Intrapartum Stillbirths Research Articles

Maternal and Neonatal Characteristics for Late Foetal Death in Latvia between 2001 and 2014: Population-Based Study.

Introduction Stillbirth is one of the most common adverse pregnancy outcomes worldwide. Late foetal death (LFD) rates are mostly used for international comparisons because of the large variations in stillbirth rates between countries. Objective To examine trends in LFD (including antepartum and intrapartum) by multiple births, birth weight, and maternal age in two time periods. Methods A retrospective cohort study was used to analyse data from the Medical Birth Register (2001–2014), divided into 2 periods of 7 years each. In total, data on 1,340 singletons were analysed. This study calculated LFD rates and rate ratios (RR). Results The overall LFD rate showed a slight statistically significant reduction (p < 0.001) of 18% between 2001–2007 and 2008–2014. There was a slight increase in the mortality rate from multiple pregnancies (RR 1.1/1000; 95% CI 0.6-1.9). There were no major differences in the LFD rate by maternal age during the time periods. Conclusions LFD decreased (RR 0.8/1000 births), as well as intrapartum LFD (RR 0.6/1000 births). Older maternal age influenced pregnancy outcomes, and higher LFD rates were observed in the age group ≥35 years. Substantial intrapartum stillbirths rates indicate problems with quality of intrapartum care and emergency obstetric care. Further research is needed to evaluate the strategies necessary to substantially reduce the number of stillbirths in the country.

Perinatal asphyxia in a rural Nigerian hospital: Incidence and determinants of early outcome.

Perinatal asphyxia is an important cause of morbidity and mortality in the neonatal period, accounting for 20-30% of neonatal mortality. A substantial proportion (estimated at 26%) of the 1 million annual intrapartum stillbirths result from asphyxia. Probably higher than the mortality is the plethora of morbidity associated with asphyxia, especially long term neuro-developmental problems including cerebral palsy.The real burden of perinatal asphyxia is difficult to establish because of paucity of information from the rural communities where the majority of neonatal morbidity and deaths occur. Extended Apgar scores and HIE grade have been identified as predictive tools in prognosticating asphyxia, however HIE staging require a certain level of medical expertise which is not widely available. To determine the incidence of asphyxia, the mortality rate and factors associated with mortality in Irrua Specialist Hospital. It was a descriptive, retrospective study of neonates admitted into the special care baby unit (SCBU) between October 2013 and September 2014 with diagnosis of perinatal asphyxia. Data was obtained from babies' and mother's case notes. The outcome was classified as survived or died. Perinatal asphyxia accounted for 45 out of 347 (13%) of admissions within the review period. The mean gestational age and birth weight of the subjects were 39.2±2.2 weeks and 3020±520 grams respectively. The mortality rate was 31.1% and the factors significantly associated with mortality include lack of antenatal care and HIE stage III. The burden of perinatal asphyxia in Irrua Specialist Hospital is comparable to figures from similar settings in the developing world. Lack of antenatal care and HIE stage III are associated with mortality. Continuous efforts should be made to improve the uptake of antenatal care and high risk pregnancies should be delivered in centres with facilities for neonatal care.

Stillbirth surveillance and review in rural districts in Bangladesh

BackgroundAn estimated 2.6 million stillbirths occur every year, with the majority occurring in low- and middle-income countries. Understanding the cause of and factors associated with stillbirth is important to help inform the design and implementation of interventions aimed at reducing preventable stillbirths.MethodsPopulation-based surveillance with identification of all stillbirths that occurred either at home or in a health facility was introduced in four districts in Bangladesh. Verbal autopsy was conducted for every fifth stillbirth using a structured questionnaire. A hierarchical model was used to assign likely cause of stillbirth.ResultsSix thousand three hundred thirty-three stillbirths were identified for which 1327 verbal autopsies were conducted. 63.9% were intrapartum stillbirths. The population-based stillbirth rate obtained was 20.4 per 1000 births; 53.9% of all stillbirths occurred at home. 69.6% of mothers had accessed health care in the period leading up to the stillbirth. 48.1% had received care from a highly trained healthcare provider. The three most frequent causes of stillbirth were maternal hypertension or eclampsia (15.2%), antepartum haemorrhage (13.7%) and maternal infections (8.9%). Up to 11.3% of intrapartum stillbirths were caused by hypoxia. However, it was not possible to identify a cause of death with reasonable certainty using information obtained via verbal autopsy in 51.9% of stillbirths.ConclusionsIntroducing surveillance for stillbirths at community level is possible. However, verbal autopsy yields limited data, and the questionnaire used for this needs to be revised and/or combined with information obtained through case note review.Most women accessed and received care from a qualified healthcare provider. To reduce the number of preventable stillbirths, the quality of antenatal and intrapartum care needs to be improved.

Profile of Risk Factors Associated with Stillbirth at Western Regional Hospital

Background: Stillbirth (SB) incidents are one of the most common adverse outcomes to occur during pregnancy. Studies indicate that approximately 3.3 million stillbirths are reported annually across the developing world. Institutional registration and under reporting of still birth to an authorized centre is a common problem.&#x0D; Objective: The objective of this study is to find out the incidence of SB after 28 weeks gestation and to find out the associated risk factors at Western Regional Hospital of Nepal.&#x0D; Materials and Methods: This is a cross sectional study carried out at Western Regional Hospital. Stillbirth babies born after 28 weeks of gestation or birth weight ≥ 1 kilogram and their mothers were recruited for the study. Intrapartum stillbirths were included despite of their ages, races or socio-economic status. Descriptive analysis was done on the data.&#x0D; Results: There were 3380 deliveries during the period of study. Among them, 50 cases were stillborn babies with a rate of 14 per thousand deliveries. The major risk factors associated were oligohydramnios, decreased fetal movement, growth restriction, meconium stained liquor and cord prolapse.&#x0D; Conclusion: Oligohydramnios (amniotic fluid index &lt; 5cm) was the most common risk factor for stillbirth. Early identification and appropriate perinatal management could help to promote perinatal health.

Stillbirths in urban Guinea-Bissau: A hospital- and community-based study.

BackgroundStillbirth rates remain high in many low-income settings, with fresh (intrapartum) stillbirths accounting for a large part due to limited obstetrical care. We aimed to determine the stillbirth rate and identify potentially modifiable factors associated with stillbirth in urban Guinea-Bissau.MethodsThe study was carried out by the Bandim Health Project (BHP), a Health and Demographic Surveillance System site in the capital Bissau. We assessed stillbirth rates in a hospital cohort consisting of all deliveries at the maternity ward at the National Hospital Simão Mendes (HNSM), and in a community cohort, which only included women from the BHP area. Stillbirth was classified as fresh (FSB) if fetal movements were reported on the day of delivery.ResultsFrom October 1 2007 to April 15 2013, a total of 38164 deliveries were registered at HNSM, among them 3762 stillbirths (99/1000 births). Excluding deliveries referred to the hospital from outside the capital (9.6%), the HNSM stillbirth rate was 2786/34490 births (81/1000). During the same period, 15462 deliveries were recorded in the community cohort. Of these, 768 were stillbirths (50/1000).Of 11769 hospital deliveries among women from Bissau with data on fetal movement, 866 (74/1000) were stillbirths, and 609 (70.3%) of these were FSB, i.e. potentially preventable. The hospital FSB rate was highest in the evening from 4 pm to midnight (P = 0.04). In the community cohort, antenatal care (ANC) attendance correlated strongly with stillbirth reduction; the stillbirth rate was 71/1000 if the mother attended no ANC consultations vs. 36/1000 if she attended ≥7 consultations (P<0.001).ConclusionIn Bissau, the stillbirth rate is alarmingly high. The majority of stillbirths are preventable FSB. Improving obstetrical training, labour management (including sufficient intrapartum monitoring and timely intervention) and hospital infrastructure is urgently required. This should be combined with proper community strategies and additional focus on antenatal care.

The impact of time of delivery on gestations complicated by preterm premature rupture of membranes: daytime versus nighttime

Background: Perinatal death, in particular intrapartum stillbirth and short-term neonatal death, as well as neonatal short-term and long-term morbidity have been associated with the time of day that the birth occurs. Indeed, evening and nighttime deliveries were associated with an increased risk of an adverse perinatal outcome when compared to similar daytime deliveries. Impact of shift change, as well as time of day delivery have been extensively studied in the context of maternal and neonatal complications of cesarean delivery, however, no studies were previously performed on timing of delivery and its effect on the outcome of pregnancies complicated by preterm premature rupture of membranes.Objective: Our objective was to compare obstetric, neonatal as well as long-term outcomes between women delivered in the daytime versus nighttime, in singleton gestations whose pregnancies were complicated by preterm premature rupture of membranes.Study design: This was a secondary analysis of a trial of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network “A Randomized Clinical Trial of the Beneficial Effects of Antenatal Magnesium Sulfate for the Prevention of Cerebral Palsy.” For this analysis, the time of delivery was divided into the daytime, from 07:01 to 19:00, and the nighttime, from 19:01 to 07:00. Epidemiological, obstetric characteristics as well as neonatal and long-term outcomes were compared between deliveries occurring during the daytime versus the nighttime periods. Inclusion criteria consisted of singleton gestations diagnosed with preterm premature rupture of membranes (PPROM). Multifetal gestations and pregnancies with preterm labor without preterm premature rupture of membranes were excluded.Results: A total of 1752 patients met inclusion criteria, 881 delivering during the daytime, while 871 during the nighttime. There were no differences in demographic maternal variables. There were no differences in the number of patients receiving steroids and the doses of steroids. Antibiotic prophylaxis was also equal in both groups. Postpartum endometritis, chorioamnionitis, and the latency to delivery were also equivalent between both the groups. Cesarean delivery for distress was the only different outcome, more prevalent in daytime deliveries (157 (44.7%) versus 108 (35.9%) of the nighttime ones p = .02). Neonatal adverse outcomes as well as long-term outcomes were similar between the two groups.Conclusions: In the setting of delivery at a tertiary care center, and in the era of universal use of steroids, and latency antibiotics for the management of preterm premature of membranes, there is no marked difference in pregnancy, neonatal as well as long-term outcomes for infants delivered in the daytime versus nighttime.

Intermittent fetal heart rate monitoring using a fetoscope or hand held Doppler in rural Tanzania: a randomized controlled trial

BackgroundNeonatal mortality is a global challenge, with an estimated 1.3 million intrapartum stillbirths in 2015. The majority of these were found in low resource settings with limited options to intrapartum fetal heart monitoring devices. This trial compared frequency of abnormal fetal heart rate (FHR) detection and adverse perinatal outcomes (i.e. fresh stillbirths, 24-h neonatal deaths, admission to neonatal care unit) among women intermittently assessed by Doppler or fetoscope in a rural low-resource setting.MethodsThis was an open-label randomized controlled trial conducted at Haydom Lutheran Hospital from March 2013 through August 2015. Inclusion criteria were; women in labor, singleton, cephalic presentation, normal FHR on admission (120–160 beats/minute), and cervical dilatation ≤7 cm. Verbal consent was obtained.ResultsA total of 2684 women were recruited, 1309 in the Doppler and 1375 in the fetoscope arms, respectively. Abnormal FHR was detected in 55 (4.2%) vs 42 (3.1%). (RR = 1.38; 95%CI: 0.93, 2.04) in the Doppler and fetoscope arms, respectively. Bag mask ventilation was performed in 80 (6.1%) vs 82 (6.0%). (RR = 1.03; 95%CI: 0.76, 1.38) of neonates, and adverse perinatal outcome was comparable 32(2.4%) vs 35(2.5%). (RR = 0.9; 95%CI: 0.59, 1.54), in the Doppler and fetoscope arms, respectively.ConclusionThis trial failed to demonstrate a statistically significant difference in the detection of abnormal FHR between intermittently used Doppler and fetoscope and adverse perinatal outcomes. However, FHR measurements were not performed as often as recommended by international guidelines. Conducting a randomized controlled study in rural settings with limited resources is associated with major challenges.Trial registrationThis clinical trial was registered on April 2013 with registration number NCT01869582.

Accelerating newborn survival in Ghana through a low-dose, high-frequency health worker training approach: a cluster randomized trial

BackgroundNewborn deaths comprise nearly half of under-5 deaths in Ghana, despite the fact that skilled birth attendants (SBAs) are present at 68% of births, which implies that evidence-based care during labor, birth and the immediate postnatal period may be deficient. We assessed the effect of a low-dose, high-frequency (LDHF) training approach on long-term evidence-based skill retention among SBAs and impact on adverse birth outcomes.MethodsFrom 2014 to 2017, we conducted a cluster-randomized trial in 40 hospitals in Ghana. Eligible hospitals were stratified by region and randomly assigned to one of four implementation waves. We assessed the relative risks (RRs) of institutional intrapartum stillbirths and 24-h newborn mortality in months 1–6 and 7–12 of implementation as compared to the historical control period, and in post-intervention facilities compared to pre-intervention facilities during the same period. All SBAs providing labor and delivery care were invited to enroll; their knowledge and skills were assessed pre- and post-training, and 1 year later.ResultsAdjusting for region and health facility type, the RR of 24-h newborn mortality in the 40 enrolled hospitals was 0·41 (95% CI 0·32–0·51; p < 0.001) in months 1–6 and 0·30 (95% CI 0·21–0·43; p < 0·001) in months 7–12 compared to baseline. The adjusted RR of intrapartum stillbirth was 0·64 (95% CI 0·53–0·77; p < 0·001) in months 1–6 and 0·48 (95% CI 0·36–0·63; p < 0·001) in months 7–12 compared to baseline. Four hundred three SBAs consented and enrolled. After 1 year, 200 SBAs assessed had 28% (95% CI 25–32; p < 0·001) and 31% (95% CI 27–36; p < 0·001) higher scores than baseline on low-dose 1 and 2 content skills, respectively.ConclusionsThis training approach results in a sustained decrease in facility-based newborn mortality and intrapartum stillbirths, and retained knowledge and skills among SBAs after a year. We recommend use of this approach for future maternal and newborn health in-service training and programs.Trial registrationRetrospectively registered on 25 September 2017 at Clinical Trials, identifier NCT03290924.

Modifiable Factors for Increased Risk of Antepartum and Intrapartum Stillbirth in Migrants and Non‐Caucasian Ethnicities

Modifiable Factors for Increased Risk of Antepartum and Intrapartum Stillbirth in Migrants and Non‐Caucasian Ethnicities

Every Caesarean Section Must Count

(Aust N Z J Obstet Gynaecol. 2016;56(5):450–452) This opinion piece supports the argument that cesarean section rates (CSR) are an essential indicator of the quality of care and should be monitored. Between 1985 and 2013 the CSR increased from 15% to 32.8%—more than a doubling in &lt;3 decades. Arguments against the monitoring of CSR include the rights of women to opt for the procedure, high intrapartum stillbirth rates, and the preventable burden of lifelong disabilities caused by intrapartum asphyxia and perineal lacerations resulting from vaginal deliveries. Yet, the risks associated with cesarean section (CS) and the potential morbidity as a result of an increased CSR support making sure each CS is indicated.

Socioeconomic inequity in survival for deliveries at 22–24 weeks of gestation

ObjectiveGuidelines recommend individual decision making on resuscitating infants of 22–24 weeks’ gestational age (GA) at birth. When the decision not to resuscitate is made, infants would likely die soon after...

Andrea Fleisch Marcus, PhD, MPH winner of the American College of Epidemiology Annals of Epidemiology Junior Investigator Award, 2017

To determine the association between maternal exposure to childhood maltreatment (CM) and risk of stillbirth (fetal death at or after 20 weeks' gestation).Population-based case-control study from the Stillbirth Collaborative Research Network (SCRN) conducted in 2006–2008, and the follow-up study, SCRN-Outcomes after Study Index Stillbirth (SCRN-OASIS), conducted in 2009 in the United States. Cases (n = 133) included women who experienced a stillbirth, excluding stillbirths attributed to genetic/structural or umbilical cord abnormalities and intrapartum stillbirths. Controls (n = 500) included women delivering a healthy term live birth (excluding births less than 37 weeks gestation, neonatal intensive care unit admission, or death). CM exposure was measured using the Childhood Trauma Questionnaire, administered during the SCRN-OASIS study. Dichotomized scores for five subscales of CM (physical abuse, physical neglect, emotional abuse, emotional neglect, and sexual abuse) and an overall measure of CM exposure were analyzed using logistic regression.Generally, there was no association between CM and stillbirth, except for the emotional neglect subscale (OR: 1.93; 95% CI: 1.17, 3.19).Childhood neglect is understudied in comparison to abuse and should be included in the future studies of associations between CM and pregnancy outcomes, including stillbirth.

Associations between Shiftwork and 25-hydroxy Vitamin D3 Levels among Police Officers

To determine the association between maternal exposure to childhood maltreatment (CM) and risk of stillbirth (fetal death at or after 20 weeks' gestation).Population-based case-control study from the Stillbirth Collaborative Research Network (SCRN) conducted in 2006–2008, and the follow-up study, SCRN-Outcomes after Study Index Stillbirth (SCRN-OASIS), conducted in 2009 in the United States. Cases (n = 133) included women who experienced a stillbirth, excluding stillbirths attributed to genetic/structural or umbilical cord abnormalities and intrapartum stillbirths. Controls (n = 500) included women delivering a healthy term live birth (excluding births less than 37 weeks gestation, neonatal intensive care unit admission, or death). CM exposure was measured using the Childhood Trauma Questionnaire, administered during the SCRN-OASIS study. Dichotomized scores for five subscales of CM (physical abuse, physical neglect, emotional abuse, emotional neglect, and sexual abuse) and an overall measure of CM exposure were analyzed using logistic regression.Generally, there was no association between CM and stillbirth, except for the emotional neglect subscale (OR: 1.93; 95% CI: 1.17, 3.19).Childhood neglect is understudied in comparison to abuse and should be included in the future studies of associations between CM and pregnancy outcomes, including stillbirth.

The cost effectiveness of a quality improvement program to reduce maternal and fetal mortality in a regional referral hospital in Accra, Ghana.

ObjectiveTo evaluate the cost-effectiveness of a quality improvement intervention aimed at reducing maternal and fetal mortality in Accra, Ghana.DesignQuasi-experimental, time-sequence intervention, retrospective cost-effectiveness analysis.MethodsData were collected on the cost and outcomes of a 5-year Kybele-Ghana Health Service Quality Improvement (QI) intervention conducted at Ridge Regional Hospital, a tertiary referral center in Accra, Ghana, focused on systems, personnel, and communication. Maternal deaths prevented were estimated comparing observed rates with counterfactual projections of maternal mortality and case-fatality rates for hypertensive disorders of pregnancy and obstetric hemorrhage. Stillbirths prevented were estimated based on counterfactual estimates of stillbirth rates. Cost-effectiveness was then calculated using estimated disability-adjusted life years averted and subjected to Monte Carlo and one-way sensitivity analyses to test the importance of assumptions inherent in the calculations.Main outcome measureIncremental Cost-effectiveness ratio (ICER), which represents the cost per disability-adjusted life-year (DALY) averted by the intervention compared to a model counterfactual.ResultsFrom 2007–2011, 39,234 deliveries were affected by the QI intervention implemented at Ridge Regional Hospital. The total budget for the program was $2,363,100. Based on program estimates, 236 (±5) maternal deaths and 129 (±13) intrapartum stillbirths were averted (14,876 DALYs), implying an ICER of $158 ($129-$195) USD. This value is well below the highly cost-effective threshold of $1268 USD. Sensitivity analysis considered DALY calculation methods, and yearly prevalence of risk factors and case fatality rates. In each of these analyses, the program remained highly cost-effective with an ICER ranging from $97-$218ConclusionQI interventions to reduce maternal and fetal mortality in low resource settings can be highly cost effective. Cost-effectiveness analysis is feasible and should regularly be conducted to encourage fiscal responsibility in the pursuit of improved maternal and child health.

Maternal exposure to childhood maltreatment and risk of stillbirth

PurposeTo determine the association between maternal exposure to childhood maltreatment (CM) and risk of stillbirth (fetal death at or after 20 weeks' gestation). MethodsPopulation-based case-control study from the Stillbirth Collaborative Research Network (SCRN) conducted in 2006–2008, and the follow-up study, SCRN-Outcomes after Study Index Stillbirth (SCRN-OASIS), conducted in 2009 in the United States. Cases (n = 133) included women who experienced a stillbirth, excluding stillbirths attributed to genetic/structural or umbilical cord abnormalities and intrapartum stillbirths. Controls (n = 500) included women delivering a healthy term live birth (excluding births less than 37 weeks gestation, neonatal intensive care unit admission, or death). CM exposure was measured using the Childhood Trauma Questionnaire, administered during the SCRN-OASIS study. Dichotomized scores for five subscales of CM (physical abuse, physical neglect, emotional abuse, emotional neglect, and sexual abuse) and an overall measure of CM exposure were analyzed using logistic regression. ResultsGenerally, there was no association between CM and stillbirth, except for the emotional neglect subscale (OR: 1.93; 95% CI: 1.17, 3.19). ConclusionsChildhood neglect is understudied in comparison to abuse and should be included in the future studies of associations between CM and pregnancy outcomes, including stillbirth.

Reducing fresh full term intrapartum stillbirths through leadership and accountability in a low-resource setting, Mpilo Central Hospital, Bulawayo, Zimbabwe

BackgroundStillbirths are distressing to the parents and healthcare workers. Globally large numbers of babies are stillborn. A number of strategies have been implemented to try and reduce stillbirths worldwide. The objective of this study was to assess the impact of leadership and accountability changes on reducing full term intrapartum stillbirths.MethodsLeadership and accountability changes were implemented in January 2016. This retrospective cohort study was carried out to assess the impact of the changes on fresh full term intrapartum stillbirths covering the period 6 months prior to the implementation date and 12 months after the implementation date. The changes included leadership and accountability. Fresh full term stillbirths (>37 weeks gestation) occurring during the intrapartum stage of labour were analysed to see if there would be any reduction in numbers after the measures were put in place.ResultsThere was a reduction in the number of fresh full term intrapartum stillbirths after the introduction of the measures. There was a statistical difference before and after implementation of the changes, 50% vs 0%, P = 0.025. There was a reduction in the time it took to perform an emergency caesarean section from a mean of 30 to 15 min by the end of the study, a 50% reduction.ConclusionsClear and consistent clinical leadership and accountability can help in the global attempts to reduce stillbirth figures. Simple measures can contribute to improving perinatal outcomes.

Changing the midwifery audit landscape in Africa

African Journal of Midwifery and Women's HealthVol. 11, No. 3 EditorialChanging the midwifery audit landscape in AfricaSabina WakasiakaSabina WakasiakaSearch for more papers by this authorSabina WakasiakaPublished Online:21 Jul 2017https://doi.org/10.12968/ajmw.2017.11.3.109AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Gicheha EW, Richens Y, Kivai RM, Lavender T (2017) Why clinical audit is important in midwifery: experiences from Kenya. African Journal of Midwifery and Women's Health 11(2): 62–5 Link, Google ScholarKalusopa VM, Mayimbo S, Muleya M et al. (2017) Use of the partograph among midwives at University Teaching Hopsital, Lusaka: a LAMRN project in Zambia. African Journal of Midwifery and Women's Health 11(2): 84–7 Link, Google ScholarKanyunyuzi AE, Ekong EN, Namukwaya RE (2017) A criteria-based audit to improve early postnatal care in Jinja, Uganda. African Journal of Midwifery and Women's Health 11(2): 78–83 Link, Google ScholarKasengele CT, Mowa R, Katai C et al. (2017) Factors contributing to intrapartum stillbirth: a criteria-based audit to support midwifery practice in Zambia. African Journal of Midwifery and Women's Health 11(2): 67–71 Link, Google ScholarNamwaya Z, Ayebare E, Muwanguzi S et al. (2017) Partograph initiation and completion: a criteria-based audit study in Uganda. African Journal of Midwifery and Women's Health 11(2): 72–65 Link, Google Scholar FiguresReferencesRelatedDetails 2 July 2017Volume 11Issue 3ISSN (online): 2052-4293 Metrics History Published online 21 July 2017 Published in print 2 July 2017 Information© MA Healthcare LimitedPDF download

Neonatal resuscitation in global health settings: an examination of the past to prepare for the future.

As rates of childhood mortality decline, neonatal deaths account for nearly half of under-5 deaths worldwide. Intrapartum-related events (birth asphyxia) contribute to approximately one-quarter of neonatal deaths, many of which can be prevented by simple resuscitation and newborn care interventions. This paper reviews various lines of research that have influenced the global neonatal resuscitation landscape. A brief situational analysis of asphyxia-related newborn mortality in low-resource settings is linked to renewed efforts to reduce neonatal mortality in the Every Newborn Action Plan. Possible solutions to gaps in care are identified. Building on international scientific evidence, tests of educational efficacy, and community-based trials established the feasibility and effectiveness of training in resource-limited settings and identified successful implementation strategies. Implementation of neonatal resuscitation programs has been shown to decrease intrapartum stillbirth rates and early neonatal mortality. Challenges remain with respect to provider competencies, coverage, and quality of interventions. The combination of resuscitation science, strategies to increase educational effectiveness, and implemention of interventions with high coverage and quality has resulted in reduced rates of asphyxia-related neonatal mortality. Further efforts to improve coverage and implementation of neonatal resuscitation will be necessary to meet the 2035 goal of eliminating preventable newborn deaths.

Mediation of the effect of malaria in pregnancy on stillbirth and neonatal death in an area of low transmission: observational data analysis

BackgroundMalaria in pregnancy is preventable and contributes significantly to the estimated 5.5 million stillbirths and neonatal deaths that occur annually. The contribution of malaria in pregnancy in areas of low transmission has not been quantified, and the roles of maternal anaemia, small-for-gestational-age status, and preterm birth in mediating the effect of malaria in pregnancy on stillbirth and neonatal death are poorly elucidated.MethodsWe analysed observational data routinely collected at antenatal clinics on the Thai-Myanmar border (1986–2015). We used Cox regression and sequential mediation analysis to determine the effect of falciparum and vivax malaria in pregnancy on antepartum (death in utero) and intrapartum (death during labour) stillbirth and neonatal mortality as well as mediation through maternal anaemia, preterm birth, and small-for-gestational-age status.ResultsOf 61,836 women, 9350 (15%) had malaria in pregnancy, and 526 (0.8%) had stillbirths. In a sub-set of 9090 live born singletons followed from birth there were 153 (1.7%) neonatal deaths. The hazard of antepartum stillbirth increased 2.24-fold [95% confidence interval: 1.47, 3.41] following falciparum malaria (42% mediated through small-for-gestational-age status and anaemia), driven by symptomatic falciparum malaria (hazard ratio, HR: 2.99 [1.83, 4.89]) rather than asymptomatic falciparum malaria (HR: 1.35 [0.61, 2.96]). The hazard of antepartum stillbirth increased 2.21-fold [1.12, 4.33] following symptomatic vivax malaria (24% mediated through small-for-gestational-age status and anaemia) but not asymptomatic vivax malaria (HR: 0.54 [0.20, 1.45]). There was no association between falciparum or vivax malaria in pregnancy and intrapartum stillbirth (falciparum HR: 1.03 [0.58, 1.83]; vivax HR: 1.18 [0.66, 2.11]). Falciparum and vivax malaria in pregnancy increased the hazard of neonatal death 2.55-fold [1.54, 4.22] and 1.98-fold [1.10, 3.57], respectively (40% and 50%, respectively, mediated through small-for-gestational-age status and preterm birth).ConclusionsPrevention of malaria in pregnancy, new and existing interventions to prevent small-for-gestational-age status and maternal anaemia, and improved capacity for managing preterm and small-for-gestational-age newborns will reduce the number of malaria-associated stillbirths and neonatal deaths in malaria-endemic areas.

Evaluation of Helping Babies Breathe Quality Improvement Cycle (HBB-QIC) on retention of neonatal resuscitation skills six months after training in Nepal

BackgroundEach year 700,000 infants die due to intrapartum-related complications. Implementation of Helping Babies Breathe (HBB)-a simplified neonatal resuscitation protocol in low-resource clinical settings has shown to reduce intrapartum stillbirths and first-day neonatal mortality. However, there is a lack of evidence on the effect of different HBB implementation strategies to improve and sustain the clinical competency of health workers on bag-and-mask ventilation. This study was conducted to evaluate the impact of multi-faceted implementation strategy for HBB, as a quality improvement cycle (HBB-QIC), on the retention of neonatal resuscitation skills in a tertiary hospital of Nepal.MethodsA time-series design was applied. The multi-faceted intervention for HBB-QIC included training, daily bag-and-mask skill checks, preparation for resuscitation before every birth, self-evaluation and peer review on neonatal resuscitation skills, and weekly review meetings. Knowledge and skills were assessed through questionnaires, skill checklists, and Objective Structured Clinical Examinations (OSCE) before implementation of the HBB-QIC, immediately after HBB training, and again at 6 months. Means were compared using paired t-tests, and associations between skill retention and HBB-QIC components were analyzed using logistic regression analysis.ResultsOne hundred thirty seven health workers were enrolled in the study. Knowledge scores were higher immediately following the HBB training, 16.4 ± 1.4 compared to 12.8 ± 1.6 before (out of 17), and the knowledge was retained 6 months after the training (16.5 ± 1.1). Bag-and-mask skills improved immediately after the training and were retained 6 months after the training. The retention of bag-and-mask skills was associated with daily bag-and-mask skill checks, preparation for resuscitation before every birth, use of a self-evaluation checklist, and attendance at weekly review meetings. The implementation strategies with the highest association to skill retention were daily bag-and-mask skill checks (RR-5.1, 95% CI 1.9–13.5) and use of self-evaluation checklists after every delivery (RR-3.8, 95% CI 1.4–9.7).ConclusionsHealth workers who practiced bag-and-mask skills, prepared for resuscitation before every birth, used self-evaluation checklists, and attended weekly review meetings were more likely to retain their neonatal resuscitation skills. Further studies are required to evaluate HBB-QIC in primary care settings, where the number of deliveries is gradually increasing.Trial registrationISRCTN97846009. Date of Registration- 15 August 2012.