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.

ObjectiveTo determine whether a national quality improvement programme implementing continuous positive airway pressure (CPAP) at government hospitals in Malawi improved outcomes for neonates prioritised by an algorithm recommending early CPAP for infants weighing 1.0–1.3 kg (the 50th percentile weight at 30 weeks’ gestation).DesignThe analysis includes neonates admitted with respiratory illness for 5.5 months before CPAP was introduced (baseline period) and for 15 months immediately after CPAP was implemented (implementation period). A follow-up data analysis was completed for neonates treated with CPAP for a further 11 months.Setting and patientsNeonates with admission weights of 1.0–1.3 kg before (106 neonates treated with nasal oxygen) and after implementation of CPAP (153 neonates treated with nasal oxygen, 103 neonates treated with CPAP) in the newborn wards at Malawi government district hospitals. Follow-up analysis included 87 neonates treated with CPAP.InterventionNeonatal CPAP.Main outcome measureWe assessed survival to discharge at 23 government district hospitals with no significant differences in transfer rates before and after implementation of CPAP.ResultsSurvival improved for neonates with admission weights from 1.0 to 1.3 kg treated with CPAP (30.1%) as compared with neonates of the same weight band treated with oxygen during the baseline (17.9%) and implementation (18.3%) periods. There was no significant difference in survival for neonates treated with CPAP during the implementation and follow-up periods (30.1% vs 28.7%).ConclusionsSurvival for neonates weighing 1.0–1.3 kg significantly increased with a nurse-led CPAP service in a low-resource setting and improvements were sustained during follow-up.

This study evaluated whether peer mentorship was an effective and sustainable way of improving and maintaining knowledge and skills on neonatal continuous positive airway pressure (CPAP) in a low-resource setting with a high turnover of healthcare providers. The Malawi Ministry of Health recruited five nurses with considerable CPAP experience and provided them with mentorship training from July to August 2014. The mentors then provided 1-week on-site mentorship for 113 colleagues at 10 secondary and one tertiary hospital where gaps in neonatal CPAP use had been identified. CPAP competencies and outcomes were compared 3 months before and after each mentorship. In the 3 months before and after mentorship, the average CPAP competency score increased from 32 ± 4% to 97 ± 2%, while CPAP usage increased from 7% to 23% among eligible neonates. Survival following CPAP mentorship increased from 23% to 35%, but this was not significant due to the small sample size. Both mentees and mentors reported useful transfers of knowledge and skills when using CPAP. Mentorship effectively bridged the knowledge and skills gaps among health workers and increased CPAP use, competency scores and survival rates.

Aim This study evaluated whether peer mentorship was an effective and sustainable way of improving and maintaining knowledge and skills on neonatal continuous positive airway pressure (CPAP) in a low-resource setting with a high turnover of healthcare providers. Methods The Malawi Ministry of Health recruited five nurses with considerable CPAP experience and provided them with mentorship training from July to August 2014. The mentors then provided 1-week on-site mentorship for 113 colleagues at 10 secondary and one tertiary hospital where gaps in neonatal CPAP use had been identified. CPAP competencies and outcomes were compared 3 months before and after each mentorship. Results In the 3 months before and after mentorship, the average CPAP competency score increased from 32 +/- 4% to 97 +/- 2%, while CPAP usage increased from 7% to 23% among eligible neonates. Survival following CPAP mentorship increased from 23% to 35%, but this was not significant due to the small sample size. Both mentees and mentors reported useful transfers of knowledge and skills when using CPAP. Conclusion Mentorship effectively bridged the knowledge and skills gaps among health workers and increased CPAP use, competency scores and survival rates.

OBJECTIVES: Our aim in this observational study was to monitor continuous positive airway pressure (CPAP) usage and outcomes in newborn wards at 26 government hospitals in Malawi after the introduction of CPAP as part of a quality-improvement initiative. CPAP was implemented in 3 phases from 2013 through 2015. METHODS: Survival to discharge was analyzed for neonates treated with nasal oxygen and/or CPAP with admission weights of 1 to 2.49 kg at 24 government hospitals with transfer rates <15%. This analysis includes neonates admitted with respiratory illness for 5.5 months before (621 neonates) and 15 months immediately after CPAP implementation (1836 neonates). A follow-up data analysis was completed for neonates treated with CPAP at all hospitals during an additional 11 months (194 neonates). RESULTS: On implementation of CPAP, survival to discharge improved for all neonates admitted with respiratory distress (48.6% vs 54.5%; P = .012) and for those diagnosed with respiratory distress syndrome (39.8% vs 48.3%; P = .042). There were no significant differences in outcomes for neonates treated with CPAP during the implementation and follow-up periods. Hypothermia on admission was pervasive and associated with poor outcomes. Neonates with normal mean temperatures during CPAP treatment experienced the highest survival rates (65.7% for all neonates treated with CPAP and 60.0% for those diagnosed with respiratory distress syndrome). CONCLUSIONS: A nurse-led CPAP service can improve outcomes for neonates in respiratory distress in low-resource settings. However, the results show that real-world improvements in survival may be limited without access to comprehensive newborn care, especially for small and sick infants.