Setting
This cross-sectional study is a sub-study within a collaborative project between Uppsala University, Paropakar Maternity and Women’s Hospital (PMWH) in Kathmandu, and the Ministry of Health and Population in Nepal. The aim of the main project is to evaluate and improve neonatal resuscitation and survival in a tertiary hospital in Kathmandu [12]. This will be achieved by using the Helping Babies Breathe (HBB) protocol; a neonatal resuscitation guideline developed in association with the American Academy of Paediatrics, designed to train birth attendants in developing countries the essential skill of new born resuscitation [13]. PMWH is a tertiary government hospital and works as a central referral hospital of the country, providing gynaecological and obstetric services. The hospital has just over 23 000 deliveries per year, which gives an average delivery rate at about 63 babies per day. The perinatal mortality rate (PMR) at the hospital is currently about 30 per 1,000 live births, with an early neonatal mortality rate (death in the first 7 days of life) of 9 per 1,000 and a stillbirth rate of 19 per 1,000 pregnancies. Abnormal deliveries account for 26% - 28% of the total deliveries, and the caesarean rate is about 17% [14].
Data collection
Budget Dome change-coupled device (CCD) Cameras (model no. MTC-505DH) were used to collect data on the hospital’s neonatal resuscitation routines. A camera was placed at each of the 6 resuscitation tables in the hospital, arranged accordingly: one in the Operating Theatre, one in the maternal and newborn service centre (MNSC), one in the emergency admission room and three in the labour rooms. The cameras had a progressive scan sensor and excellent low light performance. The cameras were equipped with motion sensors that recorded all movement within the camera’s field of vision. All film material recorded were sent to and stored on the main computer for data collection. Material captured by the CCD- cameras that did not contain a resuscitation situation, such as equipment checks, babies placed on the table for other reasons than resuscitation, staff using the table as support for updating medical records etc., where reviewed and disregarded as disturbance.
Two separate forms were uniquely developed for this study: a Case Record Form and a CCD Observation Record Form. Time and place of the resuscitations recorded by the CCD-cameras were captured. This was then matched to medical records and the Case Record Form, which contained the mother’s name, identification- and admission number. This information was transferred to the CCD Observation Record Form (Additional file 1), where a total of 12 sections had to be completed using information obtained from the Case Record Forms. In addition to the mother’s name, ID- and admission number, these included date, time, and place of birth, the baby’s gestational age, Apgar-score at one and five minutes, birth weight, sex, and whether the baby was referred or not after the resuscitation.
The CCD Observation Record Form was then used to register information from the corresponding resuscitation case recorded by the CCD-cameras. Surveillance officers, not in other ways connected to the hospital or the staff, were trained in how to use the data collection software and how to fill in the Observation Forms. The form had 14 sections to be filled out regarding observations made when watching the camera recordings. These sections included place, date, and time of resuscitation, whether the baby was crying when resuscitation was initiated, which specific resuscitation techniques were used (i.e. stimulation, suction, oxygen and ventilation) and the time intervals of which they were performed, time of first cry, and outcome. The surveillance officers then had to sign the Observation Forms and hand them to the staff in charge of data management.
Data management
A data entry officer transferred the completed CCD Observation Forms into The Census and Survey Processing System (CSPro), a public domain software package developed and supported by the U.S. Census Bureau and ICF Macro, which is interfaced with Statistical Package for the Social Sciences (SPSS 12.0).
Data analysis
The data collected from resuscitation cases recorded between July 1st and October 31st 2012 were analyzed to assess the resuscitation routines at the hospital. These were then compared with existing guidelines. Relations between the use of bag and mask ventilation and factors such as sex, birth weight, mode, and time of delivery and were also analyzed. In order for future comparison before and after HBB-intervention, Apgar-scores were extracted from medical records and analyzed in terms of resuscitation techniques used.
50 CCD-camera recordings were randomly selected out of 257 recorded in October and November 2012. To evaluate the inter- and intra-rater reliability of the observational forms, two independent observers completed two sets of forms for each case, with roughly 6 weeks in-between the two viewings conducted by each observer. Out of the 14 original sections in the Observational form, 12 were used when analyzing the reliability. Place and date of the resuscitation were filled out in order to match the two sets of forms together, and thus were not included in the analysis. Using the time intervals given for each of the four individual resuscitation techniques, the total time each technique was performed was calculated and analyzed as four additional variables. The total time from when the baby was placed at the resuscitation table until the first cry was also calculated. In total there were 17 variables individually analyzed and cross-compared in each resuscitation case. Analyses were made in SPSS 12.0. A confidence level of 95% was considered significant.
Ethical approval
CCD cameras were mounted at all resuscitation tables with the permission of hospital management. All babies brought to the tables were recorded. Because of logistic concerns, since it being impossible to predict who needed resuscitation, written informed consent was obtained from all parents of referent population before discharge [12]. The video material for referent babies was thereafter edited and stored in a safe location and was only utilized by the researchers. The study was approved by the Nepal Health Research Council (reg. No 37/2012) and the Ethical Review Board of Uppsala University (dnr 2012/267).