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Evaluation of Helping Babies Breathe Quality Improvement Cycle (HBB-QIC) on retention of neonatal resuscitation skills six months after training in Nepal
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). United Nations Childrens Fund UNICEF, UN House, Lalitpur, Nepal.ORCID iD: 0000-0002-0541-4486
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
Latter-day Saint Charities, Salt Lake City, Utah, USA.
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2017 (English)In: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 17, 103Article in journal (Refereed) Published
Abstract [en]

Background: Each year 700,000 infants die due to intrapartum-related complications. Helping Babies Breathe (HBB) uses an algorithm to increase knowledge and improve skills on neonatal resuscitation. Implementation of HBB in low-resource clinical settings has shown to reduce intrapartum stillbirths and first-day neonatal mortality. However, there is a lack of evidence on the effect of different HBB implementation strategies to improve and sustain the clinical competency of health workers on bag-and-mask ventilation. This study was conducted to evaluate the impact of multi-faceted implementation strategy for HBB as quality improvement cycle (HBB-QIC) on retention of neonatal resuscitation skills in a tertiary hospital of Nepal.

Methods: A Time series design was applied. The multi-faceted intervention for HBB-QIC included training, daily bag-and-mask skill checks, preparation for resuscitation before every birth, self-evaluation and peer review on neonatal resuscitation skills and weekly review meetings. Knowledge and skills were assessed through questionnaires, skill checklists, and Objective Structured Clinical Examinations (OSCE) before implementation of the HBB-QIC, immediately after HBB training, and again at six months. Means were compared using paired t-tests, and associations between skill retention and HBB-QIC components were analyzed using logistic regression analysis.

Results: 137 health workers were enrolled in the study. Knowledge scores were higher immediately following the HBB training, 16.4  1.4 compared to 12.8  1.6 before (out of 17), and the knowledge was retained six months after the training (16.5  1.1). Bag-and-mask skills improved immediately after the training and were retained six months after the training. The retention of bag-and-mask skills was associated with daily bag-and-mask skill checks, preparation for resuscitation before every birth, use of a self-evaluation checklist, and attendance at weekly review meetings. The implementation strategies with the highest association to skill retention were daily bag-and-mask skill checks (RR-5.1, 95% CI 1.9-13.5) and use of self-evaluation checklists after every delivery (RR-3.8, 95% CI 1.4-9.7).

Conclusions: Health workers who practiced bag-and-mask skills, prepared for resuscitation before every birth, used self-evaluation checklists and attended weekly review meetings retained their neonatal resuscitation skills. Further studies are required to evaluate HBB-QIC in primary care settings, where the number of deliveries is gradually increasing.

Place, publisher, year, edition, pages
2017. Vol. 17, 103
Keyword [en]
Neonatal resuscitation, Helping Babies Breathe, retention of skills, multi-faceted implementation strategy, quality improvement cycle, Nepal
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
International Health
Identifiers
URN: urn:nbn:se:uu:diva-267918DOI: 10.1186/s12887-017-0853-5ISI: 000398776700001OAI: oai:DiVA.org:uu-267918DiVA: diva2:874834
Funder
Swedish Society of Medicine
Available from: 2015-11-29 Created: 2015-11-29 Last updated: 2017-12-01Bibliographically approved
In thesis
1. Neonatal Resuscitation: Understanding challenges and identifying a strategy for implementation in Nepal
Open this publication in new window or tab >>Neonatal Resuscitation: Understanding challenges and identifying a strategy for implementation in Nepal
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Despite the unprecedented improvement in child health in last 15 years, burden of stillbirth and neonatal death remain the key challenge in Nepal and the reduction of these deaths will be crucial for reaching the health targets for Sustainable development goal by 2030.

The aim of this thesis was to explore the risk factors for stillbirth and neonatal death and change in perinatal outcomes after the introduction of the Helping Babies Breathe Quality Improvement Cycle (HBB QIC) in Nepal.

This was a prospective cohort study with a nested case-control design completed in a tertiary hospital in Nepal. Information were collected from the women who had experienced perinatal death and live birth among referent population; a video recording was done in the neonatal resuscitation corner to collect information on the health workers’ performance in neonatal resuscitation. 

Lack of antenatal care had the highest association with antepartum stillbirth (aOR 4.2, 95% CI 3.2–5.4), births that had inadequate fetal heart rate monitoring were associated with intrapartum stillbirth (aOR 1.9, CI 95% 1.5–2.4), and babies who were born premature and small-for-gestational-age had the highest risk for neonatal death in the hospital (aOR 16.2, 95% CI 12.3–21.3). Before the introduction of the HBB QIC, health workers displayed poor adherence to the neonatal resuscitation protocol. After the introduction of HBB QIC, the health workers demonstrated improvement in their neonatal resuscitation skills and these were retained until six months after training. Daily bag-and-mask skill checks (RR 5.1 95% CI 1.9–13.5), preparation for birth (RR 2.4, 95% CI 1.0–5.6), self-evaluation checklists (RR 3.8, 95% CI 1.4–9.7) and weekly review and reflection meetings (RR 2.6, 95% 1.0–7.4) helped the health workers to retain their neonatal resuscitation skills. The health workers demonstrated improvement in ventilation of babies within one minute of birth and there was a reduction in intrapartum stillbirth (aOR 0.46, 95% CI 0.32–0.66) and first-day neonatal mortality (aOR 0.51, 95% CI 0.31–0.83). 

The study provides information on challenges in reducing stillbirth and neonatal death in low income settings and provides a strategy to improve health workers adherence to neonatal resuscitation to reduce the mortality. The HBB QIC can be implemented in similar clinical settings to improve quality of care and survival in Nepal, but for primary care settings, the QIC need to be evaluated further.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2016. 83 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1166
Keyword
antepartum stillbirth, intrapartum stillbirth, neonatal mortality, first-day neonatal mortality, antenatal care, fetal heart rate monitoring, partogram, preterm, small-for-gestational-age, clinical adherence, neonatal resuscitation, skill retention, quality improvement cycle, Nepal
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
International Health
Identifiers
urn:nbn:se:uu:diva-267917 (URN)978-91-554-9434-6 (ISBN)
Public defence
2016-02-10, Museum Gustavianum, Akademigatan 3, Uppsala, 09:00 (English)
Opponent
Supervisors
Available from: 2016-01-20 Created: 2015-11-29 Last updated: 2016-02-12

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KC, AshishWrammert, JohanEwald, UwePeterson, Stefan SwartlingMålqvist, Mats

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