Despite the unprecedented improvement in child health in last 15 years, burden of stillbirth and neonatal death remain the key challenge in Nepal and the reduction of these deaths will be crucial for reaching the health targets for Sustainable development goal by 2030. The aim of this thesis was to explore the risk factors for stillbirth and neonatal death and change in perinatal outcomes after the introduction of the Helping Babies Breathe Quality Improvement Cycle (HBB QIC) in Nepal. This was a prospective cohort study with a nested case-control design completed in a tertiary hospital in Nepal. Information were collected from the women who had experienced perinatal death and live birth among referent population; a video recording was done in the neonatal resuscitation corner to collect information on the health workers’ performance in neonatal resuscitation.  Lack of antenatal care had the highest association with antepartum stillbirth (aOR 4.2, 95% CI 3.2–5.4), births that had inadequate fetal heart rate monitoring were associated with intrapartum stillbirth (aOR 1.9, CI 95% 1.5–2.4), and babies who were born premature and small-for-gestational-age had the highest risk for neonatal death in the hospital (aOR 16.2, 95% CI 12.3–21.3). Before the introduction of the HBB QIC, health workers displayed poor adherence to the neonatal resuscitation protocol. After the introduction of HBB QIC, the health workers demonstrated improvement in their neonatal resuscitation skills and these were retained until six months after training. Daily bag-and-mask skill checks (RR 5.1 95% CI 1.9–13.5), preparation for birth (RR 2.4, 95% CI 1.0–5.6), self-evaluation checklists (RR 3.8, 95% CI 1.4–9.7) and weekly review and reflection meetings (RR 2.6, 95% 1.0–7.4) helped the health workers to retain their neonatal resuscitation skills. The health workers demonstrated improvement in ventilation of babies within one minute of birth and there was a reduction in intrapartum stillbirth (aOR 0.46, 95% CI 0.32–0.66) and first-day neonatal mortality (aOR 0.51, 95% CI 0.31–0.83).  The study provides information on challenges in reducing stillbirth and neonatal death in low income settings and provides a strategy to improve health workers adherence to neonatal resuscitation to reduce the mortality. The HBB QIC can be implemented in similar clinical settings to improve quality of care and survival in Nepal, but for primary care settings, the QIC need to be evaluated further.

This study aimed to assess the magnitude, trends and determinants of intrapartum stillbirths in the public health facilities in Addis Ababa. A case-control study design was used along with quantitative data collection methods. Obstetric care data on key variables were collected from medical records of 728 cases and 1551 controls in the public health facilities during July 1, 2010 and June 30, 2015. Data were analysed using SPSS version 24 to determine associations and risk factors against intrapartum stillbirth. HMIS data from different sources were further analysed for the same period to determine trends of stillbirth in the public health facilities of Addis Ababa. Findings from this study showed a staggering high prevalence of stillbirth at an average rate of 28 per 1000 births during the period 2010-2015. This figure was comparable with the population level prevalence of prenatal death in Addis Ababa which was 30 per 1000 birth (Central Statistical Agency 2011:115). No statistically significant associations were revealed against the effects of maternal medical conditions including diabetes, hypertension, cardiac and renal diseases and key socio-demographic variables including age, parity and marital status, and intrapartum stillbirth. On the contrary, HIV and syphilis infections, foetal presentations, multiple pregnancy and the frequency of ANC visits during the index pregnancy had statistically significant associations with intrapartum stillbirth. Furthermore, low FHR, non-vertex foetal presentations and ruptured cervical membrane on admission to labour were among risk factors for intrapartum stillbirth. Similarly, women in the stillbirth group received substandard care regarding the timely assessment of foetal decent, cervical dilatation, labour induction, and episiotomy care compared to women in the livebirth group. Obstetrical complications including obstructed labour, eclampsia and preeclampsia were more common among women in the intrapartum stillbirth group indicating that the above variables were key determinant of intrapartum stillbirth. These findings suggest that poor quality of obstetric care during labour and childbirth were the underlying risk factors for intrapartum stillbirth. In conclusion, strategies to overhaul the obstetric care practices in the public health facilities through skills building, accurate use of labour monitoring tools, close supervisions, accurate classification of stillbirth, proper documentation, and ongoing research efforts. / Health Studies / D. Litt. et Phil. (Health Studies)