Survival rates and associated factors for preterm neonates at Rev. John Chilembwe Hospital in Phalombe district in Malawi: a prospective cohort study

Abstract Background : Preterm neonatal mortality is high in resource-constrained settings such as district-based health facilities in Malawi. However, data on survival rates at each point in time and associated factors is scanty. We aimed to estimate survival rates and median overall survival (OS) time as well as assess time-to-death determinants of preterm neonates during the first 28 days of life at Rev. John Chilembwe Hospital in Phalombe district in Malawi. Methods : Using a prospective cohort study design, we collected data on maternal age, gestational age, sex, HIV exposure, delivery mode, length of hospital stay, birthweight, Apgar score, birth place, respiratory distress, plurality, congenital anomaly, danger warning signs, vital signs and baby size of preterm neonates born and recruited from 01 st January to 31 st December, 2025. We followed-up each preterm neonate until death or censoring time. We estimated survival rates on day 1, 3, 7, 14, 21 and 28 using Kaplan-Meier curves. We planned to estimate median OS time but it was not reached during the 28-day follow-up period. We identified time-to-death determinants using Cox hazards proportion analysis. Results : Of 136 preterm neonates followed-up, 55% (n = 75) were females. Median maternal age, gestational age, birthweight and initial body temperature were 23 years (interquartile range [IQR]: 20 years to 28 years), 33 weeks (IQR: 30 weeks to 34 weeks), 1,500g (IQR: 1,300g to 1,800g) and 35.10˚C (IQR: 34.50˚C to 35.95˚C), respectively. Survival estimates on day 1, 3, 7, 14, 21 and 28 were 91.2% (95% confidence interval [CI]: 86.5% to 96.1%), 80.9% (95% CI: 74.5% to 87.8%), 75.7% (95% CI: 68.9% to 83.3%), 72.8% (95% CI: 65.7% to 80.7%), 69.9% (95% CI: 62.6% to 78.0%) and 68.4% (95% CI: 61.0% to 76.7%), respectively. Each 100g increase in birthweight of preterm neonates reduced hazard of death by 19% (adjusted Hazard Ratio [aHR]: 0.81, 95% CI: 0.69 to 0.93, p<0.001). Conclusion: Survival rates were low, with most deaths occurring in the first week of life. Lower birthweight was an important time-to-death determinant. Enhancing maternal nutrition, treatment of infections during pregnancy, early identification and management of preterm labor may help improve survival rates.