Not Crying After Birth as a Predictor of Not Breathing

Facilitators and barriers for implementation of a novel resuscitation quality improvement package in public referral hospitals of Nepal

BACKGROUND

Improving the healthcare providers (HCP) basic resuscitation skills can reduce intrapartum related mortality in low- and middle-income countries. However, the resuscitation intervention's successful implementation is largely dependent on proper facilitation and context. This study aims to identify the facilitators and barriers for the implementation of a novel resuscitation package as part of the quality improvement project in Nepal.

METHODS

The study used a qualitative descriptive design. The study sites included four purposively chosen public hospitals in Nepal, where the resuscitation package (Helping Babies Breathe [HBB] training, resuscitation equipment and NeoBeat) had been implemented as part of the quality improvement project. Twenty members of the HCP, who were trained and exposed to the package, were selected through convenience sampling to participate in the study interviews. Data were collected through semi-structured interviews conducted via telephone and video calls. Twenty interview data were analyzed with a deductive qualitative content analysis based on the core components of the i-PARiHS framework.

RESULTS

The findings suggest that there was a move to more systematic resuscitation practices among the staff after the quality improvement project's implementation. This positive change was supported by a neonatal heart rate monitor (NeoBeat), which guided resuscitation and made it easier. In addition, seeing the positive outcomes of successful resuscitation motivated the HCPs to keep practicing and developing their resuscitation skills. Facilitation by the project staff enabled the change. At the same time, facilitators provided extra support to maintain the equipment, which can be a challenge in terms of sustainability, after the project. Furthermore, a lack of additional resources, an unclear leadership role, and a lack of coordination between nurses and medical doctors were barriers to the implementation of the resuscitation package.

CONCLUSION

The introduction of the resuscitation package, as well as the continuous capacity building of local multidisciplinary healthcare staff, is important to continue the accelerated efforts of improving newborn care. To secure sustainable change, facilitation during implementation should focus on exploring local resources to implement the resuscitation package sustainably.

TRIAL REGISTRATION

Not applicable.

Spontaneous behaviors during breast crawling and factors influencing self-locating mothers' breasts in newborns: A cross-sectional study

Breast crawling in newborns to propel themselves to their mothers' breasts normally occurs upon skin-to-skin contact with mothers immediately after birth but is often missed by the neglect of hospital staff and insufficient evidence support. Hence, this study described the behavioral characteristics of 135 newborns from China during breast crawling and further explored the factors influencing newborns' self-locating mothers' breasts (measured by whether fail to experience the familiarization stage, initial time and duration of the familiarization stage) using multivariable analysis. The findings supported and extended previous studies that newborns could emerge in nine instinctive stages and corresponding spontaneous behaviors early in life. Moreover, abnormal fetal heart rate during labor appeared to interfere with newborns experiencing the familiarization stage (aOR = 9.27, 95% CI: 1.41 to 61.07, P = 0.021), while using synthetic oxytocin (β = 5.94, 95% CI: 0.35 to 11.54, P = 0.037), using antibiotics (β = 11.09, 95% CI: 4.11 to 18.07, P = 0.002), and newborns' gender (β = -5.69, 95% CI: 11.26 to -0.12, P = 0.045) would alter the initial time of the familiarization stage. Finally, this study proposes evidence-based strategies to prevent abnormal fetal heart rates and improve medication use.

Observational study comparing heart rate in crying and non-crying but breathing infants at birth

BACKGROUND

Stimulating infants to elicit a cry at birth is common but could result in unnecessary handling. We evaluated heart rate in infants who were crying versus non-crying but breathing immediately after birth.

METHODS

This was single-centre observational study of singleton, vaginally born infants at ≥33 weeks of gestation. Infants who were crying or non-crying but breathing within 30 s after birth were included. Background demographic data and delivery room events were recorded using tablet-based applications and synchronised with continuous heart rate data recorded by a dry-electrode electrocardiographic monitor. Heart rate centile curves for the first 3 min of life were generated with piecewise regression analysis. Odds of bradycardia and tachycardia were compared using multiple logistic regression.

RESULTS

1155 crying and 54 non-crying but breathing neonates were included in the final analyses. There were no significant differences in the demographic and obstetric factors between the cohorts. Non-crying but breathing infants had higher rates of early cord clamping <60 s after birth (75.9% vs 46.5%) and admission to the neonatal intensive care unit (13.0% vs 4.3%). There were no significant differences in median heart rates between the cohorts. Non-crying but breathing infants had higher odds of bradycardia (heart rate <100 beats/min, adjusted OR 2.64, 95% CI 1.34 to 5.17) and tachycardia (heart rate ≥200 beats/min, adjusted OR 2.86, 95% CI 1.50 to 5.47).

CONCLUSION

Infants who are quietly breathing but do not cry after birth have an increased risk of both bradycardia and tachycardia, and admission to the neonatal intensive care unit.

TRIAL REGISTRATION NUMBER

ISRCTN18148368.

Usability, acceptability and feasibility of a novel technology with visual guidance with video and audio recording during newborn resuscitation: a pilot study

OBJECTIVE

Inadequate adherence to resuscitation for non-crying infants will have poor outcome and thus rationalise a need for real-time guidance and quality improvement technology. This study assessed the usability, feasibility and acceptability of a novel technology of real-time visual guidance, with sound and video recording during resuscitation.

SETTING

A public hospital in Nepal.

DESIGN

A cross-sectional design.

INTERVENTION

The technology has an infant warmer with light, equipped with a tablet monitor, NeoBeat and upright bag and mask. The tablet records resuscitation activities, ventilation sound, heart rate and display time since birth. Healthcare providers (HCPs) were trained on the technology before piloting.

DATA COLLECTION AND ANALYSIS

HCPs who had at least 8 weeks of experience using the technology completed a questionnaire on usability, feasibility and acceptability (ranged 1-5 scale). Overall usability score was calculated (ranged 1-100 scale).

RESULTS

Among the 30 HCPs, 25 consented to the study. The usability score was good with the mean score (SD) of 68.4% (10.4). In terms of feasibility, the participants perceived that they did not receive adequate support from the hospital administration for use of the technology, mean score (SD) of 2.44 (1.56). In terms of acceptability, the information provided in the monitor, that is, time elapsed from birth was easy to understand with mean score (SD) of 4.60 (0.76).

CONCLUSION

The study demonstrates reasonable usability, feasibility and acceptability of a technological solution that records audio visual events during resuscitation and provides visual guidance to improve care.

Adapted Helping Babies Breathe approach to neonatal resuscitation in Haiti: a retrospective cohort study

Background

Helping Babies Breathe (HBB) is an American Academy of Pediatrics neonatal resuscitation program designed to reduce neonatal mortality in low resource settings. The 2017 neonatal mortality rate in Haiti was 28 per 1000 live births and an estimated 85 % of Haitian women deliver at home. Given this, the Community Health Initiative implemented an adapted HBB (aHBB) in Haiti to evaluate neonatal mortality.

Methods

Community Health Workers taught an aHBB program to laypeople, which didn’t include bag-valve-mask ventilation. Follow-up after delivery assessed for maternal and neonatal mortality and health.

Results

Analysis included 536 births of which 84.3 % (n=452) were attended by someone trained in aHBB. The odds of neonatal mortality was not significantly different among the two groups (aOR=0.48 [0.16-1.44]). Composite outcome of neonatal health as reported by the mother (subjective morbidity and mortality) was significantly lower in aHBB attended births (aOR=0.31 [0.14-0.70]).

Conclusion

This analysis of the aHBB program indicates that community training to laypersons in low resource settings may reduce neonatal ill-health but not neonatal mortality. This study is likely underpowered to find a difference in neonatal mortality. Further work is needed to evaluate which components of the aHBB program are instrumental in improving neonatal health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02987-4.

Dynamics of cortical oxygenation during immediate adaptation to extrauterine life

The neonatal transition involves physiological modifications as a consequence of the complexity of the perinatal period. Various strategies can be used to attain the same level of postnatal cerebral oxygenation, depending on the status of the infant at birth. We evaluated such strategies by recording 20 full-term newborns by near-infrared spectroscopy during the first 10 min of life. The acid–base status at birth revealed two clustered profiles of cerebral oxygenation dynamics. Lower pH and base excess and higher lactate levels were associated with more rapid attainment of the 95% maximal tissue oxygenation index value. These results suggest that metabolic mechanisms drive initial cerebral oxygenation dynamics during this critical period. These results confirm the capacity of newborns to develop multiple strategies to protect the brain.

Predictors for timely initiation of breastfeeding after birth in the hospitals of Nepal- a prospective observational study

Background

Timely initiation of breastfeeding can reduce neonatal morbidities and mortality. We aimed to study predictors for timely initiation of breastfeeding (within 1 h of birth) among neonates born in hospitals of Nepal.

Method

A prospective observational study was conducted in four public hospitals between July and October 2018. All women admitted in the hospital for childbirth and who consented were included in the study. An independent researchers observed whether the neonates were placed in skin-to-skin contact, delay cord clamping and timely initiation of breastfeeding. Sociodemographic variables, obstetric and neonate information were extracted from the maternity register. We analysed predictors for timely initiation of breastfeeding with Pearson chi-square test and multivariate logistic regression.

Results

Among the 6488 woman-infant pair observed, breastfeeding was timely initiated in 49.5% neonates. The timely initiation of breastfeeding was found to be higher among neonates who were placed skin-to-skin contact (34.9% vs 19.9%, p - value < 0.001). The timely initiation of breastfeeding was higher if the cord clamping was delayed than early cord clamped neonates (44.5% vs 35.3%, p - value < 0.001). In multivariate analysis, a mother with no obstetric complication during admission had 57% higher odds of timely initiation of breastfeeding (aOR 1.57; 95% CI 1.33, 1.86). Multiparity was associated with less timely initiation of breastfeeding (aOR 1.56; 95% CI 1.35, 1.82). Similarly, there was more common practice of timely initiation of breastfeeding among low birthweight neonates (aOR 1.46; 95% CI 1.21, 1.76). Neonates who were placed skin-to-skin contact with mother had more than two-fold higher odds of timely breastfeeding (aOR 2.52; 95% CI 2.19, 2.89). Likewise, neonates who had their cord intact for 3 min had 37% higher odds of timely breastfeeding (aOR 1.37; 95% CI 1.21, 1.55).

Conclusions

The rate of timely initiation of breastfeeding practice is low in the health facilities of Nepal. Multiparity, no obstetric complication at admission, neonates placed in skin-to-skin contact and delay cord clamping were strong predictors for timely initiation of breastfeeding. Quality improvement intervention can improve skin-to-skin contact, delayed cord clamping and timely initiation of breastfeeding.

A multicenter study of incidence, risk factors and outcomes of babies with birth asphyxia in Nepal

Background

Perinatal events which result in compromised oxygen delivery to the fetus can lead to Birth Asphyxia (BA). While the incidence, risk factors and outcomes of BA have been characterized, less is known in low resource settings.

Aim

To determine the incidence of Birth Asphyxia (BA) in Nepal and to evaluate associated risk factors and outcomes of this condition.

Methods

A nested observational study was conducted in 12 hospitals of Nepal for a period of 14 months. Babies diagnosed as BA at ≥37 weeks of gestation were identified and demographics were reviewed. Data were analyzed using binary logistic regression followed by multiple logistic regression analysis.

Results

The incidence of BA in this study was 6 per 1000 term livebirths and was higher among women 35 years and above. Predictors for BA were instrumented vaginal delivery (aOR:4.4, 95% CI, 3.1–6.1), fetal distress in labour (aOR:1.9, 95% CI, 1.0–3.6), malposition (aOR:1.8, 95% CI, 1.0–3.0), birth weight less than 2500 g (aOR:2.0, 95% CI, 1.3–2.9), gestational age ≥ 42 weeks (aOR:2.0, 95% CI, 1.3–3.3) and male gender (aOR:1.6, 95% CI, 1.2–2.0). The risk of pre-discharge mortality was 43 times higher in babies with BA (aOR:42.6, 95% CI, 32.2–56.3).

Conclusion

The incidence of Birth asphyxia in Nepal higher than in more resourced setting. A range of obstetric and neonatal risk factors are associated with BA with an associated high risk of pre-discharge mortality. Interventions to improve management and decrease rates of BA could have marked impact on outcomes in low resource settings.

Back rubs or foot flicks for neonatal stimulation at birth in a low-resource setting: A randomized controlled trial

BACKGROUND

Approximately 15% of infants require stimulation in low-resource settings, but data on effectiveness of different stimulation approaches are limited. We aimed to compare two recommended approaches of stimulation (back rubs vs. foot flicks) in reducing the need for face-mask ventilation in newly born infants who were not crying immediately after birth in a low-resource setting.

METHODS

A single center, open-label, randomized, superiority trial was conducted at St. Kizito Hospital in Matany (Uganda) between November 2019 and May 2020. Newly born infants with expected birthweight > 1500 grams who were not crying immediately after birth were randomly assigned to stimulation using back rubs or foot flicks. The primary outcome measure was the success rate of the stimulation, defined as the achievement of an effective crying preventing the need for face-mask ventilation.

RESULTS

Success of stimulation was achieved in 76/93 neonates (82%) using back rubs and 68/93 neonates (73%) using foot flicks (risk ratio 1.12, 95% confidence interval 0.96-1.31). No procedure-associated complications arose during the study. Time to first cry was not statistically different between the two arms (mean difference -11 seconds, 95% confidence interval -39 to 18).

CONCLUSIONS

In newly born infants who were not crying immediately after birth, this trial did not provide a conclusive message in favor of back rubs or foot flicks. Nonetheless, we could not exclude a possible benefit of back rubs in avoiding the need for positive pressure ventilation and, possibly, further advanced resuscitative maneuvers.

CLINICAL TRIALS REGISTRATION

clinicalTrial.gov: NCT04056091.

Performance of health workers on neonatal resuscitation care following scaled-up quality improvement interventions in public hospitals of Nepal - a prospective observational study

BACKGROUND

High-quality resuscitation among non-crying babies immediately after birth can reduce intrapartum-related deaths and morbidity. Helping Babies Breathe program aims to improve performance on neonatal resuscitation care in resource-limited settings. Quality improvement (QI) interventions can sustain simulated neonatal resuscitation knowledge and skills and clinical performance. This study aimed to evaluate the effect of a scaled-up QI intervention package on the performance of health workers on basic neonatal resuscitation care among non-crying infants in public hospitals in Nepal.

METHODS

A prospective observational cohort design was applied in four public hospitals of Nepal. Performances of health workers on basic neonatal care were analysed before and after the introduction of the QI interventions.

RESULTS

Out of the total 32,524 births observed during the study period, 3031 newborn infants were not crying at birth. A lower proportion of non-crying infants were given additional stimulation during the intervention compared to control (aOR 0.18; 95% CI 0.13-0.26). The proportion of clearing the airway increased among non-crying infants after the introduction of QI interventions (aOR 1.23; 95% CI 1.03-1.46). The proportion of non-crying infants who were initiated on BMV was higher during the intervention period (aOR 1.28, 95% CI 1.04-1.57) compared to control. The cumulative median time to initiate ventilation during the intervention was 39.46 s less compared to the baseline.

CONCLUSION

QI intervention package improved health workers' performance on the initiation of BMV, and clearing the airway. The average time to first ventilation decreased after the implementation of the package. The QI package can be scaled-up in other public hospitals in Nepal and other similar settings.

Survey of women's report for 33 maternal and newborn indicators: EN-BIRTH multi-country validation study

BACKGROUND

Population-based household surveys, notably the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), remain the main source of maternal and newborn health data for many low- and middle-income countries. As part of the Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study, this paper focuses on testing validity of measurement of maternal and newborn indicators around the time of birth (intrapartum and postnatal) in survey-report.

METHODS

EN-BIRTH was an observational study testing the validity of measurement for selected maternal and newborn indicators in five secondary/tertiary hospitals in Bangladesh, Nepal and Tanzania, conducted from July 2017 to July 2018. We compared women's report at exit survey with the gold standard of direct observation or verification from clinical records for women with vaginal births. Population-level validity was assessed by validity ratios (survey-reported coverage: observer-assessed coverage). Individual-level accuracy was assessed by sensitivity, specificity and percent agreement. We tested indicators already in DHS/MICS as well as indicators with potential to be included in population-based surveys, notably the first validation for small and sick newborn care indicators.

RESULTS

33 maternal and newborn indicators were evaluated. Amongst nine indicators already present in DHS/MICS, validity ratios for baby dried or wiped, birthweight measured, low birthweight, and sex of baby (female) were between 0.90-1.10. Instrumental birth, skin-to-skin contact, and early initiation of breastfeeding were highly overestimated by survey-report (2.04-4.83) while umbilical cord care indicators were massively underestimated (0.14-0.22). Amongst 24 indicators not currently in DHS/MICS, two newborn contact indicators (kangaroo mother care 1.00, admission to neonatal unit 1.01) had high survey-reported coverage amongst admitted newborns and high sensitivity. The remaining indicators did not perform well and some had very high "don't know" responses.

CONCLUSIONS

Our study revealed low validity for collecting many maternal and newborn indicators through an exit survey instrument, even with short recall periods among women with vaginal births. Household surveys are already at risk of overload, and some specific clinical care indicators do not perform well and may be under-powered. Given that approximately 80% of births worldwide occur in facilities, routine registers should also be explored to track coverage of key maternal and newborn health interventions, particularly for clinical care.

Neonatal resuscitation: EN-BIRTH multi-country validation study

BACKGROUND

Annually, 14 million newborns require stimulation to initiate breathing at birth and 6 million require bag-mask-ventilation (BMV). Many countries have invested in facility-based neonatal resuscitation equipment and training. However, there is no consistent tracking for neonatal resuscitation coverage.

METHODS

The EN-BIRTH study, in five hospitals in Bangladesh, Nepal, and Tanzania (2017-2018), collected time-stamped data for care around birth, including neonatal resuscitation. Researchers surveyed women and extracted data from routine labour ward registers. To assess accuracy, we compared gold standard observed coverage to survey-reported and register-recorded coverage, using absolute difference, validity ratios, and individual-level validation metrics (sensitivity, specificity, percent agreement). We analysed two resuscitation numerators (stimulation, BMV) and three denominators (live births and fresh stillbirths, non-crying, non-breathing). We also examined timeliness of BMV. Qualitative data were collected from health workers and data collectors regarding barriers and enablers to routine recording of resuscitation.

RESULTS

Among 22,752 observed births, 5330 (23.4%) babies did not cry and 3860 (17.0%) did not breathe in the first minute after birth. 16.2% (n = 3688) of babies were stimulated and 4.4% (n = 998) received BMV. Survey-report underestimated coverage of stimulation and BMV. Four of five labour ward registers captured resuscitation numerators. Stimulation had variable accuracy (sensitivity 7.5-40.8%, specificity 66.8-99.5%), BMV accuracy was higher (sensitivity 12.4-48.4%, specificity > 93%), with small absolute differences between observed and recorded BMV. Accuracy did not vary by denominator option. < 1% of BMV was initiated within 1 min of birth. Enablers to register recording included training and data use while barriers included register design, documentation burden, and time pressure.

CONCLUSIONS

Population-based surveys are unlikely to be useful for measuring resuscitation coverage given low validity of exit-survey report. Routine labour ward registers have potential to accurately capture BMV as the numerator. Measuring the true denominator for clinical need is complex; newborns may require BMV if breathing ineffectively or experiencing apnoea after initial drying/stimulation or subsequently at any time. Further denominator research is required to evaluate non-crying as a potential alternative in the context of respectful care. Measuring quality gaps, notably timely provision of resuscitation, is crucial for programme improvement and impact, but unlikely to be feasible in routine systems, requiring audits and special studies.

Mistreatment of newborns after childbirth in health facilities in Nepal: Results from a prospective cohort observational study

BACKGROUND

Patient experience of care reflects the quality of health care in health facilities. While there are multiple studies documenting abuse and disrespect to women during childbirth, there is limited evidence on the mistreatment of newborns immediately after childbirth. This paper addresses the evidence gap by assessing the prevalence and risk factors associated with mistreatment of newborns after childbirth in Nepal, based on a large-scale observational study.

METHODS AND FINDINGS

This is a prospective observational cohort study conducted over a period of 18 months in 4 public referral hospitals in Nepal. All newborns born at the facilities during the study period, who breathed spontaneously and were observed, were included. A set of indicators to measure mistreatment for newborns was analysed. Principal component analysis was used to construct a single newborn mistreatment index. Uni-variate, multi-variate, and multi-level analysis was done to measure the association between the newborn mistreatment index and demographic, obstetric, and neonatal characteristics. A total of 31,804 births of newborns who spontaneously breathed were included. Among the included newborns, 63.0% (95% CI, 62.5-63.5) received medical interventions without taking consent from the parents, 25.0% (95% CI, 24.5-25.5) were not treated with kindness and respect (roughly handled), and 21.4% (95% CI, 20.9-21.8) of them were suctioned with no medical need. Among the newborns, 71.7% (95% CI, 71.2-72.3) had the cord clamped within 1 minute and 77.6% (95% CI, 77.1-78.1) were not breast fed within 1 hour of birth. Only 3.5% (95% CI, 3.2-3.8) were kept in skin to skin contact in the delivery room after birth. The mistreatment index showed maximum variation in mistreatment among those infants born to women of relatively disadvantaged ethnic groups and infants born to women with 2 or previous births. After adjusting for hospital heterogeneity, infants born to women aged 30-34 years (β, -0.041; p value, 0.01) and infants born to women aged 35 years or more (β, -0.064; p value, 0.029) were less mistreated in reference to infants born to women aged 18 years or less. Infants born to women from the relatively disadvantaged (chhetri) ethnic groups (β, 0.077; p value, 0.000) were more likely to be mistreated than the infants born to relatively advantaged (brahmin) ethnic groups. Female newborns (β, 0.016; p value, 0.015) were more likely to be mistreated than male newborns.

CONCLUSIONS

The mistreatment of spontaneously breathing newborns is high in public hospitals in Nepal. Mistreatment varied by hospital, maternal ethnicity, maternal age, and sex of the newborn. Reducing mistreatment of newborns will require interventions at policy, health system, and individual level. Further, implementation studies will be required to identify effective interventions to reduce inequity and mistreatment of newborns at birth.

[Newborn resuscitation and support of transition of infants at birth]

The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.

Impact of stimulation among non-crying neonates with intact cord versus clamped cord on birth outcomes: observation study

BACKGROUND

Stimulation of non-crying neonates after birth can help transition to spontaneous breathing. In this study, we aim to assess the impact of intact versus clamped umbilical cord on spontaneous breathing after stimulation of non-crying neonates.

METHODS

This is an observational study among non-crying neonates (n=3073) born in hospitals of Nepal. Non-crying neonates born vaginally at gestational age ≥34 weeks were observed for their response to stimulation with the cord intact or clamped. Obstetric characteristics of the neonates were analysed. Association of spontaneous breathing with cord management was assessed using logistic regression.

RESULTS

Among non-crying neonates, 2563 received stimulation. Of these, a higher proportion of the neonates were breathing in the group with cord intact as compared with the group cord clamped (81.1% vs 68.9%, p<0.0001). The use of bag-and-mask ventilation was lower among those who were stimulated with the cord intact than those who were stimulated with cord clamped (18.0% vs 32.4%, p<0.0001). The proportion of neonates with Apgar Score ≤3 at 1 min was lower with the cord intact than with cord clamped (7.6% vs 11.5%, p=0.001). In multivariate analysis, neonates with intact cord had 84% increased odds of spontaneous breathing (adjusted OR, 1.84; 95% CI: 1.48 to 2.29) compared with those with cord clamped.

CONCLUSIONS

Stimulation of non-crying neonates with intact cord was associated with more spontaneous breathing than among infants who were stimulated with cord clamped. Intact cord stimulation may help establish spontaneous breathing in apnoeic neonates, but residual confounding variables may be contributing to the findings. This study provides evidence for further controlled research to evaluate the effect of initial steps of resuscitation with cord intact.