Practice and outcomes of neonatal resuscitation for newborns with birth asphyxia at Kakamega County General Hospital, Kenya: a direct observation study

Globally, approximately 4 million deaths occur in neonates with 99% of them occurring in low and middle income countries [1]. Birth asphyxia, defined as the failure to initiate and sustain breathing at birth by WHO, causes about a quarter of all the neonatal deaths [2]. Approximately three – quarters of all neonatal deaths occur during the first week of life, with a million babies dying on the day they are born [3]. Conspicuously, over half of these neonatal deaths occur within the first 24 h after birth [4, 5]. However, morbidity and mortality from birth asphyxia is mostly preventable and treatable [6]. Effective resuscitation at birth can prevent a large proportion – approximately 30% - of these deaths [7]. Furthermore, resuscitation may avert 5–10% of deaths due to complications of preterm birth [8].

Evidence around the world also show that the risk of death increases by 16% for every 30 s delay in initiating ventilation up to six minutes and every 6% for every minute of delay of applied bag and mask ventilation [5]. Therefore, it is clear that the first minutes after birth are critical to reducing neonatal mortality. Evidence suggests that successful neonatal resuscitation by well – trained HCPs to provide appropriate and adequate resuscitation has the potential to prevent perinatal mortality caused by intrapartum related asphyxia for almost two million babies annually [3]. Newborns with birth asphyxia can suffer from short- to long-term neurological complications. Severe asphyxia has been linked to cerebral palsy, mental retardation, epilepsy and learning disabilities [9]. Therefore, there is need for urgent referral of complicated birth asphyxia cases to higher well specialized facilities in order to assist prevent some of these complications if anticipated early enough [6].

Neonatal mortality in Kenya is still high at 21 per 1000 live births [10] with Kenya aiming to achieve the global SDG target of neonatal mortality to at least as low as 12 per 1000 live births by 2030 [11]. Birth asphyxia is the leading cause of neonatal mortality contributing to 29% of the deaths in the country [12]. The ministry of health (Kenya) recognizes the importance of neonatal resuscitation (NR) as part of the basic emergency obstetric and newborn care (BEmONC) from level 2 health facilities [13]. National guidelines in the form of protocols have been developed and reviewed over time to standardize the performance of NR for newborns with birth asphyxia [14].

However, despite the HCPs’ pre – service and in – service training, guidelines and job aids with adequate equipment in NR, practices of HCPs with regard to NR are still reported to be poor [15‐17]. Ineffective or wrong resuscitation practices are linked to the persistently high neonatal deaths from birth asphyxia in the first 1–24 h [18]. Kakamega county region is the second most populated region in the country with a high neonatal mortality rate of 28 per 1000 live births [19]. To better describe the healthcare practice and outcomes, the three Donabedian domains of healthcare assessment: structures/resources, process and outcomes are used [20]. This study aimed to describe the practice of NR and outcomes of newborns with birth asphyxia in a busy main regional referral hospital.

This was a cross - sectional study employing direct observations of NR in labour ward and maternity theatre between April and June 2016 at the regional Kakamega County General Hospital. This method is non – intrusive, where the HCPs do what they normally do (resuscitation) without being interrupted or disturbed by the observer [21, 22]. This allowed the HCPs to be observed in their natural fashion providing NR without interfering in their process of care. However, the newborn unit was excluded as newborns are only referred here after stabilizing from the initial resuscitation done in labor ward or maternity theatre immediately after delivery.

All the HCPs who were involved in resuscitating a newborn and voluntarily consented to participate in the study were observed during resuscitation sessions. The HCPs should have been working in the labor ward and/or the maternity theatre and providing direct NR services. Trainee nursing and medical students were excluded (unlicensed to practice). Newborns with birth asphyxia who met the inclusion criteria based on the WHO and the American Academy of Pediatrics were recruited [2, 23]. The criteria included: failure to initiate spontaneous respirations at birth/within 1 min of delivery and/or gasping breathing at 30 s after birth and/or baby is floppy and/or bluish or has central cyanosis (blue tongue). Stillbirths (birth of a baby who shows no signs of life [no gasping, breathing, heartbeat or movement]) and those with congenital abnormalities incompatible with life were excluded. Consecutive sampling was used to select all the newborns that required NR immediately after birth and met the inclusion criteria until the required sample size was achieved. It is estimated that about 1 in 10 babies needs help to breathe immediately after birth and therefore, a quick assessment immediately after birth remains the best way to know if a baby needs help to breathe [24]. The Kish Leslie formula (n = Z ² pq/e ² ) for cross – sectional studies was used to calculate the sample size of the NRs to be observed [25]. The Z (variate from normal distribution that represents the level of confidence) was 1.96; p (estimated proportion of attribute present in a population) was set at 10% as the number of newborns who require resuscitation to breathe at birth [24]; and q = 1 – p. The desired level of precision (e) was set at 95% (minimum acceptable errors at 5%) giving a total of 138 as the desired newborn resuscitations to be observed. Each HCP was observed for between three to five times providing NR care.

HCPs working with newborns must be well equipped with NR knowledge and skills in order to reduce neonatal mortality related to birth asphyxia. Our findings showed that most HCPs had undergone formal NR trainings over a year ago before this study. Supportive supervision was equally conducted for most HCPs by either the unit manager or ward in – charge at least over 6 months prior to this study. Absence of frequent monitoring of NR skills and refresher trainings every 6 months for HCPs make NR skills to decline rapidly over time as shown by a recent multi – country study on Helping Babies Breathe [27]. Elsewhere, there is evidence that HCPs with over two years of experience working in maternity unit had better NR skills compared to those with less in the same unit [15]. It is expected that those with more years of experience working in the unit help impart the same knowledge and skills to the new HCPs who join the service along the continuum.

Our findings revealed that HCPs were skilled in key critical NR steps in airway maintenance to initiate spontaneous breathing. This finding is reported in other studies conducted in other health facilities in the country [16, 17]. This could be explained by the availability of NR guidelines and action plans in NR, formal and/or informal trainings in NR and the necessary equipment to provide care in the hospital. However, a few newborns miss out on the most important step: being kept warm adequately and this could result in further neonatal deaths precipitated by hypothermia. Immediate essential newborn care after birth will reduce the neonatal morbidity and mortality that are most prevalent at this critical first hour after birth [6].

Bag and mask ventilation was initiated for all newborns who did not establish breathing after drying and airway clearance (with secretions). Our study finding show that HCPs clearly recognize the indication for bag and ventilation in newborns without or gasping respirations as recommended [2, 24]. However, BMV intervention was not initiated within the golden minute for most resuscitations after failed stimulation and airway clearance to initiate breathing as recommended by the national and international guidelines [14, 24]. When breathing is delayed, the window of opportunity to reverse the consequences of asphyxia (reductions in important blood pressure & cerebral blood flow and cardiac arrest) is small. Our finding showed that HCPs’ understanding of the importance of initiating BMV within the Golden minute after birth was poor. Evidence indicates that there is significant improvement in myocardial function and cerebral oxygenation when BMV is initiated within the Golden minute [2].

There is evidence that most resuscitated newborns will initiate spontaneous breathing after simple stimulation with very few going through the advanced NR steps involving chest compressions and drugs [8]. This implies that even in resource limited settings, many babies with birth asphyxia only require simple interventions to be able to initiate spontaneous breathing without difficulties. Good NR skills in drying/stimulating and airway clearance in cases of airway obstruction due to secretions and ensuring that the babies are kept warm may be all that is required to avert most of the neonatal deaths due to birth asphyxia.

Secretions obstruct the airway worsening the asphyxia. Our findings showed that newborns born with meconium – stained amniotic fluid in the airway who did not start breathing on their own had reduced chances of survival in the first hour after birth. Similarly, HCPs’ NR skills were poor in airway clearance in presence of meconium in babies who did not start breathing on their own. Healthcare providers dried/stimulated newborns before airway clearance in presence of meconium in non – breathing newborns contrary to both the international and national guidelines on the management of meconium presence in the airway [2, 14, 24]. Clearing airway in meconium presence in newborns not breathing should be done before drying the baby thoroughly as meconium inhaled into the lungs can cause breathing problems [24]. Other studies done in Kenya also demonstrated that meconium presence was a predictor of birth asphyxia and yet this study found that clearing meconium before stimulation was poorly performed by majority of health workers observed [16, 17, 28]. This is despite the most recent national updates on NR guidelines revised in 2013 being available [14]. This indicates that there is a knowledge deficit and/or lack of regular updates on the part of the HCPs on the significance of meconium in the airway. As a result, many newborns born through meconium may suffer both short term and long term sequelae ranging from birth asphyxia and eventual early neonatal death.

Bag and mask ventilation with room air and subsequent transfer to positive pressure ventilation using the nasal cannulae for unstable newborns was the standard practice on oxygen use during resuscitation. This is to ensure that asphyxiated newborns are given the highest quality of care to improve their chances of survival as recommended [24]. This is critical as in cases where there is no oxygen, HCPs may tend to give priority to sourcing for oxygen instead of starting ventilation using bag and mask with room air and may cause loss of critical seconds/minutes in the first hour after birth. This is similar from other global findings where only a small number of newborns (less than 1%) may fail to respond to the initial treatment and thus require advanced resuscitation [29].

Potentially harmful/inappropriate NR practices are still prevalent in the labor wards. This finding is widely reported in the most recent studies on adherence of HCPs to the national NR guidelines in Kenya [16, 17, 28, 30]. This can be explained by the fact that most HCPs had undergone NR trainings to improve their knowledge and skills more than a year ago before this study. Recent evidence in Helping Babies Breathe training in Kenya and India has shown that NR skills decline more than knowledge over time [27].

Prematurity is among the top three causes of neonatal mortality in Kenya [12] and the leading cause globally [3]. Resuscitated newborns delivered at gestation age ≥ 37 weeks had increased chances of survival in our study. Absence of sophisticated equipment and personnel for specialized intensive newborn care for preterm babies at the facility could explain this disparity. This include the recommended pulse oximetry for deciding on the need for supplemental oxygen and to monitor the needed concentration of oxygen related to its benefits on mortality [2]. Healthcare providers need the evidence – based training required for urgent specialized care for premature birthing mothers and their premature babies to improve the perinatal outcomes. Sophisticated equipment and personnel with the special skill set for caring for preterm babies at the regional referral facility will benefit clients seeking care at the regional referral facilities.

This study did not consider possible maternal factors that could have led to the deaths of the resuscitated newborns. The Hawthorn’s effect is a major drawback in direct observation studies; however, this helps to observe the ‘where’ and ‘when’ of the ongoing process/situation/behavior wanted. Multiple resuscitations per HCP were observed on the assumption that after a few minutes, the HCP would become accustomed to our presence and function in a more natural fashion. The small number of observations for the NR steps after failed initial stimulation and airway maintenance entails that our results should be interpreted in light of the small sample size.

The hospital is prepared with the basic equipment to provide NR with nurses/midwives being the primary providers of NR services. In addition, training in neonatal resuscitation for HCPs is poorly spaced allowing deterioration of key skills. Nurses/midwives and other HCPs providing NR need regular cost – effective NR trainings with focus on maintaining the warm chain for the newborns, airway clearance in meconium – stained amniotic fluid in airways of newborns not breathing, bag and mask ventilation and care for premature babies focusing on the knowledge and practical skills at least after every 6 months. Besides, mentorship programs for the new HCPs in the maternity unit by the more experienced HCPs in the maternity can help to pass knowledge and skills to the new staff joining the unit [31].