Quality of Care for Maternal and Newborn Health in Health Facilities in Nepal

Introduction

Nepal has pledged to substantially reduce maternal and newborn death by 2030. Improving quality of intrapartum health services will be vital to reduce these deaths. This paper examines quality of delivery and newborn services in health facilities of Nepal.

Methods

Data were sourced from the Nepal Health Facility Survey 2015, which covered a national representative sample of health facilities. The datasets were analysed to assess service readiness, availability and quality of delivery and newborn care in a sample of 992 health facilities.

Results

Of the 992 facilities in the sample, 623 provided delivery and newborn care services. Of the 623 facilities offering delivery and newborn care services, 13.3% offered comprehensive emergency obstetric care (CEmONC), 19.6% provided basic emergency obstetric care (BEmONC) and 53.9% provided basic delivery and newborn service. The availability of essential equipment for delivery and newborn care was more than 80% in health facilities. Except for the coverage of vitamin K injection, the coverage of immediate newborn care was more than 85% in all health facilities. The coverage of use of chlorhexidine ointment to all newborns was more than 70% in government hospitals and primary health care centers (PHCCs) and only 32.3% in private hospitals.

Conclusions

These findings show gaps in equipment and drugs, especially in PHCCs and private health facilities. Improving readiness and availability of equipment and drugs in PHCCs and private health facility will help improve the quality of care to further reduce maternal and newborn mortality in Nepal.

     

Type of delivery attendant, place of delivery and risk of early neonatal mortality: analyses of the 1994-2007 Indonesia Demographic and Health Surveys

Access to skilled birth attendants and emergency obstetric care are thought to prevent early neonatal deaths. This study aims to examine the association between the type of delivery attendant and place of delivery and early neonatal mortality in Indonesia. Four Indonesia Demographic and Health Surveys from 1994, 1997, 2002/2003 and 2007 were used, including survival information from 52?917 singleton live-born infants of the most recent birth of a mother within a 5-year period before each survey. Cox proportional hazards regression models were used to obtain the hazard ratio for univariable and multivariable analyses. Our study found no significant reduction in the risk of early neonatal death for home deliveries assisted by the trained attendants compared with those assisted by untrained attendants. In rural areas, the risk of early neonatal death was higher for home deliveries assisted by trained attendants than home deliveries assisted by untrained attendants. In urban areas, a protective role of institutional deliveries was found if mothers had delivery complications. However, an increased risk was associated with deliveries in public hospitals in rural areas. Infants of mothers attending antenatal care services were significantly protected against early neonatal deaths, irrespective of the urban or rural setting. An increased risk of early neonatal death was also associated with male infants, infants whose size at birth was smaller than average and/or infants reported to be born early. A reduced risk was observed amongst mothers with high levels of education. Continuous improvement in the skills and the quality of the village midwives might benefit maternal and newborn survival. Efforts to strengthen the referral system and to improve the quality of delivery and newborn care services in health facilities are important, particularly in public hospitals and in rural areas.     

Traditional birth attendants in rural Nepal: Knowledge,attitudes and practices about maternal and newborn health

Abstract

Efforts to formalise the role of traditional birth attendants (TBAs) in maternal and neonatal health programmes have had limited success. TBAs’ continued attendance at home deliveries suggests the potential to influence maternal and neonatal outcomes. The objective of this qualitative study was to identify and understand the knowledge, attitudes and practices of TBAs in rural Nepal. Twenty-one trained and untrained TBAs participated in focus groups and in-depth interviews about antenatal care, delivery practices, maternal complications and newborn care. Antenatal care included advice about nutrition and tetanus toxoid (TT) immunisation, but did not include planning ahead for transport in cases of complications. Clean delivery practices were observed by most TBAs, though hand-washing practices differed by training status. There was no standard practice to identify maternal complications, such as excessive bleeding, prolonged labour, or retained placenta, and most referred outside in the event of such complications. Newborn care practices included breastfeeding with supplemental feeds, thermal care after bathing, and mustard seed oil massage. TBAs reported high job satisfaction and desire to improve their skills. Despite uncertainty regarding the role of TBAs to manage maternal complications, TBAs may be strategically placed to make potential contributions to newborn survival.     

Maternal and neonatal service delivery by traditional birth attendants in rural Benin: A case for integration?

ABSTRACT

The Republic of Benin faces high maternal, newborn and child (MNCH) morbidity and mortality. Traditional birth attendants (TBAs) continue to operate on the margins of the health system yet provide critical services to women and children. This study aims to further the understanding of TBA’s scope of practice for developing appropriate strategies to strengthen MNCH services at the community-level. TBAs were identified and surveyed on education, training, system support and scope of practice including management of obstetric and newborn emergencies. TBAs were found to perform diverse preventive and health promotion activities, including antenatal and newborn care counselling, promotion of family planning and immunizations. Among 109 TBAs, 11,102 births were documented in the prior year with a maternal mortality ratio (MMR) of 790/100,000 and neonatal mortality rate (NMR) 12.2/1000. The scope of TBA practices is broad and rural communities rely on this cadre for services. However, TBAs report higher rates of adverse maternal events compared to national statistics. Better understanding is needed on community preferences, training and methods of participation of TBAs within the health system. This could improve identification and referral for emergencies, reinforce safer practices and increase preventive and promotive health activities at the community level.     

Risk factors for neonatal mortality in rural areas of Bangladesh served by a large NGO programme

Neonatal deaths account for about half of all deaths among children under 5 years of age in Bangladesh, making prevention a major priority. This paper reports on a study of neonatal deaths in 12 areas of Bangladesh served by a large NGO programme, which had high coverage of reproductive health outreach services and relatively low neonatal mortality in recent years. The study aimed to identify the main factors associated with neonatal mortality in these areas, with a view to developing appropriate strategies for prevention. A case-control design was adopted for collection of data from mothers whose children, born alive in 2003, died within 28 days postpartum (142 cases), or did not (617 controls). Crude and adjusted odds ratios (AOR) were calculated as estimates of relative risk for neonatal death, using 'neighbourhood' controls (241) and 'non-neighbourhood' controls (376). A similar proportion of case and control mothers had received NGO health education and maternal health services. The main risk factors for neonatal death among 122 singleton babies, based on the two sets of controls, were: complications during delivery [AOR, 2.6 (95% CI: 1.5-4.5) and 3.1 (95% CI: 1.8-5.3)], prematurity [AOR, 7.2 (95% CI: 3.6-14.4) and 8.3 (95% CI: 4.2-16.5)], care for a sick neonate from an unlicensed 'traditional healer' [AOR, 2.9 (95% CI 0.9-9.5 and 5.9 (95% CI: 1.3-26.3)], or care not sought at all [AOR, 23.3 (95% CI: 3.9-137.4)]. The strongest predictor of neonatal death was having a previous sibling not vaccinated against measles [AOR, 5.9 (95% CI: 2.2-15.5) and 12.0 (95% CI: 4.5-31.7)]. The findings of this study indicate the need for identification of babies at high risk and early postpartum interventions (40.2% of the deaths occurred within 24 hours of delivery). Relevant strategies include special counselling during pregnancy for mothers with risk characteristics, training birth attendants in resuscitation, immediate postnatal check-up in the home for high-risk babies identified at delivery, advice for mothers on appropriate care-seeking for sick babies, improving the capacity of sub-district hospitals for emergency obstetric and newborn care, and promotion of institutional deliveries.     

Prospective community-based cluster census and case-control study of stillbirths and neonatal deaths in the West Bank and Gaza Strip

Obstetric complications and newborn illnesses amenable to basic medical interventions underlie most perinatal deaths. Yet, despite good access to maternal and newborn care in many transitional countries, perinatal mortality is often not monitored in these settings. The present study identified risk factors for perinatal death and the level and causes of stillbirths and neonatal deaths in the West Bank and Gaza Strip. Baseline and follow-up censuses with prospective monitoring of pregnant women and newborns from September 2001 to August 2002 were conducted in 83 randomly selected clusters of 300 households each. A total of 113 of 116 married women 15-49 years old with a stillbirth or neonatal death and 813 randomly selected women with a surviving neonate were interviewed, and obstetric and newborn care records of women with a stillbirth or neonatal death were abstracted. The perinatal and neonatal mortality rates, respectively, were 21.2 [95% confidence interval (CI) 16.5, 25.9] and 14.7 [95% CI 10.2, 19.2] per 1000 livebirths. The most common cause (27%) of 96 perinatal deaths was asphyxia alone (21) or with neonatal sepsis (5), while 18/49 (37%) early and 9/19 (47%) late neonatal deaths were from respiratory distress syndrome (12) or sepsis (9) alone or together (6). Constraint in care seeking, mainly by an Israeli checkpoint, occurred in 8% and 10%, respectively, of 112 pregnancies and labours and 31% of 16 neonates prior to perinatal or late neonatal death. Poor quality care for a complication associated with the death was identified among 40% and 20%, respectively, of 112 pregnancies and labour/deliveries and 43% of 68 neonates. (Correction added after online publication 5 June 2008: The denominators 112 pregnancies, labours, and labour/deliveries, and 16 and 68 neonates were included; and 9% of labours was corrected to 10%.) Risk factors for perinatal death as assessed by multivariable logistic regression included preterm delivery (odds ratio [OR] = 11.9, [95% CI 6.7, 21.2]), antepartum haemorrhage (OR = 5.6, [95% CI 1.5, 20.9]), any severe pregnancy complication (OR = 3.4, [95% CI 1.8, 6.6]), term delivery in a government hospital and having a labour and delivery complication (OR = 3.8, [95% CI 1.2, 12.0]), more than one delivery complication (OR = 4.4, [95% CI 1.8, 10.5]), mother's age >35 years (OR = 2.9, [95% CI 1.3, 6.8]) and primiparity in a full-term pregnancy (OR = 2.6, [1.1, 6.3]). Stillbirths are not officially reportable in the West Bank and Gaza Strip and this is the first time that perinatal mortality has been examined. Interventions to lower stillbirths and neonatal deaths should focus on improving the quality of medical care for important obstetric complications and newborn illnesses. Other transitional countries can draw lessons for their health care systems from these findings.     

Is Institutional Delivery Protective Against Neonatal Mortality Among Poor or Tribal Women? A Cohort Study From Gujarat,India

Objectives In low-income settings, neonatal mortality rates (NMR) are higher among socioeconomically disadvantaged groups. Institutional deliveries have been shown to be protective against neonatal mortality. In Gujarat, India, the access of disadvantaged women to institutional deliveries has increased. However, the impact of increased institutional delivery on NMR has not been studied here. This paper examined if institutional childbirth is associated with lower NMR among disadvantaged women in Gujarat, India. Methods A community-based prospective cohort of pregnant women was followed in three districts in Gujarat, India (July 2013–November 2014). Two thousand nine hundred and nineteen live births to disadvantaged women (tribal or below poverty line) were included in the study. Data was analyzed using multivariable logistic regression. Results The overall NMR was 25 deaths per 1000 live births. Multivariable analysis showed that institutional childbirth was protective against neonatal mortality only among disadvantaged women with obstetric complications during delivery. Among mothers with obstetric complications during delivery, those who gave birth in a private or public facility had significantly lower odds of having a neonatal death than women delivering at home (AOR 0.07 95% CI 0.01–0.45 and AOR 0.03, 95% CI 0.00–0.33 respectively). Conclusions for Practice Our findings highlight the crucial role of institutional delivery to prevent neonatal deaths among those born to disadvantaged women with complications during delivery in this setting. Efforts to improve disadvantaged women’s access to good quality obstetric care must continue in order to further reduce the NMR in Gujarat, India.     

Rating maternal and neonatal health services in developing countries

OBJECTIVE: To assess maternal and neonatal health services in 49 developing countries. METHODS: The services were rated on a scale of 0 to 100 by 10 - 25 experts in each country. The ratings covered emergency and routine services, including family planning, at health centres and district hospitals, access to these services for both rural and urban women, the likelihood that women would receive particular forms of antenatal and delivery care, and supporting elements of programmes such as policy, resources, monitoring, health promotion and training. FINDINGS: The average rating was only 56, but countries varied widely, especially in access to services in rural areas. Comparatively good ratings were reported for immunization services, aspects of antenatal care and counselling on breast feeding. Ratings were particularly weak for emergency obstetric care in rural areas, safe abortion and HIV counselling. CONCLUSION: Maternal health programme effort in developing countries is seriously deficient, particularly in rural areas. Rural women are disadvantaged in many respects, but especially regarding the treatment of emergency obstetric conditions. Both rural and urban women receive inadequate HIV counselling and testing and have quite limited access to safe abortion. Improving services requires moving beyond policy reform to strengthening implementation of services and to better staff training and health promotion. Increased financing is only part of the solution.     

Availability, Utilisation and Quality of Basic and Comprehensive Emergency Obstetric Care Services in Malawi

Objective To establish a baseline for the availability, utilisation and quality of maternal and neonatal health care services for monitoring and evaluation of a maternal and neonatal morbidity/mortality reduction programme in three districts in the Central Region of Malawi. Methods Survey of all the 73 health facilities (13 hospitals and 60 health centres) that provide maternity services in the three districts (population, 2,812,183). Results There were 1.6 comprehensive emergency obstetric care (CEmOC) facilities per 500,000 population and 0.8 basic emergency obstetric care (BEmOC) facilities per 125,000 population. About 23% of deliveries were conducted in emergency obstetric care (EmOC) facilities and the met need for emergency obstetric complications was 20.7%. The case fatality rate for emergency obstetric complications treated in health facilities was 2.0%. Up to 86.7% of pregnant women attended antenatal clinic at least once and only 12.0% of them attend postnatal clinic at least once. There is a shortage of qualified staff and unequal distribution with more staff in hospitals leaving health centres severely understaffed. Conclusions The total number of CEmOC facilities is adequate but the distribution is unequal, leaving some rural areas with poor access to CEmOC services. There are no functional BEmOC facilities in the three districts. In order to reduce maternal mortality in Malawi and countries with similar socio-economic profile, there is a need to upgrade some health facilities to at least BEmOC level by training staff and providing equipment and supplies.     

Causes of stillbirths and early neonatal deaths: data from 7993 pregnancies in six developing countries

OBJECTIVE: To report stillbirth and early neonatal mortality and to quantify the relative importance of different primary obstetric causes of perinatal mortality in 171 perinatal deaths from 7993 pregnancies that ended after 28 weeks in nulliparous women. METHODS: A review of all stillbirths and early newborn deaths reported in the WHO calcium supplementation trial for the prevention of pre-eclampsia conducted at seven WHO collaborating centres in Argentina, Egypt, India, Peru, South Africa and Viet Nam. We used the Baird-Pattinson system to assign primary obstetric causes of death and classified causes of early neonatal death using the International classification of diseases and related health problems, Tenth revision (ICD-10). FINDINGS: Stillbirth rate was 12.5 per 1000 births and early neonatal mortality rate was 9.0 per 1000 live births. Spontaneous preterm delivery and hypertensive disorders were the most common obstetric events leading to perinatal deaths (28.7% and 23.6%, respectively). Prematurity was the main cause of early neonatal deaths (62%). CONCLUSIONS: Advancements in the care of premature infants and prevention of spontaneous preterm labour and hypertensive disorders of pregnancy could lead to a substantial decrease in perinatal mortality in hospital settings in developing countries.     

EDITORIAL: HOMICIDE ON THE HIGHWAY

Mothers and their home birth attendants residing in rural Uttar Pradesh (UP), India, were taught to recognize and take action to resolve selected maternal and neonatal life-threatening problems. Community mobilization efforts were designed to reduce delays in transport to emergency obstetric care (EOC) referral units and to increase use of family planning. Retention of knowledge and skills for recognition and intervention for maternal bleeding and newborn sepsis was enhanced when pictorial depictions of the problem or take action message or both were used as memory aids. Advocacy efforts for use of EOC facilities were less successful. The community health promotion and home-based life-saving skills education efforts tested are recommended for replication.     

The impact of a multi-level maternal health programme on facility delivery and capacity for emergency obstetric care in Zambia

In 2012, Saving Mothers, Giving Life (SMGL), a multi-level health systems initiative, launched in Kalomo District, Zambia, to address persistent challenges in reducing maternal mortality. We assessed the impact of the programme from 2012 to 2013 using a quasi-experimental study with both household- and health facility-level data collected before and after implementation in both intervention and comparison areas. A total of 21,680 women and 75 non-hospital health centres were included in the study. Using the difference-in-differences method, multivariate logistic regression, and run charts, rates of facility-based birth (FBB) and delivery with a skilled birth provider were compared between intervention and comparison sites. Facility capacity to provide emergency obstetric and newborn care was also assessed before and during implementation in both study areas. There was a 45% increase in the odds of FBB after the programme was implemented in Kalomo relative to comparison districts, but there was a limited measurable change in supply-side indicators of intrapartum maternity care. Most facility-level changes related to an increase in capacity for newborn care. As SMGL and similar programmes are scaled-up and replicated, our results underscore the need to ensure that the health services supply is in balance with improved demand to achieve maximal reductions in maternal mortality.     

Two denominators for one numerator: the example of neonatal mortality

Preterm delivery is one of the strongest predictors of neonatal mortality. A given exposure may increase neonatal mortality directly, or indirectly by increasing the risk of preterm birth. Efforts to assess these direct and indirect effects are complicated by the fact that neonatal mortality arises from two distinct denominators (i.e. two risk sets). One risk set comprises fetuses, susceptible to intrauterine pathologies (such as malformations or infection), which can result in neonatal death. The other risk set comprises live births, who (unlike fetuses) are susceptible to problems of immaturity and complications of delivery. In practice, fetal and neonatal sources of neonatal mortality cannot be separated—not only because of incomplete information, but because risks from both sources can act on the same newborn. We use simulations to assess the repercussions of this structural problem. We first construct a scenario in which fetal and neonatal factors contribute separately to neonatal mortality. We introduce an exposure that increases risk of preterm birth (and thus neonatal mortality) without affecting the two baseline sets of neonatal mortality risk. We then calculate the apparent gestational-age-specific mortality for exposed and unexposed newborns, using as the denominator either fetuses or live births at a given gestational age. If conditioning on gestational age successfully blocked the mediating effect of preterm delivery, then exposure would have no effect on gestational-age-specific risk. Instead, we find apparent exposure effects with either denominator. Except for prediction, neither denominator provides a meaningful way to define gestational-age-specific neonatal mortality.     

产科高危因素与新生儿窒息的相关性分析

目的 探讨产科高危因素与新生儿窒息的相关性.方法 研究对象为2009年8月～2010年8月在某院分娩的1 216例新生儿,其中新生儿窒息34例(2.8％),回顾性分析新生儿窒息与产科高危因素的相关性.结果 在导致新生儿窒息的产科高危因素中,脐带缠绕32.4％,羊水异常占26.5％,胎盘因素占20.6％,早产占8.7％,胎位异常占5.9％,其他占5.9％.脐带缠绕所占比例最高,其中中度窒息占81.8％.结论 新生儿窒息是产科常见的、多发的并发症,是围生儿死亡的首要危险因素,需要积极预防,以保障母婴安全.     

181例新生儿窒息的产科因素分析

目的分析新生儿窒息的产科因素，并探讨其防治措施。方法对181例新生儿窒息的产科资料进行回顾性分析。结果脐带因素是新生儿窒息的首要原因；产程异常、高危妊娠、胎儿宫内窘迫是新生儿窒息的主要原因；自然分娩与剖宫产的新生儿窒息发生率无显著性差异，阴道助产的新生儿窒息发生率明显高于前两者（p〈0．05）。结论加强孕期保健及产时监护，积极治疗妊娠合并症和并发症，正确选择分娩方式，提高产科技术，可避免或减少新生儿窒息的发生。     

Modelling the first two delays of the "three-delays model" for emergency obstetric care in Bangladesh: a choice model approach

Women in Bangladesh have a life-time risk of dying from pregnancy and child-related causes which is estimated to be about 500 times higher than that in the developed countries. More than 100 mothers die daily in Bangladesh due to maternity-related causes. Studies show that 5% of about 600,000 patients in Bangladesh with obstetric complications attend medical facilities, 27.5% of pregnant women receive some prenatal care, 3.5% of women deliver in institutions, and practically no women go for postnatal care. The provision of emergency obstetric care is an extremely important element in the prevention of maternal mortality. While there are inadequate emergency obstetric care services in Bangladesh, those which are available are underutilized because of the medical, social, cultural, economic, geographic, and community barriers women with obstetric complications encounter. The "three-delays" model proposed by Maine in 1993 depicts the roles of communities and the health system in the use status of emergency obstetric care. The model suggests that the outcome of an obstetric emergency is influenced by factors which govern the decision to seek care, reaching the medical facility, and receiving adequate treatment. These three delays impede the use of emergency obstetric care facilities. Using an econometric choice model, the authors identify the relative importance of the factors which affect the first two delays.     

基于自制宝宝资料袋构建产科新生儿预防保健的标准化管理模式

目的探讨产科自制的宝宝资料袋构建新生儿预防保健的标准化管理模式并评价其在新生儿预防保健中的应用效果。方法对2015-2017年在安徽省立医院出生的13 602例新生儿进行非同期对照试验,2016-2017年分娩的新生儿实施预防保健的标准化管理模式,与2015年比较管理模式实施前、后年度新生儿疾病筛查的覆盖率、转诊率、失访率及年度新生儿听力筛查的覆盖率、转诊率、失访率和预防保健资料丢失率、母乳喂养咨询率的变化。结果 2016年和2017年新生儿疾病筛查的覆盖率高于2015年,失访率低于2015年;新生儿听力筛查的覆盖率高于2015年,失访率和转诊率低于2015年;预防保健资料丢失率逐年降低,母乳喂养的咨询率逐年提高;差异均有统计学意义(均P<0. 05)。结论基于自制宝宝资料袋构建新生儿预防保健的标准化管理模式有助于提高产科新生儿预防保健水平,建议在临床推广应用。     

109例新生儿窒息产科原因分析

目的:探讨新生儿窒息的相关因素及防治措施。方法:回顾性分析2005年1月～2007年12月109例新生儿窒息病例,比较不同年份新生儿窒息发生率的差异及各种产科因素与新生儿窒息的关系。结果:新生儿窒息为综合因素所致,胎儿因素中以胎儿窘迫、早产儿、脐带异常为主;母体因素中以重度子痫前期、产前出血、胎膜早破为主;分娩因素中以宫缩乏力、胎位异常、阴道助产为主。用新生儿窒息新法复苏后新生儿窒息发生率特别是早产儿窒息发生率逐年下降,其差异均具有统计学意义。结论:加强孕期保健,及早发现异常,积极治疗妊娠合并症和并发症,适时选择正确的分娩方式终止妊娠;加强产儿科合作,提高助产和复苏技术,是降低新生儿窒息发生率的关键。     

Transition to Skilled Birth Attendance: Is There a Future Role for Trained Traditional Birth Attendants?

A brief history of training of traditional birth attendants (TBAs), summary of evidence for effectiveness of TBA training, and consideration of the future role of trained TBAs in an environment that emphasizes transition to skilled birth attendance are provided. Evidence of the effectiveness of TBA training, based on 60 studies and standard meta-analytic procedures, includes moderate-to-large improvements in behaviours of TBAs relating to selected intrapartum and postnatal care practices, small significant increases in women's use of antenatal care and emergency obstetric care, and small significant decreases in perinatal mortality and neonatal mortality due to birth asphyxia and pneumonia. Such findings are consistent with the historical focus of TBA training on extending the reach of primary healthcare and a few programmes that have included home-based management of complications of births and the newborns, such as birth asphyxia and pneumonia. Evidence suggests that, in settings characterized by high mortality and weak health systems, trained TBAs can contribute to the Millennium Development Goal 4--a two-thirds reduction in the rate of mortality of children aged less than 14 years by 2015--through participation in key evidence-based interventions.     

Safer Muslim motherhood: Social conditions and maternal mortality in the Muslim world

The greatest variation in maternal mortality is among poor countries and wealthy countries that rely on emergency obstetric technology to save a woman’s life during childbirth. However, substantial variation in maternal mortality ratios (MMRs) exists within and among poor countries with uneven access to advanced obstetric services. This article examines MMRs across the Muslim world and compares the impact of national wealth, female education, and skilled birth attendants on maternal mortality. Understanding how poor countries have lowered MMRs without access to expensive obstetric technologies suggests that certain social variables may act protectively to reduce the maternal risk for life-threatening obstetric complications that would require emergency obstetric care.