Reducing Perinatal Mortality in Nepal Using Helping Babies Breathe

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

The intrapartum stillbirth rate decreased from 9.0 to 3.2 per thousand deliveries, and first-day mortality from 5.2 to 1.9 per thousand live births after intervention, demonstrating a reduction of approximately half in the odds of intrapartum stillbirth (adjusted odds ratio [OR] 0.46, 95% confidence interval [CI] 0.32-0.66) and first-day mortality (adjusted OR 0.51, 95% CI 0.31-0.83). After intervention, the odds of inappropriate use of suction and stimulation decreased by 87% (OR 0.13, 95% CI 0.09-0.17) and 62% (OR 0.38, 95% CI 0.29-0.49), respectively. Before intervention, none of the infants received bag-and-mask ventilation within 1 minute of birth, compared with 83.9% of infants after.

CONCLUSIONS

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

Risk factors for antepartum stillbirth: a case-control study in Nepal

Background

Globally, at least 2.65 million stillbirths occur every year, of which more than half are during the antepartum period. The proportion of intrapartum stillbirths has substantially declined with improved obstetric care; however, the number of antepartum stillbirths has not decreased as greatly. Attempts to lower this number may be hampered by an incomplete understanding of the risk factors leading to the majority of antepartum stillbirths. We conducted this study in a tertiary hospital in Nepal to identify the specific risk factors that are associated with antepartum stillbirth in this setting.

Methods

This case-control study was conducted between July 2012 and September 2013. All women who had antepartum stillbirths during this period were included as cases, while 20 % of all women delivering at the hospital were randomly selected and included as referents. Information on potential risk factors was taken from medical records and interviews with the women. Logistic regression analysis was completed to determine the association between those risk factors and antepartum stillbirth.

Results

During the study period, 4567 women who delivered at the hospital were enrolled as referents, of which 62 had antepartum stillbirths and were re-categorized into the case population. In total, there were 307 antepartum stillbirths. An association was found between the following risk factors and antepartum stillbirth: increasing maternal age (aOR 1.0, 95 % CI 1.0–1.1), less than five years of maternal education (aOR 2.4, 95 % CI 1.7–3.2), increasing parity (aOR 1.2, 95 % CI 1.0–1.3), previous stillbirth (aOR 2.6, 95 % CI 1.6–4.4), no antenatal care attendance (aOR 4.2, 95 % CI 3.2–5.4), belonging to the poorest family (aOR 1.3, 95 % CI 1.0–1.8), antepartum hemorrhage (aOR 3.7, 95 % CI 2.4–5.7), maternal hypertensive disorder during pregnancy (aOR 2.1, 95 % CI 1.5–3.1), and small weight-for-gestational age babies (aOR 1.5, 95 % CI 1.2–2.0).

Conclusion

Lack of antenatal care attendance, which had the strongest association with antepartum stillbirth, is a potentially modifiable risk factor, in that increasing the access to and availability of these services can be targeted. Antenatal care attendance provides an opportunity to screen for other potential risk factors for antepartum stillbirth, as well as to provide counseling to women, and thus, helps to ensure a successful pregnancy outcome.

Clinical trial registration

ISRCTN97846009 (url. www.isrctn.com/ISRCTN97846009)

Dimensions of Learning Organizations Questionnaire (DLOQ) in a low-resource health care setting in Nepal

Background

Knowledge-based organizations, such as health care systems, need to be adaptive to change and able to facilitate uptake of new evidence. To be able to assess organizational capability to learn is therefore an important part of health systems strengthening. The aim of the present study is to assess context using the Dimensions of the Learning Organization Questionnaire (DLOQ) in a low-resource health setting in Nepal.

Methods

DLOQ was translated and administered to 230 employees at all levels of the hospital. Data was analyzed using non-parametric tests.

Results

The DLOQ was able to detect variations across employee’s perceptions of the organizational context. Nurses scored significantly lower than doctors on the dimension “Empowerment” while doctors scored lower than nurses on “Strategic leadership”. These results suggest that the hospital’s organization carries attributes of a centralized, hierarchical structure that might hinder a progress towards a learning organization.

Conclusions

This study demonstrates that, despite the designing and developing of the DLOQ in the USA and its main utilization in company settings, it can be used and applied in hospital settings in low-income countries. The application of DLOQ provides valuable insights and understanding when designing and evaluating efforts for healthcare improvement.

Poor adherence to neonatal resuscitation guidelines exposed; an observational study using camera surveillance at a tertiary hospital in Nepal

Background

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

Methods

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

Results

During the study period 1827 newborns were taken to the resuscitation table, and more than half of them (53.3%) were noted as not crying prior to resuscitation.

Suction was used in almost 90% of newborns brought to the resuscitation table, whereas bag-and-mask ventilation was only used in less than 10%. The chance to receive ventilation with bag-and-mask for a newborn not crying when brought to the resuscitation table was higher for boys (AdjOR 1.44), low birth weight babies (AdjOR 1.68) and babies that were delivered by caesarean section (AdjOR 1.64).

The reliability of the observational form varied considerably amongst the different variables analyzed, but was high for all variables concerning the use of bag-and-mask ventilation and the variable whether suction was used or not, all matching in over 91% of the forms.

Conclusions

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

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2431-14-233) contains supplementary material, which is available to authorized users.

Implementing a simplified neonatal resuscitation protocol-helping babies breathe at birth (HBB) - at a tertiary level hospital in Nepal for an increased perinatal survival

Background

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

Methods/Design

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

Discussion

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

Trial registration

ISRCTN97846009

Community participation and mobilization in community-based maternal, newborn and child health programmes in Nepal

A number of studies on community mobilization for maternal and newborn health have demonstrated that community participation is of profound importance in the delivery of community based survival interventions for mother, newborn and children and a cost effective way to reduce mortality. However, the lessons learnt from the efficacy trials have not been tested within the health systems. Nepal is well known for its public health programmes and wide successes in campaign based interventions as a result of active involvement of volunteers and organizations based in the community. This paper analyzes the degree of community participation and mobilization in community-based maternal, newborn and child health programmes and its potential implication in acceleration towards achieving Millennium Development Goals 4 and 5. The study is based on analysis of the existing national community based maternal, neonatal and child health programmes in terms of degree of community mobilization and participation for ownership and sustainability of programmes. Furthermore, a qualitative assessment was carried out to assess the level of engagement of community structures in community based maternal, newborn and child health programme. None of the national community based maternal, newborn and child health programmes used the community action cycle approach and there was minimal level of involvement of community networks. The mother's groups had been least engaged in identifying and solving the maternal, newborn and child health problems and Female community health volunteer were engaged in delivering messages at household level and not through the mother's groups. Though the Community Action Cycle was studied in Nepal and it was found effective to achieve the objectives, getting its lessons into practice to design community health programs were lacking. The mother's groups need to be revitalized to ensure their active participation in identifying, analyzing and agreeing on steps to solve the problems related to maternal, neonatal and child health so that care seeking and utilization of health services will be further enhanced. The national strategies need to explore the possibilities of incorporating the community action cycle frame into its programmes, test the frame and ensure its implementation in the National community based programs in order to improve health outcomes of mother, newborn and children.

Study of enteric fever and antibiogram of Salmonella isolates at a teaching hospital in Kathmandu Valley

Enteric fever is one of the common public health problems in Nepal. This study was carried out at Nepal Medical College Teaching Hospital located at peri-urban area in Kathmandu Valley to find out the prevalence of enteric fever and the sensitivity pattern of the Salmonella isolates. A total of 479 patients with fever were included in the study. Venous blood samples collected aseptically were subjected to culture and were studied following the standard bacteriological procedure. The overall prevalence of enteric fever was 5.4% (26/479). Of them more than half (65.4%) were caused by S. paratryphi A whereas remaining (34.6%) by S. typhi. The positive rate was higher in children aged 1-15 years (8.9%) followed by 15-30 years of age (4.3%) and others (1.9%). Gender wise, females to male ratio was 1.4:1. The occurrence of infections was higher in Dalit (7.1%), Khas (Brahmin and Chhetri) (5.9%) and Madeshi (5.9%) whereas lowest was in Adibasi Janajati (4.8%). Prevalence rate of enteric fever among different sex, age and ethnic group was not significant (p > 0.05). Isolates were highly sensitive to Amikacin (100.0%) and Ciprofloxacin (96.1%) whereas least sensitive to Gentamycin (68.7%).