Birth In Malawi Research Articles

Exploring the Relationship between Anemia and Postpartum Depression: Evidence from Malawi.

Study findings suggest association between anemia and postpartum depression, but available evidence is scant and inconsistent. We investigate whether anemia is related to postpartum depression among women who have recently given birth in Malawi, where anemia prevalence is high. We use cross-sectional data from 829 women who were 18-36 years old, married, lived in Lilongwe, Malawi, and gave birth between August 2017 and February 2019. The primary outcome is postpartum depression in the year after birth, defined by the Patient Health Questionnaire-9 (PHQ-9). Anemia status was assessed using hemoglobin levels that were measured at the time of the interview. Multivariate logistic regression analyses were used to investigate the relationship between postpartum depression and anemia status. Our analysis sample consists of 565 women who completed the PHQ-9, tested for anemia, and had no missing values for covariates. Of these women, 37.5% had anemia (hemoglobin levels ≤ 110 g/L), and 2.7% were classified as showing symptoms of a major depressive disorder (MDD). After adjusting for potential confounders, anemia was significantly associated with increased risk of MDD (OR: 3.48, 95% CI: 1.15-10.57, p-value: 0.03). No significant associations were found between other covariates and postpartum depression. Our findings suggest a potential association between anemia and postpartum depression among women in Malawi. Policies that aim to improve nutrition and health outcomes for pregnant and postpartum women could generate a "double benefit" by both preventing anemia and reducing the risk of postpartum depression.

LB 1: PPaX: Cluster randomized trial of xylitol chewing gum on prevention of preterm birth in Malawi

Studies have shown an association between maternal periodontal disease and preterm birth (PTB), but randomized trials of dental scaling/planing in pregnancy have not demonstrated preventative benefit. Xylitol chewing gum reduces dental caries, but its effect on improving periodontal health and reducing PTB is unknown. Hypothesizing that daily xylitol gum use starting periconception would reduce periodontitis and PTB, we undertook a cluster randomized trial in Malawi, the country with the highest known PTB rate (22%). This was a multicenter, open label, cluster randomized trial enrolling subjects from 8 health centers spanning a 79 km urban-rural region in Lilongwe, Malawi over 6 years with follow up of 28 days postpartum. Subjects were consented & enrolled pre-pregnancy or < 20 weeks gestation. Four centers were randomized to group perinatal and oral health education plus daily xylitol chewing gum use (intervention), and compared to 4 centers randomized to only education (control). Analysis of significant impact on the primary outcomes delivery < 37 weeks and/or < 2500 grams was by group allocation (xylitol vs control) following adjustment for confounders. 10,069 women were enrolled (4549 intervention & 5520 control) with 9,670 outcomes available at follow-up. Perinatal xylitol chewing gum use resulted in a significant PTB reduction (12.6% vs. 16.5%; aRR 0.76, 95% CI 0.59-0.99) and fewer < 2500g neonates (8.9% vs 12.9%; aRR 0.70, 95% CI 0.49-0.99), largely attributable to reducing late PTB (34-36 6/7 weeks; 9.9% vs 13.5%, aRR 0.73, 95% CI 0.53-0.99; Table 1). Among n=4220 subjects compliant with dental visits, a significant reduction in periodontitis occurred with xylitol gum use (p=0.03 vs p=0.29, Fig.1). In a cluster randomized trial in Malawi, periconception initiation and use of xylitol chewing gum resulted in a reduced incidence of PTB and < 2500g newborns, predominately due to significantly fewer late PTBs and in association with less periodontitis. To prevent a case of PTB, 26 patients would need to chew daily xylitol gum at an estimated retail cost of $1087.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Informing prevention of stillbirth and preterm birth in Malawi: development of a minimum dataset for health facilities participating in the DIPLOMATIC collaboration

ObjectiveThe global research group, DIPLOMATIC (Using eviDence, Implementation science, and a clinical trial PLatform to Optimise MATernal and newborn health in low Income Countries), aims to reduce stillbirths and preterm...

Early malaria infection, dysregulation of angiogenesis, metabolism and inflammation across pregnancy, and risk of preterm birth in Malawi: A cohort study.

BackgroundMalaria in pregnancy is associated with adverse birth outcomes. However, the underlying mechanisms remain poorly understood. Tight regulation of angiogenic, metabolic, and inflammatory pathways are essential for healthy pregnancies. We hypothesized that malaria disrupts these pathways leading to preterm birth (PTB).Methods and findingsWe conducted a secondary analysis of a randomized trial of malaria prevention in pregnancy conducted in Malawi from July 21, 2011, to March 18, 2013. We longitudinally assessed circulating mediators of angiogenic, metabolic, and inflammatory pathways during pregnancy in a cohort of HIV-negative women (n = 1,628), with a median age of 21 years [18, 25], and 562 (35%) were primigravid. Pregnancies were ultrasound dated, and samples were analyzed at 13 to 23 weeks (Visit 1), 28 to 33 weeks (Visit 2), and/or 34 to 36 weeks (Visit 3). Malaria prevalence was high; 70% (n = 1,138) had PCR-positive Plasmodium falciparum infection at least once over the course of pregnancy and/or positive placental histology. The risk of delivering preterm in the entire cohort was 20% (n = 304/1506). Women with malaria before 24 weeks gestation had a higher risk of PTB (24% versus 18%, p = 0.005; adjusted relative risk [aRR] 1.30, 95% confidence interval [CI] 1.04–1.63, p = 0.021); and those who were malaria positive only before week 24 had an even greater risk of PTB (28% versus 17%, p = 0.02; with an aRR of 1.67, 95% CI 1.20–2.30, p = 0.002). Using linear mixed-effects modeling, malaria before 24 weeks gestation was associated with altered kinetics of inflammatory (C-Reactive Protein [CRP], Chitinase 3-like protein-1 [CHI3L1], Interleukin 18 Binding Protein [IL-18BP], soluble Tumor Necrosis Factor receptor II [sTNFRII], soluble Intercellular Adhesion Molecule-1 [sICAM-1]), angiogenic (soluble Endoglin [sEng]), and metabolic mediators (Leptin, Angiopoietin-like 3 [Angptl3]) over the course of pregnancy (χ2 > 13.0, p ≤ 0.001 for each). Limitations include being underpowered to assess the impact on nonviable births, being unable to assess women who had not received any antimalarials, and, because of the exposure to antimalarials in the second trimester, there were limited numbers of malaria infections late in pregnancy.ConclusionsCurrent interventions for the prevention of malaria in pregnancy are initiated at the first antenatal visit, usually in the second trimester. In this study, we found that many women are already malaria-infected by their first visit. Malaria infection before 24 weeks gestation was associated with dysregulation of essential regulators of angiogenesis, metabolism, and inflammation and an increased risk of PTB. Preventing malaria earlier in pregnancy may reduce placental dysfunction and thereby improve birth outcomes in malaria-endemic settings.

Neurological letter from Malawi

Malawi is a country in Southern Africa (figures 1 and 2) and gained its independence from the British Colony in 1964. Currently 17.5 million people live in Malawi, and about...

Maternal overweight and obesity and the risk of caesarean birth in Malawi

BackgroundOverweight and obese women are at risk of pregnancy and delivery complications. This study investigates the trend and association between maternal overweight and obesity on caesarean births in Malawi.MethodsWe utilised cross-sectional population-based Demographic Health Surveys (DHSs) data collected from mothers aged 18–49 years in 2004/05, 2010, and 2015/16 in Malawi. The outcome measure was caesarian birth within 5 years preceding the surveys. The main independent variable was maternal Body Mass Index (BMI) measured as weight in kilograms by height in meters squared (kg/m2) and categorized according to the World Health Organization (WHO) guidelines. Generalized estimating equations (GEE) regression models were constructed to analyze total samples of 6795, 4474 and 4363 in 2004/05, 2010 and 2015/16 respectively.ResultsThere was an observed increase in the trend of caesarean births as well as maternal overweight and obesity from 2004 to 2015. The results of the multivariate analyses showed that maternal overweight (adjusted odds ratio [aOR] = 1.35; 95% Confidence Interval [CI] 1.01–1.83) in 2015/16 and (aOR = 1.36; 95% CI: 1.10–1.65) from 2004 to 2015 were risk factors for caesarean births in Malawi. In addition, being obese (aOR = 2.15; 95% CI: 1.12–4.11) in 2004/05, (aOR = 1.66; 95% CI: 1.08–2.55) in 2010, (aOR = 2.18; 95% CI: 1.48–3.21) in 2015/16, and (aOR = 2.16; 95% CI: 1.65–2.84) from 2004 to 2015) increased the risk of caesarean births. In addition, women who had one parity, and lived in the northern region were significantly more likely to have undergone caesarean birth.ConclusionsIn order to reduce non-elective cesarean birth in Malawi, specific public health programs should be focus on reducing overweight and obesity among women of reproductive age. More focus attention may be given to women with one parity, particularly in the urban and the northern region of Malawi.

Qualitative assessment of knowledge transfer regarding preterm birth in Malawi following the implementation of targeted health messages over 3 years.

BackgroundIn 2012, we performed a needs assessment and gap analysis to qualitatively assess providers’ and patients’ knowledge and perceptions regarding preterm birth (PTB). During the study, we identified knowledge gaps surrounding methods to reduce the risk of occurrence of PTB and management options if preterm labor/birth occur. We targeted health messages toward these gaps. The objective of the present study was to assess the impact of our community health worker-based patient education program 3 years after it was implemented.MethodsFifteen focus groups including 70 participants were included in the study. The groups comprised either patients/patient couples or health providers. A minimum of two facilitators led each group using 22 a priori designed and standardized lead-in prompts for participants with four additional prompts for providers only. A single researcher recorded responses, and transcript notes were reviewed by the facilitators and interpreters immediately following each group discussion to ensure accuracy.ResultsThe understanding of term vs preterm gestation was generally accurate. Every participant knew of women who had experienced PTB, and the general perception was that two to three women out of every ten had this experience. The majority of respondents thought that women should present to their local health clinic if they experience preterm contractions; few were aware of the use of antenatal steroids for promoting fetal lung maturity, but many acknowledged that the neonate may be able to receive life-sustaining treatment if born at a higher level of care facility. The majority of participants were aware that PTB could recur in subsequent pregnancies. All respondents were able to list ways that women could potentially reduce the risk of PTB.ConclusionAfter employing targeted health messages, the majority of participants expressed improved understanding of the definition of PTB, methods to prevent risk of PTB, and management options for preterm labor or PTB.

Maternal and neonatal health in Malawi: An integrative literature review

Background/Aims: A conservative estimate suggests women giving birth in Malawi are 14 times more likely to die giving birth than women in western nations. Despite attempts to address maternal and neonatal health, Malawi will not meet World Health Organization Millennium Development Goals 3, 4 and 5 for improving gender equity, reducing child mortality and improving maternal health by 2015. This integrative literature review looks through a social lens to view Malawi's progress towards meeting Millennium Development Goals 3, 4 and 5. Methods: A search was conducted using CINAHL, Google Scholar, Medline and Health Source online databases. Initial keywords included but were not limited to: gender bias; gender inequality; midwifery care; maternity; traditional birth attendants; skilled birth attendants; and social determinants. All searches included keywords with Boolean operator ‘and’ Malawi. Search filters were limited to publications dated from 2010 to 2015 and in English only. Additionally, reference lists from articles selected were reviewed, which led to further relevant sources. Although 48 articles were accessed, only 13 were considered to have high relevance, credibility and currency and were therefore included. Findings: Poverty underpins all social determinants of health and is the primary barrier to Malawi achieving the Millennium Development Goals. Poverty limits girls' access to education, which increases their risk of being exposed to infectious diseases. A lack of education is also associated with limited use of primary maternity care with a skilled birth attendant. Conclusions: Primary maternity care needs to be affordable and acceptable to Malawian women and provided close to their families and communities. The primary responsibility for this rests with Malawi's government, which should be encouraged to adopt supportive, enabling policies. To assist in this, western governments need to be socially responsible in deployment of their foreign aid and strategies to attract and retain skilled workers.

The Demographic Promise of Expanded Female Education: Trends in the Age at First Birth in Malawi.

The expansion of female education has been promoted as a way to postpone the age of first birth. In sub-Saharan Africa, the first cohorts to benefit from policies that expanded access to education are now reaching adulthood and beginning childbearing. I investigate whether the expansion of education in Malawi, which implemented a free primary education policy in 1994 and subsequently expanded secondary schooling, has led to a later age at first birth and whether the education gradient in fertility timing has remained stable over time. Despite increases in female grade attainment over the past twenty years, the age at first birth has not changed. Using instrumental variables analysis, I find a significant negative association between grade attainment and age at first birth, suggesting that the deterioration of school quality and shift in the age pattern of enrollment that accompanied educational expansion may have compromised the transformative potential of education.

Born too small: who survives in the public hospitals in Lilongwe, Malawi?

ObjectiveMalawi has the highest estimated preterm birth rate in the world. The survival rate of these babies is not known. The main objective of this study was to demonstrate the...

Qualitative assessment of attitudes and knowledge on preterm birth in Malawi and within country framework of care

BackgroundThe overarching goal of this study was to qualitatively assess baseline knowledge and perceptions regarding preterm birth (PTB) and oral health in an at-risk, low resource setting surrounding Lilongwe, Malawi. The aims were to determine what is understood regarding normal length of gestation and how gestational age is estimated, to identify common language for preterm birth, and to assess what is understood as options for PTB management. As prior qualitative research had largely focused on patient or client-based focused groups, we primarily focused on groups comprised of community health workers (CHWs) and providers.MethodsA qualitative study using focus-group discussions, incidence narrative, and informant interviews amongst voluntary participants. Six focus groups were comprised of CHWs, patient couples, midwives, and clinical officers (n = 33) at two rural health centers referring to Kamuzu Central Hospital. Semi-structured questions facilitated discussion of PTB and oral health (inclusive of periodontal disease), including definitions, perception, causation, management, and accepted interventions.ResultsEvery participant knew of women who had experienced “a baby born too soon”, or preterm birth. All participants recognized both an etiology conceptualization and disease framework for preterm birth, distinguished PTB from miscarriage and macerated stillbirth, and articulated a willingness to engage in studies aimed at prevention or management. Identified gaps included: (1) discordance in the definition of PTB (i.e., 28–34 weeks or less than the 8th month, but with a corresponding fetal weight ranging 500 to 2300 grams); (2) utility and regional availability of antenatal steroids for prevention of preterm infant morbidity and mortality; (3) need for antenatal referral for at-risk women, or with symptoms of preterm birth. There was no evident preference for route of progesterone for the prevention of recurrent PTB.ConclusionsQualitative research was useful in (1) identifying gaps in knowledge in urban and rural Malawi, and (2) informing the development of educational materials and implementation of programs or trials ultimately aimed at reducing PTB. As a result of this qualitative work, implementation planning was focused on the gaps in knowledge, dissemination of knowledge (to both patients and providers), and practical solutions to barriers in known efficacious therapies.

Factors Associated with Preterm, Early Preterm and Late Preterm Birth in Malawi

BackgroundAssessment of risk factors for preterm birth in a population with high incidence of preterm birth and HIV infection.MethodsSecondary analysis of data for 2,149 women included in a community based randomized placebo controlled trial for the prevention of preterm birth (APPLe trial (ISRCTN84023116) with gestational age at birth determined through ultrasound measurement in early pregnancy. Multivariate Logistic Regression analyses to obtain models for three outcome variables: all preterm, early preterm, and late preterm birth.FindingsNo statistical differences were noted for the prevalence of HIV infection (p = 0.30) or syphilis (p = 0.12) between women who delivered preterm versus term. BMI (Adjusted OR 0.91 (0.85–0.97); p = 0.005) and weight gain (Adjusted OR 0.89 (0.82–0.97); p = 0.006) had an independent, protective effect. Previous preterm birth doubled the odds of preterm birth (Adjusted OR 2.13 (1.198–3.80); p = 0.01). Persistent malaria (despite malaria prophylaxis) increased the risk of late preterm birth (Adjusted OR 1.99 (1.05–3.79); p = 0.04). Age <20 (Adjusted OR 1.73 (1.03–2.90); p = 0.04) and anemia (Adjusted OR 1.95 (1.08–3.52); p = 0.03) were associated with early preterm birth (<34 weeks).ConclusionsDespite claims that HIV infection is an important cause of preterm birth in Africa, we found no evidence of an association in this population (unexposed to anti-retroviral treatment). Persistent malaria was associated with late preterm birth. Maternal undernourishment and anemia were independently associated with early preterm birth. The study did not assess whether the link was direct or whether a common precursor such as chronic infection was responsible for both maternal effects and early labour.

Insights on skilled attendance at birth in Malawi - the findings of a structured document and literature review

Increasing the number of women who access skilled attendance at birth is the goal of many developing countries including Malawi. The Skilled Attendance for Everyone (SAFE) international research programme coordinated by the Dugald Baird Centre for research on Women\'s Health at the University of Aberdeen, developed a Strategy Development Tool (SDT). The tool comprised five modules: Problem identification, Situation analysis (Document and Literature review and Interpretive guidelines), Needs assessment, Monitoring system and Synthesis. The Document and Literature review component of the tool was piloted in Malawi in collaboration with the Ministry of Health & Population. The findings revealed that Malawi has a critical shortage of Skilled Attendance which encompasses both the Skilled Attendant and an enabling environment. While health sector educational programmes appear to be strong, the country has lost significant numbers of health personnel, especially Midwives through resignation death and retirement. Only 55% of women access health facilities and of these, 56% are assisted by Skilled Attendants at birth. Cultural factors, staff negative attitudes and long distances among other factors, hinder access and utilization of the available Skilled Attendance at birth. Malawi Medical Journal Vol.16(2) 2005: 40-42