Participation in an international study on delivery room management has given neonatologists in Uzbekistan the chance to hold up a mirror to their own practice. The results have triggered a process of learning and change.

When Professor Mario Rüdiger, the director of the Center for Feto-Neonatal Health at the Universitätsklinikum in Dresden, thinks back to the beginning of his career, he remembers how invasive neonatal care in Germany used to be. Resuscitation was commonplace. Doctors often used intensive care techniques to treat premature babies as they developed problems after birth. 

Over the course of his working life it has become clear that, while intensive interventions can help pre-term babies to survive, they do not prevent other health challenges from emerging as the babies grow older. This realisation has led to a shift in philosophy away from treating problems in pre-term babies towards preventing them from developing in the first place. 

Starting right in the delivery room, Professor Rüdiger and his colleagues now aim to support babies to transition from in utero to ex utero with the lightest possible touch. ‘We watch the baby carefully, use some equipment to check what the baby is doing, and then add the small part that it’s not doing itself,’ explains Professor Rüdiger. It takes experience to know when and how to intervene, he continues, but ‘by doing things differently, and learning as we went, we came to understand that the less we do, the better it is for the baby.’ 

Uzbek neonatologists analyse their delivery room practices  

Over the past two years, Professor Rüdiger has had the opportunity to share some of what he has learned about introducing changes into the practice of neonatal medicine with a group of neonatologists from Uzbekistan who are in the midst of a similar transition in their own institutions. 

The collaboration is occurring under the auspices of a three-way institutional partnership between the Center for Feto-Neonatal Health, the Republican Perinatal Center in Tashkent, and Uzbekistan’s Center for the Development of Professional Qualifications of Medical Workers. The partnership is supported by Germany’s Federal Ministry for Economic Cooperation and Development (BMZ) and implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) through a project on the effective use of advanced medical technology in Uzbekistan.

One aspect of the partnership has seen neonatal teams from six perinatal centers across Uzbekistan join an international research collaboration on delivery room management – the Survey on Currently Applied Interventions in Neonatal Resuscitation (SCIN) study – which is led by the Universitätsklinikum Dresden. More than 70 hospitals in 20 countries are taking part in the research, whose aim is to document what interventions are actually applied in delivery rooms during neonatal resuscitation and to compare these with international guidelines. For six months the participating centers collected data about every intervention they provided in the delivery room, in accordance with a standardised research protocol. 

For Dr Umida Nasirova, the chief neonatologist of Uzbekistan and the deputy director of the Center for the Development of Professional Qualifications of Medical Workers, the opportunity to participate in the SCIN study has come at exactly the right moment. Although Uzbekistan has enjoyed success in reducing its neonatal mortality rate in recent years, other challenges are now coming to the fore. Problems such as retinopathy of prematurity – an eye disease which can lead to blindness – and bronchopulmonary dysplasia – a serious lung condition – are emerging in premature babies as they grow and develop. The SCIN study offers a chance to better understand the reasons behind these problems, and to find ways to solve them.

 ‘Analysing your own work is really meaningful,’ says Dr Nasirova. ‘When you pay continuous attention to what you are doing, step by step, it becomes much clearer how to do it better – or how to change something.’

A detailed look at the ‘real situation’

Professor Mario Rüdiger analysed the SCIN data from the six hospitals in Uzbekistan and presented the results to neonatologists during a workshop in Tashkent in October 2023. The results from each Uzbek institution – initially without identifying information – were shown alongside those from the Center for Feto-Neonatal Health in Dresden and from all other participating institutions worldwide. The findings, which contained some unexpected information, triggered a process of deep reflection and change.

The data revealed, for example, differences in the extent to which the six participating perinatal centers use suction and provide oxygen during resuscitation – interventions which are no longer recommended in most cases. Another finding was that few delivery rooms use caffeine, which is a simple and effective method for countering neonatal apnea. The SCIN data also showed that the temperature of premature babies upon admission to neonatal intensive care units is often too low – a factor which can negatively influence mortality and morbidity.

Notably, one of the perinatal centers had delivery practices much closer to those in Dresden than to its in-country peers. It was the only one, for example, which did not employ suction at all during resuscitation. It made frequent use of CPAP (continuous positive air pressure) and low use of ventilation, and was also the only one of the six hospitals to use caffeine in the delivery room. When these marked differences in practice became apparent during the presentation of results, the Uzbek colleages agreed to ‘unblind’ the study findings. Professor Mario Rüdiger turned the floor over to the participants from that particular hospital to explain in detail how they work. ‘They did all the teaching,’ he says. ‘This was a great self-empowerment process.’

For Dr Umida Nasirova, participation in the study was like holding up a mirror to current practice: ‘The study gave us a look at the “real situation” and provided very helpful information,’ she says. ‘We assume that all of our doctors are working according to international guidelines, and following everything step by step, but now we understand that some parts are missing.’ 

Keen interest to introduce changes – and to collect the data again

Dr Nasirova is satisfied with the impulse the SCIN study has given to the field of neonatology in Uzbekistan. ‘When the study began it was quite difficult. People were not used to working like this,’ explains Dr Nasirova. But after seeing their practice analysed in this way, and realising the conclusions which could be drawn from the data, doctors’ attitudes changed. She explains that there is now a huge demand to act upon the findings, to adjust practices, and to repeat the exercise again in 2024 – this time with the participation of all 14 perinatal centers.  

At the Republican Perinatal Center in Tashkent, the Deputy Director, Dr Nodira Kasimova, and her colleagues have wasted no time in changing their routines. For example, after reflecting on the SCIN results, they started using CPAP right in the delivery room and transferring babies to the neonatal intensive care unit (NICU) using a transport incubator. The advantage of this approach – as opposed to the previous practice, in which they moved babies to NICU and then administered surfactant, an intervention for treating respiratory distress – is that the babies’ lungs are kept open the entire time. 

While participation in the study is already paying dividends in terms of improvements to neonatal practice, it is also giving neonatologists in Uzbekistan a chance to engage in an international research collaboration for the first time. ‘The Uzbek experts at the perinatal centers feel real ownership of the data they are generating,’ says Aliya Zhalmagambetova, a technical advisor with GIZ who coordinates the Dresden-Tashkent partnership. ‘They know that they are part of a global study and that the results will be published. This is very motivating. It broadens their professional horizons.’ 

Seeing problems is the first step to fixing them

According to Dr Nodira Kasimova, the Deputy Director of the Republican Perinatal Center, the most important aspect of the collaboration with Dresden is that ‘it is allowing us see our problems and to find ways to fix them.’ Recognising gaps and shortcomings is the first step towards addressing them, but as Professor Mario Rüdiger knows from his own experience, change management within large perinatal institution takes time. ‘You can’t change things from one day to the next. You need a long period of time, because you have to involve everyone, from obstetricians to nurses,’ he notes. The most important requirements are a desire to do things differently and openness to learning from others’ – and one’s own – experiences. The enthusiastic response to the SCIN study in Uzbekistan suggests that both these conditions are in place.

Karen Birdsall,
February 2024