Improving quality of neonatal care practices in Nepal

Abstract: Despite the availability of cost-effective interventions, resource-poor countries are facing a high burden of preventable neonatal deaths, mainly due to low coverage and poor quality of care. The aim of this thesis was to evaluate the effect of a scaled-up neonatal resuscitation quality improvement (QI) package on newborn care practices in Nepal. The studies were conducted in 12 second-level public hospitals in Nepal where the QI package was scaled up. The QI package was based on the Plan-Do-Study and Act (PDSA) approach with three major implementation strategies; facilitation, training, and audit and feedback. At baseline, readiness and availability of perinatal care services were evaluated using a cross-sectional design (Paper I). A pre-post study design was used to assess the effect of the QI package on the competency of health workers on neonatal resuscitation (Paper II). Prospective observational studies were conducted in four out of the 12 hospitals to assess the effect of QI package on neonatal resuscitation and early essential newborn care (EENC) practices (Paper III and IV).  At baseline, only five out of the 12 hospitals had all basic newborn care services under assessment and only 60% of the health workers had received training on neonatal resuscitation. After introducing the QI package, we observed an improvement in the knowledge and skills of health workers on neonatal resuscitation, which was maintained over time in all participating hospitals. In clinical practice, the proportion of clearing the airway increased among non-crying infants. We observed improved performance of health workers on the most crucial neonatal resuscitation action; initiation of bag and mask ventilation (BMV). The cumulative median time to first ventilation during the implementation period was 39 seconds less compared to the baseline. Overall, the rate of initiation of breastfeeding increased from 5% to 13%, and delayed cord clamping increased from 25% to 31%. The likelihood for a newborn to receive at least three of the four observed EENC practices increased threefold during the intervention period. The QI package showed a positive impact in improving quality of newborn care and can be scaled up in other hospitals in Nepal and similar settings.