OBJECTIVE: Central lines in NICUs have long dwell times. Success in reducing central line-associated bloodstream infections (CLABSIs) requires a multidisciplinary team approach to line maintenance and insertion. The Perinatal Quality Collaborative of North Carolina (PQCNC) CLABSI project supported the development of NICU teams including parents, the implementation of an action plan with unique bundle elements and a rigorous reporting schedule. The goal was to reduce CLABSI rates by 75%. METHODS:Thirteen NICUs participated in an initiative developed over 3 months and deployed over 9 months. Teams participated in monthly webinars and quarterly face-to-face learning sessions. NICUs reported on bundle compliance and National Health Surveillance Network infection rates at baseline, during the intervention, and 3 and 12 months after the intervention. Process and outcome indicators were analyzed using statistical process control methods (SPC). RESULTS:Near-daily maintenance observations were requested for all lines with a 68% response rate. SPC analysis revealed a trend to an increase in bundle compliance. We also report significant adoption of a new maintenance bundle element, central line removal when enteral feedings reached 120 ml/kg per day. The PQCNC CLABSI rate decreased 71%, from 3.94 infections per 1000 line days to 1.16 infections per 1000 line days with sustainment 1 year later (P 5 .01). CONCLUSIONS:A collaborative structure targeting team development, family partnership, unique bundle elements and strict reporting on line care produced the largest reduction in CLABSI rates for any multiinstitutional NICU collaborative.

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BackgroundNeonatal mortality comprises an increasing proportion of childhood deaths in the developing world. Essential newborn care practices as recommended by the WHO may improve neonatal outcomes in resource limited settings. Our objective was to pilot a Helping Babies Breathe and Essential Care for Every Baby (HBB and ECEB) implementation package using HBB-ECEB training combined with supportive supervision in rural Nicaragua.MethodsWe employed an HBB-ECEB implementation package in El Ayote and Santo Domingo, two rural municipalities in Nicaragua and used a pre- and post- data collection design for comparison. Following a period of pre-intervention data collection (June–August 2015), care providers were trained in HBB and ECEB using a train-the- trainer model. An external supportive supervisor monitored processes of care and collected data. Data on newborn care processes and short-term outcomes such as hypothermia were collected from facility medical records and analyzed using standard run charts. Home visits were used to determine breastfeeding rates at 7, 30 and 60 days.ResultsThere were 480 institutional births during the study period (June 2015–June 2016). Following the HBB-ECEB implementation package, cord care improved (pre-intervention median 66%; post-intervention shift to ≥85%) and early skin-to-skin care improved (pre-intervention median 0%; post-intervention shift to ≥56%, with a high of 92% in June 2016). Rates of administration of ophthalmic ointment and vitamin K were high pre-intervention (median 97%) and remained high. Early initiation of breastfeeding increased with a pre-intervention median of 25% and post-intervention shift to ≥28%, with a peak of 81% in June 2016. Exclusive breastfeeding rates increased short-term but were not significantly different by 60-days of life (9% pre-intervention versus 21% post-intervention).ConclusionsThe implementation of the HBB-ECEB programs combined with supportive supervision improved the quality of care for newborns in terms of cord care, early skin-to-skin care and early initiation of breastfeeding. The rates of administration of ophthalmic ointment and vitamin K were high pre- intervention and remained high afterwards. These findings show that HBB-ECEB programs implemented with supportive supervision can improve quality of care for newborns.

Background Nulliparity has been associated with lower birth weight (BW) and other adverse pregnancy outcomes, with most of the data coming from high-income countries. In this study, we examined birth weight for gestational age z-scores and neonatal (28-day) mortality in a large prospective cohort of women dated by first trimester ultrasound from multiple sites in low and middle-income countries. Methods Pregnant women were recruited during the first trimester of pregnancy and followed through 6 weeks postpartum from Maternal Newborn Health Registry (MNHR) sites in the Democratic Republic of Congo (DRC), Guatemala, Belagavi and Nagpur, India, and Pakistan from 2017 and 2018. Data related to the pregnancy and its outcomes were collected prospectively. First trimester ultrasound was used for determination of gestational age; (BW) was obtained in grams within 48 h of delivery and later transformed to weight for age z-scores (WAZ) adjusted for gestational age using the INTERGROWTH-21st standards. Results 15,121 women were eligible and included. Infants of nulliparous women had lower mean BWs (males: 2676 gr, females: 2587 gr, total: 2634 gr) and gestational age adjusted weight for age z-scores (males: − 0.73, females: − 0.77, total: − 0.75,) than women with one or more previous pregnancies. The largest differences were between zero and one previous pregnancies among female infants. The associations of parity with BW and z-scores remained even after adjustment for maternal age, maternal height, maternal education, antenatal care visits, hypertensive disorders, and socioeconomic status. Nulliparous women also had a significantly higher < 28-day neonatal mortality rate (27.7 per 1,000 live births) than parous women (17.2 and 20.7 for parity of 1–3 and ≥ 4 respectively). Risk of preterm birth was higher among women with ≥ 4 previous pregnancies (15.5%) compared to 11.3% for the nulliparous group and 11.8% for women with one to three previous pregnancies (p = 0.0072). Conclusions In this large sample from diverse settings, nulliparity was independently associated with both lower BW and WAZ scores as well as higher neonatal mortality compared to multiparity.