Doctoral dissertation

Born too soon in Malawi

Born too soon in Malawi: Maternal nutrition as a predictor of preterm delivery and community and professional views on the care of the preterm infant. The doctoral dissertation of Austrida Gondwe will be publicly examined in the Faculty of Medicine and Health Technology.

The incidence of preterm birth (PTB) remains high in Malawi and is currently estimated at 18.1%. Various underlying factors could contribute to PTBs in Africa, including maternal nutrition before pregnancy and during pregnancy. In Malawi, evidence is lacking making it difficult to estimate the relationship between maternal pre-pregnancy nutrition and pregnancy outcomes (duration of pregnancy and size of the newborn including weight, length and head circumference).

To address the existing gaps in knowledge on PTBs, the present study had three aims. The first aim was to describe the local perceptions of PTB, care practices for preterm infants, and challenges associated with PTB among people in a rural lowincome community in Malawi. The second aim was to investigate views of the health workers about the care of the preterm infants in the health facilities and existence of any treatment guidelines such as policy documents for delivery of care to the preterm infants in Malawian health facilities. Finally, the third aim was to determine the strength of association between maternal nutritional status before and during pregnancy as well as birth outcomes among women in Malawi.

Twenty in-depth interviews and 14 focus group discussions (FGDs) were used to explore the perceived causes of PTB, care practices for preterm infants and challenges associated with PTB among community members in Mangochi district. Participants perceived that diseases such as hypertension, malaria and traditional diseases (likango and mwanamphepo) during pregnancy as well as poor diet during pregnancy, having many children and history of a PTB in the family causes/lead to PTBs. The main reported care practice for preterm infants in the community was keeping the infant warm through dressing the infant with many warm clothes and covering an infant with wrappers, making fire inside the house and closing doors and windows to keep the house warm. Some of the reported challenges included lack of knowledge on how to properly care for preterm infants and poverty which limited the caregivers to buy the infants warm clothes and delay in seeking medical care when needed.

A total of 16 in-depth interviews with health care workers and policy makers were used to explore the care of preterm infants in the health facilities and existence of any treatment guidelines for delivery of care to the preterm infants in the health facilities. Some of the health workers reported that, policy and protocol guidelines for care of preterm infants were not available in some district hospitals and health centers, but those working in tertiary hospitals acknowledged availability of the policy and protocol guidelines. Additionally, policy makers believed that policy documents and protocol guidelines were available in all health facilities that would guide care of preterm infants. The analysis of documents also revealed that a policy document, produced by Ministry of Health (MOH) Malawi explaining care of preterm infants was available in Malawi.

The third study was a prospective cohort study nested within the International Lipid-Based Nutrient Supplement trial in Malawi (iLiNS DYAD-M) that enrolled 1,391 women with uncomplicated pregnancies in a randomized, controlled trial in Mangochi District of Malawi. Regression analysis was used to investigate the association between maternal pre-pregnancy BMI and weight gain during pregnancy with birth outcomes (duration of pregnancy and size of the newborn including weight, length and head circumference). No significant statistical associations were observed between pre-pregnancy BMI and pregnancy duration, but pre-pregnancy BMI was associated with birth weight and head circumference. Gestational weekly weight gain (GWG) was a strong predictor for birth outcomes as it was associated with almost all measured outcomes.

In conclusion, the local perceptions of PTBs in Mangochi district include; maternal diseases, maternal behavioral related issues and social cultural practices. Participants feel that they face many challenges to care for preterm infants in the community and in the health facilities. Policy makers believe that, treatment guidelines are available in health facilities that could guide service providers to care for preterm infants. Low GWG is strongly associated with increased risk of having infants with poor outcomes in Malawi.

The doctoral dissertation of Master of Philosophy in International Community Health Austrida Gondwe Born too soon in Malawi: Maternal nutrition as a predictor of preterm delivery and community and professional views on the care of the preterm infant will be publicly examined in the Faculty of Medicine and Health Technology of Tampere University in Arvo building Jarmo Visakorpi Auditorium, Arvo Ylpön katu 34, Tampere, on Friday August 23th 2019, at 12 o’clock. The Opponent will be Professor Thorkild Tylleskär form University of Bergen. The Custos is Professor Per Ashorn.

The dissertation is available online at http://urn.fi/URN:ISBN:978-952-03-1206-0