Hospital-based care for newborns in Malawi: Staying the course for improved outcomes amid COVID-19

By Dr. Msandeni Chiume Kayuni

As a pediatrician and the head of the Department of Pediatrics at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi, my focus is improving care for newborns and children in our hospital and supporting the referring districts. My colleagues and I remain committed to caring for small and sick newborns during the COVID-19 pandemic despite the additional challenges it presents.

Things in Malawi started to change in March 2020. Global healthcare partners in Malawi began recalling their staffs and doctors to their home countries. These were huge shifts in staffing—losing eight doctors (more than half our staff) at once in any healthcare facility is a significant undertaking with enormous challenges. The shift largely affected HIV and emergency care efforts, with minor disruptions to the neonatal wards. Then nursing staff and junior workers became scarce due to restrictions and difficulties traveling. This situation was worsened by protests on lack of adequate Personal Protective Equipment (PPE) and a demand of better medical risk allowance.

What stood out for the newborn intensive care unit (NICU) at KCH—and has made it more successful than other departments in weathering the current staffing challenges—is the importance our department had placed prior to COVID-19 on establishing a team of local healthcare workers to care for newborns.

Being part of the Newborn Essential Solutions & Technologies (NEST360°) program—which focuses on local sustainability, capacity-building, and training of local staff and professionals in its approach to improve care for small and sick newborns—means that we experienced less disruption to our NICU staffing. Of course, we still experience some staffing shortages. In the period when junior staff were unable to make it to the unit due to logistical challenges, our senior team members and the matrons jumped in to cover the workload in the NICU. Our efforts over the years to build sustainability has put us on a better footing during this crisis.

Changes in the NICU for infection prevention & control

We are seeing some positive changes in our facilities as our staff continues to focus on our main purpose: to improve care for small and sick newborns.

Measures for infection prevention have taken on new importance with the arrival of the pandemic. We are seeing success in health education on handwashing and hygiene, for both families and staff, and facilities improvements to support water and sanitation needs.

COVID-19 distancing measures have led to a new urgency in meeting our needs for more space for the NICUs. Where we normally have over 100 neonates in one ward, we have been able to get more space in the hospital to dedicate to the NICU, allowing for more space per patient.

To reduce the risks of contracting COVID-19, a hospital-wide policy has been put in place to limit the number of people allowed in the wards, including the NICU. While policies have been in place before COVID-19 to reduce overcrowding in our wards by limiting the family and guardians in the hospital, the response to COVID-19 has made these efforts more successful. Having fewer people in the hospital helps us control infections and provides us with more space for the healthcare workers and the neonates within the ward.

Clinicians are concerned about the availability of PPE. We and our partners are coming together to solve this critical problem. With strong support from the government and our partner universities, we are actively developing local solutions to supply PPE to our healthcare workers and to reduce infection.

Training, protocols & guidelines for COVID treatment in the newborn

Practical approaches to improving care for small and sick newborns within the framework of a COVID-19 response include training, updated protocols, and establishing guidelines for COVID-19 care within our NICUs.

We are awaiting additional guidelines from the Ministry of Health, but in the meantime, KCH has launched a special team to develop a plan and materials to train our staff locally on the hospital’s guidelines for COVID-19 and the associated new procedures for the NICU.

Because COVID is presenting like pneumonias, we are training the staff to be sure that they understand the best practices for infection prevention and breathing support informed by the experiences of NICUs from around the world and their handling of COVID-19 in newborns. These training sessions do not teach any new skills but are important to give confidence to our staff and medical professionals in their pediatric protocols.

We learned from Italy that ventilation is helpful, but not always the best or only care, giving us confidence that the lack of ventilators will be a negligible challenge in the management of pediatric cases. We have evidence that when we resuscitate children with CPR, it tends to be unsuccessful due to lack of adequate monitoring and supportive measures in this limited resource setting. In view of this, we decided, from a clinical perspective, that CPR would not be performed, because of the safety risk to the healthcare worker and the lack of good outcome for the patient. We are making these decisions about protocols before our case numbers surge, so that our staff can know how to proceed and remain safe on their job.

Continuing to Develop Our Response

Although there is a decline in the number of admissions at the hospital due to the fear of COVID, we are seeing more complicated pediatric cases arriving at our hospitals. The assumption is that people are staying home and delaying seeking treatment until they can no longer manage. With more complicated cases, we are relying on staffing, training, and equipment, including breathing assistance received as part of our partnership with NEST360°. We are adjusting to these changes in our workload.

We believe that the decline in patients is temporary, as people have developed a significant amount of trust in our hospital based NICU care. I believe that the trust remains, and people will return to our hospital for newborn and maternal care once COVID-19 is under control. I am very proud of our staff and medical professionals for creating this trust by having improved care for small and sick newborns—their skills and professionalism will help see us through.

Msandeni Chiume Kayuni

Pediatrician & Head of the Department of Pediatrics at KCH in Lilongwe, Malawi