1. THE IMPACT OF NEONATAL RESUSCITATION TRAINING
ON INFANT OUTCOMES
IN LOW RESOURCE COUNTRIES
A MASTER’S PROJECT
SUBMITTED TO THE GRADUATE FACULTY
OF THE CENTER FOR GRADUATE AND CONTINUTING STUDIES
BETHEL UNIVERSITY
BY
JILL ANN BAUER
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE OF
MASTER OF ARTS IN NURSING
SEPTEMBER, 2012
2. BETHEL UNIVERSITY
THE IMPACT OF NEONATAL RESUSCITATION TRAINING
ON INFANT OUTCOMES
IN LOW-RESOURCE COUNTRIES
Jill Ann Bauer
September, 2012
Approved: _______________________________Project Advisor
_______________________________Signature
APPROVED
__________________________________
Department Chairperson
_ _________________________________
Director of Graduate Nursing Program
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3. Acknowledgements
With my deepest gratitude and thanksgiving:
To God, Who has remained faithful to me all of my life. I can never express
adequately my appreciation for His guidance into the perfect career. Nursing has
awakened my deepest passions for life, as I have been blessed to care for mothers and
infants in various areas of the world that He has allowed and called me to go!
To my husband Dan who would not allow me to give up on my dream of a
graduate degree. He has never stopped encouraging and supporting me throughout the
past two years of studies. Somehow, he realized how strong my desire for this degree has
been, and through his selfless and unending support, he maintained our life while I
muddled through the mountains of homework to achieve it. During that time, he never
wavered in his willingness to accept and adore me unconditionally no matter what the
mood or circumstance; helping me to reach this finish line!
To my children, they are the greatest joy of my life and whom I love them dearly.
I hope that as they see me finally reach this important goal in life, it will inspire them to
know that they can always dream bigger, and that it is never too late to achieve the
desires of their heart.
To the nurses, that I came to know in the Neonatal Intensive Care Units of
Minnesota, Wisconsin, Guatemala, Uganda and/or Saudi Arabia. They have impacted and
touched my life deeply, and in many ways. I have learned from them, taught them, and
shared my passion with them. In doing so, we have worked together to improve the
quality of life for neonates and their families.
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4. And finally, to some of the tiniest miracles and their families that I have met
along the way, I am grateful. They have inspired me to continue trying to be the best
nurse that I can be. As I hope that I may have touched their lives with compassion, love,
a gentle hand, or the knowledge that parents needed to care for their child, they have
contributed far more to my life as they helped me find my way.
To Mya, Jana, and Brandon, I am thankful for having been able to care for them
and so many other infants. It was a joy to watch them along with their families, as they
were able to heal and grow. And in remembrance of Hailee, it was a blessing to share her
brief life and to be there with her parents as she left this world with grace and dignity.
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5. Abstract
Background/Purpose: Reducing infant deaths relies on improving the quality of care
delivered in low resource countries where 99% of deaths occur. This critical review will
identify and analyze the impact of neonatal resuscitation practices to determine strategies
for education and practice that result in improved global morbidity and mortality.
Conceptual Framework: Nola Pender’s Health Promotion Model (Pender, Murdaugh &
Parsons, 2002) was used as the framework for analyzing the literature.
Method: Twenty three research articles with data retrieved from low resource countries
were reviewed. Primary factors examined included implementation of resuscitation
training, impact on infant outcomes, and elements that affected the final outcomes.
Results: Neonatal morbidity and mortality can be reduced in low resource countries with
quality resuscitation training using low cost, low technology techniques.
Conclusion: Neonatal resuscitation training of birth attendants in low resource countries
using evidence based practices results in improved morbidity and mortality rates. When
also incorporating comprehensive training programs that include neonatal resuscitation,
prevention of hypothermia and sepsis, early feeding, and promotion of mother care,
morbidity and mortality rates show additional improvement.
Implications for Nursing Education and Research: Nurse leaders have an opportunity
to impact global infant outcomes by sharing their knowledge, skills, and expertise. In
doing so, they can create, implement, and support educational programs, as well as
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6. participate in research; promoting best outcomes through global practice of evidence
based nursing care.
Key Words: NRP, developing world, newborn resuscitation training, newborn
resuscitation program, low resource, newborn training, low income, neonatal training,
developing country, newborn resuscitation effectiveness, developing NRP, developing
countries, and neonatal outcomes.
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7. TABLE OF CONTENTS
ACKNOWLEDGEMENTS……………………………………………………………….3
ABSTRACT…………………….…………………………………………………………5
LIST OF TABLES…………………………………………….…………………………..9
LIST OF FIGURES………………………………..………………………………....….10
CHAPTER 1: INTRODUCTION…………………….……………………………….…11
Evidence of Need for the Critical Review………...……………………….…….11
Significance to Nursing…………………………………………………………..15
Personal Experience…………….………………………………………….…….17
Nursing Theoretical Framework……………………….………………………...18
Summary…………………………………………………………………………22
CHAPTER 2: METHODS…………………………………………………………….…23
Criteria for Inclusion or Exclusion of Research Studies……………….………...23
Search and Review Process………………………...……………………………23
Number and Types of Studies Selected…………………………………………24
Summary…………………………………………………………………………25
CHAPTER 3: LITERATURE REVIEW AND ANALYSIS……………………….…..26
The Matrix………………………………………………………………….……26
Major Findings……………………………………………………………..…….26
Training Effectiveness…………………………………………….…..…28
Impact on Prematurity……..………………………………………...…...31
Combined Educational Programs…………………...……………...……31
Impact on Health Systems……………………………………………….34
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8. Reaching Infants in the Home and Community………………………….35
Strengths of Salient Studies………………………...……………………….…...36
Weaknesses of Salient Studies……………………...…………………………....37
Summary………………………………………………………………….……...39
CHAPTER 4: DISCUSSION, IMPLICATIONS, AND CONCLUSIONS………...……65
Current Trends…………………………………………………………………...65
Nursing Educational Interventions...……………………..………………...……67
Implications for Education of Nurses………….……………………………...…69
Gaps in the Literature………………………………………….…………………70
Recommendations for Research…………………………………………………73
Integration and Application of Theoretical Framework…………………………75
Conclusion……………………………………………………………………….76
REFERENCES…………………………………………………………………………..78
ADDITIONAL REFERENCES………………………………………………….………84
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10. LIST OF FIGURES
Figure 1: Required Resuscitation in Newborns………………………………………….13
Figure 2: The Health Promotion Model of Nursing Care…......…………………………20
Figure 3: Mortality Impact of Resuscitation Interventions on Birth Asphyxia
and Preterm Birth.……………………………………………………………..30
Figure 4: Survey Results on Priority Areas of Birth Asphyxia Education………….…...70
Figure 5: Survey Results on Key Birth Asphyxia Research Priorities..……..…………..74
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11. CHAPTER 1: INTRODUCTION
The purpose of this capstone project is to analyze the literature on the potential for
nurses to create a significant impact in the outcomes of infants globally. By reviewing
research on evidence based infant resuscitation training and techniques, the intent is to
examine how infant outcomes may be impacted in low resource countries. The discussion
will include a review of the data that investigates the morbidity and mortality of infants
before and after healthcare staff have received neonatal resuscitation education.
This review will examine the most current evidence available, and provide
discussion resulting from information obtained through the research articles. More
specifically, the discussion in this critical review will focus on training and infant
outcomes within low resource environments. It will consider the relationship of neonatal
resuscitation training for healthcare workers and the resulting impact on neonatal
outcomes in those countries.
Evidence of Need for the Critical Review
According to the World Health Organization (WHO), approximately 4 million
infants die each year. Of those deaths, 98-99% of them occur in developing countries
(Chombra et al., 2008; Lawn, Cousens, & Zupan, 2005; Opiyo et al., 2008), and 75%
occur within the first 7 days of life (Carlo, Chomba, Goudar, Kodkany, et al., 2010). An
estimated 904,000 of these neonatal deaths in infants of term gestation are related to
hypoxic events that occur in the intrapartum (childbirth or delivery) period (Lawn et al.,
2009). While it is often difficult to distinguish between birth asphyxia (decreased oxygen
to organs before, during, or immediately after birth, resulting in cell death) and stillborn
(death in the uterus) births, it is estimated that an additional 1.02 million stillbirths occur
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12. each year as well (Lawn et al., 2009). These stillborn deaths occurring in low-resourced
settings may often be difficult for caregivers, birth attendants, or families to distinguish
from intrapartum hypoxia (lack of oxygen to the fetus during the labor and delivery
process), as they closely resemble the severely depressed newborn (an infant displaying
symptoms of intrapartum hypoxia). Without proper assessments and interventions of the
cause however, these infants remain in the vast majority of neonatal deaths predicted to
be caused by preventable and treatable conditions (Lawn, et al., 2005).
With asphyxia considered to be a leading cause of infant deaths throughout the
world, initiation of breathing is a critical step that must be taken in the first few moments
when an infant transitions from intra-uterine to extra-uterine life. The American
Academy of Pediatrics (AAP) estimates that 5-10% of all newborns will require some
assistance to establish this initial breathing at birth. Therefore, approximately 10 million
infants per year must be identified quickly and as they will need assistance to initiate
their first breaths (Wall et al., 2009). The vast majority of these infants will be easily
resuscitated with interventions such as simple warming, drying, and stimulation, or may
require slightly more complex actions such as delivering positive pressure ventilation by
bag or mouth to initiate breaths, which is shown in Figure 1.
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13. Figure 1. Required Resuscitation in Newborns. Estimate of annual number of all newborns who require
assistance to breathe at birth, along with varying levels of neonatal resuscitation. Adapted from
Lee, A. C., Cousens, S., Wall, S. N., Niermeyer, S., Darmstadt, G. L., Carlo, W. A., Keenan, W.
J., ... Lawn, J. E. (2011). Neonatal resuscitation and immediate newborn assessment and
stimulation for the prevention of neonatal deaths: A systematic review, meta-analysis and Delphi
estimation of mortality effect. BMC Public Health, 11.
In low resource countries, these steps are easy to perform using low technology in
the early stages of neonatal life, often preventing the morbidity or mortality that might
have resulted without these steps. It is estimated that with this assistance, approximately
23% of deaths related to perinatal asphyxia might be altered by this described quick and
early assessment and intervention (Lee et al., 2011).
However, in developing countries, poverty, lack of resources, poor care-seeking
behaviors, isolation, perception of inaccessible care, poor hygiene, a belief that the infant
is without full personhood and weak health systems can contribute to the numbers of
infants who are not identified or assisted in time. Even when infants are considered
stillborn but then demonstrate signs of life, birth attendants may often lack the knowledge
or training to intervene. As a result, these infants often die (Marsh et al., 2002). The many
factors listed above contribute to high morbidity and mortality statistics, ultimately
causing infants to suffer that morbidity and/or mortality very early in the neonatal stages
<1% of infants require
advanced resuscitation
(cardiac compressions and
medications)
3-5% require basic
resuscitation (bag/mask
ventilation)
5-10% require simple
stimulation at birth to help
them breathe.
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14. of life. To save these infants, an immediate need for wide-scale implementation of cost-
effective healthcare training programs promoting evidence-based interventions, such as
neonatal resuscitation interventions, must be promoted in order to improve newborn
health outcomes.
WHO, recognizing that the vast numbers of infant deaths occur in low resource
regions, has implemented a Millennium Goal to reduce deaths of children under the age
of 5 years by two thirds. However, if this goal is to be achieved by the designated year of
2015, neonatal deaths, which compromise the majority of these mortality statistics, must
be addressed (Haws, Thomas, Bhutta, & Darmstadt, 2007). Education for key
individuals, with attention to cultural and environmental factors involved in low
successes, must be studied so that appropriate care and training programs for the newborn
infant can be developed to promote their health and survivability.
Globally, most neonatal deaths occur in South-Central Asia and sub-Saharan
Africa. Zambia has recorded the highest infant mortality rate at 102 of 1000 live births
(Chombra et al., 2008). Despite these facts, 90% of research on this topic is currently
carried out in the more developed areas of the world, where only 10% of infant morbidity
and mortality is experienced (Singhal & Bhutta, 2008). Therefore, although the evidence
and quality of research is somewhat limited, this critical review of the literature will
specifically look at the relationship of resuscitation education for healthcare workers in
low resource countries, and examine whether or not there is significant research evidence
to demonstrate that this education, when administered to nurses (and other healthcare
workers), can impact the morbidity and mortality rates of infants in low resource areas
following resuscitation education.
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15. Significance to Nursing
The guiding question for this critical review is: Can the promotion of nursing
resuscitation knowledge and education in low resource countries improve the outcomes
of infants in the low resource environments? Promoting the health of patients, families,
and communities is a common and basic nursing function that is most often done through
counseling, education, and service (Montgomery & Schubart, 2010). Nurses, one of the
most influential frontline caregivers, are often positioned at the bedside where they can
greatly impact health and improve patient care through knowledgeable and timely
interventions. Positioned as such, their expertise and skill (or lack thereof) can directly
impact patient care outcomes. Nurses with advanced practice skills and education in
particular, may possess the skills to also promote strategies through research, education,
and community health practices, which can elevate the level of health among neonates in
a given area.
Nurses may have an especially strong ability to impact patient care outcomes in
acute care settings, such as in the case of an infant delivery. Whether the delivery occurs
in a home environment, community, or health care setting, the knowledge and abilities
possessed by a nurse attending the birth of a newly born infant have the potential to
impact the morbidity and/or mortality of that infant. Therefore, all nurses in perinatal care
areas, including those in low-resource environments, should be taught appropriate
evidence-based care strategies and interventions, infant assessments, and recognition of
potential danger signs or complications at birth. This knowledge can help them to
respond quickly with appropriate actions for the infant in distress, promoting the health
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16. and survival of an infant experiencing difficulty shortly after birth by delivering
appropriate life saving care when needed.
This critical review will examine available research to find out what practices and
interventions show the greatest effectiveness in these low resource environments. As
evidence is uncovered to support the most beneficial nursing practice and skills, infant
outcomes may be promoted through shared education of these practices. While all nurses
have the opportunity to progress the outcomes of their patients, encouraging nurses in
low resource environments to advance their practice and leadership abilities may also
position them to progress health systems and communities through increased knowledge,
skills, collaborative efforts, and leadership actions.
Through collaboration and collegiality, nurses in both the high and low resource
environments have a role to play in advancing neonatal outcomes. As nurses in low
resource countries work to advance their knowledge, skill, and expertise, nurses
practicing in high resource areas have the opportunity to take on leadership roles in the
creation of programs to build and sustain that practice; together reducing global
morbidity and mortality rates of infants. These nurses, choosing to share knowledge with
their global peers, may recognize that they have the ability, and even a calling, to
positively impact patient outcomes by taking an active role in advancing practice in low
resource countries in the area of neonatal care. This review will assist nurses to
effectively impact global infant morbidity and mortality rates through education, as well
as empower their peers and advance their own profession.
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17. Personal Experience
This critical review of the literature was inspired through my own experience of
teaching nurses in the low resource countries of Guatemala and Uganda. These
environments are typically identified by their poor or non-existent infrastructure and
human resources. In low resource countries where some of these elements do exist, they
are often limited in quality, quantity and/or accessibility. These limitations create many
difficulties in the healthcare settings of these environments. Despite these difficulties
however, I found that nurses in these countries often demonstrated persistence,
determination, creativity, and strength in their circumstances. When education was
offered, their eagerness to absorb the information, practice new skills, and advance the
care of infants was valiant.
In both of these countries, the low quality of nursing education, the ability to do
patient assessments, and knowledge about the care of patients was striking compared to
the practices of nurses in the United States. Despite great efforts, their skills, expertise,
and interventions in general seemed to be about twenty years behind those used in this
country. Some of the reasons for this discrepancy that I observed included limited
educational opportunities (particularly for women), limited educational tools and
resources, the impact of poverty, lack of equipment and resources, and the apparent
detrimental effects of local social practices or beliefs. These issues are addressed by
Laaser & Epstein (2010) as elements that threaten global health and opportunity for
effective change. I also observed that these factors limited the ability of nurses to
contribute to positive outcomes, and appeared to affect how and why a nurse chose to
care or not to care for an infant, even after education was offered.
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18. In both countries that I visited for intervals of two to four weeks for each visit, I
was able to offer evidence based education to nurses during my stay. However, I often
did not see an immediate or significant impact or change in the way that care was
delivered following the education. Infant outcomes also did not seem to change. I began
to wonder what important factors in the culture and environment impacted this, and
whether other approaches or methods of education might be more effective. This
experience fueled my curiosity to examine the current research to look for answers that
ultimately might help me develop educational content or methods that might more
effectively result in improved patient outcomes.
Nursing Theoretical Framework
Nola Pender’s Health Promotion Model (PHPM), (Pender, Murdaugh & Parsons,
2002) examines background factors and beliefs that influence health-promoting behavior.
These factors and beliefs, which are shown in Figure 2, include individual characteristics
and life experiences, the social, cultural and physical environment, the collaboration of
nurses to create opportunities for health promotion, an individual’s reference to health
and illness, personal benefits, barriers and commitment to action, perceived self-efficacy,
interpersonal and situational influences, and competing demands. Since each of these
areas can influence an individual’s motivation and ability to learn and thus the likelihood
of improved health practice and outcomes, identifying them can provide an opportunity
for the nurse educator to intervene in ways that can alter their instructional interventions
to improve learning and practice. In doing so, they can ultimately promote education and
skills that result in better health of a population.
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19. Identifying the factors outlined in PHPM can assist the nurse educator to discover
how they can improve the effectiveness of the education and improve the resulting health
promoting behaviors. Knowledge gained through use of this model in this review can
provide an opportunity for creating the most effective educational methods for neonatal
resuscitation training, in order to promote the learners understanding of the benefits of the
training, remove barriers to learning, provide motivation for the learner to incorporate the
knowledge and skills into their practice, and increase the commitment to sustain these
practices. Throughout this review, this model will be incorporated to assist in
identification of individual, behavioral, environmental, and cultural perspectives that
might influence the success of implementing educational programs intended to promote
improved health of infants in low resource environments. If education does not have a
positive impact of improved infant outcomes, this model can help to identify and explain
contributing factors for that result.
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20. Figure 2. The Health Promotion Model of Nursing Care. Adapted from Pender, N.J., Murdaugh,
C. L., & Parsons, M.A., 2002. Health promotion in nursing practice (4th
ed.). Upper
Saddle River, NJ: Prentice-Hall. Used with permission.
When differences exist in low resource environments where resuscitation
education has been implemented, it will be important to identify contributing factors so
that training might be modified to account for those factors. This identification may assist
educators to improve the successful impact of training, and ultimately contribute to
overall infant outcomes following that training. Where variations or unexpected
outcomes are observed, consideration will be given as to whether cultural practices and
beliefs, environment, personal or community perceptions, or individual characteristics
may have impacted them. PHPM can be helpful in this critique by assisting to provide
ideas or explanations of how or why these impacts exist. As causative factors are
identified, the model may also help to increase the usefulness or educational impact of
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21. resuscitation training by modifying the education taught in low-resource environments so
that its impact is improved in that setting.
PHPM encourages the empowerment of nurses through enhanced education and
personal development. The model also assists the nurse to explain and predict health
perceptions and health-promoting behaviors within various groups of people, and to study
what motivates people to change behaviors that can improve health. Assumptions of
PHPM consider multiple factors that can impact education and health promotion through
cultural characteristics, and thus impact the effect of the educational benefits in that
community. Some of these assumptions resulting in a positive or negative impact on
patient outcomes might include: perceived benefits, perceived barriers, perceived self
efficacy, interpersonal influences, situational influences, competing demands, and the
commitment to adhering to the health-promoting plan (Pender, Murdaugh & Parsons,
2002). Questions for staff in low resource environments that relate to PHPM and the
promotion of resuscitation techniques may include: Will these changes/techniques help
my family or community? Do my peers accept the changes? Am I capable of learning and
performing these techniques in my environment? Are the changes supported by my
leaders? Am I motivated to sustain these changes? Do these techniques make sense? Do
my personal beliefs or traditions conflict with the new changes?
Each of these assumptions can be influenced by specific practices or beliefs, and
should be examined closely to explain its relationship to the educational intervention and
resulting practice behavioral change (Pender et al., 2002). As a nurse’s practice may be
altered in various ways following educational interventions, it is important to examine
these assumptions to determine how the education and knowledge shared in low resource
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22. environments and cultures might be interpreted and used more effectively. Gaining an
understanding of these influences may help to discover ways in which education may be
delivered alternatively to accommodate for these factors, potentially increasing its
effectiveness particularly in low resource settings.
Summary
Over four million infant deaths occur worldwide each year. Of these deaths, 99%
occur in low resource regions of the world and are predictably caused by preventable or
treatable conditions such as asphyxia. Although the developed world incorporates
evidence based interventions in infant resuscitation to avoid such deaths, these measures
are scarce in low resource environments. To determine the effectiveness of these
interventions in a low resource environment and to determine what role nurses can play
in the elimination of global infant morbidity and mortality related to these interventions, a
critical review of the literature is being done. Incorporating Pender’s Health Promotion
Model in the review will assist in evaluating the personal, psychological, socio-cultural,
interpersonal, and environmental influences present in low-resource countries that might
have a significant impact in these environments.
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23. CHAPTER TWO: METHODS
This chapter describes the databases, search engines, and methods that were used
to collect articles and research for the critical review of the literature. Included in this
chapter is discussion about the search strategies utilized to identify research studies,
criteria for including or excluding these studies, a summary of the number and types of
studies selected for review, and criteria for evaluating this research.
Criteria for Inclusion and Exclusion of Research Studies
All articles included in this literature review were written between 2001 and 2012.
Earlier articles may have been utilized for background knowledge and understanding of
the topic, but were not included in the matrix and review process. Multiple articles were
found that focused on staff ability to retain concepts learned from the Neonatal
Resuscitation Program (NRP) training in low resource countries, and put them into
practice. These were also excluded as only articles whose primary intent was to
determine how the resuscitation training of healthcare staff impacted the morbidity and
mortality outcomes of infants were included and reviewed.
Search and Review Process
To identify research articles for this synthesis, the review process began by
searching the following databases: Cumulative Index to Nursing and Allied Health
Literature (CINAHL and CINAHL Plus with full text), Cochrane Central Register of
Controlled Trials, PubMed/Medline, Google Scholar, ProQuest Nursing and Allied
Health Source Trial, Academic Search Premier, and ScienceDirect. Key search words
used to locate research articles focusing on my topic of interest were: NRP, developing
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24. world, newborn resuscitation training, neonatal resuscitation program, low resource,
newborn training, low income, neonatal training, developing country, newborn
resuscitation effectiveness, developing NRP, developing countries and neonatal
outcomes. Once the initial articles of research were identified, references at the end of
those articles were searched to identify other authors and research studies that were
related to the literature review topic.
Number and Types of Studies Selected
Initially, 46 journal articles were found addressing the topic of neonatal
resuscitation in low resource countries. However, upon close review of those articles, 23
had to be eliminated due to content or poor quality and strength of evidence. The John’s
Hopkins Evidence Appraisal (Newhouse, Dearholt, Poe, Pugh, & White, 2007) was
useful to help identify which articles did or did not meet sufficient criteria for use in the
review. This method of appraisal provided a systematic tool for examining elements such
as the design method, sample size, procedure quality, and use of valid and reliable
measures to determine the value of each study.
As strength and quality of the articles were examined, many were found to lack
content that addressed the impact of resuscitation education or training on infant
outcomes. Instead, some of the articles focused on the success and/or retention of
resuscitation education by the healthcare worker. Since this information was useful as a
resource but is not a main topic of the critical review, these articles were placed in the
additional reference section and were not a part of the critical review process.
The articles ultimately accepted for the review included randomized controlled
trials, prospective observational and cluster randomized controlled studies, pre and post
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25. intervention studies, data extraction research using statistical and meta-analysis to
summarize the data extracted, retrospective studies, and surveys between the years of
2001 and 2012. Commentary and opinion articles, as well as case studies, organizational
experiences, or clinical practice guidelines were eliminated due to potential bias that
would skew the overall results of this review. Most all of the articles accepted for this
review were written within the last seven years. However, due to limited studies and data
available from low-resource countries, one article that was written as early as 2001 was
also accepted.
Summary
This review used the most current data available from low resource environments.
Forty-six articles written from 2001 to 2012 were located by searching multiple large
data bases and using key terms. Content, quality, and strength of the evidence in each
article determined whether the literature was accepted or rejected for matrix review. The
John’s Hopkins Evidence Appraisal (Newhouse, Dearholt, Poe, Pugh, & White, 2007)
helped to identify articles that met sufficient criteria for quality and strength. While
efforts were made to find the highest quality data, research in low resource environments
was somewhat limited and only 23 articles were ultimately placed on the matrix and
accepted for critical review.
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26. CHAPTER 3: LITERATURE REVIEW AND ANALYSIS
This chapter will focus on a review and analysis of the current literature. It will
identify the major strengths and weaknesses of salient studies, as well as synthesize the
major findings in the data.
The Matrix
The Matrix Method process was used to help organize information obtained in the
literature reviewed (Garrard, 2011). This method assists in first identifying relevant
literature, then organizing and critically evaluating its value. In this review, this method
will also assist in synthesizing major new findings; making decisions about significant
factors, barriers, or obstacles; and helping to formulate strategies for advancing
knowledge and education of individuals assisting with births in low resource areas, in
order to facilitate improvements in infant outcomes.
This literature analysis organized 23 articles in the Matrix, listing them
alphabetically by author’s last name. Headings in the Matrix were used to identify the
author, article title, journal, year published, and purpose of the study, subject/sample size,
interventions, results/implications, and strengths/weaknesses of the study as shown in
Table 1. The Matrix also identified the strength and quality of each study using the John’s
Hopkins Nursing Evidence-Based Practice Research Appraisal (Newhouse et al., 2007)
and identified which articles used a train-the-trainer intervention, a method to train a core
of individuals first, and then pass the information to larger groups.
Major Findings
A review of the current evidence suggests that appropriate neonatal care provided
within the first few minutes of life can positively impact morbidity and mortality rates in
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27. developing countries (Carlo, Chomba, Goudar et al., 2010; Carlo, Chomba, McClure et
al., 2010; and Duran, Aladag, Vatansever, Acunas, & Sut, 2008). Singhal and Bhutta
(2008) found that the majority of neonatal morbidity and mortality occurs in these low
resource environments within the first moments of life. The most common two causes
were identified to be either birth asphyxia in the intrapartum period, or consequences
related to prematurity. Lesser major causes were identified as complications related to
low birth-weight and neonatal infection. Although many people perceive that
improvements to these causes of morbidity and mortality of infants can only be achieved
through high technology and expensive interventions, in fact, low cost, low technology
training, and interventions that promote prompt actions taken in the first moments after
birth can be enough to make dramatic improvements in infant outcomes (Manasyan et al.,
2011). The major findings of what successfully impacts infant outcomes however, may
be affected by various factors.
PHPM discusses that factors such as perceived barriers to action can interrupt the
successful promotion of health. The misperception that high technology is needed to
create significant changes in outcomes of infants is an example of an area that can be
impacted through education. By disseminating education and evidence that demonstrates
the impact of how low technology interventions can improve infant outcomes,
commitment to a plan of action to implement these changes is more likely to occur.
Identifying barriers to health promotion action and addressing the following additional
areas of impact, can increase the effectiveness of resuscitation education and assure that
positive infant outcomes are achieved.
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28. Training Effectiveness
In the United States, neonatal resuscitation training has significantly improved the
morbidity and mortality of infants requiring assistance to breathe at birth. Programs such
as the Neonatal Resuscitation Program (NRP), established in the 1970’s, quickly gained
popularity as it proved successful in saving many infant lives. Through the years, it has
been demonstrated to be an effective program for improving the knowledge and skills of
health professionals; thus promoting infant outcomes (Hole, Olmsted, Kiromera, &
Chamberlain, 2012). Today, many hospitals in this country have mandatory training for
their staff to assure that these evidence based guidelines are followed.
The NRP, established by the American Academy of Pediatrics and the American
Heart Association, has been a standard of care for the past decades, assisting staff to
prevent adverse outcomes of asphyxiated infants (Enweronu-Laryea, Engmann, Osafo, &
Bose, 2009). Although some low resource countries have had the opportunity to learn
programs such as this, infant outcomes in those countries have often remained poor after
the training. Those countries that have demonstrated effective interventions and
improvements in infant outcomes following training are primarily those that include
training individuals present at infant deliveries to perform simple actions. Some of these
actions include stimulating, drying, and providing initial ventilation support to the infant
(either by bag or mouth), which is likely beneficial since the majority of infants typically
require only this basic amount of support.
Predominantly, studies included in this review used only the initial basic steps of
resuscitation in their training. However, some did include the basic and advanced
training, while others did not specify which level of training was used. All were accepted
28
29. as long as the study designs and outcome measures were comparable. Interestingly,
advanced training in low resource environments overall were found to be minimally
beneficial as only a small percentage of infants (estimated to be less than 0.1 - 1%)
required advanced resuscitation including chest compressions, medications, or other
technology assistance (Lee et al., 2011). In addition, the benefits of these actions in low
resource environments have been found to be minimal and often unavailable (Lee et al.,
2011; Perlman & Risser, 1995; Zhu et al., 1997).
All of the studies by Carlo et al. (2010) also determined that the low cost
interventions included in basic neonatal resuscitation training appear to help reduce rates
of death attributable to the major causes of morbidity and mortality. These authors
suggested that the knowledge and ability of birth attendants to intervene with basic
resuscitation skills would enable them to effectively reduce the rates of morbidity and
mortality in the majority of cases. A similar study examining the value of basic
resuscitation used a systematic review, meta-analysis, and Delphi panel to determine the
impact of early neonatal intervention strategies taught in the neonatal resuscitation
techniques (Lee et al., 2011). The expert panel concluded that intrapartum related birth
asphyxia and preterm mortality could be reduced by approximately 10% through
immediate assessment and stimulation of the infant without equipment. The
corresponding meta-analysis suggested that in addition to that, another 30% of infants
would be spared mortality through neonatal resuscitation training in facilities (Lee et al.,
2011).
In communities where trained birth attendants or midwives deliver the infant in
the home, a 20% reduction in mortality of term infants related to birth asphyxia, and a 5%
29
30. reduction of deaths related to preterm deliveries was estimated (Lee et al., 2011). In these
cases, both birth weight and gestational age were shown to be high predictors of infant
survival and outcomes of infants less than 1500 grams were not improved with
resuscitative attempts (Carlo, Chomba, Goudar, Jehan, et al., 2010). This data is
summarized in Figure 3.
Approximate effect on asphyxia:
Immediate newborn assessment, drying, and stimulation: 10%
Basic neonatal resuscitation (facility): 30%
Basic neonatal resuscitation (community): 20 %
(*note that the resuscitation effect is in addition to immediate assessment, drying,
and stimulation)
Approximate effect on preterm birth:
Immediate newborn assessment, drying, and stimulation: 10%
Basic neonatal resuscitation (facility): 10%
Basic neonatal resuscitation (community): 5%
(*note that the resuscitation effect is in addition to immediate assessment, drying,
and stimulation)
*Quality of input evidence very low: based on Delphi
Figure 3. Mortality Impact of Resuscitation Interventions on Birth Asphyxia and Preterm
Birth. Adapted from Lee, A.C., Cousens, S., Wall, S.N., Niermeyer, S., Darmstadt, G.L.,
Carlo, W.A…. Lawn, J. E. (2011). Neonatal resuscitation and immediate newborn assessment
and stimulation for the prevention of neonatal deaths: A systematic review, meta-analysis and
Delphi estimation of mortality effect. BMC Public Health, 11.
The concepts of PHPM address support for the basic steps of education in
neonatal resuscitation as a first step to promote health. Since these simple steps are most
often all that is needed to improve the morbidity and mortality of most infants, education
that increases the perception of benefit and decreases the perception of a barrier for
improving outcomes, would promote use of the steps. As individuals in low resource
environments learn these simple actions and then witness positive outcomes, commitment
30
31. to incorporating them into their practice would advance. These basic skills would also
promote individual success and positive self-efficacy, as learners are able to gain
competence and success through these simple interventions. Health for infants would be
promoted as changes in resuscitation practices are advanced.
Impact on Prematurity
Although the outcomes of term infants were significantly improved when
resuscitation techniques were implemented, outcomes of premature infants had much less
impact. Premature infant rates of asphyxia were reduced, but overall death rates were not
impacted as there was no advanced care available following the initial resuscitation. This
is believed to be due to the lack of treatments available in low resource environments
such as steroids, surfactant, continuous positive airway pressure (CPAP) support, or
ongoing necessary mechanical ventilation support (Carlo, Chomba, Goudar, Jehan, et al.,
2010). Without these advanced treatments and interventions, the ability to maintain a
resuscitated surviving premature infant who is initially saved through resuscitation
techniques, will be limited long term. However, for late preterm infants who required
only initial support but did not require ongoing assistance with ventilation, morbidity
rates were found to be closer to a 10% improvement when their only requirement for
assistance included initial ventilation support (Lee et al., 2011).
Combined Educational Programs
The initial intent of this review was to look solely at the impact of neonatal
resuscitation training interventions. However, over half of the studies included in the
review used training interventions that combined specific neonatal resuscitation
techniques with other, more comprehensive programs. The WHO’s Essentials of
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32. Newborn Care (ENC) training package was the most common one identified in this
review, and was used in at least six of the studies (all studies by Carlo et al., 2010; Lee et
al., 2011; Manasyan et al., 2011; Matendo et al., 2011). This training, along with the
initial steps included in the Neonatal Resuscitation Program (NRP) training, provided a
bundled package that was often found to be both cost and outcome effective, but
sometimes made it difficult to distinguish which interventions had the largest impact.
The ENC package includes basic resuscitation techniques as well as training on
such things as universal precautions, prevention of hypothermia, early and exclusive
breastfeeding, kangaroo care (holding the infant skin-to-skin; typically on the parent’s
chest), and danger signs for early recognition and management of common illnesses in
the newborn (Manasyan et al.). A study by Matendo et al. (2011) found that when ENC
training and impact data collection was instituted first and followed by NRP training and
data collection, there was no significant decreases noted in infant morbidity or mortality
following the NRP training. However, this may be explained by the fact that the ENC
program includes the very basic steps of neonatal resuscitation, which is the limitation for
these low resource environments. More detailed NRP interventions cannot be maintained
or adequately incorporated to make an impact beyond the basic resuscitation techniques
included in the ENC program. Carlo, Goudar, Jehan, Chomba, Tshefu, Garces, Parida,
Althabe, McClure, Derman, Goldenberg, Bose, Krebs, et al., (2010), analyzed the results
of a packaged training that included both ENC and the NRP, and with statistical
correction for infants lost in follow-up monitoring, demonstrated that the specific steps of
NRP training was indeed responsible for a reduction in the 7 day neonatal mortality rates.
32
33. Although intrapartum and postnatal packages for infant care were found to have a
significant impact on morbidity and mortality improvements (Manasyan et al., 2011),
studies that incorporated resuscitation and elements of the ENC along with bundled
training that included safe mother care and child survival training, favorably and
significantly increased the morbidity and mortality outcomes beyond training with a
single program. This dual benefit was found in large part to be due to the fact that the
maternal morbidity and mortality is closely linked with the related infant’s morbidity and
mortality (Bhutta, Darmstadt, Hasan & Haws, 2005).
Globally, sub-Saharan Africa and South-Central Asia record the highest infant
mortality rates (Chombra et al., 2008). However, national level newborn survival
programs in these regions exist in only 20 to 27 (or approximately 74%) of these
developing countries (Lawn, Cousens, & Zupan, 2005). Considering the vast number of
infants impacted in this area, one study estimated that by equipping hospitals in sub-
Saharan Africa alone with the knowledge to provide basic services during childbirth
(including resuscitation), more than 93,000 newborn lives may be saved each year (Wall
et al., 2010). Another study, which included over 40,000 infants, found that specific
training of midwives to perform the ENC interventions (including resuscitation),
demonstrated that all-cause 7 day mortality rates could be decreased from 11.5 per 1000
to 6.8 per 1000. When separated out, the impact on asphyxia related morbidity was
decreased from 3.4 to 1.9 per 1000 and infection mortality was reduced from 2.1 to 1.0
per 1000 (Manasyan et al., 2011).
Although these combined programs had many positive impacts, outcome data was
sometimes left unclear when training programs were introduced as a package. Packaged
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34. training that incorporated ENC elements along with elements of basic and/or advanced
NRP sometimes resulted in difficulty establishing which intervention impacted the actual
outcomes: that of simple resuscitation training or a combination of resuscitation and other
information (Carlo, Goudar, Jehan, Chomba, Tshefu, Garces, Parida, Althabe, McClure,
Derman, Goldenberg, Bose, Krebs, et al., 2010).
Impact of Health Systems
Despite the many studies that demonstrated improvements in morbidity of infants
following NRP or combination training, a study by Wall et al. (2009) that collected data
from six African countries, showed that between 72-93% of birth attendants had no
resuscitation training, and 53-84% of facilities in those countries were missing basic
resuscitation equipment. This included equipment used for implementing basic
ventilation support, such as a bag and mask. Deorari, Paul & Vidyasagar (2001) also
found that facilities in sixteen developed or developing countries lacked basic
resuscitation equipment, had equipment that was in poor condition, and/or employed
health professionals that did not have any proper training in neonatal resuscitation. These
health systems, handicapped by a lack of resources, are also often negatively impacted by
bureaucracy, corruption, and/or a lack of financial infrastructure. Together, these factors
all contribute to the high rates of morbidity and mortality among the low resource and
underdeveloped nations (Haws et al., 2007; Manasyan et al., 2011).
Strengthening of these health systems takes funding, leadership, and long-term
investment; elements that are often missing in low resource environments. When
opportunities for effective programs such as the ENC and NRP are available, crippled
health systems often cannot get the programs to the staff that needs them. When they did,
34
35. these effective training opportunities were often found to be intermittent, and lacking in
quality, long-term objectives, and resources. They also often have logistical restraints due
to poor leadership and weak systems infrastructure which did not support long-term
sustainability.
PHPM supports the belief that persons are more likely to commit to a change in
health promoting behavior when it is modeled. Commitment also increases when
behaviors are expected by significant others (such as healthcare leaders), and when they
are given the assistance and support to enable that behavior change (Pender, Murdaugh &
Parsons, 2002). Therefore, in order to increase and sustain valuable resuscitation training
and practices, leadership infrastructure and education must also be strengthened in these
environments.
Reaching Infants in the Home and Community
When training and supplies do reach hospitals and health facilities in low resource
regions, they can typically serve more than half of the infants that are born in low-
resource, developing environments. However, approximately 32% of births that occur in
countries such as Africa are estimated to be born in the home. Once again, this reality
creates missed opportunities to impact large numbers of infant lives. Many of these births
in regions such as Africa, are either not attended, or are attended by untrained family
members (Lawn, Cousens, Zupan, & Lancet neonatal Survival Steering Team, 2005). In
rural, poverty stricken areas such as the Democratic Republic of the Congo, three fourths
of the births are in the home and attended by either a total birth attendant (TBA) or
family member only. These individuals often lack any type of formal resuscitation
training (Matendo et al., 2011).
35
36. Therefore, in these remote areas, training birth attendants, village health workers,
families, and community individuals how to perform the simple steps of drying,
warming, and skin-to-skin care also has the potential to reduce infant mortality. Lee et al.
(2011) believed that these interventions would have a limited impact on infant morbidity
and mortality. However, two other studies opposed this assumption, and determined that
the training that could be effective for reducing mortality and morbidity in infants was
low cost, and involved minimal time, making it a feasible intervention to improve infant
outcomes in those remote regions (Bang, Bang, Baitule, Reddy, & Deshmukh, 2005; Gill
et. al., 2011).
The data in the studies of Bang et al. (2005) and Gill et al., (2011) focused
specifically on the impact of minimally trained birth attendants, or Village Health
Workers (VHW), in the steps of basic infant resuscitation. These individuals were then
responsible for attending the deliveries of infants in the homes of remote villages; areas
lacking access to health care mainly due to location and the inability to travel at time of
delivery. The studies demonstrated a 65% and 67% reduction (respectively), in neonatal
morbidity following the training. This significant reduction shows evidence of the
effectiveness of training lay workers to reduce mortality rates outside of the hospital
setting.
Strengths of Salient Studies
The studies that had the most salient data in this review according to the John’s
Hopkins Nursing Evidence Appraisal (Newhouse et al., 2011), were those that included
data from multiple countries, were population-based, and/or used birth registries to
capture 90-100% of all births (Bang, Bang, Baitule, Reddy, & Deshmukh, 2005; Carlo,
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37. Chomba, McClure, et al., 2010; Carlo, Chomba, Goudar, Kodkany, et al., 2010; Carlo,
Goudar, Jehan et al., 2010; Gill et. al., 2011; Matendo et al., 2011). These studies
typically had a large sample size that improved the strength and quality of the evidence
(Newhouse et al., 2007). In addition, rates of participation for both staff and those
mothers who were delivering were high, as was the consent and participation of follow-
up for those studies that did seven day follow-up or more. Rigorous training was typically
present in these studies using master instructors and/or local trainers to teach birth
attendants. These factors also added strength to the data.
Weaknesses of Salient Studies
There were some common areas of weaknesses found in many of the studies
included in this literature review; including those with salient results. One area of
weakness involved data that was frequently found to be missing or lacking verifiable
accuracy. High quality data from well designed studies in low resource countries was
frequently limited, and data collection was noted to be difficult due to environmental
factors and lack of system organization or resources.
Data corruption and bias created weaknesses in many of the studies (Carlo,
Chomba, McClure, et al., 2010; Gill et al., 2011; Hole, Olmsted, Kiromera, &
Chamberlain, 2012; Opiyo et al., 2008; Pattinson, 2003). At least two studies identified
potential bias noting that the data had been collected (though closely supervised) by the
birth attendants who implemented the interventions (Carlo, Chomba, Goudar, Kodkany,
et al., 2010; Matendo et al., 2011). Difficulties in the collection process due to
technology, logistics, and follow-through, were also common in low resource
environments where opportunities and environments are harsh. Although collecting data
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38. in some communities was shown to be an effective way of involving communities and
increasing recognition of asphyxia, Opiyo and English (2010), found that even with this
knowledge, long term data collection that established clear outcome effects was limited
and difficult to acquire.
Currently, the largest barrier for collecting data about the impact and effectiveness
of infant resuscitation in low resource environments was the confusion and
inconsistencies among health care workers and birth attendants in these regions about
how to recognize and assess for asphyxia of infants (Lawn et al., 2007). More precise
definitions of asphyxia, as well as indicators for recognizing it, are needed so that the
risks and incidences of asphyxia can be noticed, and programs developed to address the
issue. This inability to define and identify asphyxia is especially difficult in the low
resource areas where many infants are born at home and where stillbirths are prevalent
and difficult to distinguish from early neonatal deaths (Lee et al., 2011).
Lawn et al. (2007) discussed that while 82% of individuals from industrialized
countries found asphyxia to be an important cause of morbidity and mortality in infants,
only 64% of individuals from developing countries believed that to be true. In addition,
this study also found that while 93% of policy makers in low resource countries identified
asphyxia as a major health problem, only 52% of community-based program personnel
had that same perception. This discrepancy is most likely explained by the fact that these
policy makers have better access to data informing them of the evidence for
complications. This statistic also provides evidence supported in PHPM, that information
and knowledge must be shared with communities so that change in perceptions,
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39. perceived benefit, and motivation and commitment to health promoting behaviors in
infant care can occur (Pender, Murdaugh & Parsons, 2002).
Although the question of personal perception about asphyxia is generally
subjective, the viewpoint associated with it is closely linked to belief in the larger
community of the importance for the need for intervention, training, and program
development; thereby giving the data greater importance. Though many low resource
communities did not recognize the vast impact of asphyxia as it related to the high
number of infant deaths and morbidity, people in sub-Saharan Africa surprisingly did
recognize it as being a major cause of neonatal death. In that region, respondents who
considered asphyxia as “very important” also generally were more involved in programs
designed to address and reduce its incidence (Lawn et al., 2005). Education must improve
in order to bring awareness to the cause of infant morbidity and mortality. Increased
awareness improves support and motivation, which in turn increases the knowledge of
specific measures that can be taken to prevent infant deaths.
Summary
The available literature has been reviewed using the Matrix Method by Garrard
(2011). As much as possible, the intent was to look for the most recent research to review
current literature with strong evidence and accuracy. However, obtaining strong research
evidence was somewhat difficult to obtain due to the limited or poor quality data
recorded from low-resource countries. There were also limitations in the accuracy and/or
quality of the data that was recorded in those environments. Therefore, although the John
Hopkins Evidence Appraisal methodology was incorporated to identify levels of evidence
39
40. quality and strength, the quality and strength available in the research data may be
somewhat decreased or compromised due to these limitations.
The Matrix Method (Garrard, 2011) assisted in the evaluation of the articles with
a structured abstract form, using topic headings that summarized pertinent research data.
All papers were listed in alphabetical order according to the author’s last name.
Current research described many factors that affect the impact of resuscitation
training on neonatal outcomes in low resource environments including limitations in
resources, understanding of asphyxia, and limitations on research and quality data. While
many of the studies demonstrated at least some improvement in either morbidity or
mortality of infants following basic resuscitation training of birth attendants in these
environments, there is still much research and data to be completed before the degree of
impact becomes clear.
40
