SITUATIONAL ANALYSIS of NEWBORN HEALTH IN MALAWI 2013

Naor Bar-Zeev
Melissa Gladstone
Esther Kungwimba
Bagrey Ngwira
Queen Dube
Sarah Bar-Zeev
28 October 2013
Blantyre, Malawi

This situational analysis of newborn health in Malawi was undertaken for:

Reproductive Health Unit, Ministry of Health Malawi

Through the generous support of the following partners:

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

Acquired Immunodeficiency Syndrome

Antenatal Care
Basic Emergency Obstetric Care
Comprehensive Emergency Obstetric Care
District Health Medical Team
District Health Officer
Essential Health Package
Emergency Obstetric and Newborn Care
Focus group discussion
Helping Babies Breathe
Human Immunodeficiency Virus
Infant Mortality Rate
Intermittent Preventive Therapy during Pregnancy
Intrauterine growth restriction
Kangaroo mother care
Low birth weight
Millennium Development Goal
Ministry of Health
Prevention Mother To Child Transmission
Queen Elizabeth Central Hospital
Quality of care
Sulfadoxine-Pyrimethamine
Sector Wide Approach
United Nations Childrens Fund
World Health Organization

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

The spontaneous loss of a pregnancy which occurs before 28

weeks gestation (this includes if the baby is born alive)
A transitional stage of physical and psychological development
occurring from puberty to adulthood. UNICEF defined age
range: 10-19 years.
A complex multiorgan syndrome arising from lack of oxygen
occurring during the period immediately before, during and
immediately after birth. In clinical practice it is often defined
less specifically by low Apgar score at 1 and 5 minutes of life.
Severity is measured using the Sarnat (or other) scale.
Death occurring after 1 completed year of life and before 5
completed years.
Death occurring during the first year of life
Weight at birth <2500 gram
Death of a woman at any time from conception to 6 weeks
following delivery
Death occurring during the first 28 days of life
A child less than 29 days of age
Death occurring from 29 days of life and before 12 completed
months.
Birth occurring before 37 completed weeks gestation
Birth of child with no signs of life at or after 28 weeks
gestation.

Under-5 mortality

Death occurring before 5 completed years of life

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

Quick Facts: What is known about newborn mortality?

Globally:
Deaths during the 1st month of life account for 40% of the nearly 7.8 million child
deaths younger than 5 years that occur in the world each year (that is nearly 3.1
million newborn deaths each year)1.
99% of these deaths occur in developing countries. Three quarters of these deaths
occur in the 1st 7 days of life, and half of those during the 1st day of life.
Of 15 million babies born preterm each year globally, more than 1 million die shortly
after birth.
The proportion of under 5 deaths occurring within the 1st month has increased 17%
since 1990 (36% to 43%) due to declines in neonatal mortality rate being slower than
those in the mortality rate for older children.
Sub Saharan Africa has the highest risk of death in the first month of life and is among
the regions showing the least progress1.
Stillbirths account for many more deaths that are under-recognised.
Some countries are making good progress towards improving neonatal mortality and
an understanding of why is crucial to targeting the issues on a countrywide level.
Malawi: The situation at present

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

CHAPTER 1: INTRODUCTION - The state of Malawis newborns

Over 3 million newborns are still dying each year worldwide, almost all in developing countries and
approximately one third of these deaths occur in Sub-Saharan Africa. Sub- Saharan Africa has the
highest risk of death in the first month of life and is among the regions showing the least progress 1.
The proportion of under 5 deaths occurring within the 1 st month has increased in the last twenty
years as neonatal mortality rates are slower to decrease than those for older children.
Approximately 40% of deaths in children worldwide occur during the neonatal period. Malawi has a
very high rate of premature and low birth weight births along with a very high fertility rate with
many births in adolescent mothers, a known risk factor for preterm birth. In order to achieve
further gains in child mortality, it is important to target neonatal mortality 8.

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

CHAPTER 2: LITERATURE REVIEW

Newborns in Malawi the present situation
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 and is doing better than its regional peers in reducing neonatal
mortality (ARR 3.5% versus 1.5%). There have been substantial improvements in under five
mortality from figures of 227 deaths per 1,000 live births in 1990 to 164 deaths per 1,000 live births
in 2000 to 83 deaths per 1,000 live births in 2011 (annual rate of reduction of 4.8). (Figure 3(a))

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.

Neonatal survival/mortality: current levels and trends

Neonatal mortality rates in Malawi have dropped from 44/1000 in the 1990s to 27/1000 live births
in 20111. (Figure 3b) This rate of decline is a fall of 3.5% annually since 2000. Despite this, neonatal
mortality still accounts for over 40% of the under 5 mortality and rates of reduction are not falling
as fast as would be hoped1. Figure 3 (b) shows the decline in neonatal mortality in Malawi from
data gathered at each of the Malawi Demographic Health Surveys since 1992. This is given in
comparison to overall UN estimates of rate of fall.

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

Main causes of newborn deaths

Three conditions account for the vast majority 10 89%9 of newborn deaths in Malawi. These are
complications from preterm birth, severe infections (sepsis) and intrapartum related birth asphyxia.
The relative proportions of these have not significantly changed over the past ten years 9 Malawi
has however made progress in eliminating maternal and neonatal tetanus and has now been
certified for elimination since 200411. Deaths due to diarrhoea occur but are a minor cause12.

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).

Low birth weight

Low birth weight (LBW) is a birth weight of <2500 gram. LBW may be associated with prematurity
(less than 37 weeks gestation at birth) and/or being smaller than expected for gestational age,
which may be due to intrauterine growth restriction (IUGR). Babies with LBW have a poorer
prognosis in comparison to babies of good weight 22. LBW is a global public health issue with 6080% of neonatal deaths occur among LBW infants23. . It is also an important risk factor for postneonatal infant mortality. LBW neonates who survive infancy are at a high risk of growth and
developmental problems and small-for-date babies are predisposed to chronic adult disorders such
as hypertension, diabetes, and heart disease24.
19

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.

Rates of preterm birth in Malawi

Malawi has the highest rates of preterm birth in the world with rates from community based
studies estimated at 18.131 to 20.2%32. Rates vary depending on the method used antenatal
ultrasound dating is the most accurate method, and with this method the prevalence is up to
20.2%33. Other sources of data on preterm birth come from symphisio-fundal height measurement,
or estimated gestation as recorded in birth records.

20

Risk of mortality associated with prematurity

Mortality is very high for infants born preterm. Research from community studies in Southern
Malawi has shown that among premature compared to term babies the odds ratio for perinatal
mortality is 9.6 and for neonatal mortality is 1133. This risk for those born very premature (24-33
weeks) is even higher, with 75% risk of death within the first six weeks36. Most preterm babies are
over 32 weeks gestation (late preterm) at birth, but even in this group there is a higher risk of
death than for those born at term33.

Causes and interventions for prematurity in Malawi

The causes of preterm labour and birth are multiple and many processes which lead to preterm
birth are likely to start much earlier in pregnancy 30. These include bacterial vaginosis, sexually
transmitted diseases, urinary tract infections, malaria, HIV, schistosomiasis, domestic violence,
multiparity, previous preterm birth and young or old maternal age 37. Recent studies have
confirmed associations between IUGR and primiparity, short maternal stature, anemia and malaria
at delivery as well as associations between premature birth and primiparity, number of antenatal
visits and the MUAC of the mother25. Further studies have shown an association between fetal
anemia and prematurity38
There is compelling evidence that infection and in particular ascending genital tract infection may
be related to early preterm birth. Studies specific to Malawi demonstrated high burdens of
infection morbidity including HIV seropositivity, malaria, syphilis, trichomonas (26%) and candidiasis
(37%)40. Recent studies in Malawi, using Azithromycin prophylaxis did not show a benefit of
provision in the antenatal period to reduce the chance of premature birth 40.
It is clear that to reduce premature birth, intervention needs to start early in pregnancy with
improved nutrition, prevention of sexually transmitted diseases and identification and treatment of
infections which occur during pregnancy.
Corticosteroids given to women in early labour help foetal lung maturation and so reduce the
number of babies who suffer breathing problems at birth and consequently die. A recent Cochrane
review (March 2013) that included a review of 21 trials showed that a single course of
corticosteroid, given to the mother in preterm labour was associated with an overall reduction in
neonatal death by 31%, respiratory distress syndrome 34%, cerebroventricular haemorrhage 46%,
necrotizing enterocolitis by 54% and systemic infections within the first 48 hours by 44%. Treatment
with antenatal corticosteroids does not increase risk to the mother of death, chorioamnionitis or
puerperal sepsis. Malawi recently developed guidelines on the use of corticosteroids in preterm
labour. These have been incorporated in the integrated manual for maternal and newborn health.
National use of antenatal corticosteroids is scheduled for introduction in late 2013.
21

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

Sepsis and pneumonia

Neonatal sepsis results in half a million deaths worldwide each year, the vast majority of which are
in developing countries24. The burden of mortality in children younger than 5 years varies across
WHO regions but Africa has 3.6 million deaths, the largest number of deaths and 2.6 of these due to
infectious causes43. This is also a major problem in Malawi. Hospital studies in Malawi examining
the aetiology of neonatal sepsis have identified Group B streptococcus (S. agalactiae) (17%),
Streptococcus 22neumonia (10%) and non typhoidal salmonella (14%) 44. Mortality in neonatal
sepsis is very high (33-48%). Group B streptococcal carriage rate among hospitalised antenatal
mothers is 21% and is not affected by HIV status 45. We know that simple cord care and clean
practices at birth and postnatally can make differences to the rates of sepsis
Research priorities have however emphasised that interventions to prevent and manage newborn
infections at policy and systems level. Some studies from Bangladesh and India have linked the
continuum of care from hospital to community to making the biggest difference to outcomes in
neonatal sepsis. Community strategies where home visits by community health workers are
combined with community mobilisation has been shown to have good effect in reducing neonatal
mortality in some settings worldwide. Much of this is linked to early detection and treatment of
sepsis and pneumonia through regular visits from community health workers. A recently launched
Community Based Maternal And Newborn Care package hopes to bridge that gap between
community and facility level care as well as maternal, newborn and child health as well as HIV
(Human Immunodeficiency Virus)/AIDS (Acquired Immunodeficiency Syndrome) and malaria, but
coverage is still low.

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.

Services for newborn health in Malawi

There are a number of key interventions that have been shown to be effective in reducing neonatal
mortality worldwide. These include interventions at the preconception, antenatal, intrapartum and
postnatal stages 49. The interventions in Table 1 are also identified in Malawis Committing to Child
Survival Report)8 Health system strengthening to achieve high coverage with these interventions
should be a priority in Malawi.

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).

Table 2: Table of essential antenatal care as recommended by WHO

Between 2000 and 2010 in Malawi there has been an improvement in a number of areas relating to
newborn care9. Improvements highlighted in a recent review include:
1. Contraceptive use
2. One to three antenatal care visits (but not for 4 or more visits)
3. Tetanus toxoid vaccine (2 or more doses)
4. Skilled birth attendance
5. Facility births
6. Deliveries by caesarean section.
7. Babies weighed at birth
8. Initiation of breast feeding within one hour of birth
9. Postnatal care within two days of birth
10. Exclusive breast feeding 0-1 month.
26

Antenatal care in Malawi:

Preconception care
Preconception care is the promotion of reproductive planning and the provision of interventions to
reduce risk of unintended pregnancy, allowing women to enter pregnancy in the best possible
health and to optimise the chance of giving birth to a healthy newborn. It often also involves
prevention of sexually transmissible infection, and promotes the empowerment of women and
their decision making capacity. In order to maximise the successful impact on maternal and
newborn health outcomes, outreach and preconception education must begin in adolescence 29. In
Malawi, preconception care is likely to be limited but there is little in the way of good reviews on
this subject for Malawi.

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).

Optimising prepregnancy/pregnancy weight and nutrition:

We know that early food supplementation of mothers can decrease the risk of low birth weight,
prematurity77 and neonatal mortality78, as well as improve maternal child interaction , food
security79 and neurodevelopmental outcomes. There is evidence that maternal supplementation
with folic acid decreases the risk of neural tube defects and that there is benefit to neonatal zinc,
iron and iodine supplementation49. We also know that improved maternal nutrition will decrease
the likelihood of prematurity.

Number and timing of antenatal visits

Antenatal care is a key strategy to improve maternal and infant health. Survey data from subSaharan Africa show that most women only initiate antenatal care after the first trimester and few
achieve the recommended number of antenatal clinic visits. This is certainly the case in Malawi.
Antenatal attendance for one visit in Malawi is high at 95%, but for more visits, the number of
women attending has dropped in the last ten years to 46% from 56% for those attending more than
4 visits5. A recent study has shown the increased risk of stillbirths with increased blood pressure in
women on antiretrovirals80 and how crucial therefore monitoring of blood pressure in the
antenatal period can be.
It is unclear as to why most mothers are not attending more than one visit. Some studies have
demonstrated how volunteer peer counselling can improve uptake of skilled antenatal
attendance81. An extensive qualitative study from Ghana, Kenya and Malawi looked at barriers to
attendance at antenatal care. These include the costs of being away from home in terms of leaving
chores that needed to be done, the cost of travel (especially if there was reliance by the woman for
cash from her husband) as well as the physical cost often in walking to and from a health facility
this particularly in view of not always being provided with good information as to the goals of
antenatal care (ANC). Some evidence from these qualitative studies also point to women only being
able to attend ANC once a confirmed and palpable pregnancy was found contributing to lateness
of ANC. The lack of pregnancy test kits in Malawi added to this lack in comparison to similar groups
in Ghana where it is considered routine to attend ANC early on in pregnancy 82. Improving the
accessibility of pregnancy tests may have the potential to reduce uncertainty amongst women.
29

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.

Essential components of focused antenatal care:

Focused antenatal care is designed to facilitate and support the well being of the mother and fetus
through out normal pregnancy and birth. There has been a reduction in the number of visits from
the traditional antenatal schedule partly due to an emphasis on the quality of visits rather than
quantity. Specific targeted interventions such as ensuring women are provided with at least two IPT
doses of SP in the second and third trimester) are tied to individual visits. First visits recommended
by the end of the 4th month or when woman identifies she is pregnant, second visit recommended
at least once during second trimester (5-6 months), third visit at 7-8 months and fourth visit at 9
months (36 weeks). Women with special needs and complications may require more than 4 visits 61.
The overarching goals of focused antenatal care are:
1. The early detection and treatment of problems and complications
2. Prevention of diseases and complications
3. Preparedness for birth including identification of skill birth attendant, place of birth, danger
signs and complications
4. Health education and promotion

Antenatal services to prevent infection

Many studies have concentrated in Malawi on the effect of PMTCT (prevention of mother to child
transmission) of HIV with antiretrovirals over the last ten years. PMTCT services began in 2003 and
have increased year on year 83. The provision of PMTCT in Malawi was slow compared with that of
ART. Some of this low uptake has been due to fear as well as inadequate referral systems between
general maternal and child health services and PMTCT programmes 84 . One study has shown that
newborn complications and PMTCT programmes are among the lowest of those needed
interventions in the Essential Health Package intervention85.
Tetanus toxoid vaccine in Malawi is provided to all mothers and shows a high level of coverage.
Malawi has been certified free of neonatal tetanus since 2004 11.

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.

Childbirth and intrapartum care

In Malawi, numbers of facility births are increasing 9, as are the skilled birth attendance rates and
the number of deliveries by caesarean section. The percentage of births taking place in a facility has
increased dramatically over the past few years with rates being now as high as 73% (2010). Studies
from 2000 in Malawi have demonstrated that antenatal risk identification (if mother has a risk
factor such as previous C/S, obstructed labour, toxaemia, high BP etc) has not necessarily promoted
safe deliveries in clinic facilities 88. More recent studies (2013) demonstrated no differences in
31

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.

Treatments during labour

A study conducted in Malawi in 1994 using 0.25% chlorhexidine vaginal wipes with each vaginal
examination approximately four hours apart and a neonatal wipe soon after birth demonstrated
significant reductions in newborn hospital admissions, admissions due to sepsis, early neonatal
mortality and neonatal mortality due to sepsis and reductions in maternal hospital admissions,
length of stay and admissions due to sepsis96. This was not an RCT however and definitive clinical
trials are still warranted to clarify the potential of chlorhexidine 97. Some studies have even
suggested that providing antibiotics during labour may be detrimental. A study by Kafulafula 98 (a
secondary analysis of HIV infected and uninfected women) showed no significant associations
between exposure to antibiotics and early neonatal death but possibly more illnesses at birth and
more admissions to SCBU among infants exposed to intrapartum antibiotics.
32

Immediate and essential newborn care

A study conducted recently where neonatal training was provided at St. Gabriels hospital Namitete
where 6 hours of training consisting of 2 hours of lecture, one hour of demonstration and three
hours of hands on scenario driven sessions using mannequins were used with 14 of 26 birth
attendants over one day. There was improvement in knowledge but no change in rates of neonatal
mortality in the hospital99.
A very small qualitative study at QECH demonstrated that despite many midwives who had a lot of
professional experience particularly due to the number of deliveries performed, there was a general
lack of confidence among staff in assessing newborns and recognising the need for resuscitation.
Furthermore a lack of resources (availability of staff, equipment (suction, oxygen, warming trolley)
and supplies (linen) and standard protocols for newborn resuscitation, facilitators to introduce
resuscitation) emerged as well as ethical dilemmas (caring for the mother vs. caring for the
newborn)100.
The Enhancing Training and Appropriate Technologies for Mother and Babies in Africa (ETAMBA)
project is an 18 month programme of skills training and practice in specific obstetric, neonatal,
research and leadership skills to improve maternal and perinatal mortality. It aims to improve the
clinical training and leadership skills of clinical officers and others involved in providing neonatal
care. This trial is still under way 21.

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.

Case management of newborn infection and IMCI

Community neonatal care:

The recent review of the role of community health workers within facilitated referral for newborns
with danger signs in Malawi by Save the Children demonstrated that despite improved training and
emphasis on community maternal and neonatal care, there are still issues surrounding referrals in
Malawi. The report showed difficulties for HSA with protocols for referral and counter referral as
well as tracking data. Furthermore, counselling should be provided in mediating the barriers that
affect compliance with referral. In Malawi, this focused on barriers to reaching care at time of birth
but not for newborns with danger signs. The Malawian HSAs had a good knowledge (96% could
name at least three newborn danger signs) but that there were issues of lack of supplies or
equipment for screening newborns for danger signs and low birth weight. Many HSAs (68%) did not
have a timer and 15% did not have a functional thermometer. Data showed a low volume of
referrals for newborns with danger signs (8% had referred at least one newborn and 11% had
referred at least one newborn or LBW in the previous three months) 108.
Integrated management of childhood illness (IMCI) is a strategy introduced by WHO and UNICEF in
1993. It aims to use integrated approaches to look at the well being of the whole child. The strategy
has always included three main components; improving case management skills of health care staff,
improving overall health systems and improving family and community health practices 109.
Community case management is a delivery strategy that involves training and support of
community based workers to assess, classify and treat common childhood illnesses from guidelines
adapted from IMCI. A recent study reviewed over 130 Health Surveillance Assistants trained in
CCM. Antimalarials were provided correctly for 79% of children and oral rehydration salts to 69%.
62% of children with confirmed fever (malaria), cough with fast breathing (?suspected pneumonia)
and/or diarrhoea were treated correctly 110. This compares well with results from quality of care
surveys by the Ministry of Health111. As pneumonia, particularly in neonates, is such a large
problem, it may be worth thinking about ways to improve assessment of pneumonia in particular,
possibly by better methods of training to measure respiratory rate and interpret it in neonates. In
this study, it was found that inadequate drug stocks also contributed to inappropriate treatment of
children presenting with fever and diarrhoea.
35

Malawi health care system Newborns in context

Malawi has a three-tier health care delivery system: primary, secondary and tertiary levels of care.
The aim is to have an integrated health delivery system managed at district level by the District
Health Management Team (DHMT)112. This is headed by the District Health Officer (DHO) and aims
to coordinate the provision of promotive, preventive, curative and rehabilitative services and to
ensure that sufficient resources are available, and that they are used effectively and efficiently.
There are two primary health service provider systems: government and the Christian Health
Association of Malawi (CHAM), which provides about 39% of the facility, based services. The
Ministry of Health (MoH) and CHAM have entered into service level agreements in 2002 subsidizing
CHAM constituent institutions to deliver free services to the poorest families 113.
Recently, the District Health Management Team has been integrated into the District Assembly
structures with DHOs now reporting directly to the District Commissioners. Under the devolved
plan primary and secondary levels of care have been handed over to Local Assemblies (LAs).
Districts develop their own health plans using community participatory structures and funding for
health services is channelled directly to the Local Assemblies.
The MOH in Malawi implements a health service delivery strategy based on the delivery of the
Essential Health Package (EHP). This was conceptualised in 2002 to guide both planning and funding
of health service delivery and ensure an orientation towards the local burden of disease and
mortality. The priorities revolve around the provision of the EHP, that is delivered free of charge at
the point of delivery, and focuses on interventions against 11 major health problems. These
include: vaccine preventable diseases; malaria; acute respiratory infections (ARI) including
pneumonia; diarrheal diseases including cholera; sexual and reproductive health including family
planning; HIV/AIDS and sexually transmitted infections; tuberculosis; schistosomiasis; nutritional
deficiencies; common injuries; and ear, eye and skin infections 112. In order to operationalise this,
the Emergency Human Resource Programme has been developed to increase the number of health
workers through trainings and incentives and through strengthening health training institutions 114.
Health Surveillance Assistants are at the middle of this with them delivering a wide portfolio of
preventive and promotive services and have begun to take on select curative tasks such as
community case management of childhood malaria, pneumonia, diarrhoea, severe malnutrition and
neonatal sepsis115.
In 2004, the Government of Malawi adopted the SWAp (Sector Wide Approach) as a mechanism of
coordinating the activities of all stakeholders in the health sector in order to support a common
plan and expenditure framework that ultimately contributes to the MDGs. A recent study has
36

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.

Structure of Malawi health system newborn health

Plans to improve neonatal care have had much more emphasis since 2005 when the Ministry of
Helath developed a national initiative The Road Map for Accelerating Reduction of Maternal and
Newborn Mortality and Morbidity in Malawi. This was developed by the WHO Africa office 116 and
linked to SWAp and had a costed implementation plan . This Ministry of Health document has
focussed mainly on maternal outcomes and increasing the number of facility births but more
neonatal content has been added since the publication of the Lancet Neonatal Series. There has
been an emphasis within this programme to improve and integrate the many existing training
materials which are for facility based health workers into the one integrated package 117 which
includes maternal care, essential newborn care, basic EmOC and newborn care, KMC and postnatal
care118.
The Ministry of Health have adopted the Community Based Maternal and Newborn Care (CBMNC)
package in 2007 with an aim to address gaps in community demand and primary level service
provision. Malawi has been one of the first African countries to nationally adopt an integrated
community based package for mothers and newborns. This was particularly after a UNICEF funded
tour of India where MoH policy makers reviewed an evidence-based neonatal care programme. The
Malawian package was centred around addressing neonatal sepsis but added preventative
community based maternal and newborn services. This package trains HSAs to do three home visits
37

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.

Quality and availability of services

Over half the population in Malawi lives further than 5 km from a health facility with only 20% living
within 25km of a hospital. In some areas, maternity waiting homes have been created in some
facilities although there is little evidence that these have improved pregnancy outcomes. There
have been initiatives such as provision of motorcycle ambulances and community transport
schemes, radio communication systems to reduce delays in seeking care but these are not yet
widely available.
In terms of the use of facilities in Malawi, there has been a massive increase in facility births. It is
clear however that the quality of the care is not at a level it should be. A recent report by Zimba put
rates of estimated met need for EmOC being only up to 22% in 2010. Rates from the audit study
show good rates of CEOC in the major centres but very few (6%) meeting targets for BEOC. Some
assessments of health care services have found that the quality of newborn care services is lower
than for other health services. A subnational Performance and Quality Improvement evaluation
showed that newborn survival interventions which included care at birth and postnatal care had
fewer improvements in clinical standards than other interventions 119.
The government of Malawi has officially shifted Traditional Birth Attendant roles towards skilled
birth attendants in deliveries94. This has even included policies in some places to restrict TBAs from
operating and encouraging facility birth through the use of grandparents and community members
to encourage facility delivery. Although skilled birth attendant rates are up with a 17% increase in
ten years, it is still reported that there are many issues with position vacancies and frequent
absenteeism120. One small qualitative study in Mchinji reported up to 25% of facility births as being
unassisted121.

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.

Data collection methods

To supplement the literature review, a survey of 4 districts in Malawi was undertaken. The districts
selected represent the north, central, southern and south-eastern regions of the country (see Table
1). Health facility assessments were undertaken in 8 hospitals and 11 health centres. We aimed to
include facilities located in urban, peri-urban and rural areas of the districts and the District Nursing
Officers and Safe Motherhood Co-ordinators purposefully selected these facilities.
Health facility assessment tools were adapted for the local context using best practice interventions
and a WHO quality of care assessment tool122 used to assess the availability and use of resources
and interventions necessary for the provision of neonatal care. In addition individual level data on
preterm infants born in 2012-2013 were collected from maternity registers at each health facility
We assessed quality of care in terms of prevention of preterm birth, management of preterm
labour and the care of the preterm baby. Health facility assessments were used to capture the
quality of care for the management of preterm labour. The tools used to assess the quality of
antenatal care and care provided to preterm infants in their first 24 hours of hospital admission was
based on key cost-effective interventions with proven efficacy for new born survival 49,
40

Table 3: Regions, districts and health facilities visited in the situational analysis
Region

District

Health facilities visited

Southern

Blantyre

Queen Elizabeth Central Hospital

Malambe Mission Hospital
Lirangwe Health Centre
Dziwe Health Centre
Ndirande Health Centre

South Eastern

Mulanje

Mulanje Mission Hospital

Mulanje District Hospital
Namulenga Health Centre
Thuchila Health Centre
Chonde Health Centre

Central

Mchinji

Mchinji District Hospital

Kaigwazanga Health Center
Ludzi Community Hospital
Kochilira Community Hospital
Mkanda Health Centre

Northern

Karonga

Karonga District Hospital

Nyungwe Health Centre
Kasoba Health Centre
Kaporo Health Centre

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)

All facilities listed in Table 1

Retrospective cohort
study on preterm birth
outcomes using routinely
collected data in facility
maternity register

All births 28 to <37 weeks that

occurred from May 2012-May
2013 (n=2695)

All facilities listed in Table 1

Evaluation of QOC during

the antenatal period

All women in the antenatal/

postnatal wards of the
surveyed health facility with at
a health passport (n=361)

All facilities listed in Table 1

Evaluation of QOC for

preterm babies in their
1st 24 hours of life

All in-patient preterm infants

with an available medical
record (n=36)

Queen Elizabeth Central Hospital

Mulanje Mission Hospital
Mchiniji District Hospital

In-depth individual
interviews
In-depth individual
interviews

Key stakeholders (n=34)

All facilities listed in Table 1

Women with in-patient

preterm infants (n=14)

Queen Elizabeth Central Hospital

Mchinji District Hospital

Structured
questionnaires to assess
the availability of
essential newborn care
facilities at district level

Safe Motherhood Coordinators (n=25)

Focus Group Discussions

(1)

Health Care providers (n=11)

Focus Group Discussions

(5)

Community members
(n=40)

Karonga, Mchinji, Nsanje,

Nkhatabay, Balaka, Kasungu,
Chikwawa, Salima, Thyolo,
Mangochi, Neno, Machinga,
Dedza, Mulanje, Chiladzuro,
Mwanza, Mzimba South,
Ntchisi, Nkhotakota, Rumphi,
Ntcheu, Zomba, Chipeta,
Mzimba, Phalombe

42

Health care providers from Mulanje

District Hospital and surrounding
facilities
Community members from Mponde
village and 6 surrounding villages,
Mulanje. Queen Elizabeth Central
Hospital, Blantyre
Dwiza Health Centre, Blantyre

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

CHAPTER 4: KEY FINDINGS AND DISCUSSION

This chapter provides an overview of the findings and integrated discussion from the situational
analysis. Birth outcomes from the four surveyed districts will be presented followed by a
description of the use, availability and quality of antenatal, intrapartum and postnatal care in the
surveyed factilities. Quality of care delivered to preterm infants in the neonatal nursery during the
1st 24 hours of life will also be presented. Key findings of interviews involving key stakeholders, Safe
Motherhood co-ordinators, mothers of preterm infants and community FGDs are integrated
throughout the chapter.

Maternal Register Data

This section presents an analysis of 2,695 births extracted from maternal registers at all study
facilities in 4 districts. These registers record for all births attending the facility the place of birth (if
born prior to arrival at the facility), whether a child was sent or received as a referral across the
health system, gestational age if known or estimated, birth weight and birth outcome (live birth,
still birth (fresh or macerated), and death prior to discharge from hospital. Maternal registers do
not directly capture information on referral patterns or transportation accessibility, nor do they
provide information on quality of care, these will be the subject of subsequent chapters.

Total births and proportion pre-term

Facilities in Karonga saw per month on average 109.5 (SD 80.5) births of which were 4 (SD 5.9) still
births. Among stillbirths, 59% were fresh and the rest were in macerated condition. There were
105.5 live births per month, of which 27.6 (30.7%) were classified as pre-term in the register.
Among live births in facilities in Karonga, 91.5% were attended by a skilled practitioner, 3.9% by an
unqualified ward attendant or cleaner and 4.5% by any other unlisted person.

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

Figure 7: Place of birth

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

Figure 8: Proportion of preterm births in the 4 study districts

Compared to home births, births in health centre were on average 647.5 (95% CI: 403.3 to 891.7)
gram heavier, p<0.001; and those in hospital were 239.9 (95% CI: -2.8 to 482.5) gram heavier,
p=0.05. Compared to hospital births, births in health centres were on average 407.6 (95%CI: 355.5
to 459.9) gram heavier, p<0.001. These differences may either reflect referral bias (smaller out born
45

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

Figure 9: Gestational age at birth and place of birth

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

Figure 10: Birth weight by place of birth

46

5 ,0 0 0

Gestational age and birth weight by birth outcomes

Macerated stillbirths and live born babies who died before discharge had a younger gestational age
on average than other birth outcomes. Among live born babies, 2468 who survived to discharge had
a mean gestational age of 34.6 (SD 2.8) weeks and 59 who died before discharge had mean
gestational age 32.6 (SD 4.4), p<0.001. Survivors had a mean birth weight of 2283.0 (SD 665.5) gram
and non-survivors had mean birth weight 1504.0 (SD 75.5), p<0.001. The proportion of very
preterm and extremely preterm births was greater among children who died than children who
survived to discharge (Figure 11).

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 )

Figure 11: Gestational age of preterm babies by birth outcome

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

Figure 12: Birth weight by birth outcome

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

Figure 13: Gestational age of preterm babies by category

48

5 ,0 0 0

Mortality by gestational age and birth weight

For each additional week of gestation, mortality reduces by 16.6% (OR 0.83 95% CI:0.8 to 0.9).
When adjusted for birth weight, the impact of gestational week is no longer significant, but the
effect of every 100gram increase in birthweight reduces mortality by 19.3% (OR 0.81 95% CI: 0.8 to
0.9). When comparing the presence of low birth weight (any birth weight < 2500g) adjusted for
gestational age, both factors are associated with mortality with a weekly reduction in mortality of
12.7% (OR 0.87 95% CI: 0.81 to 0.94), but with a 7-fold increase in odds of death from LBW (OR 7.0
95% CI: 2.2 to 22.8). The risk among LBW babies remains significantly greatest with extreme
prematurity. Compared to older gestations and adjusted for low birth weight, being born at <28
weeks compared is associated with mortality increase of more than 4-fold (OR 4.5 95% CI: 1.7 to
12.4), all p-values <0.01.
Mortality by place of birth
Among all 2695 pre-term or low birth weight births seen at health facilities, 2606 (96.7%) were born
in those facilities and 89 (3.3%) were born outside, referred in and arrived. For 2586 live births
attending facilities, mortality to discharge was significantly higher among those born outside of a
health centre or hospital compared with those born in such facilities. Of facility live births 56 of
2448 (2.2%) died compared with 6 of 82 (7.3%) births outside such facilities, p=0.003. The odds of
dying before discharge was 3.3 (95% CI: 1.4 to 7.9) times higher for out born babies than those born
in facilities, p=0.007. There was no difference in mortality between those born in hospital and those
born in health centres. These results do indeed provide good reason for women to deliver in health
facilities. The point estimate of odds ratio of mortality to discharge was greater in 433 term low
birth weight babies (OR 3.6, 95%CI: 0.8 to 17.4) than among 2262 pre-term babies (OR 3.0, 95%CI:
1.1 to 8.7)
True mortality rate for home births is unknown. The higher mortality rate for out borns may reflect
a referral bias as only sicker babies may be referred, or may underestimate the true mortality if
children are dying at home and are not being referred at all.
Referrals
Among 1127 live births outside hospital there were 115 (10.2%) referrals out. Within this group,
among 24 born at home onward referral occurred in 8 (33.3%), and among 33 born in transit, 5
were referred (15.2%). Onward referral was associated with lower birth weight and younger
gestational age. Mean birth weight among 111 live out borns referred on was 1777.9 (SD 454.0)
grams and among 768 not referred mean birth weight was 2672.0 (SD 610.1) grams, p<0.001.
Babies with birth weight below 1000 gram or above 2260 gram tended not to be referred. Among
110 babies referred on with recorded gestation, mean gestational age was 33.4 (SD 3.5) weeks, and
among 770 not referred it was 35.1 (SD 2.0) weeks, p<0.001. A sample mean difference of 1.7
49

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

'R e f e r r e d ' v s 'N o t r e f e r r e d ' t - t e s t p < 0 . 0 0 1

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

'R e f e r r e d ' v s 'N o t r e f e r r e d ' t - t e s t p < 0 . 0 0 1

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

Figure 16: Gestational age of preterm babies by place of birth

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

Figure 18: Gestational age of preterms by district

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

Figure 19: Gestational age of preterm babies by age category

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

500 1000 1500 2000 2500 3000 3500 4000 4500

B ir t h W e ig h t ( g r a m s )

60

500 1000 1500 2000 2500 3000 3500 4000 4500

B ir t h W e i g h t ( g r a m s )

500 1000 1500 2000 2500 3000 3500 4000 4500

B ir t h W e i g h t ( g r a m s )

500 1000 1500 2000 2500 3000 3500 4000 4500

B ir t h W e ig h t ( g r a m s )

K a r o n g a p a t t e r n lik e l y d u e t o o v e r c a ll in g g e s t a t io n a s '3 6 ' w e e k s in t e r m b a b ie s

Figure 20: Birth weight of preterm babies by district

Place of birth by district

Compared to Blantyre, births outside of hospital were more likely in Karonga (OR 2.7 95% CI: 2.3 to
3.3, p<0.001) and less likely in Mchinji (OR 0.5 95% CI: 0.43 to 0.69) & Mulanje (OR 0.7 95% CI: 0.49
to 0.91). Births in a facility (hospital or health centre) were twice as likely in Karonga than Blantyre
(OR 2.3 95% CI: 1.3 to 4.0), and 3 times as likely in Mulanje (3.2 95% CI: 1.1 to 9.0). But there was no
appreciable difference between Mchinji and Blantyre. Although these differences are significant,
the absolute numbers are small. Out of facility births occurred in Blantyre in 29 of 764 (3.4%),
Karonga in 20 of 992 (2.0%), Mchinji in 29 of 659 (4.4%) and Mulanje in 4 of 269 (1.5%).
Mortality by district
In-hospital mortality among live born infants was 13/730 (1.8%) in Blantyre, 22/973 (2.3%) in
Karonga, 23/627 (3.7%) in Mchinji and 4/252 (1.6%) in Mulanje. Compared to Blantyre only Mchinji
has significantly greater mortality, odds ratio 2.1 (95% CI: 1.1 to 4.2, p=0.04).

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

birth weight (100g) 0.79 (0.75 to 0.83)

p<0.001

gestational age

1.0 (0.9 to 1.1)

p=0.98

district

Karonga 5.9 (2.9 to 11.9)

Mchinji 2.6 (1.3 to 5.1)

p<0.001
p=0.005

facility birth

1.2 (0.15 to 9.6)

p=0.86

Born in transit

4.8 (1.3 to 18.4)

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

Figure 21: Number of ANC visits during pregnancy by category

Quality and availability of services
Interventions consistently performed less than half the time included measuring blood pressure,
excluding maternal anaemia, bacteriuria and syphilis. The latter three conditions directly contribute
to pre-term birth, and poorer neonatal outcomes. The patterns observed were largely consistent
across all districts.
Reports from many health facilities included in this survey indicate that implication of focused ANC
is suboptimal. Most health care providers stated that missing or broken equipment significantly
impacted upon their ability to provide quality antenatal care. Equipment for syphilis testing had not
been available in many facilities for more than 18 months. It was observed that screening for
haemoglobin levels, urinalysis for asymptomatic bacteriuria and blood pressure were not routine
practice in all facilities.
A number of health care providers also noted that given the high number of women presenting
with complex medical problems, there was little time to address health promotion in depth. ANC
provides the opportunity to assist women to prepare for birth, logistically, emotionally and
physically. However, health care providers also reported that they were often unable to spend the
time required planning with women and counselling them on danger signs and postnatal care
because of a lack of staff and high volume of women presenting for care. A number of health care
59

providers expressed their frustration of working in under-resourced and understaffed facilities:

As one nurse midwife technician described: We tell the women to come to us in an emergency
when they are pregnant but then what can we do? We dont enough nurses..we dont have the
drugs we needwe dont have the equipment we need to treat the women

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

Figure 22: Quality of ANC indicators

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

Figure 23: BP checked at every ANC visit

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

Figure 24: Quality ANC indicators: Blantyre

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

Figure 25: Quality ANC indicators: Mchinji

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

Figure 26: Quality ANC indicators: Karonga

62

.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

Figure 27: Quality ANC indicators: Mulanje

Health facility assessments
Health facility assessments were conducted evaluating the readiness and availability of resources at
facilities to provide high quality newborn care. Eighteen facilities were included in comprehensive
assessment, including the district hospitals of Karonga, Mchinji and Mulanje as well as QECH
Blantyre, and included 3 peri-urban and 10 rural health facilities.
Five of 18 facilities had dedicated beds for the care of sick newborns. Seven of the facilities receive
newborn referrals; fourteen facilities refer on for complex cases (i.e. 5 facilities both receive and
refer newborns). Fifteen facilities reported receiving or referring via road ambulance.
Table 6: Availability of ambulances in emergency
Road ambulance availability in emergency
Facilities
Less than 1hr
5
Less than 3hr
5
Less than 6hr
3
Up to 24h
1
Unreliably available
1

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

N N bag & m ask

R esusc space
C h lo r h e x id in e
B a b y h a ts
B a b y b la n k e t s
D r y in g , la t e b a t h
D e la y c la m p in g

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

N N bag & m ask

S in k & w a t e r
B a b y h a ts
B a b y b la n k e t s
H e a te d c o ts
G lu c o m e t e r
O 2 c o n c e n tra to r
P u ls e o x y m e t e r
W e ig h t s c a le s
P h o to th e ra p y
S p a c e fo r K M C

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

Quality of care delivered to preterm infants

A medical chart audit of care delivered to preterm infants within the 1 st 24 hours of admission to
the neonatal nursery was undertaken at QECH, Mchinji District Hospital and Mulanje Mission
Hospital. The medical records of current preterm infant inpatients were reviewed (n=35). The
results of quality of care are presented by clinical scenario for routine essential care, respiratory
distress syndrome, and sepsis/hypothermia. Very serious gaps in quality of care are evident, with
inadequate implementation of interventions that are proven to reduce neonatal mortality. Ensuring
implementation of these basic services should be a priority in tackling newborn mortality.
A lack of supportive supervision for junior staff, clear guidelines for the care of preterm infants,
inadequate staffing levels and equipment to provide care were the leading reasons given for the
gaps in care delivery for preterm infants by health staff working in the neonatal nursery. Staff also
cited that often they provided a basic assessment of the newborn but given the busyness of the
units it was difficult to provide frequent on-going care such as regular temperature checks and
ensure feeding was on schedule. Staff also reported difficulties finding time to document care
practices and at times this was left until the end of the day.
70

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

Table 11: Availability of newborn interventions across Malawi

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

Available at health system level (as per cent of 25 districts):

District level
Every Health Centre Sometimes available Never Available
68
56
20
16
88
72
4
8
68
24
44
12
16
12
0
84
100
84
0
0
44
20
16
32
92
68
72
100
80
80
88
68
80
44
68
24
16
20
32
8
72

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:

1. Low uptake of ANC services

2. Low socioeconomic status
3. Malaria
4. Preeclampsia
5. Malnutrition
6. Teenage pregnancy
7. Inadequate resources
8. Lack of life saving skills
9. Maternal medical conditions e.g. anaemia
10.Maternal infections
Strategies for improving newborn survival that were mentioned included heaters for KMC units,
mobilisation of resources and capacity building. While the second two are broad and show an
understanding of the deeper systems issues underlying the challenges of adequate care delivery,
73

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

sick newborns requiring inpatient care

4. Expand the use of trained breast feeding support counsellors to conduct home visit to early

post-natal mothers and supported through engaged local community groups.

Health facility level:

1. Improve infrastructure and supplies: Ensure every district and referral hospital has the
capacity to provide essential newborn care, and care for the sick or preterm/LBW newborn,
such as a neonatal unit, functional and adequate Kangaroo Mother Care Unit, equipment
and continuous supplies of essential drugs and supplies, including oxygen concentrator.
Consideration should be given to the programmatic availability of neonatal CPAP support
(including appropriately skilled staffing) at District Hospital level. The wider availability of
CPAP should be subject to formal evaluation and cost-effectiveness analysis.
2. Investment in maintenance of emergency transport at district level and strengthening of

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

beyond the initial pilot districts (Save the Children)

8. Ensure performance by health care providers of newborn care practices to protect against

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

CHAPTER 6: GUIDELINES ON OPERATIONAL USE OF ANTENATAL

CORTICOSTEROIDS AND TOCOLYTICS IN THE MANAGEMENT OF
PRETERM LABOUR
There is sufficient evidence that maternal corticosteroid use in preterm labour improves neonatal
outcomes. Corticosteroid therapy is relatively inexpensive but it is underused particularly in the
developing setting in the management of preterm labour. Malawi has the highest preterm birth
rate globally yet corticosteroids are not routinely used in the management of preterm labour. It was
very clear from the findings in the situational analysis for preterm births in Malawi that
corticosteroid use in preterm labour was non existent in all but one facility that were assessed. This
chapter will try and outline some of the important steps towards successful implementation of
maternal corticosteroid use in Malawi.
Implementation of maternal corticosteroid use in preterm labour

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

Appendix 1: Health facility assessment tool

1.
2.
3.
4.
5.

Date of data collection (dd/mm/yyyy): ________________________

6.

Facility location: Urban peri-urban rural

7.

Contact person at this facility: __________________________________

Person completing data collection: BN QD NBZ SBZ EK

Name of district: Karonga Mchinji Blantyre Mulanje
Name of facility: ______________________________________________
Type of facility: District hospital Health centre Other

Name: ___________________________________________________________
Job title: _________________________________________________________
Phone number: __________________________________________________
Email: ___________________________________________________________

85

Facility data

8.

What is the size of the population served by this facility?

__________________________________________________________

9.

Total number of beds in this facility? ___________________________

10.Number of dedicated neonatal cots? ________________________

10.1 How many staff currently provide newborn care in this facility:
Clinical Officers __________________________________________________
Medical Assistants ________________________________________________
Doctors ____________________________________________________
Surgeons _________________________________________________________
Anaesthetist ______________________________________________________
Registered Nurse Midwife _________________________________________
Nurse Midwife Technician__________________________________________
Other: ____________________________________________________________
11.1 How many staff providing newborn care have attended Helping Babies Breathe (HBB) training?
____________________________________________
11.2 How often have staff attended newborn care refresher training in the past 12 months?
(select 1 only)
3 monthly
6 monthly
Yearly
Never
Other Explain:________________________
Staff infant ratio in:
Labour ward
Nursery
Health Centre
Sick babies separate from well babies: Is there a dedicated space for the care of sick newborns?
86

YES NO If yes, where?

PN Ward
Dedicated newborn nursery
Paediatric ward
Other: Specify: __________________
Facility observation: (Please visit the locations below with a local member of staff and review the
availability of the following with the staff member. Try to see for yourself as much as possible.)
ANTENATAL AREA
INTERVENTION

SEEN TODAY

AVAILABLE LAST 3
MONTHS?

Syphilis screening (rapid test/VDRL available)

YES NO

Always available
Stock outs occur
Not available

Benzylpenicillin (Crystapen/Xpen) available in stock

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

Smoking cessation promotion materials available

YES NO

Always available
Stock outs occur
Not available

Working BP cuff seen at antenatal clinic

YES NO

Always available
Stock outs occur
Not available

Working stethoscope seen at antenatal clinic

YES NO

Always available
Stock outs occur
Not available

Pinard seen at antenatal clinic

YES NO

Always available
Stock outs occur
Not available

Calcium supplementation (for prevention of preeclampsia/eclampsia)

YES NO

Always available
Stock outs occur
Not available

Urine dipsticks for asymptomatic bacteriuria available in

stock

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

Oral amoxycillin in stock available in pharmacy

YES NO

Always available
Stock outs occur
Not available

Intermittent preventive treatment for malaria (SP/Fansidar)

available in stock

YES NO

Always available
Stock outs occur
Not available

88

INTRAPARTUM/LABOUR WARD
INTERVENTION

SEEN TODAY

AVAILABLE LAST 3
MONTHS?

Erythromycin for preterm premature rupture of membranes

available in stock in labour ward

YES NO

Always available
Stock outs occur
Not available

Erythromycin for preterm premature rupture of membranes

available in stock in pharmacy

YES NO

Always available
Stock outs occur
Not available

Corticosteroids for preterm labour

YES NO

Always available
Stock outs occur
Not available

Tocolytics (salbutamol or indomethacin or nifedipine)

available specifically for suppression of preterm labour

YES NO

Always available
Stock outs occur
Not available

Partogram used for every birth

YES NO

Always available
Stock outs occur
Not available

Management guidelines for preterm birth available on

delivery suite

YES NO

Always available
Stock outs occur
Not available

POSTPARTUM IN LABOUR WARD

INTERVENTION

SEEN TODAY

AVAILABLE LAST 3 MONTHS?

Neonatal bag and mask?

YES NO

Always available
Not functional/missing
Not available

Dedicated space for newborn resuscitation

YES NO

Always available
Not functional/missing
Not available

Sink with running water

YES NO

Always available
Stock out
Not available

Soap

YES NO

Always available
Stock out
Not available

Chlorhexidine for clean cord care

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

Delayed cord clamping

YES NO

Always available
Inconsistently done
Not done

Drying, warming, delayed bathing

YES NO

Always available
Inconsistently done
Not done

POSTPARTUM IN NEWBORN NURSERY OR WARD

INTERVENTION

SEEN TODAY

AVAILABLE LAST 3
MONTHS?

Neonatal bag and mask?

YES NO

Always available
Not functional/missing
Not available

Airway suction equipment (e.g. nasal bulb/Penguin

sucker)

YES NO

Always available
Not functional/missing
Not available

Dedicated space for newborn resuscitation

YES NO

Always available
Not functional/missing
Not available

Sink with running water

YES NO

Always available
Stock out
Not available

Soap

YES NO

Always available
Stock out
Not available

Chlorhexidine for clean cord care

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

Dedicated space for Kangaroo Mother Care

YES NO

Always available
Sometimes share
Not available

Individual cot for every baby

YES NO

Always available
Sometimes share
Not available

Overhead heaters

YES NO

Always available
Not functional/missing
Not available

Heated cots (e.g. under bed heat lamps)

YES NO

Always available
Not functional/missing
Not available

Oxygen concentrator

YES NO

Always available
Not functional/missing
Not available

Splitter for oxygen concentrator

YES NO

Always available
Stock out
Not available

Tubing and neonatal size nasal prongs

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

Bilirubin measurement available

YES NO

Always available
Not functional/missing
Not available

Phototherapy capacity 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

Tetracycline eye ointment

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

Paediatric IV cannulae 24G/22G

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

Nasogastric tubes Size 6 and 8

YES NO

Always available
Stock outs occur
Not available

Infant formula

YES NO

Always available
Stock outs occur
Not available

Equipment to assist mothers in expressing breast

milk

YES NO

Always available
Stock outs occur
Not available

Facilities for storage and labelling of expressed

breast milk

YES NO

Always available
Stock outs occur
Not available

Equipment for cup feeding calibrated cups

YES NO

Always available
Stock outs occur
Not available

Management guidelines for newborn care in ward

YES NO

Always available
Inconsistently available
Not available

Referral guidelines/ referral policy available in ward

YES NO

Always available
Inconsistently available
Not available

Guidelines for infant feeding

YES NO

Always available
Inconsistently available
Not available

Functional telephone/2-way radio for referrals

YES NO

Always available
Inconsistently available
Not available

Drug dosing guidelines in ward

YES NO

Always available

93

Inconsistently available
Not available
Newborn observation chart

YES NO

Always available
Inconsistently available
Not available

Condoms given upon discharge from health facility

YES NO

Always available
Stock outs occur
Not available

IUD insertion available given upon discharge from

health facility

YES NO

Always available
Stock outs occur
Not available

Contraception given upon discharge from health

facility

YES NO

Always available
Stock outs occur
Not available

Materials for promotion of birth spacing

YES NO

Always available
Inconsistently available
Not available

Home based postnatal visits for preterm infants

YES NO

Always available
Inconsistently done
Not available

Monitoring & Evaluation tools of preterm birth are

available (e.g. HBB register, maternity register)

YES NO

Always available
Inconsistently done
Not available

Facility based quality improvement activities (e.g.

audits)

YES NO

Always available
Inconsistently done
Not available

MANAGEMENT OF PRETERM LABOUR

Using partographs of women who had a preterm labour in the past 3 months (15 from hospital or 10
partographs from health facility) record the following:
How many files were reviewed at this facility? ___________
How many women had:
prophylactic antibiotics given during labour? __________
more than one dose of antibiotics? ___________
tocolytics? __________
corticosteroids? ____________
normal vaginal birth? __________
vacuum extraction? ____________
caesarean section? ____________
94

What was the vaginal dilatation on admission or the 1 st VE?

Cervical dilatation on admission or1st VE

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

Appendix 2: Maternity register tool

From the maternity register in this facility, excluding births <28 weeks gestation
for the past 12 months (May 2012-May 2013) record the following:
Include both preterm births and LBW births
May 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.)
June 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.)
July 2012
Total number of all births (include both live births and stillbirths)

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

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.)
October 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.)
November 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.)
December 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
99

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.)

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

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.)
April 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.)

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

Appendix 3: FGD guide

Focus Group Discussion Guide: MEN
Interview Schedule
Interviewer Comments:

FGD WITH MEN OF REPRODUCTIVE AGE ABOUT PRETERM BIRTH

Interview code: _________________
Interviewer: _______________________________________________________________
Others involved in conducting FGD and role: _______________________________
___________________________________________________________________________
Date: ___________________________
District: _________________________
Location: _______________________
Venue: _________________________
Time: from _______ to ___________
Number of participants: _________
OBJECTIVES OF FGD
(For the interviewers, not to be read aloud to participants):
To explore mens perceptions of the causes and experiences of preterm birth among their own famil ies and the community
To explore mens role in decision making for care seeking around preterm birth
To determine factors that may underlie household and community level delays in seeking skilled care
for preterm birth
To investigate barriers and strategies to prevention of preterm birth in their community
Say: Thank you for joining us today.
In Malawi, many babies are born preterm or too early before their due date. The Ministry of Health wants to
know more about how we can improve this situation for babies and their families.
I want to ask you questions about what your community thinks about the issue of preterm birth, because we
know that men are very important in the family.
1. UNDERSTANDING, CAUSES AND EXPERIENCES OF PRETERM BIRTH

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?

What do you think causes babies to be born too early?

What can happen to babies who are born too early?

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?

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 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?
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

Focus Group Discussion Guide: WOMEN

Interview Schedule
Interviewer Comments:

FGD WITH WOMEN OF REPRODUCTIVE AGE ABOUT PRETERM BIRTH

Interview code: _________________
Interviewer: _______________________________________________________________
Others involved in conducting FGD and role: _______________________________
___________________________________________________________________________
Date: ___________________________
District: _________________________
Location: _______________________
Venue: _________________________
Time: from _______ to ___________
Number of participants: _________
OBJECTIVES OF FGD
(For the interviewers, not to be read aloud to participants):
To explore womens perceptions of the causes and the experiences of preterm birth among them selves, their own families and the community
To explore decision making for care seeking around preterm birth
To determine factors that may underlie household and community level delays in seeking skilled care
for preterm birth
To investigate barriers and strategies to prevention of preterm birth in their community
Say: Thank you for joining us today.
In Malawi, many babies are born preterm or too early before their due date. The Ministry of Health wants to
know more about how we can improve this situation for babies and their families.
I want to ask you questions about what your community thinks about the issue of preterm birth.
1. UNDERSTANDING, CAUSES AND EXPERIENCES OF PRETERM BIRTH
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 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?

What do you think causes babies to be born too early?

What can happen to babies who are born too early?

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 4: Newborn care record QOC

DATA COLLECTION FORM: QUALITY OF PRETERM CARE IN THE 1ST 24 HOURS
Data collector name: ________________________________
Date completed: (dd/mm/yy) __________________________
Audit number:
USING THE INFANT RECORD AND ACCOMPANYING OBSERVATION CHARTS
COMPLETE THE FOLLOWING:
1. BIRTHWEIGHT: ________ (gram) or N/R
2. GESTATION: ________ (weeks) or N/R
3. PLACE OF BIRTH:
QECH
HEALTH CENTRE
HOME
OTHER HOSPITAL
N/R
Other specify: _________
4. APGARS: ___ @ 1MINUTE OR N/R

___@5 MINUTES OR N/R

5. RESUSCITATION REQUIRED: NONE STIMULATION

CLEARING THE AIRWAY - SUCTION BAG AND MASK VENTILATION CARDIAC COMPRESSIONS OTHER
SPECIFY: _______________________
IN THE 1ST 24 HOURS OF ADMISSION DID THIS INFANT HAVE DOCUMENTED EVIDENCE OF THE FOLLOWING:
6. WEIGHT RECORDED NO YES
7. BLOOD SUGAR LEVEL RECORDED NO YES
7.1 IF YES: BSL VALUE: ________ mmol OR ________ mg/dl OR N/R
7.2 IF BSL LESS THAN 2.5 WERE ANY OF THE FOLLOWING DOCUMENTED:
7.2.1 INITIATE EARLY BF: NO YES
7.2.2 NG FEED: NO YES
7.2.3 IV GLUCOSE: NO YES
8. HOW MANY TIMES WAS A TEMPERATURE RECORDED WITHIN THE 1 ST 24 HOURS OF ADMISSION? NONE
1 2 3 4 5 6+
8.1 IF A TEMPERATURE WAS RECORDED <36.0 WERE ANY OF THE FOLLOWING DOCUMENTED:
8.1.1 PROVIDED WARMTH (e.g. any of: HAT, BLANKET, RADIANT WARMER, SKIN TO SKIN):
NO YES
8.1.2 INITIATE BF: NO YES
8.1.3 RECHECK TEMPERATURE AFTER 1 HOUR: NO YES
8.1.4 SCREEN FOR INFECTION: NO YES
8.1.5 BLOOD CULTURE: NO YES
8.1.6 LP: NO YES
109

8.1.7 ANTIBIOTICS COMMENCED: NO YES

9. HOW MANY TIMES WAS A RESPIRATORY RATE RECORDED WiTHIN THE 1 st 24 HOURS OF ADMISSION? 0
1 2 3 4 5 6+
9.1 WERE THERE ANY SIGNS OF RESPIRATORY DISTRESS SYNDROME RECORDED (GRUNTING, TACHYPNEA
RR >60, CHEST RECESSION, CYANOSIS)? NO YES
9.2 IF YES, WERE ANY OF THE FOLLOWING DOCUMENTED?
9.2.1 OXYGEN COMMENCED: NO YES
9.2.2 WARMTH PROVIDED: NO YES
9.2.3 TEMPERATURE CHECKED: NO YES
9.2.4 BLS CHECKED: NO YES
9.2.5 ANTIBIOTICS COMMENCED: NO YES
10. HOW MANY TIMES WAS A HEART RATE RECORDED?
NONE 1 2 3 4 5 6+
11. WAS A PHYSICAL EXAMINATION DOCUMENTED? NO YES
12. WAS A PLAN OF CARE DOCUMENTED? NO YES
13. HOW MANY FEEDS WERE DOCUMENTED AS GIVEN IN THE 1ST 24 HOURS?
NONE 1 2 3 4 5 6+
IF FEEDS DOCUMENTED:
13.1 WAS THE VOLUME OF FEED DOCUMENTED FOR ALL FEED? NO YES
13.2 WAS THE FREQUENCY OF FEEDS DOCUMENTED FOR FEEDS? NO YES
13.3 WAS THE ROUTE OF ADMINISTRATION DOCUMENTED FOR ALL FEEDS?
NO YES
14. WAS THIS INFANT REVIEWED BY A CLINICIAN IN THE 1ST 24 HOURS OF ADMISSION? NO YES

Appendix 5: AN audit
Quality of antenatal care audit
1. Name of data collector:________ date: _____________ health facility: _____________________
2.

Age: ____________ parity: __________

3.

Pregnancy type: Singleton pregnancy multiple pregnancy

4.

Record of previous preterm birth: YES NO N/A

5.

(If the data are collected retrospectively:) Infant birth weight: _______ (grams)

6.

(If the data are collected retrospectively:) Gestation: _________ (weeks)

7.

Number of ANC visits for this pregnancy: 1 2 3 4 5+

gravida: ______________

110

8.

Is this the 1st visit? YES NO

9.

Gestation recorded at first visit: ____________ weeks

10. EDC recorded YES NO

11. Record of fundal height at each visit >2nd trimester: YES NO
12. Hb recorded at least once: YES NO
13. Iron supplementation at least once: YES NO
14. HIV screening: YES NO
15. HIV test result recorded: YES NO
16. If positive, treatment commenced? YES NO
17. Record of bp at each visit: YES NO
18. Number of ANC visits in which BP was done: ___________
19. If bp >140/90 at any visit, is there a record of urine tested for protein? YES NO N/A
20. Record of weight at each visit: YES NO
21. Record of malaria prophylaxis in 2nd trimester at least once: YES NO N/A
22. Record of smoking: YES NO
23. If YES, record of smoking cessation advice YES NO
24. Record of syphillis screening done: YES NO
25. Syphilis result recorded: YES NO N/A
26. If YES, documented syphilis: YES NO
27. If YES, documented treatment for syphilis: YES NO
28. Record of screening for asymptomatic bacteruria: YES NO
29. Documented uti indicating need for antibiotics: YES NO
30. If YES, antibiotics given: YES NO
31. Record of screening for other genitourinary infections: YES NO
32. If detected, record of antibiotics: YES NO
33.
34.
35.
36.
37.

Record of any dose of tetanus toxoid given : YES NO

If yes, what was the gestation at first dose: _________(weeks gestation)
If yes, how many doses given: 1 2 3
Record of foetal heart rate recorded at every visit during second and third trimester: YES NO
At how many visits during second and third trimester was foetal heart recorded:
0 1 2 3 4 5+

111

Appendix 6: Phone questionnaire

PHONE QUESTIONNAIRE (Safe Motherhood Co-ordinator)

Participant
number:

Interviewer name: __________________________________________________

Date interview completed: (dd/mm/yy) _____________________________

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

care within 2 days of birth

Percent of newborns who received postnatal
care within 2 days of birth
Percent of women who give birth in a health
facility
Number of functional ambulances in the
district

3. KEY INTERVENTIONS TO PROMOTE NEWBORN SURVIVAL

We want to find out which of the key interventions that promote newborn survival are currently available in
your district as part of the government health service:
INTERVENTION

CURRENT AVAILABILITY

PRECONCEPTION
All hospitals
Folic acid supplementation

All health centres

Some hospitals
Some health centres
Not available

ANTENATAL
Tetanus toxoid immunisation

All hospitals
All health centres
Some hospitals
Some health centres
Not available

113

All hospitals
Syphilis screening and treatment

All health centres

Some hospitals
Some health centres
Not available

Calcium supplementation (for PE and Eclampsia

prevention)
Treatment for malaria

All hospitals
All health centres
Some hospitals
Some health centres
Not available

Detection and treatment of asymptomatic

bacteriuria

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

Corticosteroids for preterm labour

All hospitals

114

All health centres

Some hospitals
Some health centres
Not available

Tocolytic nifedipine for preterm labour

All hospitals
All health centres
Some hospitals
Some health centres
Not available

Tocolytic salbutamol for preterm labour

All hospitals
All health centres
Some hospitals
Some health centres
Not available

Tocolytics indomethacin for preterm labour

All hospitals
All health centres
Some hospitals
Some health centres
Not available

Detection and management of breech (caesarean

section)

All hospitals
All health centres

115

Some hospitals
Some health centres
Not available

Partographs for labour surveillance

All hospitals
All health centres
Some hospitals
Some health centres
Not available

Clean delivery practices birth kits

All hospitals
All health centres
Some hospitals
Some health centres
Not available

Running water and soap

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

Some health centres

Not available

KMC

All hospitals
All health centres
Some hospitals
Some health centres
Not available

How many facilities have dedicated

KMC units? ______

Promotion of breastfeeding

All hospitals
All health centres
Some hospitals
Some health centres
Not available

How many facilities have baby

friendly credentials?

______________

Prevention and management of hypothermia:

Equipment available in:

Radiant heaters or other heating devices

All hospitals

Thermometers

All health centres

117

Hats

Some hospitals

BSL monitors

Some health centres

BSL sticks

Not available

What is most commonly NOT available

from this list?

Is this provided in the district?

Community-based pneumonia case management

Yes No
If yes, who provides this?

How are cases identified?

Home based newborn care

Available in all areas

Available in some areas
Not available

If available 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?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________

6. What are the barriers to improving quality of care for newborns?

_________________________________________________________________________________________
_________________________________________________________________________________________
119

_________________________________________________________________________________________
_______________________________

120

REFERENCES
1. UN Inter-agency Group for Child Mortality Estimation (UNICEF W, World Bank, UN). Levels & Trends in
Child Mortality Report 2012: Estimates Developed by the New York: UNICEF, 2012.
2. World Bank. World Bank Data: Malawi, 2011.
3. Bank W. World Bank Database: Malawi. Washington, DC.: World Bank, 2013.
4. Macro NSOaI. Malawi Demographic Health Survey 2010. Zomba, Malawi and Calverton, Maryland, 2011.
5. Africa WHOROf. Atlas of Health Statistics of the African Region 2012. In: Organisation WH, editor.
Publication and Language Services Unit, Brazzaville, Republic of Congo: WHO Regional Office for
Africa, 2012.
6. Estimation UI-aGfCM. Levels and Trends in Child Mortality: Estimates Developed by the UN Inter-agency
group for Child Mortality Estimation. New York: UNICEF, WHO, World Bank, 2012.
7. Lawn JE, Blencowe H, Pattinson R, Cousens S, Kumar R, Ibiebele I, et al. Stillbirths: Where? When? Why?
How to make the data count? Lancet 2011;377(9775):1448-63.
8. UNICEF Division of Policy and Strategy. Committing to Child Survival: A Promise Renewed. In: UNICEF,
editor. New York: United Nations Children's Fund, 2012.
9. Zimba E, Kinney MV, Kachale F, Waltensperger KZ, Blencowe H, Colbourn T, et al. Newborn survival in
Malawi: a decade of change and future implications. Health Policy and Planning 2012;27(Suppl.
3):iii88-iii103.
10. Chihana ML, Price A, Mboma S, Mvula H, French N, Crampin AC, et al. The effect of maternal HIV status
on under-5 mortality in rural northern Malawi: a prospective cohort study. The Lancet;381,
Supplement 2(0):S29.
11. World Health Organisation. Assessment of neonatal tetanus elimination in Malawi. Weekly
Epidemiological Record 2004;79:2-6.
12. Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, et al. Global, regional, and national causes of child
mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet
2012;379(9832):2151-61.
13. Ellenberg JH, Nelson KB. The association of cerebral palsy with birth asphyxia: a definitional quagmire.
14. Lawn JE, Bahl R, Bergstrom S, Bhutta ZA, Darmstadt GL, Ellis M, et al. Setting research priorities to reduce
almost one million deaths from birth asphyxia by 2015. PLoS medicine 2011;8(1):e1000389.
15. Lawn JE, Bahl R, Bergstrom S, Bhutta ZA, Darmstadt GL, Ellis M, et al. Setting research priorities to reduce
almost one million deaths from birth asphyxia by 2015. PLoS medicine 2011;8(1).
16. Perlman JM, Risser R. Cardiopulmonary resuscitation in the delivery room. Associated clinical events.
Archives of pediatrics & adolescent medicine 1995;149:20-5.
17. Lawn JE, Kinney M, Lee AC, Chopra M, Donnay F, Paul VK, et al. Reducing intrapartum-related deaths and
disability: can the health system deliver? Int J Gynaecol Obstet 2009;107 Suppl 1:S123-40, S40-2.
18. Organization. WH. Monitoring emergency obstetric care: A handbook: Averting maternal death and
disability. Geneva: World Health Organization, 2009.
19. UNICEF. Monitoring the situation of children and women: Multiple Indicators Cluster Survey; Malawi
2006. New York: UNICEF, National Statistics Office, 2008.
20. Chikuse B, Chirwa E, Maluwa A, Malata A, Odland J. Midwives adherence to guidelines on the
management of birth asphyxia in Malawi. Open Journal of Nursing 2012;2:351-57.
21. Ellard D, Simkiss D, Quenby S, Davies D, Kandala N, Kamwendo F, et al. The impact of training nonphysician clinicians in Malawi on maternal and perinatal mortality: a cluster randomised controlled
evaluation of the enhancing training and appropriate technologies for mothers and babies in Africa
(ETATMBA) project. BMC Pregnancy and Childbirth 2012;12(116):(25 October 2012)-(25 October 12).
22. UNICEF., Organisation. WH. Low Birth weight: Country, Regional and Global Estimates. UNICEF, New
York., 2004.
121

23. Lawn JE, Cousens S, Zupan J, for the Lancet Neonatal Survival Steering T. Neonatal Survival 1. 4 million
neonatal deaths: When? Where? Why? The Lancet 2005;365:891-900.
24. Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? Where? Why? Lancet
2005;365(9462):891-900.
25. Verhoeff FH, Kazembe P, Wit JM, Broadhead RL, Brabin BJ, Buuren Sv, et al. An analysis of intra-uterine
growth retardation in rural Malawi. European journal of clinical nutrition 2001;55(8):682-89.
26. Organisation WH. The incidence of low birth weight, a critical review of available information. World
Health Quarterly Statistics 1980;33:197.
27. Blencowe H, Cousens S, Oestergaard MZ, Chou D, Moller AB, Narwal R, et al. National, regional, and
worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected
countries: a systematic analysis and implications. Lancet 2012;379(9832):2162-72.
28. SPARCLE. Study of Participation of Children with Cerebral Palsy Living in Europe. In: Colver A, editor.
Newcastle Upon Tyne, 2012.
29. Goldenberg RL, Culhane JF, Iarns JD, Romero R. Preterm Birth 1. Epidemiology and causes. The Lancet
2008;371:75-84.
30. Simhan HN, Caritis SN. Prevention of preterm delivery. New England Journal of Medicine 2007;357:47787.
31. Kulmala T, Vaahtera M, Ndekha M, Koivisto AM, Cullinan T, Salin ML, et al. The importance of preterm
births for peri- and neonatal mortality in rural Malawi. Paediatric and perinatal epidemiology
2000;14(3):219-26.
32. Van den Broek N, Ntonya C, Kayira E, White S, Neilson JP. Preterm birth in rural Malawi: high incidence in
ultrasound dated population. Human Reproduction 2005;20(11):3235-37.
33. Broek Nvd, Ntonya C, Kayira E, White S, Neilson JP. Preterm birth in rural Malawi: high incidence in
ultrasound-dated population. Human Reproduction 2005;20(11):3235-37.
34. Vaahtera M, Kulmala T, Maleta K, Cullinan T, Salin ML, Ashorn P. Epidemiology and predictors of infant
morbidity in rural Malawi. Paediatric and perinatal epidemiology 2000;14(4):363-71.
35. Vaahtera M, Kulmala T, Ndeka M, Koivisto AM, Cullinan T, Salin MJ, et al. Ante and perinatal predictors of
infant mortality in rural Malawi. Archives of Diseases in Childhood Fetal and Neonatal Edition.
2000;82:F200-F04.
36. Van den Broek N, White SA, Goodall M, Ntonya C, Kayira E, Kafulafula G, et al. The APPLe study: a
randomized, community based, placebo-controlled trial of azithromycin for the prevention of preterm birth, with meta-analysis (In press). PLoS medicine 2009.
37. Born too Soon. The Global Action Report on Preterm Birth. In: Howson CP, Kinney, M.V., Lawn, J.E. ,
editor. Geneva: World Health Organization, 2012.
38. Brabin B, Kalanda BF, Verhoeff F, Chimsuku L, Broadhead R. Risk factors for fetal anaemia in a malarious
area of Malawi. Annals of tropical paediatrics 2004;24:311-21.
39. Goldenberg RL, Culane JF, Iams J, Romero R. Epidemiology and causes of preterm birth. The Lancet
2008;371:73-82.
40. van den Broek NR, White SA, Goodall M, Ntonya C, Kayira E, Kafulafula G, et al. The APPLe study: a
randomized, community-based, placebo-controlled trial of azithromycin for the prevention of
preterm birth, with meta-analysis. PLoS medicine 2009;6(12):e1000191.
41. Metaferia AM, Muula AS. Stillbirths and hospital early neonatal deaths at Queen Elizabeth Central
Hospital, Blantyre-Malawi. International archives of medicine 2009;2(1):25.
42. McDermott JM, Steketee R, Wirima J. Mortality associated with multiple gestation in Malawi.
International Journal of Epidemiology 1995;24(2):413-19.
43. Downie L, Armiento R, Subhi R, Kelly J, Duke T, Clifford V. Community-acquired neonatal and infant sepsis
in developing countries: Efficacy of WHO's currently recommended antibiotics - Systematic review
and meta-analysis. Archives of disease in childhood 2013;98(2):146-54.
122

44. Milledge J, Calis JCJ, Graham SM, Phiri A, Wilson LK, Soko D, et al. Aetiology of neonatal sepsis in
Blantyre, Malawi: 1996-2001. Annals of tropical paediatrics 2005;25(2):101-10.
45. Gray KJ, Kafulafula G, Matemba M, Kamdolozi M, Membe G, French N. Group B streptococcus and HIV
infection in pregnant women, Malawi, 2008-2010. Emerging Infectious Diseases 2011;17(10):193235.
46. Arifeen SE, Mullany LC, Shah R, Mannan I, Rahman SM, Talukder MR, et al. The effect of cord cleansing
with chlorhexidine on neonatal mortality in rural Bangladesh: a community-based, clusterrandomised trial. Lancet 2012;379(9820):1022-8.
47. Blencowe H, Cousens S, Mullany LC, Lee AC, Kerber K, Wall S, et al. Clean birth and postnatal care
practices to reduce neonatal deaths from sepsis and tetanus: a systematic review and Delphi
estimation of mortality effect. BMC public health 2011;11 Suppl 3:S11.
48. Bhutta ZA, Zaidi AK, Thaver D, Humayun Q, Ali S, Darmstadt GL. Management of newborn infections in
primary care settings: a review of the evidence and implications for policy? The Pediatric infectious
disease journal 2009;28(1 Suppl):S22-30.
49. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L. Evidence-based, cost-effective
interventions: how many newborn babies can we save? Lancet 2005;365(9463):977-88.
50. Bahl R, Qazi S, Darmstadt GL, Martines J. Why is continuum of care from home to health facilities
essential to improve perinatal survival? Seminars in perinatology 2010;34(6):477-85.
51. Bang AT, Reddy HM, Deshmukh MD, Baitule SB, Bang RA. Neonatal and Infant Mortality in the Ten Years
(1993 to 2003) of the Gadchiroli Field Trial: Effect of Home-Based Neonatal Care. Journal of
Perinatology 2005;25:92-107.
52. Chinombo A, Kachale F, Rashidi T, Rozario A. Increasing Utilization of Maternal Health Services through
Targeted Community Interventions. In: Programme MaCHI, editor: USAID, 2013.
53. Health. MMo. HIV and Syphilis Sero-Survey and National HIV Prevalence and AIDS Estimates Report for
2010. Lilongwe: Ministry of Health, 2011.
54. Mwapasa V, Rogerson SJ, Kwiek JJ, Wilson PE, Milner D, Molyneux ME, et al. Maternal syphilis infection is
associated with increased risk of mother-to-child transmission of HIV in Malawi. AIDS
2006;20(14):1869-77.
55. Steketee RW, Nahlen BL, Parise ME, Menendez C. The burden of malaria in pregnancy in malaria-endemic
areas. American Journal of Tropical Medicine and Hygiene 2001;64(Suppl. 1):28-35.
56. Brabin B, Maxwell S, Chimsuku L, Verhoeff F, van der Kaay HJ, Broadhead R, et al. A study of the
consequences of malarial infection in pregnant women and their infants. Parassitologia 1993;35
Suppl:9-11.
57. Chimsuku L, Verhoeff FH, Maxvell SM, Broadhead RL, Thomas A, van der Kaay HJ, et al. The consequences
of malaria infection in pregnant women and their infants. Memorias do Instituto Oswaldo Cruz
1994;89 Suppl 2:1-2.
58. Conroy AL, McDonald CR, Kain KC. Malaria in pregnancy: diagnosing infection and identifying fetal risk.
Expert review of anti-infective therapy 2012;10(11):1331-42.
59. Kalanda BF, van Buuren S, Verhoeff FH, Brabin BJ. Catch-up growth in Malawian babies, a longitudinal
study of normal and low birthweight babies born in a malarious endemic area. Early human
development 2005;81(10):841-50.
60. Conroy AL, McDonald CR, Silver KL, Liles WC, Kain KC. Complement activation: a critical mediator of
adverse fetal outcomes in placental malaria? Trends in parasitology 2011;27(7):294-9.
61. Health. MGMo. Focused antenatal care and prevention of malaria during pregnancy: Training manual for
health care providers. Lilongwe, Malawi. : USAID, ECSA, WHO and UNICEF, 2006.
62. Kayentao K, Garner P, van Eijk AM, Naidoo I, Roper C, Mulokozi A, et al. Intermittent preventive therapy
for malaria during pregnancy using 2 vs 3 or more doses of sulfadoxine-pyrimethamine and risk of
low birth weight in Africa: systematic review and meta-analysis. JAMA 2013;309(6):594-604.
123

63. Lawn JE, Lee AC, Kinney M, Sibley L, Carlo WA, Paul VK, et al. Two million intrapartum-related stillbirths
and neonatal deaths: where, why, and what can be done? Int J Gynaecol Obstet 2009;107 Suppl
1:S5-18, S19.
64. Luntamo M, Kulmala T, Mbewe B, Cheung YB, Maleta K, Ashorn P. Effect of repeated treatment of
pregnant women with sulfadoxine-pyrimethamine and azithromycin on preterm delivery in Malawi:
a randomized controlled trial. The American journal of tropical medicine and hygiene
2010;83(6):1212-20.
65. Luntamo M, Rantala AM, Meshnick SR, Cheung YB, Kulmala T, Maleta K, et al. The effect of monthly
sulfadoxine-pyrimethamine, alone or with azithromycin, on PCR-diagnosed malaria at delivery: a
randomized controlled trial. PloS one 2012;7(7):e41123.
66. Rogawski ET, Chaluluka E, Molyneux ME, Feng G, Rogerson SJ, Meshnick SR. The effects of malaria and
intermittent preventive treatment during pregnancy on fetal anemia in Malawi. Clinical infectious
diseases : an official publication of the Infectious Diseases Society of America 2012;55(8):1096-102.
67. Steketee RW, Wirima JJ, Hightower AW, Slutsker L, Heymann DL, Breman JG. The effect of malaria and
malaria prevention in pregnancy on offspring birthweight, prematurity, and intrauterine growth
retardation in rural Malawi. . American Journal of Tropical Medicine and Hygiene 1996;55(Suppl.
1):33-41.
68. Yakoob MY, Lawn JE, Darmstadt GL, Bhutta ZA. Stillbirths: epidemiology, evidence, and priorities for
action. Seminars in perinatology 2010;34(6):387-94.
69. Chasela CS, Hudgens MG, Jamieson DJ, Kayira D, Hosseinipour MC, Kourtis AP, et al. Maternal or infant
antiretroviral drugs to reduce HIV-1 transmission. The New England journal of medicine
2010;362(24):2271-81.
70. Molesworth AM, Ndhlovu R, Banda E, Saul J, Ngwira B, Glynn JR, et al. High accuracy of home-based
community rapid HIV testing in rural Malawi. J Acquir Immune Defic Syndr 2010;55(5):625-30.
71. You D, Anthony D. Generation 2025 and Beyond. In: Paper UO, editor. New York.: UNICEF Division of
Policy and Strategy, 2012.
72. World Health Organisation. Accelerating Universal Access to Reproductive Health, 2011.
73. Chintsanya J. Trends and Correlates of Contraceptive Use among Married Women in Malawi: Evidence
from 2000-2010 Malawi Demographic and Health Surveys Reports: United States Agency for
International Development, 2013.
74. Corcoran J, Pillai VK. Effectiveness of secondary pregnancy prevention programs: A meta-analysis.
Research on Social Work Practice 2007;17:5-18.
75. Dicenso A, Guyatt G, Willan A, Griffith L. Interventions to reduce unintended pregnancies among
adolescents: systematic review of randomised controlled trials. British Medical Journal
2002;324(7351):1426.
76. Gavin LE, Catalano RF, David-Ferdon C, Gloppen KM, Markham CM. A review of positive youth
development programs that promote adolescent sexual and reproductive health. Journal of
Adolescent Health 2010;46:S75-S91.
77. Barros FC, Bhutta ZA, Batra M, Hansen TN, Victora CG, Rubens CE. Global report on preterm birth and
stillbirth (3 of 7): evidence for effectiveness of interventions. . BMC Pregnancy and Childbirth
2010;10(Suppl 1):S3.
78. Shankar AH, Jahari AB, Sebayang SK, Aditiawarman, Apriatni M, Harefa B, et al. Effect of maternal
multiple micronutrient supplementation on fetal loss and infant death in Indonesia: a double-blind
cluster-randomised trial. Lancet 2008;371(9608):215-27.
79. Frith AL, Naved RT, Persson LA, Rasmussen KM, Frongillo E. Early participation in a prenatal food
supplementation program ameliorates the negative association of food insecurity with quality of
maternal-infant interaction. The Journal of nutrition 2012.

124

80. Kilewo C, Natchu UC, Young A, Donnell D, Brown E, Read JS, et al. Hypertension in pregnancy among HIVinfected women in sub-Saharan Africa: prevalence and infant outcomes. Afr J Reprod Health
2009;13(4):25-36.
81. Lewycka S, Mwansambo C, Rosato M, Kazembe P, Phiri T, Mganga A, et al. Effect of women's groups and
volunteer peer counselling on rates of mortality, morbidity, and health behaviours in mothers and
children in rural Malawi (MaiMwana): a factorial, cluster-randomised controlled trial. Lancet
2013;381(9879):1721-35.
82. Pell C, Meaca A, Were F, Afrah NA, Chatio S, Manda-Taylor L, et al. Factors Affecting Antenatal Care
Attendance: Results from Qualitative Studies in Ghana, Kenya and Malawi. PloS one
2013;8(1):e53747.
83. Landes M, van Lettow M, Chan AK, Mayuni I, Schouten EJ, Bedell RA. Mortality and health outcomes of
HIV-exposed and unexposed children in a PMTCT cohort in Malawi. PloS one 2012;7(10):e47337.
84. Manzi M, Zachariah R, Teck R, Buhendwa L, Kazima J, Bakali E, et al. High acceptability of voluntary
counselling and HIV-testing but unacceptable loss to follow up in a prevention of motherto-child HIV
transmission programme in rural Malawi: scaling-up requires a different way of acting. . Tropical
medicine & international health : TM & IH 2005;10:1242-50.
85. Bowie C, Mwase T. Assessing the use of an essential health package in a sector wide approach in Malawi.
Health Research Policy and Systems 2011;9(1):4.
86. Harrington WE, Mutabingwa TK, Muehlenbachs A, Sorensen B, Bolla MC, Fried M, et al. Competitive
facilitation of drug-resistant Plasmodium falciparum malaria parasites in pregnant women who
receive preventive treatment. Proceedings of the National Academy of Sciences of the United States
of America 2009;106(22):9027-32.
87. Feng G, Simpson JA, Chaluluka E, Molyneux ME, Rogerson SJ. Decreasing burden of malaria in pregnancy
in Malawian women and its relationship to use of intermittent preventive therapy or bed nets. PloS
one 2010;5(8):e12012.
88. Kulmala T, Vaahtera M, Rannikko J, Ndekha M, Cullinan T, Salin ML, et al. The relationship between
antenatal risk characteristics, place of delivery and adverse delivery outcome in rural Malawi. Acta
Obstetricia et Gynecologica Scandinavica 2000;79(11):984-90.
89. Lohela TJ, Campbell OMR, Gabrysch S. Distance to care, facility delivery and early neonatal mortality in
Malawi and Zambia. PloS one 2012;7(12):e52110-e10.
90. Kumbani LC, Chirwa E, Malata A, yvind Odland J, Bjune G. Do Malawian women critically assess the
quality of care? A qualitative study on womens perceptions of perinatal care at a district hospital in
Malawi. Reproductive Health 2012;9(30).
91. Hussein J, Goodburn EA, Damisoni H, Lema V, Graham W. Monitoring obstetric services: putting the UN
Guidelines into practice in Malawi: 3 years on. Int J Gynecol Obstet 2001;75:63-73.
92. Leigh B, Mwale TG, Lazaro D, Lunguzi J. Emergency obstetric care: How do we Stand in Malawi? Int J
Gynecol Obstet 2008;101:107-11.
93. Kongnyuy EJ, Hofman J, Mlava G, Mhango C, van den Broek N. Availability, Utilisation and Quality of Basic
and Comprehensive Emergency Obstetric Care Services in Malawi. Matern Child Healt J 2009;13:687
- 94.
94. Ameh C, Msuya S, Hofman J, Raven J, Mathai M, Broek Nvd. Status of Emergency Obstetric Care in six
developing countries five years before the MDG targets for maternal and newborn health. PloS one
2012;7(12):e49938-e38.
95. Fenton PM, Whitty CJM, Reynolds F. Caesarean section in Malawi: prospective study of early maternal
and perinatal mortality. BMJ 2003;327:587-92.
96. Taha TE, Biggar RJ, Broadhead RL, Mtimavalye LAR, Justesen AB, Liomba GN, et al. Effect of cleansing the
birth canal with antiseptic solution on maternal and newborn morbidity and mortality in Malawi:
clinical trial. British Medical Journal (Clinical Research edition) 1997;315(7102):216-20.
125

97. Goldenberg RL, McClure EM, Saleem S, Rouse D, Vermund S. Use of vaginally administered chlorhexidine
during Labor to improve pregnancy outcomes. Obstetrics and gynecology 2006;107(5):1139-46.
98. Kafulafula G, Mwatha A, Chen YQ, Aboud S, Martinson F, Hoffman I, et al. Intrapartum antibiotic
exposure and early neonatal, morbidity, and mortality in Africa. Pediatrics 2009;124(1):e137-e44.
99. Hole MK, Olmsted K, Kiromera A, Chamberlain L. A neonatal resuscitation curriculum in Malawi, Africa:
did it change in-hospital mortality? International journal of pediatrics 2012;2012:Article ID 408689Article ID 89.
100. Bream K, Gennaro S, Kafulafula U, Mbweza E, Hehir D. Barriers to and Facilitators for Newborn
Resuscitation in Malawi, Africa. J Midwifery Womens Health 2005;50:329 - 34.
101. Brown J, Machen H, Kawaza K, Mwanza Z, Iniguez S, Lang H, et al. A High-Value, Low-Cost Bubble
Continuous Positive Airway Pressure System for Low-Resource Settings: Technical Assessment and
Initial Case Reports. PloS one 2013;8(1):1-6.
102. Lewycka S, Mwansambo C, Kazembe P, Phiri T, Mganga A, Rosato M, et al. A cluster randomised
controlled trial of the community effectiveness of two interventions in rural Malawi to improve
health care and to reduce maternal, newborn and infant mortality. Trials 2010;11:88.
103. Rosato M, Lewycka S, Mwansambo C, Kazembe A, Costello A. Women's groups perceptions of neonatal
and infant health problems in rural Malawi. Malawi medical journal : the journal of Medical
Association of Malawi 2009;21(4):168-73.
104. Lawn JE, Mwansa-Kambafwile J, Barros FC, Horta BL, Cousens S. 'Kangaroo mother care' to prevent
neonatal deaths due to pre-term birth complications. Int J Epidemiol 2010.
105. Kinney MV, Lawn JL, Kerber K. Science in action: Saving the lives of Africas mothers, newborns and
children. Report for the African Academy Science Development Initiative. Cape Town, South Africa,
2009.
106. Blencowe H, Kerac M, Molyneux E. Safety, effectiveness and barriers to follow-up using an 'early
discharge' Kangaroo Care policy in a resource poor setting. J Trop Pediatr 2009;55(4):244-8.
107. Bergh AM, Banda L, Lipato T, Ngwira G, Luhanga R, Ligowe R. Evaluation of Kangaroo Mother Care
Services in Malawi: Save the Children, USAID, MCHIP, Ministry of Health, University of Pretoria,
February 2012.
108. Children St. Facilitated Referral for Newborns with Danger Signs. Washington, : Save the Children, 2013.
109. World Health O. Integrated Management of Childhood Illness, 2009.
110. Gilroy KE, Callaghan-Koru JA, Cardemil CV, Nsona H, Amouzou A, Mtimuni A, et al. Quality of sick child
care delivered by Health Surveillance Assistants in Malawi. Health Policy Plan 2012.
111. Malawi Ministry of Health WHO. IMCI Health Facility Survey Report, April-May 2009. Lilongwe, Malawi:
Malawi Ministry of Health and the World Health Organization, 2010.
112. . RoMaHMN. Health Information Systems Assessment Report. Lilongwe, Malawi.: Ministry of Health,
2009.
113. DFID Management Sciences for Health. Evaluation of Malawis Emergency Human Resource Programme.
Cambridge MA: Management Sciences for Health., 2010.
114. Health. DMSf. Evaluation of Malawi's Emergency Human Resource Programme. Cambridge MA:
Management Sciences for Health, 2010.
115. World Health Organisation. Caring for Newborns and Children in the Community.Manual for Health
Surveillance Assistants. Lilongwe: Government of Malawi and World Health Organisation., 2010.
116. Lawn J, Kerber K. Opportunities for Africas Newborns: Practical data, policy and programmatic support
for newborn care in Africa. . Cape Town.: PMNCH, Save the Children, UNFPA, UNICEF, USAID, WHO,
2006.
117. Organization WH, Fund UNP, UNICEF, Bank TW. Pregnancy, childbirth, postpartum and newborn care: A
guide for essential practice. . 3rd Edition ed. Geneva: World Health Organisation, 2009.
118. Robb-McCord J, Waltensperger KZ, Russell J. Malawi Newborn Health Program Report of the Mid-term
Evaluation. Washington DC: USAID and Save the Children, 2009.
126

119. Evaluation of a national quality improvement initiative in infection prevention and reproductive health
services in Malawi. American Public Health Association 138th Annual Meeting & Expo; November,
2010; Denver, CO, USA.
120. Mueller DH, Lungu D, Acharya A, Palmer N. Constraints to Implementing the Essential Health Package in
Malawi. PloS one 2011;6(6):1-9.
121. Yoder P, Rosato M, Mahmud R. Womens Recall of Delivery and Neonatal Care in Bangladesh and
Malawi: A Study of Terms, Concepts, and Survey Questions. Calverton, MD, USA. : ICF Macro, 2010.
122. World Health Organization. Improving quality of paediatric care - assessment tools: pretoria 2001, 2002.

127