title: Reducing Perinatal Mortality in Nepal Using Helping Babies Breathe.
abstract: Newborns are at the highest risk of dying around the time of birth, due to intrapartum-related complications. Our study's objective was to improve adherence to the Helping Babies Breathe (HBB) neonatal resuscitation protocol and reduce perinatal mortality by using a quality improvement cycle (QIC) in a tertiary hospital in Nepal.
  
  
  
  The HBB QIC was implemented through a multifaceted approach, including the formation of quality improvement teams; development of quality improvement goals, objectives, and standards; HBB protocol training; weekly review meetings; daily skill checks; use of self-evaluation checklists; and refresher training. A cohort design, including a nested case-control study was used to measure changes in clinical outcomes and adherence to the resuscitation protocol through video recording, before and after implementation of the QIC.
  
  
  
  The intrapartum stillbirth rate decreased from 9.0 to 3.2 per thousand deliveries, and first-day mortality from 5.2 to 1.9 per thousand live births after intervention, demonstrating a reduction of approximately half in the odds of intrapartum stillbirth (adjusted odds ratio [OR] 0.46, 95% confidence interval [CI] 0.32-0.66) and first-day mortality (adjusted OR 0.51, 95% CI 0.31-0.83). After intervention, the odds of inappropriate use of suction and stimulation decreased by 87% (OR 0.13, 95% CI 0.09-0.17) and 62% (OR 0.38, 95% CI 0.29-0.49), respectively. Before intervention, none of the infants received bag-and-mask ventilation within 1 minute of birth, compared with 83.9% of infants after.
  
  
  
  The HBB QIC reduced intrapartum stillbirth and first-day neonatal mortality and led to use of suctioning and stimulation more frequently. The HBB QIC requires further testing in primary settings across Nepal.
authors.affiliation: Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden; Health Section, UNICEF Nepal Country Office, UN House, Pulchowk, Lalitpur, Nepal; aaashis7@yahoo.com.
authors.forename: Ashish
authors.initials: A
authors.lastname: Kc
authors.affiliation: Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden;
authors.forename: Johan
authors.initials: J
authors.lastname: Wrammert
authors.affiliation: Latter-Day Saints Charities, Salt Lake City, Utah; and.
authors.forename: Robert B
authors.initials: RB
authors.lastname: Clark
authors.affiliation: Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden;
authors.forename: Uwe
authors.initials: U
authors.lastname: Ewald
authors.affiliation: Paropakar Maternity and Women's Hospital, Kathmandu, Nepal.
authors.forename: Ravi
authors.initials: R
authors.lastname: Vitrakoti
authors.affiliation: Paropakar Maternity and Women's Hospital, Kathmandu, Nepal.
authors.forename: Pushpa
authors.initials: P
authors.lastname: Chaudhary
authors.affiliation: Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden;
authors.forename: Asha
authors.initials: A
authors.lastname: Pun
authors.affiliation: Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden;
authors.forename: Hendrikus
authors.initials: H
authors.lastname: Raaijmakers
authors.affiliation: Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden;
authors.forename: Mats
authors.initials: M
authors.lastname: Målqvist
mesh_terms: D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007231:Infant, Newborn; D009390:Nepal / Q000453:epidemiology; D066087:Perinatal Death / Q000517:prevention & control*; D054238:Perinatal Mortality / Q000639:trends; D011247:Pregnancy; D058996:Quality Improvement; D012151:Resuscitation / Q000193:education / Q000592:standards* / Q000706:statistics & numerical data; D050497:Stillbirth / Q000453:epidemiology