Newborn Resuscitation Training in Resource-Limited Settings: A Systematic Literature Review

Abstract

CONTEXT: Birth asphyxia contributes substantially to neonatal mortality in low-and middleincome countries (LMICs). The effects of training birth attendants in neonatal resuscitation (NR) on mortality are limited by falloff of skills and knowledge over time and transference of learned skills into clinical practice.OBJECTIVE: This review examined acquisition and retention of NR knowledge and skills by birth attendants in LMICs and the effectiveness of interventions to improve them.DATA SOURCES: Medline, Cochrane, Embase, CINAHL, Bireme, and African Index Medicus databases were searched. We reviewed Web pages and reports from non-peer-reviewed (or "gray") literature sources addressing NR training in LMICs. STUDY SELECTION:Articles on acquisition and retention of NR knowledge and skills, and interventions to improve them, were limited to LMICs. RESULTS:The initial search identified 767 articles, of which 45 met all inclusion criteria. Of these, 31 articles analyzed acquisition of knowledge and skills, and 19 analyzed retention. Most studies found high acquisition rates, although birth attendants struggled to learn bag-mask ventilation. Although significant falloff of knowledge and skills occurred after training, refresher training seemed to improve retention. Results of the gray literature analysis suggest that formal, structured practice sessions improve retention. LIMITATIONS: This review did not analyze training's direct impact on mortality.CONCLUSIONS: Knowledge and skills falloff is a significant barrier to the success of NR training programs and possibly to reducing newborn mortality in LMICs. Refresher training and structured practice show significant promise. Additional research is needed to implement and assess retention improvement strategies in classroom and clinical settings.a Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; b Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts; c Harvard Medical School, Boston, Massachusetts; and d Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah Dr Reisman oversaw the literature reviews, interpreted the results, and drafted the initial manuscript; Ms Arlington assisted with the gray literature search and reviewed and revised the manuscript; Dr Jensen performed the initial gray literature analysis and reviewed and revised the manuscript; Mr Louis and Ms SuarezRebling conducted the initial literature review; and Dr Nelson conceptualized and designed the literature review and reviewed and revised the manuscript. All authors approved the fi nal manuscript as submitted.

Perinatal outcomes following Helping Babies Breathe training and regular peer–peer skills practice among village midwives in Sudan

“…The importance of this should not be underestimated as many studies have shown that booster training is vital in maintaining resuscitation skills over time 14. In a systematic review, Reisman et al 25 showed significantly improved retention of neonatal resuscitation knowledge and skills in health workers who, among other things, practised bag-and-mask skills regularly.…”

Assessment of the quality of neonatal care in the Solomon Islands

“…Past assessments of health‐care worker knowledge and skills in newborn care in lower‐middle‐income countries have also identified that many staff perform below competency levels . Barriers in establishing supportive practices following birth, such as with kangaroo mother care, require significant training time and resources, and resuscitation skills can be affected by decrement in knowledge and skills with time, requiring a long‐term approach to quality improvement …”

Effect of a Low-Dose/High-Frequency Training on Real-Life Neonatal Resuscitation in a Low-Resource Setting

“…The poor achievement of chest rise in all resuscitations suggests that effective ventilation was not reliably accomplished. Along with stimulation, highquality BMV is one of the most important interventions, but several studies reported that learning to provide BMV was more difficult than other aspects of newborn resuscitation for birth attendants [16,17].…”

“…In situ simulation and lowdose/high-frequency training have been demonstrated to be effective in high-resource settings [13], and encouraging results have been reported in low-resource settings [14][15][16][17]. Our previous study in a low-resource setting showed improved clinical performance of midwives after participation in an adapted NRP course, while the quality and timing of resuscitations remained below the recommended standards [18].…”