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  • 1.
    Ashish, K. C.
    et al.
    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). Nepal Country Off, United Nations Childrens Fund, Lalitpur, Nepal..
    Wrammert, Johan
    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).
    Nelin, Viktoria
    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).
    Ewald, Uwe
    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).
    Clark, Robert
    Latter Day St Char, Salt Lake City, UT USA..
    Målqvist, Mats
    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 Univ, Dept Womens & Childrens Hlth, Int Maternal & Child Hlth, Uppsala, Sweden..
    Level of mortality risk for babies born preterm or with a small weight for gestation in a tertiary hospital of Nepal2015In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 15, article id 877Article in journal (Refereed)
    Abstract [en]

    Background: Globally, 15 million babies were born prematurely in 2012, with 37.6 % of them in South Asia. About 32.4 million infants were born small for gestational age (SGA) in 2010, with more than half of these births occurring in South Asia. In Nepal, 14 % of babies were born preterm and 39.3 % were born SGA in 2010. We conducted a study in a tertiary hospital of Nepal to assess the level of risk for neonatal mortality among babies who were born prematurely and/or SGA. Methods: This case-control study was completed over a 15-month period between July 2012 and September 2013. All neonatal deaths that occurred during the study period were included as cases and 20 % of women with live births were randomly selected as referents. Information on potential risk factors was taken from medical records and interviews with the women. Logistic regression analyses were conducted to determine the level of risk for neonatal mortality among babies born preterm and/or SGA. Results: During this period, the hospital had an incidence of preterm birth and SGA of 8.1 and 37.5 %, respectively. In the multivariate model, there was a 12-fold increased risk of neonatal death among preterm infants compared to term. Babies who were SGA had a 40 % higher risk of neonatal death compared to those who were not. Additionally, babies who were both preterm and SGA were 16 times more likely to die during the neonatal period. Conclusions: Our study showed that the risk of neonatal mortality was highest when the baby was born both preterm and SGA, followed by babies who were born preterm, and then by babies who were SGA in a tertiary hospital in Nepal. In tertiary care settings, the risk of mortality for babies who are born preterm and/or SGA can be reduced with low-cost interventions such as Kangaroo Mother Care or improved management of complications through special newborn care or neonatal intensive care units. The risk of death for babies who are born prematurely and/or SGA can thus be used as an indicator to monitor the quality of care for these babies in health facility settings.

  • 2.
    Guo, Yue
    et al.
    Univ North Carolina Chapel Hill, Chapel Hill, NC 27514 USA..
    Wrammert, Johan
    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).
    Singh, Kavita
    Univ North Carolina Chapel Hill, Chapel Hill, NC 27514 USA..
    KC, Ashish
    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 Nepal, Kathmandu, Nepal..
    Bradford, Kira
    Univ North Carolina Chapel Hill, Chapel Hill, NC 27514 USA..
    Krishnamurthy, Ashok
    Univ North Carolina Chapel Hill, Chapel Hill, NC 27514 USA..
    Automatic Analysis of Neonatal Video Data to Evaluate Resuscitation Performance2016In: 2016 IEEE 6TH INTERNATIONAL CONFERENCE ON COMPUTATIONAL ADVANCES IN BIO AND MEDICAL SCIENCES (ICCABS), 2016Conference paper (Refereed)
    Abstract [en]

    Approximately 3% of births require neonatal resuscitation, which has a direct impact on the immediate survival of these infants. This report proposes an automatic video analysis method for neonatal resuscitation performance evaluation, which helps improve the quality of this procedure. More specifically, we design a deep learning based action model which incorporates motion and spatial information in order to classify neonatal resuscitation actions in videos. First, we use a Convolutional Neural Network to select regions containing infants and only keep those that are motion salient. Second, we extract deep spatial-temporal features to train a linear SVM classifier. Finally, we propose a pair-wise model to ensure consistent classification in consecutive frames. We evaluate the proposed method on a dataset consisting of 17 videos and compare the result against the state-of-the-art method for action classification in videos. To our best knowledge, this work is the first to attempt automatic evaluation of neonatal resuscitation videos and identifies several issues that require further work.

  • 3.
    Gurung, Rejina
    et al.
    Golden Community, Jwagal, Lalitpur, Nepal.
    Jha, Anjani Kumar
    Govt Nepal, Minist Hlth & Populat, Kathmandu, Nepal.
    Pyakurel, Susheel
    Nepal Hlth Res Council, Kathmandu, Nepal.
    Gurung, Abhishek
    Golden Community, Jwagal, Lalitpur, Nepal.
    Litorp, Helena
    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).
    Wrammert, Johan
    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).
    Jha, Bijay Kumar
    Govt Nepal, Minist Hlth & Populat, Kathmandu, Nepal.
    Paudel, Prajwal
    Anweshan, Lalitpur, Nepal.
    Rahman, Syed Moshfiqur
    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).
    Malla, Honey
    Golden Community, Jwagal, Lalitpur, Nepal.
    Sharma, Srijana
    Golden Community, Jwagal, Lalitpur, Nepal.
    Gautam, Manish
    Anweshan, Lalitpur, Nepal.
    Linde, Jorgen Erland
    Stavanger Univ Hosp, Dept Paediat, Stavanger, Norway.
    Moinuddin, Md
    ICDDR B, Maternal & Child Hlth Div, Dhaka, Bangladesh.
    Ewald, Uwe
    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).
    Målqvist, Mats
    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).
    Axelin, Anna
    Univ Turku, Turku, Finland.
    KC, Ashish
    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). Soc Publ Hlth Phys Nepal, Lalitpur, Nepal.
    Scaling Up Safer Birth Bundle Through Quality Improvement in Nepal (SUSTAIN) - a stepped wedge cluster randomized controlled trial in public hospitals2019In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 14, article id 65Article in journal (Refereed)
    Abstract [en]

    Background: Each year, 2.2 million intrapartum-related deaths (intrapartum stillbirths and first day neonatal deaths) occur worldwide with 99% of them taking place in low- and middle-income countries. Despite the accelerated increase in the proportion of deliveries taking place in health facilities in these settings, the stillborn and neonatal mortality rates have not reduced proportionately. Poor quality of care in health facilities is attributed to two-thirds of these deaths. Improving quality of care during the intrapartum period needs investments in evidence-based interventions. We aim to evaluate the quality improvement packageScaling Up Safer Bundle Through Quality Improvement in Nepal (SUSTAIN)on intrapartum care and intrapartum-related mortality in public hospitals of Nepal.

    Methods: We will conduct a stepped wedge cluster randomized controlled trial in eight public hospitals with each having least 3000 deliveries a year. Each hospital will represent a cluster with an intervention transition period of 2months in each. With a level of significance of 95%, the statistical power of 90% and an intra-cluster correlation of 0.00015, a study period of 19months should detect at least a 15% change in intrapartum-related mortality. Quality improvement training, mentoring, systematic feedback, and a continuous improvement cycle will be instituted based on bottleneck analyses in each hospital. All concerned health workers will be trained on standard basic neonatal resuscitation and essential newborn care. Portable fetal heart monitors (Moyo (R)) and neonatal heart rate monitors (Neobeat (R)) will be introduced in the hospitals to identify fetal distress during labor and to improve neonatal resuscitation. Independent research teams will collect data in each hospital on intervention inputs, processes, and outcomes by reviewing records and carrying out observations and interviews. The dose-response effect will be evaluated through process evaluations.

    Discussion: With the global momentum to improve quality of intrapartum care, better understanding of QI package within a health facility context is important. The proposed package is based on experiences from a similar previous scale-up trial carried out in Nepal. The proposed evaluation will provide evidence on QI package and technology for implementation and scale up in similar settings.

  • 4.
    KC, Ashish
    et al.
    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), International Child Health and Nutrition. Health Section, UNICEF, UN House, Lalitpur, Nepal.
    Bergström, Anna
    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), International Child Health and Nutrition. Institute for Global Health, University College London, London, UK.
    Chaulagain, Dipak
    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), International Child Health and Nutrition. Lifeline Nepal, Kathmandu, Nepal.
    Brunell, Olivia
    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), International Child Health and Nutrition.
    Ewald, Uwe
    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), International Child Health and Nutrition.
    Gurung, Abhishek
    Lifeline Nepal, Kathmandu, Nepal.
    Eriksson, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Litorp, Helena
    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), International Maternal and Reproductive Health and Migration.
    Wrammert, Johan
    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), International Child Health and Nutrition.
    Grönqvist, Erik
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Economics.
    Edin, Per-Anders
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Economics.
    Le Grange, Claire
    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), International Child Health and Nutrition.
    Lamichhane, Bikash
    Department of Health Services, Ministry of Health, Nepal.
    Shrestha, Parashuram
    Department of Health Services, Ministry of Health, Nepal.
    Pokharel, Amrit
    Department of Health Services, Ministry of Health, Nepal.
    Pun, Asha
    Health Section, UNICEF, UN House, Lalitpur, Nepal.
    Singh, Chahana
    Health Section, UNICEF, UN House, Lalitpur, Nepal .
    Målqvist, Mats
    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), International Child Health and Nutrition.
    Scaling up quality improvement intervention for perinatal care in Nepal (NePeriQIP); study protocol of a cluster randomised trial2017In: BMJ global health, Vol. 2, no 3, article id e000497Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Nepal Perinatal Quality Improvement Project (NePeriQIP) intends to scale up a quality improvement (QI) intervention for perinatal care according to WHO/National guidelines in hospitals of Nepal using the existing health system structures. The intervention builds on previous research on the implementation of Helping Babies Breathe-quality improvement cycle in a tertiary healthcare setting in Nepal. The objective of this study is to evaluate the effect of this scaled-up intervention on perinatal health outcomes.

    METHODS/DESIGN: Cluster-randomised controlled trial using a stepped wedged design with 3 months delay between wedges will be conducted in 12 public hospitals with a total annual delivery rate of 60 000. Each wedge will consist of 3 hospitals. Impact will be evaluated on intrapartum-related mortality (primary outcome), overall neonatal mortality and morbidity and health worker's performance on neonatal care (secondary outcomes). A process evaluation and a cost-effectiveness analysis will be performed to understand the functionality of the intervention and to further guide health system investments will also be performed.

    DISCUSSION: In contexts where resources are limited, there is a need to find scalable and sustainable implementation strategies for improved care delivery. The proposed study will add to the scarce evidence base on how to scale up interventions within existing health systems. If successful, the NePeriQIP model can provide a replicable solution in similar settings where support and investment from the health system is poor, and national governments have made a global pledge to reduce perinatal mortality.

    TRIAL REGISTRATION NUMBER: ISRCTN30829654.

  • 5.
    KC, Ashish
    et al.
    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), International Child Health and Nutrition.
    Ewald, Uwe
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Basnet, Omkar
    Golden Community, Jawgal, Lalitpur, Nepal.
    Gurung, Abhishek
    Golden Community, Jawgal, Lalitpur, Nepal.
    Pyakuryal, Sushil Nath
    Nepal Hlth Res Council, Kathmandu, Nepal.
    Jha, Bijay Kumar
    Govt Nepal, Minist Hlth & Populat, Kathmandu, Nepal.
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. UCL, UCL Inst Global Hlth IGH, London, England.
    Eriksson, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Paudel, Prajwal
    Nepal Hlth Res Council, Kathmandu, Nepal.
    Karki, Sushil
    Life Line Nepal, Kathmandu, Nepal.
    Gajurel, Sunil
    Kamana Hlth Nepal, Kathmandu, Nepal.
    Brunell, Olivia
    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), International Child Health and Nutrition.
    Wrammert, Johan
    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).
    Litorp, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Målqvist, Mats
    Effect of a scaled-up neonatal resuscitation quality improvement package on intrapartum-related mortality in Nepal: A stepped-wedge cluster randomized controlled trial2019In: PLoS Medicine, ISSN 1549-1277, E-ISSN 1549-1676, Vol. 16, no 9, article id e1002900Article in journal (Refereed)
    Abstract [en]

    Background Improving quality of intrapartum care will reduce intrapartum stillbirth and neonatal mortality, especially in resource-poor settings. Basic neonatal resuscitation can reduce intrapartum stillbirth and early neonatal mortality, if delivered in a high-quality health system, but there is a dearth of evidence on how to scale up such evidence-based interventions. We evaluated the scaling up of a quality improvement (QI) package for neonatal resuscitation on intrapartum-related mortality (intrapartum stillbirth and first day mortality) at hospitals in Nepal. Methods and findings We conducted a stepped-wedge cluster randomized controlled trial in 12 hospitals over a period of 18 months from April 14, 2017, to October 17, 2018. The hospitals were assigned to one of four wedges through random allocation. The QI package was implemented in a stepped-wedge manner with a delay of three months for each step. The QI package included improving hospital leadership on intrapartum care, building health workers' competency on neonatal resuscitation, and continuous facilitated QI processes in clinical units. An independent data collection system was set up at each hospital to gather data on mortality through patient case note review and demographic characteristics of women using semi-structured exit interviews. The generalized linear mixed model (GLMM) and multivariate logistic regression were used for analyses. During this study period, a total of 89,014 women-infant pairs were enrolled. The mean age of the mother in the study period was 24.0 +/- 4.3 years, with 54.9% from disadvantaged ethnic groups and 4.0% of them illiterate. Of the total birth cohort, 54.4% were boys, 16.7% had gestational age less than 37 weeks, and 17.1% had birth weight less than 2,500 grams. The incidence of intrapartum-related mortality was 11.0 per 1,000 births during the control period and 8.0 per 1,000 births during the intervention period (adjusted odds ratio [aOR], 0.79; 95% CI, 0.69-0.92; p = 0.002; intra-cluster correlation coefficient [ICC], 0.0286). The incidence of early neonatal mortality was 12.7 per 1,000 live births during the control period and 10.1 per 1,000 live births during the intervention period (aOR, 0.89; 95% CI, 0.78-1.02; p = 0.09; ICC, 0.1538). The use of bag-and-mask ventilation for babies with low Apgar score (<7 at 1 minute) increased from 3.2% in the control period to 4.0% in the intervention period (aOR, 1.52; 95% CI, 1.32-1.77, p = 0.003). There were two major limitations to the study; although a large sample of women-infant pairs were enrolled in the study, the clustering reduced the power of the study. Secondly, the study was not sufficiently powered to detect reduction in early neonatal mortality with the number of clusters provided. Conclusion These results suggest scaled-up implementation of a QI package for neonatal resuscitation can reduce intrapartum-related mortality and improve clinical care. The QI intervention package is likely to be effective in similar settings. More implementation research is required to assess the sustainability of QI interventions and quality of care.

  • 6.
    KC, Ashish
    et al.
    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).
    Målqvist, Mats
    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).
    Wrammert, Johan
    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).
    Verma, Sheela
    Paropakar Maternity and Women´s Hospital, Kathmandu, Nepal.
    Aryal, Dhan Raj
    Paropakar Maternity and Women´s Hospital, Kathmandu, Nepal.
    Clark, Robert
    Latter Day Saints Charity, Salt Lake City, USA.
    Kc, Naresh P
    Ministry of Health and Population, Kathmandu, Nepal.
    Vitrakoti, Ravi
    Paropakar Maternity and Women´s Hospital, Kathmandu, Nepal.
    Baral, Kedar
    Patan Academy of Health Sciences, Patan, Nepal.
    Ewald, Uwe
    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).
    Implementing a simplified neonatal resuscitation protocol-helping babies breathe at birth (HBB): at a tertiary level hospital in Nepal for an increased perinatal survival2012In: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 12, no 1, p. 159-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Reducing neonatal death has been an emerging challenge in low and middle income countries in the past decade. The development of the low cost interventions and their effective delivery are needed to reduce deaths from birth asphyxia. This study will assess the impact of a simplified neonatal resuscitation protocol provided by Helping Babies Breathe (HBB) at a tertiary hospital in Nepal. Perinatal outcomes and performance of skilled birth attendants on management of intrapartum-related neonatal hypoxia will be the main measurements.

    METHODS:

    The study will be carried out at a tertiary level maternity hospital in Nepal. A prospective cohort-study will include a six-month baseline a six month intervention period and a three-month post intervention period. A quality improvement process cycle will introduce the neonatal resuscitation protocol. A surveillance system, including CCD cameras and pulse oximeters, will be set up to evaluate the intervention.

    DISCUSSION:

    Along with a technique to improve health workers performance on the protocol, the study will generate evidence on the research gap on the effectiveness of the simplified neonatal resuscitation protocol on intrapartum outcome and early neonatal survival. This will generate a global interest and inform policymaking in relation to delivery care in all income settings.Trial registrationISRCTN97846009.

  • 7.
    K.C, Ashish
    et al.
    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).
    Nelin, Viktoria
    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).
    Wrammert, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Pediatrics.
    Ewald, Uwe
    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).
    Vitrakoti, Ravi
    Baral, Geha Nath
    Målqvist, Mats
    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).
    Risk factors for antepartum stillbirth: a case-control study in Nepal2015In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 15, article id 146Article in journal (Refereed)
    Abstract [en]

    Background: Globally, at least 2.65 million stillbirths occur every year, of which more than half are during the antepartum period. The proportion of intrapartum stillbirths has substantially declined with improved obstetric care; however, the number of antepartum stillbirths has not decreased as greatly. Attempts to lower this number may be hampered by an incomplete understanding of the risk factors leading to the majority of antepartum stillbirths. We conducted this study in a tertiary hospital in Nepal to identify the specific risk factors that are associated with antepartum stillbirth in this setting. Methods: This case-control study was conducted between July 2012 and September 2013. All women who had antepartum stillbirths during this period were included as cases, while 20 % of all women delivering at the hospital were randomly selected and included as referents. Information on potential risk factors was taken from medical records and interviews with the women. Logistic regression analysis was completed to determine the association between those risk factors and antepartum stillbirth. Results: During the study period, 4567 women who delivered at the hospital were enrolled as referents, of which 62 had antepartum stillbirths and were re-categorized into the case population. In total, there were 307 antepartum stillbirths. An association was found between the following risk factors and antepartum stillbirth: increasing maternal age (aOR 1.0, 95 % CI 1.0-1.1), less than five years of maternal education (aOR 2.4, 95 % CI 1.7-3.2), increasing parity (aOR 1.2, 95 % CI 1.0-1.3), previous stillbirth (aOR 2.6, 95 % CI 1.6-4.4), no antenatal care attendance (aOR 4.2, 95 % CI 3.2-5.4), belonging to the poorest family (aOR 1.3, 95 % CI 1.0-1.8), antepartum hemorrhage (aOR 3.7, 95 % CI 2.4-5.7), maternal hypertensive disorder during pregnancy (aOR 2.1, 95 % CI 1.5-3.1), and small weight-for-gestational age babies (aOR 1.5, 95 % CI 1.2-2.0). Conclusion: Lack of antenatal care attendance, which had the strongest association with antepartum stillbirth, is a potentially modifiable risk factor, in that increasing the access to and availability of these services can be targeted. Antenatal care attendance provides an opportunity to screen for other potential risk factors for antepartum stillbirth, as well as to provide counseling to women, and thus, helps to ensure a successful pregnancy outcome.

  • 8.
    Kc, Ashish
    et al.
    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). UN Childrens Fund, Nepal Country Off, UN House, Pulchowk, Nepal.
    Wrammert, Johan
    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).
    Clark, Robert B
    Latter-day Saint Charities, Salt Lake City, UT, USA.
    Ewald, Uwe
    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).
    Målqvist, Mats
    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).
    Inadequate fetal heart rate monitoring and poor use of partogram associated with intrapartum stillbirth: a case-referent study in Nepal2016In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 233Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Newborns are at the greatest risk for dying during the intrapartum period, including labor and delivery, and the first day of life. Fetal heart rate monitoring (FHRM) and partogram use to track labor progress are evidence-based techniques that can help to identify maternal and fetal risk factors so that these can be addressed early. The objective of this study was to assess health worker adherence to protocols for FHRM and partogram use during the intrapartum period, and to assess the association between adherence and intrapartum stillbirth in a tertiary hospital of Nepal.

    METHODS: A case-referent study was conducted over a 15-month period. Cases included all intrapartum stillbirths, while 20 % of women with live births were randomly selected on admission to make up the referent population. The frequency of FHRM and the use of partogram were measured and their association to intrapartum stillbirth was assessed using logistic regression analysis.

    RESULTS: During the study period, 4,476 women with live births were enrolled as referents and 136 with intrapartum stillbirths as cases. FHRM every 30 min was only completed in one-fourth of the deliveries, and labor progress was monitored using a partogram in just over half. With decreasing frequency of FHRM, there was an increased risk of intrapartum stillbirth; FHRM at intervals of more than 30 min resulted in a four-fold risk increase for intrapartum stillbirth (aOR 4.17, 95 % CI 2.0-8.7), and the likelihood of intrapartum stillbirth increased seven times if FHRM was performed less than every hour or not at all (aOR 7.38, 95 % CI 3.5-15.4). Additionally, there was a three-fold increased risk of intrapartum stillbirth if the partogram was not used (aOR 3.31, 95 % CI 2.0-5.4).

    CONCLUSION: The adherence to FHRM and partogram use was inadequate for monitoring intrapartum progress in a tertiary hospital of Nepal. There was an increased risk of intrapartum stillbirth when fetal heart rate was inadequately monitored and when the progress of labor was not monitored using a partogram. Further exploration is required in order to determine and understand the barriers to adherence; and further, to develop tools, techniques and interventions to prevent intrapartum stillbirth.

    CLINICAL TRIAL REGISTRATION: ISRCTN97846009 .

  • 9.
    KC, Ashish
    et al.
    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.
    Wrammert, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Pediatrics.
    Clark, Robert
    Latter-day Saint Charities, Salt Lake City, Utah, USA.
    Ewald, Uwe
    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).
    Vitrakoti, Ravi
    Paropakar Maternity and Women's Hospital, Kathmandu, Nepal.
    Chaudhary, Pushpa
    Paropakar Maternity and Women's Hospital, Kathmandu, Nepal.
    Pun, Asha
    UNICEF, Health Section, Nepal.
    Raaijmakers, Hendrikus
    UNICEF, Health Section, Nepal.
    Målqvist, Mats
    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).
    Reducing perinatal mortality in Nepal using Helping Babies Breathe2016In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 137, no 6, article id e20150117Article in journal (Refereed)
    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.

  • 10.
    K.C, Ashish
    et al.
    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).
    Wrammert, Johan
    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).
    Ewald, Uwe
    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).
    Clark, Robert
    Latter-day Saint Charities, Salt Lake City, Utah, USA.
    Gautam, Jageshwor
    Paropakar Maternity and Women's Hospital, Nepal.
    Baral, Gehanath
    Paropakar Maternity and Women's Hospital.
    Baral, Kedar
    Patan Academy of Health Sciences.
    Målqvist, Mats
    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).
    Incidence of intrapartum stillbirth and associated risk factors in tertiary care setting of Nepal: a case-control study2016In: Reproductive Health, ISSN 1742-4755, E-ISSN 1742-4755, Vol. 12, article id 103Article in journal (Refereed)
    Abstract [en]

    Background: Each year, 1.2 million intrapartum stillbirths occur globally. In Nepal, about 50% of the total number of stillbirths occur during the intrapartum period. An understanding of the risk factors associated with intrapartum stillbirth will facilitate the development of preventative strategies to reduce the burden of death. This study was conducted in a tertiary-care setting with the aim to identify the risk factors associated with intrapartum stillbirth.

    Methods: A case-control study was completed from July 2012 to September 2013. All women who had an intrapartum stillbirth during the study period were included as cases, and 20% of women with live births were randomly selected on admission to make up the referent population. Information from the clinical records of case and referent women was retrieved. In addition, interviews were completed with each woman on their demographic and obstetric history.

    Results: During the study period, 4,476 women with live births were enrolled as referents and 136 women with intrapartum stillbirths as cases.  The following factors were found to increase the risk for intrapartum stillbirth: poor familial wealth quintile (Adj OR 1.8, 95% CI-1.1-3.4); less maternal education (Adj OR, 3.2 95% CI-1.8-5.5); lack of antenatal care (Adj OR, 4.8 95% CI 3.2-7.2); antepartum hemorrhage (Adj OR 2.1, 95% CI 1.1-4.2); multiple births (Adj. OR-3.0, 95% CI- 1.9-5.4); obstetric complication during the labor period (Adj. OR 4.5, 95% CI-2.9-6.9); lack of fetal heart rate monitoring per protocol (Adj. OR-1.9, 95% CI 1.5-2.4); no partogram use (Adj. OR-2.1, 95% CI 1.1-4.1); small weight for gestational age (Adj. OR-1.8, 95% CI-1.2-1.7); premature birth (Adj. OR-5.4, 95% CI 3.5-8.2); and being born premature and with small weight for gestational age (Adj. OR-9.0, 95% CI 7.3-15.5).

    Conclusion: Inadequate Fetal heart rate monitoring and partogram use are risk factors associated with intrapartum stillbirth and increasing the adherence to the interventions that can reduce the risk of intrapartum stillbirth. Preterm birth and small weight for gestational age were the factors that had the highest risk for intrapartum stillbirth, which indicates that adequate antenatal care can improve the health and growth of the baby and prevent premature death.

  • 11.
    KC, Ashish
    et al.
    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.
    Wrammert, Johan
    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).
    Nelin, Viktoria
    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).
    Clark, Robert
    Latter-day Saint Charities, Salt Lake City, Utah, USA.
    Ewald, Uwe
    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).
    Peterson, Stefan Swartling
    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). Global Health, Public Health Sciences, Karolinska Institute, Sweden.; School of Public Health, Makerere University, Uganda.; United Nations Children Fund UNICEF, Hlth Sect, Programme Div, United Nations Plaza, New York, NY 10017 USA.
    Målqvist, Mats
    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).
    Evaluation of Helping Babies Breathe Quality Improvement Cycle (HBB-QIC) on retention of neonatal resuscitation skills six months after training in Nepal2017In: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 17, article id 103Article in journal (Refereed)
    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.

  • 12.
    Lindbäck, Caroline
    et al.
    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).
    KC, Ashish
    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).
    Wrammert, Johan
    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).
    Vitrakoti, Ravi
    Paropakar Women’s and Maternity Hospital, Kathmandu, Nepal.
    Ewald, Uwe
    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).
    Målqvist, Mats
    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).
    Poor adherence to neonatal resuscitation guidelines exposed; an observational study using camera surveillance at a tertiary hospital in Nepal2014In: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 14, p. 233-Article in journal (Refereed)
    Abstract [en]

    Background: Each year an estimated 10 million newborns require assistance to initiate breathing, and about 900 000 die due to intrapartum-related complications. Further research is required in several areas concerning neonatal resuscitation, particularly in settings with limited resources where the highest proportion of intrapartum-related deaths occur. The aim of this study is to use CCD-camera recordings to evaluate resuscitation routines at a tertiary hospital in Nepal.

    Methods: CCD-cameras recorded the resuscitations taking place and CCD-observational record forms were completed for each case. The resuscitation routines were then assessed and compared with existing guidelines. To evaluate the reliability of the observational form, 50 films were randomly selected and two independent observers completed two sets of forms for each case. The results were then cross-compared.

    Results: During the study period 1827 newborns were taken to the resuscitation table, and more than half of them (53.3%) were noted as not crying prior to resuscitation. Suction was used in almost 90% of newborns brought to the resuscitation table, whereas bag-and-mask ventilation was only used in less than 10%. The chance to receive ventilation with bag-and-mask for a newborn not crying when brought to the resuscitation table was higher for boys (AdjOR 1.44), low birth weight babies (AdjOR 1.68) and babies that were delivered by caesarean section (AdjOR 1.64). The reliability of the observational form varied considerably amongst the different variables analyzed, but was high for all variables concerning the use of bag-and-mask ventilation and the variable whether suction was used or not, all matching in over 91% of the forms.

    Conclusions: CCD camera technique was a feasible method to assess resuscitation practices in this low resource hospital setting. In most aspects, the staff did not adhere to guidelines regarding neonatal resuscitation. The use of bag-and-mask ventilation was inadequate, and suction was given excessively in terms of protocol. Further studies exploring the underlying causes behind the lack of adherence to the neonatal resuscitation guidelines should be conducted.

  • 13. Thapa, Jeevan
    et al.
    Budhathoki, Shyam Sundar
    Gurung, Rejina
    Paudel, Prajwal
    Jha, Bijay
    Ghimire, Anup
    Wrammert, Johan
    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), International Child Health and Nutrition.
    KC, Ashish
    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), International Child Health and Nutrition.
    Equity and Coverage in the Continuum of Reproductive, Maternal, Newborn and Child Health Services in Nepal-Projecting the Estimates on Death Averted Using the LiST Tool.2019In: Maternal and Child Health Journal, ISSN 1092-7875, E-ISSN 1573-6628Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: The third Sustainable Development Goal, focused on health, includes two targets related to the reduction in maternal, newborn and under-five childhood mortality. We found it imperative to examine the equity and coverage of reproductive, maternal, newborn and child health (RMNCH) interventions from 2001 to 2016 in Nepal; and the death aversion that will take place during the SDG period.

    METHODS: We used the datasets from the Nepal Demographic Health Surveys (NDHS) 2001, 2006, 2011 and 2016. We calculated the coverage and equity for RMNCH interventions and the composite coverage index (CCI). Based on the Annualized Rate of Change (ARC) in the coverage for selected RMNCH indicators, we projected the trend for the RMNCH interventions by 2030. We used the Lives Saved Tools (LiST) tool to estimate the maternal, newborn, under-five childhood deaths and stillbirths averted. We categorised the interventions into four different patterns based on coverage and inequity gap.

    RESULTS: Between 2001 and 2016, a significant improvement is seen in the overall RMNCH intervention coverage-CCI increasing from 46 to 75%. The ARC was highest for skilled attendance at birth (11.7%) followed by care seeking for pneumonia (8.2%) between the same period. In 2016, the highest inequity existed for utilization of the skilled birth attendance services (51%), followed by antenatal care (18%). The inequity gap for basic immunization services reduced significantly from 27.4% in 2001 to 5% in 2016. If the current ARC continues, then an additional 3783 maternal deaths, 36,443 neonatal deaths, 66,883 under-five childhood deaths and 24,024 stillbirths is expected to be averted by the year 2030.

    CONCLUSION: Nepal has experienced an improvement in the coverage and equity in RMNCH interventions. Reducing inequities will improve coverage for skilled birth attendants and antenatal care. The current annual rate of change in RMNCH coverage will further reduce the maternal, neonatal, under-five childhood deaths and stillbirths.

  • 14.
    Wrammert, Johan
    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).
    Surviving birth: Studies of a simplified neonatal resuscitation protocol in a low-income context using a mixed-methods approach2017Doctoral 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.

    List of papers
    1. Teamwork among midwives during neonatal resuscitation at a maternity hospital in Nepal
    Open this publication in new window or tab >>Teamwork among midwives during neonatal resuscitation at a maternity hospital in Nepal
    Show others...
    2017 (English)In: Women and Birth, ISSN 1871-5192, E-ISSN 1878-1799, Vol. 30, no 3, p. 262-269, article id S1871-5192(16)30120-2Article in journal (Refereed) Published
    Abstract [en]

    PROBLEM: The ability of health care providers to work together is essential for favourable outcomes in neonatal resuscitation, but perceptions of such teamwork have rarely been studied in low-income settings.

    BACKGROUND: Neonatal resuscitation is a proven intervention for reducing neonatal mortality globally, but the long-term effects of clinical training for this skill need further attention. Having an understanding of barriers to teamwork among nurse midwives can contribute to the sustainability of improved clinical practice.

    AIM: To explore nurse midwives' perceptions of teamwork when caring for newborns in need of resuscitation.

    METHODS: Nurse midwives from a tertiary-level government hospital in Nepal participated in five focus groups of between 4 and 11 participants each. Qualitative Content Analysis was used for analysis.

    FINDINGS: One overarching theme emerged: looking for comprehensive guidelines and shared responsibilities in neonatal resuscitation to avoid personal blame and learn from mistakes. Participants discussed the need for protocols relating to neonatal resuscitation and the importance of shared medical responsibility, and the importance of the presence of a strong and transparent leadership.

    DISCUSSION: The call for clear and comprehensive protocols relating to neonatal resuscitation corresponded with previous research from different contexts.

    CONCLUSION: Nurse midwives working at a maternity health care facility in Nepal discussed the benefits and challenges of teamwork in neonatal resuscitation. The findings suggest potential benefits can be made from clarifying guidelines and responsibilities in neonatal resuscitation. Furthermore, a structured process to deal with clinical incidents must be considered. Management must be involved in all processes.

    Keywords
    Low-income population, Neonatal resuscitation, Nurse midwives, Practice guidelines, Teamwork
    National Category
    Nursing
    Identifiers
    urn:nbn:se:uu:diva-316658 (URN)10.1016/j.wombi.2017.02.002 (DOI)000405407500015 ()28254364 (PubMedID)
    Funder
    Swedish Research Council
    Available from: 2017-03-06 Created: 2017-03-06 Last updated: 2017-10-24Bibliographically approved
    2. Reducing perinatal mortality in Nepal using Helping Babies Breathe
    Open this publication in new window or tab >>Reducing perinatal mortality in Nepal using Helping Babies Breathe
    Show others...
    2016 (English)In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 137, no 6, article id 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.

    Keywords
    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:nbn:se:uu:diva-267919 (URN)10.1542/peds.2015-0117 (DOI)000378520100001 ()
    Funder
    Swedish Society of Medicine
    Available from: 2015-11-29 Created: 2015-11-29 Last updated: 2017-12-01Bibliographically approved
    3. Improved postnatal care is needed to maintain gains in neonatal survival after the implementation of the Helping Babies Breathe initiative
    Open this publication in new window or tab >>Improved postnatal care is needed to maintain gains in neonatal survival after the implementation of the Helping Babies Breathe initiative
    2017 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 106, no 8, p. 1280-1285Article in journal (Refereed) Published
    Abstract [en]

    Aim Helping Babies Breathe (HBB) is a neonatal resuscitation protocol proven to reduce intrapartum-related mortality in low-income settings. The aim of this study was to describe the timing and causes of neonatal in-hospital deaths before and after HBB training at a maternity health facility in Nepal.

    Methods A prospective cohort study was conducted at the facility between July 2012 and September 2013. All 137 staff, including medical doctors and midwives, were trained in January 2013. The causes of 299 neonatal deaths and the day of death, up to 27 days, were collected before and after the training course.

    Results Deaths caused by intrapartum-related complications were reduced from 51% to 33%.  Preterm infants survived for more days (p<0.01) during the neonatal period, but overall in-hospital neonatal mortality was unchanged (p=0.46) after training. The survival rates linked to complications of infection, congenital anomalies and other causes were unaffected by the intervention.

    Conclusion The continuum of postnatal care for newborn infants needs to be strengthened after Helping Babies Breathe training, in order to maintain the gains in neonatal survival on the day of delivery. Additional interventions in the postnatal period are therefore required to increase neonatal survival at facilities in low-income settings.

    Keywords
    cause of death, low-income settings, neonatal resuscitation, perinatal mortality, postnatal
    National Category
    Pediatrics
    Identifiers
    urn:nbn:se:uu:diva-316710 (URN)10.1111/apa.13835 (DOI)000405233800012 ()28316097 (PubMedID)
    Funder
    Swedish Research Council
    Available from: 2017-03-06 Created: 2017-03-06 Last updated: 2018-02-20Bibliographically approved
    4. Resuscitation practices of low and normal birth weight infants in Nepal: an observational study using video camera recordings
    Open this publication in new window or tab >>Resuscitation practices of low and normal birth weight infants in Nepal: an observational study using video camera recordings
    Show others...
    2017 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1322372Article in journal (Other academic) Published
    Abstract [en]

    Background: The global burden of stillbirth and neonatal deaths remains achallenge in low-income countries. Training in neonatal resuscitation canreduce intrapartum stillbirth and early neonatal mortality. Previous resultsdemonstrate that infants who previously would have been registered asstillbirths are successfully resuscitated after such training, suggesting thatthere is a process of selection for resuscitation that needs to be explored.

    Objective: To compare neonatal resuscitation of low birth weight andnormal birth weight infants born at a facility in a low-income setting.

    Methods: Motion-triggered video cameras were installed above theresuscitation tables at a maternity health facility during an interventionstudy (ISRCTN97846009) employing the Helping Babies Breatheresuscitation protocol in Kathmandu, Nepal. Recordings were analysed,noting crying, stimulation, ventilation, suctioning and oxygenadministration during resuscitation. Birth weight, Apgar scores and sex ofthe infant were retrieved from matched hospital registers. The results wereanalysed by chi-square and logistic regression.

    Results: A total of 2253 resuscitation cases were recorded. Low birthweight infants in need of resuscitation had higher odds of receivingventilation (aOR 1.73), and lower odds of receiving suctioning (aOR 0.53)after adjustment for the Helping Babies Breathe intervention, sex of theinfant and place of resuscitation within the facility. The rate of stimulationand administration of oxygen was the same in both groups.

    Conclusions: Low birth weight was associated with more ventilation andless suctioning during neonatal resuscitation in a low-income setting. Asventilation is the most important intervention when the infant does notinitiate breathing after birth, low birth weight was not a predictor for thedecision to withhold resuscitation. Frequent routine use of suctioning of thelower airways continues to be a problem in the studied context, even afterthe introduction of the Helping Babies Breathe protocol.

    Place, publisher, year, edition, pages
    Taylor & Francis, 2017
    Keywords
    neonatal resuscitation, low birth weight, guideline adherence, video recording, low-income population
    National Category
    Pediatrics
    Identifiers
    urn:nbn:se:uu:diva-316720 (URN)10.1080/16549716.2017.1322372 (DOI)000402549800001 ()
    Available from: 2017-03-06 Created: 2017-03-06 Last updated: 2017-08-16Bibliographically approved
  • 15.
    Wrammert, Johan
    et al.
    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). Children's University Hospital, Akademiska Sjukhuset, Uppsala, Sweden.
    KC, Ashish
    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). Health Section, UNICEF Nepal Country office, Leknath Marg, Nepal.
    Ewald, Uwe
    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).
    Målqvist, Mats
    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).
    Improved postnatal care is needed to maintain gains in neonatal survival after the implementation of the Helping Babies Breathe initiative2017In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 106, no 8, p. 1280-1285Article in journal (Refereed)
    Abstract [en]

    Aim Helping Babies Breathe (HBB) is a neonatal resuscitation protocol proven to reduce intrapartum-related mortality in low-income settings. The aim of this study was to describe the timing and causes of neonatal in-hospital deaths before and after HBB training at a maternity health facility in Nepal.

    Methods A prospective cohort study was conducted at the facility between July 2012 and September 2013. All 137 staff, including medical doctors and midwives, were trained in January 2013. The causes of 299 neonatal deaths and the day of death, up to 27 days, were collected before and after the training course.

    Results Deaths caused by intrapartum-related complications were reduced from 51% to 33%.  Preterm infants survived for more days (p<0.01) during the neonatal period, but overall in-hospital neonatal mortality was unchanged (p=0.46) after training. The survival rates linked to complications of infection, congenital anomalies and other causes were unaffected by the intervention.

    Conclusion The continuum of postnatal care for newborn infants needs to be strengthened after Helping Babies Breathe training, in order to maintain the gains in neonatal survival on the day of delivery. Additional interventions in the postnatal period are therefore required to increase neonatal survival at facilities in low-income settings.

  • 16.
    Wrammert, Johan
    et al.
    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).
    Sapkota, Sabitri
    Marie Stopes International.
    Baral, Kedar
    Patan Academy of Health Sciences.
    KC, Ashish
    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).
    Målqvist, Mats
    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).
    Larsson, Margareta
    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).
    Teamwork among midwives during neonatal resuscitation at a maternity hospital in Nepal2017In: Women and Birth, ISSN 1871-5192, E-ISSN 1878-1799, Vol. 30, no 3, p. 262-269, article id S1871-5192(16)30120-2Article in journal (Refereed)
    Abstract [en]

    PROBLEM: The ability of health care providers to work together is essential for favourable outcomes in neonatal resuscitation, but perceptions of such teamwork have rarely been studied in low-income settings.

    BACKGROUND: Neonatal resuscitation is a proven intervention for reducing neonatal mortality globally, but the long-term effects of clinical training for this skill need further attention. Having an understanding of barriers to teamwork among nurse midwives can contribute to the sustainability of improved clinical practice.

    AIM: To explore nurse midwives' perceptions of teamwork when caring for newborns in need of resuscitation.

    METHODS: Nurse midwives from a tertiary-level government hospital in Nepal participated in five focus groups of between 4 and 11 participants each. Qualitative Content Analysis was used for analysis.

    FINDINGS: One overarching theme emerged: looking for comprehensive guidelines and shared responsibilities in neonatal resuscitation to avoid personal blame and learn from mistakes. Participants discussed the need for protocols relating to neonatal resuscitation and the importance of shared medical responsibility, and the importance of the presence of a strong and transparent leadership.

    DISCUSSION: The call for clear and comprehensive protocols relating to neonatal resuscitation corresponded with previous research from different contexts.

    CONCLUSION: Nurse midwives working at a maternity health care facility in Nepal discussed the benefits and challenges of teamwork in neonatal resuscitation. The findings suggest potential benefits can be made from clarifying guidelines and responsibilities in neonatal resuscitation. Furthermore, a structured process to deal with clinical incidents must be considered. Management must be involved in all processes.

  • 17.
    Wrammert, Johan
    et al.
    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).
    Zetterlund, Camilla
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    KC, Ashish
    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).
    Ewald, Uwe
    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).
    Målqvist, Mats
    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).
    Resuscitation practices of low and normal birth weight infants in Nepal: an observational study using video camera recordings2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1322372Article in journal (Other academic)
    Abstract [en]

    Background: The global burden of stillbirth and neonatal deaths remains achallenge in low-income countries. Training in neonatal resuscitation canreduce intrapartum stillbirth and early neonatal mortality. Previous resultsdemonstrate that infants who previously would have been registered asstillbirths are successfully resuscitated after such training, suggesting thatthere is a process of selection for resuscitation that needs to be explored.

    Objective: To compare neonatal resuscitation of low birth weight andnormal birth weight infants born at a facility in a low-income setting.

    Methods: Motion-triggered video cameras were installed above theresuscitation tables at a maternity health facility during an interventionstudy (ISRCTN97846009) employing the Helping Babies Breatheresuscitation protocol in Kathmandu, Nepal. Recordings were analysed,noting crying, stimulation, ventilation, suctioning and oxygenadministration during resuscitation. Birth weight, Apgar scores and sex ofthe infant were retrieved from matched hospital registers. The results wereanalysed by chi-square and logistic regression.

    Results: A total of 2253 resuscitation cases were recorded. Low birthweight infants in need of resuscitation had higher odds of receivingventilation (aOR 1.73), and lower odds of receiving suctioning (aOR 0.53)after adjustment for the Helping Babies Breathe intervention, sex of theinfant and place of resuscitation within the facility. The rate of stimulationand administration of oxygen was the same in both groups.

    Conclusions: Low birth weight was associated with more ventilation andless suctioning during neonatal resuscitation in a low-income setting. Asventilation is the most important intervention when the infant does notinitiate breathing after birth, low birth weight was not a predictor for thedecision to withhold resuscitation. Frequent routine use of suctioning of thelower airways continues to be a problem in the studied context, even afterthe introduction of the Helping Babies Breathe protocol.

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