Reducing Perinatal Mortality in Nepal Using Helping Babies Breathe

Abstract

BACKGROUND AND OBJECTIVE: Newborns are at the highest risk of dying around the time of birth, due to intrapartum-related complications. Our study’s objective was to improve adherence to the Helping Babies Breathe (HBB) neonatal resuscitation protocol and reduce perinatal mortality by using a quality improvement cycle (QIC) in a tertiary hospital in Nepal. METHODS: The HBB QIC was implemented through a multifaceted approach, including the formation of quality improvement teams; development of quality improvement goals, objectives, and standards; HBB protocol training; weekly review meetings; daily skill checks; use of self-evaluation checklists; and refresher training. A cohort design, including a nested case-control study was used to measure changes in clinical outcomes and adherence to the resuscitation protocol through video recording, before and after implementation of the QIC. RESULTS: The intrapartum stillbirth rate decreased from 9.0 to 3.2 per thousand deliveries, and first-day mortality from 5.2 to 1.9 per thousand live births after intervention, demonstrating a reduction of approximately half in the odds of intrapartum stillbirth (adjusted odds ratio [OR] 0.46, 95% confidence interval [CI] 0.32–0.66) and first-day mortality (adjusted OR 0.51, 95% CI 0.31–0.83). After intervention, the odds of inappropriate use of suction and stimulation decreased by 87% (OR 0.13, 95% CI 0.09–0.17) and 62% (OR 0.38, 95% CI 0.29–0.49), respectively. Before intervention, none of the infants received bag-and-mask ventilation within 1 minute of birth, compared with 83.9% of infants after. CONCLUSIONS: The HBB QIC reduced intrapartum stillbirth and first-day neonatal mortality and led to use of suctioning and stimulation more frequently. The HBB QIC requires further testing in primary settings across Nepal.

Resuscitation practices of low and normal birth weight infants in Nepal: an observational study using video camera recordings

“…However, when analysing both periods together and adjusting for the HBB training, results were in line with the baseline, suggesting that the intervention did not change the resuscitation practice for LBW compared to NBW infants in this setting. The finding of higher odds of ventilation of LBW infants supports the previous finding of a reduced rate of intrapartum stillbirths after training in HBB, as almost half of those stillbirths were LBW infants [8]. The data for gestational age in this study were not complete, but the cases with available information on gestational age confirmed the global estimates of the relatively high proportion of moderately premature infants [25,26].…”

“…This study focused on evaluating differences in steps of neonatal resuscitation between LBW and NBW infants; therefore it is difficult to compare with previous observational studies of HBB interventions. However, HBB training in Nepal and India resulted in an increased rate of ventilation whereas the same intervention in Tanzania demonstrated a lower rate of ventilation after training [6–8]. …”

“…In 2012 there were approximately 22,000 deliveries at the facility with a stillbirth rate of 19 and an early neonatal mortality rate of 9 per 1000 live births [8]. …”

“…The Helping Babies Breathe (HBB) protocol was developed to respond to the need for increased coverage of clinical skills regarding neonatal resuscitation in low-income settings [5]. Studies on outcomes in low-income settings after training in HBB have demonstrated a reduction in intrapartum stillbirths along with reduced or unchanged early neonatal mortality [6–8]. The results imply that newborns who would have previously been classified as stillbirths were successfully resuscitated post-training.…”

Retention and use of newborn resuscitation skills following a series of helping babies breathe trainings for midwives in rural Ghana

“…Although the skills acquired through initial training diminish over time, our findings indicate the skills diminish less quickly when supplemented by a single two-day refresher course provided one year after the initial training. It is also likely that the midwives’ self-reflection after each delivery as a result of maintaining delivery logs also contributed to the delay in skills decay following the refresher when compared to the initial course, which has also been suggested by a study in Nepal [14]. …”