| 1. |
- Gautam Paudel, Pragya, et al.
(author)
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Prevalence, risk factors and consequences of newborns born small for gestational age : a multisite study in Nepal.
- 2020
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In: BMJ Paediatrics Open. - : BMJ. - 2399-9772. ; 4:1
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Journal article (peer-reviewed)abstract
- Objective: To identify the prevalence, risk factors and health impacts associated with small for gestational age (SGA) births in Nepal.Methods: A cross-sectional study was conducted in 12 public hospitals in Nepal from 1 July 2017 to 29 August 2018. A total of 60 695 babies delivered in these hospitals during the study period were eligible for inclusion. Clinical information of mothers and newborns was collected by data collectors using a data retrieval form. A semistructured interview was conducted at the time of discharge to gather sociodemographic information from women who provided the consent (n=50 392). Babies weighing less than the 10th percentile for their gestational age were classified as SGA. Demographic, obstetric and neonatal characteristics of study participants were analysed for associations with SGA. The association between SGA and likelihood of babies requiring resuscitation or resulting in stillbirth and neonatal death was also explored.Results: The prevalence of SGA births across the 12 hospitals observed in Nepal was 11.9%. After multiple variable adjustment, several factors were found to be associated with SGA births, including whether mothers were illiterate compared with those completing secondary and higher education (adjusted OR (AOR)=1.73; 95% CI 1.09 to 2.76), use of polluted fuel compared with use of clean fuel for cooking (AOR=1.51; 95% CI 1.16 to 1.97), first antenatal care (ANC) visit occurring during the third trimester compared with first trimester (AOR=1.82; 95% CI 1.27 to 2.61) and multiple deliveries compared with single delivery (AOR=3.07; 95% CI 1.46 to 6.46). SGA was significantly associated with stillbirth (AOR=7.30; 95% CI 6.26 to 8.52) and neonatal mortality (AOR=5.34; 95% CI 4.65 to 6.12).Conclusions: Low literacy status of mothers, use of polluted fuel for cooking, time of first ANC visit and multiple deliveries are associated with SGA births. Interventions encouraging pregnant women to attend ANC visits early can reduce the burden of SGA births.
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| 2. |
- Budhathoki, Shyam Sundar, et al.
(author)
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Epidemiology of neonatal infections in hospitals of Nepal : evidence from a large- scale study
- 2020
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In: Archives of Public Health. - : BMC. - 0778-7367 .- 2049-3258. ; 78
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Journal article (peer-reviewed)abstract
- Background: Every year, neonatal infections account for approximately 750,000 neonatal deaths globally. It is the third major cause of neonatal death, globally and in Nepal. There is a paucity of data on clinical aetiology and outcomes of neonatal infection in Nepal. This paper aims to assess the incidence and risk factors of neonatal infection in babies born in public hospitals of Nepal.Methods: This is a prospective cohort study conducted for a period of 14 months, nested within a large-scale cluster randomized control trial which evaluated the Helping Babies Breathe Quality Improvement package in 12 public hospitals in Nepal. All the mothers who consented to participate within the study and delivered in these hospitals were included in the analysis. All neonates admitted into the sick newborn care unit weighing > 1500 g or/and 32 weeks or more gestation with clinical signs of infection or positive septic screening were taken as cases and those that did not have an infection were the comparison group. Bivariate and multi-variate analysis of socio-demographic, maternal, obstetric and neonatal characteristics of case and comparison group were conducted to assess risk factors associated with neonatal infection.Results: The overall incidence of neonatal infection was 7.3 per 1000 live births. Babies who were born to first time mothers were at 64% higher risk of having infection (aOR-1.64, 95% CI, 1.30-2.06, p-value< 0.001). Babies born to mothers who had no antenatal check-up had more than three-fold risk of infection (aOR-3.45, 95% CI, 1.82-6.56, p-value< 0.001). Babies born through caesarean section had more than two-fold risk (aOR-2.06, 95% CI, 1.48-2.87, p-value< 0.001) and babies with birth asphyxia had more than three-fold risk for infection (aOR-3.51, 95% CI, 1.71-7.20, p-value = 0.001).Conclusion: Antepartum factors, such as antenatal care attendance, and intrapartum factors such as mode of delivery and birth asphyxia, were risk factors for neonatal infections. These findings highlight the importance of ANC visits and the need for proper care during resuscitation in babies with birth asphyxia.
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| 3. |
- Ekman, Beatrice, et al.
(author)
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Adherence to World Health Organisation guidelines for treatment of early onset neonatal sepsis in low-income settings; a cohort study in Nepal.
- 2020
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In: BMC infectious diseases. - : Springer Science and Business Media LLC. - 1471-2334. ; 20:1
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Journal article (peer-reviewed)abstract
- Neonatal sepsis is one of the major causes of death during the first month of life and early empirical treatment with injectable antibiotics is a life-saving intervention. Adherence to World Health Organisation guidelines on first line antibiotics is crucial to mitigate the risks of increased antimicrobial resistance. The aim of this paper was to evaluate if treatment of early onset neonatal sepsis in a low-income facility setting observe current guidelines and if compliance is influenced by contextual factors.This cohort study used data on antimicrobial treatment of neonatal sepsis onset within 72 h of life from 12 regional hospitals participating in a scale-up trial of a neonatal resuscitation quality improvement package intervention in Nepal. Infants treated according to guidelines were compared with those receiving other antimicrobials. A multiple logistic regression analysis adjusted for the intervention and time trend was applied.1564 infants with a preliminary diagnosis of early onset sepsis were included. A majority (74.9%) were treated according to guidelines and adherence was increasing over time. Infants born at larger facilities (adjusted Odds Ratio 5.6), those that were inborn (adjusted Odds Ratio 1.97) or belonging to a family of dis-advantaged caste (adjusted Odds Ratio 2.15) had higher odds for treatment according to guidelines. A clinical presentation of lethargy or tachypnoea was associated with adherence to guidelines.Adherence to guidelines for antibiotic treatment of early neonatal sepsis was moderately high in this low-income setting. Odds for observing guidelines increased with facility size, for inborn infants and if the family belonged to a dis-advantaged caste. Cefotaxime was a common alternative choice when guidelines were not followed, highly relevant for the risk of increased antimicrobial resistance.ISRCTN, ISRCTN30829654 , registered 17th of May, 2017.
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| 4. |
- Gurung, Abhishek, et al.
(author)
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Incidence, risk factors and consequences of preterm birth - findings from a multi-centric observational study for 14 months in Nepal
- 2020
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In: Archives of Public Health. - : BMC. - 0778-7367 .- 2049-3258. ; 78:1
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Journal article (peer-reviewed)abstract
- Background Preterm birth is a worldwide epidemic and a leading cause of neonatal mortality. In this study, we aimed to evaluate the incidence, risk factors and consequences of preterm birth in Nepal. Methods This was an observational study conducted in 12 public hospitals of Nepal. All the babies born during the study period were included in the study. Babies born < 37 weeks of gestation were classified as preterm births. For the association and outcomes for preterm birth, univariate followed by multiple regression analysis was conducted. Results The incidence of preterm was found to be 93 per 1000 live births. Mothers aged less than 20 years (aOR 1.26;1.15-1.39) had a high risk for preterm birth. Similarly, education of the mother was a significant predictor for preterm birth: illiterate mothers (aOR 1.41; 1.22-1.64), literate mothers (aOR 1.21; 1.08-1.35) and mothers having basic level of education (aOR 1.17; 1.07-1.27). Socio-demographic factors such as smoking (aOR 1.13; 1.01-1.26), use of polluted fuel (aOR 1.26; 1.17-1.35) and sex of baby (aOR 1.18; 1.11-1.26); obstetric factors such as nulliparity (aOR 1.33; 1.20-1.48), multiple delivery (aOR 6.63; 5.16-8.52), severe anemia during pregnancy (aOR 3.27; 2.21-4.84), antenatal visit during second trimester (aOR 1.13; 1.05-1.22) and third trimester (aOR 1.24; 1.12-1.38), < 4 antenatal visits during pregnancy (aOR 1.49; 1.38-1.61) were found to be significant risk factors of preterm birth. Preterm has a risk for pre-discharge mortality (10.60; 9.28-12.10). Conclusion In this study, we found high incidence of preterm birth. Various socio-demographic, obstetric and neonatal risk factors were associated with preterm birth. Risk factor modifications and timely interventions will help in the reduction of preterm births and associated mortalities.
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| 5. |
- Gurung, Rejina, et al.
(author)
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Predictors for timely initiation of breastfeeding after birth in the hospitals of Nepal- a prospective observational study.
- 2021
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In: International breastfeeding journal. - : Springer Science and Business Media LLC. - 1746-4358. ; 16:1
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Journal article (peer-reviewed)abstract
- Timely initiation of breastfeeding can reduce neonatal morbidities and mortality. We aimed to study predictors for timely initiation of breastfeeding (within 1 h of birth) among neonates born in hospitals of Nepal.A prospective observational study was conducted in four public hospitals between July and October 2018. All women admitted in the hospital for childbirth and who consented were included in the study. An independent researchers observed whether the neonates were placed in skin-to-skin contact, delay cord clamping and timely initiation of breastfeeding. Sociodemographic variables, obstetric and neonate information were extracted from the maternity register. We analysed predictors for timely initiation of breastfeeding with Pearson chi-square test and multivariate logistic regression.Among the 6488 woman-infant pair observed, breastfeeding was timely initiated in 49.5% neonates. The timely initiation of breastfeeding was found to be higher among neonates who were placed skin-to-skin contact (34.9% vs 19.9%, p - value < 0.001). The timely initiation of breastfeeding was higher if the cord clamping was delayed than early cord clamped neonates (44.5% vs 35.3%, p - value < 0.001). In multivariate analysis, a mother with no obstetric complication during admission had 57% higher odds of timely initiation of breastfeeding (aOR 1.57; 95% CI 1.33, 1.86). Multiparity was associated with less timely initiation of breastfeeding (aOR 1.56; 95% CI 1.35, 1.82). Similarly, there was more common practice of timely initiation of breastfeeding among low birthweight neonates (aOR 1.46; 95% CI 1.21, 1.76). Neonates who were placed skin-to-skin contact with mother had more than two-fold higher odds of timely breastfeeding (aOR 2.52; 95% CI 2.19, 2.89). Likewise, neonates who had their cord intact for 3 min had 37% higher odds of timely breastfeeding (aOR 1.37; 95% CI 1.21, 1.55).The rate of timely initiation of breastfeeding practice is low in the health facilities of Nepal. Multiparity, no obstetric complication at admission, neonates placed in skin-to-skin contact and delay cord clamping were strong predictors for timely initiation of breastfeeding. Quality improvement intervention can improve skin-to-skin contact, delayed cord clamping and timely initiation of breastfeeding.
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| 6. |
- Gurung, Rejina, et al.
(author)
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REFINE (Rapid Feedback for quality Improvement in Neonatal rEsuscitation): an observational study of neonatal resuscitation training and practice in a tertiary hospital in Nepal.
- 2020
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In: BMC pregnancy and childbirth. - : Springer Science and Business Media LLC. - 1471-2393. ; 20:1
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Journal article (peer-reviewed)abstract
- Simulation-based training in neonatal resuscitation is more effective when reinforced by both practice and continuous improvement processes. We aim to evaluate the effectiveness of a quality improvement program combined with an innovative provider feedback device on neonatal resuscitation practice and outcomes in a public referral hospital of Nepal.A pre- and post-intervention study will be implemented in Pokhara Academy of Health Sciences, a hospital with 8610 deliveries per year. The intervention package will include simulation-based training (Helping Babies Breathe) enhanced with a real-time feedback system (the NeoBeat newborn heart rate meter with the NeoNatalie Live manikin and upright newborn bag-mask with PEEP) accompanied by a quality improvement process. An independent research team will collect perinatal data and conduct stakeholder interviews.This study will provide further information on the efficiency of neonatal resuscitation training and implementation in the context of new technologies and quality improvement processes.https://doi.org/10.1186/ISRCTN18148368 , date of registration-31 July 2018.
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| 7. |
- Gurung, Rejina, et al.
(author)
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Scaling Up Safer Birth Bundle Through Quality Improvement in Nepal (SUSTAIN) - a stepped wedge cluster randomized controlled trial in public hospitals
- 2019
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In: Implementation Science. - : BMC. - 1748-5908. ; 14
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Journal article (peer-reviewed)abstract
- 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.
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| 8. |
- Gurung, Rejina, et al.
(author)
-
Scaling Up Safer Birth Bundle Through Quality Improvement in Nepal (SUSTAIN)-a stepped wedge cluster randomized controlled trial in public hospitals.
- 2019
-
In: Implementation science : IS. - : Springer Science and Business Media LLC. - 1748-5908. ; 14:1
-
Journal article (peer-reviewed)abstract
- 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 package-Scaling Up Safer Bundle Through Quality Improvement in Nepal (SUSTAIN)-on intrapartum care and intrapartum-related mortality in public hospitals of Nepal.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 2 months 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 19 months 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®) and neonatal heart rate monitors (Neobeat®) 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.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.ISRCTN16741720 . Registered on 2 March 2019.
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| 9. |
- Gurung, Rejina, et al.
(author)
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The burden of misclassification of antepartum stillbirth in Nepal
- 2019
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In: BMJ Global Health. - : BMJ. - 2059-7908. ; 4:6
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Journal article (peer-reviewed)abstract
- 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.
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| 10. |
- Gurung, Rejina, et al.
(author)
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The burden of misclassification of antepartum stillbirth in Nepal.
- 2019
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In: BMJ global health. - : BMJ. - 2059-7908. ; 4:6
-
Journal article (peer-reviewed)abstract
- 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.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.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).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.ISRCTN30829654.
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| 11. |
- KC, Ashish, 1982-, et al.
(author)
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Effect of a scaled-up neonatal resuscitation quality improvement package on intrapartum-related mortality in Nepal : A stepped-wedge cluster randomized controlled trial
- 2019
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In: PLoS Medicine. - : PUBLIC LIBRARY SCIENCE. - 1549-1277 .- 1549-1676. ; 16:9
-
Journal article (peer-reviewed)abstract
- 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.
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| 12. |
- KC, Ashish, 1982, et al.
(author)
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Effect of a scaled-up neonatal resuscitation quality improvement package on intrapartum-related mortality in Nepal: A stepped-wedge cluster randomized controlled trial.
- 2019
-
In: PLoS medicine. - : Public Library of Science (PLoS). - 1549-1676 .- 1549-1277. ; 16:9
-
Journal article (peer-reviewed)abstract
- 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.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.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.ISRCTN30829654.
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| 13. |
- KC, Ashish, 1982, et al.
(author)
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Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study.
- 2020
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In: The Lancet. Global health. - 2214-109X. ; 8:10, s. e1273-e1281
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Journal article (peer-reviewed)abstract
- The COVID-19 pandemic response is affecting maternal and neonatal health services all over the world. We aimed to assess the number of institutional births, their outcomes (institutional stillbirth and neonatal mortality rate), and quality of intrapartum care before and during the national COVID-19 lockdown in Nepal.In this prospective observational study, we collected participant-level data for pregnant women enrolled in the SUSTAIN and REFINE studies between Jan 1 and May 30, 2020, from nine hospitals in Nepal. This period included 12·5 weeks before the national lockdown and 9·5 weeks during the lockdown. Women were eligible for inclusion if they had a gestational age of 22 weeks or more, a fetal heart sound at time of admission, and consented to inclusion. Women who had multiple births and their babies were excluded. We collected information on demographic and obstetric characteristics via extraction from case notes and health worker performance via direct observation by independent clinical researchers. We used regression analyses to assess changes in the number of institutional births, quality of care, and mortality before lockdown versus during lockdown.Of 22 907 eligible women, 21 763 women were enrolled and 20 354 gave birth, and health worker performance was recorded for 10 543 births. From the beginning to the end of the study period, the mean weekly number of births decreased from 1261·1 births (SE 66·1) before lockdown to 651·4 births (49·9) during lockdown-a reduction of 52·4%. The institutional stillbirth rate increased from 14 per 1000 total births before lockdown to 21 per 1000 total births during lockdown (p=0·0002), and institutional neonatal mortality increased from 13 per 1000 livebirths to 40 per 1000 livebirths (p=0·0022). In terms of quality of care, intrapartum fetal heart rate monitoring decreased by 13·4% (-15·4 to -11·3; p<0·0001), and breastfeeding within 1 h of birth decreased by 3·5% (-4·6 to -2·6; p=0·0032). The immediate newborn care practice of placing the baby skin-to-skin with their mother increased by 13·2% (12·1 to 14·5; p<0·0001), and health workers' hand hygiene practices during childbirth increased by 12·9% (11·8 to 13·9) during lockdown (p<0·0001).Institutional childbirth reduced by more than half during lockdown, with increases in institutional stillbirth rate and neonatal mortality, and decreases in quality of care. Some behaviours improved, notably hand hygiene and keeping the baby skin-to-skin with their mother. An urgent need exists to protect access to high quality intrapartum care and prevent excess deaths for the most vulnerable health system users during this pandemic period.Grand Challenges Canada.
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| 14. |
- Kukka, Antti Juhani, et al.
(author)
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NeuroMotion Smartphone Application for Remote General Movements Assessment : a Feasibility Study in Nepal
- 2024
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In: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 14:3
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Journal article (peer-reviewed)abstract
- OBJECTIVES: To evaluate the feasibility of using the NeuroMotion smartphone application for remote General Movements Assessment for screening of infants for cerebral palsy in Kathmandu, Nepal. METHOD: Thirty-one term born infants at risk of cerebral palsy due to birth asphyxia or neonatal seizures were recruited for the follow-up at Paropakar Maternity and Women’s Hospital, 1st October 2021 to 7th January 2022. Parents filmed their children at home using the app at 3 months’ age and the videos were assessed for technical quality using a standardized form and for fidgety movements by Prechtl’s General Movements Assessment. Usability of the app was evaluated through a parental survey. RESULTS: Twenty families sent in altogether 46 videos out of which 35 had approved technical quality. Sixteen children had at least one video with approved technical quality. Three infants lacked fidgety movements. The level of agreement between assessors was acceptable (Krippendorf alpha 0.781). Parental answers to the usability survey were in general positive. INTERPRETATION: Engaging parents in screening of cerebral palsy with the help of a smartphone-aided remote General Movements Assessment is possible in the urban area of a South Asian lower middle-income country.
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| 15. |
- Paudel, Prajwal, et al.
(author)
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Burden and consequence of birth defects in Nepal-evidence from prospective cohort study.
- 2021
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In: BMC pediatrics. - : Springer Science and Business Media LLC. - 1471-2431. ; 21:1
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Journal article (peer-reviewed)abstract
- Every year an estimated 7.9 million babies are born with birth defect. Of these babies, more than 3 million die and 3.2 million have disability. Improving nationwide information on prevalence of birth defect, risk factor and consequence is required for better resource allocation for prevention, management and rehabilitation. In this study, we assess the prevalence of birth defect, associated risk factors and consequences in Nepal.This is a prospective cohort study conducted in 12 hospitals of Nepal for 18 months. All the women who delivered in the hospitals during the study period was enrolled. Independent researchers collected data on the social and demographic information using semi-structured questionnaire at the time of discharge and clinical events and birth outcome information from the clinical case note. Data were analyzed on the prevalence and type of birth defect. Logistic regression was done to assess the risk factor and consequences for birth defect.Among the total 87,242 livebirths, the prevalence of birth defects was found to be 5.8 per 1000 live births. The commonly occurring birth defects were anencephaly (3.95%), cleft lip (2.77%), cleft lip and palate (6.13%), clubfeet (3.95%), eye abnormalities (3.95%) and meningomyelocele (3.36%). The odds of birth defect was higher among mothers with age < 20 years (adjusted Odds ratio (aOR) 1.64; 95% CI, 1.18-2.28) and disadvantaged ethnicity (aOR 1.78; 95% CI, 1.46-2.18). The odds of birth asphyxia was twice fold higher among babies with birth defect (aOR 1.88; 95% CI, 1.41-2.51) in reference with babies without birth defect. The odds of neonatal infection was twice fold higher among babies with birth defect (aOR 1.82; 95% CI, 1.12-2.96) in reference with babies without birth defect. Babies with birth defect had three-fold risk of pre-discharge mortality (aOR 3.00; 95% CI, 1.93-4.69).Maternal age younger than 20 years and advantaged ethnicity were risk factors of birth defects. Babies with birth defect have high risk for birth asphyxia, neonatal infection and pre-discharge mortality at birth. Further evaluation on the care provided to babies who have birth defect is warranted.Swedish Research Council (VR).
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| 16. |
- Paudel, Prajwal, et al.
(author)
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Meconium aspiration syndrome : incidence, associated risk factors and outcome-evidence from a multicentric study in low-resource settings in Nepal
- 2020
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In: Journal of Paediatrics and Child Health. - : WILEY. - 1034-4810 .- 1440-1754. ; 56:4, s. 630-635
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Journal article (peer-reviewed)abstract
- AimThe aim of this study was to identify the incidence, risk factors and outcome associated with meconium aspiration syndrome (MAS).MethodsAn observational study was conducted in 12 public hospitals in Nepal from 1 July 2017 to 29 August 2018. All babies born within the study period were included in the study. Babies who were diagnosed as MAS were designated as outcome. Data were analysed with bivariate analysis followed by multiple regression analysis.ResultsThe overall incidence of MAS was 2.0 per 1000 livebirths. Babies born at post‐term gestation (adjusted odds ratio (AOR) = 2.41; 95% confidence interval (CI): 1.05–5.55), nulliparity (AOR = 2.26; 95% CI: 1.20–4.28), instrumental delivery (AOR = 4.79; 95% CI: 2.52–9.10) and caesarean delivery (AOR = 3.67; 95% CI: 2.29–5.89) were significantly associated with MAS. Babies with MAS had a 10‐fold risk for pre‐discharge mortality (odds ratio = 9.87; 95% CI: 5.81–16.76).ConclusionsThe findings in this study are consistent with that reported in other studies. MAS has a high risk of neonatal mortality. Thus, monitoring during pregnancy and labour is necessary for early identification of high‐risk conditions associated with MAS. Strengthening of newborn care services is essential to curtail mortality.
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| 17. |
- Paudel, Prajwal, et al.
(author)
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Meconium aspiration syndrome: incidence, associated risk factors and outcome-evidence from a multicentric study in low-resource settings in Nepal.
- 2020
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In: Journal of paediatrics and child health. - : Wiley. - 1440-1754 .- 1034-4810. ; 56:4, s. 630-635
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Journal article (peer-reviewed)abstract
- The aim of this study was to identify the incidence, risk factors and outcome associated with meconium aspiration syndrome (MAS).An observational study was conducted in 12 public hospitals in Nepal from 1 July 2017 to 29 August 2018. All babies born within the study period were included in the study. Babies who were diagnosed as MAS were designated as outcome. Data were analysed with bivariate analysis followed by multiple regression analysis.The overall incidence of MAS was 2.0 per 1000 livebirths. Babies born at post-term gestation (adjusted odds ratio (AOR) = 2.41; 95% confidence interval (CI): 1.05-5.55), nulliparity (AOR = 2.26; 95% CI: 1.20-4.28), instrumental delivery (AOR = 4.79; 95% CI: 2.52-9.10) and caesarean delivery (AOR = 3.67; 95% CI: 2.29-5.89) were significantly associated with MAS. Babies with MAS had a 10-fold risk for pre-discharge mortality (odds ratio = 9.87; 95% CI: 5.81-16.76).The findings in this study are consistent with that reported in other studies. MAS has a high risk of neonatal mortality. Thus, monitoring during pregnancy and labour is necessary for early identification of high-risk conditions associated with MAS. Strengthening of newborn care services is essential to curtail mortality.
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| 18. |
- Sunny, Avinash K, et al.
(author)
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A multicenter study of incidence, risk factors and outcomes of babies with birth asphyxia in Nepal.
- 2021
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In: BMC pediatrics. - : Springer Science and Business Media LLC. - 1471-2431. ; 21:1
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Journal article (peer-reviewed)abstract
- Perinatal events which result in compromised oxygen delivery to the fetus can lead to Birth Asphyxia (BA). While the incidence, risk factors and outcomes of BA have been characterized, less is known in low resource settings.To determine the incidence of Birth Asphyxia (BA) in Nepal and to evaluate associated risk factors and outcomes of this condition.A nested observational study was conducted in 12 hospitals of Nepal for a period of 14 months. Babies diagnosed as BA at ≥37 weeks of gestation were identified and demographics were reviewed. Data were analyzed using binary logistic regression followed by multiple logistic regression analysis.The incidence of BA in this study was 6 per 1000 term livebirths and was higher among women 35 years and above. Predictors for BA were instrumented vaginal delivery (aOR:4.4, 95% CI, 3.1-6.1), fetal distress in labour (aOR:1.9, 95% CI, 1.0-3.6), malposition (aOR:1.8, 95% CI, 1.0-3.0), birth weight less than 2500 g (aOR:2.0, 95% CI, 1.3-2.9), gestational age ≥ 42 weeks (aOR:2.0, 95% CI, 1.3-3.3) and male gender (aOR:1.6, 95% CI, 1.2-2.0). The risk of pre-discharge mortality was 43 times higher in babies with BA (aOR:42.6, 95% CI, 32.2-56.3).The incidence of Birth asphyxia in Nepal higher than in more resourced setting. A range of obstetric and neonatal risk factors are associated with BA with an associated high risk of pre-discharge mortality. Interventions to improve management and decrease rates of BA could have marked impact on outcomes in low resource settings.
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| 19. |
- Thapa, Jeevan, et al.
(author)
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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.
- 2020
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In: Maternal and child health journal. - : Springer Science and Business Media LLC. - 1573-6628 .- 1092-7875. ; 24:Suppl 1, s. 22-30
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Journal article (peer-reviewed)abstract
- 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.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.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.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.
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