Neonatal resuscitation in low-resource settings: what, who, and how to overcome challenges to scale up?

Abstract

Background: Each year approximately 10 million babies do not breathe immediately at birth, of which about 6 million require basic neonatal resuscitation. The major burden is in low-income settings, where health system capacity to provide neonatal resuscitation is inadequate.

Objective: To systematically review the evidence for neonatal resuscitation content, training and competency, equipment and supplies, cost, and key program considerations, specifically for resource-constrained settings.

Results: Evidence from several observational studies shows that facility-based basic neonatal resuscitation may avert 30% of intrapartum-related neonatal deaths. Very few babies require advanced resuscitation (endotracheal intubation and drugs) and these newborns may not survive without ongoing ventilation; hence, advanced neonatal resuscitation is not a priority in settings without neonatal intensive care. Of the 60 million nonfacility births, most do not have access to resuscitation. Several trials have shown that a range of community health workers can perform neonatal resuscitation with an estimated effect of a 20% reduction in intrapartum-related neonatal deaths, based on expert opinion. Case studies illustrate key considerations for scale up.

Conclusion: Basic resuscitation would substantially reduce intrapartum-related neonatal deaths. Where births occur in facilities, it is a priority to ensure that all birth attendants are competent in resuscitation. Strategies to address the gap for home births are urgently required. More data are required to determine the impact of neonatal resuscitation, particularly on long-term outcomes in low-income settings.

Fig. 1

Estimates of global numbers of babies undergoing resuscitation at birth. Source: Estimates based on references [1-4,8,9].

Fig. 2

Estimates from 6 countries for the percentage of babies born in facilities, and the percentage of facilities with staff trained in neonatal resuscitation and with bag-and-mask. Source: Egypt: Ministry of Health and Population, El-Zanaty Associates, and ORC Macro. Egypt Service Provision Assessment Survey 2004: Key Findings. Calverton, Maryland, USA: Ministry of Health and Population and ORC Macro; 2005. Ghana: Ghana Statistical Service (GSS), Health Research Unit, Ministry of Health, and ORC Macro. Ghana Service Provision Assessment Survey 2002. Calverton, Maryland: Ghana Statistical Service and ORC Macro; 2003: 135. Kenya: National Coordinating Agency for Population and Development (NCAPD) [Kenya], Ministry of Health (MOH), Central Bureau of Statistics (CBS), ORC Macro. Kenya Service Provision Assessment Survey 2004. Nairobi, Kenya: National Coordinating Agency for Population and Development, Ministry of Health, Central Bureau of Statistics, and ORC Macro; 2005. Rwanda: National Institute of Statistics (NIS) [Rwanda], Ministry of Health (MOH) [Rwanda], and Macro International Inc. Rwanda Service Provision Assessment Survey 2007. Calverton, Maryland, USA: NIS, MOH, and Macro International Inc; 2008. Tanzania: National Bureau of Statistics [Tanzania], Ministry of Health and Social Welfare [Tanzania], and Macro International Inc. Tanzania Service Provision Assessment Survey 2006: Key Findings on Family Planning, Maternal and Child Health, and Malaria. Dar es Salaam, Tanzania: National Bureau of Statistics and Macro International, Inc; 2006:13. Uganda: Ministry of Health (MOH) [Uganda] and Macro International Inc. Uganda Service Provision Assessment Survey 2007. Kampala, Uganda: Ministry of Health and Macro International Inc. 2008; 132.

Fig. 3

Neonatal algorithm for advanced resuscitation according to the American Heart Association and the American Academy of Pediatric’s updated version of the original ILCOR algorithm. Reprinted with permission from Pediatrics, 117, e1029–e1038, Copyright ©2005 by the American Heart Association and American Academy of Pediatrics. Source [18].

Fig. 4

Neonatal Resuscitation Algorithm based on WHO Pocketbook of Hospital Care for Children and updated with ILCOR 2005 Recommendations. Source [19]. *Items altered from the original for consistency with ILCOR. *^a Changed instruction for 5 initial inflations to beginning regular ventilations as the 5 inflations based on just one study. Altered ventilate rate to a range of 30–40 instead of 40 based on more recent ILCOR guidelines. *^b Changed heart rate to stop cardiac massage at from 100 per minute (WHO) to 60 per minute.*^c Added criteria for stopping ventilation. Color coding added to be consistent with Integrated Management of Childhood Illness (green = well; yellow = ongoing care; pink = add now).

Fig. 5

Action Plan for Helping Babies Breathe for lower levels of the health system. Reprinted with permission granted by American Academy of Pediatrics, 2009 [20].

Fig. 6

Neonatal resuscitation and post-resuscitation care, equipment, and innovations required [107,108]. *Note reference to specific devices or use of images does not constitute endorsement. Bag-and-mask image reprinted with permission granted by from Programme for Appropriate Technology in Health (PATH); Reusable sterilizable bulb suction device (“penguin”) image and training mannequin images reprinted with permission granted by Laerdal.