ReviewResuscitation in resource-limited settings
Introduction
In 1994 the International Conference on Population and Development set a number of goals and objectives to be attained by 2015 including universal access to comprehensive reproductive health services with reduction in maternal and perinatal mortality and morbidity [1]. The United Nations Millennium Declaration from 2000 emphasizes many agenda items from the above programme in the eight Millennium Developmental Goals (MDG) [2]. The MDG 4 target of reducing the <5-year-old child mortality by two-thirds from 13.2 million in 1990 to 5 million in 2015 still requires a substantial reduction in neonatal mortality, now accounting for >40% of the total deaths [3], [4], [5]. Additionally 1.2 million intrapartum-related stillbirths (uncertainty range: 0.8–2.0 million) are not included in the MDG 4 goals [6]. Many of these may be non-breathing infants with heart activity rather than true stillbirths.
Each year ∼136 million babies are born globally. It is estimated that about 90% make the transition from intrauterine to extrauterine life without any intervention [7]. This successful transition is dependent on several factors (e.g. the health of the mother, the pregnancy, and the labor process), and healthy fetuses are likely to tolerate some intrapartum hypoxia remarkably well. However, with severe or sustained lack of oxygen during labor, progression to hypoxic–ischemic injury will result in the birth of a non-breathing baby. Approximately 10% or 13.6 million newborns are delivered with absent or poor respiratory effort and need some degree of support to achieve cardiopulmonary stability [8], [9]. It is estimated that 3–6% need assisted positive pressure ventilation, and that <1% require advanced resuscitation including intubation, chest compressions, and medications [8]. However, these estimates are based on five reports [8], [9], [10], [11], [12], none of which reflect Sub-Saharan Africa where the burden of perinatal deaths and morbidity is considered to be highest [[4], [7].
Section snippets
Neonatal mortality
Neonatal mortality is defined as death before one month of age (per 1000 live births), and recent global estimates range from 2.9 to 3.6 million deaths per year [4], [13], [14], [15]. Of these, 50–70% occur within the first day of life [4], [16], [17], [18], and almost 99% take place in resource-poor settings [4]. The presumed causes of neonatal deaths have remained unchanged over the past decade and include infections (∼30%), preterm birth (∼30%), and birth asphyxia (∼25%) [13], [18], [19].
Perinatal mortality
Perinatal mortality is defined as intrapartum-related deaths (fresh stillbirths) and early (one week) neonatal deaths per 1000 live births. We find it irrational not to look at these deaths together, because the causes are usually similar whether the baby dies immediately before delivery (fresh stillbirth) or immediately after delivery (early neonatal death). Each year, intrapartum-related hypoxia (equated with birth asphyxia) is estimated to account for about two million perinatal deaths
Current resuscitation guidelines and new science
In 2011, the World Health Organization (WHO) published new clinical recommendations on basic newborn stabilization and resuscitation to guide birth attendants in settings with poor human and/or technological resources [29]. The WHO guidelines build on the International Liaison Committee on Resuscitation (ILCOR) evidence-based guidelines on neonatal resuscitation [30]. The 2010 ILCOR guideline for resuscitation of newborns is based on limited research with few human cases and has several
‘Utstein formula of survival’[36]
The most up-to-date evidence-based guidelines will not help a single baby, either in resource-limited or high-resourced settings, unless they are translated into clinical practice. The Utstein formula of survival states that patient outcome is a product of medical science, educational efficiency, and implementation (Fig. 2). It is predicted that all factors in the formula contribute equally to patient outcome. Hypothetically, if all the factors are optimal, patient survival would be 100%;
Educational programs
HBB is a simulation-based educational program, developed to train large numbers of birth attendants in low-income countries in basic neonatal stabilization/resuscitation [37]. The scientific basis of the HBB curriculum stems from the neonatal evidence evaluation of ILCOR. HBB was developed under the leadership of the American Academy of Pediatrics with input from world experts from multiple countries. HBB attempts to ensure that even a single provider can care for the baby and mother in a
Kirkpatrick model for evaluation of educational programs
If we have adequate medical evidence and good educational courses to train health providers, what does it take to translate the acquired knowledge and skills into clinical practice for the benefit of the patient? How can we ensure and sustain necessary changes in the clinical setting over time? There is a universal lack of implementation research – the last factor in the Utstein formula of survival (Fig. 2). Most studies/reviews focus on the evidence of ‘what to do’ – not on ‘what is actually
Program for newborn stabilization and resuscitation
These studies point to the need for a consistent program (opposed to a single course) targeting ongoing training and local mentoring to impact clinical management and patient outcome. Fig. 3 presents an overview of factors thought to influence newborn resuscitation at birth. Program-developers may need to be aware of, understand and take into account all these factors if they want to develop a successful program that will improve patient outcome over time. For newborn resuscitation in a
Summary
Globally perinatal mortality accounts for an increasing proportion of mortality in children aged <5 years. Current guidelines for resuscitation of newborns are based on limited research with few cases and have several knowledge gaps. Nonetheless, some recent studies from resource-limited settings where the burden of deaths is highest document the importance of fetal heart rate monitoring coupled with immediate basic actions at birth. ‘The three delays model’ described for maternal ill-health is
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Cited by (43)
Characterization of teamwork and guideline compliance in prehospital neonatal resuscitation simulations
2022, Resuscitation PlusCitation Excerpt :Out-of-hospital births are at increased risk for morbidity and mortality.3,4 Ten percent of babies born will require some form of resuscitation.5–8 According to a recent National Academy of Medicine report, the number of out-of-hospital births is growing.
Oxygen for respiratory support of moderate and late preterm and term infants at birth: Is air best?
2020, Seminars in Fetal and Neonatal MedicineCitation Excerpt :The burden of perinatal asphyxia is considerably heavier in developing than in developed countries. The use of positive pressure ventilation and the recognition that air can be a substitute for oxygen has allowed resuscitation of infants previously considered to be “stillbirths”, especially in lower-resourced countries where access to appropriate education and basic resuscitation equipment, including oxygen is more difficult [49]. In 1993, Ramji et al. published the outcomes of 84 hypoxic infants to randomized by date of birth (quasi-randomization) to resuscitation with air or 100% oxygen in India [10].
The impact of skilled birth attendants trained on newborn resuscitation in Tanzania: A literature review
2019, International Journal of Africa Nursing SciencesNeonatal Resuscitation in Low-Resource Settings
2016, Clinics in PerinatologyCitation Excerpt :Critical to achieving these goals will be attention to equity gaps through expanded access to resuscitation programming and equipment as well as an ongoing national and global commitment to providing skilled care at all deliveries, whether they occur in a health care facility, community setting or home. Several publications have reviewed the status of newborn resuscitation in LRSs.11,15,17,20,21 This article summarizes the status as of 2016, with attention to the impact of recent updates to the WHO and the International Liaison Committee on Resuscitation (ILCOR) guidelines, updates to educational programming, and the current status of resuscitation equipment.