Perspectives Preventing those so-called Jonathan M Spector a & Subhash Daga b

Increased recognition of the dispro- neonatal resuscitation is not universal. to distinguish between the two condi- portionately large contribution of Translation of resuscitation principles tions. The health-care team or family newborn health to global child survival into practice might be straightfor- may prefer a diagnosis to cir- has fuelled efforts to address neonatal ward in health-care environments that cumvent matters of culpability or to mortality in resource-limited settings. benefit from highly-skilled and well- avoid acknowledging the tragic reality Stillbirths have not been as well studied outfitted resuscitation teams, but is un- of limited medical proficiency in that despite the fact that more than 3 mil- derstandably difficult in settings where region. Logistical or financial incentives lion stillbirths occur annually, a disease practitioners lack training in newborn relating to, for instance, vital registra- burden that approaches that of postnatal care and where access to essential resus- tion or burial practices may also play a deaths. The poorest countries have the citation equipment is limited. In parts role. Finally, traditional belief systems highest incidences with two regions, of many low-income countries, for may influence categorization since still- sub-Saharan Africa and south Asia, example, resuscitation algorithms may births and child deaths can carry dif- together accounting for nearly 70% of be nonexistent or inappropriate. Bulb ferential spiritual significance in the eyes 1 worldwide stillbirths. Limited health syringes and bag-and-mask devices may of local community members. Since services undeniably constitute the ma- be sub-standard or unavailable; even documentation at peripheral health jor determinant in , when present and functioning, staff may centres directly informs district, provin- but there is growing concern that high be unfamiliar with their use. Moreover, cial, and central level reporting, system- stillbirth rates in many regions are also stethoscopes, which can play a crucial atic errors introduced locally adversely being driven by less apparent, potentially role in helping practitioners to recog- impact the legitimacy of national and preventable factors. nize a live birth by detecting a regional statistics. Birth , defined as the fail- rate, may also be either inaccessible or Our experience working alongside ure to establish at birth, ac- unused. Customary practice in some neonatal care providers in sub-Saharan counts for an estimated 900 000 deaths regions dictates use of a stethoscope Africa and India illustrates how resus- each year and is one of the primary only by doctors, who may not regularly citation practices influence stillbirth causes of early neonatal mortality.2 attend deliveries. statistics. In rural Sudan, we have seen Guidelines for neonatal resuscitation, Given that perinatal asphyxia oc- a cyanotic, apnoeic newborn with a such as those endorsed by WHO and the American Academy of , curs with regular frequency and that pulse be set aside following birth and represent a standard practice set that health-care workers in many areas of left to herself to initiate the process of improves outcomes in asphyxiated the world are ill-equipped to manage spontaneous breathing. After nearly two newborns. These algorithms stress the it, there is no mystery as to why large minutes of non-intervention by the de- importance of drying, stimulating and numbers of newborns are dying in the livery attendants, we were compelled to warming babies in distress, as well as immediate postpartum period. What is step outside of our role as observers and clearing their airways. In the face of unknown, however, is the accuracy and act quickly to provide stimulation and persistent apnoea or bradycardia, ven- consistency with which these fatalities positive pressure ventilation. The infant tilation with the use of bag-and-mask are being recorded. Obtaining reliable responded to manual breaths and the or equivalent device is indicated, and information that describes perinatal outcome was good. Subsequent discus- is felt by many to constitute the critical mortality in less developed countries sions with the local staff indicated that step in managing asphyxiated infants.3 can be challenging due to high rates of the infant would have been considered Newborns have a remarkable ability to home births as well as variation in ter- stillborn had she died. withstand hypoxia and many improve minology and data collection systems. On another occasion, midwives at rapidly with timely implementation of Strictly speaking, stillbirths are a large public hospital in Liberia were these techniques. Few infants go on to fetal deaths. Nevertheless, live-born in- observed to routinely favour medi- require chest compressions or pharma- fants who are inadequately resuscitated cation administration alone in the ceutical administration. and die may be misclassified as still- management of apnoeic newborns. Despite being a relatively simple births for several reasons.4 Unskilled This approach was confirmed as com- and inexpensive intervention, effective health workers may simply not be able mon institutional practice by written

a UMass Memorial Children’s Medical Center, Worcester, MA, United States of America. b BJ Medical College and Sassoon General Hospital, Pune, India. Correspondence to Jonathan Spector (e-mail: [email protected]). doi:10.2471/07.049924 (Submitted: 24 November 2007 – Accepted: 5 March 2008 )

Bulletin of the World Health Organization | April 2008, 86 (4) 315 Perspectives Preventing those so-called stillbirths Jonathan M Spector & Subhash Daga assessment in which 78% of delivery was a central component.5 This find- newborn deaths resulting from birth practitioners failed to correctly identify ing is consistent with a recent study in asphyxia strengthens the appeal for positive pressure ventilation as a key Fatehpur, India, through which nurses investment in research that identifies element in resuscitation of asphyxi- and ward aides with minimal education effective and feasible mechanisms for ated babies (Spector, unpublished data, were trained in a basic neonatal resusci- delivery of essential newborn care. 2007). More than 2000 deliveries are tation programme. Recorded stillbirth Priority interventions in parts of the conducted at this hospital annually, yet rates decreased in the hospitals where world most affected should include there was virtually no documentation the course was taught. Participating high coverage of skilled birth attendants of neonatal deaths. In contrast, the re- physicians’ comments were revealing: and integration of competency-based corded stillbirth rate was extremely high following the intervention, nurses dem- neonatal resuscitation training into (70 out of 1000 live births). onstrated skilful use of bag-and-mask existing programmes for maternal and Can improvement in neonatal re- during resuscitation whereas “before, child health. If just 1 in 100 stillbirths suscitation skills result in decreased the babies had died”.6 is actually a poorly-resuscitated viable stillbirths? Evidence suggests that it can. Misclassification of stillbirths has newborn, greater than 30 000 lives In Dahanu, India, the stillbirth rate significant implications for national could potentially be saved each year by dropped from 18.6% to 9% over a health policies and global strategies for improving neonatal resuscitation prac- three-year period with introduction of a reducing perinatal mortality, particu- tices in austere settings. ■ traditional birth attendant training pro- larly with regard to resource allocation. gramme in which neonatal resuscitation Recognizing so-called stillbirths as Competing interests: None declared.

References 1. Lawn J, Shibuya K, Stein C. No cry at birth: global estimates of intrapartum 4. Stanton C, Lawn JE, Rahman H, Wilczynska-Ketende K, Hill K. Stillbirth stillbirths and intrapartum-related neonatal deaths. Bull World Health Organ rates: delivering estimates in 190 countries. Lancet 2006;367:1487-94. 2005;83:409-17. PMID:15976891 PMID:16679161 doi:10.1016/S0140-6736(06)68586-3 2. Lawn JE, Manandhar A, Haws RA, Darmstadt GL. Reducing one million child 5. Daga SR, Daga AS, Dighole RV, Patil RP, Dhinde HL. Rural neonatal care: deaths from birth asphyxia: a survey of health systems gaps and priorities. Dahanu experience. Indian Pediatr 1992;29:189-93. PMID:1592499 Health Res Policy Syst 2007;5:4. PMID:17506872 doi:10.1186/1478- 6. Cowles W. Decreasing perinatal mortality in rural India: a basic neonatal 4505-5-4 resuscitation program. Acad Emerg Med 2007;14:e109. doi:10.1197/j. 3. Rehan VK, Phibbs RH. Delivery room management. In: Avery’s neonataology: aem.2007.02.004 pathophysiology and management of the newborn. 6th ed. Philadelphia: Lippincott Williams & Wilkins Press; 2005.

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