Breastfeeding and complementary feeding practices in rural Malawi.

UNLABELLED: To facilitate optimal growth of newborns, many countries have developed infant feeding recommendations, usually suggesting 4-6 mo of exclusive breastfeeding and then the gradual introduction of complementary foods. We prospectively studied the changes in infant diets and predictors of adherence to national infant feeding recommendations in a cohort of 720 newborn babies in rural Malawi, Sub-Saharan Africa. Monthly interviews of the main guardians indicated that breastfeeding was universal for 18 mo. As most babies were given water or other supplemental foods soon after birth, the exclusive breastfeeding rates were only 19%, 8%, 2% and 0% at ages 1, 2, 3 and 4 mo, respectively. Complementary foods and family foods were introduced at median ages of 2.5 and 6.3 mo, i.e. much earlier than recommended. Better adherence to recommendations was associated with smaller number of children in the family, increased maternal education and some other socio-economic or environmental variables. CONCLUSION: Exclusive breastfeeding is uncommon and complementary foods were introduced early to newborns among these rural families. Education and family planning may improve adherence to infant feeding recommendations and reduce the incidence of early childhood malnutrition in Malawi.

Gestational health and predictors of newborn weight amongst pregnant women in rural Malawi.

This study was conducted to provide community-based data on maternal health and predictors of newborn weight in rural Malawi. Data were obtained prospectively from a community-based cohort of 581 pregnant women who attended an antenatal clinic and delivered a term, live-born, singleton infant in Lungwena, rural Malawi. Morbidity from infectious diseases and anaemia was common. Maternal weight gain in rural Malawi was slower but fundal height gain was comparable to that of an affluent western population. The mean +/- SD weight of term newborns was 3.2 +/- 0.5 kilograms. A regression model including data from all routine investigations explained only 24% of the variance in newborn weights, suggesting that routine antenatal measurements had a limited power to predict the size of term live-born babies. Maternal parity, initial weight, the duration of pregnancy and gestational weight gain were associated with newborn weights and should, therefore, be systematically recorded in rural Malawian antenatal clinics.

Epidemiology and predictors of infant morbidity in rural Malawi.

In rural Malawi, 703 newborns were visited monthly for 1 year to describe the epidemiology and health-seeking behaviour during acute episodes of diarrhoea, respiratory infections (ARI) and malaria. On average, the infants suffered from 1.3 annual episodes (11.0 illness days) of diarrhoea, 1.1 episodes (9.4 days) of ARI and 0.7 episodes (4.8 days) of malaria. Multivariate analysis with polychotomous logistic regression indicated that the amount of morbidity was associated with the child's area of residence, weight in early life, number of siblings, father's marital status and the source of drinking water. Diarrhoea and malaria were most common at 6-12 months of age and during the rainy months whereas respiratory infections peaked at 1-3 months of age and in the cold season. Ten per cent of diarrhoea, 9% of ARI and 7% of malaria episodes lasted for more than 14 days. Fifty-eight infants died, giving case fatality rates of 1% for diarrhoea, 2% for ARI and 4% for malaria. One-third (37%) of the illness episodes were managed at home without external advice. A traditional healer was consulted in 16% of episodes and a medical professional in 55% of episodes. If consulted, traditional healers were seen earlier than medical professionals (median duration after the onset of symptoms 0.7 vs. 1.8 days, P < 0.001). Traditional healers were significantly more commonly used by those families whose infants died than by those whose infants did not die (odds ratio 1.8, 95% CI 1.1, 3.0). Our results emphasise the influence of seasonality, care and living conditions on the morbidity of infants in rural Malawi. Case fatality for diarrhoea, ARI and malaria was high and associated with health-seeking behaviour among the guardians. Future interventions must aim at early and appropriate management of common childhood illnesses during infancy.

The relationship between antenatal risk characteristics, place of delivery and adverse delivery outcome in rural Malawi.

OBJECTIVE: To describe and compare the frequency of antenatally identified maternal 'risk' characteristics, place of delivery and occurrence of delivery complications. METHODS: A prospective cohort study of 780 pregnant women completing antenatal follow-up at a rural health center in Malawi. RESULTS: Three-quarters of the subjects had at least one commonly accepted risk characteristic. Only 30% of these women, and 22% of those with no risk characteristics, delivered in a modern health facility. Four women died, 127 experienced other delivery complications and there were 52 perinatal deaths. The 'at-risk' classification had over 80% sensitivity but less than 30% specificity to predict delivery complications or perinatal deaths. The positive predictive values were as low as 20% for delivery complications and 7% for perinatal mortality. Most individual 'risk' characteristics were not associated with adverse delivery outcomes, even when adjusted for the place of delivery. CONCLUSIONS: Antenatal risk identification failed to promote safe deliveries because of a poor predictive value of the 'risk' variables and the failure of the identified 'at-risk' individuals to deliver in modern health facilities.

The importance of preterm births for peri- and neonatal mortality in rural Malawi.

Peri- and neonatal mortality remain high in developing countries, especially in sub-Saharan Africa. In the present study, we quantified and identified the most important predictors of early mortality in rural Malawi. Data were obtained from a community-based cohort of 795 pregnant women and their 813 fetuses, followed prospectively from mid-pregnancy. In this group, peri- and neonatal mortality rates were 65.3 deaths per 1000 births and 37.0 deaths per 1000 live births respectively. When controlled for month of birth, maternal age and selected socio-economic variables, preterm birth was the strongest independent predictor of both peri- and neonatal mortality (adjusted odds ratios 9.6 for perinatal and 11.0 for neonatal mortality; 95% confidence intervals: [4.4, 21.0] and [3.7, 32.7] respectively). Weaker risk factors for mortality included a maternal history of stillbirth and abnormal delivery. Preterm delivery was associated with primiparity and peripheral malaria parasitaemia of the mother, and it accounted for 65% of the population-attributable risk for perinatal and 68% of the neonatal mortality. Successful intervention programmes to reduce peri- and neonatal mortality in Malawi have to include strategies to predict and prevent prematurity.

Antenatal and perinatal predictors of infant mortality in rural Malawi.

BACKGROUND: The slow pace in the reduction of infant mortality in sub-Saharan Africa has partially been attributed to the epidemic of human immunodeficiency virus (HIV) infection. To facilitate early interventions, antenatal and perinatal predictors of 1st year mortality were identified in a rural community in southern Malawi. METHODS: A cohort of 733 live born infants was studied prospectively from approximately 24 gestation weeks onwards. Univariate analysis was used to determine relative risks for infant mortality after selected antenatal and perinatal exposures. Multivariate modelling was used to control for potential confounders. FINDINGS: The infant mortality rate was 136 deaths/1000 live births. Among singleton newborns, the strongest antenatal and perinatal predictors of mortality were birth between May and July, maternal primiparity, birth before 38th gestation week, and maternal HIV infection. Theoretically, exposure to these variables accounted for 22%, 22%, 17%, and 15% of the population attributable risk for infant mortality, respectively. INTERPRETATION: The HIV epidemic was an important but not the main determinant of infant mortality. Interventions targetting the offspring of primiparous women or infants born between May and July or prevention of prematurity would all have considerable impact on infant survival.

Health for all in the 21st century?

Approximately two decades ago world health authorities met in Alma-Ata to discuss the unequal distribution of health and other global questions. The meeting produced a declaration that emphasized the role of primary care in the provision of health services. Furthermore, adequate socioeconomic support, such as availability of food security, clean water, appropriate housing, and education, were all considered integral parts of health development. After the meeting, the World Health Organization developed a programme called 'Health for All by 2000', outlining strategies towards maximal health improvements all over the world. Thereafter, individual countries have developed national modifications from this agenda, and global development of health has on average been favourable. In the economically least developed countries, however, progress has been significantly slower than elsewhere. This editorial discusses the problem of inadequate socioeconomic development and increasing global health disparity through an example from Lungwena, a rural area in Sub-Saharan Africa. In the 21st century, poverty reduction is the key strategy towards health improvement in the least developed countries.

Childhood immunization in rural Malawi: time of administration and predictors of non-compliance.

A cohort of 760 newborns was followed prospectively for 2 years to ascertain the time of administration of childhood vaccinations in rural Malawi and to study predictors of non-compliance with national vaccination recommendations. At 1 year of age, 99% of the infants were fully vaccinated against tuberculosis, 91% against polio, 90% against diphtheria, pertussis and tetanus and 64% against measles. At 2 years, the corresponding vaccination coverages were 99%, 93%, 93% and 84%. On average, all vaccinations were given 1-3 months later than recommended. Many of the delayed measles vaccinations were given during a separate vertical campaign, during which 25% of previously unvaccinated 21-23-month-old children were identified and immunized. Non-compliance with vaccination recommendations was associated with living in villages with no access to mobile vaccination teams, birth between April and June and birth at home. In this rural Malawian area, most vaccination services were functioning well. To increase measles vaccination coverage, regular outreach activities should be encouraged.

Socio-economic support for good health in rural Malawi.

OBJECTIVE: To study the socio-economic support for good health among subsistence farmers in rural Malawi. DESIGN: A cross-sectional survey. SETTING: Lungwena, a rural area with 17,000 inhabitants in southern Malawi. PARTICIPANTS: Seven hundred and ninety five pregnant women who attended the antenatal clinic at Lungwena Health Centre between June 1995 and September 1996. INTERVENTIONS: Interviews about socio-economic conditions. Measurements of cultivated land areas and distances between home and the local health centre. MAIN OUTCOME MEASURES: Proportion of households lacking literate adults, adequate water source and sanitation, easy access to modern health care or food security. RESULTS: Only 14% of the interviewed women could read and write and half of the households had no literate members. Every fifth household was lacking both an access to safe drinking water and a proper sanitary facility. The distance to the health centre was more than 5 km among half of the households and only 37% had enough land to grow food for all family members. When other potential means of obtaining food were taken into account, 27% of the households had no food security. Numerous households were lacking more than one socio-economic prerequisites of good health: three or more were missing from a quarter of the families. CONCLUSIONS: Socio-economic prerequisites of health were commonly missing in Lungwena. Subsequent health interventions should strengthen the investments into general poverty alleviation.