| 1. |
- Ameen, Shafiqul, et al.
(author)
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Survey of women's report for 33 maternal and newborn indicators: EN-BIRTH multi-country validation study.
- 2021
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In: BMC pregnancy and childbirth. - : Springer Science and Business Media LLC. - 1471-2393. ; 21:Suppl 1
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Journal article (peer-reviewed)abstract
- Population-based household surveys, notably the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), remain the main source of maternal and newborn health data for many low- and middle-income countries. As part of the Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study, this paper focuses on testing validity of measurement of maternal and newborn indicators around the time of birth (intrapartum and postnatal) in survey-report.EN-BIRTH was an observational study testing the validity of measurement for selected maternal and newborn indicators in five secondary/tertiary hospitals in Bangladesh, Nepal and Tanzania, conducted from July 2017 to July 2018. We compared women's report at exit survey with the gold standard of direct observation or verification from clinical records for women with vaginal births. Population-level validity was assessed by validity ratios (survey-reported coverage: observer-assessed coverage). Individual-level accuracy was assessed by sensitivity, specificity and percent agreement. We tested indicators already in DHS/MICS as well as indicators with potential to be included in population-based surveys, notably the first validation for small and sick newborn care indicators.33 maternal and newborn indicators were evaluated. Amongst nine indicators already present in DHS/MICS, validity ratios for baby dried or wiped, birthweight measured, low birthweight, and sex of baby (female) were between 0.90-1.10. Instrumental birth, skin-to-skin contact, and early initiation of breastfeeding were highly overestimated by survey-report (2.04-4.83) while umbilical cord care indicators were massively underestimated (0.14-0.22). Amongst 24 indicators not currently in DHS/MICS, two newborn contact indicators (kangaroo mother care 1.00, admission to neonatal unit 1.01) had high survey-reported coverage amongst admitted newborns and high sensitivity. The remaining indicators did not perform well and some had very high "don't know" responses.Our study revealed low validity for collecting many maternal and newborn indicators through an exit survey instrument, even with short recall periods among women with vaginal births. Household surveys are already at risk of overload, and some specific clinical care indicators do not perform well and may be under-powered. Given that approximately 80% of births worldwide occur in facilities, routine registers should also be explored to track coverage of key maternal and newborn health interventions, particularly for clinical care.
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| 2. |
- Andersson, Ola, et al.
(author)
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Intact cord resuscitation versus early cord clamping in the treatment of depressed newborn infants during the first 10 minutes of birth (Nepcord III) - : a randomized clinical trial
- 2019
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In: Maternal health, neonatology and perinatology. - : Springer Science and Business Media LLC. - 2054-958X. ; 5:15
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Journal article (peer-reviewed)abstract
- Background: Experiments have shown improved cardiovascular stability in lambs if umbilical cord clamping is postponed until positive pressure ventilation is started. Studies on intact cord resuscitation on human term infants are sparse. The purpose of this study was to evaluate differences in clinical outcomes in non-breathing infants between groups, one where resuscitation is initiated with an intact umbilical cord (intervention group) and one group where cord clamping occurred prior to resuscitation (control group).Methods: Randomized controlled trial, inclusion period April to August 2016 performed at a tertiary hospital in Kathmandu, Nepal. Late preterm and term infants born vaginally, non-breathing and in need of resuscitation according to the 'Helping Babies Breathe' algorithm were randomized to intact cord resuscitation or early cord clamping before resuscitation. Main outcome measures were saturation by pulse oximetry (SpO2), heart rate and Apgar at 1, 5 and 10 minutes after birth.Results: At 10 minutes after birth, SpO2 (SD) was significantly higher in the intact cord group compared to the early cord clamping group, 90.4 (8.1) vs 85.4 (2.7) %, P < .001). In the intact cord group, 57 (44%) had SpO2 < 90% after 10 minutes, compared to 93 (100%) in the early cord clamping group, P < 0.001. SpO2 was also significantly higher in the intervention (intact cord) group at one and five minutes after birth. Heart rate was lower in the intervention (intact cord) group at one and five minutes and slightly higher at ten minutes, all significant findings. Apgar score was significantly higher at one, five and ten minutes. At 5 minutes, 23 (17%) had Apgar score < 7 in the intervention (intact cord) group compared to 26 (27%) in the early cord clamping group, P < .07. Newborn infants in the intervention (intact cord) group started to breathe and establish regular breathing earlier than in the early cord clamping group.Conclusions: This study provides new and important information on the effects of resuscitation with an intact umbilical cord. The findings of improved SpO2 and higher Apgar score, and the absence of negative consequences encourages further studies with longer follow-up.Trial registration: Clinicaltrials.gov NCT02727517, 2016/4/4.
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| 3. |
- Berg, Johan Henrik Martin, et al.
(author)
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Effect of Delayed Cord Clamping on Neurodevelopment at 3 Years : A Randomized Controlled Trial
- 2021
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In: Neonatology. - : S. Karger. - 1661-7800 .- 1661-7819. ; 118:3, s. 282-288
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Journal article (peer-reviewed)abstract
- Introduction: Iron deficiency (ID) is associated with poor neurodevelopment. We have previously shown that delayed umbilical cord clamping (CC) improves iron stores at 8 months and neurodevelopment at 1 year in term, healthy infants in Nepal.Objective: The aim of this study was to assess the effects of delayed CC (≥180 s) compared to early CC (≤60 s) on neurodevelopment using the Ages and Stages Questionnaire (ASQ) at age 3 years.Methods: In 2014, 540 healthy Nepalese infants born at term were randomized in a 1:1 ratio to delayed or early CC. At 3 years of age, ASQ assessment was performed by phone interviews with parents. A score >1 standard deviation below the mean was defined as "at risk" for developmental impairment.Results: At 3 years of age, 350 children were followed up, 170 (63.0%) in the early CC group and 180 (66.7%) in the delayed CC group. No significant differences in ASQ scores in any domains between groups were found. However, more girls were "at risk" for affected gross motor development in the early CC group: 14 (18.9%) versus 6 (6.3%), p = 0.02.Conclusion: There were no significant differences in ASQ scores in any domains between groups. In the subgroup analysis, fewer girls who underwent delayed CC were "at risk" for delayed gross motor development. Due to the pronounced difference in iron stores at 8 months postpartum in this cohort, follow-up studies at an older age are motivated since neurodevelopmental impairment after early ID may be more detectable with increasing age.
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| 4. |
- Berg, Johan Henrik Martin, et al.
(author)
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Effect of Delayed Cord Clamping on Neurodevelopment at 3 Years: A Randomized Controlled Trial.
- 2021
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In: Neonatology. - : S. Karger AG. - 1661-7819 .- 1661-7800. ; 118:3, s. 282-288
-
Journal article (peer-reviewed)abstract
- Iron deficiency (ID) is associated with poor neurodevelopment. We have previously shown that delayed umbilical cord clamping (CC) improves iron stores at 8 months and neurodevelopment at 1 year in term, healthy infants in Nepal.The aim of this study was to assess the effects of delayed CC (≥180 s) compared to early CC (≤60 s) on neurodevelopment using the Ages and Stages Questionnaire (ASQ) at age 3 years.In 2014, 540 healthy Nepalese infants born at term were randomized in a 1:1 ratio to delayed or early CC. At 3 years of age, ASQ assessment was performed by phone interviews with parents. A score >1 standard deviation below the mean was defined as "at risk" for developmental impairment.At 3 years of age, 350 children were followed up, 170 (63.0%) in the early CC group and 180 (66.7%) in the delayed CC group. No significant differences in ASQ scores in any domains between groups were found. However, more girls were "at risk" for affected gross motor development in the early CC group: 14 (18.9%) versus 6 (6.3%), p = 0.02.There were no significant differences in ASQ scores in any domains between groups. In the subgroup analysis, fewer girls who underwent delayed CC were "at risk" for delayed gross motor development. Due to the pronounced difference in iron stores at 8 months postpartum in this cohort, follow-up studies at an older age are motivated since neurodevelopmental impairment after early ID may be more detectable with increasing age.
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| 5. |
- Bhattarai, Pratiksha, et al.
(author)
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Implementing quality improvement intervention to improve intrapartum fetal heart rate monitoring during COVID-19 pandemic- observational study
- 2022
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In: PLOS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 17:10
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Journal article (peer-reviewed)abstract
- IntroductionAdherence to intrapartum fetal heart rate monitoring (FHRM) for early decision making in high-risk pregnancies remains a global health challenge. COVID-19 has led to disruption of routine intrapartum care in all income settings. This study aims to evaluate the implementation of quality improvement (QI) intervention to improve intrapartum FHRM and birth outcome before and during pandemic.Method and materialsWe conducted an observational study among 10,715 pregnant women in a hospital of Nepal, over 25 months. The hospital implemented QI intervention i.e facilitated plan-do-study-act (PDSA) meetings before and during pandemic. We assessed the change in intrapartum FHRM, timely action in high-risk deliveries and fetal outcomes before and during pandemic.ResultsThe number of facilitated PDSA meetings increased from an average of one PDSA meeting every 2 months before pandemic to an average of one PDSA meeting per month during the pandemic. Monitoring and documentation of intrapartum FHRM at an interval of less than 30 minutes increased from 47% during pre-pandemic to 73.3% during the pandemic (p<0.0001). The median time interval from admission to abnormal heart rate detection decreased from 160 minutes to 70 minutes during the pandemic (p = 0.020). The median time interval from abnormal FHR detection to the time of delivery increased from 122 minutes to 177 minutes during the pandemic (p = 0.019). There was a rise in abnormal FHR detection during the time of admission (1.8% vs 4.7%; p<0.001) and NICU admissions (2.9% vs 6.5%; p<0.0001) during the pandemic.ConclusionDespite implementation of QI intervention during the pandemic, the constrains in human resource to manage high risk women has led to poorer neonatal outcome. Increasing human resources to manage high risk women will be key to timely action among high-risk women and prevent stillbirth.
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| 6. |
- Bhattarai, Pratiksha, et al.
(author)
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Implementing quality improvement intervention to improve intrapartum fetal heart rate monitoring during COVID-19 pandemic- observational study.
- 2022
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In: PloS one. - : Public Library of Science (PLoS). - 1932-6203. ; 17:10
-
Journal article (peer-reviewed)abstract
- Adherence to intrapartum fetal heart rate monitoring (FHRM) for early decision making in high-risk pregnancies remains a global health challenge. COVID-19 has led to disruption of routine intrapartum care in all income settings. This study aims to evaluate the implementation of quality improvement (QI) intervention to improve intrapartum FHRM and birth outcome before and during pandemic.We conducted an observational study among 10,715 pregnant women in a hospital of Nepal, over 25 months. The hospital implemented QI intervention i.e facilitated plan-do-study-act (PDSA) meetings before and during pandemic. We assessed the change in intrapartum FHRM, timely action in high-risk deliveries and fetal outcomes before and during pandemic.The number of facilitated PDSA meetings increased from an average of one PDSA meeting every 2 months before pandemic to an average of one PDSA meeting per month during the pandemic. Monitoring and documentation of intrapartum FHRM at an interval of less than 30 minutes increased from 47% during pre-pandemic to 73.3% during the pandemic (p<0.0001). The median time interval from admission to abnormal heart rate detection decreased from 160 minutes to 70 minutes during the pandemic (p = 0.020). The median time interval from abnormal FHR detection to the time of delivery increased from 122 minutes to 177 minutes during the pandemic (p = 0.019). There was a rise in abnormal FHR detection during the time of admission (1.8% vs 4.7%; p<0.001) and NICU admissions (2.9% vs 6.5%; p<0.0001) during the pandemic.Despite implementation of QI intervention during the pandemic, the constrains in human resource to manage high risk women has led to poorer neonatal outcome. Increasing human resources to manage high risk women will be key to timely action among high-risk women and prevent stillbirth.
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| 7. |
- 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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| 8. |
- Budhathoki, Shyam Sundar, et al.
(author)
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The Association of Childhood Pneumonia with Household Air Pollution in Nepal: Evidence from Nepal Demographic Health Surveys.
- 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. 48-56
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Journal article (peer-reviewed)abstract
- Childhood pneumonia is a major cause of mortality worldwide while household air pollution (HAP) is a major contributor to childhood pneumonia in low and middle-income countries. This paper presents the prevalence trend of childhood pneumonia in Nepal and assesses its association with household air pollution.The study analysed data from the 2006, 2011 and 2016 Nepal Demographic Health Surveys (NDHS). It calculated the prevalence of childhood pneumonia and the factors that cause household air pollution. The association of childhood pneumonia and HAP was assessed using univariate and multi-variate analysis. The population attributable fraction (PAF) of indoor pollution for causing pneumonia was calculated using 2016 NDHS data to assess the burden of pneumonia attributable to HAP factors.The prevalence of childhood pneumonia decreased in Nepal between 2006 and 2016 and was higher among households using polluting cooking fuels. There was a higher risk of childhood pneumonia among children who lived in households with no separate kitchens in 2011 [Adjusted risk ratio (ARR) 1.40, 95% CI 1.01-1.97] and in 2016 (ARR 1.93, 95% CI 1.14-3.28). In 2016, the risk of children contracting pneumonia in households using polluting fuels was double (ARR 1.98, 95% CI 1.01-3.92) that of children from households using clean fuels. Based on the 2016 data, the PAF for pneumonia was calculated as 30.9% for not having a separate kitchen room and 39.8% for using polluting cooking fuel.Although the occurrence of childhood pneumonia in Nepal has decreased, the level of its association with HAP remained high.
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| 9. |
- 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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| 10. |
- 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
-
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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| 11. |
- 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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| 12. |
- 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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| 13. |
- 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
-
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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| 14. |
- Day, Louise Tina, et al.
(author)
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Assessment of the validity of the measurement of newborn and maternal health-care coverage in hospitals (EN-BIRTH): an observational study.
- 2021
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In: The Lancet. Global health. - : Elsevier. - 2214-109X. ; 9:3, s. e267-e279
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Journal article (peer-reviewed)abstract
- Progress in reducing maternal and neonatal deaths and stillbirths is impeded by data gaps, especially regarding coverage and quality of care in hospitals. We aimed to assess the validity of indicators of maternal and newborn health-care coverage around the time of birth in survey data and routine facility register data.Every Newborn-BIRTH Indicators Research Tracking in Hospitals was an observational study in five hospitals in Bangladesh, Nepal, and Tanzania. We included women and their newborn babies who consented on admission to hospital. Exclusion critiera at admission were no fetal heartbeat heard or imminent birth. For coverage of uterotonics to prevent post-partum haemorrhage, early initiation of breastfeeding (within 1 h), neonatal bag-mask ventilation, kangaroo mother care (KMC), and antibiotics for clinically defined neonatal infection (sepsis, pneumonia, or meningitis), we collected time-stamped, direct observation or case note verification data as gold standard. We compared data reported via hospital exit surveys and via hospital registers to the gold standard, pooled using random effects meta-analysis. We calculated population-level validity ratios (measured coverage to observed coverage) plus individual-level validity metrics.We observed 23 471 births and 840 mother-baby KMC pairs, and verified the case notes of 1015 admitted newborn babies regarding antibiotic treatment. Exit-survey-reported coverage for KMC was 99·9% (95% CI 98·3-100) compared with observed coverage of 100% (99·9-100), but exit surveys underestimated coverage for uterotonics (84·7% [79·1-89·5]) vs 99·4% [98·7-99·8] observed), bag-mask ventilation (0·8% [0·4-1·4]) vs 4·4% [1·9-8·1]), and antibiotics for neonatal infection (74·7% [55·3-90·1] vs 96·4% [94·0-98·6] observed). Early breastfeeding coverage was overestimated in exit surveys (53·2% [39·4-66·8) vs 10·9% [3·8-21·0] observed). "Don't know" responses concerning clinical interventions were more common in the exit survey after caesarean birth. Register data underestimated coverage of uterotonics (77·9% [37·8-99·5] vs 99·2% [98·6-99·7] observed), bag-mask ventilation (4·3% [2·1-7·3] vs 5·1% [2·0-9·6] observed), KMC (92·9% [84·2-98·5] vs 100% [99·9-100] observed), and overestimated early breastfeeding (85·9% (58·1-99·6) vs 12·5% [4·6-23·6] observed). Inter-hospital heterogeneity was higher for register-recorded coverage than for exit survey report. Even with the same register design, accuracy varied between hospitals.Coverage indicators for newborn and maternal health care in exit surveys had low accuracy for specific clinical interventions, except for self-report of KMC, which had high sensitivity after admission to a KMC ward or corner and could be considered for further assessment. Hospital register design and completion are less standardised than surveys, resulting in variable data quality, with good validity for the best performing sites. Because approximately 80% of births worldwide take place in facilities, standardising register design and information systems has the potential to sustainably improve the quality of data on care at birth.Children's Investment Fund Foundation and Swedish Research Council.
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| 15. |
- Day, Louise T., et al.
(author)
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"Every Newborn-BIRTH" protocol : observational study validating indicators for coverage and quality of maternal and newborn health care in Bangladesh, Nepal and Tanzania
- 2019
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In: Journal of Global Health. - : International Global Health Society. - 2047-2978 .- 2047-2986. ; 9:1
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Journal article (peer-reviewed)abstract
- Background: To achieve Sustainable Development Goals and Universal Health Coverage, programmatic data are essential. The Every Newborn Action Plan, agreed by all United Nations member states and >80 development partners, includes an ambitious Measurement Improvement Roadmap. Quality of care at birth is prioritised by both Every Newborn and Ending Preventable Maternal Mortality strategies, hence metrics need to advance from health service contact alone, to content of care. As facility births increase, monitoring using routine facility data in DHIS2 has potential, yet validation research has mainly focussed on maternal recall surveys. The Every Newborn - Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study aims to validate selected newborn and maternal indicators for routine tracking of coverage and quality of facility-based care for use at district, national and global levels.Methods: EN-BIRTH is an observational study including >20000 facility births in three countries (Tanzania, Bangladesh and Nepal) to validate selected indicators. Direct clinical observation will be compared with facility register data and a pre-discharge maternal recall survey for indicators including: uterotonic administration, immediate newborn care, neonatal resuscitation and Kangaroo mother care. Indicators including neonatal infection management and antenatal corticosteroid administration, which cannot be easily observed, will be validated using inpatient records. Trained clinical observers in Labour/Delivery ward, Operation theatre, and Kangaroo mother care ward/areas will collect data using a tablet-based customised data capturing application. Sensitivity will be calculated for numerators of all indicators and specificity for those numerators with adequate information. Other objectives include comparison of denominator options (ie, true target population or surrogates) and quality of care analyses, especially regarding intervention timing. Barriers and enablers to routine recording and data usage will be assessed by data flow assessments, quantitative and qualitative analyses.Conclusions: To our knowledge, this is the first large, multi-country study validating facility-based routine data compared to direct observation for maternal and newborn care, designed to provide evidence to inform selection of a core list of indicators recommended for inclusion in national DHIS2. Availability and use of such data are fundamental to drive progress towards ending the annual 5.5 million preventable stillbirths, maternal and newborn deaths.
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| 16. |
- Day, Louise T, et al.
(author)
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"Every Newborn-BIRTH" protocol: observational study validating indicators for coverage and quality of maternal and newborn health care in Bangladesh, Nepal and Tanzania.
- 2019
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In: Journal of global health. - : International Global Health Society. - 2047-2986 .- 2047-2978. ; 9:1
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Journal article (peer-reviewed)abstract
- To achieve Sustainable Development Goals and Universal Health Coverage, programmatic data are essential. The Every Newborn Action Plan, agreed by all United Nations member states and >80 development partners, includes an ambitious Measurement Improvement Roadmap. Quality of care at birth is prioritised by both Every Newborn and Ending Preventable Maternal Mortality strategies, hence metrics need to advance from health service contact alone, to content of care. As facility births increase, monitoring using routine facility data in DHIS2 has potential, yet validation research has mainly focussed on maternal recall surveys. The Every Newborn - Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study aims to validate selected newborn and maternal indicators for routine tracking of coverage and quality of facility-based care for use at district, national and global levels.EN-BIRTH is an observational study including >20 000 facility births in three countries (Tanzania, Bangladesh and Nepal) to validate selected indicators. Direct clinical observation will be compared with facility register data and a pre-discharge maternal recall survey for indicators including: uterotonic administration, immediate newborn care, neonatal resuscitation and Kangaroo mother care. Indicators including neonatal infection management and antenatal corticosteroid administration, which cannot be easily observed, will be validated using inpatient records. Trained clinical observers in Labour/Delivery ward, Operation theatre, and Kangaroo mother care ward/areas will collect data using a tablet-based customised data capturing application. Sensitivity will be calculated for numerators of all indicators and specificity for those numerators with adequate information. Other objectives include comparison of denominator options (ie, true target population or surrogates) and quality of care analyses, especially regarding intervention timing. Barriers and enablers to routine recording and data usage will be assessed by data flow assessments, quantitative and qualitative analyses.To our knowledge, this is the first large, multi-country study validating facility-based routine data compared to direct observation for maternal and newborn care, designed to provide evidence to inform selection of a core list of indicators recommended for inclusion in national DHIS2. Availability and use of such data are fundamental to drive progress towards ending the annual 5.5 million preventable stillbirths, maternal and newborn deaths.
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| 17. |
- Day, Louise Tina, et al.
(author)
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Labour and delivery ward register data availability, quality, and utility - Every Newborn - birth indicators research tracking in hospitals (EN-BIRTH) study baseline analysis in three countries.
- 2020
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In: BMC health services research. - : Springer Science and Business Media LLC. - 1472-6963. ; 20:1
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Journal article (peer-reviewed)abstract
- Countries with the highest burden of maternal and newborn deaths and stillbirths often have little information on these deaths. Since over 81% of births worldwide now occur in facilities, using routine facility data could reduce this data gap. We assessed the availability, quality, and utility of routine labour and delivery ward register data in five hospitals in Bangladesh, Nepal, and Tanzania. This paper forms the baseline register assessment for the Every Newborn-Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study.We extracted 21 data elements from routine hospital labour ward registers, useful to calculate selected maternal and newborn health (MNH) indicators. The study sites were five public hospitals during a one-year period (2016-17). We measured 1) availability: completeness of data elements by register design, 2) data quality: implausibility, internal consistency, and heaping of birthweight and explored 3) utility by calculating selected MNH indicators using the available data.Data were extracted for 20,075 births. Register design was different between the five hospitals with 10-17 of the 21 selected MNH data elements available. More data were available for health outcomes than interventions. Nearly all available data elements were > 95% complete in four of the five hospitals and implausible values were rare. Data elements captured in specific columns were 85.2% highly complete compared to 25.0% captured in non-specific columns. Birthweight data were less complete for stillbirths than live births at two hospitals, and significant heaping was found in all sites, especially at 2500g and 3000g. All five hospitals recorded count data required to calculate impact indicators including; stillbirth rate, low birthweight rate, Caesarean section rate, and mortality rates.Data needed to calculate MNH indicators are mostly available and highly complete in EN-BIRTH study hospital routine labour ward registers in Bangladesh, Nepal and Tanzania. Register designs need to include interventions for coverage measurement. There is potential to improve data quality if Health Management Information Systems utilization with feedback loops can be strengthened. Routine health facility data could contribute to reduce the coverage and impact data gap around the time of birth.
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| 18. |
- Ekblom, Annette, et al.
(author)
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Factors associated with poor adherence to intrapartum fetal heart monitoring in relationship to intrapartum related death : A prospective cohort study
- 2022
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In: PLOS Global Public Health. - : Public Library of Science (PLoS). - 2767-3375. ; 2:5
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Journal article (peer-reviewed)abstract
- BackgroundPoor quality of intrapartum care remains a global health challenge for reducing stillbirth and early neonatal mortality. Despite fetal heart rate monitoring (FHRM) being key to identify fetus at risk during labor, sub-optimal care prevails in low-income settings. The study aims to assess the predictors of suboptimal fetal heart rate monitoring and assess the association of sub-optimal FHRM and intrapartum related deaths.MethodA prospective cohort study was conducted in 12 hospitals between April 2017 to October 2018. Pregnant women with fetal heart sound present during admission were included. Inferential statistics were used to assess proportion of sub-optimal FHRM. Multi-level logistic regression was used to detect association between sub-optimal FHRM and intrapartum related death.ResultThe study cohort included 83,709 deliveries, in which in more than half of women received suboptimal FHRM (56%). The sub-optimal FHRM was higher among women with obstetric complication than those with no complication (68.8% vs 55.5%, p-value<0.001). The sub-optimal FHRM was higher if partograph was not used than for whom partograph was completely filled (70.8% vs 15.9%, p-value<0.001). The sub-optimal FHRM was higher if the women had no companion during labor than those who had companion during labor (57.5% vs 49.6%, p-value<0.001). After adjusting for background characteristics and intra-partum factors, the odds of intrapartum related death was higher if FHRM was done sub-optimally in reference to women who had FHRM monitored as per protocol (aOR, 1.47; 95% CI; 1.13, 1.92).ConclusionAdherence to FHRM as per clinical standards was inadequate in these hospitals of Nepal. Furthermore, there was an increased odds of intra-partum death if FHRM had not been carried out as per clinical standards. FHRM provided as per protocol is key to identify fetuses at risk, and efforts are needed to improve the adherence of quality of care to prevent death.
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| 19. |
- Ekblom, Annette, et al.
(author)
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Factors associated with poor adherence to intrapartum fetal heart monitoring in relationship to intrapartum related death: A prospective cohort study.
- 2022
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In: PLOS global public health. - : Public Library of Science (PLoS). - 2767-3375. ; 2:5
-
Journal article (peer-reviewed)abstract
- Poor quality of intrapartum care remains a global health challenge for reducing stillbirth and early neonatal mortality. Despite fetal heart rate monitoring (FHRM) being key to identify fetus at risk during labor, sub-optimal care prevails in low-income settings. The study aims to assess the predictors of suboptimal fetal heart rate monitoring and assess the association of sub-optimal FHRM and intrapartum related deaths.A prospective cohort study was conducted in 12 hospitals between April 2017 to October 2018. Pregnant women with fetal heart sound present during admission were included. Inferential statistics were used to assess proportion of sub-optimal FHRM. Multi-level logistic regression was used to detect association between sub-optimal FHRM and intrapartum related death.The study cohort included 83,709 deliveries, in which in more than half of women received suboptimal FHRM (56%). The sub-optimal FHRM was higher among women with obstetric complication than those with no complication (68.8% vs 55.5%, p-value<0.001). The sub-optimal FHRM was higher if partograph was not used than for whom partograph was completely filled (70.8% vs 15.9%, p-value<0.001). The sub-optimal FHRM was higher if the women had no companion during labor than those who had companion during labor (57.5% vs 49.6%, p-value<0.001). After adjusting for background characteristics and intra-partum factors, the odds of intrapartum related death was higher if FHRM was done sub-optimally in reference to women who had FHRM monitored as per protocol (aOR, 1.47; 95% CI; 1.13, 1.92).Adherence to FHRM as per clinical standards was inadequate in these hospitals of Nepal. Furthermore, there was an increased odds of intra-partum death if FHRM had not been carried out as per clinical standards. FHRM provided as per protocol is key to identify fetuses at risk, and efforts are needed to improve the adherence of quality of care to prevent death.
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| 20. |
- 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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| 21. |
- Gurung, Rejina, et al.
(author)
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Effect of skill drills on neonatal ventilation performance in a simulated setting-observation study in Nepal
- 2019
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In: BMC Pediatrics. - : BMC. - 1471-2431. ; 19:1
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Journal article (peer-reviewed)abstract
- Aim: Maintaining neonatal resuscitation skills among health workers in low resource settings will require continuous quality improvement efforts. We aimed to evaluate the effect of skill drills and feedback on neonatal resuscitation and the optimal number of skill drills required to maintain the ventilation skill in a simulated setting. Methods: An observational study was conducted for a period of 3 months in a referral hospital of Nepal. Sixty nursing staffs were trained on Helping Babies Breathe (HBB) 2.0 and daily skill drills using a high-fidelity manikin. The high-fidelity manikin had different clinical case scenarios and provided feedback as "well done" or "improvement required" based on the ventilation performance. Adequate ventilation was defined as bag-and-mask ventilation at the rate of 40-60 breaths per minute. The effective ventilation was defined as adequate ventilation with a "well done" feedback. We assessed the correlation of number skill drills and clinical case scenario with adequate ventilation rate using pearson's correlation. We assessed the correlation of number of skill dills performed by each participant with effective ventilation using Mann Whitney test. Results: Among the total of 60 nursing staffs, all of them were competent with an average score of 12.73 +/- 1.09 out of 14 (p < 0.001) on bag-and-mask ventilation skill checklist. Among the trained staff, 47 staffs participated in daily skill drills who performed a total of 331 skill drills and 68.9% of the ventilations were done adequately. Among the 47 nursing staffs who performed the skill drills, 228 (68.9%) drills were conducted at a ventilation rate of 40-60 breathes per minute. There was no correlation of the adequate ventilation with skill drill category (p = 0.88) and the level of skill performed (p = 0.28). Out of 47 participants performing the skill drills, 74.5% of them had done effective ventilation with a mean average of 8 skill drills (SD +/- 4.78) (p-value- 0.032). Conclusion: In a simulated setting, participants who had an average skill drill of 8 in 3 months had effective ventilation. We demonstrated optimal skill drill sessions for maintain the neonatal resuscitation competency. Further evaluation will be required to validate the findings in a scale up setting.
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| 22. |
- Gurung, Rejina, et al.
(author)
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Effect of skill drills on neonatal ventilation performance in a simulated setting- observation study in Nepal.
- 2019
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In: BMC pediatrics. - : Springer Science and Business Media LLC. - 1471-2431. ; 19:1
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Journal article (peer-reviewed)abstract
- Maintaining neonatal resuscitation skills among health workers in low resource settings will require continuous quality improvement efforts. We aimed to evaluate the effect of skill drills and feedback on neonatal resuscitation and the optimal number of skill drills required to maintain the ventilation skill in a simulated setting.An observational study was conducted for a period of 3 months in a referral hospital of Nepal. Sixty nursing staffs were trained on Helping Babies Breathe (HBB) 2.0 and daily skill drills using a high-fidelity manikin. The high-fidelity manikin had different clinical case scenarios and provided feedback as "well done" or "improvement required" based on the ventilation performance. Adequate ventilation was defined as bag-and-mask ventilation at the rate of 40-60 breaths per minute. The effective ventilation was defined as adequate ventilation with a "well done" feedback. We assessed the correlation of number skill drills and clinical case scenario with adequate ventilation rate using pearson's correlation. We assessed the correlation of number of skill dills performed by each participant with effective ventilation using Mann Whitney test.Among the total of 60 nursing staffs, all of them were competent with an average score of 12.73 ± 1.09 out of 14 (p < 0.001) on bag-and-mask ventilation skill checklist. Among the trained staff, 47 staffs participated in daily skill drills who performed a total of 331 skill drills and 68.9% of the ventilations were done adequately. Among the 47 nursing staffs who performed the skill drills, 228 (68.9%) drills were conducted at a ventilation rate of 40-60 breathes per minute. There was no correlation of the adequate ventilation with skill drill category (p = 0.88) and the level of skill performed (p = 0.28). Out of 47 participants performing the skill drills, 74.5% of them had done effective ventilation with a mean average of 8 skill drills (SD ± 4.78) (p-value- 0.032).In a simulated setting, participants who had an average skill drill of 8 in 3 months had effective ventilation. We demonstrated optimal skill drill sessions for maintain the neonatal resuscitation competency. Further evaluation will be required to validate the findings in a scale up setting.
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| 23. |
- Gurung, Rejina, et al.
(author)
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Effectiveness and Acceptability of Bag-and-mask Ventilation with Visual Monitor for Improving Neonatal Resuscitation in Simulated Setting in Six Hospitals of Nepal
- 2019
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In: Journal of Nepal Health Research Council. - : Nepal Health Research Council. - 1727-5482 .- 1999-6217. ; 17:2, s. 222-227
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Journal article (peer-reviewed)abstract
- BACKGROUND: Improving the performance of health workers on neonatal resuscitation will be critical to ensure that the babies are effectively ventilated. We conducted a study to evaluate whether a bag-and-mask ventilation with monitor is effective in improving neonatal resuscitation practice in a simulated setting.METHODS: This is a cross-over design conducted in 6 public hospitals with 82 health workers of Nepal nested over a large scale stepped wedged quality improvement project. A one-day training on neonatal resuscitation was conducted. At the end of the training, participants were evaluated on the bag-and-mask ventilation performance in a manikinbased on the tidal volume, positive end expiratory pressure and air leakage from the maskin two sessions (monitor displayed versus hidden). The comparison of the neonatal resuscitation performance with and without monitor displayed is calculated. We also conducted assessment of confidence with or without monitor of the health workers.RESULTS: Adequacy of ventilation using bag-and-mask was better when the health workers were displayed monitor (90%) vs without monitor (76%) (p<0.01). The air leakage from the mask reduced when the monitor was displayed (12%) vs without (30%). The PEEP improved when the health workers used monitor as guide to conduct neonatal resuscitation in the manikin then without monitor displayed. The participants felt more confident performing ventilations during the visible sessions.CONCLUSIONS: The ventilation function monitor helped participants to improve their ventilation skills through realtime feedback of important ventilation parameters. Clinical evaluation of needs to be done to assess the effectiveness of the device.
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| 24. |
- Gurung, Rejina, et al.
(author)
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Effectiveness and Acceptability of Bag-and-mask Ventilation with Visual Monitor for Improving Neonatal Resuscitation in Simulated Setting in Six Hospitals of Nepal.
- 2019
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In: Journal of Nepal Health Research Council. - : Nepal Health Research Council. - 1999-6217 .- 1727-5482. ; 17:2, s. 222-227
-
Journal article (peer-reviewed)abstract
- Improving the performance of health workers on neonatal resuscitation will be critical to ensure that the babies are effectively ventilated. We conducted a study to evaluate whether a bag-and-mask ventilation with monitor is effective in improving neonatal resuscitation practice in a simulated setting.This is a cross-over design conducted in 6 public hospitals with 82 health workers of Nepal nested over a large scale stepped wedged quality improvement project. A one-day training on neonatal resuscitation was conducted. At the end of the training, participants were evaluated on the bag-and-mask ventilation performance in a manikinbased on the tidal volume, positive end expiratory pressure and air leakage from the maskin two sessions (monitor displayed versus hidden). The comparison of the neonatal resuscitation performance with and without monitor displayed is calculated. We also conducted assessment of confidence with or without monitor of the health workers.Adequacy of ventilation using bag-and-mask was better when the health workers were displayed monitor (90%) vs without monitor (76%) (p<0.01). The air leakage from the mask reduced when the monitor was displayed (12%) vs without (30%). The PEEP improved when the health workers used monitor as guide to conduct neonatal resuscitation in the manikin then without monitor displayed. The participants felt more confident performing ventilations during the visible sessions.The ventilation function monitor helped participants to improve their ventilation skills through realtime feedback of important ventilation parameters. Clinical evaluation of needs to be done to assess the effectiveness of the device.
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| 25. |
- 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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