A neonatal ward-strengthening program improves survival for neonates treated with CPAP at district hospitals in Malawi.

Jennifer Carns,Norman Lufesi,Maria Oden,Sara Liaghati-Mobarhan,Aba Asibon,Elizabeth Molyneux,Samuel Ngwala,Rebecca Richards-Kortum,Kondwani Kawaza,Alfred Chalira

doi:10.1371/journal.pgph.0000195

Abstract

From 2013-2015, a CPAP quality improvement program (QIP) was implemented to introduce and monitor CPAP usage and outcomes in the neonatal wards at all government district and central hospitals in Malawi. In 2016 the CPAP QIP was extended into healthcare facilities operated by the Christian Health Association of Malawi. Although clinical outcomes improved, ward assessments indicated that many rural sites lacked other essential equipment and a suitable space to adequately treat sick neonates, which likely limited the impact of improved respiratory care. The aim of this study was to determine if a ward-strengthening program improved outcomes for neonates treated with CPAP. To address the needs identified from ward assessments, a ward-strengthening program was implemented from 2017-2018 at rural hospitals in Malawi to improve the care of sick neonates. The ward-strengthening program included the distribution of a bundle of equipment, supplemental training, and, in some cases, health facility renovations. Survival to discharge was compared for neonates treated with CPAP at 12 rural hospitals for one year before and for one year immediately after implementation of the ward-strengthening program. In the year prior to ward strengthening, 189 neonates were treated with CPAP; in the year after, 232 neonates received CPAP. The overall rate of survival for those treated with CPAP improved from 46.6% to 57.3% after ward strengthening (p = 0.03). For the subset of neonates with admission weights between 1.00-2.49 kg diagnosed with respiratory distress syndrome, survival increased from 39.4% to 60.3% after ward strengthening (p = 0.001). A ward-strengthening program including the distribution of a bundle of equipment, supplemental training, and some health facility renovations, further improved survival among neonates treated with CPAP at district-level hospitals in Malawi.

Highlights

85% of neonatal deaths are attributed to complications from prematurity and low birthweight, intrapartum-related hypoxia, and infection [1]
In response to the challenges experienced during the Continuous Positive Airway Pressure (CPAP) quality improvement program (QIP), in 2017 we coordinated detailed neonatal ward assessments at all government district hospitals and Christian Health Association of Malawi (CHAM) facilities to determine specific challenges and limitations at each site
A total of 207 neonates were treated with CPAP before ward strengthening, and 254 were treated after ward strengthening

Summary

Introduction

85% of neonatal deaths are attributed to complications from prematurity and low birthweight, intrapartum-related hypoxia, and infection [1]. Neonates with these complications are susceptible to respiratory distress, thermal instability, infection, jaundice, and hypoglycaemia [2]. Healthcare facilities must be able to provide neonatal care (service availability) through the presence of essential infrastructure, functioning equipment, supplies, medicine, trained staff, and current care guidelines (service readiness) [5]. Improvements are needed in health facility service availability and service readiness to provide level-2 neonatal care [7], in rural areas where 83% of Malawi’s population live [8] and where 85% of healthcare facilities in Malawi are located [5]

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Discussion

Conclusion