The fragility of a newborn baby means they require care and attention in the moments following their birth to ensure they survive infancy. In many countries around the world, health systems remain insufficiently developed to ensure best practice reaches each of these vulnerable patients. Tragically, the consequence of this uneven distribution of information is over five million potentially avoidable deaths each year of children under the age of five.
A team of researchers led by Professor Mats Målqvist of Uppsala University has set out to tackle this global issue using a series of relatively simple and low-cost healthcare interventions. Professor Målqvist is trained as both a doctor and social scientist, providing him with a unique combination of skills which he can apply throughout his research. His research spans several countries including Nepal, Swaziland, Uganda, Tanzania and Vietnam. The work covers maternal, newborn and child health care protecting some of the most vulnerable members of society.
Professor Målqvist recognised the importance of understanding the different situations families experienced around the globe and used his contextual knowledge to apply the most appropriate technique to each situation. The work aims not only to introduce clinical best practice in isolated areas but also to ensure equal distribution of knowledge throughout all health care professionals and to create long lasting behavioural change to ensure more babies survive infancy.
Community group intervention – Vietnam
In Northern Vietnam, researchers utilised community-based groups to facilitate better knowledge sharing. The Vietnamese team was headed by Principal Investigator Dr Nguyen Thu Nga. This approach acknowledged that the healthcare challenges in this area were not caused by a lack of knowledge but rather limited means of knowledge distribution and getting knowledge into practice. The team reasoned that better-shared understanding would allow for a change of behaviour which could save lives.
The community group trial was termed Neonatal health – Knowledge Into Practice (NeoKIP) and the groups allowed participants to share and discuss their personal experience of problems with newborn health and survival. Each group contained local stakeholders and a local facilitator. The role of this facilitator was to encourage participants to find and use knowledge readily available to them. Without the provision of resources, the risk of an infant not surviving their first month of life reduced by a staggering 46%.
The community groups were available to mothers from a broad cross-section of society. The diversity of participants allowed researchers to draw conclusions about the impact of the socioeconomic status of mothers on the likelihood of their child’s survival. The team found that the importance of the focus groups was particularly prominent amongst poorer families. In the last year of the study, the risk of neonatal death was reduced by 69% for poor families, an effect not seen amongst wealthier families. Consequently, one of the conclusions of this research was that the NeoKIP groups improved equity in neonatal survival dependent on wealth.
Helping Babies Breathe – Nepal
In Nepal, Professor Målqvist and his team employed a different technique. The Nepalese research group, led by Principal Investigator Dr Ashish KC of UNICEF, sought to change the worrying fact that as many as two million newborn babies suffer fatal complications during birth each year. To tackle this problem, the team utilised an educational package entitled Helping Babies Breathe, developed by the American Academy of Pediatrics.
Helping Babies Breathe is an intervention strategy which teaches midwives and other hospital staff the critical importance of ventilation within the first minute of life. Facilitating a first breath within this so-called “Golden Minute” significantly improves the chance that a baby will survive. The programme is specifically designed for environments where resources are limited, such as Nepal, making it an excellent choice of programme for implementation in this context. Resources are made freely available online and the programme is continuously updated to ensure it remains in line with the World Health Organization’s guidelines and latest scientific updates.
In order to apply this practice in Nepal, the Paropakar Maternity and Women’s Hospital in Kathmandu was chosen. In 2012, when research began at this site, the hospital recorded a stillbirth rate of 19 per 1,000 deliveries and a further nine per 1000 live births resulted in early mortality. Throughout the hospital, skilled staff were distributed between three delivery locations. At the Maternal and Newborn Service Centre room, 11 nurse midwives were available to assist with low-risk deliveries; in the labours room low and high-risk deliveries were conducted by a team of obstetricians, doctors, midwives and students and in the operating room caesarean births were assisted by a further team of obstetricians, doctors and midwives.
Though Helping Babies Breathe is an established training programme, Professor Målqvist and colleagues also sought to understand the experiences of hospital staff to ensure best practice could continue beyond the end of the research period. By conducting focus groups with nurse midwives researchers established that as well as training to improve resuscitation skills and techniques, staff also sought clearer guidelines and protocols. Professor Målqvist had already found that knowledge retention was a challenge in this area and consequently, together with the research team, sought to develop strategies which would provide midwives with the team support they required as well as acting as a constant reminder of the Helping Babies Breathe techniques.
To develop the reinforcement strategies, a workshop was conducted with hospital leadership and a Quality Improvement Team was formed. Their goal was to improve adherence to neonatal resuscitation techniques and develop a Quality Improvement Cycle to ensure reminders were frequent and adequate support was always available. The reinforcement techniques included weekly review meetings, daily skills checks, self-evaluation and peer reviews.
By using and reinforcing, the Helping Babies Breathe programme staff were able to reduce stillbirths and deaths during the first day of life by approximately 50%. Importantly, this change in newborn survival rate lasted throughout the length of the study programme, suggesting a longer-term behavioural change had been acquired. The researchers also noted that no infants were given bag and mask ventilation in the first minute of their lives prior to training but after training 83.9% were.
Great success has been achieved at target sites so far, however, Professor Målqvist and his international team intend to continue using the techniques acquired through the Helping Babies Breathe Quality Improvement Cycles to benefit more babies around the world. The first step in this process is a further trial conducted this time in 12 hospitals in Nepal which provides evidence as to how solutions can be scaled up to accommodate multiple areas. This project, the Nepal Perinatal Quality Improvement Project (NePeriQIP), will provide a replicable model for use not only throughout Nepal but also in countries with similarly disadvantaged healthcare systems.
Professor Målqvist has shown the critical importance of understanding the context of a healthcare system before attempting to apply a ‘one size fits all’ method to reducing the devastating rate of neonatal deaths worldwide. This sensitivity will ensure that appropriate levels of flexibility are built into training programmes allowing for the varying needs of staff in different hospitals to be met.
Though the Helping Babies Breathe programme and community interventions have been successful at reducing infant mortality during birth or immediately afterwards Professor Målqvist is keen to ensure progress does not stop here. The most recent findings gathered following the completion of the trial period in Nepal showed that despite the success in helping babies survive their first day, overall mortality rates in the hospital were unchanged. This evidence strongly suggests improved postnatal care in low and middle-income countries needs to be urgently implemented to ensure babies have an equal chance at surviving infancy, regardless of their place of birth.
- American Academy of Pediatrics. (2018). Helping Babies Breathe. [online] Available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/helping-babies-survive/Pages/Helping-Babies-Breathe.aspx
- KC, A., Bergström, A., Chaulagain, D., et al., 2017. Scaling up quality improvement intervention for perinatal care in Nepal (NePeriQIP); study protocol of a cluster randomised trial. BMJ Global Health, 2(3), p.e000497.
- KC, A., Wrammert, J., Clark, R.B., Ewald, U., Vitrakoti, R., Chaudhary, P., Pun, A., Raaijmakers, H. and Målqvist, M., 2016. Reducing perinatal mortality in Nepal using helping babies breathe. Pediatrics, p.e20150117.
- Eriksson, L., Duc, D.M., Eldh, A.C., Thanh, V.P.N., Huy, T.Q., Målqvist, M. and Wallin, L., 2013. Lessons learned from stakeholders in a facilitation intervention targeting neonatal health in Quang Ninh province, Vietnam. BMC pregnancy and childbirth, 13(1), p.234.
- Målqvist, M., Hoa, D.P.T., Persson, L.Å. and Selling, K.E., 2015. Effect of facilitation of local stakeholder groups on equity in neonatal survival; results from the NeoKIP trial in Northern Vietnam. PLoS One, 10(12), p.e0145510.
- Wrammert, J., KC, A., Ewald, U. and Målqvist, M., 2017. Improved postnatal care is needed to maintain gains in neonatal survival after the implementation of the helping babies breathe initiative. Acta Paediatrica, 106(8), pp.1280-1285.
- Wrammert, J., Sapkota, S., Baral, K., KC, A., Målqvist, M. and Larsson, M., 2017. Teamwork among midwives during neonatal resuscitation at a maternity hospital in Nepal. Women and Birth, 30(3), pp.262-269.
Professor Målqvist and his team’s research aims to reduce the incidence of neonatal death using simple low-cost interventions as well as evaluate the success of interventions to ensure suitability of techniques developed for wider distribution.
- Dr Nguyen Thu Nga, Principal Investigator of the NeoKIP study
- Professor Lars-Åke Persson, Uppsala University
- Dr Ashish KC, Principal Investigator of the HBB study, UNICEF
- Professor Uwe Ewald, Uppsala University
Associate Professor Mats Målqvist, a medical doctor and social scientist by training, is a senior lecturer and researcher at International Maternal and Child Health at Uppsala University. His research focuses on the implementation of maternal, newborn and child health interventions, with projects in Nepal, Swaziland, Uganda and Tanzania.
Professor Mats Målqvist
International Maternal and Child Health (IMCH)
Department of Women’s and Children’s Health
751 85 UPPSALA
T: +46 70 2673545