A Short History of Helping Babies Breathe: Why and How, Then and Now

Qualitative Insights Into Enhancing Neonatal Resuscitation in Post-Pandemic Vietnam: A Stakeholder Perspective on the Helping Babies Breathe Program

BACKGROUND

The neonatal phase is vital for child survival, with a substantial portion of deaths occurring in the first month. Neonatal mortality rates differ significantly between Vietnam (10.52/1000 live births) and the United States (3.27/1000). In response to these challenges, interventions such as the Helping Babies Breathe (HBB) program have emerged, aiming to enhance the quality of care provided during childbirth, and the postpartum period in low-resource settings.

PURPOSE

The purpose of this study was to explore stakeholder perceptions of the HBB program in Vietnam postpandemic, aiming to identify requisites for resuming training.

METHODS

Utilizing qualitative content analysis, 19 in-person semistructured interviews were conducted with diverse stakeholders in 2 provinces of Central Vietnam.

RESULTS

The content analysis revealed following 5 main themes: (1) the pandemic's impact on HBB training; (2) resource needs for scaling up HBB training as the pandemic abates; (3) participants' perceptions of the pandemic's effect on HBB skills and knowledge; (4) the pandemic's influence on a skilled neonatal resuscitation workforce; and (5) future prospects and challenges for HBB training in a postpandemic era.

IMPLICATIONS FOR PRACTICE AND RESEARCH

This research highlights the importance of sustainable post-HBB training competencies, including skill assessment, innovative knowledge retention strategies, community-based initiatives, and evidence-based interventions for improved healthcare decision-making and patient outcomes. Healthcare institutions should prioritize skill assessments, refresher training, and collaborative efforts among hospitals, authorities, non-government organizations, and community organizations for evidence-based education and HBB implementation.

Stakeholders' Perspectives on the "Helping Babies Breathe" Program Situation in Nepal Following the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic impacted healthcare systems, including resuscitation training programs such as Helping Babies Breathe (HBB). Nepal, a country with limited healthcare resources, faces challenges in delivering effective HBB training, managing deliveries, and providing neonatal care, particularly in remote areas.

AIMS

This study assessed HBB skills and knowledge postpandemic through interviews with key stakeholders in Nepal. It aimed to identify strategies, adaptations, and innovations to address training gaps and scale-up HBB.

METHODS

A qualitative approach was used, employing semistructured interviews about HBB program effectiveness, pandemic challenges, stakeholder engagement, and suggestions for improvement.

RESULTS

The study encompassed interviews with 23 participants, including HBB trainers, birth attendants, officials, and providers. Thematic analysis employed a systematic approach by deducing themes from study aims and theory. Data underwent iterative coding and refinement to synthesize content yielding following 5 themes: (1) pandemic's impact on HBB training; (2) resource accessibility for training postpandemic; (3) reviving HBB training; (4) impacts on the neonatal workforce; and (5) elements influencing HBB training progress.

CONCLUSION

Postpandemic, healthcare workers in Nepal encounter challenges accessing essential resources and delivering HBB training, especially in remote areas. Adequate budgeting and strong commitment from healthcare policy levels are essential to reduce neonatal mortality in the future.

Neonatal mortality and video assessment of resuscitation in four district hospitals in Pemba, Tanzania

BACKGROUND

We aimed to assess risk factors for neonatal mortality, quality of neonatal resuscitation (NR) on videos and identify potential areas for improvement.

METHODS

This prospective cohort study included women in childbirth and their newborns at four district hospitals in Pemba, Tanzania. Videos were analysed for quality-of-care. Questionnaires on quality-of-care indicators were answered by health workers (HW) and women. Risk factors for neonatal mortality were analysed in a binomial logistic regression model.

RESULTS

1440 newborns were enrolled. 34 newborns died within the neonatal period (23.6 per 1000 live births). Ninety neonatal resuscitations were performed, 20 cases on video. Positive pressure ventilation (PPV) was inadequate in 15 cases (75%). Half (10/20) did not have PPV initiated within the first minute, and in one case (5.0%), no PPV was performed. PPV was not sustained in 16/20 (80%) newborns. Of the 20 videos analysed, death occurred in 10 newborns: 8 after resuscitation attempts and two within the first 24 h. Most of HW 49/56 (87.5%) had received training in NR.

CONCLUSIONS

Video analysis of NR revealed significant deviations from guidelines despite 87.5% of HW being trained in NR. Videos provided direct evidence of gaps in the quality of care and areas for future education, particularly effective PPV.

IMPACT

Neonatal mortality in Pemba is 23.6 per 1000 livebirths, with more than 90% occurring in the first 24 h of life. Video assessment of neonatal resuscitation revealed deviations from guidelines and can add to understanding challenges and aid intervention design. The present study using video assessment of neonatal resuscitation is the first one performed at secondary-level hospitals where many of the world's births are conducted. Almost 90% of the health workers had received training in neonatal resuscitation, and the paper can aid intervention design by understanding the actual challenges in neonatal resuscitation.

Impact of an Educational Clinical Video Combined with Standard Helping Babies Breathe Training on Acquisition and Retention of Knowledge and Skills among Ethiopian Midwives

Helping Babies Breathe (HBB) is an evidence-based neonatal resuscitation program designed for implementation in low-resource settings. While HBB reduces rates of early neonatal mortality and stillbirth, maintenance of knowledge and skills remains a challenge. The extent to which the inclusion of educational clinical videos impacts learners' knowledge and skills acquisition, and retention is largely unknown. We conducted a cluster-randomized controlled trial at two public teaching hospitals in Addis Ababa, Ethiopia. We randomized small training group clusters of 84 midwives to standard HBB vs. standard HBB training supplemented with exposure to an educational clinical video on newborn resuscitation. Midwives were followed over a 7-month time period and assessed on their knowledge and skills using standard HBB tools. When comparing the intervention to the control group, there was no difference in outcomes across all assessments, indicating that the addition of the video did not influence skill retention. Pass rates for both the control and intervention group on bag and mask skills remained low at 7 months despite frequent assessments. There is more to learn about the use of educational videos along with low-dose, high-frequency training and how it relates to retention of knowledge and skills in learners.

Alternatives to neonatal intubation

Opportunities to learn and maintain competence in neonatal intubation have decreased. As many clinicians providing care to the newborn infant are not skilled in intubation, alternative strategies are critical. Most preterm infants breathe spontaneously, and require stabilisation rather than resuscitation at birth. Use of tactile stimulation, deferred cord clamping, and avoidance of hypoxia can help optimise breathing for these infants. Nasal devices appear a promising alternative to the face mask for early provision of respiratory support. In term and near-term infants, supraglottic airways may be the most effective initial approach to resuscitation. Use of supraglottic airways during resuscitation can be taught to a range of providers, and may reduce need for intubation. While face mask ventilation is an important skill, it is challenging to perform effectively. Identification of the best approach to training the use of these devices during neonatal resuscitation remains an important priority.

Insights from a cross-sectional survey of neonatal resuscitation instructors from India

Neonatal resuscitation training can change outcomes of neonatal mortality due to perinatal asphyxia. Recently, in 2021, the advanced NRP course material was changed, and for Basic NRP, a hybrid course was introduced in India. We assessed the instructor's feedback to improve the conduct of the IAP NNF NRP Program as well as get their perception of the effectiveness, usefulness, and pitfalls of the new hybrid Basic NRP course (offline + online). A cross-sectional survey was conducted amongst instructors across India with current status with IAP NRP FGM Office. The data were exported to a Microsoft Excel Spreadsheet. STATA 14.2 was used for descriptive [Frequency (percent) analysis. 827 basic and 221 advanced NRP instructors responded. Bag and mask ventilation was identified as the most important step in basic 468 (56.6%) and advanced 147 (66.5%) courses. In the basic NRP, almost two third (71.0%) participants believe that it is challenging to conduct a case scenario for bag and mask ventilation, whereas, in the advanced course, intubation 116 (52.5%) was considered the most difficult step to teach and medication 80(36.2%) followed by intubation 62(28.1%) are the most difficult steps to conduct case scenario. 725(87.7%) reported that it would be easy to explain them in an offline course after completion of an online course. Most of the instructors were satisfied with the course structure, material, overall quality of the workshop, and support from the IAP NRP office. Constructive suggestions were obtained from the instructors for improvement of the course.

Cardiopulmonary resuscitation in low-resource settings: a statement by the International Liaison Committee on Resuscitation, supported by the AFEM, EUSEM, IFEM, and IFRC

Most recommendations on cardiopulmonary resuscitation were developed from the perspective of high-resource settings with the aim of applying them in these settings. These so-called international guidelines are often not applicable in low-resource settings. Organisations including the International Liaison Committee on Resuscitation (ILCOR) have not sufficiently addressed this problem. We formed a collaborative group of experts from various settings including low-income, middle-income, and high-income countries, and conducted a prospective, multiphase consensus process to formulate this ILCOR Task Force statement. We highlight the discrepancy between current cardiopulmonary resuscitation guidelines and their applicability in low-resource settings. Successful existing initiatives such as the Helping Babies Breathe programme and the WHO Emergency Care Systems Framework are acknowledged. The concept of the chainmail of survival as an adaptive approach towards a framework of resuscitation, the potential enablers of and barriers to this framework, and gaps in the knowledge are discussed, focusing on low-resource settings. Action points are proposed, which might be expanded into future recommendations and suggestions, addressing a large diversity of addressees from caregivers to stakeholders. This statement serves as a stepping-stone to developing a truly global approach to guide resuscitation care and science, including in health-care systems worldwide.

Impact of accredited advanced life support course participation on in-hospital cardiac arrest patient outcomes: A systematic review

Aim

Advanced life support courses have a clear educational impact; however, it is important to determine whether participation of one or more members of the resuscitation team in an accredited advanced life support course improves in-hospital cardiac arrest patient survival outcomes.

Methods

We searched EMBASE.com, Medline, Cochrane and CINAHL from inception to 1 November 2022. Included studies were randomised or non-randomised interventional studies assessing the impact of attendance at accredited life support courses on patient outcomes. Accredited life support courses were classified into 3 contexts: Advanced Life Support (ALS), Neonatal Resuscitation Training (NRT), and Helping Babies Breathe (HBB). Existing systematic reviews were identified for each of the contexts and an adolopment process was pursued. Appropriate risk of bias assessment tools were used across all outcomes. When meta-analysis was appropriate a random-effects model was used to produce a summary of effect sizes for each outcome.

Results

Of 2714 citations screened, 19 studies (1 ALS; 7 NRT; 11 HBB) were eligible for inclusion. Three systematic reviews which satisfied AMSTAR-2 criteria for methodological quality, included 16 of the studies we identified in our search. Among adult patients all outcomes including return of spontaneous circulation, survival to discharge and survival to 30 days were consistently better with accredited ALS training. Among neonatal patients there were reductions in stillbirths and early neonatal mortality.

Conclusion

These results support the recommendation that accredited advanced life support courses, specifically Advanced Life Support, Neonatal Resuscitation Training, and Helping Babies Breathe improve patient outcomes.

Ending Preventable Neonatal Deaths: Multicountry Evidence to Inform Accelerated Progress to the Sustainable Development Goal by 2030

INTRODUCTION

The Sustainable Development Goal (SDG) 3.2 aims for every country to reach a neonatal mortality rate (NMR) of ≤12/1,000 live births by 2030. More than 60 countries are off track, and 2.3 million newborns still die each year. Urgent action is needed, but varies by context, notably mortality level.

METHODS

We applied a five-phase NMR transition model based on national analyses for 195 UN member states: I (NMR >45), II (30-<45), III (15-<30), IV (5-<15), and V (<5). We analyzed data over the last century from selected countries to inform strategies to reach SDG3.2. We also undertook impact analyses for packages of care using the Lives Saved Tool software.

RESULTS

An NMR of <15/1,000 requires firstly wide-scale access to maternity care and hospital care for small and sick newborns, including skilled nurses and doctors, safe oxygen use, and respiratory support, such as CPAP. Neonatal mortality could be reduced to the SDG target of ≤12/1,000 with further scale-up of small and sick newborn care. To reduce neonatal mortality further, more investment is required in infrastructure, device bundles (e.g., phototherapy, ventilation), and careful attention to infection prevention. To reach phase V (NMR <5), which is closer to ending preventable newborn deaths, additional technologies and therapies such as mechanical ventilation and surfactant replacement therapy are needed, as well as higher staffing ratios.

CONCLUSIONS

Learning from high-income country is important, including what not to do. Introduction of new technologies should be according to the country's phase. Early focus on disability-free survival and family involvement is also crucial.

Immediate skin-to-skin contact for low birth weight infants is safe in terms of cardiorespiratory stability in limited-resource settings

Aim

To investigate the safety of skin-to-skin contact initiated immediately after birth on cardiorespiratory parameters in unstable low birth weight infants.

Methods

A randomized clinical trial was conducted in tertiary newborn units in Ghana, India, Malawi, Nigeria and Tanzania in 2017-2020, in infants with birth weight 1.0-1.799 kg. The intervention was Kangaroo mother care initiated immediately after birth and continued until discharge compared to conventional care with Kangaroo mother care initiated after meeting stability criteria. The results of the primary study showed that immediate Kangaroo mother care reduced neonatal mortality by 25% and the results have been published previously. The post-hoc outcomes of this study were mean heart rate, respiratory rate, oxygen saturation during the first four days and the need of respiratory support.

Results

1,602 infants were allocated to control and 1,609 to intervention. Mean birth weight was 1.5 kg (SD 0.2) and mean gestational age was 32.6 weeks (SD 2.9). Infants in the control group had a mean heart rate 1.4 beats per minute higher (95% CI -0.3-3.1, p = 0.097), a mean respiratory rate 0.4 breaths per minute higher (-0.7-1.5, p = 0.48) and a mean oxygen saturation 0.3% higher (95% CI -0.1-0.7, p = 0.14) than infants in the intervention group.

Conclusion

There were no significant differences in cardiorespiratory parameters during the first four postnatal days. Skin-to-skin contact starting immediately after birth is safe in low birth weight infants in limited-resource settings.

Oxygenation of the newborn. The impact of one molecule on newborn lives

Hypoxanthine is a purine metabolite which increases during hypoxia and therefore is an indicator of this condition. Further, when hypoxanthine is oxidized to uric acid in the presence of xanthine oxidase, oxygen radicals are generated. This was the theoretical basis for suggesting and studying, beginning in the 1990s, resuscitation of newborn infants with air instead of the traditional 100% O2. These studies demonstrated a 30% reduction in mortality when resuscitation of term and near term infants was carried out with air compared to pure oxygen. The mechanism for this is not fully understood, however the hypoxanthine -xanthine oxidase system increases oxidative stress and plays a role in regulation of the perinatal circulation. Further, hyperoxic resuscitation inhibits mitochondrial function, and one reason may be that genes involved in ATP production are down-regulated. Thus, the study of one single molecule, hypoxanthine, has contributed to the global prevention of an estimated 2-500,000 annual infant deaths.

Utilization of a novel mobile application, "HBB Prompt", to reduce Helping Babies Breathe skills decay

BACKGROUND

Helping Babies Breathe (HBB) is a newborn resuscitation training program designed to reduce neonatal mortality in low- and middle-income countries. However, skills decay after initial training is a significant barrier to sustained impact.

OBJECTIVE

To test whether a mobile app, HBB Prompt, developed with user-centred design, helps improve skills and knowledge retention after HBB training.

METHODS

HBB Prompt was created during Phase 1 of this study with input from HBB facilitators and providers from Southwestern Uganda recruited from a national HBB provider registry. During Phase 2, healthcare workers (HCWs) in two community hospitals received HBB training. One hospital was randomly assigned as the intervention hospital, where trained HCWs had access to HBB Prompt, and the other served as control without HBB Prompt (NCT03577054). Participants were evaluated using the HBB 2.0 knowledge check and Objective Structured Clinical Exam, version B (OSCE B) immediately before and after training, and 6 months post-training. The primary outcome was difference in OSCE B scores immediately after training and 6 months post-training.

RESULTS

Twenty-nine HCWs were trained in HBB (17 in intervention, 12 in control). At 6 months, 10 HCW were evaluated in intervention and 7 in control. In intervention and control respectively, the median OSCE B scores were: 7 vs. 9 immediately before training, 17 vs. 21 immediately after training, and 12 vs. 13 at 6 months after training. Six months after training, the median difference in OSCE B scores was -3 (IQR -5 to -1) in intervention and -8 (IQR -11 to -6) in control (p = 0.02).

CONCLUSION

HBB Prompt, a mobile app created by user-centred design, improved retention of HBB skills at 6 months. However, skills decay remained high 6 months after training. Continued adaptation of HBB Prompt may further improve maintenance of HBB skills.

Translating Neonatal Resuscitation Guidelines Into Practice in Brazil

BACKGROUND AND OBJECTIVES

The Brazilian Neonatal Resuscitation Program releases guidelines based on local interpretation of international consensus on science and treatment recommendations. We aimed to analyze whether guidelines for preterm newborns were applied to practice in the 20 Brazilian Network on Neonatal Research centers of this middle-income country.

METHODS

Prospectively collected data from 2014 to 2020 were analyzed for 8514 infants born at 230/7 to 316/7 weeks' gestation. The frequency of procedures was evaluated by gestational age (GA) category, including use of a thermal care bundle, positive pressure ventilation (PPV), PPV with a T-piece resuscitator, maximum fraction of inspired oxygen (Fio2) concentration during PPV, tracheal intubation, chest compressions and medications, and use of continuous positive airway pressure in the delivery room. Logistic regression, adjusted by center and year, was used to estimate the probability of receiving recommended treatment.

RESULTS

For 3644 infants 23 to 27 weeks' GA and 4870 infants 28 to 31 weeks' GA, respectively, the probability of receiving care consistent with guidelines per year increased, including thermal care (odds ratio [OR], 1.52 [95% confidence interval (CI) 1.44-1.61] and 1.45 [1.38-1.52]) and PPV with a T-piece (OR, 1.45 [95% CI 1.37-1.55] and 1.41 [1.32-1.51]). The probability of receiving PPV with Fio2 1.00 decreased equally in both GA groups (OR, 0.89; 95% CI, 0.86-0.93).

CONCLUSIONS

Between 2014 and 2020, the resuscitation guidelines for newborns <32 weeks' GA on thermal care, PPV with a T-piece resuscitator, and decreased use of Fio2 1.00 were translated into clinical practice.

Video recording as an objective assessment tool of health worker performance in neonatal resuscitation at a district hospital in Pemba, Tanzania: a feasibility study

OBJECTIVES

To assess the feasibility of using video recordings of neonatal resuscitation (NR) to evaluate the quality of care in a low-resource district hospital.

DESIGN

Prospective observational feasibility study.

SETTING

Chake-Chake Hospital, a district hospital in Pemba, Tanzania, in April and May 2019.

PARTICIPANTS

All delivering women and their newborns were eligible for participation.

MAIN OUTCOME MEASURES

Motion-triggered cameras were mounted on resuscitation tables and provided recordings that were analysed for quality of care indicators based on the national NR algorithm. Assessment of feasibility was conducted using Bowen's 8-point framework for feasibility studies.

RESULTS

91% (126 of 139) of women and 96% (24 of 26) of health workers were comfortable or very comfortable with the video recordings. Of 139 newborns, 8 underwent resuscitation with bag and mask ventilation. In resuscitations, heat loss prevention measures were not performed in half of the cases (four of eight), clearing the airway was not performed correctly in five of eight cases, and all newborns were suctioned vigorously and repeatedly, even when not indicated. In a quarter (two of eight) of cases, the newborn's head was not positioned correctly. Additionally, two of the eight newborns needing ventilation were not ventilated within the first minute of life. In none of the eight cases did ventilation appear to be performed effectively.

CONCLUSIONS

It proved feasible to use video recordings to assess quality of care during NR in a low-resource setting, and the method was considered acceptable for the delivering women and health workers. Recordings of eight resuscitations all demonstrated deviations from NR guidelines.

Telecoaching Improves Positive Pressure Ventilation Performance During Simulated Neonatal Resuscitations

INTRODUCTION

Positive pressure ventilation (PPV) is a critical skill for neonatal resuscitation. We hypothesized that telecoaching would improve PPV performance in neonatal providers during simulated neonatal resuscitations.

SETTING

Level IV neonatal intensive care unit (NICU).

METHODS

This prospective crossover study included 14 experienced NICU nurses and respiratory therapists who performed PPV on a mannequin that recorded parameters of ventilation efficiency. Participants were randomized to practice independently (control) or with live feedback from a remote facilitator through audiovisual connection (intervention) and then switched to the opposite group. Participants' mask leak percentage, ventilation rates, and pressure delivery were analyzed.

RESULTS

The primary outcome of mask leak percentage was significantly increased in the telecoaching group (19% [interquartile range {IQR} 14-59.25] vs. 100% [IQR 88-100] leak, p = 0.0001). The secondary outcome of peak inspiratory pressure (PIP) delivery was also increased (median 27.6 [IQR 23.5-34.7] vs. 23.3 [IQR 19.1-32.8] cmH₂O, p < 0.001). Differences in ventilation rates were not statistically significant (55 vs. 58 breaths/min, p = 0.51).

CONCLUSION

Participants demonstrated better PPV performance during telecoaching with less mask leak. The intervention group also had higher measured peak inspiratory pressures. Telecoaching may be a feasible method to provide real-time feedback to health care providers during simulated neonatal resuscitations.

HYPOTHESIS

Neonatal providers who receive telecoaching during simulated resuscitations will perform PPV more effectively than those who do not receive telecoaching.

Effect of Training Healthcare Providers in Helping Babies Breathe Program on Neonatal Mortality Rates

BACKGROUND

Training in the Helping Babies Breathe (HBB) Program has been associated with a reduction in early neonatal mortality rate (ENMR), the neonatal mortality rate (NMR), and fresh stillbirth rate (FSBR) in low- and middle-income countries (LMICs). This program was implemented in five different healthcare facilities in the Oliver Reginald Tambo (ORT) District, South Africa from September 2015 to December 2020.

OBJECTIVE

To determine and compare the FSBR, ENMR, and NMR between 2015 before initiation of the program (baseline) and subsequent years up to 2020 following the implementation of facility-based training of HBB in five hospitals in ORT District.

METHODS

Records of perinatal statistics from January 2015 to December 2020 were reviewed to calculate FSBR, ENMR, and NMR. Data were collected from the five healthcare facilities which included two district hospitals (Hospital A&B), two regional hospitals (Hospital C&D), and one tertiary hospital (Hospital E). Comparisons were made between pre- (2015) and post- (2016-2020) HBB implementation periods. Differences in changes over time were also assessed using linear regression analysis.

RESULTS

There were 19,275 births in 2015, increasing to 22,192 in 2020 with the majority (55.3%) of births occurring in regional hospitals. There were significant reductions in ENMR (OR-0.78, 95% CI 0.70-0.87) and NMR (OR-0.81, 95% CI 0.73-0.90), but not in FSBR, in the five hospitals combined when comparing the two time periods. Significant reduction was also noted in trends over time in ENMR (r ² = 0.45, p = 0.001) and NMR (r ² = 0.23, p = 0.026), but not in FSBR (r ² = 0.0, p = 0.984) with all hospitals combined. In looking at individual hospitals, Hospital A (r ² = 0.61, p < 0.001) and Hospital E (r ² = 0.19, p = 0.048) showed a significant reduction in ENMR over time, but there were no significant changes in all mortality rates for Hospitals B, C, and D, and for the district or regional hospitals combined.

CONCLUSION

There was an overall reduction of 22% and 19% in ENMR and NMR, respectively, from pre- to post-HBB implementation periods, although there were variations from year to year over the 5-year period and, across hospitals. These differences suggest that there were other factors that affected the perinatal/neonatal outcomes in the hospital sites in addition to the implementation of training in HBB.

Assessing Implementation of Helping Babies Breathe Program Through Observing Immediate Care of Neonates at Time of Delivery

BACKGROUND

Training in neonatal resuscitation has been shown to reduce deaths related to intrapartum asphyxia. Helping Babies Breathe (HBB) is a simulation-based program focusing on training healthcare providers (HCPs) in immediate neonatal care including stimulation, initiating bag mask ventilation (BMV) in the absence of breathing by 1 min of life, and delayed (30-60 s after birth) umbilical cord clamping (DCC). Data on implementation of HBB posttraining are limited.

OBJECTIVE

To determine time from birth to spontaneous breathing, cord clamping, and initiation of BMV in a setting where the majority of HCPs are HBB trained.

METHODS

Two research nurses observed deliveries conducted in two referral hospitals. Timing included the onset of breathing, cord clamping, and initiation of BMV. Deliveries were grouped according to the mode of delivery.

RESULTS

In total, 496 neonates were observed; 410 (82.7%) neonates cried or had spontaneous breathing (median time 17 s) soon after birth, 25/86 (29%) of neonates not breathing responded to stimulation, 61 (12.3%) neonates required BMV, and 2 (0.4%) neonates required chest compression and/or adrenalin. Neonates delivered by cesarean section (CS) took longer to initiate first breath than those delivered vaginally (median time 19 vs. 14 s; p = 0.009). Complete data were available in 58/61 (95%) neonates receiving BMV, which was initiated in 54/58 (93%) cases within 60 s of life (the "Golden Minute"). Median time to cord clamping was 74 s, with 414 (83.5%) and 313 (63.0%) having cord clamped at ≥ 30 and ≥ 60 s, respectively. Factors associated with BMV were CS delivery [odds ratio (OR) 29.9; 95% CI 3.37-229], low birth weight (LBW) (birthweight < 2,500 g) (OR 2.47; 95% CI 1.93-5.91), and 1 min Apgar score < 7 (OR 149; 95% CI 49.3-5,021). DCC (≥ 60 s) was less likely following CS delivery (OR 0.14; 95% CI 0.02-0.99) and being LBW (OR 0.43; 95% CI 0.24-0.77).

CONCLUSION

Approximately 83% of neonates initiated spontaneous breathing soon after birth and 29% of neonates not breathing responded to physical stimulation. BMV was initiated within the Golden Minute in most neonates, but under two-thirds had DCC (≥60 s). HBB implementation followed guidelines, suggesting that knowledge and skills taught from HBB are retained and applied by HCP.

Improving Newborn Resuscitation by Making Every Birth a Learning Event

One third of all neonatal deaths are caused by intrapartum-related events, resulting in neonatal respiratory depression (i.e., failure to breathe at birth). Evidence-based resuscitation with stimulation, airway clearance, and positive pressure ventilation reduces mortality from respiratory depression. Improving adherence to evidence-based resuscitation is vital to preventing neonatal deaths caused by respiratory depression. Standard resuscitation training programs, combined with frequent simulation practice, have not reached their life-saving potential due to ongoing gaps in bedside performance. Complex neonatal resuscitations, such as those involving positive pressure ventilation, are relatively uncommon for any given resuscitation provider, making consistent clinical practice an unrealistic solution for improving performance. This review discusses strategies to allow every birth to act as a learning event within the context of both high- and low-resource settings. We review strategies that involve clinical-decision support during newborn resuscitation, including the visual display of a resuscitation algorithm, peer-to-peer support, expert coaching, and automated guidance. We also review strategies that involve post-event reflection after newborn resuscitation, including delivery room checklists, audits, and debriefing. Strategies that make every birth a learning event have the potential to close performance gaps in newborn resuscitation that remain after training and frequent simulation practice, and they should be prioritized for further development and evaluation.

The injustice of unfit clinical practice guidelines in low-resource realities

To end the international crisis of preventable deaths in low-income and middle-income countries, evidence-informed and cost-efficient health care is urgently needed, and contextualised clinical practice guidelines are pivotal. However, as exposed by indirect consequences of poorly adapted COVID-19 guidelines, fundamental gaps continue to be reported between international recommendations and realistic best practice. To address this long-standing injustice of leaving health providers without useful guidance, we draw on examples from maternal health and the COVID-19 pandemic. We propose a framework for how global guideline developers can more effectively stratify recommendations for low-resource settings and account for predictable contextual barriers of implementation (eg, human resources) as well as gains and losses (eg, cost-efficiency). Such development of more realistic clinical practice guidelines at the global level will pave the way for simpler and achievable adaptation at local levels. We also urge the development and adaptation of high-quality clinical practice guidelines at national and subnational levels in low-income and middle-income countries through co-creation with end-users, and we encourage global sharing of these experiences.

Pediatric Critical Care in Resource Limited Settings-Lessening the Gap Through Ongoing Collaboration, Advancement in Research and Technological Innovations

Pediatric critical care has continued to advance since our last article, "Pediatric Critical Care in Resource-Limited Settings-Overview and Lessons Learned" was written just 3 years ago. In that article, we reviewed the history, current state, and gaps in level of care between low- and middle-income countries (LMICs) and high-income countries (HICs). In this article, we have highlighted recent advancements in pediatric critical care in LMICs in the areas of research, training and education, and technology. We acknowledge how the COVID-19 pandemic has contributed to increasing the speed of some developments. We discuss the advancements, some lessons learned, as well as the ongoing gaps that need to be addressed in the coming decade. Continued understanding of the importance of equitable sustainable partnerships in the bidirectional exchange of knowledge and collaboration in all advancement efforts (research, technology, etc.) remains essential to guide all of us to new frontiers in pediatric critical care.