129 research outputs found
Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study
No full textBACKGROUND: 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. METHODS: 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. FINDINGS: 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). INTERPRETATION: 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. FUNDING: Grand Challenges Canada
Assessment of the Required Subdivision Index for autonomous ships based on equivalent safety
No full textIn recent years, a significant amount of research has been conducted on autonomous ships. Since it is assumed that these ships will sail with a significantly reduced crew or even without people on board, the design of the ship needs reconsideration. The absence of people on board and the associated safety measures could result in a more efficient design. However, to achieve the required design freedom, the existing regulatory framework will have to be amended. In this article, we will focus on potential changes in the Convention for Safety Of Life At Sea (SOLAS) and in particular on the Required Subdivision Index. The evaluation is performed by using the principle of equivalent safety, which will ensure that unmanned ships will be at least as safe as manned ships. The index gives a requirement for the allowed probability of sinking when a ship is damaged due to collision or contact. The safety level is related to the safety of ship, cargo, environment and crew. If the crew is no longer present, the consequences of an incident will be less severe, since the probability of casualties is no longer present. If the principle of equivalent safety is applied, a lower subdivision index can be accepted for unmanned autonomous vessels. In this article, the level of risk that a manned ship is subjected to will be derived by means of a risk analysis. In this risk analysis all logical consequences of a collision will be taken into account, covering both the probability of losing the entire ship and the consequences of the cases where the ship will not sink. Thereafter, the Required Subdivision Index for unmanned ships, which ensures an equivalent safety level to an equivalent manned ship, is established. The sensitivity of the result to changes in the data is discussed as well.Ship Design, Production and Operation
Adherence to World Health Organisation guidelines for treatment of early onset neonatal sepsis in low-income settings : a cohort study in Nepal
No full textBackground: 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. Methods: 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. Results: 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. Conclusion: 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
Effect of a quality improvement package on early essential newborn care in public hospitals of Nepal, a multi-center observational cohort study
No full textBackground: 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.</p
A Review of eHealth Initiatives : Implications for Improving Health Service Delivery in Nepal
No full textThe aim of this paper is to take stock of the use of information and communication technologies in delivering health services in Nepal and identify bottlenecks in implementation for improving delivery of health services. A descriptive review was conducted from May to September 2016. Data were collected from organizations working on the different thematic areas in health where information and communication technologies was used. Fifteen ongoing eHealth projects were identified in the areas of monitoring and surveillance, electronic health records/electronic medical records, health information system, and telemedicine. Common challenges were addressed, including a lack of funding, infrastructure, electricity and network, and national capacity. Most eHealth projects were not integrated into the national system. Working at a national level to address the challenges, centralizing eHealth projects and developing national policies would ensure to adopt eHealth at a right place and to accelerate eHealth initiatives. Keywords: eHealth; health service delivery;information and communication technologies (ICT); Nepal
Measuring respectful maternal and newborn care in Nepal : Comparing linked observation and interview data- prospective cohort study
No full textBackground Respectful maternal and newborn care is the cornerstone of high-quality care, however, measuring experience of respectful care has challenges since it can be subjective, and dependent on expectations. In this study, we assess the concordance between women’s reported experiences of respectful maternal and newborn care and independent observation of their care in Nepal. Methods This is a secondary analysis of a prospective cohort study among 22832 pregnant women conducted in three high volume hospitals in the country: Koshi Provincial Hospital (Hospital A), Bharatpur Hospital (Hospital B), and Lumbini Provincial Hospital (Hospital C) for 18 months between April 2017 and October 2018. The study implemented direct observation during and semi-structured interviews at discharge to evaluate the quality of maternal and newborn care in three large public hospitals. For this analysis, three domains for respectful maternal and newborn care were considered: 1) consent and counselling 2) respect and dignity of care, and 3) care provision. The two data sources (observation checklist and semi-structured interview) were plotted to these three domains to identify common indicators. The level of agreement (LOA) between two measurements was compared using Cohen kappa scores (κ) and Bland Altman plots. Findings During the study period, 22832 women had both observation and interview completed. For consent and counseling, 78.8% of women reported being informed about routine care while only 47.3% were observed to have been consented and counseled (k, LOA = 59.1%). For respect and dignity of care, 99.0% of women reported being treated with dignity and respect and 96.4% were observed (k, LOA = 95.4%). For care provision, 37.9% reported that the infant was kept in immediate skin-to-skin contact after delivery while only 3.9% were observed (k, LOA = 61.7%). Conclusion A significant difference existed between observed and self-reported measures of maternal and newborn care. This study highlights the need for a measurement approach that incorporates independent observations alongside self-reported data. There is also a need to further explore concordance between different sources for progress monitoring
A Review of eHealth Initiatives [Elektronisk resurs] : Implications for Improving Health Service Delivery in Nepal
No full textThe aim of this paper is to take stock of the use of information and communication technologies in delivering health services in Nepal and identify bottlenecks in implementation for improving delivery of health services. A descriptive review was conducted from May to September 2016. Data were collected from organizations working on the different thematic areas in health where information and communication technologies was used. Fifteen ongoing eHealth projects were identified in the areas of monitoring and surveillance, electronic health records/electronic medical records, health information system, and telemedicine. Common challenges were addressed, including a lack of funding, infrastructure, electricity and network, and national capacity. Most eHealth projects were not integrated into the national system. Working at a national level to address the challenges, centralizing eHealth projects and developing national policies would ensure to adopt eHealth at a right place and to accelerate eHealth initiatives. Keywords: eHealth; health service delivery;information and communication technologies (ICT); Nepal.</p
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
No full textBackground 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
Implementation barriers and facilitators of Moyo foetal heart rate monitor during labour in public hospitals in Nepal
No full textBackground: Globally, every year, approximately 1 million foetal deaths take place during the intrapartum period, fetal heart monitoring (FHRM) and timely intervention can reduce these deaths. Objective: This study evaluates the implementation barriers and facilitators of a device, Moyo for FHRM. Methods: The study adopted a qualitative study design in four hospitals in Nepal where Moyo was implemented for HRM. The study participants were labour room nurses and convenience sampling was used to select them. A total of 20 interviews were done to reach the data saturation. The interview transcripts were translated to English, and qualitative content analysis using deductive approach was applied. Results: Using the deductive approach, the data were organised into three categories i) changes in practice of FHRM, ii) barriers to implementing Moyo and iii) facilitators of implementing Moyo. Moyo improved adherence to intermittent FHRM as the device could handle higher caseloads compared to the previous devices. The implementation of Moyo was hindered by difficulty to organise training ondevice during non-working hours, technical issue of the device, nurse mistrust towards the device and previous experience of poor implementation to similar innovations. Facilitators for implementation included effective training on how to use Moyo, improvement in intrapartum foetal monitoring and improvement in staff morale, ease of using the device, Plan Do Study Act (PDSA) meetings to improve use of Moyo and supportive leadership. Conclusion: The change in FHRM practice suggests that the implementation of innovative solution such as Moyo was successful with adequate facilitation, supportive staff attitude and leadership
Neurodevelopmental outcomes of a randomised trial of intact cord resuscitation
No full textAIM: It has been suggested that intact cord resuscitation can reduce the risk of brain damage. We investigated the effects on neurodevelopment at two years of age.METHODS: This study was performed in Kathmandu, Nepal. In 2016, 231 late preterm and term infants born vaginally and not breathing were randomised to resuscitation with an intact cord or the standard practice of early cord clamping (CC). At two years of age, the World Health Organization's Infant and Young Child Development tool was used to assess the child's neurodevelopment, during telephone interviews with caregivers.RESULTS: We followed up 138 infants (59.7%) at a mean age of 24.8 ±0.8 months. A significant difference was seen in the development for age Z-score, between the group resuscitated with an intact umbilical cord and the group resuscitated with early CC. The median (range) scores were 1.0 (0.1-2.1) versus. 0.9 (-2.0-1.8), respectively (p=0.04). There were no difference in the motor, language-cognitive and socio-emotional domains.CONCLUSION: Neurodevelopment improvements were observed at two years of age in infants resuscitated with an intact rather than early clamped umbilical cord. No definitive conclusions could be drawn due to protocol violations and a low follow-up rate. More research is needed
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