Last week, I had the privilege to travel with Sam, Allysha, Norman (from the Ministry of Health), and Elled (from CHAM) to six more hospitals in southern Malawi. It was interesting seeing and comparing the government-run district hospitals with the church-run Christian hospitals. Below you will find information about the current neonatal services offered at each hospital, as well as, visions for furthering strengthening and design of neonatal wards.
For reference, Malawi has set the following national goals for mortality, which we hope to help reach with renovations, trainings, and improved care:
Maternal 155/100,000 0.155%
Neonatal 12/1,000 1.2%
Infant 45/1,000 0.45%
Under 5 78/1,000 0.78%
Malamulo Seventh-Day Adventist Hospital is located 65 kilometers southeast of Blantyre in Thyolo District, one of the poorest districts in Malawi. The average income of residents is less than $1 a day. The hospital serves a far range of villages and is located at the center of a rural landscape encompassing miles of bright tea plantations. The hospital itself is quite beautiful and serves many. In fact, according to the CEO at Malamulo, 40% of Malawians receive healthcare from non-government hospitals. Therefore, it is our goal to provide access to neonatal care in as many hospitals as possible, no matter how far-reaching some are.
The leaders of the hospital informed us that although Malamulo has excellent facilities, it does not have a nursery. Although they have only faced two maternal deaths in the last 2 years, they have endured dozens of infant deaths. Each month, Malamulo serves 140-150 babies; the health professionals admitted that they tend to lose many of the sick babies because they do not have access to resources for adequate and sustainable neonatal care. Currently, Malamulo does not have phototherapy lights, heaters, transfusion machines, etc. and sick babies are placed with their mothers in the KMC room. Babies that need bCPAP do have access, but often the hospital runs short of supplies needed to maintain the bCPAP, being that the hospital is so remote. The hospital also needs more nurses and has the funding for them, yet it is difficult to recruit nurses in the rural setting. Malamulo created a previous plan for a nursery, but it was not completed – now, we hope to make their plan a reality and renovate a space that will serve thousands of babies in years to come.
Mulanje Mission Hospital is a mission hospital of the Church of Central Africa Presbyterian and is located in a rural region near Mount Mulanje. Mulanje Mission has been renovating and refurbishing wards to provide better quality services for patients over the last decade – this includes renovating the neonatal ward successfully. Norman Lufesi, Program Manager for the Acute Respiratory Infections (ARI) program at the Ministry of Health, plans to publish a story showcasing the success of the neonatal ward renovations and consequent improvement in neonatal mortality. While we were there, we witnessed a baby born 600 g discharged and sent home healthy, as well as a baby born 700 g surviving well on bCPAP – how terrific and commendable is that?
Although Mulanje Mission has already invested resources and care into neonatal health, they are missing a few essential resources that could improve neonatal mortality even more so. The hospital leaders would like a second bCPAP machine, new heaters, oxygen splitters, and recessitation equipment to better serve sick neonates. Moreover, the phototherapy unit is currently broken and requires repair. We plan to equip the hospital with these necessary equipment and repairs within the coming weeks.
The Hospital Director also graciously provided us with helpful tips for renovations of the other hospitals. She emphasized the benefit of extra insulation in the ceiling to reduce electricity costs. Electricity for the rather small neonatal room at Mulanje Mission used to cost about $1 million kwacha (about $192.50 dollars) per month in order to maintain an ideal temperature of 30 degrees C (86 degrees F) to prevent hypothermia. Now, they are paying less than half of that to power the space. She also taught us that beyond a new space and equipment most important is regular, accurate training and equipping of doctors and nurses. She shared that this is what’s made a huge impact for Mulanje Mission.
Mulanje District Hospital is located nearby Mulanje Mission but serves a different area of Mulanje which is more populous and urban. At Mulanje District, the leaders at the hospital admit that they “make do” with the nursery they have, for it is extremely small for the numbers of babies they typically serve a day. Sometimes, they are serving up to 12 babies at once. They informed us that some of the biggest issues, besides size, with the current nursery are 1) heating, 2) new healthcare workers coming in who are not trained to use equipment for neonatal care, 3) lack of space established for KMC, and 4) the lack of repair of the bCPAP machine. We hope to fix each of these issues and create spaces that will serve as many sick babies as possible.
We spoke to Mulanje District about the possibility of installing solar panels to store electricity for heating and equipment use, and hope to do this for each of the hospitals if we can find extra funding from environmental agencies in Malawi. We will also ensure that Mulanje District has more frequent check-ups and trainings for the bCPAP and other technologies.
Holy Family Mission Hospital, located in Phalombe at the foot of Mulanje Mountain, has done an excellent job decreasing neonatal mortality in the last 10 years. According to leaders at the hospital, infant mortality was 39% in 2005, and in reference to a report from June-Dec 2015, the mortality has decreased to one-tenth of what it was in 2005: 3.9%. Holy Family has 8 beds for KMC, but no nursery and according to staff, KMC is often full. Presently, babies are situated in the Labor ward, and share oxygen concentrators, heaters, etc. with laboring mothers. Thankfully, space is available for a nursery which can serve 10-12 babies, and the leaders seemed excited to welcome this new innovation.
An important consideration in creating the renovation plans is having distinct spaces for infectious babies from the communities and babies born in the hospital who are sick and immediately delivered to the neonatal space upon birth. Mixing these populations in a single space could cause significant infection and mortality, which is certainly avoidable with conscious design. Lots of referrals come to Holy Family for neonatal care and unfortunately, most outcomes are not very good. We hope to work with hospital staff to design a healthy and accessible space for improved care for all babies.
Trinity Hospital – Muona is next to Nafafa in Nsanje District near the Mozambique border. Trinity serves about 130 babies a month and 10-15 pre-mature babies each month. According to leaders at the hospital, during a 3-month period from January to March 2016, there were many neonatal deaths and the highest cause of death was birth asphyxia. Leaders at Trinity described neonatal care as “not adequate,” and are very eager to improve care. The District Health Officer (DHO) said, “We have to take care of the little ones – everything else comes afterwards.”
Because there is not a specified nursery at this time, maternal beds are used as neonatal beds. The hospital also does not have access to enough incubators, oxygen concentrators, or phototherapy machines at this time. Leaders at Trinity told us that there are typically 5-6 critically ill babies each month born within the hospital and another 5-6 sick babies born outside of the hospital who need extensive neonatal care. These leaders had the idea to create separate spaces for those babies who are critically ill and those babies which are almost ready to go home for infection control purposes.
They also explained that the power goes out about 3 times a week for over 2 hours at a time. They have a generator but it was donated in 1967 and no longer functions properly. The leaders of the hospital told us that some solar panels are actually already installed, but the energy is only being used to heat water. They would like more solar panels in order to store energy and utilize it during frequent power outages. This spurred our idea to equip each of the nurseries with solar panels if financially feasible so that each neonatal ward can continue to run when the power goes out, which will hopefully save many future newborn lives.
Chickwawa District Hospital’s neonatal ward renovation plan is already under-way. The hospital has hired an architect, a structural engineer, a civil engineer, and an electrical engineer to create the nursery. We will be collaborating with these professionals in order to coordinate optimal equipment placement within the new space. Another big need is modification and insulation of windows in several of the proposed neonatal ward spaces across the country. Being that the nursery must be kept very warm and low temperature/hypothermia is a major cause of mortality, we will work with the hospitals to select windows which will let in natural lighting but prevent the escape of warm air. Chickwawa District Hospital would also like to tile the entire space, including KMC, in order to improve infection control.
We look forward to working with these hospitals further on their renovation plans. We have begun creating budgets together for construction and equipment and are talking with architects and contractors in the area who are interested in assisting in the renovations. I am excited for this opportunity and all that is to come. My favorite part of these ward assessments has been meeting and learning from diverse leaders at each of the hospitals who are so willing to share their ideas and experiences, then work tirelessly to ensure the well-being of their little but oh so important patients.