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Observational Study
. 2021 Mar 26;21(Suppl 1):235.
doi: 10.1186/s12884-020-03422-9.

Neonatal resuscitation: EN-BIRTH multi-country validation study

Ashish Kc #  1 , Kimberly Peven #  2   3 , Shafiqul Ameen  4 , Georgina Msemo  5   6 , Omkar Basnet  7 , Harriet Ruysen  2 , Sojib Bin Zaman  4 , Martha Mkony  5 , Avinash K Sunny  7 , Qazi Sadeq-Ur Rahman  4 , Josephine Shabani  5 , Ram Chandra Bastola  8   9 , Evelyne Assenga  10 , Naresh P Kc  11 , Shams El Arifeen  4 , Edward Kija  5 , Honey Malla  7 , Stefanie Kong  2 , Nalini Singhal  12 , Susan Niermeyer  13 , Ornella Lincetto  14 , Louise T Day #  2 , Joy E Lawn #  2 ; and EN-BIRTH Study Group
Collaborators, Affiliations
Observational Study

Neonatal resuscitation: EN-BIRTH multi-country validation study

Ashish Kc et al. BMC Pregnancy Childbirth. .

Abstract

Background: Annually, 14 million newborns require stimulation to initiate breathing at birth and 6 million require bag-mask-ventilation (BMV). Many countries have invested in facility-based neonatal resuscitation equipment and training. However, there is no consistent tracking for neonatal resuscitation coverage.

Methods: The EN-BIRTH study, in five hospitals in Bangladesh, Nepal, and Tanzania (2017-2018), collected time-stamped data for care around birth, including neonatal resuscitation. Researchers surveyed women and extracted data from routine labour ward registers. To assess accuracy, we compared gold standard observed coverage to survey-reported and register-recorded coverage, using absolute difference, validity ratios, and individual-level validation metrics (sensitivity, specificity, percent agreement). We analysed two resuscitation numerators (stimulation, BMV) and three denominators (live births and fresh stillbirths, non-crying, non-breathing). We also examined timeliness of BMV. Qualitative data were collected from health workers and data collectors regarding barriers and enablers to routine recording of resuscitation.

Results: Among 22,752 observed births, 5330 (23.4%) babies did not cry and 3860 (17.0%) did not breathe in the first minute after birth. 16.2% (n = 3688) of babies were stimulated and 4.4% (n = 998) received BMV. Survey-report underestimated coverage of stimulation and BMV. Four of five labour ward registers captured resuscitation numerators. Stimulation had variable accuracy (sensitivity 7.5-40.8%, specificity 66.8-99.5%), BMV accuracy was higher (sensitivity 12.4-48.4%, specificity > 93%), with small absolute differences between observed and recorded BMV. Accuracy did not vary by denominator option. < 1% of BMV was initiated within 1 min of birth. Enablers to register recording included training and data use while barriers included register design, documentation burden, and time pressure.

Conclusions: Population-based surveys are unlikely to be useful for measuring resuscitation coverage given low validity of exit-survey report. Routine labour ward registers have potential to accurately capture BMV as the numerator. Measuring the true denominator for clinical need is complex; newborns may require BMV if breathing ineffectively or experiencing apnoea after initial drying/stimulation or subsequently at any time. Further denominator research is required to evaluate non-crying as a potential alternative in the context of respectful care. Measuring quality gaps, notably timely provision of resuscitation, is crucial for programme improvement and impact, but unlikely to be feasible in routine systems, requiring audits and special studies.

Keywords: Birth; Coverage; Health management information systems; Hospital records; Measurement; Neonatal resuscitation; Quality; Survey; Validity.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Helping Babies Breathe algorithm decision points to measure neonatal resuscitation coverage
Fig. 2
Fig. 2
Neonatal resuscitation validation design, EN-BIRTH study. EN-BIRTH validation design comparing observation gold standard with register-recorded and women’s report on exit survey; EN-BIRTH data collection tools (observation checklist, register data extraction tool and exit survey tool) are published separately [22]
Fig. 3
Fig. 3
Flow diagram of cases for neonatal resuscitation analysis, EN-BIRTH study (n = 22,752)
Fig. 4
Fig. 4
Neonatal resuscitation numerators and denominators, EN-BIRTH study (individually weighted, observation data, n = 22,752)
Fig. 5
Fig. 5
Hospital register design and completeness for stimulation and bag-mask-ventilation, EN-BIRTH study (n = 22,752)
Fig. 6
Fig. 6
Coverage (and 95%CI) of bag-mask-ventilation measured by observation, register, and exit survey, EN-BIRTH study (n = 22,752). *Random effects meta-analysis; BD = Bangladesh, NP = Nepal, TZ = Tanzania, stim. = stimulation, suct. = suction, BMV = bag mask ventilation, FSB = fresh stillbirth; BMV = bag mask ventilation; Full denominator details presented in Additional file 14
Fig. 7
Fig. 7
Validity ratios for exit survey-reported and register-recorded coverage of bag-mask-ventilation, EN-BIRTH study (n = 22,752). Full denominator details presented in Additional file 14
Fig. 8
Fig. 8
Gap analysis for coverage and quality among newborns non-crying/not responding to stimulation/suction, EN-BIRTH study (n = 200). BD = Bangladesh, NP = Nepal, TZ = Tanzania; BMV = Bag-mask-ventilation; Full denominator details presented in Additional file 14
Fig. 9
Fig. 9
Time to bag-mask-ventilation by denominator, EN-BIRTH study (n = 991). BD = Bangladesh, NP = Nepal, TZ = Tanzania; D1: n = 991, D2: n = 672, D3: n = 454, No cry/breath/response: n = 142
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