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  • 1.
    Andersson, Ola
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Rana, Nisha
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Ewald, Uwe
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Stripple, Gunilla
    Basnet, Omkar
    Subedi, Kalpana
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Intact cord resuscitation versus early cord clamping in the treatment of depressed newborn infants during the first 10 minutes of birth (Nepcord III) -: a randomized clinical trial2019Ingår i: Maternal health, neonatology and perinatology, ISSN 2054-958X, Vol. 5, nr 15Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Experiments have shown improved cardiovascular stability in lambs if umbilical cord clamping is postponed until positive pressure ventilation is started. Studies on intact cord resuscitation on human term infants are sparse. The purpose of this study was to evaluate differences in clinical outcomes in non-breathing infants between groups, one where resuscitation is initiated with an intact umbilical cord (intervention group) and one group where cord clamping occurred prior to resuscitation (control group).

    Methods: Randomized controlled trial, inclusion period April to August 2016 performed at a tertiary hospital in Kathmandu, Nepal. Late preterm and term infants born vaginally, non-breathing and in need of resuscitation according to the 'Helping Babies Breathe' algorithm were randomized to intact cord resuscitation or early cord clamping before resuscitation. Main outcome measures were saturation by pulse oximetry (SpO2), heart rate and Apgar at 1, 5 and 10 minutes after birth.

    Results: At 10 minutes after birth, SpO2 (SD) was significantly higher in the intact cord group compared to the early cord clamping group, 90.4 (8.1) vs 85.4 (2.7) %, P < .001). In the intact cord group, 57 (44%) had SpO2 < 90% after 10 minutes, compared to 93 (100%) in the early cord clamping group, P < 0.001. SpO2 was also significantly higher in the intervention (intact cord) group at one and five minutes after birth. Heart rate was lower in the intervention (intact cord) group at one and five minutes and slightly higher at ten minutes, all significant findings. Apgar score was significantly higher at one, five and ten minutes. At 5 minutes, 23 (17%) had Apgar score < 7 in the intervention (intact cord) group compared to 26 (27%) in the early cord clamping group, P < .07. Newborn infants in the intervention (intact cord) group started to breathe and establish regular breathing earlier than in the early cord clamping group.

    Conclusions: This study provides new and important information on the effects of resuscitation with an intact umbilical cord. The findings of improved SpO2 and higher Apgar score, and the absence of negative consequences encourages further studies with longer follow-up.

    Trial registration: Clinicaltrials.gov NCT02727517, 2016/4/4.

  • 2.
    Ashish, K. C.
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH). Nepal Country Off, United Nations Childrens Fund, Lalitpur, Nepal..
    Wrammert, Johan
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Nelin, Viktoria
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Ewald, Uwe
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Clark, Robert
    Latter Day St Char, Salt Lake City, UT USA..
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH). Uppsala Univ, Dept Womens & Childrens Hlth, Int Maternal & Child Hlth, Uppsala, Sweden..
    Level of mortality risk for babies born preterm or with a small weight for gestation in a tertiary hospital of Nepal2015Ingår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 15, artikel-id 877Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

  • 3.
    Boggs, Dorothy
    et al.
    London Sch Hyg & Trop Med, Maternal Adolescent Reprod & Child Hlth Ctr, London, England;London Sch Hyg & Trop Med, Int Ctr Evidence Disabil, London, England.
    Milner, Kate M.
    London Sch Hyg & Trop Med, Maternal Adolescent Reprod & Child Hlth Ctr, London, England;Murdoch Childrens Res Inst, Melbourne, Vic, Australia.
    Chandna, Jaya
    Univ Liverpool, Inst Translat Med, Liverpool, Merseyside, England.
    Black, Maureen
    Univ Maryland, Sch Med, Baltimore, MD 21201 USA;RIT Int, Durham, NC USA.
    Cavallera, Vanessa
    WHO, Dept Mental Hlth & Subst Abuse, Geneva, Switzerland.
    Dua, Tarun
    WHO, Dept Mental Hlth & Subst Abuse, Geneva, Switzerland.
    Fink, Guenther
    Swiss Trop & Publ Hlth Inst, Basel, Switzerland;Univ Basel, Basel, Switzerland.
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Grantham-McGregor, Sally
    UCL, Fac Populat Hlth Sci, Inst Child Hlth, London, England.
    Hamadani, Jena
    Int Ctr Diarrhoeal Dis Res, Maternal & Child Hlth Div, Dhaka, Bangladesh.
    Hughes, Rob
    Childrens Investment Fund Fdn, London, England;London Sch Hyg & Trop Med, Dept Populat Hlth, Maternal & Child Hlth Intervent Res Grp, London, England.
    Manji, Karim
    Muhimbili Univ Allied Hlth Sci, Dept Paediat & Child Hlth, Dar Es Salaam, Tanzania.
    Mccoy, Dana Charles
    Harvard Univ, Harvard Grad Sch Educ, Cambridge, MA 02138 USA.
    Tann, Cally
    London Sch Hyg & Trop Med, Maternal Adolescent Reprod & Child Hlth Ctr, London, England;Univ Coll Hosp NHS Trust, Neonatal Med, London, England.
    Lawn, Joy E.
    London Sch Hyg & Trop Med, Maternal Adolescent Reprod & Child Hlth Ctr, London, England.
    Rating early child development outcome measurement tools for routine health programme use2019Ingår i: Archives of Disease in Childhood, ISSN 0003-9888, E-ISSN 1468-2044, Vol. 104, s. S22-S33Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background Identification of children at risk of developmental delay and/or impairment requires valid measurement of early child development (ECD). We systematically assess ECD measurement tools for accuracy and feasibility for use in routine services in low-income and middle-income countries (LMIC). Methods Building on World Bank and peer-reviewed literature reviews, we identified available ECD measurement tools for children aged 0-3 years used in >= 1 LMIC and matrixed these according to when (child age) and what (ECD domains) they measure at population or individual level. Tools measuring <2 years and covering >= 3 developmental domains, including cognition, were rated for accuracy and feasibility criteria using a rating approach derived from Grading of Recommendations, Assessment, Development and Evaluations. Results 61 tools were initially identified, 8% (n=5) population-level and 92% (n=6) individual-level screening or ability tests. Of these, 27 tools covering >= 3 domains beginning <2 years of age were selected for rating accuracy and feasibility. Recently developed population-level tools (n=2) rated highly overall, particularly in reliability, cultural adaptability, administration time and geographical uptake. Individual-level tool (n=25) ratings were variable, generally highest for reliability and lowest for accessibility, training, clinical relevance and geographical uptake. Conclusions and implications Although multiple measurement tools exist, few are designed for multidomain ECD measurement in young children, especially in LMIC. No available tools rated strongly across all accuracy and feasibility criteria with accessibility, training requirements, clinical relevance and geographical uptake being poor for most tools. Further research is recommended to explore this gap in fit-for-purpose tools to monitor ECD in routine LMIC health services.

  • 4.
    Budhathoki, Shyam Sundar
    et al.
    BP Koirala Inst Hlth Sci, Sch Publ Hlth & Community Med, Dharan, Nepal.
    Gurung, Rejina
    Golden Community, Jawagal, Nepal.
    Ewald, Uwe
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Thapa, Jeevan
    BP Koirala Inst Hlth Sci, Sch Publ Hlth & Community Med, Dharan, Nepal.
    Ashish, K. C.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Does the Helping Babies Breathe Programme impact on neonatal resuscitation care practices?: Results from systematic review and meta-analysis2019Ingår i: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 108, nr 5, s. 806-813Artikel, forskningsöversikt (Refereegranskat)
    Abstract [en]

    Aim: This paper examines the change in neonatal resuscitation practices after the implementation of the Helping Babies Breathe (HBB) programme.

    Methods: A systematic review was carried out on studies reporting the impact of HBB programmes among the literature found in Medline, POPLINE, LILACS, African Index Medicus, Cochrane, Web of Science and Index Medicus for the Eastern Mediterranean Region database. We selected clinical trials with randomised control, quasi-experimental and cross-sectional designs. We used a data extraction tool to extract information on intervention and outcome reporting. We carried out a meta-analysis of the extracted data on the neonatal resuscitation practices following HBB programme using Review Manager.

    Results: Four studies that reported on neonatal resuscitation practices before and after the implementation of the HBB programme were identified. The pooled results showed no changes in the use of stimulation (RR-0.54; 95% CI, 0.21-1.42), suctioning (RR-0.48; 95% CI, 0.18-1.27) and bag-and-mask ventilation (RR-0.93; 95% CI, 0.47-1.83) after HBB training. The proportion of babies receiving bag-and-mask ventilation within the Golden Minute of birth increased by more than 2.5 times (RR-2.67; 95% CI, 2.17-3.28).

    Conclusion: The bag-and-mask ventilation within Golden minute has improved following the HBB programme. Implementation of HBB training improves timely initiation of bag-and-mask ventilation within one minute of birth.

  • 5.
    Day, Louise T.
    et al.
    LSHTM, Maternal Adolescent Reprod & Child Hlth MARCH Ctr, Keppel St, London WC1E 7HT, England.
    Ruysen, Harriet
    LSHTM, Maternal Adolescent Reprod & Child Hlth MARCH Ctr, Keppel St, London WC1E 7HT, England.
    Gordeev, Vladimir S.
    LSHTM, Maternal Adolescent Reprod & Child Hlth MARCH Ctr, Keppel St, London WC1E 7HT, England.
    Gore-Langton, Georgia R.
    LSHTM, Maternal Adolescent Reprod & Child Hlth MARCH Ctr, Keppel St, London WC1E 7HT, England.
    Boggs, Dorothy
    LSHTM, Maternal Adolescent Reprod & Child Hlth MARCH Ctr, Keppel St, London WC1E 7HT, England.
    Cousens, Simon
    LSHTM, Maternal Adolescent Reprod & Child Hlth MARCH Ctr, Keppel St, London WC1E 7HT, England.
    Moxon, Sarah G.
    LSHTM, Maternal Adolescent Reprod & Child Hlth MARCH Ctr, Keppel St, London WC1E 7HT, England.
    Blencowe, Hannah
    LSHTM, Maternal Adolescent Reprod & Child Hlth MARCH Ctr, Keppel St, London WC1E 7HT, England.
    Baschieri, Angela
    LSHTM, Maternal Adolescent Reprod & Child Hlth MARCH Ctr, Keppel St, London WC1E 7HT, England.
    Rahman, Ahmed Ehsanur
    Int Ctr Diarrhoeal Dis Res, Maternal & Child Hlth Div, Dhaka, Bangladesh.
    Tahsina, Tazeen
    Int Ctr Diarrhoeal Dis Res, Maternal & Child Hlth Div, Dhaka, Bangladesh.
    Bin Zaman, Sojib
    Int Ctr Diarrhoeal Dis Res, Maternal & Child Hlth Div, Dhaka, Bangladesh.
    Hossain, Tanvir
    Int Ctr Diarrhoeal Dis Res, Maternal & Child Hlth Div, Dhaka, Bangladesh.
    Rahman, Qazi Sadeq-ur
    Int Ctr Diarrhoeal Dis Res, Maternal & Child Hlth Div, Dhaka, Bangladesh.
    Ameen, Shafiqul
    Int Ctr Diarrhoeal Dis Res, Maternal & Child Hlth Div, Dhaka, Bangladesh.
    El Arifeen, Shams
    Int Ctr Diarrhoeal Dis Res, Maternal & Child Hlth Div, Dhaka, Bangladesh.
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Shrestha, Shree Krishna
    Pokhara Acad Hlth Sci, Pokhara Ranipauwa, Nepal.
    Naresh, P. K. C.
    Minist Hlth, Dept Hlth Serv, Kathmandu, Nepal.
    Singh, Del
    Pokhara Acad Hlth Sci, Pokhara Ranipauwa, Nepal.
    Jha, Anjani Kumar
    Nepal Hlth Res Council, Kathmandu, Nepal.
    Jha, Bijay
    Nepal Hlth Res Council, Kathmandu, Nepal.
    Rana, Nisha
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Basnet, Omkar
    Golden Community, Kathmandu, Nepal.
    Joshi, Elisha
    LifeLine Nepal, Kathmandu, Nepal.
    Paudel, Asmita
    Kanti Childrens Hosp, Kathmandu, Nepal.
    Shrestha, Parashu Ram
    Minist Hlth, Dept Hlth Serv, Kathmandu, Nepal.
    Jha, Deepak
    Minist Hlth, Dept Hlth Serv, Kathmandu, Nepal.
    Bastla, Ram Chandra
    Matri Shishu Miteri Hosp, Pokhara, Nepal.
    Ghimire, Jagat Jeevan
    Nepal Hlth Res Council, Kathmandu, Nepal.
    Paudel, Rajendra
    Kanti Childrens Hosp, Kathmandu, Nepal.
    Salim, Nahya
    Muhimbili Univ Hlth & Allied Sci, Dept Paediat & Child Hlth, Dar Es Salaam, Tanzania.
    Shamb, Donat
    Ifakara Hlth Inst, Dept Hlth Syst Impact Evaluat & Policy, Dar Es Salaam, Tanzania.
    Manji, Karim
    Muhimbili Univ Hlth & Allied Sci, Dept Paediat & Child Hlth, Dar Es Salaam, Tanzania.
    Shabani, Josephine
    Ifakara Hlth Inst, Dept Hlth Syst Impact Evaluat & Policy, Dar Es Salaam, Tanzania.
    Shirima, Kizito
    Ifakara Hlth Inst, Dept Hlth Syst Impact Evaluat & Policy, Dar Es Salaam, Tanzania.
    NamalaMkopi,
    Mrisho, Mwifadhi
    Ifakara Hlth Inst, Dept Hlth Syst Impact Evaluat & Policy, Dar Es Salaam, Tanzania.
    Manzi, Fatuma
    Ifakara Hlth Inst, Dept Hlth Syst Impact Evaluat & Policy, Dar Es Salaam, Tanzania.
    Jaribu, Jennie
    Ifakara Hlth Inst, Dept Hlth Syst Impact Evaluat & Policy, Dar Es Salaam, Tanzania.
    Kija, Edward
    Muhimbili Univ Hlth & Allied Sci, Dept Paediat & Child Hlth, Dar Es Salaam, Tanzania.
    Assenga, Evelyne
    Muhimbili Univ Hlth & Allied Sci, Dept Paediat & Child Hlth, Dar Es Salaam, Tanzania.
    Kisenge, Rodrick
    Muhimbili Univ Hlth & Allied Sci, Dept Paediat & Child Hlth, Dar Es Salaam, Tanzania.
    Pembe, Andrea
    Muhimbili Univ Hlth & Allied Sci, Dept Paediat & Child Hlth, Dar Es Salaam, Tanzania.
    Hanson, Claudia
    Karolinska Inst, Publ Hlth Sci Global Hlth Hlth Syst & Policy, Stockholm, Sweden.
    Mbaruku, Godfrey
    Ifakara Hlth Inst, Dept Hlth Syst Impact Evaluat & Policy, Dar Es Salaam, Tanzania.
    Masanja, Honorati
    Ifakara Hlth Inst, Dept Hlth Syst Impact Evaluat & Policy, Dar Es Salaam, Tanzania.
    Amouzou, Agbessi
    Johns Hopkins Univ, Inst Int Programs, Dept Int Hlth, Baltimore, MD USA.
    Azim, Tariq
    Univ N Carolina, MEAUSRE Evaluat, Chapel Hill, NC 27515 USA.
    Jackson, Debra
    UNICEF, Hlth Sect, Knowledge Management & Implementat Res Unit, New York, NY USA.
    Kabuteni, Theopista John
    WHO, Family & Reprod Hlth, Dar Es Salaam, Tanzania.
    Mathai, Matthews
    Univ Liverpool Liverpool Sch Trop Med, Ctr Maternal & Newborn Hlth, Liverpool, Merseyside, England.
    Monet, Jean-Pierre
    UNFPA, Dept Sexual & Reprod Hlth, New York, NY USA.
    Moran, Allisyn
    WHO, Dept Maternal Newborn Child & Adolescent Hlth, Geneva, Switzerland.
    Ram, Pavani
    US Agcy Int Dev, Bur Global Hlth, Off Hlth Infect Dis & Nutr, Washington, DC 20523 USA.
    Rawlins, Barbara
    Jhpiego Baltimore, Baltimore, MD USA.
    Saebo, Johan Ivar
    Univ Oslo, Dept Informat, Oslo, Norway.
    Serbanescu, Fiorina
    Ctr Dis Control & Prevent CDC, Div Reprod Hlth, Atlanta, GA USA.
    Vaz, Lara
    Save Children, Washington, DC USA.
    Zaka, Nabila
    UNICEF, Hlth Sect, Knowledge Management & Implementat Res Unit, New York, NY USA.
    Lawn, Joy E.
    LSHTM, Maternal Adolescent Reprod & Child Hlth MARCH Ctr, Keppel St, London WC1E 7HT, England.
    "Every Newborn-BIRTH" protocol: observational study validating indicators for coverage and quality of maternal and newborn health care in Bangladesh, Nepal and Tanzania2019Ingår i: Journal of Global Health, ISSN 2047-2978, E-ISSN 2047-2986, Vol. 9, nr 1, artikel-id 010902Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: To achieve Sustainable Development Goals and Universal Health Coverage, programmatic data are essential. The Every Newborn Action Plan, agreed by all United Nations member states and >80 development partners, includes an ambitious Measurement Improvement Roadmap. Quality of care at birth is prioritised by both Every Newborn and Ending Preventable Maternal Mortality strategies, hence metrics need to advance from health service contact alone, to content of care. As facility births increase, monitoring using routine facility data in DHIS2 has potential, yet validation research has mainly focussed on maternal recall surveys. The Every Newborn - Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study aims to validate selected newborn and maternal indicators for routine tracking of coverage and quality of facility-based care for use at district, national and global levels.

    Methods: EN-BIRTH is an observational study including >20000 facility births in three countries (Tanzania, Bangladesh and Nepal) to validate selected indicators. Direct clinical observation will be compared with facility register data and a pre-discharge maternal recall survey for indicators including: uterotonic administration, immediate newborn care, neonatal resuscitation and Kangaroo mother care. Indicators including neonatal infection management and antenatal corticosteroid administration, which cannot be easily observed, will be validated using inpatient records. Trained clinical observers in Labour/Delivery ward, Operation theatre, and Kangaroo mother care ward/areas will collect data using a tablet-based customised data capturing application. Sensitivity will be calculated for numerators of all indicators and specificity for those numerators with adequate information. Other objectives include comparison of denominator options (ie, true target population or surrogates) and quality of care analyses, especially regarding intervention timing. Barriers and enablers to routine recording and data usage will be assessed by data flow assessments, quantitative and qualitative analyses.

    Conclusions: To our knowledge, this is the first large, multi-country study validating facility-based routine data compared to direct observation for maternal and newborn care, designed to provide evidence to inform selection of a core list of indicators recommended for inclusion in national DHIS2. Availability and use of such data are fundamental to drive progress towards ending the annual 5.5 million preventable stillbirths, maternal and newborn deaths.

  • 6.
    Ersdal, Hege L.
    et al.
    Stavanger Univ Hosp, Dept Anaesthesiol & Intens Care, Stavanger, Norway..
    Singhal, Nalini
    Univ Calgary, Div Neonatol, Calgary, AB, Canada..
    Msemo, Georgina
    Minist Hlth & Social Serv, Reprod & Child Hlth Serv, Dar Es Salaam, Tanzania..
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH). UNICEF, Hlth Sect, Kathmandu, Nepal..
    Data, Santorino
    Mbarara Univ Sci & Technol, Pediat & Child Hlth, Mbarara, Uganda..
    Moyo, Nester T.
    Int Confederat Midwives, Harare, Zimbabwe..
    Evans, Cherrie L.
    Johns Hopkins Univ, Jhpiego, Baltimore, MD USA..
    Smith, Jeffrey
    Johns Hopkins Univ, Jhpiego, Baltimore, MD USA..
    Perlman, Jeffrey M.
    Weill Cornell Med Coll, Div Newborn Med, New York, NY USA..
    Niermeyer, Susan
    Univ Colorado, Sch Med, Sect Neonatol, Aurora, CO USA..
    Successful implementation of Helping Babies Survive and Helping Mothers Survive programs-An Utstein formula for newborn and maternal survival2017Ingår i: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 12, nr 6, artikel-id e0178073Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Globally, the burden of deaths and illness is still unacceptably high at the day of birth. Annually, approximately 300.000 women die related to childbirth, 2.7 million babies die within their first month of life, and 2.6 million babies are stillborn. Many of these fatalities could be avoided by basic, but prompt care, if birth attendants around the world had the necessary skills and competencies to manage life-threatening complications around the time of birth. Thus, the innovative Helping Babies Survive (HBS) and Helping Mothers Survive (HMS) programs emerged to meet the need for more practical, low-cost, and low-tech simulation-based training. This paper provides users of HBS and HMS programs a 10-point list of key implementation steps to create sustained impact, leading to increased survival of mothers and babies. The list evolved through an Utstein consensus process, involving a broad spectrum of international experts within the field, and can be used as a means to guide processes in low-resourced countries. Successful implementation of HBS and HMS training programs require country-led commitment, readiness, and follow-up to create local accountability and ownership. Each country has to identify its own gaps and define realistic service delivery standards and patient outcome goals depending on available financial resources for dissemination and sustainment.

  • 7.
    Guo, Yue
    et al.
    Univ North Carolina Chapel Hill, Chapel Hill, NC 27514 USA..
    Wrammert, Johan
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Singh, Kavita
    Univ North Carolina Chapel Hill, Chapel Hill, NC 27514 USA..
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH). UNICEF Nepal, Kathmandu, Nepal..
    Bradford, Kira
    Univ North Carolina Chapel Hill, Chapel Hill, NC 27514 USA..
    Krishnamurthy, Ashok
    Univ North Carolina Chapel Hill, Chapel Hill, NC 27514 USA..
    Automatic Analysis of Neonatal Video Data to Evaluate Resuscitation Performance2016Ingår i: 2016 IEEE 6TH INTERNATIONAL CONFERENCE ON COMPUTATIONAL ADVANCES IN BIO AND MEDICAL SCIENCES (ICCABS), 2016Konferensbidrag (Refereegranskat)
    Abstract [en]

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

  • 8. Gurung, Abhishek
    et al.
    Bajracharya, Kiran
    Gurung, Rejina
    Budhathoki, Shyam Sundar
    Kc, Naresh Pratap
    Shrestha, Parashu Ram
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    The Association of Women's Empowerment with Stillbirths in Nepal.2019Ingår i: Maternal and Child Health Journal, ISSN 1092-7875, E-ISSN 1573-6628Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Globally, 2.6 million stillbirths occur each year. Empowering women can improve their overall reproductive health and help reduce stillbirths. Women empowerment has been defined as women's ability to make choices in economic decision-making, household and health care decision-making. In this paper, we aimed to evaluate if women's empowerment is associated with stillbirths.

    METHODS: Data from 2016 Nepal Demographic Health Surveys (NDHS) were analysed to evaluate the association between women's empowerment and stillbirths. Equiplots were generated to assess the distribution of stillbirths by wealth quintile, place of residence and level of maternal education using data from NHDS 1996, 2001, 2006, 2011 and 2016 data. For the association of women empowerment factors and stillbirths, univariate and multivariate analyses were conducted.

    RESULTS: A total of 88 stillbirths were reported during the survey. Univariate analysis showed age of mother, education of mother, age of husband, wealth index, head of household, decision on healthcare and decision on household purchases had significant association with stillbirths (p < 0.05). In multivariate analysis, only maternal age 35 years and above was significant (aOR 2.42; 1.22-4.80). Education of mother (aOR 1.48; 0.94-2.33), age of husband (aOR 1.54; 0.86-2.76), household head (aOR 1.51; 0.88-2.59), poor wealth index (aOR 1.62; 0.98-2.68), middle wealth index (aOR 1.37; 0.76-2.47), decision making for healthcare (aOR 1.36; 0.84-2.21) and household purchases (aOR 1.01; 0.61-1.66) had no any significant association with stillbirths.

    CONCLUSIONS: There are various factors linked with stillbirths. It is important to track stillbirths to improve health outcomes of mothers and newborn. Further studies are necessary to analyse women empowerment factors to understand the linkages between empowerment and stillbirths.

  • 9. Gurung, Rejina
    et al.
    Gurung, Abhishek
    Rajbhandari, Priyanka
    Ewald, Uwe
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Basnet, Omkar
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Effectiveness and Acceptability of Bag-and-mask Ventilation with Visual Monitor for Improving Neonatal Resuscitation in Simulated Setting in Six Hospitals of Nepal.2019Ingår i: Journal of Nepal Health Research Council, ISSN 1727-5482, E-ISSN 1999-6217, Vol. 17, nr 2, s. 222-227Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Improving the performance of health workers on neonatal resuscitation will be critical to ensure that the babies are effectively ventilated. We conducted a study to evaluate whether a bag-and-mask ventilation with monitor is effective in improving neonatal resuscitation practice in a simulated setting.

    METHODS: This is a cross-over design conducted in 6 public hospitals with 82 health workers of Nepal nested over a large scale stepped wedged quality improvement project. A one-day training on neonatal resuscitation was conducted. At the end of the training, participants were evaluated on the bag-and-mask ventilation performance in a manikinbased on the tidal volume, positive end expiratory pressure and air leakage from the maskin two sessions (monitor displayed versus hidden). The comparison of the neonatal resuscitation performance with and without monitor displayed is calculated. We also conducted assessment of confidence with or without monitor of the health workers.

    RESULTS: Adequacy of ventilation using bag-and-mask was better when the health workers were displayed monitor (90%) vs without monitor (76%) (p<0.01). The air leakage from the mask reduced when the monitor was displayed (12%) vs without (30%). The PEEP improved when the health workers used monitor as guide to conduct neonatal resuscitation in the manikin then without monitor displayed. The participants felt more confident performing ventilations during the visible sessions.

    CONCLUSIONS: The ventilation function monitor helped participants to improve their ventilation skills through realtime feedback of important ventilation parameters. Clinical evaluation of needs to be done to assess the effectiveness of the device.

  • 10.
    Gurung, Rejina
    et al.
    Golden Community, Jawgal 11, Lalitpur, Nepal.
    Gurung, Abhishek
    Golden Community, Jawgal 11, Lalitpur, Nepal.
    Sunny, Avinash K.
    Golden Community, Jawgal 11, Lalitpur, Nepal.
    Basnet, Omkar
    Golden Community, Jawgal 11, Lalitpur, Nepal.
    Shrestha, Shree Krishna
    Pokhara Acad Hlth Sci, Ramghat 10, Pokhara, Nepal.
    Gomo, Oystein Herwig
    Laerdal Global Hlth, Laerdal Med, Stavanger, Norway.
    Myklebust, Helge
    Laerdal Global Hlth, Laerdal Med, Stavanger, Norway.
    Girnary, Sakina
    Laerdal Global Hlth, Laerdal Med, Stavanger, Norway.
    Ashish, K. C.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH). Uppsala Univ, Dept Womens & Childrens Hlth, Dag Hammarskjolds Vag 14B,Floor 1, Uppsala, Sweden.
    Effect of skill drills on neonatal ventilation performance in a simulated setting-observation study in Nepal2019Ingår i: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 19, nr 1, artikel-id 387Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Aim: Maintaining neonatal resuscitation skills among health workers in low resource settings will require continuous quality improvement efforts. We aimed to evaluate the effect of skill drills and feedback on neonatal resuscitation and the optimal number of skill drills required to maintain the ventilation skill in a simulated setting. Methods: An observational study was conducted for a period of 3 months in a referral hospital of Nepal. Sixty nursing staffs were trained on Helping Babies Breathe (HBB) 2.0 and daily skill drills using a high-fidelity manikin. The high-fidelity manikin had different clinical case scenarios and provided feedback as "well done" or "improvement required" based on the ventilation performance. Adequate ventilation was defined as bag-and-mask ventilation at the rate of 40-60 breaths per minute. The effective ventilation was defined as adequate ventilation with a "well done" feedback. We assessed the correlation of number skill drills and clinical case scenario with adequate ventilation rate using pearson's correlation. We assessed the correlation of number of skill dills performed by each participant with effective ventilation using Mann Whitney test. Results: Among the total of 60 nursing staffs, all of them were competent with an average score of 12.73 +/- 1.09 out of 14 (p < 0.001) on bag-and-mask ventilation skill checklist. Among the trained staff, 47 staffs participated in daily skill drills who performed a total of 331 skill drills and 68.9% of the ventilations were done adequately. Among the 47 nursing staffs who performed the skill drills, 228 (68.9%) drills were conducted at a ventilation rate of 40-60 breathes per minute. There was no correlation of the adequate ventilation with skill drill category (p = 0.88) and the level of skill performed (p = 0.28). Out of 47 participants performing the skill drills, 74.5% of them had done effective ventilation with a mean average of 8 skill drills (SD +/- 4.78) (p-value- 0.032). Conclusion: In a simulated setting, participants who had an average skill drill of 8 in 3 months had effective ventilation. We demonstrated optimal skill drill sessions for maintain the neonatal resuscitation competency. Further evaluation will be required to validate the findings in a scale up setting.

  • 11.
    Gurung, Rejina
    et al.
    Golden Community, Jwagal, Lalitpur, Nepal.
    Jha, Anjani Kumar
    Govt Nepal, Minist Hlth & Populat, Kathmandu, Nepal.
    Pyakurel, Susheel
    Nepal Hlth Res Council, Kathmandu, Nepal.
    Gurung, Abhishek
    Golden Community, Jwagal, Lalitpur, Nepal.
    Litorp, Helena
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Wrammert, Johan
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Jha, Bijay Kumar
    Govt Nepal, Minist Hlth & Populat, Kathmandu, Nepal.
    Paudel, Prajwal
    Anweshan, Lalitpur, Nepal.
    Rahman, Syed Moshfiqur
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Malla, Honey
    Golden Community, Jwagal, Lalitpur, Nepal.
    Sharma, Srijana
    Golden Community, Jwagal, Lalitpur, Nepal.
    Gautam, Manish
    Anweshan, Lalitpur, Nepal.
    Linde, Jorgen Erland
    Stavanger Univ Hosp, Dept Paediat, Stavanger, Norway.
    Moinuddin, Md
    ICDDR B, Maternal & Child Hlth Div, Dhaka, Bangladesh.
    Ewald, Uwe
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Axelin, Anna
    Univ Turku, Turku, Finland.
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH). Soc Publ Hlth Phys Nepal, Lalitpur, Nepal.
    Scaling Up Safer Birth Bundle Through Quality Improvement in Nepal (SUSTAIN) - a stepped wedge cluster randomized controlled trial in public hospitals2019Ingår i: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 14, artikel-id 65Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

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

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

  • 12. Gurung, Rejina
    et al.
    Litorp, Helena
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell kvinno- och mödrahälsovård och migration. Department of Global Health, Karolinska Institutet.
    Berkelhamer, Sara
    Zhou, Hong
    Tinkari, Bhim Singh
    Paudel, Prajwal
    Malla, Honey
    Sharma, Srijana
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    The burden of misclassification of antepartum stillbirth in Nepal2019Ingår i: BMJ Global Health, E-ISSN 2059-7908, Vol. 4, nr 6, artikel-id e001936Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background Globally, every year 1.1 million antepartum stillbirths occur with 98% of these deaths taking place in countries where the health system is poor. In this paper we examine the burden of misclassification of antepartum stillbirth in hospitals of Nepal and factors associated with misclassification.

    Method A prospective observational study was conducted in 12 hospitals of Nepal for a period of 6 months. If fetal heart sounds (FHS) were detected at admission and during the intrapartum period, the antepartum stillbirth (fetal death ≥22 weeks prior labour) recorded in patient’s case note was recategorised as misclassified antepartum stillbirth. We further compared sociodemographic, obstetric and neonatal characteristics of misclassified and correctly classified antepartum stillbirths using bivariate and multivariate analysis.

    Result A total of 41 061 women were enrolled in the study and 39 562 of the participants’ FHS were taken at admission. Of the total participants whose FHS were taken at admission, 94.8% had normal FHS, 4.7% had abnormal FHS and 0.6% had no FHS at admission. Of the total 119 recorded antepartum stillbirths, 29 (24.4%) had FHS at admission and during labour and therefore categorised as misclassified antepartum stillbirths. Multivariate analysis performed to adjust the risk of association revealed that complications during pregnancy resulted in a threefold risk of misclassification (adjusted OR-3.35, 95% CI 1.95 to 5.76).

    Conclusion Almost 25% of the recorded antepartum stillbirths were misclassified. Improving quality of data is crucial to improving accountability and quality of care. As the interventions to reduce antepartum stillbirth differ, accurate measurement of antepartum stillbirth is critical.

  • 13.
    Gurung, Rejina
    et al.
    Golden Community, Lalitpur, Nepal.
    Zaka, Nabila
    UNICEF, Hlth Sect, Programme Div, New York, NY USA.
    Budhathoki, Shyam Sundar
    Golden Community, Lalitpur, Nepal;Imperial Coll London, Sch Publ Hlth, Dept Primary Care & Publ Hlth, London, England.
    Sunny, Avinash K.
    Golden Community, Lalitpur, Nepal.
    Thapa, Jeevan
    Sch Publ Hlth & Community Med, BP Koirala Inst Hlth Sci, Dharan, Nepal.
    Zhou, Hong
    Peking Univ, Beijing, Peoples R China.
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Study protocol: Impact of quality improvement interventions on perinatal outcomes in health facilities-a systematic review2019Ingår i: Systematic Reviews, E-ISSN 2046-4053, Vol. 8, nr 1, artikel-id 205Artikel, forskningsöversikt (Refereegranskat)
    Abstract [en]

    Background

    About 5.8 million maternal deaths, neonatal deaths and stillbirths occur every year with 99% of them taking place in low- and middle-income countries. Two thirds of them could be prevented through cost-effective interventions during pregnancy, intrapartum and postpartum periods. Despite the availability of standards and guidelines for the care of mother and newborn, challenges remain in translating these standards into practice in health facilities. Although several quality improvement (QI) interventions have been systematically reviewed by the Cochrane Effective Practice and Organization of Care (EPOC) group, evidence lack on QI interventions for improving perinatal outcomes in health facilities. This systematic review will identify QI interventions implemented for maternal and neonatal care in health facilities and their impact on perinatal outcomes.

    Methods/design

    This review will look at studies of mothers, newborn and both who received inpatient care at health facilities. QI interventions targeted at health system level (macro), at healthcare organization (meso) and at health workers practice (micro) will be reviewed. Mortality of mothers and newborn and relevant health worker practices will be assessed. The MEDLINE, Embase, World Health Organization Global Health Library, Cochrane Library and trial registries electronic databases will be searched for relevant studies from the year 2000 onwards. Data will be extracted from the identified relevant literature using Epi review software. Risk of bias will be assessed in the studies using the Cochrane risk of bias tool for randomized and observational studies. Standard data synthesis and analysis will be used for the review, and the data will be analysed using EPPI Reviewer 4.

    Discussion

    This review will inform the global agenda for evidence-based health care by (1) providing a basis for operational guidelines for implementing clinical standards of perinatal care, (2) identify research priorities for generating evidence for QI interventions and (3) QI intervention options with lessons learnt for implementation based on the level of needed resources.

  • 14.
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa.
    Neonatal Resuscitation: Understanding challenges and identifying a strategy for implementation in Nepal2016Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
    Abstract [en]

    Despite the unprecedented improvement in child health in last 15 years, burden of stillbirth and neonatal death remain the key challenge in Nepal and the reduction of these deaths will be crucial for reaching the health targets for Sustainable development goal by 2030.

    The aim of this thesis was to explore the risk factors for stillbirth and neonatal death and change in perinatal outcomes after the introduction of the Helping Babies Breathe Quality Improvement Cycle (HBB QIC) in Nepal.

    This was a prospective cohort study with a nested case-control design completed in a tertiary hospital in Nepal. Information were collected from the women who had experienced perinatal death and live birth among referent population; a video recording was done in the neonatal resuscitation corner to collect information on the health workers’ performance in neonatal resuscitation. 

    Lack of antenatal care had the highest association with antepartum stillbirth (aOR 4.2, 95% CI 3.2–5.4), births that had inadequate fetal heart rate monitoring were associated with intrapartum stillbirth (aOR 1.9, CI 95% 1.5–2.4), and babies who were born premature and small-for-gestational-age had the highest risk for neonatal death in the hospital (aOR 16.2, 95% CI 12.3–21.3). Before the introduction of the HBB QIC, health workers displayed poor adherence to the neonatal resuscitation protocol. After the introduction of HBB QIC, the health workers demonstrated improvement in their neonatal resuscitation skills and these were retained until six months after training. Daily bag-and-mask skill checks (RR 5.1 95% CI 1.9–13.5), preparation for birth (RR 2.4, 95% CI 1.0–5.6), self-evaluation checklists (RR 3.8, 95% CI 1.4–9.7) and weekly review and reflection meetings (RR 2.6, 95% 1.0–7.4) helped the health workers to retain their neonatal resuscitation skills. The health workers demonstrated improvement in ventilation of babies within one minute of birth and there was a reduction in intrapartum stillbirth (aOR 0.46, 95% CI 0.32–0.66) and first-day neonatal mortality (aOR 0.51, 95% CI 0.31–0.83). 

    The study provides information on challenges in reducing stillbirth and neonatal death in low income settings and provides a strategy to improve health workers adherence to neonatal resuscitation to reduce the mortality. The HBB QIC can be implemented in similar clinical settings to improve quality of care and survival in Nepal, but for primary care settings, the QIC need to be evaluated further.

  • 15.
    KC, Ashish
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Axelin, Anna
    Litorp, Helena
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell kvinno- och mödrahälsovård och migration.
    Tinkari, Bhim Singh
    Sunny, Avinash K
    Gurung, Rejina
    Coverage, associated factors, and impact of companionship during labor: A large-scale observational study in six hospitals in Nepal.2019Ingår i: Birth, ISSN 0730-7659, E-ISSN 1523-536XArtikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Companionship at the time of birth is a nonclinical intervention that has been proven to improve the quality of intrapartum care. This study aims to evaluate the coverage, associated factors, and impact of companionship during labor at public hospitals in Nepal.

    METHODS: We conducted a cross-sectional observational study in six public hospitals in Nepal. The study was conducted from July 2018 to August 2018. Data were collected on sociodemographic, maternal, obstetric, and neonatal characteristics from patient case notes and through predischarge interviews. Coverage of companionship during labor and its association with intrapartum care was analyzed. Bivariate and multivariate analyses were done to assess the association between companionship during labor and demographic, obstetric, and neonatal characteristics.

    RESULTS: A total of 63 077 women participated in the study with 19% of them having a companion during labor. Women aged 19-24 years had 65% higher odds of having a companion during labor compared with women aged 35 years and older (aOR 1.65 [95% CI, 1.40-1.94]). Women who were from an advantaged ethnic group (Chhetri/Brahmin) had fourfold higher odds of having a companion than women from a disadvantaged group (aOR 3.84; [95% CI, 3.24-4.52]). Women who had companions during labor had fewer unnecessary cesarean births than those who had no companions (5.2% vs 6.8%, P < .001).

    CONCLUSIONS: In Nepal, sociodemographic factors affect women's likelihood of having a companion during labor. As companionship during labor is associated with improved quality of care, health facilities should encourage women's access to birth companions.

  • 16.
    KC, Ashish
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Bajracharya, K
    Maharajgunj Nursing Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.
    State of Midwives in Nepal: HRH to Improve Maternal and Neonatal Health and Survival2013Ingår i: Journal of Nepal Health Research Council, ISSN 1999-6217, Vol. 11, nr 23, s. 98-101Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Improving health and survival of mothers and newborns depends on the delivery of evidence-based cost effective interventions through a skilled care provider. Evidence suggests that midwives are compassionate skilled care providers to mothers, and ensuring these skilled human resources is a key to progress towards Millennium Development Goals 4 and 5. With this in mind, this article analyses the state of midwifery in Nepal and what strategies are needed to ensuretheir accessibility and availability. In Nepal, as a result of community mobilization through Female Community Health Volunteers for birth preparedness and complication readiness, there has been a demand for skilled care at birth. However the supply of skilled birth attendants has been inadequate both in terms of number as well as quality of care.

  • 17.
    KC, Ashish
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition. Health Section, UNICEF, UN House, Lalitpur, Nepal.
    Bergström, Anna
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition. Institute for Global Health, University College London, London, UK.
    Chaulagain, Dipak
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition. Lifeline Nepal, Kathmandu, Nepal.
    Brunell, Olivia
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Ewald, Uwe
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Gurung, Abhishek
    Lifeline Nepal, Kathmandu, Nepal.
    Eriksson, Leif
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för folkhälso- och vårdvetenskap, Vårdvetenskap.
    Litorp, Helena
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell kvinno- och mödrahälsovård och migration.
    Wrammert, Johan
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Grönqvist, Erik
    Uppsala universitet, Humanistisk-samhällsvetenskapliga vetenskapsområdet, Samhällsvetenskapliga fakulteten, Nationalekonomiska institutionen.
    Edin, Per-Anders
    Uppsala universitet, Humanistisk-samhällsvetenskapliga vetenskapsområdet, Samhällsvetenskapliga fakulteten, Nationalekonomiska institutionen.
    Le Grange, Claire
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Lamichhane, Bikash
    Department of Health Services, Ministry of Health, Nepal.
    Shrestha, Parashuram
    Department of Health Services, Ministry of Health, Nepal.
    Pokharel, Amrit
    Department of Health Services, Ministry of Health, Nepal.
    Pun, Asha
    Health Section, UNICEF, UN House, Lalitpur, Nepal.
    Singh, Chahana
    Health Section, UNICEF, UN House, Lalitpur, Nepal .
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Scaling up quality improvement intervention for perinatal care in Nepal (NePeriQIP); study protocol of a cluster randomised trial2017Ingår i: BMJ global health, Vol. 2, nr 3, artikel-id e000497Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

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

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

    TRIAL REGISTRATION NUMBER: ISRCTN30829654.

  • 18.
    KC, Ashish
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Berkelhamer, Sara
    Gurung, Rejina
    Hong, Zhou
    Wang, Haijun
    Sunny, Avinash K
    Bhattarai, Pratiksha
    Poudel, Pragya G
    Litorp, Helena
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    The burden of and factors associated with misclassification of intrapartum stillbirth: Evidence from a large scale multicentric observational study.2019Ingår i: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    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.

  • 19.
    KC, Ashish
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Ewald, Uwe
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa.
    Basnet, Omkar
    Golden Community, Jawgal, Lalitpur, Nepal.
    Gurung, Abhishek
    Golden Community, Jawgal, Lalitpur, Nepal.
    Pyakuryal, Sushil Nath
    Nepal Hlth Res Council, Kathmandu, Nepal.
    Jha, Bijay Kumar
    Govt Nepal, Minist Hlth & Populat, Kathmandu, Nepal.
    Bergström, Anna
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa. UCL, UCL Inst Global Hlth IGH, London, England.
    Eriksson, Leif
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för folkhälso- och vårdvetenskap, Vårdvetenskap.
    Paudel, Prajwal
    Nepal Hlth Res Council, Kathmandu, Nepal.
    Karki, Sushil
    Life Line Nepal, Kathmandu, Nepal.
    Gajurel, Sunil
    Kamana Hlth Nepal, Kathmandu, Nepal.
    Brunell, Olivia
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Wrammert, Johan
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Litorp, Helena
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa.
    Målqvist, Mats
    Effect of a scaled-up neonatal resuscitation quality improvement package on intrapartum-related mortality in Nepal: A stepped-wedge cluster randomized controlled trial2019Ingår i: PLoS Medicine, ISSN 1549-1277, E-ISSN 1549-1676, Vol. 16, nr 9, artikel-id e1002900Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

  • 20.
    KC, Ashish
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Jha, Anjani Kumar
    Shrestha, Mahendra Prasad
    Zhou, Hong
    Gurung, Abhishek
    Thapa, Jeevan
    Budhathoki, Shyam Sundar
    Trends for Neonatal Deaths in Nepal (2001-2016) to Project Progress Towards the SDG Target in 2030, and Risk Factor Analyses to Focus Action.2019Ingår i: Maternal and Child Health Journal, ISSN 1092-7875, E-ISSN 1573-6628Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Nepal has made considerable progress on improving child survival during the Millennium Development Goal period, however, further progress will require accelerated reduction in neonatal mortality. Neonatal survival is one of the priorities for Sustainable Development Goals 2030. This paper examines the trends, equity gaps and factors associated with neonatal mortality between 2001 and 2016 to assess the likelihood of Every Newborn Action Plan (ENAP) target being reached in Nepal by 2030.

    METHODS: This study used data from the 2001, 2006, 2011 and 2016 Nepal Demographic and Health Surveys. We examined neonatal mortality rate (NMR) across the socioeconomic strata and the annual rate of reduction (ARR) between 2001 and 2016. We assessed association of socio-demographic, maternal, obstetric and neonatal factors associated with neonatal mortality. Based on the ARR among the wealth quintile between 2001 and 2016, we made projection of NMR to achieve the ENAP target. Using the Lorenz curve, we calculated the inequity distribution among the wealth quintiles between 2001 and 2016.

    RESULTS: In NDHS of 2001, 2006, 2011 and 2016, a total of 8400, 8600, 13,485 and 13,089 women were interviewed respectively. There were significant disparities between wealth quintiles that widened over the 15 years. The ARR for NMR declined with an average of 4.0% between 2001 and 2016. Multivariate analysis of the 2016 data showed that women who had not been vaccinated against tetanus had the highest risk of neonatal mortality (adjusted odds ratio [AOR] 3.38; 95% confidence interval [CI] 1.20-9.55), followed by women who had no education (AOR 1.87; 95% CI 1.62-2.16). Further factors significantly associated with neonatal mortality were the mother giving birth before the age of 20 (AOR 1.76; CI 95% 1.17-2.59), household air pollution (AOR 1.37; CI 95% 1.59-1.62), belonging to a poorest quintile (AOR 1.37; CI 95% 1.21-1.54), residing in a rural area (AOR 1.28; CI 95% 1.13-1.44), and having no toilet at home (AOR 1.21; CI 95% 1.06-1.40). If the trend of neonatal mortality rate of 2016 continues, it is projected that the poorest family will reach the ENAP target in 2067.

    CONCLUSIONS: Although neonatal mortality is declining in Nepal, if the current trend continues it will take another 50 years for families in the poorest group to attain the 2030 ENAP target. There are different factors associated with neonatal mortality, reducing the disparities for maternal and neonatal care will reduce mortality among the poorest families.

  • 21.
    Kc, Ashish
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa.
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Rana, Nisha
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Ranneberg, Linda Jarawka
    Department of Paediatrics, Hospital of Halland, Halmstad, Sweden.
    Andersson, Ola
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Pediatrik.
    Effect of timing of umbilical cord clamping on anaemia at 8 and 12 months and later neurodevelopment in late pre-term and term infants: a facility-based, randomized-controlled trial in Nepal.2016Ingår i: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 16, artikel-id 35Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Delayed cord clamping at birth has shown to benefit neonates with increased placental transfusion leading to higher haemoglobin concentrations, additional iron stores and less anaemia later in infancy, higher red blood cell flow to vital organs and better cardiopulmonary adaptation. As iron deficiency in infants even without anaemia has been associated with impaired development, delayed cord clamping seems to benefit full term infants also in regions with a relatively low prevalence of iron deficiency anaemia. In Nepal, there is a high anaemia prevalence among children between 6 and 17 months (72-78 %). The objective of the proposed study is to evaluate the effects of delayed and early cord clamping on anaemia (and haemoglobin level) at 8 and 12 months, ferritin at 8 and 12 months, bilirubin at 2-3 days, admission to Neonatal Intensive Care Unit (NICU) or special care nursery, and development at 12 and 18-24 months of age.

    METHODS/DESIGN: A randomized, controlled trial comparing delayed and early cord clamping will be implemented at Paropakar Maternity and Women's Hospital in Kathmandu, Nepal. Pregnant woman of gestational age 34-41 weeks who deliver vaginally will be included in the study. The interventions will consist of delayed clamping of the umbilical cord (≥180 s after delivery) or early clamping of the umbilical cord (≤60 s). At 8 and 12 months of age, infant's iron status and developmental milestones will be measured.

    DISCUSSION: This trial is important to perform because, although strong indications for the beneficial effect of delayed cord clamping on anaemia at 8 to 12 months of age exist, it has not yet been evaluated by a randomized trial in this setting. The proposed study will analyse both outcome as well as safety effects. Additionally, the results may not only contribute to practice in Nepal, but also to the global community, in particular to other low-income countries with a high prevalence of iron deficiency anaemia.

  • 22.
    KC, Ashish
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Wrammert, Johan
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Verma, Sheela
    Paropakar Maternity and Women´s Hospital, Kathmandu, Nepal.
    Aryal, Dhan Raj
    Paropakar Maternity and Women´s Hospital, Kathmandu, Nepal.
    Clark, Robert
    Latter Day Saints Charity, Salt Lake City, USA.
    Kc, Naresh P
    Ministry of Health and Population, Kathmandu, Nepal.
    Vitrakoti, Ravi
    Paropakar Maternity and Women´s Hospital, Kathmandu, Nepal.
    Baral, Kedar
    Patan Academy of Health Sciences, Patan, Nepal.
    Ewald, Uwe
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Implementing a simplified neonatal resuscitation protocol-helping babies breathe at birth (HBB): at a tertiary level hospital in Nepal for an increased perinatal survival2012Ingår i: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 12, nr 1, s. 159-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND:

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

    METHODS:

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

    DISCUSSION:

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

  • 23.
    KC, Ashish
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Nelin, Viktoria
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Vitrakoti, Ravi
    Foundation for Maternal and Child Health Nepal, Kathmandu, Nepal.
    Aryal, Surabhi
    College of Medical Sciences, Bharatpur, Nepal.
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Validation of the foot length measure as an alternative tool to identify low birth weight and preterm babies in a low-resource setting like Nepal: a cross-sectional study2015Ingår i: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 15, artikel-id 43Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background

    The majority of infants who die in the neonatal period are born with a low birth weight (LBW, <2500 grams), or prematurely (before 37 weeks). Most deaths among these infants could be prevented with simple, low-cost interventions like kangaroo mother care (KMC) or prevention and early identification of infection. It is difficult, however, to determine birth weight and gestational age in community settings, and therefore necessary to find an appropriate alternative screening tool that can identify LBW and preterm infants.

    Methods

    This cross-sectional study was conducted at a tertiary hospital in Nepal to compare the validity of using three different foot length measurement methods (plastic ruler, measuring tape, and paper footprint) as screening tools for identifying babies with birth weights <2000 grams or infants born preterm (<37 weeks). LBW was defined as less than 2000 grams because of the implication for use of KMC for these infants. Non-parametric receiver operating characteristics (ROC) analysis was completed to determine which measurement method best predicted LBW and preterm birth. For the method that was the best predictor for each outcome (i.e. highest area under the curve), further analyses were completed to determine sensitivity, specificity, likelihood ratios and predictive values of an operational screening cutoff to predict LBW or preterm birth in this setting.

    Results

    Of the 811 infants included in this study, 30 infants had LBW and 54 were born preterm. The plastic ruler was the measurement method with the highest area under the curve, and thus predictive score for estimating both outcomes, so operational cutoffs were identified based on this method. An operational cutoff of 7.2 cm was identified to screen for infants weighing <2000 grams at birth (sensitivity: 75.9%, specificity: 90.3%), and 7.8 cm was determined as the operational cutoff to identify preterm infants (sensitivity: 76.9%, specificity: 53.9%).

    Conclusions

    In Nepal, at least in community settings, foot length measurement with a hard ruler may be a valid proxy to identify at-risk infants when birth weight or gestational age is unavailable. Further studies and piloting should be conducted to identify exact cutoffs that can be used within community settings.

  • 24.
    K.C, Ashish
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Nelin, Viktoria
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Wrammert, Johan
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Pediatrik.
    Ewald, Uwe
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Vitrakoti, Ravi
    Baral, Geha Nath
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Risk factors for antepartum stillbirth: a case-control study in Nepal2015Ingår i: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 15, artikel-id 146Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

  • 25.
    KC, Ashish
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition. Health Section, United Nations Children’s Fund (UNICEF), Lalitpur, Nepal; Paropakar Maternity and Women’s Hospital, Kathmandu, Nepal.
    Rana, Nisha
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition. Paropakar Maternity and Women’s Hospital, Kathmandu, Nepal.
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Jarawka Ranneberg, Linda
    epartment of Pediatrics, Hospital of Halland, Halmstad, Sweden.
    Subedi, Kalpana
    Paropakar Maternity and Women’s Hospital, Kathmandu, Nepal.
    Andersson, Ola
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Effects of Delayed Umbilical Cord Clamping vs Early Clamping on Anemia in Infants at 8 and 12 Months: A Randomized Clinical Trial2017Ingår i: JAMA pediatrics, ISSN 2168-6203, E-ISSN 2168-6211, Vol. 171, nr 3, s. 264-270Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Importance: Delayed umbilical cord clamping has been shown to improve iron stores in infants to 6 months of age. However, delayed cord clamping has not been shown to prevent iron deficiency or anemia after 6 months of age.

    Objective: To investigate the effects of delayed umbilical cord clamping, compared with early clamping, on hemoglobin and ferritin levels at 8 and 12 months of age in infants at high risk for iron deficiency anemia.

    Design, Setting, and Participants: This randomized clinical trial included 540 late preterm and term infants born vaginally at a tertiary hospital in Kathmandu, Nepal, from October 2 to November 21, 2014. Follow-up included blood levels of hemoglobin and ferritin at 8 and 12 months of age. Follow-up was completed on December 11, 2015. Analysis was based on intention to treat.

    Interventions: Infants were randomized to delayed umbilical cord clamping (≥180 seconds after delivery) or early clamping (≤60 seconds after delivery).

    Main Outcomes and Measures: Main outcomes included hemoglobin and anemia levels at 8 months of age with the power estimate based on the prevalence of anemia. Secondary outcomes included hemoglobin and anemia levels at 12 months of age and ferritin level, iron deficiency, and iron deficiency anemia at 8 and 12 months of age.

    Results: In this study of 540 infants (281 boys [52.0%] and 259 girls [48.0%]; mean [SD] gestational age, 39.2 [1.1] weeks), 270 each were randomized to the delayed and early clamping groups. At 8 months of age, 212 infants (78.5%) from the delayed group and 188 (69.6%) from the early clamping group returned for blood sampling. After multiple imputation analysis, infants undergoing delayed clamping had higher levels of hemoglobin (10.4 vs 10.2 g/dL; difference, 0.2 g/dL; 95% CI, 0.1 to 0.4 g/dL). Delayed cord clamping also reduced the prevalence of anemia (hemoglobin level <11.0 g/dL) at 8 months in 197 (73.0%) vs 222 (82.2%) infants (relative risk, 0.89; 95% CI, 0.81-0.98; number needed to treat [NNT], 11; 95% CI, 6-54). At 8 months, the risk for iron deficiency was reduced in the delayed clamping group in 60 (22.2%) vs 103 (38.1%) patients (relative risk, 0.58; 95% CI, 0.44-0.77; NNT, 6; 95% CI, 4-13). At 12 months, delayed cord clamping still resulted in a hemoglobin level of 0.3 (95% CI, 0.04-0.5) g/dL higher than in the early cord clamping group and a relative risk for anemia of 0.91 (95% CI, 0.84-0.98), resulting in a NNT of 12 (95% CI, 7-78).

    Conclusions and Relevance: Delayed cord clamping reduces anemia at 8 and 12 months of age in a high-risk population, which may have major positive effects on infants' health and development.

    Trial Registration: clinicaltrials.gov Identifier: NCT02222805.

  • 26.
    KC, Ashish
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Singh, Dipendra Raman
    Upadhyaya, Madan Kumar
    Budhathoki, Shyam Sundar
    Gurung, Abhishek
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Quality of Care for Maternal and Newborn Health in Health Facilities in Nepal2019Ingår i: Maternal and Child Health Journal, ISSN 1092-7875, E-ISSN 1573-6628Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Nepal has pledged to substantially reduce maternal and newborn death by 2030. Improving quality of intrapartum health services will be vital to reduce these deaths. This paper examines quality of delivery and newborn services in health facilities of Nepal.

  • 27.
    KC, Ashish
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Singhal, Nalini
    Gautam, Jageshwor
    Rana, Nisha
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Andersson, Ola
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Effect of early versus delayed cord clamping in neonate on heart rate, breathing and oxygen saturation during first 10 minutes of birth - randomized clinical trial.2019Ingår i: Maternal health, neonatology and perinatology, ISSN 2054-958X, Vol. 5, artikel-id 7Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Delayed cord clamping (DCC) after 180 s reduces iron deficiency up to 8 months of infancy compared to babies who received Early Cord Clamping (ECC) at less than 60 s. Experimentally DCC has shown to improve cardio-vascular stability. To evaluate the effect of delayed (≥180 s) group versus early (≤60 s) cord clamping group on peripheral blood oxygenation and heart rate up to 10 min after birth on term and late preterm infants.

    Methods: We conducted a single centred randomized clinical trial in a low risk delivery unit in tertiary Hospital, Nepal. One thousand five hundred ten women, low risk vaginal delivery with foetal heart rate (FHR) ≥ 100 ≤ 160 beats per minute (bpm) and gestational age (≥33 weeks) were enrolled in the study. Participants were randomly assigned to cord clamped ≤60 s of birth and ≥ 180 s. The main outcome measures were oxygen saturation, heart rate from birth to 10 min and time of spontaneous breathing. The oxygen saturation and heart rate, the time of first breath and establishment of regular breathing was analysed using Student t-test to compare groups. We analysed the range of heart rate distributed by different centiles from the time of birth at 30 s intervals until 10 min.

    Results: The oxygen saturation was 18% higher at 1 min, 13% higher at 5 min and 10% higher at 10 min in babies who had cord clamping in delayed group compared to early group (p < 0.001). The heart rate was 9 beats lower at 1 min and3 beats lower at 5 min in delayed group compared to early group (p < 0.001). Time of first breath and regular breathing was established earlier in babies who had cord clamping at 180 s or more.

    Conclusion: Spontaneously breathing babies subjected to DCC have higher oxygen saturation up to 10 min after birth compared to those who have undergone ECC. Spontaneously breathing babies with DCC have lower heart rates compared to ECC until 390 s. Spontaneously breathing babies receiving DCC have early establishment of breathing compared to ECC.

    Trial registration: ISRCTN, 5 April 2016.

  • 28.
    KC, Ashish
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Sunny, Avinash K
    Poudel, Rajendra Prasad
    Basnet, Omkar
    A Review of eHealth Initiatives: Implications for Improving Health Service Delivery in Nepal2019Ingår i: Journal of Nepal Health Research Council, ISSN 1727-5482, E-ISSN 1999-6217, Vol. 17, nr 3, s. 269-277Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    The aim of this paper is to take stock of the use of information and communication technologies in delivering health services in Nepal and identify bottlenecks in implementation for improving delivery of health services. A descriptive review was conducted from May to September 2016. Data were collected from organizations working on the different thematic areas in health where information and communication technologies was used. Fifteen ongoing eHealth projects were identified in the areas of monitoring and surveillance, electronic health records/electronic medical records, health information system, and telemedicine. Common challenges were addressed, including a lack of funding, infrastructure, electricity and network, and national capacity. Most eHealth projects were not integrated into the national system. Working at a national level to address the challenges, centralizing eHealth projects and developing national policies would ensure to adopt eHealth at a right place and to accelerate eHealth initiatives. Keywords: eHealth; health service delivery;information and communication technologies (ICT); Nepal.

  • 29.
    Kc, Ashish
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH). UN Childrens Fund, Nepal Country Off, UN House, Pulchowk, Nepal.
    Wrammert, Johan
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Clark, Robert B
    Latter-day Saint Charities, Salt Lake City, UT, USA.
    Ewald, Uwe
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Inadequate fetal heart rate monitoring and poor use of partogram associated with intrapartum stillbirth: a case-referent study in Nepal2016Ingår i: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, artikel-id 233Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

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

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

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

    CLINICAL TRIAL REGISTRATION: ISRCTN97846009 .

  • 30.
    KC, Ashish
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH). UNICEF, Health Section, Nepal.
    Wrammert, Johan
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Pediatrik.
    Clark, Robert
    Latter-day Saint Charities, Salt Lake City, Utah, USA.
    Ewald, Uwe
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Vitrakoti, Ravi
    Paropakar Maternity and Women's Hospital, Kathmandu, Nepal.
    Chaudhary, Pushpa
    Paropakar Maternity and Women's Hospital, Kathmandu, Nepal.
    Pun, Asha
    UNICEF, Health Section, Nepal.
    Raaijmakers, Hendrikus
    UNICEF, Health Section, Nepal.
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Reducing perinatal mortality in Nepal using Helping Babies Breathe2016Ingår i: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 137, nr 6, artikel-id e20150117Artikel i tidskrift (Refereegranskat)
    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.

  • 31.
    K.C, Ashish
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Wrammert, Johan
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Ewald, Uwe
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Clark, Robert
    Latter-day Saint Charities, Salt Lake City, Utah, USA.
    Gautam, Jageshwor
    Paropakar Maternity and Women's Hospital, Nepal.
    Baral, Gehanath
    Paropakar Maternity and Women's Hospital.
    Baral, Kedar
    Patan Academy of Health Sciences.
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Incidence of intrapartum stillbirth and associated risk factors in tertiary care setting of Nepal: a case-control study2016Ingår i: Reproductive Health, ISSN 1742-4755, E-ISSN 1742-4755, Vol. 12, artikel-id 103Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

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

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

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

  • 32.
    KC, Ashish
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH). United Nations Childrens Fund UNICEF, UN House, Lalitpur, Nepal.
    Wrammert, Johan
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Nelin, Viktoria
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Clark, Robert
    Latter-day Saint Charities, Salt Lake City, Utah, USA.
    Ewald, Uwe
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Peterson, Stefan Swartling
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH). Global Health, Public Health Sciences, Karolinska Institute, Sweden.; School of Public Health, Makerere University, Uganda.; United Nations Children Fund UNICEF, Hlth Sect, Programme Div, United Nations Plaza, New York, NY 10017 USA.
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Evaluation of Helping Babies Breathe Quality Improvement Cycle (HBB-QIC) on retention of neonatal resuscitation skills six months after training in Nepal2017Ingår i: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 17, artikel-id 103Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Each year 700,000 infants die due to intrapartum-related complications. Helping Babies Breathe (HBB) uses an algorithm to increase knowledge and improve skills on neonatal resuscitation. Implementation of HBB in low-resource clinical settings has shown to reduce intrapartum stillbirths and first-day neonatal mortality. However, there is a lack of evidence on the effect of different HBB implementation strategies to improve and sustain the clinical competency of health workers on bag-and-mask ventilation. This study was conducted to evaluate the impact of multi-faceted implementation strategy for HBB as quality improvement cycle (HBB-QIC) on retention of neonatal resuscitation skills in a tertiary hospital of Nepal.

    Methods: A Time series design was applied. The multi-faceted intervention for HBB-QIC included training, daily bag-and-mask skill checks, preparation for resuscitation before every birth, self-evaluation and peer review on neonatal resuscitation skills and weekly review meetings. Knowledge and skills were assessed through questionnaires, skill checklists, and Objective Structured Clinical Examinations (OSCE) before implementation of the HBB-QIC, immediately after HBB training, and again at six months. Means were compared using paired t-tests, and associations between skill retention and HBB-QIC components were analyzed using logistic regression analysis.

    Results: 137 health workers were enrolled in the study. Knowledge scores were higher immediately following the HBB training, 16.4  1.4 compared to 12.8  1.6 before (out of 17), and the knowledge was retained six months after the training (16.5  1.1). Bag-and-mask skills improved immediately after the training and were retained six months after the training. The retention of bag-and-mask skills was associated with daily bag-and-mask skill checks, preparation for resuscitation before every birth, use of a self-evaluation checklist, and attendance at weekly review meetings. The implementation strategies with the highest association to skill retention were daily bag-and-mask skill checks (RR-5.1, 95% CI 1.9-13.5) and use of self-evaluation checklists after every delivery (RR-3.8, 95% CI 1.4-9.7).

    Conclusions: Health workers who practiced bag-and-mask skills, prepared for resuscitation before every birth, used self-evaluation checklists and attended weekly review meetings retained their neonatal resuscitation skills. Further studies are required to evaluate HBB-QIC in primary care settings, where the number of deliveries is gradually increasing.

  • 33. Källander, Karin
    et al.
    Ward, Charlotte
    Smith, Helen
    Bhattarai, Radheshyam
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Timsina, Deepak
    Lamichhane, Bikash
    Maurel, Alice
    Ram Shrestha, Parashu
    Baral, Sushil
    McWhorter, Cindy
    LaBarre, Paul
    de Cola, Monica Anna
    Baker, Kevin
    Usability and acceptability of an automated respiratory rate counter to assess childhood pneumonia in Nepal.2019Ingår i: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    AIM: Pneumonia is the leading cause of child death after the neonatal period, resulting from late care seeking and inappropriate treatment. Diagnosis involves counting respiratory rate (RR); however, RR counting remains challenging for health workers and miscounting, and misclassification of RR is common. We evaluated the usability of a new automated RR counter, the Philips Children's Respiratory Monitor (ChARM), to Female Community Health Volunteers (FCHVs), and its acceptability to FCHVs and caregivers in Nepal.

    METHODS: A cross-sectional study was conducted in Jumla district, Nepal. About 133 FCHVs were observed between September and December 2018 when using ChARM during 517 sick child consultations, 264 after training and 253 after 2 months of routine use of ChARM. Acceptability of the ChARM was explored using semi-structured interviews.

    RESULTS: FCHV adherence to guidelines after 2 months of using ChARM routinely was 52.8% (95% CI 46.6-58.9). The qualitative findings suggest that ChARM is acceptable to FCHVs and caregivers; however, capacity constraints such as older age and low literacy and impacted device usability were mentioned.

    CONCLUSION: Further research on the performance, cost-effectiveness and implementation feasibility of this device is recommended, especially among low-literate CHWs.

  • 34.
    Lindbäck, Caroline
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Wrammert, Johan
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Vitrakoti, Ravi
    Paropakar Women’s and Maternity Hospital, Kathmandu, Nepal.
    Ewald, Uwe
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Poor adherence to neonatal resuscitation guidelines exposed; an observational study using camera surveillance at a tertiary hospital in Nepal2014Ingår i: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 14, s. 233-Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

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

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

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

  • 35.
    Målqvist, Mats
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Hultstrand, Jenny Niemeyer
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Larsson, Margareta
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    High levels of unmet need for family planning in Nepal.2018Ingår i: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 17, s. 1-6Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Providing access to family planning services is a basic component and a cost-effective intervention to reduce maternal mortality worldwide. It is closely linked to women's decision-making power and female emancipation. Unmet need for family planning is thus an indicator going beyond maternal health with far reaching societal implications. This study examines the level of unmet need for family planning in Nepal and its distribution along structural determinants.

    METHODS: Data from the Multiple Indicator Cluster Survey 2014 was utilized for analysis. Prevalence of unmet need for family planning was calculated and logistic regression models used to ascertain inequity.

    RESULTS: A total unmet need for family planning of 40.9% among the 10,688 included women was observed. No major differences between socioeconomic groups could be detected, except for a somewhat higher rate of unmet need among the least educated. Total fertility rate among the women included was 2.59. Contraceptive use among adolescents was alarmingly low, with almost none reporting using any type of contraception.

    CONCLUSION: The lack of major inequity implies that the high level of unmet need for contraception is a general problem in society and must be addressed broadly. A special focus on education and provision for adolescents is needed in Nepal.

  • 36.
    Målqvist, Mats
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Pun, Asha
    UNICEF Nepal Country Off, UN Hlth Sect, UN House, Pulchowk, Nepal..
    Kc, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH). UNICEF Nepal Country Off, UN Hlth Sect, UN House, Pulchowk, Nepal..
    Essential newborn care after home delivery in Nepal2017Ingår i: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 45, nr 2, s. 202-207Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Aims: Postnatal care of the newborn is essential in order to reduce neonatal mortality. Nepal has made great efforts to improve maternal and child health by focusing on accessibility and outreach over the past decades. This study aims to examine trends, over the past decade, in levels and equity of facility delivery rates and the provision of newborn care after home delivery in Nepal. Methods: Household-level data from the Demographic Health Surveys (DHS) 2006 and 2011 and the Multiple Indicator Cluster Survey (MICS5) from 2014 performed in Nepal was sourced for the study. Coverage rates of facility delivery and newborn care after home delivery were calculated and logistic regression models were used to ascertain inequity. Results: Home delivery rate dropped from 79.2% in 2006 to 46.5% in 2014, a development showing an inequitable distribution, with a larger share of better-off families shifting to facility delivery. For those who still delivered at home there was an increased rate of early initiation of breastfeeding and adequate temperature control, but only 2.2% of women delivering at home received a home visit by a health professional in the first week of delivery. No inequity in receiving newborn care after home delivery could be detected. Conclusions: There have been significant improvements in facility delivery rates over the last 10 years in Nepal and postnatal care at home has improved. There is, however, an alarmingly low level of home visits during an infant's first week.

  • 37.
    Målqvist, Mats
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Pun, Asha
    UN Health Section, UNICEF, Nepal.
    Raaijmakers, Hendrikus
    UN Health Section, UNICEF, Nepal.
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH). UN Health Section, UNICEF, Nepal.
    Persistent inequity in maternal health care utilization in Nepal despite impressive overall gains2017Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, nr 1, artikel-id 1356083Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Maternal health care utilization is at the core of global public health provision and an area of focus in the now-concluded Millennium Development Goal agenda.

    OBJECTIVE: This study aims to examine trends in maternal health care utilization over the last 15 years in Nepal, focusing on coverage and equity.

    METHODS: This paper used data from the Demographic Health Survey (DHS) 2001, 2006 and 2011 and Multiple Indicator Cluster Survey (MICS), 2014. Coverage rates were calculated and logistic regression models used to examine inequity.

    RESULTS: Impressive gains were found in antenatal care (ANC) attendance, which increased from nearly half of women attending (49%) in 2001 to 88% in 2014, and the rate of facility delivery increased from just 7-44%. This development did not, however, influence the equity gap in ANC and skilled attendance at birth, as women from low socioeconomic backgrounds were six times more likely to deliver without skilled assistance than those from high socioeconomic backgrounds (AdjOR 6.38 CI 95% 4.57-8.90) in 2014.

    CONCLUSION: These persistent equity gaps call for targeted interventions focusing on the most disadvantaged and vulnerable women in order to achieve the new Sustainable Development Goal of universal health coverage.

  • 38.
    Målqvist, Mats
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Singh, Chahana
    UNICEF Nepal Country Off, UN Hlth Sect, Pulchowk, Nepal..
    Kc, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH). UNICEF Nepal Country Off, UN Hlth Sect, Pulchowk, Nepal..
    Care seeking for children with fever/cough or diarrhoea in Nepal: equity trends over the last 15 years2017Ingår i: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 45, nr 2, s. 195-201Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Aims: Childhood illnesses such as diarrhoea and pneumonia remain major contributors to child mortality globally and need to be continually targeted in pursuit of universal health coverage. This study analyses time trends in the prevalence of fever/cough and diarrhoea in Nepal and applies an equity lens in order to identify disadvantaged groups. Methods: Data from the Nepal Demographic Health Surveys of 2001, 2006, and 2011, together with data from the most recent Multiple Indicator Cluster Survey of 2014 performed in Nepal, were utilized for analysis. Results: Analyses revealed improvements (lower prevalence) of diarrhoea and fever/cough in children under five in Nepal over the last 15 years, with an equitable distribution of symptoms over socio-economic determinants. There was, however, a marked and maintained inequity in care seeking for these symptoms, with less educated mothers and those from poor households being only approximately half as likely to seek care for their children. Conclusions: Results highlight the persisting need for targeting care-seeking and societal barriers to treatment in order to achieve universal health access.

  • 39. Nelin, Viktoria
    et al.
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Andersson, Ola
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Rana, Nisha
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Factors associated with timing of umbilical cord clamping in tertiary hospital of Nepal.2018Ingår i: BMC Research Notes, ISSN 1756-0500, E-ISSN 1756-0500, Vol. 11, nr 1, artikel-id 89Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE: Delayed umbilical cord clamping (DCC) (≥ 60 s) is recognized to improve iron status and neurodevelopment compared to early umbilical cord clamping. The aim of this study is to identify current umbilical cord clamping practice and factors determining the timing of clamping in a low-resource setting where prevalence of anemia in infants is high.

    RESULTS: A cross-sectional study design including 128 observations of clinical practice in a tertiary-level maternity hospital in Kathmandu, Nepal. Overall 48% of infants received DCC. The mean and median cord clamping times were 61 ± 33 and 57 (38-79) s, respectively. Univariate analysis showed that infants born during the night shift were five times more likely to receive DCC (OR 5.6, 95% CI 1.4-38.0). Additionally, infants born after an obstetric complication were 2.5 times more likely to receive DCC (OR 2.5, 95% CI 1.2-5.3), and babies requiring ventilation had a 65% lower likelihood of receiving DCC (OR 0.35, 95% CI 0.13-0.88). Despite the existence of standard protocols for cord clamping and its proven benefit, the lack of uniformity in the timing of cord clamping reveals poor translation of clinical guidelines into clinical practice. Clinical trial registration ISRCTN97846009.

  • 40.
    Nonyane, Bareng As
    et al.
    International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
    K.C, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa.
    Callaghan-Koru, Jennifer A
    International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
    Guenther, Tanya
    Save the Children, Washington, DC, USA.
    Sitrin, Debora
    Save the Children, Washington, DC, USA.
    Syed, Uzma
    Save the Children, Washington, DC, USA.
    Pradhan, Yasho V
    Society of Public Health Physician.
    Khadka, Neena
    Save the Children, Washington, DC, USA.
    Shah, Rashed
    International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
    Baqui, Abdullah H
    International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
    Equity improvements in maternal and newborn care indicators: results from the Bardiya district of Nepal2016Ingår i: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 31, nr 4, s. 405-414Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Community-based maternal and newborn care interventions have been shown to improve neonatal survival and other key health indicators. It is important to evaluate whether the improvement in health indicators is accompanied by a parallel increase in the equitable distribution of the intervention activities, and the uptake of healthy newborn care practices. We present an analysis of equity improvements after the implementation of a Community Based Newborn Care Package (CB-NCP) in the Bardiya district of Nepal. The package was implemented alongside other programs that were already in place within the district. We present changes in concentration indices (CIndices) as measures of changes in equity, as well as percentage changes in coverage, between baseline and endline. The CIndices were derived from wealth scores that were based on household assets, and they were compared using t-tests. We observed statistically significant improvements in equity for facility delivery [CIndex: -0.15 (-0.24, -0.06)], knowledge of at least three newborn danger signs [-0.026(-0.06, -0.003)], breastfeeding within 1 h [-0.05(-0.11, -0.0001)], at least one antenatal visit with a skilled provider [-0.25(-0.04, -0.01)], at least four antenatal visits from any provider [-0.15(-0.19, -0.10)] and birth preparedness [-0.09(-0.12, -0.06)]. The largest increases in practices were observed for facility delivery (50%), immediate drying (34%) and delayed bathing (29%). These results and those of similar studies are evidence that community-based interventions delivered by female community health volunteers can be instrumental in improving equity in levels of facility delivery and other newborn care behaviours. We recommend that equity be evaluated in other similar settings within Nepal in order to determine if similar results are observed.

  • 41.
    Rana, Nisha
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition. Life Line Nepal, Kathmandu, Nepal.
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition. UNICEF, Hlth Sect, UN House, Lalitpur, Nepal.
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Subedi, Kalpana
    Paropakar Matern & Womens Hosp, Kathmandu, Nepal.
    Andersson, Ola
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition. Reg Halland, Dept Res & Dev, Halmstad, Sweden.
    Effect of Delayed Cord Clamping of Term Babies on Neurodevelopment at 12 Months: A Randomized Controlled Trial.2019Ingår i: Neonatology, ISSN 1661-7800, E-ISSN 1661-7819, Vol. 115, nr 1, s. 36-42Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Delayed cord clamping (DCC) is associated with an improved iron status at 8 months, a reduction of anemia at 12 months, and an improved development at 4 years. Assessment of the development after DCC has not been performed earlier in a setting with a high prevalence of iron deficiency.

    Objective: The aim of this paper was to investigate the effects of DCC compared to early cord clamping (ECC) on the development evaluated with the Ages and Stages Questionnaire (ASQ) at 12 months of age.

    Method: We conducted a randomized controlled trial investigating the effect of DCC (≥180 s) versus ECC (≤60 s) in 540 full-term deliveries. Twelve months after delivery, the parents reported their infant’s development by ASQ. Infants having a score < 1 standard deviation (SD) under the mean score were considered “at risk” of affected neurodevelopment.

    Results: At 12 months of age, 332 (61.5%) infants were assessed. Fewer children in the DCC group were “at risk” of having affected neurodevelopment measured by the ASQ total score, 21 (7.8%) versus 49 (18.1%) in the ECC group. The relative risk was 0.43 (0.26–0.71). Infants in the DCC group had higher mean total scores (SD), 290.4 (10.4) versus 287.2 (10.1), p = 0.01. Significantly fewer infants in the delayed group were “at risk” and had higher scores in the domains “communication”, “gross motor”, and “personal-social”. Conclusions: DCC after 3 min was associated with an improvement of the overall neurodevelopment assessed at 12 months of age as compared to infants in the group with cord clamping within 1 min.

  • 42.
    Rana, Nisha
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Ranneberg, Linda Jarawka
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Andersson, Ola
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Delayed cord clamping was not associated with an increased risk of hyperbilirubinaemia on the day of birth or jaundice in the first 4 weeks2019Ingår i: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227Artikel i tidskrift (Övrigt vetenskapligt)
    Abstract [en]

    Aim: Our aim was to investigate the effects of timing of cord clamping on the risk of hyperbilirubinaemia.

    Methods: We recruited 540 normal vaginal deliveries at the Paropakar Maternity and Women’s Hospital in Kathmandu, Nepal, from October 2 to November 21, 2014. They were randomised into two groups: 257/270 were cord clamped within 60 sec‐ onds and 209/270 after 180 seconds. Transcutaneous bilirubin was measured at discharge and 24 hours. At 4 weeks, 506 mothers were successfully contacted by phone, and the health status of the baby and their history of jaundice and treatment was recorded.

    Results: Based on transcutaneous bilirubin at discharge, 22/261 (8.4%) in the early group and 25/263 (9.5%) in the delayed group (P = 0.76) were at high risk of subse‐ quent hyperbilirubinemia. At the 4‐week follow‐up, jaundice was reported in 13/253 (5.1%) in the early and 17/253 (6.7%) in the delayed group (P = 0.57) and 3/253 (1.2 %) of the early and 1/253 (0.4%) of the delayed group (P = 0.62) received treatment. All analyses were based on intention‐to‐treat.

    Conclusion: Delayed cord clamping was not associated with an increased risk of hy‐ perbilirubinaemia during the first day of life or risk of jaundice within 4 weeks com‐ pared with the early group.

  • 43.
    Rana, Nisha
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Ranneberg, Linda Jarawka
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Andersson, Ola
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Effect of delayed cord clamping on risk of hyperbilirubinemia in term newborns: A randomsed clinical trial in NepalIngår i: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227Artikel i tidskrift (Övrigt vetenskapligt)
    Abstract [en]

    Aim: The aim of this study is to investigate the effects of delayed cord clamping on the risk of hyperbilirubinemia in term newborns.

    Method: Term normal vagainal deliveries (n=540) were randomized in two groups; early (≤ 60 seconds) versus delayed (≥ 180 seconds) cord clamping between 2 October and 21 November, 2014 at Paropakar Maternity and Women's hospital in Kathmandu, Nepal. At discharge, transcutaneous bilirubin was measured on both groups. At four weeks, all parents completed a semi-structured questionnaire, health status of the baby was recorded, and jaundice was assessed and treated.

    Result: Based on gestational age and age measured in hours after birth, 32.3% of the early and 33.2% of the delayed group had bilirubin levels high enough for phototherapy to be considered (p=0.78). At four weeks follow up jaundice was reported among 13 (5.1%) in the early, and 17 (6.7%) in the delayed group (p=0.57). Treatment for jaundice was gven to 3 (1.2%) of the early and 1 (0.4%) of the delayed group (p=0.62).

    Conclution: Delayed cord clamping was not associated with an increased risk of hyperbilirubinaemia during the first day of the life or risk of jaundice within 4 weeks compared with early cord clamping group.

  • 44. Thapa, Jeevan
    et al.
    Budhathoki, Shyam Sundar
    Gurung, Rejina
    Paudel, Prajwal
    Jha, Bijay
    Ghimire, Anup
    Wrammert, Johan
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH), Internationell barnhälsa och nutrition.
    Equity and Coverage in the Continuum of Reproductive, Maternal, Newborn and Child Health Services in Nepal-Projecting the Estimates on Death Averted Using the LiST Tool.2019Ingår i: Maternal and Child Health Journal, ISSN 1092-7875, E-ISSN 1573-6628Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

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

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

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

  • 45.
    Wrammert, Johan
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH). Children's University Hospital, Akademiska Sjukhuset, Uppsala, Sweden.
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH). Health Section, UNICEF Nepal Country office, Leknath Marg, Nepal.
    Ewald, Uwe
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Improved postnatal care is needed to maintain gains in neonatal survival after the implementation of the Helping Babies Breathe initiative2017Ingår i: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 106, nr 8, s. 1280-1285Artikel i tidskrift (Refereegranskat)
    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.

  • 46.
    Wrammert, Johan
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Sapkota, Sabitri
    Marie Stopes International.
    Baral, Kedar
    Patan Academy of Health Sciences.
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Larsson, Margareta
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Teamwork among midwives during neonatal resuscitation at a maternity hospital in Nepal2017Ingår i: Women and Birth, ISSN 1871-5192, E-ISSN 1878-1799, Vol. 30, nr 3, s. 262-269, artikel-id S1871-5192(16)30120-2Artikel i tidskrift (Refereegranskat)
    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.

  • 47.
    Wrammert, Johan
    et al.
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Zetterlund, Camilla
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa.
    KC, Ashish
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Ewald, Uwe
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Målqvist, Mats
    Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
    Resuscitation practices of low and normal birth weight infants in Nepal: an observational study using video camera recordings2017Ingår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, nr 1, artikel-id 1322372Artikel i tidskrift (Övrigt vetenskapligt)
    Abstract [en]

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

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

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

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

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

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