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"Safer Births Bundle of Care" Implementation and Perinatal Impact at 30 Hospitals in Tanzania-Halfway Evaluation. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020255. [PMID: 36832384 PMCID: PMC9955319 DOI: 10.3390/children10020255] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/26/2023] [Accepted: 01/28/2023] [Indexed: 02/01/2023]
Abstract
Safer Births Bundle of Care (SBBC) consists of innovative clinical and training tools for improved labour care and newborn resuscitation, integrated with new strategies for continuous quality improvement. After implementation, we hypothesised a reduction in 24-h newborn deaths, fresh stillbirths, and maternal deaths by 50%, 20%, and 10%, respectively. This is a 3-year stepped-wedged cluster randomised implementation study, including 30 facilities within five regions in Tanzania. Data collectors at each facility enter labour and newborn care indicators, patient characteristics and outcomes. This halfway evaluation reports data from March 2021 through July 2022. In total, 138,357 deliveries were recorded; 67,690 pre- and 70,667 post-implementations of SBBC. There were steady trends of increased 24-h newborn and maternal survival in four regions after SBBC initiation. In the first region, with 13 months of implementation (n = 15,658 deliveries), an estimated additional 100 newborns and 20 women were saved. Reported fresh stillbirths seemed to fluctuate across time, and increased in three regions after the start of SBBC. Uptake of the bundle varied between regions. This SBBC halfway evaluation indicates steady reductions in 24-h newborn and maternal mortality, in line with our hypotheses, in four of five regions. Enhanced focus on uptake of the bundle and the quality improvement component is necessary to fully reach the SBBC impact potential as we move forward.
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Dempsey T, Nguyen HT, Nguyen HL, Bui XA, Pham PTT, Nguyen TK, Helldén D, Cavallin F, Trevisanuto D, Höök SM, Blennow M, Olson L, Vu H, Nguyen AD, Alfvén T, Pejovic N. Endotracheal intubation performance at a large obstetric hospital delivery room, Hanoi, Vietnam. Resusc Plus 2022; 12:100338. [PMID: 36482918 PMCID: PMC9723915 DOI: 10.1016/j.resplu.2022.100338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 11/12/2022] [Accepted: 11/16/2022] [Indexed: 12/10/2022] Open
Abstract
INTRODUCTION Intrapartum-related events account for nearly 700,000 neonatal deaths globally yearly. Endotracheal intubation is a cornerstone in preventing many of these deaths, but it is a difficult skill to acquire. Previous studies have described intubation performances in high-income countries, but data from low- and middle-income countries are lacking. We aimed to assess the performance of delivery room intubation in a lower middle-income country. METHODS This prospective observational study was conducted at the Phu San Hanoi Hospital, Vietnam, from September 2020 to January 2021. Video cameras were positioned above the resuscitation tables and data were extracted using adopted software (NeoTapAS). All neonates requiring positive pressure ventilation were included. Our main variables of interest were time to first intubation attempt, first intubation attempt duration, and successful first intubation attempt. RESULTS 18,107 neonates were born during the five months. Of these, 75 (0.4%) received positive pressure ventilation, and 36 (0.2%) required endotracheal intubation of whom 24 were captured on video. The median time to the first intubation attempt was 252 seconds (range 91-771 seconds), the median first attempt duration was 49 seconds (range 10-105 seconds), and the first attempt success rate was 75%. CONCLUSION Incidences of positive pressure ventilation and endotracheal intubation were low in comparison to global estimates. Three out of four intubations were successful at the first attempt and the procedural duration was often longer than recommended. Future studies should focus on how to achieve and maintain intubation skills and could include considering alternative devices for airway management at birth.
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Affiliation(s)
- Tina Dempsey
- Department of Global Public Health, Karolinska Institutet, 17177 Solna, Sweden,Astrid Lindgren Children’s Hospital, Karolinska University Hospital, 17176 Solna, Sweden,Corresponding author at: Global Public Health, Karolinska Institutet, Tomtebodavägen 18a, 17177 Solna, Sweden.
| | - Huong Thu Nguyen
- Neonatal Department, Phu San Hanoi Hospital, Hanoi 100000, Viet Nam
| | | | - Xuan Anh Bui
- Department of Information Technology, Phu San Hanoi Hospital, Hanoi 100000, Viet Nam
| | | | - Toan K Nguyen
- Department of Gynecological Oncology, Phu San Hanoi Hospital, Hanoi 100000, Viet Nam,Department of International Collaboration, Phu San Hanoi Hospital, Hanoi 100000, Viet Nam
| | - Daniel Helldén
- Department of Global Public Health, Karolinska Institutet, 17177 Solna, Sweden
| | | | - Daniele Trevisanuto
- Department of Woman’s and Child’s Health, University Hospital of Padova, 35128 Padova, Italy
| | - Susanna Myrnerts Höök
- Department of Global Public Health, Karolinska Institutet, 17177 Solna, Sweden,Emergency Care Unit, Sachs’ Children and Youth Hospital, 11883 Stockholm, Sweden
| | - Mats Blennow
- Department of Clinical Science Intervention and Technology, Karolinska Institutet, 14152 Huddinge, Sweden
| | - Linus Olson
- Department of Global Public Health, Karolinska Institutet, 17177 Solna, Sweden,Department of Women’s and Children’s Health, Karolinska Institutet, 17177 Solna, Sweden,Department of Medical Biochemistry and Microbiology, Uppsala University, 75237 Uppsala, Sweden
| | - Hien Vu
- Department of International Collaboration, Phu San Hanoi Hospital, Hanoi 100000, Viet Nam,Intensive Care Unit and Poison Control Department, Phu San Hanoi Hospital, Hanoi 100000, Viet Nam,Social Work Department, Phu San Hanoi Hospital, Hanoi 100000, Viet Nam,University of Medicine and Pharmacy, Hanoi 100000, Viet Nam
| | - Anh Duy Nguyen
- University of Medicine and Pharmacy, Hanoi 100000, Viet Nam,Board of Directors, Phu San Hanoi Hospital, Hanoi 100000, Viet Nam
| | - Tobias Alfvén
- Department of Global Public Health, Karolinska Institutet, 17177 Solna, Sweden,Emergency Care Unit, Sachs’ Children and Youth Hospital, 11883 Stockholm, Sweden
| | - Nicolas Pejovic
- Department of Global Public Health, Karolinska Institutet, 17177 Solna, Sweden,Neonatal Unit, Sachs’ Children and Youth Hospital, 11883 Stockholm, Sweden
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Vadla MS, Moshiro R, Mdoe P, Eilevstjønn J, Kvaløy JT, Hhoki BH, Ersdal H. Newborn resuscitation simulation training and changes in clinical performance and perinatal outcomes: a clinical observational study of 10,481 births. ADVANCES IN SIMULATION (LONDON, ENGLAND) 2022; 7:38. [PMID: 36335400 PMCID: PMC9636744 DOI: 10.1186/s41077-022-00234-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/23/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Annually, 1.5 million intrapartum-related deaths occur; fresh stillbirths and early newborn deaths. Most of these deaths are preventable with skilled ventilation starting within the first minute of life. Helping Babies Breathe is an educational program shown to improve simulated skills in newborn resuscitation. However, translation into clinical practice remains a challenge. The aim was to describe changes in clinical resuscitation and perinatal outcomes (i.e., fresh stillbirths and 24-h newborn deaths) after introducing a novel simulator (phase 1) and then local champions (phase 2) to facilitate ongoing Helping Babies Breathe skill and scenario simulation training. METHODS This is a 3-year prospective before/after (2 phases) clinical observational study in Tanzania. Research assistants observed all deliveries from September 2015 through August 2018 and recorded labor/newborn information and perinatal outcomes. A novel simulator with automatic feedback to stimulate self-guided skill training was introduced in September 2016. Local champions were introduced in October 2017 to motivate midwives for weekly training, also team simulations. RESULTS The study included 10,481 births. Midwives had practiced self-guided skill training during the last week prior to a real newborn resuscitation in 34% of cases during baseline, 30% in phase 1, and 71% in phase 2. Most real resuscitations were provided by midwives, increasing from 66% in the baseline, to 77% in phase 1, and further to 83% in phase 2. The median time from birth to first ventilation decreased between baseline and phase 2 from 118 (85-165) to 101 (72-150) s, and time pauses during ventilation decreased from 28 to 16%. Ventilations initiated within the first minute did not change significantly (13-16%). The proportion of high-risk deliveries increased during the study period, while perinatal mortality remained unchanged. CONCLUSIONS This study reports a gradual improvement in real newborn resuscitation skills after introducing a novel simulator and then local champions. The frequency of trainings increased first after the introduction of motivating champions. Time from birth to first ventilation decreased; still, merely 16% of newborns received ventilation within the first minute as recommended. This is a remaining challenge that may require more targeted team-scenario training and quality improvement efforts to improve.
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Affiliation(s)
- May Sissel Vadla
- Faculty of Health Sciences, University of Stavanger, 4021, Stavanger, Norway.
| | - Robert Moshiro
- Muhimbili National Hospital, P.O Box 65000, Dar es Salaam, Tanzania
| | - Paschal Mdoe
- Haydom Lutheran Hospital, Box 9000, Haydom, Mbulu, Tanzania
| | | | - Jan Terje Kvaløy
- Department of Mathematics and Physics, University of Stavanger, 4036, Stavanger, Norway.,Department of Research, Stavanger University Hospital, 4011, Stavanger, Norway
| | | | - Hege Ersdal
- Faculty of Health Sciences, University of Stavanger, 4021, Stavanger, Norway.,Department of Anaesthesia, Stavanger University Hospital, 4011, Stavanger, Norway
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Shukla VV, Carlo WA, Niermeyer S, Guinsburg R. Neonatal resuscitation from a global perspective. Semin Perinatol 2022; 46:151630. [PMID: 35725655 DOI: 10.1016/j.semperi.2022.151630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The majority of perinatal and neonatal mortality occurs in low-resource settings in low- and middle-income countries. Access and quality of care at delivery are major determinants of the health and survival of newborn infants. Availability of basic neonatal resuscitation care at birth has improved, but basic neonatal resuscitation at birth or high-quality care continues to be inaccessible in some settings, leading to persistently high perinatal and neonatal mortality. Low-resource settings of high-income countries and socially disadvantaged communities also suffer from inadequate access to quality perinatal healthcare. Quality improvement, implementation research, and innovation should focus on improving the quality of perinatal healthcare and perinatal and neonatal outcomes in low-resource settings. The current review presents an update on issues confronting universal availability of optimal resuscitation care at birth and provides an update on ongoing efforts to address them.
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Affiliation(s)
- Vivek V Shukla
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Waldemar A Carlo
- University of Colorado School of Medicine and Colorado School of Public Health, Aurora, CO, USA
| | - Susan Niermeyer
- University of Colorado School of Medicine and Colorado School of Public Health, Aurora, CO, USA
| | - Ruth Guinsburg
- Universidade Federal de São Paulo/Escola Paulista de Medicina, São Paulo, SP, Brazil.
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Incidence of Intrapartum-Related Events at the Largest Obstetric Hospital in Hanoi, Vietnam: A Retrospective Study. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9030321. [PMID: 35327693 PMCID: PMC8947411 DOI: 10.3390/children9030321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 11/16/2022]
Abstract
Every year, 2.4 million neonates die during their first month of life and even more suffer permanent injury. The main causes are intrapartum-related events, prematurity, and infection, with sub-Saharan Africa and southern Asia being the worst affected regions. With a focus on intrapartum-related events, we aimed to assess the neonatal demographic characteristics, clinical management, and outcomes among neonates born at the largest obstetric hospital in Hanoi, Vietnam. This was a retrospective cross-sectional study that included all the inborn neonates in November 2019, which was selected as a representative month. A total of 4554 neonates were born during the study period. Of these, 1.0% (n = 44) were stillbirths, 0.15% (n = 7) died in hospital, 0.61% (n = 28) received positive pressure ventilation at birth, and 0.15% (n = 7) were diagnosed with hypoxic ischemic encephalopathy. A total of 581 (13%) neonates were admitted to the neonatal unit, among which the most common diagnoses were prematurity (37%, n = 217) and infection (15%, n = 89). Except for the intrapartum-related events, our findings are consistent with the previously documented data on neonatal morbidity. The intrapartum-related events, however, were surprisingly low in number even in comparison to high-income countries. Research on the current clinical practice at Phu San Hanoi Hospital may bring further clarity to identify the success factors.
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Vadla MS, Mdoe P, Moshiro R, Haug IA, Gomo Ø, Kvaløy JT, Oftedal B, Ersdal H. Neonatal Resuscitation Skill-Training Using a New Neonatal Simulator, Facilitated by Local Motivators: Two-Year Prospective Observational Study of 9000 Trainings. CHILDREN 2022; 9:children9020134. [PMID: 35204855 PMCID: PMC8870207 DOI: 10.3390/children9020134] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/11/2022] [Accepted: 01/14/2022] [Indexed: 11/16/2022]
Abstract
Globally, intrapartum-related complications account for approximately 2 million perinatal deaths annually. Adequate skills in neonatal resuscitation are required to reduce perinatal mortality. NeoNatalie Live is a newborn simulator providing immediate feedback, originally designed to accomplish Helping Babies Breathe training in low-resource settings. The objectives of this study were to describe changes in staff participation, skill-training frequency, and simulated ventilation quality before and after the introduction of “local motivators” in a rural Tanzanian hospital with 4000–5000 deliveries annually. Midwives (n = 15–27) were encouraged to perform in situ low-dose high-frequency simulation skill-training using NeoNatalie Live from September 2016 through to August 2018. Frequency and quality of trainings were automatically recorded in the simulator. The number of skill-trainings increased from 688 (12 months) to 8451 (11 months) after the introduction of local motivators in October 2017. Staff participation increased from 43% to 74% of the midwives. The quality of training performance, measured as “well done” feedback, increased from 75% to 91%. We conclude that training frequency, participation, and performance increased after introduction of dedicated motivators. In addition, the immediate constructive feedback features of the simulator may have influenced motivation and training quality performance.
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Affiliation(s)
- May Sissel Vadla
- Faculty of Health Sciences, University of Stavanger, 4021 Stavanger, Norway; (B.O.); (H.E.)
- Correspondence: ; Tel.:+47-98492399
| | - Paschal Mdoe
- Haydom Lutheran Hospital, Haydom P.O. Box 9000, Mbulu, Tanzania;
| | - Robert Moshiro
- Muhimbili National Hospital, Dar es Salaam P.O. Box 65000, Tanzania;
| | | | - Øystein Gomo
- Laerdal Medical, 4002 Stavanger, Norway; (I.A.H.); (Ø.G.)
| | - Jan Terje Kvaløy
- Department of Mathematics and Physics, University of Stavanger, 4036 Stavanger, Norway;
- Department of Research, Stavanger University Hospital, 4011 Stavanger, Norway
| | - Bjørg Oftedal
- Faculty of Health Sciences, University of Stavanger, 4021 Stavanger, Norway; (B.O.); (H.E.)
| | - Hege Ersdal
- Faculty of Health Sciences, University of Stavanger, 4021 Stavanger, Norway; (B.O.); (H.E.)
- Department of Anaesthesia, Stavanger University Hospital, 4011 Stavanger, Norway
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Ekblom A, Målqvist M, Gurung R, Rossley A, Basnet O, Bhattarai P, K C A. Factors associated with poor adherence to intrapartum fetal heart monitoring in relationship to intrapartum related death: A prospective cohort study. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000289. [PMID: 36962317 PMCID: PMC10021382 DOI: 10.1371/journal.pgph.0000289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 02/24/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Poor quality of intrapartum care remains a global health challenge for reducing stillbirth and early neonatal mortality. Despite fetal heart rate monitoring (FHRM) being key to identify fetus at risk during labor, sub-optimal care prevails in low-income settings. The study aims to assess the predictors of suboptimal fetal heart rate monitoring and assess the association of sub-optimal FHRM and intrapartum related deaths. METHOD A prospective cohort study was conducted in 12 hospitals between April 2017 to October 2018. Pregnant women with fetal heart sound present during admission were included. Inferential statistics were used to assess proportion of sub-optimal FHRM. Multi-level logistic regression was used to detect association between sub-optimal FHRM and intrapartum related death. RESULT The study cohort included 83,709 deliveries, in which in more than half of women received suboptimal FHRM (56%). The sub-optimal FHRM was higher among women with obstetric complication than those with no complication (68.8% vs 55.5%, p-value<0.001). The sub-optimal FHRM was higher if partograph was not used than for whom partograph was completely filled (70.8% vs 15.9%, p-value<0.001). The sub-optimal FHRM was higher if the women had no companion during labor than those who had companion during labor (57.5% vs 49.6%, p-value<0.001). After adjusting for background characteristics and intra-partum factors, the odds of intrapartum related death was higher if FHRM was done sub-optimally in reference to women who had FHRM monitored as per protocol (aOR, 1.47; 95% CI; 1.13, 1.92). CONCLUSION Adherence to FHRM as per clinical standards was inadequate in these hospitals of Nepal. Furthermore, there was an increased odds of intra-partum death if FHRM had not been carried out as per clinical standards. FHRM provided as per protocol is key to identify fetuses at risk, and efforts are needed to improve the adherence of quality of care to prevent death.
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Affiliation(s)
- Annette Ekblom
- Uppsala Global Health Research on Implementation and Sustainability (UGHRIS), Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Mats Målqvist
- Uppsala Global Health Research on Implementation and Sustainability (UGHRIS), Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Rejina Gurung
- Uppsala Global Health Research on Implementation and Sustainability (UGHRIS), Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Angela Rossley
- Uppsala Global Health Research on Implementation and Sustainability (UGHRIS), Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | | | - Ashish K C
- Uppsala Global Health Research on Implementation and Sustainability (UGHRIS), Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Society of Public Health Physicians Nepal, Kathmandu, Nepal
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Effect of resuscitation training and implementation of continuous electronic heart rate monitoring on identification of stillbirth. Resuscitation 2021; 171:57-63. [PMID: 34965451 DOI: 10.1016/j.resuscitation.2021.12.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 12/18/2022]
Abstract
AIM To evaluate the effect of resuscitation training and continuous electronic heart rate (HR) monitoring of non-breathing newborns on identification of stillbirth. METHODS We conducted a pre-post interventional trial in three health facilities in the Democratic Republic of the Congo. We collected data on a retrospective control group of newborns that reflected usual resuscitation practice (Epoch 1). In the prospective, interventional group, skilled birth attendants received resuscitation training in Helping Babies Breathe and implemented continuous electronic HR monitoring of non-breathing newborns (Epoch 2). Our primary outcome was the incidence of stillbirth with secondary outcomes of fresh or macerated stillbirth, neonatal death before discharge and perinatal death. Among a subset, we conducted expert review of electronic HR data to estimate misclassification of stillbirth in Epoch 2. We used a generalized estimating equation, adjusted for variation within-facility, to compare risks between EPOCHs. RESULTS There was no change in total stillbirths following resuscitation training and continuous electronic HR monitoring of non-breathing newborns (aRR 1.15 [0.95, 1.39]). We observed an increased rate of macerated stillbirth (aRR 1.58 [1.24, 2.02]), death before discharge (aRR 3.31 [2.41, 4.54]), and perinatal death (aRR 1.61 [1.38, 1.89]) during the intervention period. In expert review, 20% of newborns with electronic HR data that were classified by SBAs as stillborn were liveborn. CONCLUSION Resuscitation training and use of continuous electronic HR monitoring did not reduce stillbirths nor eliminate misclassification.
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Bettinger K, Mafuta E, Mackay A, Bose C, Myklebust H, Haug I, Ishoso D, Patterson J. Improving Newborn Resuscitation by Making Every Birth a Learning Event. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8121194. [PMID: 34943390 PMCID: PMC8700033 DOI: 10.3390/children8121194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/08/2021] [Accepted: 12/13/2021] [Indexed: 06/14/2023]
Abstract
One third of all neonatal deaths are caused by intrapartum-related events, resulting in neonatal respiratory depression (i.e., failure to breathe at birth). Evidence-based resuscitation with stimulation, airway clearance, and positive pressure ventilation reduces mortality from respiratory depression. Improving adherence to evidence-based resuscitation is vital to preventing neonatal deaths caused by respiratory depression. Standard resuscitation training programs, combined with frequent simulation practice, have not reached their life-saving potential due to ongoing gaps in bedside performance. Complex neonatal resuscitations, such as those involving positive pressure ventilation, are relatively uncommon for any given resuscitation provider, making consistent clinical practice an unrealistic solution for improving performance. This review discusses strategies to allow every birth to act as a learning event within the context of both high- and low-resource settings. We review strategies that involve clinical-decision support during newborn resuscitation, including the visual display of a resuscitation algorithm, peer-to-peer support, expert coaching, and automated guidance. We also review strategies that involve post-event reflection after newborn resuscitation, including delivery room checklists, audits, and debriefing. Strategies that make every birth a learning event have the potential to close performance gaps in newborn resuscitation that remain after training and frequent simulation practice, and they should be prioritized for further development and evaluation.
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Affiliation(s)
- Kourtney Bettinger
- Department of Pediatrics, University of Kansas School of Medicine, 3901 Rainbow Blvd, MS 4004, Kansas City, KS 66103, USA
| | - Eric Mafuta
- School of Public Health, University of Kinshasa, Kinshasa 11850, Democratic Republic of the Congo; (E.M.); (D.I.)
| | - Amy Mackay
- Department of Pediatrics, University of North Carolina at Chapel Hill, 101 Manning Drive, CB 7596, Chapel Hill, NC 27599-7596, USA; (A.M.); (C.B.); (J.P.)
| | - Carl Bose
- Department of Pediatrics, University of North Carolina at Chapel Hill, 101 Manning Drive, CB 7596, Chapel Hill, NC 27599-7596, USA; (A.M.); (C.B.); (J.P.)
| | - Helge Myklebust
- Laerdal Medical Strategic Research Department, Tanke Svilandsgate 30, N-4002 Stavanger, Norway; (H.M.); (I.H.)
| | - Ingunn Haug
- Laerdal Medical Strategic Research Department, Tanke Svilandsgate 30, N-4002 Stavanger, Norway; (H.M.); (I.H.)
| | - Daniel Ishoso
- School of Public Health, University of Kinshasa, Kinshasa 11850, Democratic Republic of the Congo; (E.M.); (D.I.)
| | - Jackie Patterson
- Department of Pediatrics, University of North Carolina at Chapel Hill, 101 Manning Drive, CB 7596, Chapel Hill, NC 27599-7596, USA; (A.M.); (C.B.); (J.P.)
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Kamala BA, Ersdal HL, Mduma E, Moshiro R, Girnary S, Østrem OT, Linde J, Dalen I, Søyland E, Bishanga DR, Bundala FA, Makuwani AM, Richard BM, Muzzazzi PD, Kamala I, Mdoe PF. SaferBirths bundle of care protocol: a stepped-wedge cluster implementation project in 30 public health-facilities in five regions, Tanzania. BMC Health Serv Res 2021; 21:1117. [PMID: 34663296 PMCID: PMC8524841 DOI: 10.1186/s12913-021-07145-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 10/08/2021] [Indexed: 11/15/2022] Open
Abstract
Background The burden of stillbirth, neonatal and maternal deaths are unacceptably high in low- and middle-income countries, especially around the time of birth. There are scarce resources and/or support implementation of evidence-based training programs. SaferBirths Bundle of Care is a well-proven package of innovative tools coupled with data-driven on-the-job training aimed at reducing perinatal and maternal deaths. The aim of this project is to determine the effect of scaling up the bundle on improving quality of intrapartum care and perinatal survival. Methods The project will follow a stepped-wedge cluster implementation design with well-established infrastructures for data collection, management, and analysis in 30 public health facilities in regions in Tanzania. Healthcare workers from selected health facilities will be trained in basic neonatal resuscitation, essential newborn care and essential maternal care. Foetal heart rate monitors (Moyo), neonatal heart rate monitors (NeoBeat) and skills trainers (NeoNatalie Live) will be introduced in the health facilities to facilitate timely identification of foetal distress during labour and improve neonatal resuscitation, respectively. Heart rate signal-data will be automatically collected by Moyo and NeoBeat, and newborn resuscitation training by NeoNatalie Live. Given an average of 4000 baby-mother pairs per year per health facility giving an estimate of 240,000 baby-mother pairs for a 2-years duration, 25% reduction in perinatal mortality at a two-sided significance level of 5%, intracluster correlation coefficient (ICC) to be 0.0013, the study power stands at 0.99. Discussion Previous reports from small-scale Safer Births Bundle implementation studies show satisfactory uptake of interventions with significant improvements in quality of care and lives saved. Better equipped and trained birth attendants are more confident and skilled in providing care. Additionally, local data-driven feedback has shown to drive continuous quality of care improvement initiatives, which is essential to increase perinatal and maternal survival. Strengths of this research project include integration of innovative tools with existing national guidelines, local data-driven decision-making and training. Limitations include the stepwise cluster implementation design that may lead to contamination of the intervention, and/or inability to address the shortage of healthcare workers and medical supplies beyond the project scope. Trial registration Name of Trial Registry: ISRCTN Registry. Trial registration number: ISRCTN30541755. Date of Registration: 12/10/2020. Type of registration: Prospectively Registered.
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Affiliation(s)
- Benjamin A Kamala
- Department of Research, Haydom Lutheran Hospital, Haydom, Manyara, Tanzania. .,School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania.
| | - Hege L Ersdal
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Estomih Mduma
- Department of Research, Haydom Lutheran Hospital, Haydom, Manyara, Tanzania
| | - Robert Moshiro
- Department of Research, Haydom Lutheran Hospital, Haydom, Manyara, Tanzania.,Department of Pediatrics, Muhimbili National Hospital, Dar es Salaam, Tanzania.,Paediatric Association of Tanzania, Dar es Salaam, Tanzania
| | | | | | - Jørgen Linde
- Obstetric Department, Stavanger University Hospital, Stavanger, Norway
| | - Ingvild Dalen
- Obstetric Department, Stavanger University Hospital, Stavanger, Norway
| | | | - Dunstan R Bishanga
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Felix Ambrose Bundala
- Reproductive and Child Health Section, Ministry of Health Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Ahmad M Makuwani
- Reproductive and Child Health Section, Ministry of Health Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Boniphace Marwa Richard
- Department of Health, President's Office- Regional Authority and Local Government, Dodoma, Tanzania
| | | | - Ivony Kamala
- Department of Research, Haydom Lutheran Hospital, Haydom, Manyara, Tanzania.,Tanzania Midwifery Association (TAMA), Dar es Salaam, Tanzania
| | - Paschal F Mdoe
- Department of Research, Haydom Lutheran Hospital, Haydom, Manyara, Tanzania
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Peven K, Day LT, Ruysen H, Tahsina T, Kc A, Shabani J, Kong S, Ameen S, Basnet O, Haider R, Rahman QSU, Blencowe H, Lawn JE. Stillbirths including intrapartum timing: EN-BIRTH multi-country validation study. BMC Pregnancy Childbirth 2021; 21:226. [PMID: 33765942 PMCID: PMC7995570 DOI: 10.1186/s12884-020-03238-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND An estimated >2 million babies stillborn around the world each year lack visibility. Low- and middle-income countries carry 84% of the burden yet have the least data. Most births are now in facilities, hence routine register-recording presents an opportunity to improve counting of stillbirths, but research is limited, particularly regarding accuracy. This paper evaluates register-recorded measurement of hospital stillbirths, classification accuracy, and barriers and enablers to routine recording. METHODS The EN-BIRTH mixed-methods, observational study took place in five hospitals in Bangladesh, Nepal and Tanzania (2017-2018). Clinical observers collected time-stamped data on perinatal care and birth outcomes as gold standard. To assess accuracy of routine register-recorded stillbirth rates, we compared birth outcomes recorded in labour ward registers to observation data. We calculated absolute rate differences and individual-level validation metrics (sensitivity, specificity, percent agreement). We assessed misclassification of stillbirths with neonatal deaths. To examine stillbirth appearance (fresh/macerated) as a proxy for timing of death, we compared appearance to observed timing of intrauterine death based on heart rate at admission. RESULTS 23,072 births were observed including 550 stillbirths. Register-recorded completeness of birth outcomes was > 90%. The observed study stillbirth rate ranged from 3.8 (95%CI = 2.0,7.0) to 50.3 (95%CI = 43.6,58.0)/1000 total births and was under-estimated in routine registers by 1.1 to 7.3 /1000 total births (register: observed ratio 0.9-0.7). Specificity of register-recorded birth outcomes was > 99% and sensitivity varied between hospitals, ranging from 77.7-86.1%. Percent agreement between observer-assessed birth outcome and register-recorded birth outcome was very high across all hospitals and all modes of birth (> 98%). Fresh or macerated stillbirth appearance was a poor proxy for timing of stillbirth. While there were similar numbers of stillbirths misclassified as neonatal deaths (17/430) and neonatal deaths misclassified as stillbirths (21/36), neonatal deaths were proportionately more likely to be misclassified as stillbirths (58.3% vs 4.0%). Enablers to more accurate register-recording of birth outcome included supervision and data use. CONCLUSIONS Our results show these routine registers accurately recorded stillbirths. Fresh/macerated appearance was a poor proxy for intrapartum stillbirths, hence more focus on measuring fetal heart rate is crucial to classification and importantly reduction in these preventable deaths.
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Affiliation(s)
- Kimberly Peven
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Louise T Day
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Harriet Ruysen
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Tazeen Tahsina
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (iccdr,b), Dhaka, Bangladesh
| | - Ashish Kc
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Josephine Shabani
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Stefanie Kong
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Shafiqul Ameen
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (iccdr,b), Dhaka, Bangladesh
| | - Omkar Basnet
- Research Division, Golden Community, Lalitpur, Nepal
| | - Rajib Haider
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (iccdr,b), Dhaka, Bangladesh
| | - Qazi Sadeq-Ur Rahman
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (iccdr,b), Dhaka, Bangladesh
| | - Hannah Blencowe
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Joy E Lawn
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
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12
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Increased perinatal survival and improved ventilation skills over a five-year period: An observational study. PLoS One 2020; 15:e0240520. [PMID: 33045029 PMCID: PMC7549771 DOI: 10.1371/journal.pone.0240520] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 09/28/2020] [Indexed: 12/20/2022] Open
Abstract
Background and aim The Helping Babies Breathe program gave major reductions in perinatal mortality in Tanzania from 2009 to 2012. We aimed to study whether this effect was sustained, and whether resuscitation skills changed with continued frequent training. Methods We analysed prospective data covering all births (n = 19,571) at Haydom Lutheran Hospital in Tanzania from July 2013 –June 2018. Resuscitation training was continued during this period. All deliveries were monitored by an observer recording the timing of events and resuscitation interventions. Heart rate was recorded by dry-electrode ECG and bag-mask-ventilation by sensors attached to the resuscitator device. We analyzed changes over time in outcomes, use of resuscitation interventions and performance of resuscitation using binary regression models with the log-link function to obtain adjusted relative risks. Results With introduction of user fees for deliveries since 2014, the number of deliveries decreased by 30% from start to the end of the five-year period. An increase in low heart rate at birth and need for bag-mask-ventilation indicate a gradual selection of more vulnerable newborns delivered in the hospital over time. Despite this selection, newborn deaths <24 hours did not change significantly and was maintained at an average of 8.8/1000 live births. The annual reductions in relative risk for perinatal death adjusted for vulnerability factors was 0.84 (95%CI 0.76–0.94). During the five-year period, longer duration of bag-mask ventilation sequences without interruption was observed. Delivered tidal volumes were increased and mask leak was decreased during ventilation. The time to initiation or total duration of ventilation did not change significantly. Conclusion The reduction in 24-hour newborn mortality after introduction of Helping Babies Breathe was maintained, and a further decrease over the five-year period was evident when analyses were adjusted for vulnerability of the newborns. Perinatal survival and performance of ventilation were significantly improved.
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13
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Patterson JK, Girnary S, North K, Data S, Ishoso D, Eilevstjønn J, Bose CL. Innovations in Cardiorespiratory Monitoring to Improve Resuscitation With Helping Babies Breathe. Pediatrics 2020; 146:S155-S164. [PMID: 33004638 DOI: 10.1542/peds.2020-016915h] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 11/24/2022] Open
Abstract
Ninety percent of intrapartum-related neonatal deaths are attributable to respiratory depression, with the vast majority of these deaths occurring in low- and lower-middle-income countries. Neonatal resuscitation training with Helping Babies Breathe (HBB) decreases mortality from respiratory depression. Cardiorespiratory monitoring in conjunction with HBB can provide valuable resuscitation feedback for both training and bedside purposes. In this article, we discuss 3 innovations that couple cardiorespiratory monitoring with HBB: NeoNatalie Live, the Augmented Infant Resuscitator, and NeoBeat. NeoNatalie Live is a high-fidelity manikin that facilitates bag mask ventilation training through case scenarios of varying difficulty. The Augmented Infant Resuscitator is added in-line between a face mask and ventilation bag during bag mask ventilation training to provide users with real-time feedback on ventilation quality. NeoBeat is a battery-operated heart rate meter that digitally displays the newborn heart rate during bedside resuscitations. For each innovation, we review details of the device, implementation in the field, and areas for further research. Using early experience implementing these devices, we suggest building blocks for effective translation of training into improved care. We also highlight general challenges in implementation of devices in facilities in low- and lower-middle-income countries including considerations for training, adaptations to existing workflow, and integration into the ecosystem. Although the devices highlighted in this article hold promise, more data are needed to understand their impact on newborn outcomes.
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Affiliation(s)
- Jackie K Patterson
- Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | | | - Krysten North
- Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Santorino Data
- Mbarara University of Science and Technology, Mbarara, Uganda; and
| | - Daniel Ishoso
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | | | - Carl L Bose
- Department of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
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14
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Perlman JM, Velaphi S, Massawe A, Clarke R, Merali HS, Ersdal H. Achieving Country-Wide Scale for Helping Babies Breathe and Helping Babies Survive. Pediatrics 2020; 146:S194-S207. [PMID: 33004641 DOI: 10.1542/peds.2020-016915k] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 11/24/2022] Open
Abstract
Helping Babies Breathe (HBB) was piloted in 2009 as a program targeted to reduce neonatal mortality (NM). The program has morphed into a suite of programs termed Helping Babies Survive that includes Essential Care for Every Baby. Since 2010, the HBB and Helping Babies Survive training programs have been taught to >850 000 providers in 80 countries. Initial HBB training is associated with a significant improvement in knowledge and skills. However, at refresher training, there is a knowledge-skill gap evident, with a falloff in skills. Accumulating evidence supports the role for frequent refresher resuscitation training in facilitating skills retention. Beyond skill acquisition, HBB has been associated with a significant reduction in early NM (<24 hours) and fresh stillbirth rates. To evaluate the large-scale impact of the growth of skilled birth attendants, we analyzed NM rates in sub-Saharan Africa (n = 11) and Nepal (as areas of growing HBB implementation). All have revealed a consistent reduction in NM at 28 days between 2009 and 2018; a mean reduction of 5.34%. The number of skilled birth attendants, an indirect measure of HBB sustained rollout, reveals significant correlation with NM, fresh stillbirth, and perinatal mortality rates, highlighting HBB's success and the need for continued efforts to train frontline providers. A novel live newborn resuscitation trainer as well as a novel app (HBB Prompt) have been developed, increasing knowledge and skills while providing simulation-based repeated practice. Ongoing challenges in sustaining resources (financial and other) for newborn programming emphasize the need for innovative implementation strategies and training tools.
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Affiliation(s)
- Jeffrey M Perlman
- Weill Cornell Medicine and New York-Presbyterian Komansky Children's Hospital, New York, New York;
| | - Sithembiso Velaphi
- Department of Pediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Augustine Massawe
- Department of Pediatrics and Child Health, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Robert Clarke
- Maternal and Newborn Care, Latter-day Saint Charities Affiliate Faculty and Department of Public Health, College of Life Sciences, Brigham Young University, Provo, Utah
| | - Hasan S Merali
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Canada; and
| | - Hege Ersdal
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway
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15
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Reanimação de bebês prematuros moderados e tardios em sala de parto: fatores associados. ACTA PAUL ENFERM 2020. [DOI: 10.37689/acta-ape/2020ao0134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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16
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Eilevstjønn J, Linde JE, Blacy L, Kidanto H, Ersdal HL. Distribution of heart rate and responses to resuscitation among 1237 apnoeic newborns at birth. Resuscitation 2020; 152:69-76. [DOI: 10.1016/j.resuscitation.2020.04.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/19/2020] [Accepted: 04/27/2020] [Indexed: 10/24/2022]
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17
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Ali A, Nudel J, Heberle CR, Santorino D, Olson KR, Hur C. Cost effectiveness of a novel device for improving resuscitation of apneic newborns. BMC Pediatr 2020; 20:46. [PMID: 32000740 PMCID: PMC6993372 DOI: 10.1186/s12887-020-1925-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 01/14/2020] [Indexed: 11/10/2022] Open
Abstract
Background Intrapartum-related hypoxic events are a major cause of morbidity and mortality in low resource countries. Neonates who receive proper resuscitation may go on to live otherwise healthy lives. However, even when a birth attendant is present, these babies frequently receive suboptimal ventilation with poor outcomes. The Augmented Infant Resuscitator (AIR) is a low-cost, reusable device designed to provide birth attendants real-time objective feedback on measures of ventilation quality during resuscitations and is intended for use in training and at the point of care. The goal of our study was to determine the impact and cost-effectiveness of AIR deployment in conjunction with existing resuscitation training programs in low resource settings. Methods We developed a simulation model of the natural history of intrapartum-related neonatal hypoxia and resuscitation deriving parameters from published literature and model calibration. Simulations estimated the number of disability-adjusted life years (DALYs) averted with use of the AIR by birth attendants if deployed at the point of care. Potential decreases in neonatal mortality and long-term subsequent morbidity from disability were modeled over a lifetime horizon. The primary outcome for the analysis was the cost per DALY averted. Model parameters were specific to the Mbeya region of Tanzania. Results Implementation of the AIR strategy resulted in an additional cost of $24.44 (4.80, 73.62) per DALY averted on top of the cost of existing, validated resuscitation programs. Per hospital, this adds an extra $656 to initial training costs and averts approximately 26.84 years of disability in the cohort of children born in the first year, when projected over a lifetime. The findings were robust to sensitivity analyses. Total roll-out costs for AIR are estimated at $422,688 for the Mbeya region, averting approximately 9018 DALYs on top of existing resuscitation programs, which are estimated to cost $202,240 without AIR. Conclusion Our modeling analysis finds that use of the AIR device may be both an effective and cost-effective tool when used as a supplement to existing resuscitation training programs. Implementation of this strategy in multiple settings will provide data to improve our model parameters and potentially confirm our findings.
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Affiliation(s)
- Ayman Ali
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, USA.,Gastrointestinal Unit, Massachusetts General Hospital, Boston, USA.,Tulane University School of Medicine, New Orleans, USA
| | - Jacob Nudel
- Department of General Surgery, Boston University, Boston, USA.,Institute for Health System Innovation and Policy, Boston University, Boston, USA
| | - Curtis R Heberle
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, USA.,Gastrointestinal Unit, Massachusetts General Hospital, Boston, USA
| | - Data Santorino
- Mbarara University of Science and Technology, Mbarara, Uganda.,Consortium for Affordable Medical Technologies, Mbarara, Uganda
| | - Kristian R Olson
- Consortium for Affordable Medical Technologies, Massachusetts General Hospital, Center for Global Health, Boston, USA.,Harvard Medical School, Boston, USA
| | - Chin Hur
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, USA. .,Gastrointestinal Unit, Massachusetts General Hospital, Boston, USA. .,Harvard Medical School, Boston, USA. .,Health Innovations Research and Evaluation (HIRE), Columbia University Medical Center, 630 W 168th Street, PH9 105, New York, NY, 10032, USA.
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18
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Kc A, Berkelhamer S, Gurung R, Hong Z, Wang H, Sunny AK, Bhattarai P, Poudel PG, Litorp H. The burden of and factors associated with misclassification of intrapartum stillbirth: Evidence from a large scale multicentric observational study. Acta Obstet Gynecol Scand 2019; 99:303-311. [PMID: 31600823 DOI: 10.1111/aogs.13746] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/01/2019] [Accepted: 10/03/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Global estimates suggest 2.6 million stillbirths and 2.5 million neonatal deaths occur annually worldwide. The majority of these deaths occur in low resource settings where analysis of health metrics and outcomes measurements may be challenging. We examined the misclassification of documented intrapartum stillbirth and factors associated with misclassification. MATERIAL AND METHODS A prospective observational study was performed in 12 public hospitals in Nepal. Data were extracted from the medical records of all births that occurred during the 6-month period of the study. For the study purpose, we classified birth outcome based on the presence of fetal heart sound (FHS) at admission and use of neonatal resuscitation. The health worker-documented intrapartum stillbirths were considered potentially misclassified when there were FHS present at admission and no resuscitation initiated after birth. The association between potentially misclassified intrapartum stillbirth and complications during labor, birthweight and gestational age was assessed using Pearson's chi-square test, bivariate and multivariate logistic regression. RESULTS A total of 39 562 mother-infant dyads were enrolled in the study, all of whom had FHS at admission. Among the 391 intrapartum stillbirths recorded during the study, 180 (46.0%) of them had FHS at admission with no resuscitation initiated after birth and were considered potentially misclassified intrapartum stillbirths. Among these potentially misclassified intrapartum stillbirths, 170 (43.5%) had FHS present 15 minutes before birth and 10 had no FHS 15 minutes before birth Among the potentially misclassified intrapartum stillbirths, 23.3% had complications during labor, 93.3% had birthweight less than 2500 g and 90.0% were born preterm. The risk of intrapartum misclassification was nearly four times higher among low birthweight babies (adjusted odds ratio [aOR] 3.5, 95% confidence interval [CI] 1.8 to 7.0, P < 0.001) and five times higher among preterm babies (aOR 5.3, 95% CI 3.0 to 9.3, P < 0.001). CONCLUSIONS We estimate that 46% of intrapartum stillbirths were potentially misclassified intrapartum stillbirths. Improving quality of both FHS monitoring and neonatal resuscitation as well as measurement of the care will reduce the risk of potentially misclassified intrapartum stillbirth and consequently intrapartum stillbirth.
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Affiliation(s)
- Ashish Kc
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Sara Berkelhamer
- Department of Pediatrics, University at Buffalo, Buffalo, NY, USA
| | | | - Zhou Hong
- Department of Maternal and Child Health, Peking University of Health Sciences, Peking, China
| | - Haijun Wang
- Department of Maternal and Child Health, Peking University of Health Sciences, Peking, China
| | | | | | - Pragya G Poudel
- Golden Community, Lalitpur, Nepal.,Department of Public Health, University of Tennessee, Knoxville, TN, USA
| | - Helena Litorp
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Moshiro R, Perlman JM, Mdoe P, Kidanto H, Kvaløy JT, Ersdal HL. Potential causes of early death among admitted newborns in a rural Tanzanian hospital. PLoS One 2019; 14:e0222935. [PMID: 31577806 PMCID: PMC6774517 DOI: 10.1371/journal.pone.0222935] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 09/10/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Approximately 40,000 newborns die each year in Tanzania. Regional differences in outcome are common. Reviewing current local data, as well as defining potential causal pathways leading to death are urgently needed, before targeted interventions can be implemented. OBJECTIVE To describe the clinical characteristics and potential causal pathways contributing to newborn death and determine the presumed causes of newborn mortality within seven days, in a rural hospital setting. METHODS Prospective observational study of admitted newborns born October 2014-July 2017. Information about labour/delivery and newborn management/care were recorded on data collection forms. Causes of deaths were predominantly based on clinical diagnosis. RESULTS 671 were admitted to a neonatal area. Reasons included prematurity n = 213 (32%), respiratory issues n = 209 (31%), meconium stained amniotic fluid with respiratory issues n = 115 (17%) and observation for < 24 hours n = 97 (14%). Death occurred in 124 infants. Presumed causes were birth asphyxia (BA) n = 59 (48%), prematurity n = 19 (15%), presumed sepsis n = 19 (15%), meconium aspiration syndrome (MAS) n = 13 (10%) and congenital abnormalities n = 14 (11%). More newborns who died versus survivors had oxygen saturation <60% on admission (37/113 vs 32/258; p≤0.001) respectively. Moderate hypothermia on admission was common i.e. deaths 35.1 (34.6-36.0) vs survivors 35.5 (35.0-36.0)°C (p≤0.001). Term newborns who died versus survivors were fourfold more likely to have received positive pressure ventilation after birth i.e. 4.57 (1.22-17.03) (p<0.02). CONCLUSION Intrapartum-related complications (BA, MAS), prematurity, and presumed sepsis were the leading causes of death. Intrapartum hypoxia, prematurity and attendant complications and presumed sepsis, are major pathways leading to death. Severe hypoxia and hypothermia upon admission are additional contributing factors. Strategies to identify fetuses at risk during labour e.g. improved fetal heart rate monitoring, coupled with timely interventions, and implementation of WHO interventions for preterm newborns, may reduce mortality in this low resource setting.
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Affiliation(s)
- Robert Moshiro
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Department of Paediatrics and Child Health, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Jeffrey M. Perlman
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, United States of America
| | - Paschal Mdoe
- Department of Obstetrics and Gynecology, Haydom Lutheran Hospital, Manyara, Tanzania
| | - Hussein Kidanto
- School of Medicine, Aga Khan University, Dar es Salaam, Tanzania
- Research Department, Stavanger University Hospital, Stavanger, Norway
| | - Jan Terje Kvaløy
- Research Department, Stavanger University Hospital, Stavanger, Norway
- Department of Mathematics and Physics, University of Stavanger, Stavanger, Norway
| | - Hege L. Ersdal
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
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20
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Mduma E, Kvaløy JT, Soreide E, Svensen E, Mdoe P, Perlman J, Johnson C, Kidanto HL, Ersdal HL. Frequent refresher training on newborn resuscitation and potential impact on perinatal outcome over time in a rural Tanzanian hospital: an observational study. BMJ Open 2019; 9:e030572. [PMID: 31562152 PMCID: PMC6773328 DOI: 10.1136/bmjopen-2019-030572] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Globally, perinatal mortality remains high, especially in sub-Saharan countries, mainly because of inadequate obstetric and newborn care. Helping Babies Breathe (HBB) resuscitation training as part of a continuous quality improvement (CQI) programme may improve outcomes. The aim of this study was to describe observed changes in perinatal survival during a 6-year period, while adjusting for relevant perinatal risk factors. SETTING Delivery rooms and operating theatre in a rural referral hospital in northern-central Tanzania providing comprehensive obstetric and basic newborn care 24 hours a day. The hospital serves approximately 2 million people comprising low social-economic status. PARTICIPANTS All newborns (n=31 122) born in the hospital from February 2010 through January 2017; 4893 were born in the 1-year baseline period (February 2010 through January 2011), 26 229 in the following CQI period. INTERVENTIONS The HBB CQI project, including frequent HBB training, was implemented from February 2011. This is a quality assessment analysis of prospectively collected observational data including patient, process and outcome measures of every delivery. Logistic regression modelling was used to construct risk-adjusted variable life adjusted display (VLAD) and cumulative sum (CUSUM) plots to monitor changes in perinatal survival (primary outcome). RESULTS During the 6-year CQI period, the unadjusted number of extra lives saved according to the VLAD plot was 150 despite more women admitted with pregnancy and labour complications and more caesarean deliveries. After adjusting for these risk factors, the risk-adjusted VLAD plot indicated that an estimated 250 extra lives were saved. The risk-adjusted CUSUM plot confirmed a persistent and steady increase in perinatal survival. CONCLUSIONS The risk-adjusted statistical process control methods indicate significant improvement in perinatal survival after initiation of the HBB CQI project with continuous focus on newborn resuscitation training during the period, despite a concomitant increase in high-risk deliveries. Risk-adjusted VLAD and CUSUM are useful methods to quantify, illustrate and demonstrate persistent changes in outcome over time.
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Affiliation(s)
- Estomih Mduma
- Haydom Lutheran Hospital, Haydom, Tanzania
- Department of Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Jan Terje Kvaløy
- Research, Stavanger University Hospital, Stavanger, Norway
- Department of Mathematics and Physics, University of Stavanger Department of Mathematics and Natural Science, Stavanger, Norway
| | - Eldar Soreide
- Critical Care and Anaesthesiology Research Group, Department of Clinical Medicine, Stavanger University Hospital, Stavanger, Norway
- Faculty of Medicine, University of Bergen, Bergen, Norway
| | | | - Paschal Mdoe
- Haydom Lutheran Hospital, Haydom, Tanzania
- Faculty of Social Science, University of Stavanger, Stavanger, Norway
| | - Jeffrey Perlman
- Pediatrics, Weill Cornell Medical College, New York Presbyterian Hospital, New York City, New York, USA
| | - Caroline Johnson
- Department of Mathematics and Natural Science, University of Stavanger, Stavanger, Norway
| | - Hussein Lessio Kidanto
- School of Medicine, Aga Khan University, Dar es Salaam, Tanzania
- Helse Stavanger HF, Stavanger, Norway
| | - Hege Langli Ersdal
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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21
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PATTERSON JK, AZIZ A, BAUSERMAN MS, MCCLURE EM, GOLDENBERG RL, BOSE CL. Challenges in classification and assignment of causes of stillbirths in low- and lower middle-income countries. Semin Perinatol 2019; 43:308-314. [PMID: 30981473 PMCID: PMC7894980 DOI: 10.1053/j.semperi.2019.03.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Stillbirths account for 2.6 million deaths annually. 98% occur in low- and lower middle-income countries. Accurate classification of stillbirths in low-resource settings is challenged by poor pregnancy dating and infrequent access to electronic heart rate monitoring for both the newborn and fetus. In these settings, liveborn infants may be misclassified as stillbirths, and stillbirths may be misclassified as miscarriages. Causation is available for only 3% of stillbirths globally due to the absence of registration systems. In low-resource settings where culture and autopsy are infrequently available, clinical course is used to assign cause of stillbirth. This method may miss rare or subtle causes, as well as those with non-specific clinical presentations. Verbal autopsy is another technique for assigning cause of stillbirth when objective medical data are limited. This method requires family engagement and physician attribution of cause. As interventions to reduce stillbirths in LMICs are increasingly implemented, attention to accurate classification and assignment of causes of stillbirth are critical to charting progress.
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Affiliation(s)
- Jacquelyn K PATTERSON
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Aleha AZIZ
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Melissa S BAUSERMAN
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Elizabeth M MCCLURE
- Center for Clinical Research Network Coordination, RTI International, Durham, NC
| | - Robert L GOLDENBERG
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Carl L BOSE
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
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22
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Rivenes Lafontan S, Kidanto HL, Ersdal HL, Mbekenga CK, Sundby J. Perceptions and experiences of skilled birth attendants on using a newly developed strap-on electronic fetal heart rate monitor in Tanzania. BMC Pregnancy Childbirth 2019; 19:165. [PMID: 31077139 PMCID: PMC6511185 DOI: 10.1186/s12884-019-2286-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 04/12/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Regular fetal heart rate monitoring during labor can drastically reduce fresh stillbirths and neonatal mortality through early detection and management of fetal distress. Fetal monitoring in low-resource settings is often inadequate. An electronic strap-on fetal heart rate monitor called Moyo was introduced in Tanzania to improve intrapartum fetal heart rate monitoring. There is limited knowledge about how skilled birth attendants in low-resource settings perceive using new technology in routine labor care. This study aimed to explore the attitude and perceptions of skilled birth attendants using Moyo in Dar es Salaam, Tanzania. METHODS A qualitative design was used to collect data. Five focus group discussions and 10 semi-structured in-depth interviews were carried out. In total, 28 medical doctors and nurse/midwives participated in the study. The data was analyzed using qualitative content analysis. RESULTS The participants in the study perceived that the device was a useful tool that made it possible to monitor several laboring women at the same time and to react faster to fetal distress alerts. It was also perceived to improve the care provided to the laboring women. Prior to the introduction of Moyo, the participants described feeling overwhelmed by the high workload, an inability to adequately monitor each laboring woman, and a fear of being blamed for negative fetal outcomes. Challenges related to use of the device included a lack of adherence to routines for use, a lack of clarity about which laboring women should be monitored continuously with the device, and misidentification of maternal heart rate as fetal heart rate. CONCLUSION The electronic strap-on fetal heart rate monitor, Moyo, was considered to make labor monitoring easier and to reduce stress. The study findings highlight the importance of ensuring that the device's functions, its limitations and its procedures for use are well understood by users.
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Affiliation(s)
- Sara Rivenes Lafontan
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Forskningsveien 3A, 0373 Oslo, Norway
| | - Hussein L. Kidanto
- Medical College, East Africa, Aga Khan University, Dar es Salaam, Tanzania
- Department of Research, Stavanger University Hospital, Postboks 8100, 4068 Stavanger, Norway
| | - Hege L. Ersdal
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Postboks 8100, 4068 Stavanger, Norway
- Faculty of Health Sciences, University of Stavanger, 4036 Stavanger, Norway
| | - Columba K. Mbekenga
- School of Nursing and Midwifery, Aga Khan University, Dar es Salaam, Tanzania
| | - Johanne Sundby
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Forskningsveien 3A, 0373 Oslo, Norway
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23
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Kamala B, Kidanto H, Dalen I, Ngarina M, Abeid M, Perlman J, Ersdal H. Effectiveness of a Novel Continuous Doppler (Moyo) Versus Intermittent Doppler in Intrapartum Detection of Abnormal Foetal Heart Rate: A Randomised Controlled Study in Tanzania. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E315. [PMID: 30678354 PMCID: PMC6388236 DOI: 10.3390/ijerph16030315] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/22/2019] [Accepted: 01/22/2019] [Indexed: 01/25/2023]
Abstract
Background: Intrapartum foetal heart rate (FHR) monitoring is crucial for identification of hypoxic foetuses and subsequent interventions. We compared continuous monitoring using a novel nine-crystal FHR monitor (Moyo) versus intermittent single crystal Doppler (Doppler) for the detection of abnormal FHR. Methods: An unmasked randomised controlled study was conducted in a tertiary hospital in Tanzania (ClinicalTrials.gov Identifier: NCT02790554). A total of 2973 low-risk singleton pregnant women in the first stage of labour admitted with normal FHR were randomised to either Moyo (n = 1479) or Doppler (1494) arms. The primary outcome was the proportion of abnormal FHR detection. Secondary outcomes were time intervals in labour, delivery mode, Apgar scores, and perinatal outcomes. Results: Moyo detected abnormal FHR more often (13.3%) compared to Doppler (9.8%) (p = 0.002). Time intervals from admission to detection of abnormal FHR were 15% shorter in Moyo (p = 0.12) and from the detection of abnormal FHR to delivery was 36% longer in Moyo (p = 0.007) compared to the Doppler arm. Time from last FHR to delivery was 12% shorter with Moyo (p = 0.006) compared to Doppler. Caesarean section rates were higher with the Moyo device compared to Doppler (p = 0.001). Low Apgar scores (<7) at the 1st and 5th min were comparable between groups (p = 0.555 and p = 0.800). Perinatal outcomes (fresh stillbirths and 24-h neonatal deaths) were comparable at delivery (p = 0.497) and 24-h post-delivery (p = 0.345). Conclusions: Abnormal FHR detection rates were higher with Moyo compared to Doppler. Moyo detected abnormal FHR earlier than Doppler, but time from detection to delivery was longer. Studies powered to detect differences in perinatal outcomes with timely responses are recommended.
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Affiliation(s)
- Benjamin Kamala
- Faculty of Health Sciences, University of Stavanger, 4036 Stavanger, Norway.
- Muhimbili National Hospital, P.O. Box 65000, Dar es Salaam, Tanzania.
| | - Hussein Kidanto
- Department of Research, Stavanger University Hospital, 4011 Stavanger, Norway.
- School of Medicine, Aga Khan University, P.O. Box 38129, Dar es Salaam, Tanzania.
| | - Ingvild Dalen
- Department of Research, Stavanger University Hospital, 4011 Stavanger, Norway.
| | - Matilda Ngarina
- Muhimbili National Hospital, P.O. Box 65000, Dar es Salaam, Tanzania.
| | - Muzdalifat Abeid
- School of Medicine, Aga Khan University, P.O. Box 38129, Dar es Salaam, Tanzania.
| | - Jeffrey Perlman
- Department of Paediatrics, Weill Cornell Medicine, New York, NY 10065, USA.
| | - Hege Ersdal
- Faculty of Health Sciences, University of Stavanger, 4036 Stavanger, Norway.
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, 4011 Stavanger, Norway.
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Acquiring Knowledge about the Use of a Newly Developed Electronic Fetal Heart Rate Monitor: A Qualitative Study Among Birth Attendants in Tanzania. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15122863. [PMID: 30558180 PMCID: PMC6313598 DOI: 10.3390/ijerph15122863] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 12/10/2018] [Accepted: 12/12/2018] [Indexed: 01/09/2023]
Abstract
In an effort to reduce newborn mortality, a newly developed strap-on electronic fetal heart rate monitor was introduced at several health facilities in Tanzania in 2015. Training sessions were organized to teach staff how to use the device in clinical settings. This study explores skilled birth attendants’ perceptions and experiences acquiring and transferring knowledge about the use of the monitor, also called Moyo. Knowledge about this learning process is crucial to further improve training programs and ensure correct, long-term use. Five Focus group discussions (FGDs) were carried out with doctors and nurse-midwives, who were using the monitor in the labor ward at two health facilities in Tanzania. The FGDs were analyzed using qualitative content analysis. The study revealed that the participants experienced the training about the device as useful but inadequate. Due to high turnover, a frequently mentioned challenge was that many of the birth attendants who were responsible for training others, were no longer working in the labor ward. Many participants expressed a need for refresher trainings, more practical exercises and more theory on labor management. The study highlights the need for frequent trainings sessions over time with focus on increasing overall knowledge in labor management to ensure correct use of the monitor over time.
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Kamala BA, Ersdal HL, Dalen I, Abeid MS, Ngarina MM, Perlman JM, Kidanto HL. Implementation of a novel continuous fetal Doppler (Moyo) improves quality of intrapartum fetal heart rate monitoring in a resource-limited tertiary hospital in Tanzania: An observational study. PLoS One 2018; 13:e0205698. [PMID: 30308040 PMCID: PMC6181403 DOI: 10.1371/journal.pone.0205698] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 09/28/2018] [Indexed: 01/04/2023] Open
Abstract
Background Intrapartum Fetal Heart Rate (FHR) monitoring is crucial for the early detection of abnormal FHR, facilitating timely obstetric interventions and thus the potential reduction of adverse perinatal outcomes. We explored midwifery practices of intrapartum FHR monitoring pre and post implementation of a novel continuous automatic Doppler device (the Moyo). Methodology A pre/post observational study among low-risk pregnancies at a tertiary hospital was conducted from March to December 2016. In the pre-implementation period, intermittent monitoring was conducted with a Pinard stethoscope (March to June 2016, n = 1640 women). In the post-implementation period, Moyo was used for continuous FHR monitoring (July-December 2016, n = 2442 women). The primary outcome was detection of abnormal FHR defined as absent, FHR<120or FHR>160bpm. The secondary outcomes were rates of assessment/documentation of FHR, obstetric time intervals and intrauterine resuscitations. Chi-square test, Fishers exact test, t-test and Mann-Whitney U test were used in bivariate analysis whereas binary and multinomial logistic regression were used for multivariate. Results Moyo use was associated with greater detection of abnormal FHR (8.0%) compared with Pinard (1.6%) (p<0.001). There were higher rates of non-assessment/documentation of FHR pre- (45.7%) compared to post-implementation (2.2%) (p<0.001). At pre-implementation, 8% of deliveries had FHR documented as often as ≤ 60 minutes, compared to 51% post-implementation (p<0.001). Implementation of continuous FHR monitoring was associated with a shorter time interval from the last FHR assessment to delivery i.e. median (IQR) of 60 (30,100) to 45 (21,85) minutes (p<0.001); and shorter time interval between each FHR assessment i.e. from 150 (86,299) minutes to 60 (41,86) minutes (p<0.001). Caesarean section rates increased from 2.6 to 5.4%, and vacuum deliveries from 2.2 to 5.8% (both p<0.001). Perinatal outcomes i.e. fresh stillbirths and early neonatal deaths were similar between time periods. The study was limited by both lack of randomization and involvement of low-risk pregnant women with fewer adverse perinatal outcomes than would be expected in a high-risk population. Conclusion Implementation of the Moyo device, which continuously measures FHR, was associated with improved quality in FHR monitoring practices and the detection of abnormal FHR. These improvements led to more frequent and timely obstetric responses. Follow-up studies in a high-risk population focused on a more targeted description of the FHR abnormalities and the impact of intrauterine resuscitation is a critical next step in determining the effect on reducing perinatal mortality.
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Affiliation(s)
- Benjamin A. Kamala
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Department of Obstetrics and Gynecology, Muhimbili National Hospital, Dar es Salaam, Tanzania
- * E-mail: ,
| | - Hege L. Ersdal
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Ingvild Dalen
- Department of Research, Stavanger University Hospital, Stavanger, Norway
| | - Muzdalifat S. Abeid
- Department of Obstetrics and Gynecology, Temeke Regional Referral Hospital, Dar es Salaam, Tanzania
- School of Medicine, Aga Khan University, Dar es Salaam, Tanzania
| | - Matilda M. Ngarina
- Department of Obstetrics and Gynecology, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Jeffrey M. Perlman
- Department of Pediatrics, Weill Medical College, New York, New York, United States of America
| | - Hussein L. Kidanto
- Department of Obstetrics and Gynecology, Muhimbili National Hospital, Dar es Salaam, Tanzania
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
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26
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Moshiro R, Perlman JM, Kidanto H, Kvaløy JT, Mdoe P, Ersdal HL. Predictors of death including quality of positive pressure ventilation during newborn resuscitation and the relationship to outcome at seven days in a rural Tanzanian hospital. PLoS One 2018; 13:e0202641. [PMID: 30118519 PMCID: PMC6097682 DOI: 10.1371/journal.pone.0202641] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 08/07/2018] [Indexed: 11/29/2022] Open
Abstract
Background Effective positive pressure ventilation (PPV) of non-breathing newborns is crucial in facilitating cardio-respiratory adaptation at birth. Identifying predictors of death in newborns receiving PPV is important in order to facilitate preventative strategies. Objective The objective of this study was to determine the perinatal predictors of death including the quality of PPV administered among admitted newborns. Methods An observational study of admitted newborns who received PPV after birth was conducted. Research assistants observed all deliveries and recorded perinatal events on data collection forms. Measured heart rate (HR) and ventilation parameters were then compared between newborns who died and survivors. Results Newborns (n = 232) were studied between October 2014 and November 2016. Newborns who died (n = 53) compared to survivors (n = 179) had more fetal heart rate (FHRT) abnormalities (12/53 vs 19/179; p = 0.03); lower initial HR (<100 beats/minute) at start of PPV (44/48 vs 77/139; p<0.001); and a longer time for HR to increase >100 beats/minute from birth (180 vs 149 seconds; p = 0.07). Newborns who died compared to survivors took longer time (14 vs 4 seconds; p = 0.008) and more inflations (7 vs 3; p = 0.006) to achieve an expired volume (Vt) of 6 ml/kg, respectively. Median delivered Vt during the first 60 seconds of PPV was less in newborns who died compared to survivors (5 vs 6 ml/kg; p = 0.12). Newborns who died proceeded to severe encephalopathy (15/31 vs 1/59; p<0.001) compared to survivors. Conclusion Depressed newborns who proceeded to death compared to survivors, exhibited delayed HR response to PPV which may partly reflect FHRT abnormalities related to interruption of placental blood flow, and/or a timely delay in establishing adequate Vt. Depressed newborns progressed to moderate/severe encephalopathy. Improving FHRT monitoring to identify fetuses at risk for expedited delivery, coupled with optimizing delivery room PPV might decrease mortality in this setting.
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Affiliation(s)
- Robert Moshiro
- Department of Paediatrics and Child Health, Muhimbili National Hospital, Dar es Salaam, Tanzania
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- * E-mail:
| | - Jeffrey M. Perlman
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, United States of America
| | - Hussein Kidanto
- School of Medicine, Aga Khan University, Dar es Salaam, Tanzania
- Research Department, Stavanger University Hospital, Stavanger, Norway
| | - Jan Terje Kvaløy
- Department of Mathematics and Physics, University of Stavanger, Stavanger, Norway
- Research Department, Stavanger University Hospital, Stavanger, Norway
| | - Paschal Mdoe
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Department of Obstetrics and Gynecology, Haydom Lutheran Hospital, Manyara, Tanzania
| | - Hege L. Ersdal
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
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