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This study aimed to examine the prevalence and predictors of immediate mother–newborn skin-to-skin contact (SSC) in Malawi and factors associated with missed SSC despite being delivered in health facilities.
Background:
SSC immediately after birth is an evidence-based essential newborn care intervention associated with improved thermoregulation, early breastfeeding initiation, maternal–infant bonding, and neonatal survival. Although facility delivery is expected to promote SSC, a substantial proportion of newborns in low- and middle-income countries still do not receive this recommended practice.
Methods:
We analysed data from the Malawi Demographic and Health Survey 2024. After restricting to the most recent live birth per woman and applying a complete-case approach across the outcome and all explanatory variables, the final analytic sample comprised 6,065 mother–newborn pairs (weighted sample: 6,142). The outcome was maternal report of immediate SSC after birth. Weighted descriptive statistics, chi-square tests, and multilevel logistic regression were used to identify factors associated with SSC. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) are reported.
Findings:
Overall, 77.3% of newborns experienced SSC. In the fully adjusted model, caesarean delivery (aOR = 0.13, 95% CI: 0.10–0.17) and multiple births (aOR = 0.47, 95% CI: 0.26–0.86) were associated with lower adjusted odds of receiving SSC. Institutional delivery (aOR = 5.20, 95% CI: 1.86–14.56) and antenatal care attendance were associated with higher adjusted odds of receiving SSC. Among institutional deliveries, caesarean delivery and multiple births (aOR = 0.44, 95% CI: 0.24–0.80) remained associated with lower odds of receiving SSC. Cluster-level variation was substantial (ICC = 0.172–0.173).
Anaemia during pregnancy is a public health concern, yet the relationship between household food insecurity, dietary intake and anaemia among pregnant women remains underexplored. This cross-sectional study investigated these associations in 612 second-trimester pregnant women attending antenatal care in Lilongwe, Malawi. Household food insecurity was assessed using the Household Food Insecurity Access Scale (HFIAS), dietary intake via the Semi-quantitative Food Frequency Questionnaire (SQ-FFQ) and anaemia defined as Hb <10·5 g/dL. Results showed that 21·24 % were anaemic, and 69·93 % resided in food-insecure households. Severe food insecurity (adjusted OR (a-OR): 2·58, 95 % CI 1·41–4·71), insufficient intake of energy (a-OR: 1·73, 95 % CI 1·13, 2·66), Fe (a-OR: 1·98, 95 % CI 1·21, 3·24) and vitamin C (a-OR: 1·71, 95 % CI 1·12, 2·59) were significantly associated with a higher likelihood of anaemia, whereas those with a Minimum Dietary Diversity for Women (MDD-W) had a substantially reduced risk compared with those with low dietary diversity (LDD) (a-OR: 0·19, 95 % CI 0·06, 0·61). Dietary diversity partially mediated the association between household food insecurity and anaemia among pregnant women. Findings underscore the need to promote food security, dietary diversity and nutrient intake through targeted health education and staff training. These strategies could reduce anaemia prevalence and improve maternal health outcomes.
Otoscopy is an essential but technically challenging diagnostic skill, particularly in resource-limited settings where access to specialist training is limited. Simulation may provide a scalable approach to improve otoscopy education.
Methods
A retrospective evaluation was conducted following an Otosim®-based quality improvement training initiative at three clinical sites in Malawi. Participants included ENT clinicians, audiologists, audiology students, clinical officers, and physicians. Pre- and post-training surveys assessed preparedness, confidence, perceived diagnostic ability, realism, and educational value. A literature review of otoscopy training modalities was also performed.
Results
Forty-six participants completed the training. Participants had varied clinical backgrounds and otoscopy experience. Most reported improved preparedness following simulation training and rated Otosim as useful, realistic, and effective for improving diagnostic ability and confidence. Participants also perceived simulation as more effective than traditional classroom teaching.
Conclusions
Simulation-based otoscopy training was feasible and well received in Malawi and improved participants’ perceived preparedness and confidence. Simulation may offer a valuable strategy for expanding otoscopy education in resource-constrained settings, although future studies should include objective competency measures and assessment of long-term skill retention.
This chapter investigates theorized claims about how politicians lobby and bargain with donors to achieve electoral advantages. Especially, it examines the correspondence between electoral geography and aid distribution over time in Malawi, Kenya, and Sierra Leone. The analysis shows how ruling parties have biased aid in favor of ruling party coalitions. Additionally, this chapter includes a case study analysis of how aid distribution in Kenya changed during the electoral transition from President Moi to President Kibaki in 2002.
This chapter examines what voters in Malawi know about donor activities in their communities, and how foreign aid changes voter behavior and beliefs about incumbent performance. I show using original survey data that aid recipients struggle to distinguish between the role of governments and donors in development funding. Next, I use experimental and panel data to test hypotheses about how foreign aid (and beliefs about foreign aid bargains) change voter behavior and perceptions of incumbent performance. The results are broadly consistent with the theoretical predictions in Chapter 3.
Chapter 8 extends the analysis beyond South Africa to explore the activities of protest brokers in other contexts. While previous chapters focused exclusively on South Africa to develop and test the theory in depth, this chapter argues that protest brokers are not unique to that setting. Drawing on original data from Ghana and Malawi, as well as secondary evidence from Argentina, India, the Democratic Republic of the Congo, and Uganda, it demonstrates that intermediaries who organize protest on behalf of elites can be found globally. The chapter presents three main findings. First, individuals who function as protest brokers – connecting elites to communities – exist in a variety of countries. Second, these brokers differ in their relationships with elites and communities in ways consistent with the typology developed earlier in the book. Third, variation in broker characteristics correlates with predictable differences in protest across these different contexts. While not offering a comprehensive cross-national study, this chapter provides initial comparative evidence that protest brokers are a widespread phenomenon, suggesting that the theoretical framework developed here has broad relevance for understanding global patterns of protest mobilization.
Mental health literacy (MHL) is the ability to recognise mental disorders; have knowledge of professional help available, effective self-help and prevention strategies; and have the skills to support others. MHL is linked to better help-seeking behaviours and better management of mental illness. Mental illness prevalence is increasing in Malawi. Assessing MHL in communities crucially helps identify knowledge gaps, informing the development of evidence-based interventions.
Aims
This study assessed the MHL levels of young adults (16–30 years old) in rural and urban communities in Malawi.
Method
A cross-sectional national survey was administered to 682 people across 13 districts in Malawi, using a self-reporting Mental Health Literacy questionnaire (MHLq) that assessed knowledge of mental health problems, erroneous beliefs/stereotypes, first aid skills, help-seeking behaviour and self-help strategies.
Results
Most respondents were either unemployed (36%) or enrolled in school (43%). A total of 73% completed primary or secondary education, and 48% knew someone with a mental illness, but only 14% of this group could specify the illness. The mean MHL score was 111.8 (s.d. 13.9). Individuals with primary and secondary school qualifications had significantly lower scores in factor 2 (erroneous beliefs/stereotypes) and factor 3 (first aid skills and assistance-seeking behaviour) of the MHLq than those with higher education.
Conclusions
This research highlights persisting mental health misconceptions, limited knowledge about specific mental illnesses and low help-seeking behaviour among young adult Malawians. Higher education is linked to a better understanding of mental health. Prioritising community education on causes, signs, treatments and prognosis of mental illness is crucial for increased MHL.
The procedure for mandatory reviews, also known as confirmations, has existed in Malawi since the colonial period. It requires that when a subordinate court convicts a person and imposes a punishment that passes a prescribed threshold, the case record be forwarded to a higher court for review. This article examines the evolution of this procedure in Malawi from the colonial era to how it is being currently understood and applied. It argues that the understanding that courts have recently attached to the procedure does not align with how this procedure has historically developed. Moreover, this understanding diminishes the procedure’s effectiveness in its function of protecting convicts’ rights. The article suggests ways of improving the procedure to ensure it remains relevant and suitable for the purpose for which it was originally established.
In many parts of Africa, the mass production of printed texts began with Christian missions. Missionaries’ descriptions of African languages and their compilation of dictionaries were essential for the emergence of print cultures. However, missionary linguistics mirrored missionary politics. Two Protestant missionaries in Central Africa, one in Congo and the other in Malawi, differed in their views on both African languages and the European presence in Africa. Where Walter Henry Stapleton’s dictionary took an interest in colonial rule, David Clement Scott advanced dialogue in a radical vision for race relations. Both worked with widely spoken language forms, but the missionaries were driven by disparate motivations. Between them, the two dictionaries indicate considerable variation in the nineteenth-century missionary contributions to African print cultures. They, and the missionaries who compiled them, convey sharply divergent visions for African languages as contributions to human knowledge and imagination.
Voters and politicians often blame tallying irregularities on fraud, undermining perceptions of democratic and electoral credibility. Yet such irregularities also result from capacity failures and human error. We introduce several methods to assess competing causes of tallying irregularities leveraging the quasi-random administration of polling stations. Using these methods, we revisit the case of the 2019 Malawian presidential election which was famously canceled by the High Court due to widespread result-sheet edits and accusations of fraud. Contrary to the dominant consensus, we do not find evidence that edits were motivated by fraud or that they benefited the incumbent. Instead, we show that edits increased in proportion to the complexity of filling in result-sheets, suggesting a dominant role for human error. In addition to reinterpreting a historically important election, we also make the case that policy efforts to improve electoral credibility could productively be reallocated towards electoral administration rather than anti-fraud measures.
This pilot cross-sectional study, conducted in two public hospitals in Malawi, assessed gestational diabetes mellitus (GDM) in pregnant women attending antenatal clinics and compared their dietary quality and food group consumption before and during pregnancy. The study targeted women aged 18 to 49 years within 24 to 28 weeks of gestation. GDM was diagnosed according to the International Association of Diabetes and Pregnancy Study Group criteria and assessed dietary quality before and during pregnancy using a 30-day qualitative food frequency questionnaire. We compared changes in dietary quality and specific food group mean scores using paired t-tests at p < 0.05. Of the 508 women enrolled, 22.7% were diagnosed with GDM. The overall diet quality significantly decreased during pregnancy compared to before; a similar trend was observed in women diagnosed with GDM compared to those without GDM (p < 0.0001). Among women with GDM, the mean score of the following food groups significantly (p < 0.05) decreased during pregnancy: cruciferous vegetables, deep orange vegetables and tubers, citrus fruits, deep orange fruits, other fruits, nuts and seeds, poultry, fish, low fat dairy, whole grains, and liquid oils and significantly (p < 0.05) increased in the following food groups; red meat, processed meat, sugar-sweetened beverages, sweets, sugary snacks and ice cream. In conclusion, GDM is prevalent in Malawian women enrolled in this study and is coupled with inadequate dietary quality, especially during pregnancy. Since dietary quality is pivotal to GDM management, more in-depth longitudinal dietary studies are needed to inform nutritional interventions to prevent and better manage GDM.
Climate-smart agriculture that promotes climate change adaptation and mitigation while improving livelihoods is being advocated to smallholder farmers. Most studies in this area focus on the yield and income impacts of practices, but we explore farmer well-being impacts. Using a multi-criteria analysis embedded in an in-person questionnaire, our findings suggest that smallholder farmers in Southern Malawi have diverse preferences for climate-smart practices based on location, access to markets and resources and importance placed on climate adaptation. The use of multidimensional well-being criteria provides deeper insights into the motivations and priorities of farmers, revealing trade-offs between immediate food needs and climate adaptation concerns, as well as between the need for incentives versus the risk of conditional credits. Our study calls for tailored climate-smart agriculture projects that allow farmers to adopt practices that meet their needs.
Control of female genital schistosomiasis (FGS) has gained significant international attention, driven in part, as a newly appreciated underlying aetiological risk factor for HIV, HPV and cervical dysplasia. Whilst diagnosis and clinical staging of FGS typically relies upon colposcopy, alternative methods of incrimination have grown, particularly upon application of PCR diagnostic assays that detect schistosome DNA within tissue biopsy, genital (self-)swab and/or cervicovaginal lavage (CVL). With regard to the latter, we present novel evidence that microscopy alone of CVL sediments can be sufficient to incriminate FGS and CVL sediment provides an original source of (viable) schistosome eggs and miracidia for later genetic analysis. Upon a pilot examination of 55 adult women from Malawi with previously proven urogenital schistosomiasis by egg-patent urine microscopy, 25.5% (95% CI = 14.7–39.0) were found to have schistosome eggs within CVL, with one woman having more than 50 eggs observed. After praziquantel treatments and upon re-examination one year later, the prevalence of egg-patent CVLs reduced to 14.5% (95% CI = 6.5–26.7) although the same woman again presented with more than 50 observable eggs. Molecular DNA analysis by real-time PCR of extracted DNA from CVL sediments and CVL hatched miracidia (and eggs) revealed the dominance of Schistosoma haematobium within the samples, noting a fifth with Schistosoma mattheei co-infections and the singular presence of a putative S. haematobium × mattheei hybrid miracidium. Viable schistosome eggs shed from cervicovaginal surfaces likely represent a minor environmental transmission route, thus promoting secure menstrual hygiene management is needed.
This study explores the potential of applying machine learning (ML) methods to identify and predict areas at risk of food insufficiency using a parsimonious set of publicly available data sources. We combine household survey data that captures monthly reported food insufficiency with remotely sensed measures of factors influencing crop production and maize price observations at the census enumeration area (EA) in Malawi. We consider three machine-learning models of different levels of complexity suitable for tabular data (TabNet, random forests, and LASSO) and classical logistic regression and examine their performance against the historical occurrence of food insufficiency. We find that the models achieve similar accuracy levels with differential performance in terms of precision and recall. The Shapley additive explanation decomposition applied to the models reveals that price information is the leading contributor to model fits. A possible explanation for the accuracy of simple predictors is the high spatiotemporal path dependency in our dataset, as the same areas of the country are repeatedly affected by food crises. Recurrent events suggest that immediate and longer-term responses to food crises, rather than predicting them, may be the bigger challenge, particularly in low-resource settings. Nonetheless, ML methods could be useful in filling important data gaps in food crises prediction, if followed by measures to strengthen food systems affected by climate change. Hence, we discuss the tradeoffs in training these models and their use by policymakers and practitioners.
This piece explores the parallel development of two fisheries management regimes in mid-twentieth-century Lake Malawi: one imposed by the British colonial government over the lake and the other by Senior Chief Makanjira focused on Mbenji Island. The parallel development of these regimes provides opportunity for close analysis of how fisheries management centred on different knowledge and practices led to distinctive legacies of governance legitimacy and efficacy. Given the increasing recognition that Indigenous knowledge is crucial to the future sustainability of fisheries globally, we contend that it is imperative to recognise the ways in which colonial pasts have embedded knowledge hierarchies and exclusionary decision-making processes within national fisheries governance regimes that continue to obstruct capacities to bring different knowledges, practices, and management approaches together effectively and appropriately.
The export of ornamental fishes from Malawi has received limited attention regarding its sustainability or the conservation status of any threatened species involved in this trade. To identify any species that require specific management actions, we used a negative binomial regression model to examine the relationship between the number of exported fish and year of export, adjusted for fish prices and the number of fish exporters. We also examined the correlation between export volume trends and the conservation status of fish species. We identified three groups of fish species based on their export volume trends: species with no trends, with decreasing trends and with increasing trends. There was no significant correlation between export volume trends and the conservation status of fish species. The export volume trends of individual species appear to be related to the number of exporters, price and, potentially, anthropogenic factors affecting fish populations. Based on our findings we recommend the inclusion of ornamental fishery management issues in a revised Fisheries and Aquaculture Policy. This should include strategies to control overexploitation of species with declining export volume trends, and conservation of threatened species and a ban on their export. We recommend further research to establish the population status of the exploited fish species and to identify any other factors linked to the volume trends of ornamental fish exports.
To establish the prevalence of double burden of malnutrition (DBM) and triple burden of malnutrition (TBM) among mother–child pairs in Malawi and explore their geographical distribution and associated multilevel factors.
Design:
Cross-sectional study using secondary data from the 2015–2016 Malawi Demographic and Health Survey using a mixed effects binomial model to identify multilevel factors associated with DBM and TBM. Georeferenced covariates were used to map the predicted prevalence of DBM and TBM.
Setting:
All twenty-eight districts in Malawi.
Participants:
Mother–child pairs with mothers aged 15–49 years and children aged below 60 months (n 4618 pairs) for DBM and between 6 and 59 months (n 4209 pairs) for TBM.
Results:
Approximately 5·5 % (95% confidence interval (CI): 4·7 %, 6·4 %) of mother–child pairs had DBM, and 3·1 % (95 % CI: 2·5 %, 4·0 %) had TBM. The subnational-level prevalence of DBM and TBM was highest in cities. The adjusted odds of DBM were threefold higher (adjusted Odds Ratio, AOR: 2·8, 95 % CI: 1·1, 7·3) with a higher proportion of wealthy households in a community. The adjusted odds of TBM were 60 % lower (AOR: 0·4; 95 % CI: 0·2, 0·8) among pairs where the women had some education compared with women with no education.
Conclusions:
Although the prevalence of DBM and TBM is currently low in Malawi, it is more prevalent in pairs with women with no education and in relatively wealthier communities. Targeted interventions should address both maternal overnutrition and child undernutrition in cities and these demographics.
Chiefs in Malawi exercise significant authority based on legitimacy derived from the position's purportedly deep historical origins. But, does such legitimacy confer when a new chieftaincy is created from scratch? I address this question within the context of an ongoing cultural revival of the Lhomwe ethnic group in Malawi, which has included the appointment of many new Lhomwe chiefs and the creation of a Lhomwe paramount chieftaincy. Using a combination of in-depth interviews and original survey data, I explore the political drivers, mechanisms and implications of the this newly created Lhomwe chieftaincy. I find that its creation was driven by top-down, elite-led action rather than citizen demands, and that the newly appointed chiefs enjoy the most support among urban-based backers of the political party responsible for their appointments. This research contributes to historical work on the colonial-era creation of chieftaincies, but does so using a contemporary case of cultural engineering.
This chapter considers the structure of territorial cleavage from a national perspective. It focuses on patterns of polarization between regional electoral blocs, or “territorial oppositions,” in national politics. Axes of territorial cleavage arising between predominantly rural regions tend to take canonical forms associated with core–periphery politics in countries that are undergoing national economic integration and the growth of the central state. Stable axes of sectional competition, whereby leading regions square off against each other or against those on the periphery, are visible in the electoral data and in persistent policy cleavages in countries in this study. In broad outlines, these conform to models of territorial opposition in national politics advanced by earlier scholars (Lipset & Rokkan 1967; Gourevitch 1979; Bayart 2013). The analysis is built around four countries – Kenya, Zambia, Malawi, and Uganda – that serve as archetypes of different patterns of territorial opposition and core–periphery politics. Tanzania is a shadow case.