Assessment of improved neonatal ward infrastructure on neonatal health outcomes in southern Malawi

# Background In 2019, 18 infants out of 1,000 live births died in the neonatal period on a global level. The distribution of these deaths was uneven, with the highest neonatal mortality rates (NMR) in sub-Saharan Africa, attributing to as much as 28 deaths per 1,000 live births. One of the Sustainable Development Goals (SDGs) includes reducing NMR to at least 12 per 1,000 live births by 2030. Several studies have emphasised the need for interventions to improve procedures and outcomes of childbirth to lower NMR. The NMR declined in Malawi from 41 in 2000 to 23 in 2016, but the pace of progress needs to be accelerated. The objective of this study was to describe the impact and outcomes of infrastructure improvement in neonatal care services, in a district hospital in Malawi. # Methods The data was collected at Mangochi District Hospital in Malawi, where a new nursery opened in January 2019. The outcomes of the 624 newborns admitted in the old nursery and 1,742 newborns in the New nursery were compared. # Results Birth asphyxia was the commonest diagnosis (40%), followed by sepsis (28%). Missing values attributed to 40-80% of registry records, and were significantly more common in the old nursery. Among the 1,721 (73%) newborns with information on birth weight and gestational age, 311 (18%) were born small for gestational age (SGA). Survival rates of admitted infants, including those born SGA, significantly improved in the new nursery compared to the old nursery (*P*<0.001). The severe shortage of staff caused increased workloads. # Conclusions Neonatal survival improved with more space, better-trained staff and upgrade of equipment. Monitoring of admitted newborns and their clinical care and data management and storage was a significant problem, alongside staff shortage. These results show that a multi-dimensional approach towards NMR is required, taking roots in improvements of quality of care, appropriate space, equipment and continuous education, as well as the supervision for better clinical monitoring and registration of clinical progress and outcome.