Review
Resuscitation in resource-limited settings

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Summary

Intrapartum-related hypoxia leading to deaths and disabilities continues to be a global challenge, especially in resource-limited settings. Primary prevention during labour is likely to have a significant impact, but secondary prevention with focus on immediate basic stabilization at birth can effectively reduce a large proportion of these adverse outcomes as demonstrated in the resource-rich settings. Infants who fail to initiate and establish spontaneous respirations at birth often respond to early interventions such as drying, stimulation, clearing the airways, as well as bag mask ventilation applied within the first minute after birth. Simple resuscitation education such as ‘Helping Babies Breathe’, which focuses on the very basic steps and pays attention to comprehensive program development with local ownership and accountability, can help transfer competency into clinical practice and lead to sustainable programs impacting neonatal mortality and morbidity.

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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