Fetal to Neonatal Heart Rate Transition during Normal Vaginal Deliveries: A Prospective Observational Study

Documentation of fetal to neonatal heart rate (HR) transition is limited. The aim of the current study was to describe HR changes from one hour before to one hour after normal vaginal deliveries. We conducted a prospective observational cohort study in Tanzania from 1 October 2020 to 30 August 2021, including normal vaginal deliveries with normal neonatal outcomes. HR was continuously recorded from one hour before to one hour after delivery, using the Moyo fetal HR meter, NeoBeat newborn HR meter, and the Liveborn Application for data storage. The median, 25th, and 75th HR percentiles were constructed. Overall, 305 deliveries were included. Median (interquartile range; IQR) gestational age was 39 (38–40) weeks and birthweight was 3200 (3000–3500) grams. HR decreased slightly during the last 60 min before delivery from 136 (123,145) to 132 (112,143) beats/minute. After delivery, HR increased within one minute to 168 (143,183) beats/min, before decreasing to around 136 (127,149) beats/min at 60 min after delivery. The drop in HR in the last hour of delivery reflects strong contractions and pushing. The rapid increase in initial neonatal HR reflects an effort to establish spontaneous breathing.publishedVersio

Neonatal Resuscitation Skill-Training Using a New Neonatal Simulator, Facilitated by Local Motivators: Two-Year Prospective Observational Study of 9000 Trainings

Globally, intrapartum-related complications account for approximately 2 million perinatal deaths annually. Adequate skills in neonatal resuscitation are required to reduce perinatal mortality. NeoNatalie Live is a newborn simulator providing immediate feedback, originally designed to accomplish Helping Babies Breathe training in low-resource settings. The objectives of this study were to describe changes in staff participation, skill-training frequency, and simulated ventilation quality before and after the introduction of “local motivators” in a rural Tanzanian hospital with 4000–5000 deliveries annually. Midwives (n = 15–27) were encouraged to perform in situ low-dose high-frequency simulation skill-training using NeoNatalie Live from September 2016 through to August 2018. Frequency and quality of trainings were automatically recorded in the simulator. The number of skill-trainings increased from 688 (12 months) to 8451 (11 months) after the introduction of local motivators in October 2017. Staff participation increased from 43% to 74% of the midwives. The quality of training performance, measured as “well done” feedback, increased from 75% to 91%. We conclude that training frequency, participation, and performance increased after introduction of dedicated motivators. In addition, the immediate constructive feedback features of the simulator may have influenced motivation and training quality performance.publishedVersio

Healthcare Workers’ Perceptions on the “SaferBirths Bundle of Care”: A Qualitative Study

Background: SaferBirths Bundle of Care (SBBC) is a package of innovative clinical and training tools coupled with low-dose high-frequency simulation-based on-job training guided by local data. This bundle of care is a new initiative being implemented in 30 health facilities from five regions of Tanzania aiming at improving birth outcomes. Objective: To assess the perception of healthcare workers and facility leaders on the “SaferBirths Bundle of Care” towards saving women’s and newborns’ lives at birth. Method: We used a qualitative approach using focused group discussion (FGD) and individual interviews. A total of 21 FGD and 43 individual interviews were conducted between August and November 2022. In total, 94 midwives and 12 doctors were involved, some of whom were in leadership roles. The framework method for the analysis of qualitative data was used for analysis. Results: Healthcare workers and facility leaders received the bundle well and regarded it as effective in saving lives and improving healthcare provision. Five themes emerged as facilitators to the acceptance of the bundle: (1) the bundle is appropriate to our needs, (2) the training modality and data use fit our context, (3) use of champions and periodic mentorship, (4) learning from our mistakes, and (5) clinical and training tools are of high quality but can be further improved. Conclusion: The relevance of SaferBirths Bundle of Care in addressing maternal and perinatal deaths, the quality and modality of training, and the culture that enhances learning from mistakes were among the facilitators of the acceptability of the SBBC. A well-accepted intervention has huge potential for bringing the intended impact in health provision.publishedVersio

Positive pressure ventilation at birth and potential pathways to newborn deaths in rural Tanzania

Background: There are 2.6 million neonatal deaths that occur globally each year, with more than 80% of these deaths occurring in low-income countries. In Tanzania, available estimates report that approximately 40,000 newborn deaths occur each year, mainly due to intrapartumrelated causes, prematurity-related complications, and sepsis. The majority of intrapartum-related neonatal deaths can be avoided by improving care around births. Interventions that have the potential to reduce intrapartum-related neonatal deaths include foetal monitoring during labour, availability of emergency obstetric care, and newborn resuscitation at birth for non-breathing newborns. Low-income countries are faced with many challenges in providing this care, including unskilled providers and inadequate training strategies that do not support the acquirement and retention of skills in newborn resuscitation. Aims: The overall aim of this thesis was to investigate the causes of early newborn deaths and the contribution of intrapartum-related events and their association with ventilation immediately after birth. Furthermore, we wanted to describe the human factors and interactions that influence effective newborn resuscitation practices in this rural setting. Methods: We applied a mixed-methods design and conducted three studies from October 2014 to July 2017. An observational study of all admitted newborns, delivered at Haydom Lutheran Hospital (n=671) between October 2014 and July 2017, was conducted to determine the presumed causes of 7-day newborn deaths and potential pathways contributing to death in this setting (Study I). A study that included the admitted newborns who received positive pressure ventilation in the delivery room (n=232) between October 2014 and November 2016 was then performed to compare ventilation characteristics with the newborn outcome at 7 days (Study II). Infants who died within the first 30 minutes of birth were excluded from both Studies I and II because they died in the delivery room. Building on the findings of the quantitative studies, a third study was conducted, consisting of in-depth interviews with midwives who performed deliveries and newborn resuscitations at Haydom Lutheran Hospital to explore factors affecting the provision of effective ventilation during newborn resuscitation (Study III). Results: In Study I, intrapartum-related complications (birth asphyxia and meconium aspiration syndrome) contributed to almost two-thirds of all deaths within 7 days. Prematurity, presumed sepsis, and congenital abnormalities were other causes of death. Intrapartum hypoxia and prematurity were the major pathways leading to death. Severe hypoxia and hypothermia upon admission were important additional contributing factors. In Study II, we showed that depressed newborns at birth who eventually died within 7 days had an abnormal foetal heart rate during labour, presented signs of bradycardia immediately after birth, and had delayed heart rate responses to positive pressure ventilation. Abnormal foetal heart rate during labour, heart rate at the end of positive pressure ventilation, and duration of positive pressure ventilation were the perinatal predictors of death in this setting. These newborns developed seizures and moderate/severe encephalopathy, likely related to intrapartum hypoxia. Despite inconsistencies in adhering to the Helping Babies Breathe algorithm, the tidal volume and heart rate responses that were recorded did not significantly influence the outcome of death or survival. In Study III, midwives reported the importance of monitoring labour and being prepared for resuscitation before delivery. They also cited good teamwork and frequent ventilation training as factors to facilitate effective ventilation. Barriers to effective ventilation were identified as being anxious and/or feeling fear during ventilation, and difficulties in assessing clinical responses during ventilation. Conclusion: The findings in this PhD thesis demonstrate the contribution of intrapartum-related neonatal deaths to early newborn mortality in a rural sub-Saharan setting. Furthermore, the data demonstrate a link between intrapartum events, likely through interrupted placental blood flow, and a state of depression in the foetus at birth, as represented by low heart rate at birth, delayed heart rate responses to positive pressure ventilation, and, eventually, death. Hypothermia and hypoxia during admission likely played a role in increasing mortality. The included studies highlight the potential for improving intrapartum care through enhanced foetal monitoring during labour to identify those at risk, as well as the benefits of optimizing positive pressure ventilation during resuscitation in the delivery room. The latter should be the focus of frequent resuscitation training sessions to address the providers’ uncertainties and inconsistencies during resuscitation. Frequent resuscitation training should build the confidence of providers to quickly assess newborns immediately after birth, and to act without delay in order to optimize the provision of positive pressure ventilation

The impact of introducing ambulance and delivery fees in a rural hospital in Tanzania

Background Access to health care facilities is a key requirement to enhance safety for mothers and newborns during labour and delivery. Haydom Lutheran Hospital (HLH) is a regional hospital in rural Tanzania with a catchment area of about two million inhabitants. Up to June 2013 ambulance transport and delivery at HLH were free of charge, while a user fee for both services was introduced from January 2014. We aimed to explore the impact of introducing user fees on the population of women giving birth at HLH in order to document potentially unwanted consequences in the period after introduction of fees. Methods Retrospective analysis of data from a prospective observational study. Data was compared between the period before introduction of fees from February 2010 through June 2013 and the period after from January 2014 through January 2017. Logistic regression modelling was used to construct risk-adjusted variable-life adjusted display (VLAD) and cumulative sum (CUSUM) plots to monitor changes. Results A total of 28,601 births were observed. The monthly number of births was reduced by 17.3% during the post-introduction period. Spontaneous vaginal deliveries were registered less frequently with a decrease of about 17/1000 births in non-cephalic presentations. Labour complications and caesarean sections increased with about 80/1000 births. There was a reduction in newborns with birth weight less than 2500 g. The observed changes were stable over time. For most variables, a significant change could be detected after a few weeks. Conclusion After the introduction of ambulance and delivery fees, an increase in labour complications and caesarean sections and a decrease in newborns with low birthweight were observed. This might indicate that women delay the decision to seek skilled birth attendance or do not seek help at all, possibly due to financial reasons. Lower rates of births in a safe health care facility like HLH is of great concern, as access to skilled birth attendance is a key requirement in order to further reduce perinatal mortality. Therefore, free delivery care should be a high priority.publishedVersio

Neonatal Resuscitation Skill-Training Using a New Neonatal Simulator, Facilitated by Local Motivators: Two-Year Prospective Observational Study of 9000 Trainings

Globally, intrapartum-related complications account for approximately 2 million perinatal deaths annually. Adequate skills in neonatal resuscitation are required to reduce perinatal mortality. NeoNatalie Live is a newborn simulator providing immediate feedback, originally designed to accomplish Helping Babies Breathe training in low-resource settings. The objectives of this study were to describe changes in staff participation, skill-training frequency, and simulated ventilation quality before and after the introduction of “local motivators” in a rural Tanzanian hospital with 4000–5000 deliveries annually. Midwives (n = 15–27) were encouraged to perform in situ low-dose high-frequency simulation skill-training using NeoNatalie Live from September 2016 through to August 2018. Frequency and quality of trainings were automatically recorded in the simulator. The number of skill-trainings increased from 688 (12 months) to 8451 (11 months) after the introduction of local motivators in October 2017. Staff participation increased from 43% to 74% of the midwives. The quality of training performance, measured as “well done” feedback, increased from 75% to 91%. We conclude that training frequency, participation, and performance increased after introduction of dedicated motivators. In addition, the immediate constructive feedback features of the simulator may have influenced motivation and training quality performance