Malawi: Giving the smallest babies the best chance at life

August 2015

Malawi has one of the highest rates of preterm birth in the world. Nearly 1 in 5 babies are born before 37 weeks of gestation. Globally, complications of prematurity, such as difficulty in feeding, breathing and regulating body temperature, are the single largest cause of neonatal death. In order to survive, these babies need specialized care and equipment—resources most developing countries do not have.

Malawi is no exception.

When Dr Elizabeth Molyneux started treating preterm babies at Queen Elizabeth Central Hospital in Blantyre, Malawi more than 40 years ago, she did not have incubators to keep babies warm. Nor did she have phototherapy lights to prevent jaundice or specialized equipment to ensure their tiny airways stayed open.

“It’s been clear over the years that the smallest babies in Malawi were the most neglected,” explains Dr Molyneux.

Determined to help, Dr Molyneux helped to set up the hospital’s neonatal care unit, which today admits more than 3 000 babies a year. At first, she introduced warm cots and kangaroo mother care, a method which encourages skin-to-skin contact, but found she also needed a way to help babies whose lungs were not fully developed to breathe.

A low-cost solution

Engineering students at Rice University in Texas, USA, were able to design the solution—a low-cost bubble continuous positive airway pressure (CPAP) device called Pumani, which means “breathe” in the Malawian language of Chichewa. And it’s working. Since 2006, more than 1000 babies’ lives have been saved.

“Before CPAP we found that, if we couldn’t give any breathing support, mortality was high. By giving CPAP to babies who needed the support, survival rates improved in premature babies with breathing difficulties from 24% to 67%,” says Norman Lufesi, Head of the Acute Respiratory Infection Unit, Malawi Ministry of Health.

This is good news in a country where 1 out of 43 newborns die within the first 4 weeks of life.

“While CPAP has made a big difference for babies with respiratory distress syndrome, we still have a long way to go to reduce neonatal mortality,” says Dr Molyneux. “We still need a package of care that can be sustained in all of our hospitals.”

Preterm birth guidelines

Worldwide, complications of prematurity are the leading cause of deaths among children under the age of 5. In order to reduce neonatal and child mortality, WHO recommends evidence-based interventions be given to women at imminent risk for preterm birth or to preterm babies after birth.

CPAP, kangaroo mother care, surfactant and oxygen therapy are all newborn interventions outlined in, "WHO recommendations on interventions to improve preterm birth outcomes," a new guideline published this month. Recommended maternal interventions to improve preterm babies’ chances of survival include antenatal corticosteroids, when gestation is confirmed to be between 24 and 34 weeks, antibiotics when the fetal membranes are ruptured, and magnesium sulfate for protecting the infant against serious neurological complications.

While Malawi has implemented CPAP, kangaroo mother care and oxygen therapy at Queen Elizabeth Central Hospital, which is the country’s largest health facility, the designated neonatal rooms in most of the district hospitals are without specialized equipment or trained staff. Over the past 2 years CPAP has been introduced into 28 district hospitals and will soon be in 8 non-profit hospitals.

Focused on every newborn

Through early adoption of global policies and programmes to increase access to life-saving newborn and child health interventions, Malawi is one of a few countries in sub-Saharan Africa to achieve Millennium Development Goal 4, which aims to reduce under-5 mortality by two-thirds by the end of this year. In 1990, 1 in 4 Malawian children died before the age of five. Today, the rate is 1 in 14.

“We have done a good job at reducing under-5 child mortality in Malawi, but 44% of the deaths continue to be babies within their first month of life,” says Fannie Kachale, Director of Reproductive Health, Malawi Ministry of Health. “We realize we could have done even better if we had focused more on newborn health.”

To improve the situation, the country recently launched an adaptation of WHO and UNICEF’s Every Newborn Action Plan, with the goal of reducing neonatal mortality to 17 per 1 000 births by 2030. As part of the plan, Malawi is increasing the number of skilled birth attendants, giving antenatal corticosteroids and antibiotics to women with preterm labour using stringent criteria as defined by WHO, and strengthening newborn care during the first 4 weeks of life.

The country is also renovating 10 neonatal care units in the district hospitals and expanding Queen Elizabeth Central Hospital’s kangaroo mother care unit to 40 beds. “Through CPAP, babies who wouldn’t otherwise have survived are now surviving,” says Lufesi. “Hopefully by adding good neonatal care units in our hospitals we’ll be able to save even more babies and reduce our neonatal mortality rates.”