| 1. |
- 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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| 2. |
- 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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| 3. |
- 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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| 4. |
- 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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| 5. |
- 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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| 6. |
- Chaulagain, Dipak Raj, 1980-
(author)
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Improving quality of neonatal care practices in Nepal
- 2022
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Doctoral thesis (other academic/artistic)abstract
- Despite the availability of cost-effective interventions, resource-poor countries are facing a high burden of preventable neonatal deaths, mainly due to low coverage and poor quality of care. The aim of this thesis was to evaluate the effect of a scaled-up neonatal resuscitation quality improvement (QI) package on newborn care practices in Nepal. The studies were conducted in 12 second-level public hospitals in Nepal where the QI package was scaled up. The QI package was based on the Plan-Do-Study and Act (PDSA) approach with three major implementation strategies; facilitation, training, and audit and feedback. At baseline, readiness and availability of perinatal care services were evaluated using a cross-sectional design (Paper I). A pre-post study design was used to assess the effect of the QI package on the competency of health workers on neonatal resuscitation (Paper II). Prospective observational studies were conducted in four out of the 12 hospitals to assess the effect of QI package on neonatal resuscitation and early essential newborn care (EENC) practices (Paper III and IV). At baseline, only five out of the 12 hospitals had all basic newborn care services under assessment and only 60% of the health workers had received training on neonatal resuscitation. After introducing the QI package, we observed an improvement in the knowledge and skills of health workers on neonatal resuscitation, which was maintained over time in all participating hospitals. In clinical practice, the proportion of clearing the airway increased among non-crying infants. We observed improved performance of health workers on the most crucial neonatal resuscitation action; initiation of bag and mask ventilation (BMV). The cumulative median time to first ventilation during the implementation period was 39 seconds less compared to the baseline. Overall, the rate of initiation of breastfeeding increased from 5% to 13%, and delayed cord clamping increased from 25% to 31%. The likelihood for a newborn to receive at least three of the four observed EENC practices increased threefold during the intervention period. The QI package showed a positive impact in improving quality of newborn care and can be scaled up in other hospitals in Nepal and similar settings.
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| 7. |
- 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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| 8. |
- 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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| 9. |
- KC, Ashish, 1982-, et al.
(author)
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Scaling up quality improvement intervention for perinatal care in Nepal (NePeriQIP); study protocol of a cluster randomised trial
- 2017
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In: BMJ Global Health. - : BMJ. - 2059-7908. ; 2:3
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Journal article (peer-reviewed)abstract
- 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.
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