Neonatal Resuscitation in Low-Resource Settings a, b Sara K. Berkelhamer, MD *, Beena D. Kamath-Rayne, MD, MPH , c Susan Niermeyer, MD, MPH KEYWORDS Neonatal resuscitation Birth asphyxia Intrapartum-related events Low-income countries Low resource Resuscitation education KEY POINTS Simplified resuscitation programs reduce fresh stillbirth and early neonatal mortality rates in low-resource settings (LRSs) where the burden of death is greatest. Goals set by the Every Newborn Action Plan call for national and global efforts to improve coverage and quality of neonatal resuscitation. The science of resuscitation demonstrates that more than 95% of babies will respond to simple steps of drying, stimulation, warmth, suctioning if needed, and bag-mask ventilation. Despite notable progress, barriers remain in access to resuscitation equipment, presence of a skilled provider at birth, and quality assurance in resuscitation training. Future efforts to advance neonatal resuscitation in LRSs need to consider preservice ed- ucation, skills retention through refresher training or low-dose, high-frequency practice, as well as expansion of health information systems and quality improvement initiatives. INTRODUCTION Almost all newborn deaths occur in low-income and middle-income countries (LMICs) where access to health care, including resuscitation at birth, is limited. Data from the last 2 decades starkly contrast the 31 million neonatal deaths in South and East Asian LMICs and 21 million in African LMICs with the 1 million neonatal deaths occurring in high-income countries.1 Estimates suggest almost one-fourth of neonatal deaths can be attributed to intrapartum-related events or what is commonly referred to as birth asphyxia.2,3 As a result, an estimated 720,000 deaths each year are thought to result from intrapartum-related events, although definitive causes cannot be confirmed.4 Disclosure: The authors have no financial obligations or affiliations to disclose. a Department of Pediatrics, University at Buffalo, SUNY, 219 Bryant Street, Buffalo, NY 14222, USA; b Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 7009, Cincinnati, OH 45229, USA; c Department of Pediatrics, University of Colo- rado, 13121 East 17th Avenue, Mail Stop 8402, Aurora, CO 80045, USA * Corresponding author. E-mail address: [email protected] Clin Perinatol 43 (2016) 573–591 http://dx.doi.org/10.1016/j.clp.2016.04.013 perinatology.theclinics.com 0095-5108/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved. 574 Berkelhamer et al Notably, studies suggest that the systematic implementation of low-cost and effective newborn resuscitation programs in low-resource settings (LRSs) has the potential to avert nearly 200,000 of these intrapartum-related deaths each year.5,6 In addition, an estimated 1.3 million intrapartum stillbirths occur annually; these deaths are poten- tially preventable by improved care during labor and at the time of delivery.7 Frequently quoted studies imply that 10% of infants require some support or stim- ulation at birth although only 3% to 6% of newborns require positive-pressure venti- lation to initiate spontaneous respirations. An even smaller proportion (<1%) requires advanced care, including chest compression or medications (Fig. 1).5,8–10 However, these estimates are biased towards care in resourced or facility settings where high rates of prenatal care, fetal monitoring, and cesarean delivery reduce the prevalence and impact of intrauterine hypoxia. These data may greatly underesti- mate the need in low-resource environments where the burden of neonatal morbidity and mortality is highest.11–13 Studies from rural home deliveries in Zambia suggest 16% to 21% of infants require stimulation at birth, whereas unpublished data from community settings in Bangladesh imply even higher rates of need for intervention.11 Although reduction of neonatal mortality calls for primary prevention through improved fetal monitoring and obstetric care, resuscitation and stabilization of nonbreathing infants alone have the potential to save lives.6 Studies have shown that even simple measures, including appropriate stimulation, clearing of the airway, and avoidance of hypothermia can reduce mortality.13,14 The addition of assisted ventilation when clinically indicated represents a simple and critical intervention to reduce both morbidity and mortality associated with birth asphyxia.15 Growing recog- nition of the burden of prematurity has included estimates implicating preterm birth as the direct cause of 35% of neonatal deaths.16 In partnership with access to special care, resuscitation education has potential to reduce this burden by supporting pre- term infants who are at greatest risk of breathing problems at birth. Fig. 1. Estimate of annual number of all newborns who require assistance to breathe at birth and varying levels of neonatal resuscitation. (From Lee AC, Cousens S, Wall SN, et al. Neonatal resuscitation and immediate newborn assessment and stimulation for the preven- tion of neonatal deaths: a systematic review, meta-analysis and Delphi estimation of mortal- ity effect. BMC Public Health 2011;11(Suppl 3):S12.) Neonatal Resuscitation in Low-Resource Settings 575 Significant progress has been made over the past decade with respect to develop- ment and distribution of educational programming and equipment for newborn resus- citation. However, numerous challenges remain in providing every infant, regardless of where they are born, access to optimal care and a chance of survival. With 50% of births in LMICs occurring in the home, possibly far from a health care facility, the chal- lenges to making sustainable changes in neonatal resuscitation coverage are formi- dable.15 Additional barriers include, but are not limited to, ineffective educational systems and programming, inadequate equipment and personnel, insufficient data monitoring, and limited political and social support to improve current care.17,18 These barriers exist despite heightened awareness of neonatal mortality as the sin- gle largest contributor to under-5 mortality, the target of Millennium Developmental Goal (MDG) 4. The commitment to reducing the global burden of neonatal mortality under the Sustainable Development Goals was renewed in 2014 by the World Health Organization (WHO), United Nations Children’s Emergency Fund (UNICEF), and mul- tiple global partners as the Every Newborn Action Plan (ENAP).19 ENAP defines an ambitious agenda to end preventable newborn deaths and stillbirths by 2035. Targets include the continued and accelerated reduction in national neonatal mortality rates to 10 or fewer per 1000 live births, with an average worldwide neonatal mortality rate of 7 per 1000 by 2035 and reduction in stillbirths to 10 or fewer per 1000 total births.19 Crit- ical to achieving these goals will be attention to equity gaps through expanded access to resuscitation programming and equipment as well as an ongoing national and global commitment to providing skilled care at all deliveries, whether they occur in a health care facility, community setting or home. Several publications have reviewed the status of newborn resuscitation in LRSs.11,15,17,20,21 This article summarizes the status as of 2016, with attention to the impact of recent updates to the WHO and the International Liaison Committee on Resuscitation (ILCOR) guidelines, updates to educational programming, and the cur- rent status of resuscitation equipment. Barriers to achieving goals established for 2035 are acknowledged and strategies for accelerating progress and improving qual- ity of resuscitative care are discussed. CURRENT RESUSCITATION GUIDELINES AND IMPLICATION FOR CARE IN LOW- RESOURCE SETTINGS Recent updates to recommendations on resuscitative care include the 2012 WHO Basic Newborn Resuscitation guidelines and the 2015 ILCOR Consensus on Science and Treatment Recommendations.22,23 Although overlap of these recommendations exists, the objective of the WHO guidelines is “to ensure that newborns in resource- limited settings who require resuscitation are effectively resuscitated.”23 In contrast, the ILCOR rigorously evaluates the evidence underlying both basic and advanced resuscitation practices in resource-intensive and resource-limited settings. Updated or newly emphasized WHO and ILCOR recommendations follow, with discussion of their relevance to LRSs. Attendance of Skilled Provider at Birth Both WHO and ILCOR suggest that every birth should be attended by a person trained in resuscitation. Surveys from LMICs identify significant gaps in access to skilled personnel.15,24 Although 72% of deliveries worldwide are attended by a skilled pro- vider, only 67% and 48% of women in South East Asia and sub-Saharan Africa give birth with skilled personnel present.25 Challenges remain most acute in assuring pres- ence of skilled providers in nonfacility settings. Multicountry and wealth-based 576 Berkelhamer et al analysis demonstrates that more than half of births occur at home, with rates of home delivery approaching 90% for the poorest women in sub-Saharan Africa, South Asia, and South East Asia (Fig. 2).26 The heightened emphasis on adequate preparation for birth in the 2015 ILCOR up- dates may affect resource distribution and support task shifting in LRSs. Approaches may include basic resuscitation training of alternative cadres, including traditional birth attendants (TBAs) or community-based midwives. TBAs are relatively common in many health