Interpretation
In our study, 87.5% of HW had attended at least one training in
neonatal resuscitation, and 70% of the HW performed resuscitations on a
regular basis. Despite this, our findings documented challenges in
adherence to NR guidelines, stressing that NR programmes cannot stand
alone. Transfer of competencies learned during training into clinical
practice remains a key challenge. A study from Nepal using HBB with a
quality improvement cycle showed improved adherence to NR guidelines.37 They attribute their success to a multifaceted
intervention involving local leadership, multidisciplinary quality
improvement teams, daily debriefings, root-cause analysis of poor NR
performance and development of inclusive quality improvement goals.37 In addition, a systematic review from 2020 of the
HBB programme from its initiation in 2010 found a reasonable translation
of knowledge and skills. 38 Yet, few studies have
documented the transfer of knowledge into clinical practice reflected in
neonatal outcomes. 38 39 A HBB review on the effect on
intrapartum-related stillbirths and neonatal mortalities found mixed
results on mortality reduction, which further supports that training
with frequent refreshers could aid in preserving knowledge and skills.39 Thus, there is a need to re-think traditional
training and, to a greater extent, support the implementation of learned
knowledge and skills into clinical practice.
Videos can help to recognise and monitor essential areas of improvement
and aid intervention design. The insights from the videos could not have
been obtained by any other means. Direct observations by research
assistants could provide some structured observations about NR but
cannot provide a real-time recording of NR for analysis and
understanding of the actual challenges. Furthermore, direct observations
generate a number of ethical issues where an observer should be a
trained clinician in order to observe such a complex clinical situation
as NR, but a trained clinician should obviously intervene in
life-threatening situations. Many studies, both from high-resource
settings and a few from low-resource settings, support videos to
understand the quality of care. 20 24-32 Video
recordings are beneficial for understanding NR, and our study from Pemba
proved that video recordings are also beneficial to understand gaps in
the quality of recommended essential newborn care and emphasizes the
need for improved post-natal care of healthy newborns to prevent
morbidity and mortality. 40 41 Similarly, a study from
Nepal reports that emphasis on post-natal care is paramount to sustain
gains in survival after resuscitation and NR programmes.23
Our findings stress the need to prioritise effective PPV since
oxygenation and reduction of shunts are the key interventions to reverse
hypoxia. 15 Our results are consistent with previous
studies from LMIC in Nepal, Mozambique, and Uganda who found unsustained
ventilation and delays in establishing ventilation. 20
26 28 31 32 42 The 2021 European Resuscitation Guidelines recommend the
omission of suction even for newborns born in thick meconium as it
delays ventilation and there is an absence of evidence of benefit.16 It has been argued that the suction device should
be removed from the resuscitation table and observations from our study
support this as critical time is diverted to suctioning instead of
ventilation. 26 The AMANHI study attributed perinatal
asphyxia as the leading cause of death responsible for more than 47% of
neonatal deaths in Pemba. 34. In addition, the
Zanzibari Ministry of Health reports birth asphyxia as the leading cause
of death in children under 13 years, accounting for 25.2 % of deaths.43
Lastly, we report an NMR of 23.6 per 1000 live births, with more than
90% of the deaths occurring within the first 24 hours. Our one-day
neonatal mortality is higher than most of the literature, suggesting
that the overall neonatal mortality rate in Pemba could be much higher
than we report. 3-5 12 The NMR in our study is
slightly higher than the official numbers from the Zanzibari Ministry of
Health and the AMANHI-study group. 34 44
Challenges in provision of quality of care according to guidelines have
many reasons beyond the capacity of HWs, including structural barriers
such as lack of human resources, lack of equipment and logistical
challenges. Maaløe et al. recommend local adaptation of guidelines, so
they are achievable and contextualised to the setting.45 In addition, there is a need to understand the
barriers to adhere to the guidelines, such as HBB and similar NRP, to
succeed and translate into improvements in knowledge and skills and
improve neonatal outcomes. Novel technology such as mHealth tools are
widely available. A study showed that the Safe Delivery App aids
knowledge and skill retention with a non-significant reduction of
perinatal mortality, and mHealth solutions such as this could be part of
the solution. 46