Improving the quality of care for newborns in Malawi

Nurse caring for a newborn in Malawi

by Kate Howell


It was a routine day in November 2015 when I visited the neonatal ward at Thyolo District Hospital, about a 45-minute drive from Malawi’s largest city of Blantyre. Ten babies were in care, accompanied by their mothers in two large, comfortable rooms. A separate room for critically ill newborns was ready to receive patients. Trained and knowledgeable clinicians and nurses were assigned to the ward. Each patient had an up-to-date chart showing the diagnosis and treatment plan, what treatment and medicines the patient had received, and data on vital signs. Every newborn was treated like an individual deserving of high-quality healthcare.

And none of this existed a year earlier.

I was visiting the hospital with Dr. Queen Dube, the passionate, warm-hearted and gregarious head of pediatrics at Queen Elizabeth Central Hospital in Blantyre. Dr. Dube works with Save the Children to improve the quality of newborn care in Malawian district hospitals.

Dr. Dube told me that when she first visited Thyolo, there was no separate neonatal unit. Twelve mothers with newborns in need of care were together in a small room in the maternity ward with only two beds. Clinicians and nurses rotated to different assignments, so no hospital staff had specialized training on caring for newborns. No patient forms were kept, so treatment of newborns was undocumented. These gaps in record-keeping resulted in the administration of medicines and other services that were actually dangerous for babies. A newborn in distress was often considered a lost cause. Many staff didn’t realize that small, sick or asphyxiated newborns could survive given proper care.

And the situation in Thyolo wasn’t unique. Newborn health and survival is a major concern throughout Malawi.

In 2015 13,720 newborns died in the country, and over 80 percent of those deaths were from preventable causes. The newborn mortality rate has been steadily decreasing, but progress on newborn health has been significantly slower than progress on health for all children under the age of 5. In addition, Malawi has the highest rate of preterm birth worldwide, with 18.1 percent of live births occurring before 37 weeks of pregnancy are complete.

Dr. Queen Dube
Dr. Queen Dube

To address these issues, Save the Children’s Saving Newborn Lives (SNL) program partnered with Dr. Dube to facilitate a locally-led quality improvement process for Malawi’s newborn health services. The process started with a series of meetings to get support from government and other stakeholders at all levels of the health system. One of the most important components of these meetings was reaching agreement that newborn health should be an area of focus and that quality of care for newborns is a major concern.

Dr. Dube worked with district managers and hospital staff in two district hospitals (Thyolo and Machinga) to identify the greatest barriers to quality newborn care. She then began the quality improvement process by advocating for:

  1. Non-rotating staff to be assigned to newborn health,
  2. A separate neonatal ward to be established, and
  3. Forms documenting newborn patients and their care be introduced.

Thyolo’s neonatal ward with dedicated staff was opened in December 2014.

Dr. Dube’s ongoing quality improvement work includes visiting both hospitals every two weeks to mentor staff on the job. She goes on ward rounds and leads teaching sessions with all staff to increase their knowledge and skills.

When Dr. Dube isn’t on site, staff from the hospital can call her for remote assistance with challenging cases. Staff from the district hospitals also come to Queen Elizabeth for two weeks of intensive on-the-job training. In addition, Dr. Dube introduced a quality-of-care audit process, during which hospital staff analyze and discuss data on newborn patients for that month and identify areas for improvement and action.

Hospital staff told me how incredibly valuable this mentorship and training support has been. They feel more confident now that they can care for newborns. Several of them are preparing to mentor additional hospital staff to continue the quality improvement process internally.

Plans are in place to spread these quality improvement efforts to other district hospitals. Dr. Dube is training other mentors, both at the central and district hospital levels, to lead quality improvement efforts at other sites. And Save the Children is partnering with other organizations doing similar work to combine efforts and institutionalize quality improvement processes.

It was clear to me during my visit that Save the Children’s and Dr. Dube’s work is making a huge difference in the lives of mothers, newborns and hospital staff in Thyolo. I’m so excited to see how further efforts through these partnerships continue to improve the quality of care for newborns in Malawi and other countries.

To learn more about newborn health efforts in Malawi and around the world, visit and consider joining the Healthy Newborn Network, sign up for the newsletter and follow the network on Facebook and Twitter (@HealthyNewborns).

1UN Interagency Group for Child Mortality Estimation (IGME) in 2015
2UN Interagency Group for Child Mortality Estimation (IGME) in 2015
3Blencowe H, Cousens S, Oestergaard M, Chou D, Moller AB, Narwal R, Adler A, Garcia CV, Rohde S, Say L, Lawn JE. National, regional and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. The Lancet, June 9 2012, 379(9832): 2162-72. Applied to 2015 livebirths

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Until March 2016, Kate Howell was a Senior Specialist for Knowledge Management and Communications, working with Save the Children’s Saving Newborn Lives (SNL) project, based in Washington, D.C. She worked closely with all seven SNL countries to document and share learning on newborn health. Kate now serves as Senior Advisor for Knowledge Management with USAID’s flagship Maternal and Child Survival Program (MCSP).