A secondary data analysis of a cluster randomized controlled trial: improved cookstoves associated with reduction in incidence of low birthweight in rural Malawi

BACKGROUND: In northern rural Malawi, the majority of households cook using open fires and there is also a high burden of adverse birth outcomes. The use of open fires or highly polluting cookstoves is associated with low birthweight in babies. There is mixed evidence on whether implementation of cleaner burning cookstoves reduces the number of babies born with low birthweight. METHODS: This is a secondary analysis of a cluster randomized control trial in Malawi, conducted over 2014–17. Households were randomized to receive improved cookstoves or to continue current practices. For this analysis, the primary outcome was low birthweight in households under routine demographic surveillance, among births occurring within the trial time frame (N = 4010). A subset of data with stricter exposure definitions respecting the original randomized allocation was also analysed (N = 1050). A causal, forwards modelling approach was used. RESULTS: The main dataset showed evidence of effect of the intervention on low birthweight [adjusted odds ratio (aOR) 0.69; 95% CI 0.48–0.99, n = 2788). The subset analysis lacked power to provide evidence of association between improved cookstoves and low birthweight in the stricter exposure definition (aOR 0.62; 95% CI 0.35–1.09, n = 932). CONCLUSIONS: This study provides some evidence that an improved cookstove intervention in rural Malawi reduced the number of babies born with low birthweight by 30%. This direction of the effect was also seen in the subset analysis. The analysis suggests that the intervention reduced the number of infants born prematurely or with intra-uterine growth restriction, indicating that improved cookstoves could be a useful maternal health intervention.