| 1. |
- Bergman, Mattias, et al.
(author)
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Prolonged Exclusive Breastfeeding Through Peer Support : A Cohort Study From a Community Outreach Project in Swaziland
- 2016
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In: Journal of community health. - : Springer Science and Business Media LLC. - 0094-5145 .- 1573-3610. ; 41:5, s. 932-938
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Journal article (peer-reviewed)abstract
- Swaziland faces great public health challenges, including suboptimal breastfeeding practices and the world's highest prevalence of HIV. The objective of this study was to estimate neonatal and infant mortality rate and rate of exclusive breastfeeding for clients enrolled in a community-based peer support project in peri-urban areas of Swaziland. The intervention builds on the so called "Philani-model" with Mentor Mothers in the community under high level of supervision. Cohort data was collected from journals kept by the Mentor Mothers. Kaplan-Meier and Cox regression were used to analyse data. Neonatal and infant mortality were estimated to 15 respectively 57 per 1000 live births. High level of social vulnerability was associated with risk of neonatal mortality (HR 1.12, CI 95 % 1.01-1.24) while the mother's positive HIV status was associated with infant mortality (HR 2.05, CI 95 % 1.15-3.65). More visits by a Mentor Mother could not be shown to result in lower mortality. The chance to practice exclusive breastfeeding for 6 months was estimated to 50 %. The risk of discontinuing exclusive breastfeeding before 6 months was lower for mothers being unemployed (HR 0.55, CI 95 % 0.44-0.69) or socially vulnerable (HR 0.95, CI 95 % 0.92-0.99) and higher for mothers being HIV positive (HR 1.22, CI 95 % 1.01-1.48). Receiving at least four visits by a Mentor Mother during pregnancy decreased the risk of discontinuing exclusive breastfeeding prematurely (HR 0.82, CI 95 % 0.67-0.99). Peer support with Mentor Mothers thus had a positive impact on exclusive breastfeeding rates in this disadvantaged population.
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| 2. |
- Brunell, Olivia, et al.
(author)
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Effect of a perinatal care quality improvement package on patient satisfaction : a secondary outcome analysis of a cluster-randomised controlled trial
- 2022
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In: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 12:6
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Journal article (peer-reviewed)abstract
- Objective To investigate the effect of a quality improvement (QI) package on patient satisfaction of perinatal care. Design Secondary analysis of a stepped-wedge cluster-randomised controlled trial. Participating hospitals were randomised by size into four different wedges. Setting 12 secondary-level public hospitals in Nepal. Participants Women who gave birth in the hospitals at a gestational age of 22 weeks, with fetal heart sound at admission. Adverse outcomes were excluded. One hospital was excluded due to data incompleteness and four low-volume hospitals due to large heterogeneity. The final analysis included 54 919 women. Intervention Hospital management was engaged and facilitators were recruited from within hospitals. Available perinatal care was assessed in each hospital, followed by a bottle-neck analysis workshop. A 3-day training in essential newborn care was carried out for health workers involved in perinatal care, and a set of QI tools were introduced to be used in everyday practice (skill-checks, self-assessment checklists, scoreboards and weekly Plan-Do-Study-Act meetings). Refresher training after 6 months. Outcome measure Women's satisfaction with care during childbirth (a prespecified secondary outcome). Results The likelihood of women being overall satisfied with care during childbirth increased after the intervention (adjusted OR (aOR): 1.66, 95% CI: 1.59 to 1.73). However, the proportions of overall satisfaction were low (control 58%, intervention 62%). Women were more likely to be satisfied with education and information from health workers after intervention (aOR: 1.34, 95% CI: 1.29 to 1.40) and to have been treated with dignity and respect (aOR: 1.81, 95% CI: 1.52 to 2.16). The likelihood of having experienced abuse during the hospital stay decreased (aOR: 0.42, 95% CI: 0.34 to 0.51) and of being satisfied with the level of privacy increased (aOR: 1.14,95% CI: 1.09 to 1.18). Conclusions Improvements in patient satisfaction were indicated after the introduction of a 01-package on perinatal care. We recommend further studies on which aspects of care are most important to improve women's satisfaction of perinatal care in hospitals in Nepal.
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| 3. |
- Brunell, Olivia, et al.
(author)
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Effect of a quality improvement package on early essential newborn care in public hospitals of Nepal, a multi-center observational cohort study.
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Other publication (other academic/artistic)abstract
- Background: Poor quality of care is a major cause of neonatal mortality and morbidity. WHO recommendations for quality care at birth includes provision of early essential newborn care (EENC): immediate and thorough drying, immediate skin-to-skin contact, delayed cord clamping, and early initiation of breastfeeding. Objective: To evaluate the impact of a Quality Improvement (QI) package on EENC practices in public hospitals of Nepal.Method: This was a multi-center observational cohort study in 4 public hospitals of Nepal. The study was conducted over a period of 15 months between July 2017 - October 2018. Using an independent research team, observations of immediate care of vaginally born neonates were done using an observation checklist. A QI package was introduced in the hospitals over a period of 12 months and we evaluated the change in EENC practices before and after, using multivariate logistic regression.Results: We included 27,009 newborns for analysis. The rate of initiation of breastfeeding within one hour increased in all hospitals in the intervention period, from 5% to 12% overall, compared to pre-intervention. Delayed cord clamping increased in three of the four study hospitals, from 22% to 33% overall. Immediate drying was widely performed both pre-intervention and during intervention, with a slight overall decrease from 98%-97%. However, immediate skin-to-skin contact dropped in three of the included hospitals, from 89% to 70% overall. Only a small proportion received all four EENC practices both pre-intervention (1.4%) and during intervention (3.8%).Conclusion: Adherence to EENC recommendations is inadequate in Nepal, and as a result not all newborn infants receive quality care at birth. Implementing QI interventions can bring changes in the EENC practices in public hospitals of Nepal, however further studies are required to assess the predictors, especially the role of the local context, to avoid unexpected negative impact.
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| 4. |
- Brunell, Olivia, et al.
(author)
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Exploration of factors affecting parent-infant closeness and separation in hospitals in Nepal : a qualitative study
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Other publication (other academic/artistic)abstract
- Aim: Closeness is crucial for the physical, emotional and social well-being of both parent and child. Though the benefits of closeness are proven for stable and unstable newborns, separation often remains standard, especially for small or sick newborns. We aimed to explore factors affecting closeness and separation of parents and newborns in hospitals in Nepal. Method: A qualitative design was used. Data was collected by individual interviews with 10 health care workers from labor rooms, post-natal wards or sick newborn care units/neonatal intensive care units, in five referral hospitals in Nepal. Data was analyzed using an inductive thematic approach. Results: Three main themes were generated, 1) Hospital resources, 2) In-hospital practices and attitudes, and 3) Parental-newborn relationships and social factors. Keeping the newborns spatially close to their mothers, offering a comfortable environment, and privacy were thought to enhance closeness, while heavy workload and lack of workforce hampered efforts to enhance closeness. Routines and rules separated parents and newborns, while actions and attitudes among health care workers strengthened closeness. Parental involvement, and the influence of various social aspects such as education, cultural beliefs and gender discrimination, were discussed.Conclusion: Though closeness was considered important, separation was common due to limited resources and existing rules and routines in the hospitals. Introducing small, low-cost changes in the wards, like offering a comfortable place to sit, can help keep the parents close and lessen the workload for health care workers. To avoid separation, hospital rules and practices should be changed, and the parents should be supported to take on the role of primary caregivers, with medical support from health care workers. There are traditions and cultural beliefs in society that hampers parental-infant closeness and gender discrimination remains a problem.
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| 5. |
- Brunell, Olivia
(author)
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Improving neonatal health care in Nepal
- 2022
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Doctoral thesis (other academic/artistic)abstract
- Every year, millions of newborns die globally due to poor quality of care around the time of birth. The overall aim of this thesis was to inform and test design of quality improvement (QI) interventions in Nepal. Contextual factors of importance for implementation of evidence-based newborn care practices were investigated, and the effect of a package of QI interventions on provision and experience of care was evaluated. In Paper I, we used focus group discussions and key informant interviews with delivery care staff to identify barriers and enablers for delayed umbilical cord clamping (DCC). Results indicate that delivery care staff needed knowledge of the benefits of DCC to gain motivation for change. Training, supervision and evaluation were requested to be able to change old routines, and they wanted authorized guidelines to bring uniformity in clinical practice. In Paper II, individual interviews with staff working with newborn infants were used to explore factors affecting parent-infant closeness in hospitals. Informants thought that offering a comfortable environment, privacy and counselling would enhance parent-infant closeness, but hospital resources were insufficient to achieve this. They described routines in the hospitals, and traditions and cultural beliefs in the society, which separated parents and newborns. In Paper III, a stepped-wedge randomized control design was applied to evaluate the effect of a QI package including training, facilitation and feedback, on patient satisfaction. The likelihood of women being overall satisfied with care during childbirth increased (aOR 1.66 [CI: 1.59-1.73, ICC: 0.275]) but the overall proportion of satisfaction was low, increasing from 58% to 62%. In Paper IV, clinical observations of early essential newborn care (EENC) practices were done before and after the introduction of the QI package. Overall, the rate of initiation of breastfeeding within one hour increased from 5% to 12%, and DCC increased from 22% to 33%. In conclusion, when designing interventions to improve quality of care, in Nepal or similar settings, it is important to use authorized guidelines and include education, training, supervision and evaluation. Hospital resources, routines and cultural beliefs need to be considered. The results indicate that a multi-pronged QI package can improve quality of newborn care in Nepal.
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| 6. |
- Chaulagain, Dipak, et al.
(author)
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Effect of a scaled-up quality improvement intervention on health workers' competence on neonatal resuscitation in simulated settings in public hospitals : A pre-post study in Nepal
- 2021
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In: PLOS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 16:4
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Journal article (peer-reviewed)abstract
- Background Helping Babies Breathe (HBB) training improves bag and mask ventilation and reduces neonatal mortality and fresh stillbirths. Quality improvement (QI) interventions can improve retention of neonatal resuscitation knowledge and skills. This study aimed to evaluate the effect of a scaled-up QI intervention package on uptake and retention of neonatal resuscitation knowledge and skills in simulated settings. Methods This was a pre-post study in 12 public hospitals of Nepal. Knowledge and skills of trainees on neonatal resuscitation were evaluated against the set standard before and after the introduction of QI interventions. Results Altogether 380 participants were included for knowledge evaluation and 286 for skill evaluation. The overall knowledge test score increased from 14.12 (pre-basic) to 15.91 (post-basic) during basic training (p < 0.001). The knowledge score decreased over time; 15.91 (post-basic) vs. 15.33 (pre-refresher) (p < 0.001). Overall skill score during basic training (16.98 1.79) deteriorated over time to 16.44 1.99 during refresher training (p < 0.001). The proportion of trainees passing the knowledge test increased to 91.1% (post-basic) from 67.9% (pre-basic) which decreased to 86.6% during refresher training after six months. The knowledge and skill scores were maintained above the set standard (>14.0) over time at all hospitals during refresher training. Conclusion HBB training together with QI tools improves health workers' knowledge and skills on neonatal resuscitation, irrespective of size and type of hospitals. The knowledge and skills deteriorate over time but do not fall below the standard. The HBB training together with QI interventions can be scaled up in other public hospitals. Trial registration This study was part of the larger Nepal Perinatal Quality Improvement Project (NePeriQIP) with International Standard Randomised Controlled Trial Number, ISRCTN30829654, registered 17(th) of May, 2017.
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| 7. |
- Chaulagain, Dipak, et al.
(author)
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Effect of a scaled-up quality improvement intervention on health workers' competence on neonatal resuscitation in simulated settings in public hospitals: A pre-post study in Nepal.
- 2021
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In: PloS one. - : Public Library of Science (PLoS). - 1932-6203. ; 16:4
-
Journal article (peer-reviewed)abstract
- Helping Babies Breathe (HBB) training improves bag and mask ventilation and reduces neonatal mortality and fresh stillbirths. Quality improvement (QI) interventions can improve retention of neonatal resuscitation knowledge and skills. This study aimed to evaluate the effect of a scaled-up QI intervention package on uptake and retention of neonatal resuscitation knowledge and skills in simulated settings.This was a pre-post study in 12 public hospitals of Nepal. Knowledge and skills of trainees on neonatal resuscitation were evaluated against the set standard before and after the introduction of QI interventions.Altogether 380 participants were included for knowledge evaluation and 286 for skill evaluation. The overall knowledge test score increased from 14.12 (pre-basic) to 15.91 (post-basic) during basic training (p < 0.001). The knowledge score decreased over time; 15.91 (post-basic) vs. 15.33 (pre-refresher) (p < 0.001). Overall skill score during basic training (16.98 ± 1.79) deteriorated over time to 16.44 ± 1.99 during refresher training (p < 0.001). The proportion of trainees passing the knowledge test increased to 91.1% (post-basic) from 67.9% (pre-basic) which decreased to 86.6% during refresher training after six months. The knowledge and skill scores were maintained above the set standard (>14.0) over time at all hospitals during refresher training.HBB training together with QI tools improves health workers' knowledge and skills on neonatal resuscitation, irrespective of size and type of hospitals. The knowledge and skills deteriorate over time but do not fall below the standard. The HBB training together with QI interventions can be scaled up in other public hospitals.This study was part of the larger Nepal Perinatal Quality Improvement Project (NePeriQIP) with International Standard Randomised Controlled Trial Number, ISRCTN30829654, registered 17th of May, 2017.
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| 8. |
- Chaulagain, Dipak, et al.
(author)
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Performance of health workers on neonatal resuscitation care following scaled-up quality improvement interventions in public hospitals of Nepal - a prospective observational study.
- 2021
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In: BMC health services research. - : Springer Science and Business Media LLC. - 1472-6963. ; 21:1
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Journal article (peer-reviewed)abstract
- High-quality resuscitation among non-crying babies immediately after birth can reduce intrapartum-related deaths and morbidity. Helping Babies Breathe program aims to improve performance on neonatal resuscitation care in resource-limited settings. Quality improvement (QI) interventions can sustain simulated neonatal resuscitation knowledge and skills and clinical performance. This study aimed to evaluate the effect of a scaled-up QI intervention package on the performance of health workers on basic neonatal resuscitation care among non-crying infants in public hospitals in Nepal.A prospective observational cohort design was applied in four public hospitals of Nepal. Performances of health workers on basic neonatal care were analysed before and after the introduction of the QI interventions.Out of the total 32,524 births observed during the study period, 3031 newborn infants were not crying at birth. A lower proportion of non-crying infants were given additional stimulation during the intervention compared to control (aOR 0.18; 95% CI 0.13-0.26). The proportion of clearing the airway increased among non-crying infants after the introduction of QI interventions (aOR 1.23; 95% CI 1.03-1.46). The proportion of non-crying infants who were initiated on BMV was higher during the intervention period (aOR 1.28, 95% CI 1.04-1.57) compared to control. The cumulative median time to initiate ventilation during the intervention was 39.46 s less compared to the baseline.QI intervention package improved health workers' performance on the initiation of BMV, and clearing the airway. The average time to first ventilation decreased after the implementation of the package. The QI package can be scaled-up in other public hospitals in Nepal and other similar settings.
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| 9. |
- Chaulagain, Dipak, 1980-, et al.
(author)
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Service readiness and availability of perinatal care in public hospitals - a multi-centric baseline study in Nepal
- 2022
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In: BMC Pregnancy and Childbirth. - : BioMed Central (BMC). - 1471-2393 .- 1471-2393. ; 22:1
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Journal article (peer-reviewed)abstract
- BackgroundPoor quality of maternal and newborn care contributes to nearly two million deaths of mothers and their newborns worldwide annually. Assessment of readiness and availability of perinatal care services in health facilities provides evidence to underlying bottlenecks for improving quality of care. This study aimed to evaluate the readiness and availability of perinatal care services in public hospitals of Nepal using WHO’s health system framework.MethodsThis was a mixed methods study conducted in 12 public hospitals in Nepal. A cross-sectional study design was used to assess the readiness and availability of perinatal care services. Three different data collection tools were developed. The tools were pretested in a tertiary maternity hospital and the discrepancies in the tools were corrected before administering in the study hospitals. The data were collected between July 2017 to July 2018.ResultsOnly five out of 12 hospitals had the availability of all the basic newborn care services under assessment. Kangaroo mother care (KMC) service was lacking in most of the hospitals (7 out of 12). Only two hospitals had all health workers involved in perinatal care services trained in neonatal resuscitation. All of the hospitals were found not to have all the required equipment for newborn care services. Overall, only 60% of the health workers had received neonatal resuscitation training. A small proportion (3.2%) of the newborn infants with APGAR < 7 at one minute received bag and mask ventilation. Only 8.2% of the mothers initiated breastfeeding to newborn infants before transfer to the post-natal ward, 73.4% of the mothers received counseling on breastfeeding, and 40.8% of the mothers kept their newborns in skin-to-skin contact immediately after birth.ConclusionThe assessment reflected the gaps in the availability of neonatal care services, neonatal resuscitation training, availability of equipment, infrastructure, information system, and governance. Rapid scale-up of neonatal resuscitation training and increased availability of equipment is needed for improving the quality of neonatal care services.
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| 10. |
- Chaulagain, Dipak, 1980-, et al.
(author)
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Service readiness and availability of perinatal care in public hospitals - a multi-centric baseline study in Nepal.
- 2022
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In: BMC pregnancy and childbirth. - : Springer Science and Business Media LLC. - 1471-2393. ; 22:1
-
Journal article (peer-reviewed)abstract
- Poor quality of maternal and newborn care contributes to nearly two million deaths of mothers and their newborns worldwide annually. Assessment of readiness and availability of perinatal care services in health facilities provides evidence to underlying bottlenecks for improving quality of care. This study aimed to evaluate the readiness and availability of perinatal care services in public hospitals of Nepal using WHO's health system framework.This was a mixed methods study conducted in 12 public hospitals in Nepal. A cross-sectional study design was used to assess the readiness and availability of perinatal care services. Three different data collection tools were developed. The tools were pretested in a tertiary maternity hospital and the discrepancies in the tools were corrected before administering in the study hospitals. The data were collected between July 2017 to July 2018.Only five out of 12 hospitals had the availability of all the basic newborn care services under assessment. Kangaroo mother care (KMC) service was lacking in most of the hospitals (7 out of 12). Only two hospitals had all health workers involved in perinatal care services trained in neonatal resuscitation. All of the hospitals were found not to have all the required equipment for newborn care services. Overall, only 60% of the health workers had received neonatal resuscitation training. A small proportion (3.2%) of the newborn infants with APGAR < 7 at one minute received bag and mask ventilation. Only 8.2% of the mothers initiated breastfeeding to newborn infants before transfer to the post-natal ward, 73.4% of the mothers received counseling on breastfeeding, and 40.8% of the mothers kept their newborns in skin-to-skin contact immediately after birth.The assessment reflected the gaps in the availability of neonatal care services, neonatal resuscitation training, availability of equipment, infrastructure, information system, and governance. Rapid scale-up of neonatal resuscitation training and increased availability of equipment is needed for improving the quality of neonatal care services.
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