District Hospitals In Malawi Research Articles

Strategies for scaling up pre-ART advanced HIV disease screening at a secondary referral hospital—Malawi: a qualitative study

BackgroundImplementation of the World Health Organization (WHO) recommended Advanced HIV Disease screening package, remains poor in most settings with limited resources. More than 50% of newly diagnosed-HIV clients are missed on screening as a result of implementation barriers. It is important to mitigate the existing barriers and leverage enablers’ inorder to maximize uptake of the advanced HIV disease screening. This study aimed to identify strategies for scaling up implementation of advanced HIV disease screening among newly HIV-diagnosed clients in pre-ART phase using a Consolidated Framework for Implementation Research-Expert Recommendation for Implementing Change (CFIR-ERIC) guiding tool.MethodsA qualitative study was conducted at Rumphi district hospital in Malawi (August – September, 2023). Two sessions of Focus group discussions (FDGs) involving key stakeholders were facilitated to identify specific strategies following the initial study on exploration of barriers and facilitators of advanced HIV disease screening package. Participants comprised healthcare providers, purposively selected from key hospital departments. A deductive approach was used to analyze FDG transcripts where emerging themes were mapped with ERIC list of strategies. CFIR-ERIC Matching tool version 1.0, was used to generate an output of the most to least expert-endorsed Level 1 and Level 2 strategies.FindingsAbout 25 key healthcare workers participated in FDGs. Overall, 6 Level 1 strategies (≥ 50% expert endorsement score) and 4 Level 2 strategies (≥ 20%, ≤ 49% expert endorsement score) were identified, targeting barriers associated with availability of resources, intervention complexity, access to knowledge and information, communication; and implementation leads. Most of the reported strategies were cross-cutting and aimed at enhancing clinical knowledge of the intervention (distributing training materials, educational meetings), developing stakeholders’ interrelations (network weaving) as well as improving clinical workflow (environmental restructuring). Use of evaluative and iterative strategies such as monthly data collection for evaluation were also recommended as part of continuous improvement while an AHD coordinator was recommended to be formally appointed inorder to spearhead coordination of AHD screening services.ConclusionThrough the involvement of key stakeholders and the use of CFIR-ERIC matching tool, this study has identified cross-cutting strategies that if well implemented, can help to mitigate contextual barriers and leverage enablers for an improved delivery of AHD screening package.

Antibiotic use and resistance patterns at Rumphi District Hospital in Malawi: a cross-sectional study

BackgroundOveruse of antibiotics is a key driver of antimicrobial resistance (AMR) world-wide. Malawi continues to report rising cases of AMR among both in-patients and out-patients. We investigated antibiotic use and resistance patterns among patients with suspected first line antibiotic treatment failure at Rumphi District Hospital, Malawi.MethodsWe used a cross-sectional study design in which records of patients data on culture and antimicrobial sensitivity tests were extracted, alongside treatment history from 2019 to March, 2023, retrospectively. We also included findings for point prevalence survey (PPS) conducted within four hospital wards in June, 2022 by a well-trained multi-disciplinary team from within the hospital. The data was analyzed for antibiotic use, characterization of pathogens and their susceptibility patterns using Microsoft excel and STATA-14 software.ResultsA total of 85 patients’ data records were reviewed on antibiotics resistance pattern in which 54 (63.5%) were females. Patient antibiotic history captured indicated Metronidazole (23%), Gentamycin (20%) and Doxycycline (23%) as the most frequently used antibiotics among clients referred for microbiological investigations. Among locally available antibiotics with over 50% sensitivity were Chloramphenicol (61%), ciprofloxacin (55%), and ceftriaxone (54%). Penicillins were among antibiotics with highest resistance: ampicillin (100%), amoxyclav (90%), Piperacilin-tazobactam (63%). The majority of patients came from STI clinic and presented with genital discharges 44% (n = 39). Over 80% of the isolated N. gonorrhoeae exhibited a reduced susceptibility to gentamycin. Prevalence of Methicillin resistant staphylococcus Aureus (MRSA) was 46% and were mostly isolated from wound pus. Among 80 data records of the patients reviewed during PPS, Ceftriaxone (54.3%) and Metronidazole (23.3%) emerged as the most frequently used antibiotics in the wards which were prescribed empirically without a microbiological indication.ConclusionIn this study setting, we observed high use of watch antibiotics along with problem of multi-drug resistant infections in patients experiencing clinical failure in a variety of clinical syndromes. The findings underline the need to revamp diagnostic microbiology to increase the uptake of antimicrobial susceptibility testing to guide specific prescriptions of broad-spectrum antibiotics in the watch list.

Prevalence and Associated Factors of Psychological Distress among Diabetic Patients at Thyolo District Hospital in Malawi: Hospital-Based Cross-Section Study [Response to Letter

Prevalence and Associated Factors of Psychological Distress among Diabetic Patients at Thyolo District Hospital in Malawi: Hospital-Based Cross-Section Study [Response to Letter

Prevalence and Associated Factors of Psychological Distress Among Diabetic Patients at Thyolo District Hospital in Malawi: A Hospital-Based Cross-Sectional Study [Letter

Prevalence and Associated Factors of Psychological Distress Among Diabetic Patients at Thyolo District Hospital in Malawi: A Hospital-Based Cross-Sectional Study [Letter

Prevalence and Associated Factors of Psychological Distress Among Diabetic Patients at Thyolo District Hospital in Malawi: A Hospital-Based Cross-Sectional Study.

Emotional distress experienced by individuals with diabetes represents a type of psychological strain specific to the challenges posed by diabetes. It mirrors the emotional reactions arising from coping with the demands of the illness and the essential care associated with diabetes. The study aimed to determine the prevalence and associated factors of psychological distress among diabetic patients at Thyolo District Hospital in Malawi. To determine the prevalence and associated factors of psychological distress among diabetic patients at Thyolo District Hospital in Malawi. The cross-sectional study involved 171 participants chosen using a simple random sampling technique at Thyolo District Hospital. The study was conducted from June 28 to July 27, 2023. The data were inputted into SPSS version 23.0, and descriptive statistics were employed for analysis. Cross-tabulation, utilizing Pearson chi-square, and correlation analysis were performed. The statistical significance level was established at P <0.05. Out of the 171 participants included in the study, 44 (25.7%) reported experiencing diabetic distress. According to levels of psychological distress, the study reports that 27 (15.8%) had mild depression, while 5 (2.9%) presented with moderate depression and 1 (0.6%) had extremely severe depression. As regards to levels of anxiety, 14 (8.2%) had mild anxiety, while 5 (2.9%) had moderate anxiety. In terms of stress levels, only one participant (0.6%) reported mild stress, and an equal proportion reported moderate stress. Additionally, age was identified as a significant factor associated with psychological distress, with a p-value of 0.001. Approximately 33% of the diabetic patients involved in this study revealed psychological distress, and this condition showed a statistically significant association with age. Conducting routine assessments and implementing early control measures for the associated factors are crucial in mitigating both the prevalence and the impact of psychological distress among diabetic patients.

Critical Care Units in Malawi: A Cross-Sectional Study.

The global burden of critical illness falls disproportionately outside high-income countries. Despite younger patient populations with similar or lower disease severity, critical illness outcomes are poor outside high-income countries. A lack of data limits attempts to understand and address the drivers of critical care outcomes outside high-income countries. We aim to characterize the organization, available resources, and service capacity of public sector critical care units in Malawi and identify barriers to improving care. We conducted a secondary analysis of the Malawi Emergency and Critical Care Survey, a cross-sectional study performed from January to February 2020 at all four central hospitals and a simple random sample of nine out of 24 public sector district hospitals in Malawi, a predominantly rural, low-income country of 19.6 million in southern Africa. Data from critical care units were used to characterize resources, processes, and barriers to care. There were four HDUs and four ICUs across the 13 hospitals in the Malawi Emergency and Critical Care Survey sample. The median critical care beds per 1,000,000 catchment was 1.4 (IQR: 0.9 to 6.7). Absent equipment was the most common barrier in HDUs (46% [95% CI: 32% to 60%]). Stockouts was the most common barriers in ICUs (48% [CI: 38% to 58%]). ICUs had a median 3.0 (range: 2 to 8) functional ventilators per unit and reported an ability to perform several quality mechanical ventilation interventions. Although significant gaps exist, Malawian critical care units report the ability to perform several complex clinical processes. Our results highlight regional inequalities in access to care and support the use of process-oriented questions to assess critical care capacity. Future efforts should focus on basic critical care capacity outside of urban areas and quantify the impact of context-specific variables on critical care mortality.

The burden of ocular morbidities among elderly patients visiting a district healthcare facility in Malawi: A retrospective study.

The population of older adults is growing dramatically. Sadly, this populace is highly prone to develop various ocular morbidities, which if left unattended can lead to blindness. To determine the distribution of ocular morbidities among older adults at a secondary hospital in Malawi. This was a retrospective cross-sectional study conducted at Mzimba North District Hospital in Malawi. We retrieved 314 patient records from the hospital's ophthalmic outpatient registry from August 2020 to July 2022 using a nonprobability census sampling technique. Data entry and analysis were done employing SPSS (v.26). More females 164 (52.2%) than males 150 (47.8%) had ocular morbidities. Cataract 108 (34.4%) was the most common ocular morbidity followed by allergic conjunctivitis 104 (33.1%), then pingueculae 44 (14%), and glaucoma 8 (2.5%) Cataract showed a statistically significant difference between males and females (p < 0.05). And Glaucoma portrayed a statistically significant variation according to age groups (p < 0.05). According to the time of the year, most cases were attended to in March compared to August. The majority of blinding conditions among the elderly in Malawi are preventable similar to other geographical settings. Therefore, it is feasible to enhance the quality of life for senior Malawians and lessen the impact of blindness on individuals, families, and communities by addressing preventable causes of blindness through focused interventions.

An evaluation of funding challenges in the Malawian public healthcare delivery sector

Background: Reliable and adequate healthcare funding is crucial in public healthcare service delivery. However, district hospitals in Malawi, face funding challenges as evidenced by poor service delivery.Aim: This study aimed at investigating funding challenges experienced by public district hospitals of Malawi in the provision of healthcare services and proposing strategies for improved funding.Setting: The research presented in this article evaluates funding challenges in the public healthcare sector in Malawi, a developing country.Method: An exploratory sequential mixed method design was used. Qualitative data were collected through semi-structured interviews with 10 purposively selected individuals and were analysed thematically. Quantitative data were collected using questionnaires from 328 respondents. Quantitative data underwent factor and univariate analysis.Results: The study revealed that government funding is received late and is inadequate; donor funding was declining and earmarked for specific health activities; while income generation capacity of hospitals and Councils is weak. The study suggests that hospitals should introduce fees for service, government should be lobbied for increased funding allocations, and revenue–generating capacity of hospitals and Councils should be enhanced.Conclusion: The study concludes that there is an urgent need for government to prioritise the healthcare delivery sector and increase its funding. Hospitals and Councils should be innovative in order to generate additional funding for operations and the revenue generation capacity of hospitals and Councils should thus, be enhanced.Contribution: The study adds to the healthcare funding debate in developing countries by providing a context–specific analysis of healthcare funding challenges and suggesting improvement strategies.

Non-communicable disease burden among inpatients at a rural district hospital in Malawi

BackgroundThe burden of non-communicable diseases (NCDs) is high in Malawi. However, resources and training for NCD care remain scarce, especially in rural hospitals. Current care for NCDs in the developing world focuses on the WHO’s traditional 4 × 4 set. However, we do not know the full burden of NCDs outside of that scope, like neurological disease, psychiatric illness, sickle cell disease, and trauma. The goal of this study was to understand the burden of NCDs among inpatients in a rural district hospital in Malawi. We broadened our definition of NCDs beyond the traditional 4 × 4 set of NCDs, and included neurological disease, psychiatric illness, sickle cell disease, and trauma.MethodsWe conducted a retrospective chart review of all inpatients who were admitted to the Neno District Hospital between January 2017 and October 2018. We broke patients down by age, date of admission, type, and number of NCD diagnoses, and HIV status, and constructed multivariate regression models for length of stay and in-hospital mortality.ResultsOf 2239 total visits, 27.5% were patients with NCDs. Patients with NCDs were older (37.6 vs 19.7 years, p < 0.001) and made up 40.2% of total hospital time. We also found two distinct populations of NCD patients. The first were patients 40 years and older with primary diagnoses of hypertension, heart failure, cancer, and stroke. The second were patients under 40 years old with primary diagnoses of mental health conditions, burns, epilepsy, and asthma. We also found significant trauma burden, accounting for 40% of all NCD visits. In multivariate analysis, carrying a medical NCD diagnosis was associated with longer length of stay (coefficient 5.2, p < 0.001) and a higher risk of in-hospital mortality (OR 1.9, p = 0.03). Burn patients also had significantly longer length of stay (coefficient 11.6, p < 0.001).ConclusionsThere is a significant burden of NCDs in a rural hospital in Malawi, including those outside of the traditional 4 × 4 set. We also found high rates of NCDs in the younger population (under 40 years of age). Hospitals must be equipped with adequate resources and training to meet this burden of disease.

Status of information, education, and communication as perceived by clients receiving antenatal care at Chiradzulu District Hospital in Malawi

BackgroundInformation, education, and communication is a strategy to spread awareness through communication channels to a target audience to achieve a desired positive result. Women are supposed to receive information, education, and communication at each contact with the health worker during antenatal care. In Malawi, information, education, and communication for antenatal care is inadequate despite high antenatal care coverage. Most women do not receive it as stipulated. This could be one of the reasons that maternal and neonatal mortality is high. The provision of information, education, and communication is supposed to help in reducing maternal mortality because it is intended to develop positive attitudes towards health behaviours to support pregnant women accessing health services when required. This study, therefore, assessed the status of information, education, and communication as perceived by clients receiving antenatal care at Chiradzulu District Hospital in Malawi.MethodsA descriptive study design with a sample of 384 pregnant women attending antenatal care was used. The sample size for the study was calculated using Lemeshow, Hosmer, Klar and Rwanga's formula. Systematic random sampling method was used to select the study participants. Data were analysed using a statistical package for social sciences software version 20.0.ResultsFindings revealed that information, education, and communication provided during antenatal care were inadequate. Most information was offered. However, no topic was rated adequate by 80% of the respondents according to the Likert Scale that was used. The majority of the respondents (71.4%, n = 274) (95% CI 66.5. 75.8) preferred to receive information, education, and communication from midwives who are in the category of skilled attendants. Results further showed that more than half of the respondents participated passively and spent little time receiving information, education, and communication.ConclusionThe findings signify that information, education, and communication provided to women receiving antenatal care at Chiradzulu District Hospital had some gaps. It was inadequate and some topics were not taught. The target audience participated passively. It is recommended that midwives should provide the information, education, and communication and must have adequate contact time with the women. This is so because they are believed to be trusted sources of information.

The Chichewa Wijma delivery expectancy/experience questionnaire: a factor analytic study for postpartum women in Malawi

Objective To test the validity and reliability of the Chichewa Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) in Malawian postpartum women. Methods A cross-sectional study of postnatal women (N= 415) at 1 day after vaginal birth was conducted at a district hospital in Malawi. The W-DEQ, Edinburgh Postnatal Depression Scale and the World Health Organization Quality of Life Scale were used to measure fear of birth (FOB), depressive symptoms and quality of life (QoL). Principal component analysis (PCA) and confirmatory factor analysis (CFA), Cronbach’s alpha, the average variance extracted (AVE) and the composite reliability (CR) and Pearson correlation were used to test the construct validity, reliability, convergent and divergent validity of the Chichewa W-DEQ (CW-DEQ). Results The participants had a mean age of 28.3 ± 6.7 years. A multidimensional structure containing three factors – a lack of positive feelings, fear and concerns about childbirth – with an appropriate model fit was reported for the CW-DEQ version. The Cronbach’s α of the CW-DEQ was 0.87. The AVE and CR values were highly acceptable in lack of positive feelings – 0.17 (0.68), and concerns about childbirth – 0.79 (0.88) factors which proved the convergent validity of each; however, was marginally acceptable in the fear factor – 0.14 (0.53). Low range of correlations between the CW-DEQ constructs (r = 0.27 ∼ 0.42, p < .001), confirmed the divergent validity. Conclusions In this study, we found the CW-DEQ to be a reliable and valid tool for assessing FOB in postpartum women.

Comparing parametric and Cox regression models using HIV/AIDS survival data from a retrospective study in Ntcheu district in Malawi.

Background:The study was designed to compare parametric and Cox regression survival models. It was also aimed at determining risk factors of death due to HIV/AIDS.Design and methods:The models were fitted to time from ART initiation to death due to HIV/AIDS while using data that was collected from 6670 patients records who registered for ART from 2007 to 2012 at Ntcheu district hospital in Malawi. The best fitting model was used to determine risk factors of death due to HIV/AIDS.Results:The exponential and Gompertz model competed very well with the Cox regression. Patients in WHO clinical stage 4 (HR = 1.69, p-value <0.001) and males (HR = 1.74, p-value <0.001) were associated with increased hazard of death than those in WHO clinical stage 3 and females. Patients with high body mass index (HR = 0.82, p-value <0.001) were associated with lower hazard of death than those with lower body mass index.Conclusions:Parametric models may perform as good as the Cox regression and the plausibility of all models needs to be investigated to use the correct model for accurate inferences. Furthermore, strategies to limit deaths due to HIV/AIDS should initiate ART early before WHO clinical stage 4 and males should receive special attention. The strategies should also aim at improving the body mass index of patients.

Identifying modifiable risk factors for mortality in children aged 1–59 months admitted with WHO-defined severe pneumonia: a single-centre observational cohort study from rural Malawi

ObjectiveAlthough HIV infection, severe malnutrition and hypoxaemia are associated with high mortality in children with WHO-defined severe pneumonia in sub-Saharan Africa, many do not have these conditions and yet mortality...

Healthcare worker perspectives on mother\u2019s insufficient milk supply in Malawi

BackgroundHuman milk insufficiency is a significant barrier to implementing breastfeeding, and it is identified as a prevalent concern in 60–90% of mothers in low-and-middle-income countries. Breastmilk insufficiency can lead to hypoglycemia, hypernatremia, nutritional deficiencies, and failure to thrive in newborns and infants. Studies investigating the impact of breastfeeding interventions to improve milk production highlight inconsistencies between healthcare workers and mothers perceived support, as well as gaps in practical knowledge and training. The aim of this study was to determine perceptions surrounding human milk insufficiency from Malawian healthcare workers.MethodsThis study is a secondary analysis of 39 interviews with healthcare workers from one tertiary and three district hospitals in Malawi employing content analysis. Interviewed healthcare workers included nurses, clinical officers, midwives, and medical doctors. An inclusive coding framework was developed to identify themes related to human milk insufficiency, which were analyzed using an iterative process with NVivo12 software. Researchers focused on themes emerging from perceptions and reasons given by healthcare workers for human milk insufficiency.ResultsInability to produce adequate breastmilk was identified as a prevalent obstacle mothers face in the early postpartum period in both district and tertiary facilities in Malawi. The main reasons given by participants for human milk insufficiency were mothers’ perceived normalcy of milk insufficiency, maternal stress, maternal malnutrition, and traditional beliefs around food and eating. Three focused solutions were offered by participants to improve mother’s milk production – improving education for mothers and training for healthcare providers on interventions to improve mother’s milk production, increasing breastfeeding frequency, and ensuring adequate maternal nutrition pre- and post-partum.ConclusionHealth care workers perspectives shed light on the complexity of causes and solutions for human milk insufficiency in Malawi. This research highlights that a respectful professional relationship between health care workers and mothers is an essential bridge to improving communication, detecting human milk insufficiency early, and implementing appropriate interventions. The results of this study may help to inform research, clinical practice, and education in Malawi to improve human milk production.

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

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.

The Malawi emergency and critical care survey: A cross-sectional national facility assessment.

SummaryBackgroundData on emergency and critical care (ECC) capacity in low-income countries (LICs) are needed to improve outcomes and make progress towards realizing the goal of Universal Health Coverage.MethodsWe developed a novel research instrument to assess public sector ECC capacity and service readiness in LICs. From January 20th to February 18th, 2020 we administered the instrument at all four central hospitals and a simple random sample of nine of 24 district hospitals in Malawi, a landlocked and predominantly rural LIC of 19·1 million people in Southern Africa. The instrument contained questions on the availability of key resources across three domains and was administered to hospital administrators and clinicians from outpatient departments, emergency departments, and inpatient units. Results were used to generate an ECC Readiness Score, with a possible range of 0 to 1, for each facility.FindingsA total of 114 staff members across 13 hospitals completed interviews for this study. Three (33%) district hospitals and all four central hospitals had ECC Readiness Scores above 0·5 (p-value 0·070). Absent equipment was identified as the most common barrier to ECC Readiness. Central hospitals had higher median ECC Readiness Scores with less variability 0·82 (interquartile range: 0·80–0·89) than district hospitals (0·33, 0·23 to 0·50, p-value 0·021).InterpretationThis is the first study to employ a systematic approach to assessing ECC capacity and service readiness at both district and central hospitals in Malawi and provides a framework for measuring ECC capacity in other LICs. Prior ECC assessments potentially overestimated equipment availability and our methodology may provide a more accurate approach. There is an urgent need for investments in ECC services, particularly at district hospitals which are more accessible to Malawi's predominantly rural population. These findings highlight the need for long-term investments in health systems strengthening and underscore the importance of understanding capacity in LIC settings to inform these efforts.FundingDivision of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Department of Emergency Medicine, Brigham and Women's Hospital.

Prevalence and Socio-Demographic Determinants of Unintended Pregnancy among Women Attending Antenatal Clinic in Thyolo District, Malawi

Background: Unintended pregnancies remain a public health problem. Unintended pregnancies continue to be a leading predisposing factor to the high total fertility rate, high maternal and child health morbidity and mortality. Unintended pregnancies lead to unsafe abortion and poor health-seeking behavior, especially among young and poor women. Knowledge of associated factors can help to design and implement appropriate interventions. Objectives: This study aimed to determine the prevalence and socio-demographic factors associated with unintended pregnancy among women attending antenatal clinic (ANC) at Thyolo District Hospital in Malawi. Methodology: It was a quantitative cross-sectional study. Data was collected through face-to-face interviews with 396 women using a questionnaire. Systematic random sampling was used to recruit study participants. STATA version 13 package was used for univariate descriptive statistics, and logistic regression for bivariate and multivariate data analysis. Results: Slightly over half (54%) of women attending the antenatal clinic at Thyolo District Hospital had an unintended pregnancy. Unintended pregnancy was more likely to be reported among women of less than 20 years, education below secondary school level, marriage before 20 years, and polygamous relationships. In addition, families relying on farming alone other than employment or business were more likely to have an unintended pregnancy. Primgravidity and having no living child were also significantly associated with unintended pregnancy. Conclusion: Prevalence of unintended pregnancy is a health burden in Thyolo. Strategies to keep the girl child in school and delay marriage could address this challenge. Increasing access to effective contraceptive methods for the youth could mitigate the problem.

Rates of surgical deaths and infections at district hospitals in Malawi and Zambia: a prospective multicentre cohort study

ObjectiveThis paper reports perioperative mortality and postoperative infection rates of surgical patients who underwent operations at district-level hospitals in Malawi and Zambia, and the associations of these outcomes with patient...

Epidemiology of fractures and their treatment in Malawi: Results of a multicentre prospective registry study to guide orthopaedic care planning.

ImportanceInjuries cause 30% more deaths than HIV, TB and malaria combined, and a prospective fracture care registry was established to investigate the fracture burden and treatment in Malawi to inform evidence-based improvements.ObjectiveTo use the analysis of prospectively-collected fracture data to develop evidence-based strategies to improve fracture care in Malawi and other similar settings.DesignMulticentre prospective registry study.SettingTwo large referral centres and two district hospitals in Malawi.ParticipantsAll patients with a fracture (confirmed by radiographs)—including patients with multiple fractures—were eligible to be included in the registry.ExposureAll fractures that presented to two urban central and two rural district hospitals in Malawi over a 3.5-year period (September 2016 to March 2020).Main outcome(s) and measure(s)Demographics, characteristics of injuries, and treatment outcomes were collected on all eligible participants.ResultsBetween September 2016 and March 2020, 23,734 patients were enrolled with a median age of 15 years (interquartile range: 10–35 years); 68.7% were male. The most common injuries were radius/ulna fractures (n = 8,682, 36.8%), tibia/fibula fractures (n = 4,036, 17.0%), humerus fractures (n = 3,527, 14.9%) and femoral fractures (n = 2,355, 9.9%). The majority of fractures (n = 21,729, 91.6%) were treated by orthopaedic clinical officers; 88% (20,885/2,849) of fractures were treated non-operatively, and 62.7% were treated and sent home on the same day. Open fractures (OR:53.19, CI:39.68–72.09), distal femoral fractures (OR:2.59, CI:1.78–3.78), patella (OR:10.31, CI:7.04–15.07), supracondylar humeral fractures (OR:3.10, CI:2.38–4.05), ankle fractures (OR:2.97, CI:2.26–3.92) and tibial plateau fractures (OR:2.08, CI:1.47–2.95) were more likely to be treated operatively compared to distal radius fractures.Conclusions and relevanceThe current model of fracture care in Malawi is such that trained orthopaedic surgeons manage fractures operatively in urban referral centres whereas orthopaedic clinical officers mainly manage fractures non-operatively in both district and referral centres. We recommend that orthopaedic surgeons should supervise orthopaedic clinical officers to manage non operative injuries in central and district hospitals. There is need for further studies to assess the clinical and patient reported outcomes of these fracture cases, managed both operatively and non-operatively.

Assessment of improved neonatal ward infrastructure on neonatal health outcomes in southern Malawi

Background In 2019, 18 infants out of 1,000 live births died in the neonatal period on a global level. The distribution of these deaths was uneven, with the highest neonatal mortality rates (NMR) in sub-Saharan Africa, attributing to as much as 28 deaths per 1,000 live births. One of the Sustainable Development Goals (SDGs) includes reducing NMR to at least 12 per 1,000 live births by 2030. Several studies have emphasised the need for interventions to improve procedures and outcomes of childbirth to lower NMR. The NMR declined in Malawi from 41 in 2000 to 23 in 2016, but the pace of progress needs to be accelerated. The objective of this study was to describe the impact and outcomes of infrastructure improvement in neonatal care services, in a district hospital in Malawi. Methods The data was collected at Mangochi District Hospital in Malawi, where a new nursery opened in January 2019. The outcomes of the 624 newborns admitted in the old nursery and 1,742 newborns in the New nursery were compared. Results Birth asphyxia was the commonest diagnosis (40%), followed by sepsis (28%). Missing values attributed to 40-80% of registry records, and were significantly more common in the old nursery. Among the 1,721 (73%) newborns with information on birth weight and gestational age, 311 (18%) were born small for gestational age (SGA). Survival rates of admitted infants, including those born SGA, significantly improved in the new nursery compared to the old nursery (P&lt;0.001). The severe shortage of staff caused increased workloads. Conclusions Neonatal survival improved with more space, better-trained staff and upgrade of equipment. Monitoring of admitted newborns and their clinical care and data management and storage was a significant problem, alongside staff shortage. These results show that a multi-dimensional approach towards NMR is required, taking roots in improvements of quality of care, appropriate space, equipment and continuous education, as well as the supervision for better clinical monitoring and registration of clinical progress and outcome. &lt;br&gt;