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Surviving birth: Studies of a simplified neonatal resuscitation protocol in a low-income context using a mixed-methods approach
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). (Internationell mödra- och barnhälsovård, International Maternal and Child Health)
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

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

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

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

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

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2017. , 73 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1308
Keyword [en]
cause of death, focus group, guideline adherence, infant, low-income population, low birth weight, Nepal, neonatal resuscitation, nurse midwives, neonatal mortality, newborn, perinatal mortality, preterm, quality improvement cycle, teamwork, postnatal, video recording
National Category
Pediatrics
Identifiers
URN: urn:nbn:se:uu:diva-316728ISBN: 978-91-554-9839-9 (print)OAI: oai:DiVA.org:uu-316728DiVA: diva2:1079015
Public defence
2017-04-28, Auditorium Minus, Museum Gustavianum, Akademigatan 3, Uppsala, 09:00 (English)
Opponent
Supervisors
Available from: 2017-04-07 Created: 2017-03-07 Last updated: 2017-04-21
List of papers
1. Teamwork among midwives during neonatal resuscitation at a maternity hospital in Nepal.
Open this publication in new window or tab >>Teamwork among midwives during neonatal resuscitation at a maternity hospital in Nepal.
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2017 (English)In: Women and Birth, ISSN 1871-5192, E-ISSN 1878-1799, S1871-5192(16)30120-2Article in journal (Refereed) Epub ahead of print
Abstract [en]

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

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

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

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

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

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

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

Keyword
Low-income population, Neonatal resuscitation, Nurse midwives, Practice guidelines, Teamwork
National Category
Nursing
Identifiers
urn:nbn:se:uu:diva-316658 (URN)10.1016/j.wombi.2017.02.002 (DOI)28254364 (PubMedID)
Available from: 2017-03-06 Created: 2017-03-06 Last updated: 2017-03-07
2. Reducing perinatal mortality in Nepal using Helping Babies Breathe
Open this publication in new window or tab >>Reducing perinatal mortality in Nepal using Helping Babies Breathe
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2016 (English)In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 137, no 6, e20150117Article in journal (Refereed) Published
Abstract [en]

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

 

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

 

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

 

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

Keyword
intrapartum stillbirth, intrapartum-related neonatal death, Helping Babies Breathe, quality improvement cycle, Nepal
National Category
Pediatrics Public Health, Global Health, Social Medicine and Epidemiology
Research subject
International Health; Pediatrics
Identifiers
urn:nbn:se:uu:diva-267919 (URN)10.1542/peds.2015-0117 (DOI)000378520100001 ()
Funder
Swedish Society of Medicine
Available from: 2015-11-29 Created: 2015-11-29 Last updated: 2017-03-07Bibliographically approved
3. Improved postnatal care is needed to maintain gains in neonatal survival after the implementation of the Helping Babies Breathe initiative
Open this publication in new window or tab >>Improved postnatal care is needed to maintain gains in neonatal survival after the implementation of the Helping Babies Breathe initiative
(English)Article in journal (Refereed) Accepted
Abstract [en]

Aim

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

Methods

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

Results

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

Conclusion

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

Keyword
cause of death, low-income settings, neonatal resuscitation, perinatal mortality, postnatal
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-316710 (URN)
Available from: 2017-03-06 Created: 2017-03-06 Last updated: 2017-03-14
4. Resuscitation practices of low and normal birth weight infants in Nepal: an observational study using video camera recordings
Open this publication in new window or tab >>Resuscitation practices of low and normal birth weight infants in Nepal: an observational study using video camera recordings
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2017 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, 1322372Article in journal (Other academic) Published
Abstract [en]

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

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

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

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

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

Place, publisher, year, edition, pages
Taylor & Francis, 2017
Keyword
neonatal resuscitation, low birth weight, guideline adherence, video recording, low-income population
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-316720 (URN)10.1080/16549716.2017.1322372 (DOI)000402549800001 ()
Available from: 2017-03-06 Created: 2017-03-06 Last updated: 2017-08-16Bibliographically approved

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