib e d
W e ig h t r e c o r d e d a ll v is it s
H IV te s t d o n e
S P g iv e n
B P d o n e e v e r y v is it
S y p h ilis s c r e e n in g
B a c t e r u r ia s c r e e n in g
0 .0 0
0 .9 8
0 .1 2
0 .9 1
0 .9 3
0 .9 8
0 .6 5
0 .2 7
0 .0 0
.2
.4
.6
P r o p o r t io n
.8
Q u a lit y A N C a r e in d ic a t o r s : M u la n je
1 .0 0
0 .3 5
G A r e c o r d e d a t 1 s t v is it
E D C re c o rd e d
S F H re c o rd e d
H b re c o rd e d
I r o n p r e s c r ib e d
W e ig h t r e c o r d e d a ll v is it s
H IV te s t d o n e
S P g iv e n
B P d o n e e v e r y v is it
S y p h ilis s c r e e n in g
B a c t e r u r ia s c r e e n in g
0 .7 1
0 .2 9
0 .9 5
0 .8 6
0 .8 6
0 .9 0
0 .3 0
0 .3 8
0 .0 0
.2
.4
.6
P r o p o r t io n
.8
63
At the major district and referral hospitals neonatal cots make up 3.6 to 4.8% of the total bed
capacity. Staffing ratios for the care of sick newborns varied. In labour ward midwives were
responsible for a mean of 6.5 newborns at any time, but ranged up to 30 babies per midwife. In
newborn nursery wards the mean ratio was 6, though in large units with high acuity and complexity
the ratio was as high as 23. In peripheral health centres the ratio was 5.7 babies per staff member.
The availability of services, drug and equipment was assessed on a scale of always, intermittently or
never available. And over 12 months, the last three months, and observed by the surveillance team
on the day of the visit. Data presented here reflect availability in the last three months prior to the
audit visit.
Table 7: Uninterrupted supply of services, drugs and equipment for ANC during the last 3 months
Uninterrupted availability of supply
Antenatal care
Per cent
Syphilis VDRL
17
Benzylpenicillin
44
Syringes
78
Smoking cessation materials
0
Working sphygmomanometer
28
Stethoscope
61
Pinard
83
Calcium
6
Urine dipsticks
17
Amoxycillin
61
SP for iPTp
89
Table 8: Uninterrupted supply of services, drugs and equipment for intrapartum care during the
last 3 months
Intrapartum care
Per cent
Erythromycin
56
Corticosteroids
17
Tocolytics
56
Partogram
50
Management guidelines
0
Neonatal bag & mask
72
Dedicated space for newborn
resuscitation
83
Chlorhexidine for cord
22
Baby hats
17
Baby blanket
17
Delayed cord clamping
72
Drying & delayed bathing
100
64
The impact of the lack of drugs and equipment was well identified and described by mothers who
had recently given birth to a preterm infant:
Three weeks ago I came to hospital in (preterm) labour with my twinsthe nurses said you have to
go and buy the drugs now to help the babys lungs..I went..I did my best but there were no drugs to
buyand then my babies were born too early and one died (Mother of surviving twin born at 1900
grams KMC Unit)
Similarly the lack of basic equipment, particularly for providing thermoregulation to preterm
infants was noted by many health care providers working in health centre as a key contributing
factor to the high number of newborn deaths, most of which occur before transfer to hospital:
I feel too sad when we have babies born early herethe mothers do not come ready.. no wraps, no
hat and we dont have any blanketsso we are trying to deliver the placenta and look after the
mother and the baby just lies there in the coldnothing to keep it warm, nothing (NMT, Health
Centre)
Our small babies often die before they get to they reach the district hospitalwhat can we do, they
are born and we have no way to keep them warm, so they die of cold (NMT, Health Centre talking
about preterm babies referred to the DHO for further care)
Clinical guidelines
The lack of clinical guidelines and protocols around EmONC, particularly management of preterm
labour was found to compromise the health care providers decision making and ability to provide
high quality of care. Midwives were not familiar with drug doses for steroids or tocolytics and often
relied on doctors or clinical officers to provide this information. However, it was apparent that
there were also knowledge gaps among these cadres also:
Yes..I have worked with a clinical officer who will just write in the medical record give the drug
dose as per protocol but I ask..what is the protocol?.. and he says to me I dont know..I thought
you would know..so really no one knows! (Midwife, DHO)
65
Table 9: Uninterrupted supply of services, drugs and equipment for postnatal newborn care
Uninterrupted availability of supply
Postnatal newborn care
Newborn bag & mask
Airway suction equipment (nasal bulb)
Dedicated space for newborn resuscitation
Sink with running water
Soap
Chlorhexidine
Baby hats
Baby blankets
Space for Kangaroo Mother Care
Individual cot for every baby
Overhead heater
Heated cot
Oxygen concentrator
Splitter for concentrator
Oxygen tubing
Oxygen cylinder
Oxygen saturation monitor
Weighing scale
Bilirubin measurement available
Phototherapy facility
Aminonophylline
Penicillin
Gentamicin
Cloxacillin
Ceftriaxone
Nevirapine
Vitamin K
Tetracycline Eye Ointment
Phenobarbitone
Glucometer
Glucometer sticks
Sharps bin
Paediatric IV cannulae (22/24G)
IV giving sets
Paediatric IV burettes
Nasogastric tubes (Sizes 6/8Fr)
Infant formula
Equipment for expressing breast milk
Facility for EBM labelling & storage
Calibrated cups for cup feeding
Referral guidelines
Infant feeding guidelines
Functioning telephone/communication
Drug dosing guidelines
Newborn observation chart
Per cent
56
44
56
83
28
11
33
39
44
17
17
6
28
22
17
6
6
78
17
11
50
61
44
6
33
94
17
94
28
17
11
56
56
89
0
22
6
6
0
28
6
33
78
22
22
66
Table 10: Uninterrupted supply of services, drugs and equipment for postnatal maternal care
Uninterrupted availability of supply
Postnatal maternal care
Per cent
Condoms given on discharge
11
IUD insertion available
11
Contraception given on discharge
22
Promotion of birth spacing
33
Home based postnatal visit for pre-terms
6
M&E tool for audit of pre-term care
89
Facility has active quality improvement
39
67
U n in t e r r u p t e d a v a ila b ilit y in la s t 3 m o n t h s
A n t e n a t a l e q u ip m e n t - a ll d is t r ic t s
0 .7 8
0 .6 1
S y r in g e s
S te th o c o p e
P in a r d
W o r k in g B P c u f f
0 .8 3
0 .2 8
.2
.4
.6
.8
Figure 28: Uninterrupted availability of antenatal equipment in all districts during the last 3 months
U n in t e r r u p t e d a v a ila b ilit y in la s t 3 m o n t h s
I n t r a p a r t u m e q u ip m e n t / d r u g s - a ll d is t r ic t s
0 .5 6
0 .1 7
E r y t h r o m y c in
C o r t ic o s t e r o id s
T o c o ly t ic s
P a rto g ra m s
G u id e lin e s
0 .5 6
0 .5 0
0 .0 0
.2
.4
.6
.8
Figure 29: Uninterrupted availability of intrapartum drugs/equipment in all districts during the
last 3 months
68
U n in t e r r u p t e d a v a ila b ilit y in la s t 3 m o n t h s
L a b o u r w a r d n e w b o r n e q u ip m e n t - a ll d is t r ic t s
0 .7 2
0 .8 3
0 .2 2
0 .1 7
0 .1 7
1 .0 0
0 .7 2
.2
.4
.6
.8
Figure 30: Uninterrupted availability of labour ward equipment for newborns in all districts
during the last 3 months
U n in t e r r u p t e d a v a ila b ilit y in la s t 3 m o n t h s
N e o n a t a l e q u ip m e n t - a ll d is t r ic t s
0 .5 6
0 .8 3
0 .3 3
0 .3 9
0 .0 6
0 .1 1
0 .2 8
0 .0 6
0 .7 8
0 .1 1
0 .4 4
.2
.4
.6
.8
Figure 31: Uninterrupted availability of neonatal equipment during the last 3 months
69
U n in t e r r u p t e d a v a ila b ilit y in la s t 3 m o n t h s
N e o n a t a l d r u g s - a ll d is t r ic t s
0 .6 1
0 .4 4
B e n z y lp e n c illin
G e n t a m ic in
C lo x a c illin
C e f t r ia x o n e
N e v ir a p in e
V it a m in K
A m in o p h y llin e
P h e n o b a r b it o n e
T e t r a c y c e y e o in t
0 .0 6
0 .3 3
0 .9 4
0 .1 7
0 .5 0
0 .2 8
0 .9 4
.2
.4
.6
.8
Figure 32: Uninterrupted availability of neonatal drugs in all districts during the last 3 months
Figure 33: Quality of care provided to preterm infants during the 1 st 24 hours of admission to
neonatal nursery
Figure 34: Quality of care provided to preterm infants in the 1st 24 hours of neonatal nursery
admission for respiratory distress syndrome
71
Figure 35: Quality of care provided to preterm infants in the 1st 24 hours of neonatal nursery
admission for hypothermia/suspected sepsis
Item/Service
Folic acid supplementation
Tetanus toxoid immunization
Syphilis screening and treatment
Calcium supplementation
Treatment for malaria
Detection and treatment of asymptomatic bacteria
Antibiotics for preterm
premature rupture of membranes
Corticosteroids for preterm labor
Detection and management of breech
Partographs for labor surveillance
Clean delivery practices birth kits
Running water and soap
Bag and mask for resuscitation of newborn
Kangaroo Mother Care
Prevention and management of hypothermia
Radiant heaters or other heating devices
Thermometers
Hats
BSL monitors
Tocolytic Nifedipine
Tocolytic Salbutamol
Tocolytic Indomethacin
Promotion of breastfeeding
72
40
8
8
64
48
32
48
12
48
0
64
4
0
16
20
4
56
16
24
32
4
44
64
44
0
8
40
24
32
36
20
28
20
100
4
20
0
0
4
0
0
0
32
40
24
52
44
52
48
64
24
Stakeholder interviews
Safe Motherhood coordinators
Interviews were conducted with 25 of 27 district Safe Motherhood coordinators. Their opinions
were sought on the challenges in their district relating to care delivery of maternal and newborn
services, and about the availability or lack of such services. A summary of the availability of services
is shown in the table below. Tetanus toxoid, malaria treatment, antibiotics for premature rupture,
partograph for labour surveillance, bag and mask for resuscitation are reported to be universally
available. Though the findings in our review presented above differ from these reports. Calcium
supplementation, treatment of asymptomatic bacteriuria, blood sugar monitoring and use of
tocolytics is limited. According to the safe motherhood coordinators an average of 69% of women
attending the postnatal services and 66% of newborns received postnatal care within 2 days of
birth. Up to 80% of the sites reported to practice community case management for pneumonia. This
is provided by HSAs based on IMCI defined case definitions.
Up to 96% of the districts reported HBB as an intervention aimed at improving newborn health.
Majority are supported by NGOs to deliver this intervention (training etc.). Ambulances are in short
supply, with only 1 vehicle shared among 10 facilities. Many coordinators reported anecdotal
reports of maternal deaths occurring while awaiting appropriate transportation. Some specifically
mentioned awaiting disbursement of funds for fuel from central level. The availability of facilities
able to provide BEmOC and CEmOC was also only 1 in every 10 facilities.
Safe Motherhood coordinators identified the three major causes of newborn death as birth
asphyxia (92% of respondents), prematurity (60%) and neonatal sepsis (48%). Causes of preterm
birth mentioned included:
they were also reasonably non-specific strategies, and even when prompted for more specific
interventions in their districts that could make an immediate difference there was a tendency for
the coordinators to remain vague about the required steps.
Barriers to improving quality of care that were listed included:
1. Lack of capacity
2. Long distances to facilities
3. Religion and culture
4. Low staff and low motivation
5. Lack of knowledge
6. Poverty
Health care providers and management staff
Thirty four additional interviews with key stakeholders working in maternal and newborn health
across the 19 surveyed health facilities were undertaken. Interviews were conducted to understand
stakeholder perspectives on the key reasons for the high rate of preterm birth in Malawi, strategies
needed to reduce preterm birth and improve newborn survival overall and barriers to
implementing these strategies. Interview participants were predominantly senior nurse midwives
and clinical officers as well as paediatricians, obstetricians, paediatric and obstetric registrars and
health service managers.
The most prevalent reasons cited by participants for Malawi's high preterm birth rate were the high
burden of pre-existing maternal infections such as HIV and malaria, malnutrition, teenage
pregnancies and poor socio economic status of women and their families.
The majority of participants focused on the need to improve the quality, content and access to
antenatal care as a strategy to improve newborn survival and reduce preterm birth. Antenatal care
which included the provision of nutritional supplements, access to all screening services and
preventative treatment for syphilis, malaria and anaemia and improving health education and
counselling particularly for adolescents were viewed as the main areas that require strengthening in
ANC services. Other strategies cited by participants included improve health care providers ability
to deliver newborn resuscitation, improving the quality of pre-service education around the
management of early newborn illness, improving the resourcing and functioning of neonatal
nurseries to include CPAP and increasing the availability of antenatal corticiosteroids for the
prevention of preterm birth.
Community based strategies were infrequently reported but those that were reported included the
need to provide community sensitization on the benefits of early ANC and the consequences of
preterm birth, particularly to adolescents and males.
Many challenges exist for the effective implementation of these strategies. These challenges and
barriers most frequently related to the of unavailability of drugs (steroids, tocolytics, antibiotics)
and equipment for essential newborn care such as resuscitation equipment, hats and blankets. Poor
supply chain management, procurement processes and insufficient funding for newborn health
were thought to be the major contributing factors to the unreliable supply of drugs, equipment and
ambulances needed for referral of newborns from health centres to referral hospitals. A lack of
74
motivation by staff to provide high quality care was also thought to be contributed to by
inadequate numbers of trained staff, lack of incentives to work long hours, overtime or in rural
areas, low salaries and few opportunities to improve knowledge and skills through in-service
training or courses.
Many participants also discussed the lack of engagement by health services with males around
reproductive and newborn health care. Participants reported health staff often not being
welcoming or inclusive of male involvement around women's health care issues. This was seen as a
major reason for women reporting late in pregnancy for ANC, choosing to birth at home and care
seeking delays for the mother and infant. As decisions for care seeking are largely influenced by the
male in the household, a lack of engagement with males around reproductive health issues was
thought to contribute to men not valuing the importance of early ANC, nutrition for women in
pregnancy or treatment seeking for complications. This is an especially important issue and should
be investigated more fully. Cultural and religious beliefs were also seen as barriers to early care
seeking by women for preterm birth and for infants with illness.
Pre-service training for health care providers
Interviews with lecturers providing medical and midwifery pre-service education identified major
gaps in curriculum related to the management of preterm labour and care of the preterm infant.
This content is typically covered in lectures and for medical students and knowledge and skills
consolidated in a specific rotation through the newborn nursery as part of their paediatric training
to develop skills in preterm management. However, lecturers believed that the curriculum was not
sufficiently comprehensive and required review.
Midwifery students are not assessed in the clinical area on their knowledge and skills of preterm
management of labour and birth. Further, there is an absence of guidelines in the management of
premature labour in the clinical area and mentoring by midwives around this issue does not appear
to be well done. Typically, women who present in early preterm labour are sent to the antenatal
ward where monitoring of these women is difficult and students do not receive enough hands on
experience caring for these women. Furthermore, midwives do not prescribe medication for
women with preterm labour and medications such as antenatal corticosteroids are often
unavailable. As a result, students do not acquire adequate knowledge and skills required to
competently care for women in preterm labour and early management of preterm infants.
Community level barriers to improving newborn outcomes
Delays in decision making for care seeking
Interviews with mothers of preterm infants (n=14) and FGDs demonstrated a good understanding
of the causes of preterm birth and danger signs in pregnancy. Women generally lacked autonomy in
health care decision-making. Care seeking was delayed by nearly all women until permission was
obtained from their husband or other relative, even though the women knew they were
75
experiencing danger signs. Once permission had been sought to access care, most women walked
alone for 1-3 hours to a health centre due to a lack of alternative transport or funds for transport.
Timely access to services
Many women reported difficulties obtaining appropriate treatment once they reached a health
facility and waiting for more than two hours at times to be seen, despite telling staff that their baby
was coming too early. Most women interviewed delivered at the health facility and their babies
transferred to a neonatal unit at the hospital after birth. Seasonal factors, distance from health
facility, poor roads also contributed to delays in accessing care.
Cost
The hospital related costs for most women who had a preterm infant in the KMC unit was
equivalent to their entire family salary or more. Some families resorted to acquiring loans or selling
animals to cover the cost of the hospital stay. This was despite government hospitals providing free
care for newborn infants. Most women either had a small business or were married to a farmer or
small business owner. Food, transport for family members to and from the hospital and loss of
income represented the major costs to families. Two women described their worry regarding ongoing costs if their infant had future health problems resulting from preterm birth. Women were
not given an option to relocate to a health facility with a KMC unit closer to their home, despite
most of them living in districts where KMC was provided.
Stigma resulting from preterm birth
Participants in FGDs and mothers of preterm infants spoke of the stigma and shame that
surrounded prematurity in their home villages: To have a small baby it is like your body has failed
you. Women were blamed at times for their preterm birth as in some communities it represented
womens infidelity to their husbands. All women interviewed were happy to provide KMC within
the confines of the hospital KMC unit and felt supported by other mothers who also had preterm
infants but some were reluctant to continuously provide KMC outside of the hospital, especially in
their home village or market as they would be laughed at or mocked.
Conclusion
There is strong government commitment and investment towards improving newborn health in
Malawi. Many active collaborations and strategies are currently being implemented with
development partners to address newborn health issues. However, challenges still exist at the
community, district and referral levels for newborn care. These include timely and affordable access
to health care services, stigma and cultural practices, broader health systems issues related to
consistent availability of drugs, supplies and equipment, adequate human resources as well as the
knowledge and skills of health care providers caring for preterm or sick newborns.
76
77
CHAPTER 5 Recommendations
Malawi has made great strides towards improving newborn health and reducing mortality. It is one
of the few countries on track to achieve MDG 4. There are many immediate opportunities for action
to reduce the major causes of newborn death in Malawi at the community and health service level.
The priority recommendations are:
Community level:
1. Conduct community sensitization for all members of the community (including males)
regarding preterm birth and neonatal infections encourage early recognition of danger
signs for preterm birth or birth complications and early presentation to a health service, and
the addressing of stigmatisation associated with preterm birth.
2. Engage communities in early birth preparedness for ALL mothers but focus on those with a
history of preterm birth, still birth, pre-eclampsia or adolescent pregnancy. Encourage the
use of maternity waiting homes, planning for birth at a health facility and emergency
transport
3. Reduce the economic burden of a hospital stay on women and their families for preterm or
referral mechanisms between communities and health facilities, including managerial and
financial arrangements that ensure continuous availability of fuel for emergency transport
vehicles.
78
3. Improve the quality and coverage of antenatal care: screening and management of urinary
tract infections, sexually transmitted infections, high blood pressure and proteinuria, HIV,
IPTp, tetanus toxoid, early antenatal nutritional packages iron/folate and micronutrient
supplementation for mothers/adolescent girls, counselling on danger signs and essential
newborn care practices.
4. Introduction of chlorhexidine for cord care for institutional deliveries
5. Increase coverage and ensure continuous availability of antenatal corticosteroids and
tocolytics for the prevention of preterm birth and antibiotics for preterm labour, including
appropriate prescribing rights for practitioners. Ensure local policy allows for non-clinician
health care providers to administer steroids or tocolytics without having to wait for a
doctors prescription.
6. Recruit and retain staff who can provide high quality maternal and newborn care Increase
coverage of supportive supervision and mentoring for staff and students. Provide
competency based training and assessments in emergency obstetric and newborn care (i.e.:
Helping Babies Breath and Making it Happen programmes) and case management of
newborn illness for all health care providers working in maternal and newborn health
services. Ensure that all birth attendants are appropriately skilled in newborn resuscitation.
7. Increase coverage of early postnatal care in the community by health surveillance assistants
infection and hypothermia (skin to skin contact, drying, hat and blanket, delayed cord
clamping, early breastfeeding initiation)
9. Improve the availability of management and referral guidelines and protocols for the
assessment and management of preterm labour, preterm and sick newborns and the
administration of corticosteroids.
10. Implement regular standards based audits to measure quality of care provided for
management of newborn illness, birth asphyxia and preterm birth. Facilities with poor
performance (for example in being able to provide bag and mask ventilation to a newborn)
should undergo retraining and be accountable for poor performance and commended for
good performance or improving performance. Audit and feedback has been shown to
improve clinical performance of health care providers 123. A recent qualitative study in
Thyolo and Thekerani District Hospitals showed that staff considered audit and feedback
79
valuable tools to enhance the quality of care provided and this has become routine in this
district 124.
11. Review the content and quality of pre-service curriculum for the recognition and
management of preterm labour, birth and care of the preterm infant. Integration of
standardized competencies for management of preterm labour, asphyxia, treatment of
newborn infection as part of all pre-service education and more hands on practical skills for
students.
12. Engagement of regulatory boards (nursing and medical) to establish competencies in
emergency obstetric and newborn care as part of annual re-registration requirements for
health care providers working with mothers and babies
Additional recommendations to consider:
13. Immunisation Beyond maternal tetanus toxoid vaccination, there is evidence that
influenza vaccine reduces rates of preterm birth 125. Studies are underway in South Africa
to assess the impact of maternal influenza vaccination on infant morbidity. Given the high
rate of neonatal mortality and of preterm birth in Malawi, a study in Malawi of the impact
of maternal influenza vaccination on neonatal mortality, birth weight and preterm birth
should be considered. A phase 2 trial of maternal Group B streptococcal (GBS) vaccine has
been conducted in Blantyre though results have not yet been published. Further trials on
the role of GBS vaccine or of maternal pneumococcal vaccination should be considered
80
Conclusion
Whilst Malawi has made remarkable progress towards achieving MDG 4 over the past decade,
neonatal mortality remains high. Infections, preterm birth and birth asphyxia account for the majority
of neonatal deaths in Malawi. There are many existing solutions that can save the lives of these
newborns and improve the health of their mothers. At the community level, these solutions include
ensuring adequate transport, education, sanitation and timely and affordable access to high quality
routine and emergency services during pregnancy, birth and in the postpartum period. The quality and
coverage of pregnancy, birth, postpartum and neonatal nursery services must be addressed through
further human resource investments and consistent and reliable availability of drugs, supplies,
equipment and treatment guidelines to provide effective care and ultimately improve outcomes.
Pre service education of health care providers also needs to ensure sufficient knowledge and skills in
caring for sick and preterm newborns. Evidence based interventions such as chlorhexidine for cord
care and antenatal corticosteroids have a major role to play in improving newborn survival however
are not yet widely available in Malawi. Increasing the coverage of high impact interventions and
strengthening the quality of care provided to mothers and their newborns could save many lives and
increase Malawis chances of achieving MDG 4.
81
The major barrier to implementation of corticosteroid therapy is the difficulty of identifying women
at risk of preterm delivery in time to administer corticosteroids. This requires an effective and wellutilized antenatal service. Successful implementation of this intervention would involve:
Education of health-care providers regarding the effectiveness and implementation of corticosteroid therapy
Introduction of protocols for its use
Identification of women at risk, including effective antenatal screening for urinary tract infections,
sexually transmitted diseases hypertension and proteinuria, as preeclampsia is an important cause
of preterm delivery in low-income countries;
Providing information to pregnant women. The information to pregnant women would need to focus on early reporting to a health facility at the first signs of pregnancy complications such as preterm uterine contractions, preterm rupture of membranes and symptoms of pre-eclampsia.
The trials on corticosteroid use in preterm labour were all done in a health facility. It is therefore
important that perhaps Malawi should start implementing use of corticosteroids at a health facility
level. A phased approach can be used where implementation starts with the central hospitals,
CHAM and district hospitals. Implementation at a health centre level would be the last phase.
Lessons learnt need to be drawn at each stage of the process.
Standardised guidelines on maternal corticosteroid use in preterm labour
Malawi recently developed draft guidelines on maternal corticosteroid use in preterm labour. These
guidelines need to be finalised and made available in all health facilities and all undergraduate
82
clinical, medical and nursing colleges. Inclusion of these guidelines in the undergraduate
programmes will ensure sustainability in the long term.
This being a new guideline there is need for training of all staff involved in managing women in
preterm labour. There is also need for continuous refresher trainings that could be built in within
the continuous professional development programme. A system needs to be in place that ensures
regular updating of the guidelines. There is need for posters carrying the corticosteroid messages,
which will act as a reminder to health care providers.
The community needs to be sensitized on the significance of women in preterm labour presenting
early to a health facility and on the role of corticosteroids in the management of preterm labour
and their impact on outcome of the newborn. This will hopefully help with acceptability of this new
policy.
Availability of Corticosteroids
Dexamethasone and betamethasone are the 2 reported corticosteroids that have shown an impact
on neonates that were born premature. Dexamathasone is however less expensive and readily
available compared to betamethasone and it would be better for Malawi to pick dexamethasone as
the corticosteroid of choice. Dexamethasone for prevention of respiratory distress syndrome needs
to be added on the essential drug list for Malawi.
Malawi needs to build up a system of sustained availability of corticosteroids to the most peripheral
facility. It was very clear even from the QECH where steroids were being used that not uncommonly
were the women requested to go and buy the steroids from a private pharmacy and this led to
delays or failure in administering the steroids to women in preterm labour.
Preterm labour should be treated as an emergency as such the corticosteroids should be treated as
an emergency drug. They should be part of the drugs available in the emergency drug box so as to
ensure their availability round the clock. This will ensure that every woman who presents in
preterm labour should be able to access the drugs regardless of the time of day that they present.
Who Prescribes Corticosteroids?
There is need for clear guidelines on who prescribes the corticosteroids. Midwives and clinicians
should be able to prescribe the steroids for women in preterm labour.
In most of the health facilities a clinician will not be available round the clock on the maternity unit
but a midwife is much more likely to be available and as such giving them the go ahead to prescribe
and administer steroids to women in preterm labour would have a positive impact. There is need to
consult regulatory bodies on the issue of midwives being allowed to prescribe corticosteroids.
83
Appendices
Appendix 1: Health facility assessment tool
Appendix 2: Maternity registration tool
Appendix 3: FGD guide Men and Women
Appendix 4: Newborn case record Quality of Care form
Appendix 5: Antenatal audit form
Appendix 6: Phone questionnaire
84
1.
2.
3.
4.
5.
6.
7.
Name: ___________________________________________________________
Job title: _________________________________________________________
Phone number: __________________________________________________
Email: ___________________________________________________________
85
Facility data
8.
__________________________________________________________
9.
SEEN TODAY
AVAILABLE LAST 3
MONTHS?
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
Syringes available
YES NO
Always available
Stock outs occur
Not available
Needles available
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
87
Not available
Oral amoxycillin in stock available in labour ward
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
88
INTRAPARTUM/LABOUR WARD
INTERVENTION
SEEN TODAY
AVAILABLE LAST 3
MONTHS?
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
SEEN TODAY
YES NO
Always available
Not functional/missing
Not available
YES NO
Always available
Not functional/missing
Not available
YES NO
Always available
Stock out
Not available
Soap
YES NO
Always available
Stock out
Not available
YES NO
Always available
Stock out
89
Not available
Baby hats
YES NO
Always available
Stock out
Not available
Blankets
YES NO
Always available
Stock out
Not available
YES NO
Always available
Inconsistently done
Not done
YES NO
Always available
Inconsistently done
Not done
SEEN TODAY
AVAILABLE LAST 3
MONTHS?
YES NO
Always available
Not functional/missing
Not available
YES NO
Always available
Not functional/missing
Not available
YES NO
Always available
Not functional/missing
Not available
YES NO
Always available
Stock out
Not available
Soap
YES NO
Always available
Stock out
Not available
YES NO
Always available
Stock out
Not available
Baby hats
YES NO
Always available
Stock out
Not available
90
Blankets
YES NO
Always available
Stock out
Not available
YES NO
Always available
Sometimes share
Not available
YES NO
Always available
Sometimes share
Not available
Overhead heaters
YES NO
Always available
Not functional/missing
Not available
YES NO
Always available
Not functional/missing
Not available
Oxygen concentrator
YES NO
Always available
Not functional/missing
Not available
YES NO
Always available
Stock out
Not available
YES NO
Always available
Stock out
Not available
Oxygen cylinder
YES NO
Always available
Stock out
Not functional/missing
Not available
Saturation monitor
YES NO
Always available
Not functional/missing
Not available
Weighing scales
YES NO
Always available
Not functional/missing
Not available
YES NO
Always available
Not functional/missing
Not available
YES NO
Always available
Not functional/missing
91
Not available
Aminophylline
YES NO
Always available
Stock outs occur
Not available
Pencilling
YES NO
Always available
Stock outs occur
Not available
Gentamicin
YES NO
Always available
Stock outs occur
Not available
Cloxacillin
YES NO
Always available
Stock outs occur
Not available
Ceftriaxone
YES NO
Always available
Stock outs occur
Not available
Nevirapine
YES NO
Always available
Stock outs occur
Not available
Vitamin K
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
Phenobarbitone
YES NO
Always available
Stock outs occur
Not available
Glucometer
YES NO
Always available
Stock outs occur
Not functional/missing
Not available
Glucometer sticks
YES NO
Always available
Stock outs occur
Not functional/missing
Not available
Sharps bin
YES NO
Always available
Stock outs occur
Not available
92
YES NO
Always available
Stock outs occur
Not available
IV giving sets
YES NO
Always available
Stock outs occur
Not available
Paediatric burettes
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
Infant formula
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Inconsistently available
Not available
YES NO
Always available
Inconsistently available
Not available
YES NO
Always available
Inconsistently available
Not available
YES NO
Always available
Inconsistently available
Not available
YES NO
Always available
93
Inconsistently available
Not available
Newborn observation chart
YES NO
Always available
Inconsistently available
Not available
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Stock outs occur
Not available
YES NO
Always available
Inconsistently available
Not available
YES NO
Always available
Inconsistently done
Not available
YES NO
Always available
Inconsistently done
Not available
YES NO
Always available
Inconsistently done
Not available
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
PRETERM BIRTH REFERRALS:
Does this facility receive referrals of women in preterm labour and preterm infants from other facilities?
YES NO
If YES, list the 5 main facilities from which referrals occur and their distance from the receiving facility:
1. Name: ________________
2. Name: ________________
3. Name: ________________
4. Name: ________________
5. Name: ________________
Distance: _____________(km)
Distance: _____________(km)
Distance: _____________(km)
Distance: _____________(km)
Distance: _____________(km)
Does the facility refer out to other health facilities women in preterm labour and infants born preterm
out? YES NO
If Yes, list the 3 main facilities to which cases are referred and their distance from the referring facility
1. Name: ________________ Distance: _____________(km)
2. Name: ________________ Distance: _____________(km)
3. Name: ________________ Distance: _____________(km)
The most common form of transport for the referral is? (select 1 option only)
Road ambulance
95
Bicycle ambulance
Minibus
Private car/motorbike
Private bicycle
Walk
Other
If a road ambulance is requested in an emergency, how long does it take for it to arrive at your facility?
(select 1 option only)
Less than 1 hour
Less than 3 hours
Less than 6 hours
Up to 24 hours
Longer than 24 hours
Ambulance never arrives
96
97
Total number of all births <37 weeks (include both live births and stillbirths)
Total number of live births
Total number of live births <37 weeks
For stillbirths only total number fresh stillbirths
For stillbirths only total number macerated stillbirths
Total number of births attended by a qualified or skilled birth attendant
Total number of births attended by a patient or ward attendant or cleaner
Total number of births attended by any other person (family member, TBA, etc.)
August 2012
Total number of all births (include both live births and stillbirths)
Total number of all births <37 weeks (include both live births and stillbirths)
Total number of live births
Total number of live births <37 weeks
For stillbirths only total number fresh stillbirths
For stillbirths only total number macerated stillbirths
Total number of births attended by a qualified or skilled birth attendant
Total number of births attended by a patient or ward attendant or cleaner
Total number of births attended by any other person (family member, TBA, etc.)
September 2012
Total number of all births (include both live births and stillbirths)
Total number of all births <37 weeks (include both live births and stillbirths)
Total number of live births
Total number of live births <37 weeks
For stillbirths only total number fresh stillbirths
For stillbirths only total number macerated stillbirths
Total number of births attended by a qualified or skilled birth attendant
98
100
January 2013
Total number of all births (include both live births and stillbirths)
Total number of all births <37 weeks (include both live births and stillbirths)
Total number of live births
Total number of live births <37 weeks
For stillbirths only total number fresh stillbirths
For stillbirths only total number macerated stillbirths
Total number of births attended by a qualified or skilled birth attendant
Total number of births attended by a patient or ward attendant or cleaner
Total number of births attended by any other person (family member, TBA, etc.)
February 2013
Total number of all births (include both live births and stillbirths)
Total number of all births <37 weeks (include both live births and stillbirths)
Total number of live births
Total number of live births <37 weeks
For stillbirths only total number fresh stillbirths
For stillbirths only total number macerated stillbirths
Total number of births attended by a qualified or skilled birth attendant
Total number of births attended by a patient or ward attendant or cleaner
Total number of births attended by any other person (family member, TBA, etc.)
March 2013
Total number of all births (include both live births and stillbirths)
Total number of all births <37 weeks (include both live births and stillbirths)
Total number of live births
Total number of live births <37 weeks
101
102
May 2013
Total number of all births (include both live births and stillbirths)
Total number of all births <37 weeks (include both live births and stillbirths)
Total number of live births
Total number of live births <37 weeks
For stillbirths only total number fresh stillbirths
For stillbirths only total number macerated stillbirths
Total number of births attended by a qualified or skilled birth attendant
Total number of births attended by a patient or ward attendant or cleaner
Total number of births attended by any other person (family member, TBA, etc.)
103
104
Say: Around here some women give birth early. It would be helpful to hear more about this in (whatever
district you are in).
What do we mean by preterm birth? How many months should a pregnancy last for?
Have any of your wives or close female relatives every had a baby born too early?
What happened? What were the signs that the baby was coming early? Did the women receive any
care? Who provided this?
If a woman in your community is experiencing preterm labour or baby being born too early what can
she and her family do?
Is there anything that they can try at home to solve the problem?
Where can they go and get help in your community?
Should they go to a health facility? Which kinds of health facilities can they go to?
What kinds of arrangements do they need to make if they decide to go to a health facility?
What kind of transport can they take to get to a health facility?
What do you think can happen for the mother once they get to a facility?
DECISION MAKING
Say: If a women in your family was having some pregnancy problems, such as being in preterm labour we
want to find out how decisions are made for the women to get care.
Who would make the decision about where she would get care?
Who would decide when she would get care?
**If it is men saying they would make decisions, Ask: What would make you decide that the woman needs
care/or agree to the woman getting care?
STRATEGIES
Say: You have given us lots of information about what you think causes preterm birth and what you think
women should do if they have a preterm labour.
Wed like to know what are some of the ways that you can think of to prevent preterm birth?
What are your thoughts about this a medicine like this being used on pregnant women who have
preterm labour?
105
If this were available to your wife or someone you knew who was having a preterm labour, would
you think it was a good idea for them to take this?
Say: Thank you for answering all our questions about preterm birth. Your answers have been very helpful.
Maybe you have thought of something that we have left out. Is there anything else that youd like to tell
me/us about your experience?
Thank you very much for taking the time to talk and meet with us.
106
What do we mean by preterm birth? How many months should a pregnancy last for?
Have any of you or anyone you know every had a baby born too early?
What happened? What were the signs that the baby was coming early? Did you (or the woman you
know) receive any care? Who provided this?
If a women is experiencing preterm labour or baby being born too early what can she and her family
do?
Is there anything that they can try at home to solve the problem?
Where can they go and get help in your community?
Should they go to a health facility? Which kinds of health facilities can they go to?
107
What kinds of arrangements do they need to make if they decide to go to a health facility?
What kind of transport can they take to get to a health facility?
What do you think can happen for the mother once they get to a facility?
DECISION MAKING
Say: Great. Now, we would like to find out about how decisions are made to seek care for preterm birth.
Who would make the decision about where a woman would get care? Would it usually be the womans decision? Would you need to ask anyone else first?
Who would decide when the woman would get care?
If it is men or other people other than the woman making the decision about the decision to seek
care ask: What would make the man/other person decide that the woman needed care?
STRATEGIES
Say: You have given us lots of information about what you think causes preterm birth and what you think
women should do if they have a preterm labour.
Wed like to know what are some of the ways that you can think of to prevent preterm birth?
BARRIERS TO PREVENT PRETERM BIRTH
Say: Great. You have given us some good ideas about strategies to prevent preterm birth.
Are there any barriers that would stop these ideas from being put into practice? Are there any problems accessing health services for pregnant mothers who need emergency care?
ANTENATAL CORTICOSTEROIDS
Say: There is medicine that can now be given to women who are having their baby too early. This medicine
needs to be given to women when they are in labour through an injection and it is designed to make the
babys lungs strong and reduce their chance of having problems with their breathing when they are born.
This drug stops a lot of babies who are born too early from dying.
What are your thoughts about this a medicine like this being used on pregnant women who have
preterm labour?
If this were available to you or someone you knew who was having a preterm labour, would you
think it was a good idea to take this?
Say: Thank you for answering all our questions about preterm birth. Your answers have been very helpful.
Maybe you have thought of something that we have left out. Is there anything else that youd like to tell
me/us about your experience?
Thank you very much for taking the time to talk and meet with us.
108
Appendix 5: AN audit
Quality of antenatal care audit
1. Name of data collector:________ date: _____________ health facility: _____________________
2.
3.
4.
5.
(If the data are collected retrospectively:) Infant birth weight: _______ (grams)
6.
7.
gravida: ______________
110
8.
9.
111
Participant
number:
1. PARTICIPANT INFORMATION
1a. Participant name: _______________________________________________
1b. Contact phone number and email: ______________________________
1c. Participant job title: _____________________________________________
1d. Name of organisation and location of employment:
____________________________________________________________________
1e. Professional qualifications: _______________________________________
1f. Number of years in current position: _______________________________
2. DISTRICT INDICATORS
District population
Number of health centres
Number of hospitals
Number of BEmOC sites
Number of CEmOC sites
Number of births 2012
Number of live births 2012
Number of stillbirths 2012
Number of NNDs 2012
Number of preterm births 2012
Main causes of newborn death
Percent of women who receive postnatal
112
CURRENT AVAILABILITY
PRECONCEPTION
All hospitals
Folic acid supplementation
ANTENATAL
Tetanus toxoid immunisation
All hospitals
All health centres
Some hospitals
Some health centres
Not available
113
All hospitals
Syphilis screening and treatment
All hospitals
All health centres
Some hospitals
Some health centres
Not available
All hospitals
All health centres
Some hospitals
Some health centres
Not available
INTRAPARTUM
Antibiotics for preterm premature rupture of
membranes
All hospitals
All health centres
Some hospitals
Some health centres
Not available
All hospitals
114
All hospitals
All health centres
Some hospitals
Some health centres
Not available
All hospitals
All health centres
Some hospitals
Some health centres
Not available
All hospitals
All health centres
Some hospitals
Some health centres
Not available
All hospitals
All health centres
115
Some hospitals
Some health centres
Not available
All hospitals
All health centres
Some hospitals
Some health centres
Not available
All hospitals
All health centres
Some hospitals
Some health centres
Not available
All hospitals
All health centres
Some hospitals
Some health centres
Not available
POSTNATAL
Equipment (bag and mask) for resuscitation of
newborn
All hospitals
All health centres
Some hospitals
116
KMC
All hospitals
All health centres
Some hospitals
Some health centres
Not available
Promotion of breastfeeding
All hospitals
All health centres
Some hospitals
Some health centres
Not available
______________
All hospitals
Thermometers
Hats
Some hospitals
BSL monitors
BSL sticks
Not available
Yes No
If yes, who provides this?
3. Are there any other interventions or activities that you know about to improve newborn health taking
place in your district? (HBB training etc.)
118
Yes No
If yes, what are these activities and who are they delivered by (NGO, MOH, community group etc.)?
Activity/intervention
1.
Providers
2.
3.
4.
5.
6.
7.
8.
4. What other strategies are needed to improve newborn survival in this district?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________
5. Malawi has the highest rate of preterm birth in the world. What do you think are the reasons are for this?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________
_________________________________________________________________________________________
_______________________________
120
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