Maximizing the benefits of CPAP in low- and middle-resource settings

To meet the ENAP roadmap goal to end preventable newborn deaths, district hospitals will need to offer Level-2 newborn care, including CPAP, by 2025. Our study shows a boost in survival when CPAP installation occurs alongside distributing other essential equipment, training and mentoring staff, and providing a suitable space to adequately treat sick neonates.

Malawi has the world's highest preterm birth rate, with 18.1 preterm births per 100 births. Premature babies are susceptible to life-threatening breathing problems, and respiratory distress syndrome (RDS) is the most common cause of death in preterm infants.

In Malawi, a nationwide Quality Improvement Program (QIP) addressing respiratory support was implemented from 2013-2015 and significantly improved survival rates among neonates experiencing RDS. The program consisted of the introduction of CPAP technology in neonatal units in Malawi, along with supporting equipment for respiratory care and training and supportive supervision in central and district-level hospitals. These improvements in survival were achieved with a nurse-led CPAP service in the “real world” setting of central and district hospitals. However, as Malawi began expanding this program to lower-resourced rural hospitals, it became evident that many facilities lacked additional essential equipment and infrastructure that went beyond technologies and training to improve respiratory support.

To build on the improvements in survival achieved by the respiratory support QIP, researchers asked what else it takes to make CPAP work well? To address this, district hospitals in Malawi worked with researchers and members of the Ministry of Health from 2017-2018 to plan, implement, and measure the effects of a ward-strengthening program intended to improve newborn care. The first step was to collaboratively conduct a needs assessment at each hospital to determine the specific challenges and limitations experienced by a facility. Next, a bundle of equipment was implemented at each facility, along with supplemental training. In some cases, health facility renovations were necessary to address the needs identified and provide a suitable space for treating newborns. The teams also met to discuss and determine a plan for collecting and analyzing metrics to measure the impact of the ward-strengthening program.


Our recently published observational study details the methods and results of these ward-strengthening efforts in rural hospitals in Malawi.

Ward strengthening maximizes the benefits of CPAP in low-income rural hospitals

Researchers found that the ward-strengthening program further improved outcomes for newborns treated with CPAP. They found that at these low-income rural hospital facilities, the survival for babies treated with CPAP went from 46.6% to 57.3% after ward strengthening. The biggest improvements were seen for the smallest neonates (1-2.49kg) who were diagnosed with RDS, where survival increased from 39.4% to 60.3%.

(A) Outcomes for all neonates admitted with respiratory distress and treated with CPAP for one year before and after ward strengthening. (B) Outcomes for the subset of neonates treated with CPAP weighing between 1.00 – 2.49 kg on admission and diagnosed with respiratory distress syndrome (RDS).

The need for a separate suitable space to treat small and sick newborns was the most common limitation identified at these facilities; 10 out of 12 facilities included in this analysis did not have a suitable space for neonatal care. Renovations varied by facility but generally included the expansion or partitioning of an existing space, plumbing installation and repairs, installation of lighting and electrical sockets, roofing and ceiling installation and repairs, and painting. The provision of a separate space is important to allow for close monitoring of sick newborns and to provide warmth and effective infection control to these babies, who are most susceptible to hypothermia and infection.

Renovated district hospital nursery with installed essential equipment

Limited training and high staff turnover were also identified as common challenges. As part of the ward strengthening program, trainings were conducted not only with the clinical staff at the hospitals but also in collaboration with the Ministry of Health Physical Asset Management (PAM) units to allow biomedical technicians to be trained and assist with the instruction and installation at each site. To address the challenges associated with staff turnover, the program also installed the same bundle of equipment in training institutions to provide an opportunity for nurses to become familiar with this essential equipment prior to beginning their work in the hospital.


A nationwide adoption of low-cost continuous positive airway pressure (CPAP) devices can improve survival rates for premature babies with RDS in low-resource settings, as shown in our previous study. In addition, implementing ward-strengthening programs that meet the specific needs of facilities lacking a dedicated space for neonatal care, access to training and mentorship, and other essential equipment can boost these improvements. Assessing the readiness of a facility and closing gaps where they exist can maximize the impact of life-saving technologies, such as CPAP.

User training and equipment installation

A refurbished skills lab