BackgroundImproving 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 findingsWe 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.ConclusionThese 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 as...

IntroductionNepal Perinatal Quality Improvement Project (NePeriQIP) intends to scale up a quality improvement (QI) intervention for perinatal care according to WHO/National guidelines in hospitals of Nepal using the existing health system structures. The intervention builds on previous research on the implementation of Helping Babies Breathe-quality improvement cycle in a tertiary healthcare setting in Nepal. The objective of this study is to evaluate the effect of this scaled-up intervention on perinatal health outcomes.Methods/designCluster-randomised controlled trial using a stepped wedged design with 3 months delay between wedges will be conducted in 12 public hospitals with a total annual delivery rate of 60 000. Each wedge will consist of 3 hospitals. Impact will be evaluated on intrapartum-related mortality (primary outcome), overall neonatal mortality and morbidity and health worker’s performance on neonatal care (secondary outcomes). A process evaluation and a cost-effectiveness analysis will be performed to understand the functionality of the intervention and to further guide health system investments will also be performed.DiscussionIn contexts where resources are limited, there is a need to find scalable and sustainable implementation strategies for improved care delivery. The proposed study will add to the scarce evidence base on how to scale up interventions within existing health systems. If successful, the NePeriQIP model can provide a replicable solution in similar settings where support and investment from the health system is poor, and national governments have made a global pledge to reduce perinatal mortality.Trial registration number ISRCTN30829654.

Aim To explore delivery care staff’s perceptions and attitudes towards changes in practice of umbilical cord clamping in order to identify work culture barriers and enablers for improved clinical practice and implementation of the new guidelines on cord clamping. Method A purposive sampling strategy was used to include delivery staff at two major hospitals in Kathmandu, Nepal for focus group discussions. Key informant interviews were conducted with the ward in-charges and skilled birth attendant trainers at the respective hospitals. Data were analyzed using qualitative content analysis. Result Eight focus group discussions altogether with 34 delivery care staff working in the labor room and birthing units, and 12 key informant interviews with skilled birth attendant trainers/supervisors and ward in-charges from both hospitals participated in the study. Participants had positive attitudes towards delayed cord clamping as it was not perceived to be a difficult task and as they perceived it to be beneficial for mother and child. The “will to do good”, and a high level of trust both in the hierarchical system as well as in scientific evidence were identified as promoters of change. Several barriers were mentioned, such as maternal or fetal medical conditions and physical settings, as constraints to perform delayed cord clamping. They also mentioned difficulties in adopting new guidelines due to habitual practice, lack of formal training and poor coherence within the work team. In order to bring change to the practice, participants highlighted that officially approved national and institutional protocols and regular training are crucial. Conclusion Due to poor coherence within the health system and lack of national or institutional protocols, delivery staff has to rely on their own initiative to develop skills and are left to informal decision making, and are therefore hesitant to apply new routines. In order to change cord clamping practices to align with evidence and policies health-care staff needs to be better supported by the governance structures of the health system, with clear and approved guidelines made available and coherent training and support.

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 17th of May, 2017.

Background 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. Methods 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. Results 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. Conclusion 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.