This study is the first investigation into longitudinal neonatal outcomes for decentralized neonatal nursery care at Neno District Hospital in a rural, hard-to-reach setting in Malawi. The results demonstrated that the development of the ward led to significant improvement over the study period in neonatal mortality, aligning with increased resources, including space, assigned neonatal staffing with dedicated training and mentorship, and appropriately available equipment, medications and supplies. This is critical, as several studies in similar contexts within sub-Saharan Africa have shown that neonatal care provision in rural resource-limited settings remains a challenge[2, 5, 24, 27, 33]. This study suggests, however, that with similar inputs and improvements as in Neno, comparable improvements in neonatal survival are possible [35–37]. In this study, at Neno District Hospital, admissions to the nursery increased fivefold as the neonatal ward was developed and expanded. This is partly due to the increased number of births at Neno District Hospital over the study period but also likely indicates increased neonatal condition recognition and referral from primary surrounding facilities. Increased admissions and primary diagnoses (birth asphyxia, sepsis and prematurity were > 95% of all admissions) of this cohort were comparable to recent studies in sub-Saharan Africa regarding district-level neonatal care units [2, 3, 38, 39, 40]. These trends suggest that critical inputs are required for improved neonatal mortality.
Over the seven years of this study, there was a significant increase in the number of neonates discharged alive for all diagnoses. Our results demonstrate a significant association between neonatal outcomes over the three study periods, with neonates admitted during study period III sixfold more likely to be discharged alive than neonates admitted during study period I. These findings mirror recent studies in similar low-income contexts with improvements in available space for caring for sick neonates (i.e., isolation and KMC units), increased numbers of trained staff dedicated to the nursery, and appropriate equipment with backup of solar electricity for durable use for resuscitation, respiratory support and temperature control [5, 23, 35, 39, 41, 42]. Strengthening existing in-service training programs, such as longitudinal mentorship, is critical to addressing the high staff turnover due to rotations and attrition, ultimately improving patient outcomes [5, 25]. Our observation in study period III was that nursing staff allocation to the neonatal care unit improved, and a clinical officer was assigned to the neonatal care unit. Strengthening neonatal care units with dedicated space, equipment, and staff training and mentorship can yield an optimal reduction in NMR [2, 3, 38, 39, 40, 44].
In the examination of specific diagnostic outcomes in Neno District Hospital, birth asphyxia survival to discharge increased with the establishment of the nursery, but it did not significantly improve from 2016–2021 throughout the final nursery period. Other studies have demonstrated that to significantly improve birth asphyxia, training, clinical mentorship and quality improvement programs in appropriate resuscitation, perinatal monitoring and neonatal care are required [35, 41, 45, 46]. Therefore, future training, processes, and guidelines for peripartum and postnatal management and quality improvement are required at Neno District Hospital in collaboration with antenatal and perinatal maternal care to prevent and decrease birth asphyxia mortality and morbidity.
The proportion of neonates with sepsis who were discharged alive improved significantly in our study from 3.3–73%. This was likely due to earlier recognition, clinical diagnosis and better treatment with the establishment of the nursery. Recent studies in similar contexts with neonatal nurseries have suggested that multidisciplinary approaches such as antibiotic stewardship, hygiene and protocols for feeding are necessary to further reduce the burden of sepsis in preterm infants [47, 48, 49], which can be extrapolated to full-term infant sepsis prevention. Future interventions might include improved diagnostics, empiric antibiotic treatment when sepsis is clinically suspected, and improved patient observation [49–50].
Our study had an overall preterm birth rate of 21%, higher than the estimated average of 12.3% in the sub-Saharan Africa region [51]. This could be due to the increase in referrals of preterm births to the facility for advanced care and structural factors. One limitation in Neno District is the lack of first-trimester antenatal ultrasound dating with the need for postnatal determination of neonates who are preterm versus low birth weight. If postnatal dating of neonates is not completed, especially within 24 hours of admission, using birth weight or maternal or health care worker reports of the number of months pregnant to determine gestational age can lead to an overestimation of preterm deliveries. Further capacity for early antenatal dating and mentorship on effective early postnatal dating and recognition of LBW versus preterm birth is required to accurately quantify preterm birth. However, preterm neonatal outcomes improved over the seven years of our study, which is likely due to dedicated nursery and KMC units, staff training and mentorship, standardized protocols, and essential equipment and medicine availability, as demonstrated in other studies [46–49].
The health care provider inputs reflected several changes that occurred. They reported that the most important change was increased capacitated staff in study period II and even more so in period III due to dedicated mentorship. This is similar to other studies where staffing shortages were frequently mentioned as barriers to the implementation of neonatal care [51,56,57]. Second, a lack of equipment during study period I with frequent stock-outs of neonatal supplies and medications limited neonatal care, which has been reported in other neonatal nursery studies [58–59]. Study period III had additional equipment for monitoring newborns, essential supplies, and dedicated staff who received specialized training in neonatal care followed by longitudinal mentorship, which might have improved the monitoring of neonates in the ward. However, there remain opportunities for improvement in the quality of care. Overall, this study, supported by other studies in similar settings, suggests improved care and outcomes of neonates born at a secondary district hospital with decentralized capacity building [21,22,25,54,55,56].
Despite this, increased capacity of the staff through clinical skills training followed by longitudinal bedside mentorship, quality improvement of care in maternal and neonatal care such as perinatal monitoring and neonatal resuscitation may improve outcomes in similar settings [30,59]. Further quality improvement work and studies are required to identify specific interventions and diagnostics that most effectively and efficiently improve outcomes in the care of sick neonates at district-level care.
Limitations
Our study has several limitations in design and data collection. First, it is data from only one district hospital neonatal nursery in a rural setting and may not broadly demonstrate the challenges and facilitators in improving neonatal outcomes. However, other studies in similar settings confirm our findings, suggesting the replicability and validity of the results [24, 35, 41, 43]. There could be several confounding factors that contributed to these improvements observed. The study had a small sample size during study period I and incomplete maternal and neonatal registers. Most of the quantitative data were from the registers of which a recent study in a similar setting [54] found poor record keeping, underreporting of maternal and neonatal complications, and discrepancies between data recorded in the monthly maternal register and client charts in the first quarter of 2018. Despite these limitations, using the registers provides the most comprehensive data repository with routine data collection in Malawi. For the staff survey reports, our study findings may have been influenced by recall bias among the key informants, as they were asked to provide information on past events but are likely limited by the small number of very discrete items they were asked to review.