Scaling Up Safer Birth Bundle Through Quality Improvement in Nepal (SUSTAIN) - A stepped wedge cluster randomized controlled trial in public hospitals

Rejina Gurung, Anjani Kumar Jha, Susheel Pyakurel, Abhishek Gurung, Helena Litorp, Johan Wrammert, Bijay Kumar Jha, Prajwal Paudel, Syed Moshfiqur Rahman, Honey Malla, Srijana Sharma, Manish Gautam, Jorgen Erland Linde, Md Moinuddin, Uwe Ewald, Mats Målqvist, Anna Axelin, Ashish Kc

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Background: Each year, 2.2 million intrapartum-related deaths (intrapartum stillbirths and first day neonatal deaths) occur worldwide with 99% of them taking place in low- and middle-income countries. Despite the accelerated increase in the proportion of deliveries taking place in health facilities in these settings, the stillborn and neonatal mortality rates have not reduced proportionately. Poor quality of care in health facilities is attributed to two-thirds of these deaths. Improving quality of care during the intrapartum period needs investments in evidence-based interventions. We aim to evaluate the quality improvement package - Scaling Up Safer Bundle Through Quality Improvement in Nepal (SUSTAIN) - on intrapartum care and intrapartum-related mortality in public hospitals of Nepal. Methods: We will conduct a stepped wedge cluster randomized controlled trial in eight public hospitals with each having least 3000 deliveries a year. Each hospital will represent a cluster with an intervention transition period of 2 months in each. With a level of significance of 95%, the statistical power of 90% and an intra-cluster correlation of 0.00015, a study period of 19 months should detect at least a 15% change in intrapartum-related mortality. Quality improvement training, mentoring, systematic feedback, and a continuous improvement cycle will be instituted based on bottleneck analyses in each hospital. All concerned health workers will be trained on standard basic neonatal resuscitation and essential newborn care. Portable fetal heart monitors (Moyo®) and neonatal heart rate monitors (Neobeat®) will be introduced in the hospitals to identify fetal distress during labor and to improve neonatal resuscitation. Independent research teams will collect data in each hospital on intervention inputs, processes, and outcomes by reviewing records and carrying out observations and interviews. The dose-response effect will be evaluated through process evaluations. Discussion: With the global momentum to improve quality of intrapartum care, better understanding of QI package within a health facility context is important. The proposed package is based on experiences from a similar previous scale-up trial carried out in Nepal. The proposed evaluation will provide evidence on QI package and technology for implementation and scale up in similar settings. Trial registration number: ISRCTN16741720. Registered on 2 March 2019.
Original languageEnglish
Article number65
JournalImplementation Science
Issue number1
Publication statusPublished - 19 Jun 2019


  • Basic neonatal resuscitation
  • Fetal heart rate monitoring
  • Nepal
  • Quality improvement interventions
  • Stepped wedge cluster randomized control trial


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