Mistreatment during childbirth and postnatal period reported by women in Nepal —a multicentric prevalence study

Introduction Trust of women and families toward health institutions has led to increased use of their services for childbirth. Whilst unpleasant experience of care during childbirth will halt this achievement and have adverse consequences. We examined the experience of women regarding the care received during childbirth in health institutions in Nepal. Method A prospective cohort study conducted in 11 hospitals in Nepal for a period of 18 months. Using a semi-structured questionnaire based on the typology of mistreatment during childbirth, information on childbirth experience was gathered from women (n = 62,926) at the time of discharge. Using those variables, principal component analysis was conducted to create a single mistreatment index. Bivariate and multivariate linear regression analyses were conducted to assess the association of the mistreatment index with sociodemographic, obstetric and newborn characteristics. Result A total of 62,926 women were consented and enrolled in the study. Of those women, 84.3% had no opportunity to discuss any concerns, 80.4% were not adequately informed before providing care, and 1.5% of them were refused for care due to inability to pay. According to multivariate regression analysis, women 35 years or older (beta, - 0.3587; p-value, 0.000) or 30-34 years old (beta,- 0.38013; p-value, 0.000) were less likely to be mistreated compared to women aged 18 years or younger. Women from a relatively disadvantaged (Dalit) ethnic group were more likely to be mistreated (beta, 0.29596; p-value, 0.000) compared to a relatively advantaged (Chettri) ethnic group. Newborns who were born preterm (beta, - 0.05988; p-value, 0.000) were less likely to be mistreated than those born at term. Conclusion The study reports high rate of some categories of mistreatment of women during childbirth. Women from disadvantaged ethnic group, young women, and term newborns are at higher risk of mistreatment. Strengthening health system and improving health workers' readiness and response will be key in experience respectful care during childbirth

Mistreatment during childbirth and postnatal period reported by women in Nepal -a multicentric prevalence study

Introduction Trust of women and families toward health institutions has led to increased use of their services for childbirth. Whilst unpleasant experience of care during childbirth will halt this achievement and have adverse consequences. We examined the experience of women regarding the care received during childbirth in health institutions in Nepal. Method A prospective cohort study conducted in 11 hospitals in Nepal for a period of 18 months. Using a semi-structured questionnaire based on the typology of mistreatment during childbirth, information on childbirth experience was gathered from women (n = 62,926) at the time of discharge. Using those variables, principal component analysis was conducted to create a single mistreatment index. Bivariate and multivariate linear regression analyses were conducted to assess the association of the mistreatment index with sociodemographic, obstetric and newborn characteristics. Result A total of 62,926 women were consented and enrolled in the study. Of those women, 84.3% had no opportunity to discuss any concerns, 80.4% were not adequately informed before providing care, and 1.5% of them were refused for care due to inability to pay. According to multivariate regression analysis, women 35 years or older (beta, - 0.3587; p-value, 0.000) or 30-34 years old (beta,- 0.38013; p-value, 0.000) were less likely to be mistreated compared to women aged 18 years or younger. Women from a relatively disadvantaged (Dalit) ethnic group were more likely to be mistreated (beta, 0.29596; p-value, 0.000) compared to a relatively advantaged (Chettri) ethnic group. Newborns who were born preterm (beta, - 0.05988; p-value, 0.000) were less likely to be mistreated than those born at term. Conclusion The study reports high rate of some categories of mistreatment of women during childbirth. Women from disadvantaged ethnic group, young women, and term newborns are at higher risk of mistreatment. Strengthening health system and improving health workers' readiness and response will be key in experience respectful care during childbirth

Mistreatment of newborns after childbirth in health facilities in Nepal: results from a prospective cohort observational study

Background: Patient experience of care reflects the quality of health care in health facilities. While there are multiple studies documenting abuse and disrespect to women during childbirth, there is limited evidence on the mistreatment of newborns immediately after childbirth. This paper addresses the evidence gap by assessing the prevalence and risk factors associated with mistreatment of newborns after childbirth in Nepal, based on a large-scale observational study. Methods and findings: This is a prospective observational cohort study conducted over a period of 18 months in 4 public referral hospitals in Nepal. All newborns born at the facilities during the study period, who breathed spontaneously and were observed, were included. A set of indicators to measure mistreatment for newborns was analysed. Principal component analysis was used to construct a single newborn mistreatment index. Uni-variate, multi-variate, and multi-level analysis was done to measure the association between the newborn mistreatment index and demographic, obstetric, and neonatal characteristics. A total of 31,804 births of newborns who spontaneously breathed were included. Among the included newborns, 63.0% (95% CI, 62.5-63.5) received medical interventions without taking consent from the parents, 25.0% (95% CI, 24.5-25.5) were not treated with kindness and respect (roughly handled), and 21.4% (95% CI, 20.9-21.8) of them were suctioned with no medical need. Among the newborns, 71.7% (95% CI, 71.2-72.3) had the cord clamped within 1 minute and 77.6% (95% CI, 77.1-78.1) were not breast fed within 1 hour of birth. Only 3.5% (95% CI, 3.2-3.8) were kept in skin to skin contact in the delivery room after birth. The mistreatment index showed maximum variation in mistreatment among those infants born to women of relatively disadvantaged ethnic groups and infants born to women with 2 or previous births. After adjusting for hospital heterogeneity, infants born to women aged 30-34 years (beta, -0.041; p value, 0.01) and infants born to women aged 35 years or more (beta, -0.064; p value, 0.029) were less mistreated in reference to infants born to women aged 18 years or less. Infants born to women from the relatively disadvantaged (chhetri) ethnic groups (beta, 0.077; p value, 0.000) were more likely to be mistreated than the infants born to relatively advantaged (brahmin) ethnic groups. Female newborns (beta, 0.016; p value, 0.015) were more likely to be mistreated than male newborns. Conclusions: The mistreatment of spontaneously breathing newborns is high in public hospitals in Nepal. Mistreatment varied by hospital, maternal ethnicity, maternal age, and sex of the newborn. Reducing mistreatment of newborns will require interventions at policy, health system, and individual level. Further, implementation studies will be required to identify effective interventions to reduce inequity and mistreatment of newborns at birth

Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study

BACKGROUND: The COVID-19 pandemic response is affecting maternal and neonatal health services all over the world. We aimed to assess the number of institutional births, their outcomes (institutional stillbirth and neonatal mortality rate), and quality of intrapartum care before and during the national COVID-19 lockdown in Nepal. METHODS: In this prospective observational study, we collected participant-level data for pregnant women enrolled in the SUSTAIN and REFINE studies between Jan 1 and May 30, 2020, from nine hospitals in Nepal. This period included 12·5 weeks before the national lockdown and 9·5 weeks during the lockdown. Women were eligible for inclusion if they had a gestational age of 22 weeks or more, a fetal heart sound at time of admission, and consented to inclusion. Women who had multiple births and their babies were excluded. We collected information on demographic and obstetric characteristics via extraction from case notes and health worker performance via direct observation by independent clinical researchers. We used regression analyses to assess changes in the number of institutional births, quality of care, and mortality before lockdown versus during lockdown. FINDINGS: Of 22 907 eligible women, 21 763 women were enrolled and 20 354 gave birth, and health worker performance was recorded for 10 543 births. From the beginning to the end of the study period, the mean weekly number of births decreased from 1261·1 births (SE 66·1) before lockdown to 651·4 births (49·9) during lockdown-a reduction of 52·4%. The institutional stillbirth rate increased from 14 per 1000 total births before lockdown to 21 per 1000 total births during lockdown (p=0·0002), and institutional neonatal mortality increased from 13 per 1000 livebirths to 40 per 1000 livebirths (p=0·0022). In terms of quality of care, intrapartum fetal heart rate monitoring decreased by 13·4% (-15·4 to -11·3; p&lt;0·0001), and breastfeeding within 1 h of birth decreased by 3·5% (-4·6 to -2·6; p=0·0032). The immediate newborn care practice of placing the baby skin-to-skin with their mother increased by 13·2% (12·1 to 14·5; p&lt;0·0001), and health workers' hand hygiene practices during childbirth increased by 12·9% (11·8 to 13·9) during lockdown (p&lt;0·0001). INTERPRETATION: Institutional childbirth reduced by more than half during lockdown, with increases in institutional stillbirth rate and neonatal mortality, and decreases in quality of care. Some behaviours improved, notably hand hygiene and keeping the baby skin-to-skin with their mother. An urgent need exists to protect access to high quality intrapartum care and prevent excess deaths for the most vulnerable health system users during this pandemic period.De två sista författarna delar sistaförfattarskapet</p

Scaling Up Safer Birth Bundle Through Quality Improvement in Nepal (SUSTAIN) - A stepped wedge cluster randomized controlled trial in public hospitals

Background: Each year, 2.2 million intrapartum-related deaths (intrapartum stillbirths and first day neonatal deaths) occur worldwide with 99% of them taking place in low- and middle-income countries. Despite the accelerated increase in the proportion of deliveries taking place in health facilities in these settings, the stillborn and neonatal mortality rates have not reduced proportionately. Poor quality of care in health facilities is attributed to two-thirds of these deaths. Improving quality of care during the intrapartum period needs investments in evidence-based interventions. We aim to evaluate the quality improvement packageScaling Up Safer Bundle Through Quality Improvement in Nepal (SUSTAIN)on intrapartum care and intrapartum-related mortality in public hospitals of Nepal. Methods: We will conduct a stepped wedge cluster randomized controlled trial in eight public hospitals with each having least 3000 deliveries a year. Each hospital will represent a cluster with an intervention transition period of 2months in each. With a level of significance of 95%, the statistical power of 90% and an intra-cluster correlation of 0.00015, a study period of 19months should detect at least a 15% change in intrapartum-related mortality. Quality improvement training, mentoring, systematic feedback, and a continuous improvement cycle will be instituted based on bottleneck analyses in each hospital. All concerned health workers will be trained on standard basic neonatal resuscitation and essential newborn care. Portable fetal heart monitors (Moyo (R)) and neonatal heart rate monitors (Neobeat (R)) will be introduced in the hospitals to identify fetal distress during labor and to improve neonatal resuscitation. Independent research teams will collect data in each hospital on intervention inputs, processes, and outcomes by reviewing records and carrying out observations and interviews. The dose-response effect will be evaluated through process evaluations. Discussion: With the global momentum to improve quality of intrapartum care, better understanding of QI package within a health facility context is important. The proposed package is based on experiences from a similar previous scale-up trial carried out in Nepal. The proposed evaluation will provide evidence on QI package and technology for implementation and scale up in similar settings

The perfect storm: Disruptions to institutional delivery care arising from the COVID-19 pandemic in Nepal

Background The COVID-19 pandemic has led to system-wide disruption of health services globally. We assessed the effect of the pandemic on the disruption of institutional delivery care in Nepal. Methods We conducted a prospective cohort study among 52356 women in nine hospitals to assess the disruption of institutional delivery care during the pandemic (comparing March to August in 2019 with the same months in 2020). We also conducted a nested follow up cohort study with 2022 women during the pandemic to assess their provision and experience of respectful care. We used linear regression models to assess the association between provision and experience of care with volume of hospital births and women’s residence in a COVID-19 hotspot area. Results The mean institutional births during the pandemic across the nine hospitals was 24563, an average decrease of 11.6% (P<0.0001) in comparison to the same time-period in 2019. The institutional birth in high-medium volume hospitals declined on average by 20.8% (P<0.0001) during the pandemic, whereas in low-volume hospital institutional birth increased on average by 7.9% (P=0.001). Maternity services halted for a mean of 4.3 days during the pandemic and there was a redeployment staff to COVID-19 dedicated care. Respectful provision of care was better in hospitals with low-volume birth (β=0.446, P<0.0001) in comparison to high-medium-volume hospitals. There was a positive association between women’s residence in a COVID-19 hotspot area and respectful experience of care (β=0.076, P=0.001). Conclusions The COVID-19 pandemic has had differential effects on maternity services with changes varying by the volume of births per hospital with smaller volume facilities doing better. More research is needed to investigate the effects of the pandemic on where women give birth and their provision and experience of respectful maternity care to inform a “building-back-better” approach in post-pandemic period

Chlorhexidine for facility-based umbilical cord care: EN-BIRTH multi-country validation study.

BACKGROUND: Umbilical cord hygiene prevents sepsis, a leading cause of neonatal mortality. The World Health Organization recommends 7.1% chlorhexidine digluconate (CHX) application to the umbilicus after home birth in high mortality contexts. In Bangladesh and Nepal, national policies recommend CHX use for all facility births. Population-based household surveys include optional questions on CHX use, but indicator validation studies are lacking. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) was an observational study assessing measurement validity for maternal and newborn indicators. This paper reports results regarding CHX. METHODS: The EN-BIRTH study (July 2017-July 2018) included three public hospitals in Bangladesh and Nepal where CHX cord application is routine. Clinical-observers collected tablet-based, time-stamped data regarding cord care during admission to labour and delivery wards as the gold standard to assess accuracy of women's report at exit survey, and of routine-register data. We calculated validity ratios and individual-level validation metrics; analysed coverage, quality and measurement gaps. We conducted qualitative interviews to assess barriers and enablers to routine register-recording. RESULTS: Umbilical cord care was observed for 12,379 live births. Observer-assessed CHX coverage was very high at 89.3-99.4% in all 3 hospitals, although slightly lower after caesarean births in Azimpur (86.8%), Bangladesh. Exit survey-reported coverage (0.4-45.9%) underestimated the observed coverage with substantial "don't know" responses (55.5-79.4%). Survey-reported validity ratios were all poor (0.01 to 0.38). Register-recorded coverage in the specific column in Bangladesh was underestimated by 0.2% in Kushtia but overestimated by 9.0% in Azimpur. Register-recorded validity ratios were good (0.9 to 1.1) in Bangladesh, and poor (0.8) in Nepal. The non-specific register column in Pokhara, Nepal substantially underestimated coverage (20.7%). CONCLUSIONS: Exit survey-report highly underestimated observed CHX coverage in all three hospitals. Routine register-recorded coverage was closer to observer-assessed coverage than survey reports in all hospitals, including for caesarean births, and was more accurately captured in hospitals with a specific register column. Inclusion of CHX cord care into registers, and tallied into health management information system platforms, is justified in countries with national policies for facility-based use, but requires implementation research to assess register design and data flow within health information systems

EMBARAZO Y PANDEMIA

Cuando golpe&oacute; la pandemia, los organismos profesionales de los proveedores de salud materna recomendaron que algunas consultaspersonales se sustituyeran por citas remotas para proteger a las mujeres del coronavirus. Pero estas medidas est&aacute;n ocasionando consecuencias terribles... Una gran cantidad de estudios de todo el mundo han informado una tendencia inquietante: desde que comenz&oacute; la pandemia de coronavirus, ha habido un aumento significativo en la proporci&oacute;n de embarazos que terminan en mortinatos, en los que los beb&eacute;s mueren en el &uacute;tero

Disclosing suboptimal indications for emergency caesarean sections due to fetal distress and prolonged labor : a multicenter cross-sectional study at 12 public hospitals in Nepal

BACKGROUND: Global caesarean section (CS) rates have raised concern of a potential overuse of the procedure in both high- and low-resource settings. We sought to assess management and outcomes of deliveries with emergency CSs due to fetal distress and prolonged labor at 12 public hospitals in Nepal and determine factors associated with suboptimal CS indications. METHODS: We conducted a cross-sectional study on all deliveries between the 14th of April 2017 and the 17th of October 2018 at 12 public hospitals in Nepal and included all emergency CSs due to fetal distress and prolonged labor. Analysis was conducted using Pearson chi-square test and bivariate and multivariate logistic regression. RESULTS: The total cohort included 104,322 deliveries of which 18,964 (18%) were CSs (13,095 [13%] emergency CSs and 5230 [5.0%] elective CSs). We identified 1806 emergency CSs due to fetal distress and 1322 emergency CSs due to prolonged labor. Among CSs due to fetal distress, only 36% had fetal heart rate monitoring performed according to protocol, and among CSs due to prolonged labor, the partograph was completely filled in only 8.6%. Gestational age &lt; 37 weeks and birth weight &lt; 2500 g were associated with more suboptimal CS indications due to fetal distress (adjusted odds ratio [aOR] 1.4, 95% confidence interval [CI] 1.1-1.8 and aOR 1.7, 95% CI 1.3-2.2 respectively) than those with gestational age &gt; 37 weeks and birth weight &gt; 2500 g. We found no association between suboptimal CS indications and maternal ethnicity or education level. CONCLUSIONS: As fetal heart rate monitoring and partograph are fundamental to diagnose fetal distress and prolonged labor, the inappropriate monitoring proceeding CS decisions disclosed in our study indicate that CSs were performed on suboptimal indications. We call for improved quality of intrapartum monitoring, enhanced documentation in medical records, and structured auditing of CS indications in order to curb the potentially harmful CS trend

Out of Pocket Expenditure for Sick Newborn Care in Referral Hospitals of Nepal.

BACKGROUND: Almost all preventable neonatal deaths take place in low- and middle-income countries and affect the poorest who have the least access to high quality health services. Cost of health care is one of the factors preventing access to quality health services and universal health coverage. In Nepal, the majority of expenses related to newborn care are borne by the caregiver, regardless of socioeconomic status. We conducted a study to assess the out of pocket expenditure (OOPE) for sick newborn care in hospitals in Nepal. METHODS: This cross-sectional study of hospital care for newborns was conducted in 11 hospitals in Nepal and explored OOPE incurred by caregivers for sick newborn care. Data were collected from the caregivers of the sick newborn on the topics of cost of travel, accommodation, treatment (drugs, diagnosis) and documented on a sick newborn case record form. RESULTS: Data were collected from 814 caregivers. Cost of caregivers' stay accounted for more than 40% of the OOPE for sick newborn care, followed by cost of travel, and the baby's stay and treatment. The overall OOPE ranged from 13.6 to 226.1 US dollars (USD). The median OOPE was highest for preterm complications ($33.2 USD; CI 14.0-226.1), followed by hyperbilirubinemia ($31.9 USD; CI 14.0-60.7), respiratory distress syndrome ($26.9 USD; 15.3-121.5), neonatal sepsis ($ 25.8 USD; CI 13.6-139.8) and hypoxic ischemic encephalopathy ($23.4 USD; CI 13.6-97.7). DISCUSSION FOR PRACTICE: In Nepal, OOPE for sick newborn care in hospitals varied by neonatal morbidity and duration of stay. The largest proportion of OOPE were for accommodation and travel. Affordable and accessible health care will substantially reduce the OOPE for sick newborn care in hospitals