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Reducing perinatal mortality in Nepal using Helping Babies Breathe
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). UNICEF, Health Section, 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, Pediatrics.
Latter-day Saint Charities, Salt Lake City, Utah, USA.
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).
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2016 (English)In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 137, no 6, e20150117Article in journal (Refereed) Published
Abstract [en]

Objective: Newborns are at the highest risk of dying around the time of birth, due to intrapartum-related complications. Our study’s objective was to improve adherence to the Helping Babies Breathe (HBB) neonatal resuscitation protocol and reduce perinatal mortality using a quality improvement cycle (QIC) in a tertiary hospital in Nepal.

 

Methods: The HBB QIC was implemented through a multi-faceted approach, including: the formation of quality improvement teams; development of quality improvement goals, objectives and standards; HBB protocol training; weekly review meetings; daily skill checks; use of self-evaluation checklists; and refresher trainings. A cohort design including a nested case-control study was used to measure changes in clinical outcomes and adherence to the resuscitation protocol through video recording, before and after implementation of the QIC.

 

Results: The intrapartum stillbirth rate decreased from 9 to 3.2 per thousand deliveries, and first-day mortality from 5.2 to 1.9 per thousand live births after intervention, demonstrating a reduction of about half in the odds of intrapartum stillbirth (aOR=0.46, 95% CI 0.32-0.66) and first-day mortality (aOR=0.51, 95% CI 0.31-0.83). After intervention, the odds of inappropriate use of suction and stimulation decreased by 87% (OR=0.13, 95% CI 0.09-0.17) and 62% (OR=0.38, 95% CI 0.29-0.49), respectively. Prior to intervention, none of the babies received bag-and-mask ventilation within 1 minute of birth, compared to 83.9% of babies after.

 

Conclusion: The HBB QIC reduced intrapartum stillbirth and first-day neonatal mortality and led to use of suctioning and stimulation more frequently. The HBB QIC requires further testing in primary settings across Nepal.

Place, publisher, year, edition, pages
2016. Vol. 137, no 6, e20150117
Keyword [en]
intrapartum stillbirth, intrapartum-related neonatal death, Helping Babies Breathe, quality improvement cycle, Nepal
National Category
Pediatrics Public Health, Global Health, Social Medicine and Epidemiology
Research subject
International Health; Pediatrics
Identifiers
URN: urn:nbn:se:uu:diva-267919DOI: 10.1542/peds.2015-0117ISI: 000378520100001OAI: oai:DiVA.org:uu-267919DiVA: diva2:874835
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
2. Surviving birth: Studies of a simplified neonatal resuscitation protocol in a low-income context using a mixed-methods approach
Open this publication in new window or tab >>Surviving birth: Studies of a simplified neonatal resuscitation protocol in a low-income context using a mixed-methods approach
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

United Nations has lately stated ambitious health targets for 2030 in the Sustainable Development Goal agenda, following the already achieved progress between 1990 and 2015 when the number of children dying before the age of five was reduced by more than half. However, the mortality reduction in the first month of life after birth has not kept the same pace. Furthermore, a large number of stillbirths have previously not been accounted for. The aim of this thesis was to evaluate the impact of clinical training in neonatal resuscitation, and to identify strategies for an effective implementation at a maternal health facility in Nepal.

Focus group discussions were used to explore the perceptions of teamwork among staff working closest to the infant at the facility. A prospective cohort study with nested referents was applied to determine effect on birth outcomes after an intervention with Helping Babies Breathe, a simplified protocol for neonatal resuscitation. Sustainability of the acquired skills after training was addressed by employing a quality improvement cycle. Video recordings of health workers performance were collected to analyse adherence to protocol.

Midwives described the need for universal protocols in neonatal resuscitation and management involvement in clinical audit and feedback. There was a reduction of intrapartum stillbirth (aOR 0.46, 95% CI 0.32–0.66) and neonatal mortality within 24 hours of life (aOR 0.51, 95% CI 0.31–0.83) after the intervention. Ventilation of infants increased (OR 2.56, 95% CI 1.67–3.93) and potentially harmful suctioning was reduced (OR 0.13, 95% CI 0.09–0.17). Neonatal death from intrapartum-related complications was reduced and preterm infants survived additional days in the neonatal period after the intervention. Low birth weight was not found to be a predictor of deferred resuscitation in the studied context.

This study confirmed the robustness of Helping Babies Breathe as an educational tool for training in neonatal resuscitation. Accompanied with a quality improvement cycle it reduced intrapartum stillbirth and mortality on the day of delivery in a low-income facility setting. Improved postnatal care is needed to maintain the gains in survival through the neonatal period. Increased management involvement in audit and quality of care could improve clinical performance among health workers.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2017. 73 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1308
Keyword
cause of death, focus group, guideline adherence, infant, low-income population, low birth weight, Nepal, neonatal resuscitation, nurse midwives, neonatal mortality, newborn, perinatal mortality, preterm, quality improvement cycle, teamwork, postnatal, video recording
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-316728 (URN)978-91-554-9839-9 (ISBN)
Public defence
2017-04-28, Auditorium Minus, Museum Gustavianum, Akademigatan 3, Uppsala, 09:00 (English)
Opponent
Supervisors
Available from: 2017-04-07 Created: 2017-03-07 Last updated: 2017-04-21

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KC, AshishWrammert, JohanEwald, UweMålqvist, Mats

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