Implementing quality improvement intervention to improve intrapartum fetal heart rate monitoring during COVID-19 pandemic- observational study.

INTRODUCTION: Adherence to intrapartum fetal heart rate monitoring (FHRM) for early decision making in high-risk pregnancies remains a global health challenge. COVID-19 has led to disruption of routine intrapartum care in all income settings. This study aims to evaluate the implementation of quality improvement (QI) intervention to improve intrapartum FHRM and birth outcome before and during pandemic. METHOD AND MATERIALS: We conducted an observational study among 10,715 pregnant women in a hospital of Nepal, over 25 months. The hospital implemented QI intervention i.e facilitated plan-do-study-act (PDSA) meetings before and during pandemic. We assessed the change in intrapartum FHRM, timely action in high-risk deliveries and fetal outcomes before and during pandemic.
RESULTS: The number of facilitated PDSA meetings increased from an average of one PDSA meeting every 2 months before pandemic to an average of one PDSA meeting per month during the pandemic. Monitoring and documentation of intrapartum FHRM at an interval of less than 30 minutes increased from 47% during pre-pandemic to 73.3% during the pandemic (p<0.0001). The median time interval from admission to abnormal heart rate detection decreased from 160 minutes to 70 minutes during the pandemic (p = 0.020). The median time interval from abnormal FHR detection to the time of delivery increased from 122 minutes to 177 minutes during the pandemic (p = 0.019). There was a rise in abnormal FHR detection during the time of admission (1.8% vs 4.7%; p<0.001) and NICU admissions (2.9% vs 6.5%; p<0.0001) during the pandemic.
CONCLUSION: Despite implementation of QI intervention during the pandemic, the constrains in human resource to manage high risk women has led to poorer neonatal outcome. Increasing human resources to manage high risk women will be key to timely action among high-risk women and prevent stillbirth.

Introduction

Globally, 295,000 maternal deaths, 2.0 million stillbirths and 2.5 million newborns deaths occur every year [1-3]. Of these, approximately 94% of the maternal mortality, 85% of the stillbirths and 98% of the neonatal deaths occur in low-and-middle income countries (LMIC) [1-3]. Intrapartum complications account for more than three-fourth of maternal deaths, almost half of the stillbirths and one-fourth of the neonatal mortality [4,5]. High quality care during labor and childbirth is a key to avert these deaths and reduce the burden of fresh stillbirths and early neonatal deaths resulting from birth asphyxia [6-8]. Therefore, intrapartum fetal heart rate monitoring (FHRM) is a key intervention to measure fetal condition during childbirth [9-11].

During the COVID-19 pandemic, disruptions in quality care during labor and childbirth has increased the risks for adverse maternal and fetal outcomes [12,13]. Fear of contracting the disease, diversion of delivery room staffs towards COVID-19 related care, implementation of heterogeneous and inconsistent guidelines in labor and delivery room management have further widened the gap for quality intrapartum care [14,15]. As such, breach in the provision of services like intrapartum FHRM, timely clinical decision making, and effective on-time intervention based on the clinical status of mother and fetus can easily be speculated [16,17].

According to the World Health Organization (WHO), FHR should be monitored every 30 minutes during the first stage of labor, and at least every 15 minutes during the second stage of labor [18-20].

Nepal has made a significant progress in maternal and newborn health in last two decades with reduction in maternal mortality, still birth rate and neonatal mortality rate by 76%, 58% and 68% respectively [21]. However, such substantial gains are at risk due to COVID- 19 pandemic, as our previous study reports that stillbirths and neonatal mortality increased by two and three folds respectively during the initial few months of the pandemic in Nepal [22]. Also, a resilient system in place can be helpful in execution of services like FHR monitoring and undertaking interventions like intrauterine resuscitation, instrumental delivery or a caesarean section timely, without any disruption despite facing various hurdles during the pandemic [23,24].

This study aims to assess the implementation of quality improvement (QI) intervention to improve FHRM and birth outcome before and during pandemic.

Materials and method

Study design

This is an observational study to evaluate the QI intervention in the hospital [25]. This study was conducted over a period of 25 months, comparing the period of 13 months before the pandemic (1st March 2019 – 30th March 2020) with the period of 12 months during the pandemic (April 2020 to 31st March 2021).

Study setting

This study was conducted at Pokhara Academy of Health Sciences (PoAHS), a referral hospital located in Pokhara, Province 4. The hospital provides Comprehensive Emergency Obstetric and Neonatal Care services. The vaginal and instrumental births were conducted in delivery units and the Caesarean births in the operation theatre. The hospital has 500 beds with approximately 7,000 annual deliveries; 15% by Cesarean Section. More specifically, there are 15 admission/waiting, 7 labor and 3 delivery beds, and a team of 7 obstetricians, 5 medical officers and 17 nurse-midwives along with varying number of rotating interns, skilled birth attendants and nursing students (Table 1). Nurses have three duty shifts per day with an average of three nurses and one medical attendant per shift. During the COVID-19 pandemic, these health workers were also assigned for COVID-19 focused care at hospital isolation ward in rotation. After completing 2-week duty in COVID-19 ward, the health workers stayed in quarantine for another two weeks and then resumed their duties at the maternity ward.

Table 1

Number of midwives in the maternity ward before and during pandemic.

Duty Shifts	Before Pandemic	During Pandemic
Morning shift	4–5	3–4
Evening shift	2–3	1–2
Night shift	3	2

In admission room, a midwife thoroughly examines the pregnant women, measures vital signs, FHR, and performs vaginal examination. Thereafter, medical history, vital signs and FHR taken are entered in the confinement book of the labor ward. Doctors on round review the patients chart and provide the initial and subsequent obstetric examination until delivery. After a normal vaginal delivery, mothers and babies are observed in the hospital for 10 to 24 hours in cases with normal delivery. Babies having any complications or requiring medical attention are admitted to the neonatal unit of the hospital.

Quality improvement intervention

At PoAHS, QI intervention was first introduced to the hospital management committee in January 2019. Brief orientation on QI intervention was provided to hospital leaders and head of departments. Based on the discussions among hospital leaders and management committee, plan to implement QI intervention was developed. From March 2019, QI intervention was implemented at PoAHS. Hospital leaders appointed hospital managers to lead and introduce QI process and facilitate delivery room staffs. The QI intervention consisted of, (a) introducing the use of innovative technologies for fetal heart rate monitoring (Moyo) and (b) Bi-weekly plan- do- study- act (PDSA) meeting [26]. A dashboard was developed to monitor the key quality metrics of maternal and newborn quality care indicators and outcome was established. These indicators were used by health workers to carry out their regular QI (PDSA) meetings (Fig 1).

Fig 1

Dashboard developed to maintain key quality metrics.

Implementation of QI intervention before and during COVID-19 pandemic

COVID-19 pandemic severed the hospital and patient management. Providing quality care was challenging to the health workers, however, despite limited human resources and fear of contracting the virus, the midwives continued their routine activities. Continuous communication with hospital leaders and maternity ward in-charge was done by QI coordinator to motivate and facilitate delivery room staffs to continue QI process. Head of department and ward in-charge along with QI coordinator encouraged midwives to conduct their regular PDSA meetings, use of Moyo for FHR monitoring, and practice daily skill drills to strengthen quality care even during the pandemic following the infection prevention protocol. Firstly, to deliver an improved quality intrapartum care, midwives conducted regular PDSA meetings where they identified their problems, prioritized it and planned a possible solution. Out of total 21 PDSA meetings conducted over a period of 25 months, 13 PDSA meetings were conducted during the period of pandemic where midwives continued to discuss on improving the key quality care indicator, fetal heart rate monitoring and documentation and constantly worked to achieve their target. Secondly, to prevent COVID-19 transmission, midwives also oriented mothers to identify normal and abnormal FHR detected by Moyo and to inform them if any abnormality occurred. Midwives provided required intervention responding to mother’s condition (Table 2).

Table 2

Brief discussion note during each PDSA meeting.

PDSA Meeting	Problems Identified	Action Taken
1st PDSA– 8th PDSA	Bag and Mask ventilation not initiated within Golden 1 minute.Babies being deprived of the benefits of Delayed cord clamping.	Pre- assemble necessary equipment.Take minimal time while stimulating and suctioning.Replacing blunt episiotomy scissors.Reminding the nursing staffs about the importance of delayed cord clamping.Reinforcing the staffs to do delay cord clamp.Nurses coordinated with nursing students and initiate resuscitation while baby is on the mother’s abdomen with cord intact.
9th PDSA– 12th PDSA	Reduced FHR monitoringBag and Mask ventilation not initiated within Golden 1 minute.	Using Moyo equipment for FHR monitoring.Ward In-charge initiated staffs in monitoring FHR until delivery.Staffs will monitor FHR immediately after admission.
13th PDSA- 16th PDSA	Breast-Feeding not initiated within 1 hour after birth.Bag and Mask ventilation not initiated within Golden 1 minute.	Encourage family members to initiate early breast feeding.Female attendant be allowed in labour room for helping mothers in breast feeding.Awareness about feeding to mothers and visitors.Breast feeding within 1 hour of birth should be done.
17th PDSA– 20th PDSA	Skin to skin contact not initiated immediately after birth.Bag and Mask ventilation not initiated within Golden 1 minute.	Initiating skin to skin contact in every crying babies.

Study population

The study participants included mothers in labor with an estimated gestational age more than 22 weeks and birth weight more than 500 grams. Women who consented to get enrolled were included in the study. Exclusions included multiple pregnancies, critically ill patients and cases with undetectable FHR or whose FHR was absent on admission.

Data collection

For this study, a validated clinical observation checklist was used to observe the labor and delivery event for all vaginal births, and women’s obstetric and neonatal information was collected from patient charts and case notes. A data collection system was set up at hospital and observations were done by independent clinical research officer.

Data management and analysis

All the data entered in the tablet based application were reviewed on a weekly basis by an independent data base manager and discussions and clarifications were done with surveillance officers after reviewing the entered data. For this study, data were extracted into SPSS software (IBM SPSS Statistics for Windows, Version 23.0) for the cleaning of the extracted data of all births and observed data of all deliveries occurring in the hospital. Data consistency was checked and mismatched cases were retrieved and corrected accordingly before the analysis.

Mean (SD), Median (IQR) and proportions were used for descriptive analysis of the background variables and pre–pandemic and during the pandemic maternal and neonatal outcomes. Pearson’s Chi- square tests were used to test for proportion differences. Mann- Whitney U test and independent t-test were used to compare group median and mean respectively. The use of Mann Whitney U or independent t-test for a continuous variable was based on the normality of the distribution using the histogram on skewness.

Variables

Primary outcome

The primary outcome measure was FHR defined as normal (100–160 beats per minute) and abnormal (absent, <100 or>160 bpm).

Secondary outcome

The secondary outcome included the APGAR score at 5 minutes (abnormal was defined as APGAR Score <7); mode of delivery (vaginal delivery, CS, instrumental), perinatal outcome at birth [i.e. normal, admission to the neonatal unit, intrapartum stillbirth (defined as those babies having FHR present during the intrapartum period and 15 minutes before birth, but were born without having any signs of life), and neonatal outcome at 24 hours [i.e. normal, referred to higher center or transferred to Neonatal Intensive Care Unit (NICU), FSB, First day Mortality (babies dying within 24 hours after birth)].

Socio-demographic characteristics

For sociodemographic characteristics, we included maternal age (<20, 20–35 and >35 years), parity defined as women who hasn’t given birth to a child previously (nulliparous), women who has given birth once or carried a pregnancy beyond 28 weeks previously (primiparous) and women having born more than one child previously (multiparous).

Obstetric characteristics

Obstetric Characteristics included complications during the time of admission (includes pre-eclampsia, eclampsia, diabetes, fever, premature rupture of membrane, pre-term premature rupture of membrane, polyhydramnios, oligohydramnios, cephalo-pelvic disproportion, breech / transverse lie, prolonged Labor, decrease Fetal movements, ante-partum hemorrhage, chorioamnionitis, cord Prolapse and cord around the neck), mode of delivery which included vaginal delivery, instrumental delivery and Caesarean births) and mothers having complications during or at the time of delivering the baby.

Time intervals included admission to first abnormal FHR detection, first abnormal heart rate detection to time of delivery.

Neonatal characteristics

For neonatal characteristics, we included preterm births (defined as <37 weeks of gestation on the basis of first day of mothers last menstrual period) and low birth weight babies (defined as baby’s birth weight ≤ 2500 grams).

Ethics statement

For this study, ethical approval (no. 87/2018) was received from the national ethical review board, Nepal Health Research Council (NHRC). Ethical clearance was also received from the Institutional Review board (IRB) from the hospital where the study was conducted. Written consent was taken from the pregnant women who agreed to participate before the extraction and clinical observations.

Result

During the study period, 15,797 women were admitted in hospital for delivery and 15,184 (96.1%) were eligible for enrolment, of whom 14,584 (92.3%) consented to participate in the study. Women whose FHR was absent at the time of admission were excluded from the study. Of the total 14,584 participants, 10,715 women were observed for their delivery events of which 7,459 (69.6%) women participated before the pandemic and 3,256 (30.4%) women participated during the pandemic (Fig 2).

Fig 2

Flow chart showing the study participants.

The figure presents the monthly change in intrapartum FHRM practice and PDSA Meetings conducted before and during the pandemic. On an average the number of facilitated PDSA meetings increased from an average of one PDSA meeting at an interval of two months to an average of one PDSA meeting per month during the period of pandemic. During the pre-pandemic period, the intrapartum FHRM ranged from 1% to the maximum of 11% while it ranged from 7% to the maximum of 66% during the pandemic (Fig 3).

Fig 3

Monthly FHRM practice before and during pandemic.

The mean age of women during the pre-pandemic period was 24.5 years (SD 4.65) which increased to 25.8 (SD 4.74) during the pandemic (p<0.0001). There was an increase in delivery by nulliparous women from 1.0% births pre- pandemic to 9.2% births during pandemic(p<0.0001). The proportion of women who had a complication during admission increased from 5.5% pre pandemic to 12.5% during the pandemic (p <0.0001). The proportion of babies born preterm (before 37 weeks) increased from 4.6% before pandemic to 6.4% during the pandemic; (p<0.0001) and there was an increased proportion of the babies born low birth weight during the pandemic (8.1% vs 10.2%, p<0.0001) (Table 3).

Table 3

Demographic and obstetric characteristics of women delivering in the hospital.

Category	Pre- Pandemic(N = 7,459)	During- Pandemic(N = 3,256)	Total(N = 10,715)	P-Value
AGE	7459	3256	10715	<0.0001
Mean±SD	24.54±4.65	24.79±4.74	24.61±4.68
< 20	550(7.4%)	186(5.7%)	736(6.9%)
20–35	6773(90.8%)	2982(91.6%)	9755(91.0%)
>35	136 (1.80%)	88(2.70%)	224(2.10%)
Parity*	5150	3252	8402	<0.0001
Nulli Para	54(1.0%)	298(9.2%)	352(4.2%)
Primi Para	2792 (54.2%)	1472(45.3%)	4264(50.7%)
Multi Para	2304(44.7%)	1482(45.6%)	3786(45.1%)
Gestational Age*	7071	3256	10327	<0.0001
Mean±SD	39.11±1.67	39.01±1.98	39.08±1.77
Preterm	328(4.6%)	208(6.4%)	536(5.2%)
Term	6743(95.4%)	3048(93.6%)	9791(94.7%)
Admission Complication*	3479	3252	6731	<0.0001
No	3288(94.5%)	2845(87.5%)	6133(91.1%)
Yes	191(5.5%)	407(12.5%)	598(8.9%)
Birth Weight*	7324	3249	10573	<0.0001
Mean±SD	3037.23±461.62	2990.09±482.58	3022.74±468.65
<2500	591(8.1%)	333(10.2%)	924(8.7%)
2500–3500	5900 (80.6%)	2565 (78.9%)	8465(80.1%)
>3500	833 (11.4%)	351(10.8%)	1184(11.2%)

*Variables with missing information.

Data shown as n (%) unless otherwise stated. SD: Standard Deviation.

Overall, the frequency of intrapartum FHR monitoring when compared to pre-pandemic period increased during the pandemic (p<0.0001). Monitoring and documentation of intrapartum FHR in an interval of less than 30 minutes increased from 47% in pre-pandemic period to 73.3% during the pandemic (p<0.0001). Among women whose intrapartum FHR was detected abnormal during labor, an increased proportion of women had their FHR monitored as per protocol during pandemic (when compared with pre-pandemic period (59.3% vs 20.0%, p<0.0001). The median time interval from admission to abnormal heart rate detection decreased from 160 minutes in pre pandemic period to 70 minutes during the pandemic (p = 0.020). The median time interval from abnormal FHR assessment to delivery increased from 122 minutes at pre-pandemic period to 177 minutes during the pandemic (p = 0.019). The median time duration of continuous Moyo application was 173-minutes pre- pandemic versus 148-minutes during the pandemic (p = 0.132), respectively (Table 4).

Table 4

Frequency of intrapartum FHR monitoring pre and during pandemic period.

Category	Pre- Pandemic	During- Pandemic	P-Value
Fetal Heart Rate Monitoring	7459	3256	<0.0001
< 30 Minutes	3503 (47.0%)	2387(73.3%)
>30 Minutes	1633 (21.9%)	811 (24.9%)
FHR not monitored	2323(31.1%)	58(1.8%)
FHRM practice in mothers with Abnormal Heart rate detection	Pre-Pandemic	During-Pandemic	P- Value
	n = 123*	n = 154	<0.0001
As per protocol	23 (18.7%)	83 (59.3%)
Sporadically	95 (77.2%)	58 (37.7%)
Yes, only once	5 (4.1%)	13 (8.4%)
Time intervals (q1, q3)*	Pre-Pandemic	During-Pandemic	P- Value
	n = 123*	n = 154	0.020
Time from admission to Abnormal FHR detection median (Q1, Q3) in minutes	160(36,300)	70(10,297)
	n = 123*	n = 154	0.019
Time from detection of abnormal FHR to delivery median (Q1, Q3) in minutes	122(53,249)	177(79,309)
	n = 41	n = 121	0.132
Duration of Continuous Moyo median (Q1, Q3) in minutes	173(108,313)	148(65,250)

*Variables with missing information.

When compared with pre-pandemic period, during the pandemic an increased proportion of women was detected with abnormal fetal heart rate at the time of labor (1.8% vs 4.7%); (p<0.0001). Overall, the proportion of newborns with APGAR score <7 at 5 minutes increased from 2.7% before the pandemic to 4.5% during the pandemic; (p<0.0001). There was an increase in proportion of babies who did not cry immediately after birth during the pandemic when compared with pre-pandemic period (4.5% vs. 7.7%; p<0.0001). There was an increase in proportion of newborns receiving bag and mask ventilation (15.9% vs. 26.3%) during the pandemic as compared to pre-pandemic period. Increased proportion of babies were admitted to a neonatal intensive care unit (2.9% vs 6.5%; p <0.0001) immediately after the birth and fresh stillbirth (0.7% vs 0.9%; p<0.0001) during the period of pandemic when compared with pre-pandemic period (Table 5).

Table 5

Comparison of perinatal and neonatal outcome pre-pandemic and during the time of pandemic.

Variable	Pre- Pandemic	During- Pandemic	Total	P-Value
FHR monitoring during labor	7459	3256	10715	<0.0001
No	2323(31.1%)	58(1.8%)	2381(22.2%)
Yes	5136(68.9%)	3198 (99.2%)	8334
FHR during labor	7459	3256	10715	<0.0001
Normal	7324(98.2%)	3102(95.3%)	10426(97.3%)
Abnormal	135(1.8%)	154(4.7%)	289(2.7%)
Mode of delivery	7459	2978	10715	<0.0001
Normal	6478 (86.8%)	2978 (91.5%)	9456 (88.2%)
Instrumental	188(2.5%)	97 (3.0%)	285(2.7%)
CS	793(10.6%)	181(5.6%)	974(9.1%)
Complications to mother at the time of delivery*	5035	3231	8266	<0.0001
No	4997 (99.2%)	3174 (98.2%)	8171(98.9%)
Yes	38(0.8%)	57(1.8%)	95(1.1%)
Apgar Score at 5*	5105	3253	8072	<0.0001
>7	4965(97.3%)	3107(95.5%)	8072(96.6%)
<7	140(2.7%)	146(4.5%)	286(3.4%)
Crying at birth*	6666	3075	9741	<0.0001
No	301(4.5%)	236(7.7%)	537(5.5%)
Yes	6365(95.5%)	2839(92.3%)	9204(94.5%)
Bag and Mask Ventilation	301	236	537	0.003
No	253(84.1%)	174(73.7%)	427(79.5%)
Yes	48(15.9%)	62(26.3%)	110(20.5%)
Delivery Outcome*	6666	3075	9741	<0.0001
Live birth	6420(96.3%)	2844(92.5%)	9264(95.1%)
Transfer to NICU	194(2.9%)	201(6.5%)	395(4.1%)
Fresh Stillbirth	49(0.7%)	27(0.9%)	76(0.8%)
First day Mortality	3(0.0%)	3(0.1%)	6(0.1%)

*Variables with missing information.

Discussion

Intrapartum FHR monitoring and documentation done by health workers in the study site increased during the pandemic. Frequency of intrapartum FHR monitoring and recording in an interval of both less than 30 minutes and greater than 30 minutes increased during the pandemic. In our study, we observed increase in the proportion of women presenting with complications at the time of admission during the time of pandemic. The median time from admission to abnormal heart rate detection decreased by 90 minutes.

There are several potential reasons for increase in detection of abnormal intrapartum FHR at admission. Firstly, the number of complicated cases increased due to the lockdown restrictions and extreme fear of COVID-19 infection resulting in three delays; delay in seeking care, reaching health facility and receiving care from health care providers. This has highlighted on more women seeking health facility care only after complications has arisen. Secondly, more complicated cases arriving health facility may have resulted in more FHR abnormalities and subsequent rise in abnormal heart rate detection. Third, there is lack of dedicate human resource to manage high risk pregnancy early on.

Despite improvement in intrapartum fetal heart rate monitoring and early abnormal heart rate detection, there was delay in providing timely and appropriate interventions to both mothers and their newborns, median time from first abnormal heart rate detection to time of delivery increased by nearly an hour. We observed newborns who did not cried immediately after birth and babies receiving resuscitation increased during pandemic nearly by 2-fold. Babies requiring intensive care or transferred to other health care facility for NICU admission increased nearly by 3-fold along with increase in intrapartum stillbirth and first day mortality. Health workers working in limited resources, lack of human resources, diversion of health workers for COVID-19 focused care, and lack of timely decision making might have disrupted the proper service delivery by health care system [27,28].

Ever since COVID-19 pandemic has strained the health care system, institutional maternal mortality rate, stillbirth and neonatal mortality have been increasingly high [12]. In low resource settings like Nepal, factors contributing to these maternal deaths, stillbirths and neonatal deaths in health facility can bring detrimental effects in achieving country’s ambitious Sustainable Development Goal (SDG) of reducing stillbirths and newborn deaths by 2030 [29].

In this study, we observed that implementation of QI intervention comprising PDSA Meetings contributed to improve health worker’s performance in intrapartum FHRM. However, rise in adverse fetal outcome in health facility point towards lack in clinical decision making and failure of undertaking appropriate intervention for maternal and newborn survival which raise questions to the number of skilled health workers in health facility. Nepal is found to have 0.67 doctors and nurses per 1,000 populations which is against WHO recommendation of 2.3 doctors and nurses per 1,000 populations [30]. Technologies can guide health worker for better decision making, but human resource working on it can only bring desirable changes only if they are adequate in number. The current health workers need to be increased four-fold to optimize the service for timely intervention for women who had abnormal FHR during labor. In Nepal, government hospitals are always overloaded with cases where majority of the population seek health care; technologies can support these workforces only to some extent; however, timely and effective intervention solely depends upon obstetric workforce. It’s now high time that government should prompt their priorities in maintaining doctors, nurses and patient’s ratio in an effort to provide better service and care to women and their newborns.

Methodological consideration

Observational data collection and documenting trends in intrapartum FHR monitoring practices by trained surveillance officers in labor room despite the fear of contracting the disease in a large group of mothers makes this a rare and important study. However, we have some limitations. Our single-centered study lacks the information on health workers practice of FHR monitoring in COVID-19 positive mothers and the associated fetal outcomes as we don’t have information on the COVID-19 status of the mothers. Owing to the workload inside the delivery room, observer bias can’t be ruled out for observation of health worker’s performance.

Conclusion

Despite the improvement in intrapartum FHR monitoring and documentation, adverse intrapartum related events and neonatal deaths increased during Covid-19 pandemic. Detection of FHR abnormalities should be followed by early clinical decision making and undertaking of appropriate interventions timely for better fetal outcomes. While the implementation of quality improvement intervention can make intrapartum care better, strengthening health system resilience is vital to prevent stillbirths and neonatal deaths in low resource settings. Appraisal of health worker’s performance on quality care in labor and delivery room through regular monitoring and supervision should be a priority of the government to capacitate health workforce that can effectively execute maternal and newborn services amidst any crisis like pandemics.

(CSV)

Click here for additional data file.

(CSV)

Click here for additional data file.

17 May 2022

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Hugh Cowley

Staff Editor

PLOS ONE

Journal requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf.

2. Thank you for stating the following financial disclosure:

“This study was funded by the Innovation Norway”

Please state what role the funders took in the study.  If the funders had no role, please state: ""The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.""

If this statement is not correct you must amend it as needed.

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

3. Thank you for stating the following in the Funding Section of your manuscript:

" This study was funded by the Innovation Norway”

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

“This study was funded by the Innovation Norway”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

4. Thank you for stating the following in your Competing Interests section:

“None”

Please complete your Competing Interests on the online submission form to state any Competing Interests. If you have no competing interests, please state ""The authors have declared that no competing interests exist."", as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now

This information should be included in your cover letter; we will change the online submission form on your behalf.

5. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

6. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: 1. Why did you use median for time interval analysis? Had its normality been tested? Could you provide an explanation for this (if it's abnormal, then median was used,; if it's normal, then mean should have been used)

2. Was the decreased interval from admission to abnormality detection decreased due to lack of human resources? It should have been presented in the discussion section.

3. Was the increased number of infants admitted to NICU during Covid 19 pandemic because of the good system or the pandemic itself or poor input of the infants? Please present it in the discussion section.

4. The conclusion reports the quality improvement, yet there was lack of human resources. Would you explain how many health workers should the hospital have had?

5. The article has generally been written in the standard English and is relatively easy for the readers to understand its content. There are, however, several or minor mistakes that have to be corrected. The mistakes are contained in both the Abstract and main body of the article. They include grammatical errors (inappropriate sentence structures), inconsistent use of the tenses (the result of a study is commonly written in the Simple Past Tense instead of the Simple Present Tense), and inappropriate use of adverbs and prepositions for some verbs. I hope the author will correct the errors prior to the publication.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Ekawaty Lutfia Haksari

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

26 May 2022

24 May 2022

Response to reviewer’s comment

Comment 1#. Why did you use median for time interval analysis? Had its normality been tested? Could you provide an explanation for this (if it's abnormal, then median was used,; if it's normal, then mean should have been used)

Response- The time interval from admission to abnormal fetal heart rate detection and time interval from abnormal FHR detection to time of delivery is not normally distributed. We did a normality test to respond to the reviewer’s query, please find below the time distribution using the histogram.

Comment 2#. Was the decreased interval from admission to abnormality detection decreased due to lack of human resources? It should have been presented in the discussion section.

Response- There are two possible reasons for decreased interval from admission to abnormality detection. First, is the lack of dedicated human resource to manage the high-risk mothers early on as the proportion of CS decreased as shown in table 5. Second, there is an increase in proportion of women admitted with complication at birth (5.5% before pandemic vs 12.5% during pandemic) as noted in table 3. We have added in the discussion section.

Comment 3#. Was the increased number of infants admitted to NICU during Covid 19 pandemic because of the good system or the pandemic itself or poor input of the infants? Please present it in the discussion section.

Response- The reasons for increase in number of infants admitted to NICU during pandemic despite improvement in early detection of abnormal fetal heart rate are same as above. First, the proportion of complication at admission increased due to increase in proportion of women with obstetric complication increased during pandemic. Second, the time to action despite early detection is lack of human resource to act upon women who require the care most. So, the pandemic has induced all two delays in care, delay in women coming to the health facilities and delay in high quality care.

Comment 4#. The conclusion reports the quality improvement, yet there was lack of human resources. Would you explain how many health workers the hospital should have had?

Response- We have now provided the estimated number of health workers the hospital should have to timely action on women who had abnormal FHR during labour.

Comment 5#. The article has generally been written in the standard English and is relatively easy for the readers to understand its content. There are, however, several or minor mistakes that have to be corrected. The mistakes are contained in both the Abstract and main body of the article. They include grammatical errors (inappropriate sentence structures), inconsistent use of the tenses (the result of a study is commonly written in the Simple Past Tense instead of the Simple Present Tense), and inappropriate use of adverbs and prepositions for some verbs. I hope the author will correct the errors prior to the publication.

Response- We have now done the copy edit.

Submitted filename: Response to reviewers comment.docx

Click here for additional data file.

26 Sep 2022

Implementing Quality Improvement Interventions to improve Fetal heart rate monitoring during COVID-19 pandemic- observational study

PONE-D-21-29474R1

Dear Dr. KC,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Linglin Xie

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

**********

2 Oct 2022

PONE-D-21-29474R1

Implementing Quality Improvement Intervention to improve Intrapartum Fetal heart rate monitoring during COVID-19 pandemic- observational study

Dear Dr. KC:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Linglin Xie

Academic Editor

PLOS ONE