Background
Immediate assessment and stimulation of the newborn baby |
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Immediate assessment, warming, drying and tactile stimulation (rubbing with the drying cloth, rubbing the back or flicking the feet) of the newborn at the time of birth. This is not the same as the WHO package of essential newborn care which is more complex and includes immediate breastfeeding, resuscitation, thermal care, eye care, immunization etc. |
Basic Newborn Resuscitation
|
Airway clearing (suctioning if required) head positioning and positive pressure ventilation via bag-and- mask.* |
Advanced Newborn Resuscitation (not estimated for LiST) |
Basic neonatal resuscitation (as above) plus endotracheal intubation, supplemental oxygen, chest compressions, and medications. |
Objective
Methods
Searches
Inclusion/exclusion criteria for abstraction
Interventions definitions
Outcomes definitions
Analyses and summary measures
Delphi process for establishing expert consensus
Results
Evidence for mortality impact of neonatal resuscitation training in facilities
Author | Setting/Country | Study Design | Intervention definition | Outcomes: definition | Distinguish Preterm from Intrapartum Deaths | N (Births) A = Baseline B = Endline | Effect Size RR/OR (95%CI) |
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Zhu XY et al 1997[3] | Urban Hospital China | Before-and-after study | AAP NRP training at of all delivery room staff at hospital | 1) Early Neonatal Mortality (first 7 days): ALL cause | Not stated | A) 1,722; B) 4,751 | 1) RR 0.34 (0.17-0.67) |
Deorari AK et al 2001[2] | 14 University Hospitals, India | Before-and-after study | AAP NRP training of 2 faculty/hospital, subsequent training of DR room nurses and doctors; competency based certification | 1) Asphyxia neonatal mortality [Features of fetal hypoxia and 5 min Apgar <6 following complications of pregnancy or delivery]; 2) Hypoxic Ischemic Encephalopathy; 3) Preterm mortality [BW < 1000 g with HMD, IVH or AOP] | Excluded BW < 1000 g, death from HMD/IVH or AOP | A) 7,070; B)25,713 | 1) RR 0.70 (0.56-0.87) 2) RR 1.68 (1.06-2.67) 3) RR 0.95 (0.74-1.24) |
Vakrilova L et al 2005[44] | All hospitals with delivery rooms in Bulgaria | Before-and-after study | French-Bulgarian Program on Newborn Resuscitation, training in all obstetric wards in country | 1) Asphyxia Neonatal Mortality [ICD 9 'perinatal and intrapartum asphyxia'], 2) Early neonatal mortality (first 7 days) 3) Preterm complication [ICD-9 'immaturity related' and 'respiratory distress syndrome'] | Excluded death due to preterm complications by ICD-9 | A) 67,948; B) 67,647 | 1) RR 0.83 (0.54-1.27) 2) RR 0.86 (0.74-1.01) 3) RR 1.33 (1.03-1.73) |
18 Urban Low-risk delivery centers, Zambia | Before-and-after study,then RCT | WHO ENC Package, including basic resuscitation with bag-mask,taught by demonstration, clinical practice sessions, and performance evaluations; followed by longer in depth training in NRP including bag-mask ventilation and chest compressions | 1) Asphyxia Early Neonatal Mortality (7 d), [not breathing at birth]; 2) Early Neonatal Mortality [first 7 days]; 3) Preterm Mortality [preterm or BW <1500] | Preterm or LBW (< 1500 g) as separate cause of death, though no hierarchy specified for single cause of death | A) 8,148; B) 20,534 | 1) RR 0.56 (NS) 2) RR 0.60 (0.48-0.76) 3) RR 0.74 (NS) |
Author | Setting/Country | Study Design | Intervention definition | Outcomes: definition | Preterm vs. Intrapartum | N (Births) A = Baseline B = Endline | Effect Size RR/OR (95%CI) |
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Zhu et al* 1993[45] | Health center, Yinshan, China | Before-and-after study | ABCDE protocol of modern resuscitation with labour ward personel | 1) Asphyxia Case Fatality | Not Stated | A) Number of resuscitations 184 223 | 1) RR 0.94 |
Tholpadi SR et al* 2000[40] | 32 peripheral health centers; Kerala, India | Before-and-after study | AAP NRP Training of village health center physicians, nurses, birth attendants; performance checklist; refresher in 3 months | 1) Asphyxia 2) Asphyxia Mortality (definitions not stated) | Not Stated | A) 874; B) 960 | 1) RR 0.68 (0.15-3.04) |
Jeffery HE et al* 2004[33] | 3 Tertiary care, 13 District Hospitals; Macedonia | Before-and-after study | 10 month perinatal training program doctors and nurses (Neonatal resuscitation, thermal care, jaundice, respiratory distress syndrome, infection control) | 1) PMR 2) Fetal mortality 3) NMR | < 1000 g excluded | A) 68,755 B) 44,263 | 1) RR 0.72 (0.66-0.78) 2) RR 0.79 (0.71-0.89) 3) RR 0.64 (0.56-0.72) |
O'Hare BA et al* 2006[49] | Teaching Hospital; Kampala, Uganda | Before-and-after study | Team of nurses trained in basic resuscitation to attend all deliveries in 1 month period, performance based evaluation; | 1) Mortality of NICU admissions | Preterms excluded | A) 1296; B) 1,046 | 20.8% in control vs. 17.3% in pilot |
Duran R et al* 1998[42] | Tertiary Care Hospital; Trakya, Turkey | Before-and-after study | NRP courses in Trakya region, Turkey 2003 & 2004 | 1) "Asphyxia" NICU admissions 2) Duration of asphyxia hospitalization | Not Stated | Not Stated | 1) 35 vs 13 NICU admissions for asphyxia 2) 15 to 6 days |
Draycott et al* 2006[37] | Maternity Unit; South Meade, UK | Before-and-after study | EOC training course: CTG obstetric emergency drills, and neonatal resuscitation | 1) HIE (MacLennan): | Not Stated | A) 8,430 B) 11,030 | 1) RR 0.50 (0.26-0.95) |
Wang H et al* 2008[41] | 17 general, 23 maternal child health hospitals; China | Before-and-after study | Nationwide AAP NRP training, started in 2004 in 20 provinces | 1) Asphyxia Mortality [Delivery room death infant 1 min Apgar <7] | Preterms not excluded | A) 51,306; B) 68, 247 | 1) RR 0.67 (0.34-1.30) |
Mufti P et al* 2006[35] | Teaching Hospital, Karachi, Pakistan | Before-and-after study | Training in management of low birthweight, respiratory distress, feeding, neonatal sepsis, and neonatal resuscitation. | 1) PMR 2) NMR | Not Stated | A) 2871 B) 4106 | 1) RR 0.85 (0.69-1.05) 2) RR 0.72 (0.51-1.02) |
Boo et al* 2009[43] | National training in all states Malaysia | Historical/ecological study | AAP NRP, national training and certification Perinatal Society; written/practical test for certification; retraining | 1) PMR; 2) NMR (all cause) | Not Stated | National annual births over 8 years | Annual NMR reported over 8 years |
Sen et al* 2009[34] | District Hospital, Purulia India | Before-and-after study | Training in neonatal resuscitation, equipping labor room-OR with resuscitation equipment. | 1) Labor room death (hospital) | Not Stated | A) 5077 B) 6704 | 1) RR 0.56 (0.42-0.75) |
Opiyo N et al* 2008[46] | Public Hospital, Nairobi, Kenya | RCT and before-after | Training of delivery room nurses-midwives in adapted UK resuscitation council. Written-clinical competency assessment. | 1) NMR (all cause) | Not Stated | A) 4367 B) 4084 | NMR 25(pre) vs 26.2 (post-intervention) |
Berglund et al* 2010[36] | Three maternity wards, Ukraine | Before-and-after study | Training maternity staff WHO "Effective Perinatal Care" including emergency obstetric and neonatal care. All maternities equipped for resuscitation | 1) Early NMR | Not Stated | A) 1696 B) 2439 | No significant effect on ENMR |
No of studies | Design | Limitations | Consistency | Generalizability to Population of Interest | Generalizability of intervention of interest | Post-InterventionEvents | Control- Baseline Events | Relative Risk (95% CI) |
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Mortality
(
Intrapartum-related Neonatal Deaths
)
: Moderate outcome specific mortality
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Before-and-after | Low quality | No evidence of heterogeneity (P=0.5) | Facility settings (ranging primary to tertiary care level), LIC-MIC | Advanced NRP in 2 studies, WHO Basic ENC in another | 360* | 185 | 0.70 (0.59, 0.84)a | |
Mortality
(
Early Neonatal Deaths
)
: Moderate outcome specific mortality
| ||||||||
Before-and-after | Low quality | Strong evidence of heterogenity (P=0.002) | Facility settings (ranging primary to tertiary care level), LIC-MIC | Advanced NRP in 2 studies, WHO Basic ENC in another | 454* | 458 | 0.62 (0.41, 0.94)b | |
Morbidity
(
Hypoxic Ischemic Encephalopathy
)
: Low outcome specific morbidity
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1 [2] | Before-and-after | Low quality | NA | Only 1 study, tertiary care hospital | Advanced NRP | 128* | 21 | 1.68 (1.06, 2.66)c |
Intervention descriptions in identified studies
Outcomes reported in identified studies
Meta analyses performed and Delphi panel estimates
1) Basic neonatal resuscitation effect on intrapartum-related term neonatal deaths (“Birth asphyxia”) in facilities
2) Basic neonatal resuscitation effect on neonatal deaths due to direct complications of preterm birth in facilities
Cause of death to act on | Newborn assessment and stimulation | Basic resuscitation in the community | Basic resuscitation in facility |
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Effect (additional to assessment and stimulation) | Effect (additional to assessment and stimulation) | ||
Intrapartum-related neonatal deaths | DELPHI Median 10% (IQR: 5-15%) (Range: 0-25%) | DELPHI Median 20% (IQR: 15-25%) (Range: 10-50%) | META-ANALYSIS (Figure 2) 30% (95% CI: 16 - 41%) |
Neonatal deaths due to complications of preterm birth | DELPHI Median 10% (IQR: 5-10%) (Range: 0-20%) | DELPHI Median 5% (IQR: 5-10%) (Range: 1-40%) | DELPHI Median 10% (IQR:10-20%) (4-30%) |
3) Neonatal resuscitation effect on early neonatal deaths (within 7 days) in facilities
Evidence for mortality impact of neonatal resuscitation in community settings
Author | Country | Study design | Intervention definition | Simultaneous Interventions | Intervention Coverage | Outcomes: Definition | Preterm vs. Intrapartum Death | N (Births) A = control B = comparison | Effect Size RR/OR (95% CI) |
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Pratinidhi et al, 1985[50] | Pune, India | Before-and-after | CHW training in basic resuscitation with mouth to mouth | Management of low birth weight, preterm, feeding, illness, cord cutting, feeding, nutrition; | 80% of home births received CHW care; 75% of births at home | 1) NMR; 2) PMR | Not stated | A) 1444; B) 1546 | 1) RR 0.75 2) RR 0.98 |
Daga SR et al, 1991[51] | Maharashtra, India | Before-and-after, no control | TBA training in basic resuscitation with mouth-to-mouth breathing | Management of low birth weight, hypothermia; transport and referral of high risk babies to hospital | TBAs attended 90% of deliveries | 1) NMR; 2) PMR; 3) SBR | Not stated | A) 321; B) 660 | 1) RR 0.59 (0.32-1.09); 2) RR 0.39 (0.21-0.69); 3) RR 0.49 (0.16, 1.50) |
Kumar R et a; 1998[55] | Haryana, India | Quasi-experimental | Advanced TBA training modern resuscitation with bag mask ventilation and mucus extractor | NS | TBAs delivered 92% of babies at home; | 1) Asphyxia mortality (Verbal Autopsy); 2) PMR | Combined "not breathing" | A) 964; B) 884 | 1) RR 0.30 (0.11-0.81) 2) RR 0.82 (0.56-1.19) |
Gadichiroli, India | Quasi-experimental | 1) 1996-1999: CHW+TBA attend deliveries together, basic resuscitation with tube-mask; 2) 1999-2003: Bag mask. Refresher training every 2 months. | Community treatment of suspected neonatal sepsis, essential newborn care | VHWs attended 84% of deliveries | 1) Asphyxia mortality (Verbal autopsy) 2) NMR 3) PMR 4) SBR 5) ENMR | Combined "not breathing" [Failure to breathe at 1, 5 min] | Before-after comparison A) 763 (95-6); B) 5510 (96-03) QE comparison A)1108 B) 979 | 1) RR 0.35 (0.15-0.78)a 2) RR 0.41 (0.26-0.66)b 3) RR 0.50 (0.35-0.71)b 4) RR 0.58 (0.36-0.93)b 5) RR 0.44 (0.27-0.73)b | |
Ariawan I, et al 2006[54] | Cirebon, Indonesia | Before-and-after, no control | Community mid-wife training in resuscitation with tube-mask, refresher training 3, 6, 9 month and VCD refresher video; training in "post-resuscitation" care | Not stated | 60% of asphyxia cases managed by midwives; uncertain coverage rate | 1) Asphyxia mortality (Verbal autopsy); 2) NMR; 3) SBR | Not stated | A) est 44,000; B) est 44,000 | 1) RR 0.39 (0.31-0.48) 2) RR 0.60 (0.53-0.68) 3) RR 0.39 (0.31-0.48) |
Carlo W et al 2010[52] | Argentina, DR Congo, Guatemala, India, Pakistan, Zambia | Before-and-after ENC; cluster RCT for NRP training | Training of community birth attendants (TBAs, nurses, midwives, and physicians) in WHO Essential Newborn Care, including basic resuscitation with bag-mask ventilation | Clean delivery, thermal protection, breastfeeding, kangaroo care | 78% of births attended by community birth attendant after ENC training | 1) PMR 2) SBR 3) ENMR | BW < 1500 g excluded | A) 22,626; B) 35,017 | 1) RR 0.85 (0.70-1.02) 2) RR 0.69 (0.54-0.88) 3) RR 0.99 (0.81-1.22) |
Gill C et al 2011[53] | Zambia | Cluster RCT | TBA Training in modified neonatal resuscitation program (NRP) w/facemask; competence assessments with refresher trainings every 3-4 mos. | Thermal care, Facilitated referral for presumptive neonatal sepsis (amoxicillin and referral) | Undetermined | 1) NMR 2) Day 1 mortality 3) Asphyxia NMR (Verbal autopsy) 4)PMR | Single cause assigned by VA "asphyxia" or "preterm" | A) 1920 B) 1517 | 1) aRR 0.55, (0.33-0.90) 2) aRR 0.40, (0.19-.83) 3) aRR 0.37 (0.17-0.81) 4) aRR 0.72 (0.51-1.00) |
Azad K et al 2011 [73] | Bangladesh | Cluster RCT, factorial design | Intervention arm: TBATraining neonatal resuscitation with bag-valve mask, with subsequent retraining; Control: TBA Training in mouth-to-mouth resuscitation | Intervention and control: Clean delivery, danger signs, emergency preparedness, facility referral. Women's participatory groups in half of clusters | Intervention Coverage: 22% of home deliveries attended by trained TBA; Control 19% by trained TBA | 1) ENMR | Not stated | A) 13195 B) 12519 | 1) 0.95 (0.75-1.21) |
Intervention descriptions in identified studies
Outcome definitions in identified studies
Study quality and Delphi panel estimates
1) Basic neonatal resuscitation effect on all cause mortality in community based studies
2) Basic neonatal resuscitation effect on intrapartum-related neonatal deaths in community-based studies
3) Basic neonatal resuscitation effect on neonatal deaths due to preterm birth complications in community-based studies
4) Basic neonatal resuscitation effect on stillbirths in community-based studies
Evidence for impact of immediate newborn assessment and stimulation
1) Intrapartum-related neonatal deaths
2) Neonatal deaths due to direct complications of preterm birth
Mortality effect, combining stimulation and basic resuscitation
Summary of the results and the quality of evidence
Effect on intrapartum-related neonatal deaths (“birth asphyxia”) |
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Cause specific effect
Immediate newborn assessment, drying, and stimulation 10% (Range 0-25%, IQR 5-15%) Basic neonatal resuscitation (facility) 30% (95% CI: 16 - 41%) Basic neonatal resuscitation (community) 20 % (Range 10-50%, IQR 15-25%) (*note that the resuscitation effect is in addition to immediate assessment, drying, and stimulation)
Quality of input evidence:
Basic neonatal resuscitation (facility) - moderate (3 low quality before-and-after studies, upgraded for consistency) Immediate newborn assessment, drying, and stimulation - very low (based on Delphi) Basic neonatal resuscitation (community) - very low (based on Delphi)
Proximity of the data to cause specific mortality effect:
Moderate (cause specific mortality but lack of consistency in cause-of-death definitions)
Limitations of the evidence:
There is a lack of rigorous evaluation particularly for the effect of immediate newborn assessment, drying, and stimulation. Data are compromised by misclassification of live births and intrapartum stillbirths and by inconsistencies in cause-of-death attribution between term intrapartum-related neonatal deaths and preterm complications especially if a clinical case definition of “not breathing at birth” (“birth asphyxia”) is applied which includes both categories.
Possible adverse effects:
Babies who survive despite severe brain injury may have long term impairments. There is a dearth of data on long term outcomes from low and middle income settings. |
Effect on neonatal deaths due to preterm direct complications
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Cause specific effect
Immediate newborn assessment, drying, and stimulation 10% (Range 0-20%, IQR 5-15%) Basic neonatal resuscitation (facility) 10% (Range 4-30%, IQR 10-20%) Basic neonatal resuscitation (community) 5% (Range 1-40%, IQR5-10%) (*note that the resuscitation effect is in addition to immediate assessment, drying, and stimulation)
Quality of input evidence:
Very low (all based on Delphi)
Limitations of the evidence:
As discussed above.
Possible adverse effects:
As discussed above. |