Although significant progress has been made towards Millennium Development Goal (MDG) 4 and 5 targets, maternal and neonatal mortality rates remain unacceptably high in low- and middle-income countries (LMICs). The potential for improvements in maternal and neonatal health outcomes with increased facility utilization in these countries is undermined by a lack of appropriate and timely treatment. Skilful emergency resuscitation can be the difference between life and death; therefore, training in emergency resuscitation is essential for health-care practitioners at all levels, with regular refresher sessions to ensure skill retention. Whilst there is little robust evidence on the impact of resuscitation training interventions on practitioner skills or patient outcomes, such training interventions are likely to have the greatest impact if integrated into a broader approach to improve the quality of care. Accelerated investments in training must go hand in hand with ensuring the availability of quality equipment and upgrading infrastructure to reduce the gap between current MDG status and what is achieved by the end of 2015; and to accelerate reductions in mortality rates beyond 2015 towards new Countdown targets.
Highlights
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Improving resuscitation skills of health-care workers is vital to reduce preventable mortality and morbidity.
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Training programmes should include a commitment towards refresher/booster sessions.
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Training programmes must go together with addressing broader quality-of-care issues.
Introduction
The Millennium Summit in 2000 resulted in a series of time-bound targets (the Millennium Development Goals – MDGs) agreed upon by 189 countries and leading development institutions to combat poverty and underdevelopment on a global scale . The date for achieving targets was set for the end of 2015. Reducing child mortality (MDG 4) and improving maternal health (MDG 5) are crucial elements of the MDG strategy. MDG 4 aims to reduce the under-five mortality rate by two-thirds by 2015, from a baseline in 1990 of 12.6 million under-five deaths annually. MDG 5 consists of two components: reducing the global maternal mortality ratio (MMR) by three-quarters from the 1990 reference point (MDG 5a), and achieving universal access to reproductive health services (MDG 5b) . Progress towards these targets in 75 countries, which account for >95% of the global burden of maternal, newborn and child deaths, is tracked, stimulated and supported by Countdown to 2015, a global, multidisciplinary, multi-institutional collaboration of academics, governments, international agencies and non-governmental organizations ( www.countdown2015mnch.org ).
Status of MDG 4
Compared with the 1990 starting point, real progress towards achieving MDG 4 and 5 has been made. The global under-five mortality rate declined by approximately 47% to 6.6 million in 2012 and the median annual rate of under-five mortality reduction has increased from 1.9% to 3.8% . However, fewer than half of the 75 Countdown countries are likely to succeed in reducing their under-five child mortality by two-thirds by 2015 . Furthermore, the slowest progress in mortality reduction has occurred in neonates, with an increasing proportion of under-five deaths occurring in the first 4 weeks of life . The median percentage of newborn deaths in the 75 Countdown countries is 39% (range 26–64%) with newborns accounting for more than half of all under-five deaths in 15 Countdown countries . In addition, whilst the global neonatal mortality rate (NMR) has declined from 33 to 21 deaths per 1000 live births, substantial regional variation exists . In 2012, 25 Countdown countries had NMRs ≥30 deaths per 1000 live births, accounting for about 60% of the 2.9 million neonatal deaths annually (Nigeria and India accounting for 36% combined) . Nine countries, including eight in sub-Saharan Africa, had NMRs ≥40 . Neonatal deaths in these high-NMR countries occur in the context of high adolescent fertility rates, low literacy rates and a median overall coverage of skilled birth attendance of 55% . More than a third of all neonatal deaths (one million deaths annually) occur within 24 h of birth, and intrapartum complications (previously called birth asphyxia) are the cause for 23% of all deaths occurring within 4 weeks of life .
The tracking of progress in meeting the MDGs does not include stillbirths. In 2009, an estimated 2.64 million stillbirths occurred in the last trimester of pregnancy, with >45% in the intrapartum period . The majority of these stillbirths (98%) occur in low- and middle-income countries (LMICs) .
Status of MDG 4
Compared with the 1990 starting point, real progress towards achieving MDG 4 and 5 has been made. The global under-five mortality rate declined by approximately 47% to 6.6 million in 2012 and the median annual rate of under-five mortality reduction has increased from 1.9% to 3.8% . However, fewer than half of the 75 Countdown countries are likely to succeed in reducing their under-five child mortality by two-thirds by 2015 . Furthermore, the slowest progress in mortality reduction has occurred in neonates, with an increasing proportion of under-five deaths occurring in the first 4 weeks of life . The median percentage of newborn deaths in the 75 Countdown countries is 39% (range 26–64%) with newborns accounting for more than half of all under-five deaths in 15 Countdown countries . In addition, whilst the global neonatal mortality rate (NMR) has declined from 33 to 21 deaths per 1000 live births, substantial regional variation exists . In 2012, 25 Countdown countries had NMRs ≥30 deaths per 1000 live births, accounting for about 60% of the 2.9 million neonatal deaths annually (Nigeria and India accounting for 36% combined) . Nine countries, including eight in sub-Saharan Africa, had NMRs ≥40 . Neonatal deaths in these high-NMR countries occur in the context of high adolescent fertility rates, low literacy rates and a median overall coverage of skilled birth attendance of 55% . More than a third of all neonatal deaths (one million deaths annually) occur within 24 h of birth, and intrapartum complications (previously called birth asphyxia) are the cause for 23% of all deaths occurring within 4 weeks of life .
The tracking of progress in meeting the MDGs does not include stillbirths. In 2009, an estimated 2.64 million stillbirths occurred in the last trimester of pregnancy, with >45% in the intrapartum period . The majority of these stillbirths (98%) occur in low- and middle-income countries (LMICs) .
Status of MDG 5
Since 1990, there has been a reduction in the global MMR from about 400 to 210 maternal deaths per 100,000 live births in 2013 . This represents significant progress; however, much work remains to be done as this reduction (45%) falls significantly short of the 2015 MDG 5 target of 75%. As with NMRs, there is substantial variation in MMRs among the 75 Countdown countries: according to 2013 figures, half of the Countdown countries still have high MMRs (300–499 deaths per 100,000 live births) and 16 countries have very high MMRs between 500 and 1100 deaths per 100,000 live births .
Global efforts have been focused on increasing facility utilization of women for childbirth in these less developed countries. These efforts have been rewarded with trends towards higher rates of deliveries attended by skilled birth attendants from 56% overall in 1990 to 68% in 2012 . However, maternal death rates remain high in facilities; for example, unpublished data from a cross-sectional study conducted in Nigerian hospitals in 2012/2013 suggest an intra-facility maternal death rate of 1% of live births . Similarly, another study reviewed facility-based maternal deaths and near misses in 10 Ethiopian hospitals and reported an overall maternal death rate of 728 per 100,000 live births, and a near-miss rate of 9% . In these studies, delay in receiving care was identified as a significant contributor to maternal death, making the critical difference between a woman dying or experiencing a near-miss event. These data underscore the fact that increasing facility utilization is not enough, and the quality of care provided in facilities needs to be addressed. Training and refresher courses targeting health-care practitioner emergency resuscitation skills is a crucial element of improving the quality of facility-based care and reducing maternal mortality.
Maternal resuscitation
The most common causes of maternal deaths are haemorrhage, pre-eclampsia or eclampsia and sepsis. Maternal collapse as a result of these critical complications is usually rapid and often unpredictable, making pregnant women the highest risk group in terms of the need for emergency interventions to avert sudden and unexpected demise. As the conduct of resuscitation efforts following collapse often determines the likelihood of survival to discharge , obstetric health-care workers need to be optimally equipped to manage these life-and-death situations. Despite this and the fact that cardiopulmonary resuscitation (CPR) is an essential life-saving skill that is integral to the training of all health-care practitioners, the basic life support (BLS) skills of many doctors, nurses and medical students are frequently of poor quality .
Two reviews of training in emergency obstetric care in low- and high-resourced settings found that few training programmes have been described or evaluated. Furthermore, to our knowledge, no studies have specifically evaluated CPR/BLS training among health-care practitioners in obstetric care. There is also no evidence of the effects of advanced cardiovascular life support (ACLS) training on obstetric doctors’ skills or maternal outcomes. Professional education in BLS and ACLS needs to be rigorous and reiterative in this high-risk speciality of medicine. This should be a crucial component of training interventions aimed at reducing preventable maternal deaths. However, emergency resuscitation skills training in isolation is unlikely to impact MDG 5 without a broader approach to improving quality of care.
Neonatal resuscitation
An estimated 10 million babies each year do not initiate breathing spontaneously and, without help, can die within minutes . Interventions aimed at assisting newborns to initiate breathing within the first minute of life (the golden minute) are highly effective in reducing intrapartum-related deaths . For 5–10% of newborns, simple stimulation (rubbing and drying) at birth is all that is needed to help them breathe . However, 3–6% of newborns require basic neonatal resuscitation (airway clearing, head positioning or bag-and-mask ventilation) . Bag-and-mask ventilation is effective with room air, and it might not be enhanced by the use of supplementary oxygen . Less than 1% of newborns require advanced resuscitation including endotracheal intubation, chest compressions and medications . Thus, basic neonatal resuscitation is a well-established, highly effective, low-cost intervention that forms the cornerstone of neonatal care in developed countries. However, in countries with the highest NMRs, neonatal resuscitation is still not available for the majority of newborns who need it.
Effect of neonatal resuscitation training on skills
Neonatal resuscitation programmes (NRP) frequently involve simulation-based learning with low- or high-fidelity neonatal mannequins in simulated ‘real’ environments . This type of learning is recommended as it immerses the learner in realistic situations, having the advantage of increasing the frequency of clinical experiences without training on real patients and enabling repetitive practice . Neonatal resuscitation training is frequently incorporated into newborn care courses for health-care practitioners, which also address other aspects of newborn care including breastfeeding, cord care and kangaroo mother care (e.g., the World Health Organization essential neonatal care course) .
A 2012 systematic review of randomized and non-randomized studies included 10 studies of the effects of NRPs on skills of health-care practitioners (doctors, nurses or medical students) . The studies were conducted in Canada, Italy, Turkey and the UK, and NRP interventions consisted of simulation-based training with or without lectures. Three studies evaluated knowledge and skills immediately post training, and eight studies evaluated skill retention at follow-up testing between 6 weeks and 12 months. Reviewers found that knowledge and skills in practitioners significantly increased immediately post training; however, in all but one study, skill retention at follow-up testing between 6 weeks and 12 months was significantly lower compared with the immediate post-training assessment. They concluded that deterioration in simulator skills is highly likely as early as 3 months following training. Therefore, booster or refresher sessions are required to improve an individual’s ability to retain resuscitation skills after initial training, and these sessions should be conducted at least every 6 months .
The World Health Organization (WHO) essential newborn care course is a 5-day course aimed at health-care practitioners who have completed a secondary level of education and have some level of health-care training . It includes a session on basic neonatal resuscitation comprising lectures and practical sessions with neonatal mannequins. However, the effectiveness of training courses on resuscitation skills in health-care practitioners in LMICs, and the types of programmes most likely to be successful, has not been rigorously evaluated. Evaluating the effectiveness of neonatal resuscitation training at the facility and community levels has been identified as a top priority in recent research priority setting consultations .
A Cochrane review was conducted in 2010 to assess the effectiveness of in-service training for health-care practitioners to improve newborn and child care in LMICs, and the review found only two randomized controlled trials (RCTs) to include . One RCT evaluated a 1-day NRP course among nurses in Kenya ; the other was of essential newborn care training in doctors, nurses and midwives in Sri Lanka . The results of the Kenyan RCT, which compared neonatal resuscitation skills in 28 nurses who underwent NRP training with a control group of 55 nurses, showed a significant improvement in initial resuscitation performance and a significant reduction in inappropriate and potentially harmful practices in 97 experimental versus 115 control resuscitation efforts occurring during the 7 weeks that followed the NRP intervention. The intervention used in a Sri Lankan study of 110 participants was a more general management intervention, had limited usable data and was considered by reviewers to be at a high risk of bias. Neither study provided long-term follow-up or evaluated the impact of refresher training.
There is evidence that practical neonatal resuscitation skills after training decline faster than resuscitation knowledge . A recent survey of six community health facilities in India further highlights a huge disparity between resuscitation knowledge and skills in health-care practitioners. In this study conducted in six secondary-level facilities, the average neonatal resuscitation knowledge score was 76% among health-care practitioners compared with an average resuscitation skills score of 24%. This disparity confirms the need for ongoing professional development for all levels of providers, with practical refresher courses to ensure skill retention .
Despite an increase in health facility utilization globally, barriers to facility utilization result in many women delivering at home with traditional birth attendants (TBAs) and the reality is that a proportion of deliveries will inevitably occur at the community level . A recent review of training resources for community health workers (CHWs) identified eight integrated training packages in newborn, infant and child health – all of these packages included essential newborn care but only one included neonatal resuscitation training . The latter was developed to train CHWs providing home-based care in India . Current WHO recommendations for task shifting indicate that there is insufficient evidence on the effectiveness of using CHWs or TBAs to provide neonatal resuscitation and that its acceptability is uncertain .
Effect of neonatal resuscitation training on neonatal mortality
A meta-analysis of three before-and-after facility-based studies estimated the effect of basic neonatal resuscitation training of health-care practitioners in facilities on intrapartum-related neonatal deaths and found that it reduced the risk of term neonatal death by 30% (relative risk (RR) = 0.70, 95% confidence interval (CI) 0.59–0.84) .
In high-NMR countries, the median coverage of skilled birth attendance ranged from 40% (rural areas) to 55% (overall) in 2012 ; coverage of skilled birth attendants in some countries, e.g. Ethiopia, is as low as 10% . In these settings, key newborn care practices are dependent on promotion by CHWs or TBAs. However, CHWs are mostly not integrated into formal health services and have no basic resuscitation skills training; therefore, millions of babies born in the community continue to have no access to basic neonatal resuscitation, and they will continue to die unnecessarily unless CHW integration and training is re-evaluated.
A high-quality cluster randomized trial conducted in Zambia between September 2006 and November 2008 involved training TBAs in a simplified NRP protocol and pre-emptive antibiotics with facilitated referral (AFR) . TBAs with limited obstetric skills and low rates of literacy were instructed in NRP using a traditional training approach. The simplified NRP algorithm involved four assessments (stimulation, breathing, colour and pulse) and one decision point, whether to start positive pressure ventilation (PPV); it was combined with the provision of flannel towels, a bulb syringe for suctioning and a pocket resuscitator mask with a tube into which the rescuer blows directly to provide PPV. The training programme consisted of interactive lectures, demonstrations, small group sessions and skills practice using neonatal mannequins. The study maximized retention of skills by refresher workshops and assessments of competence every 3–4 months throughout the study . Birth outcomes of deliveries assisted by TBAs who received NRP and AFR training ( n = 60) were compared with those of TBAs applying the existing standard of care ( n = 58). Out of a total of 3497 deliveries in the study, deaths due to intrapartum conditions within the first 2 days after birth were significantly reduced by 81% (95% confidence interval, 48–93%) among live-born infants delivered by intervention TBAs compared with those delivered by the control TBAs. The largest reduction in mortality occurred on the day of delivery, where mortality was 7.8 deaths per 1000 live-born infants in the intervention group compared with 19.9 deaths per 1000 live-born infants in the control group. Remarkably, within the first month of life, the risk of infant death overall was almost halved by the interventions, with an absolute risk reduction of about 18 deaths per 1000 live births.
This important Zambian study indicates that training and maintaining basic neonatal resuscitation skills in TBAs may be feasible and may reduce inequalities by extending care to underserved populations. Thus, such TBA training needs further rigorous evaluation in the context of research. If multicentre research confirms these findings, the next step would be to integrate resuscitation training into existing CHW packages.
Other challenges
In many facilities, neonatal resuscitation is available in theory but not in practice. The survey of six community health facilities in India reported serious limitations in physical resources: resuscitation bags and masks were available in four out of six facilities, with a lack of choice in mask size; two facilities did not have suctioning equipment . Similar findings were reported in a study conducted in Kenyan hospitals, where hospitals lacked between 30% and 56% of items considered necessary for the provision of care to the seriously ill newborn . Thus, substantially more than just training interventions are needed to reduce neonatal and maternal mortality; adequate equipment and infrastructure are needed.
Disappointingly, a large cluster RCT of a combined community- and facility-based approach with a package of interventions including community birth attendant training, hospital transport, and facility staff training failed to show a detectable impact on maternal or perinatal mortality .
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