Globally, approximately 4 million deaths occur in neonates with 99 percent of them occurring in low and middle income countries [
The majority of the neonatal deaths (75 percent) occur in the first week of life, with approximately half of these occurring within the first 24 hours after birth [
Effective NR could prevent neonatal deaths by 30 percent as well as improve the outcomes of newborns delivered with birth asphyxia [
In Kenya, neonatal mortality rate is still high, currently at 22 per 1000 live births [
Early childhood mortality trends in Kenya.
Birth asphyxia remains the leading cause of neonatal mortality in Kenya at 29 percent [
Measures of quality focus on the structure, process, and outcomes [
Despite HCPs’ preservice and in-service training, guidelines, and job aids with adequate equipment, practices of HCPs with regard to NR are still reported to be poor [
This was a cross-sectional study employing direct observations of NR in labor ward and maternity theatre. This method is nonintrusive, where the HCPs do what they normally do (resuscitation) without being interrupted or disturbed by the observer [
The study was conducted between April and June 2016 at Kakamega County General Hospital’s (in Kakamega County, Western Province) labor ward and maternity theatre. However, the newborn unit was excluded as newborns are only referred here after stabilizing from the initial resuscitation done in labor ward or maternity theatre immediately after delivery. This is the main government referral facility in the Western Kenya region also serving as a training centre for trainee nurses and other healthcare professionals. Therefore, it was the ideal location to assess the quality of care during NR as it is a place where there is a high demand for NR and therefore need for updated and evidence-based practices among health care workers.
Twenty-eight HCPs who conducted NRs who met the inclusion criteria and voluntarily consented to participate in the study were recruited. The HCPs must have been working in the labor ward and/or the maternity theatre and providing direct NR services. Trainee nursing and medical students were excluded (unlicensed to practice).
Based on the WHO and the American Academy of Paediatrics, newborns who met the inclusion criteria were recruited [
All HCPs who were involved in resuscitating a newborn and consented to participate in the study were included. Consecutive sampling was used to select all the newborns that required NR immediately after birth and met the inclusion criteria until the required sample size was achieved.
It is estimated that about 1 in 10 babies needs help to breathe immediately after birth and, therefore, a quick assessment immediately after birth remains the best way to know if a baby needs help to breathe [
All NRs were performed at a central common resuscitaire serving both the labor ward and theatre. Four research assistants (RAs) were recruited and observed the NRs for both day and night shifts. The RAs were recruited from among the hospital nurses from the antenatal ward to minimize the Hawthorne effect. This was on the assumption that the HCPs were less likely to change their practices when being observed by another HCP in the same unit as opposed to an observer from outside the hospital. The RAs were nurses with experience and formal NR training. Thus, they were not given any formal NR training by the principal researcher. However, they were given a two-day overview on Helping Babies Breath and the national NR guidelines principles that were utilized in observing the resuscitations against a predetermined checklist. Two practical observations were done with the principal researcher to ensure that all the RAs used the checklist in a similar manner.
HCPs were sensitized on the study and its significance with emphasis on entirely voluntary participation. However, due to different working shifts, most of the HCPs had to be approached on an individual basis by the RAs when they were on duty. Upon agreeing to participate in the study, the HCP was assigned with a participant study code (to protect the HCP’s identity) and requested to complete a written consent form. The HCP was also requested to complete the structured observation checklist on the biodata form including information on training and qualifications, working experience, and refresher training attended by the research assistant. Importantly, HCPs were sensitized once of the researcher’s intent to observe the actual resuscitation during the consent process without subsequent reminders during the actual procedure.
Research assistants were briefed and advised to watch out for any inappropriate/harmful practices during NR. These included holding the neonate upside down, shaking the neonate vigorously, hard patting/slapping of neonate on back, flicking foot of the neonate, vigorously wiping neonate, and squeezing chest of neonate.
An RA was present every time a delivery was being conducted either in theatre or delivery room since NR is a rapid process that required the availability of the study team member at any time. In case of two resuscitations occurring at the same time, the observer proceeded with the delivery that began first. However, this situation only occurred twice. The observer strategically positioned herself near the resuscitaire in order to have a clear view of the resuscitation process from the start to end.
Initial data was collected about the availability, functionality, and accessibility of the essential NR equipment at the resuscitaire. Once a newborn was delivered, the observer included the resuscitation only if two criteria were fulfilled. First, the HCP receiving the newborn had consented to participate in the study and the newborn delivered required resuscitation (met the eligibility criteria). The RA, utilizing a predetermined checklist, observed the actual NR as conducted by the HCP on the ward to assess the skills of the HCP under observation. Importantly, national and international guidelines on NR recommend that a HCP should call for help when urgent need to save the life of newborn arises [
A structured direct observation checklist was used. It was sectioned to include the structural characteristics, health facility and the HCP characteristics; the processes, NR process with items based on the principle areas of the NR process as per the national guidelines, preparation for resuscitation, drying/stimulation, airway clearance and maintenance, and bag and mask ventilation (and advanced care/support ventilation) adapted from the Ministry of Health (Kenya), Basic Pediatrics Protocols for ages up to 5 years, Revised, July 2013 Edition [
Data collection tools were pretested at the labor ward of old Mulago National & Referral Hospital, Uganda, to maintain their reliability and validity. Random supervisory visits by principal researcher were conducted to ensure that observations were being carried out and checklists were being filled in on site. Regarding areas of uncertainty in the checklist and, in cases where the principal researcher noted any errors in terms of data collection, the error was brought to the attention of the RAs and corrected immediately. At the end of the shifts, forms and checklists were checked by the principal researcher/RA for completeness and errors before leaving the study area/site. The data collected was kept strictly confidential.
The primary outcome was quality of care during NR. It was measured as a continuous variable constructed as a composite variable from the total of 13 step items based on the 4 principle areas of NR process. They were drying/stimulation [three items], checking airway [three items], initial bag and mask ventilation [two items], and advanced bag and mask ventilation [five items] (Table
Raw data was entered in Microsoft Office Excel 2013 software. Data was cleaned, edited to identify any missing values or any other inconsistencies, and exported to STATA version 13 for analysis. The unit of analysis was the resuscitated newborn. All the data from HCPs who had 3–5 observations was analysed. This was a representative and appropriate comparison that eliminated the early initial fears of the HCP of being observed during the practice [
A binary score of yes (performed) and no (not performed) was used for all the 13 process variables based on the four principle areas of NR. The variables in each of the four principle areas (indicators of quality) of assessing quality ultimately defined quality of care. Responses from the nominal scale were scored as 1 (for yes) or 0 (for no). Higher scores of responses reflected higher quality for the nominal scale. For process indicators, descriptive statistics were summarized using the mean and standard deviation.
QoC was assessed in detail by analysing performance at each of the four principle steps of resuscitation. QoC was classified as good (if all the recommended steps performed), fair (half the recommended steps performed), and poor (majority of the recommended steps missed).
For each of the four principle steps, we summed the scores of a given HCP for the different steps under that principle step. A new variable was generated to represent a total score of a HCP who attended to a specific neonate for all the specific steps under the principle steps that the neonate received. The new generated variable was used as a measure of quality of care received by the neonate. The score generated was categorized as good, fair, or poor quality. Because of variations in the steps under each of the four principle areas, a specific scoring system for each principle area was adopted. For drying/stimulation and airway clearance (0–3), quality of care was categorized as good if all the three steps, fair if two steps, and poor if one or none of the steps under principle area was performed. For initial bag and mask ventilation (0–2), quality of care was either good if all two steps or poor if one or none of the steps was performed. For advanced/supportive bag and mask ventilation (0–5), quality of care was either good if four or all five steps, fair if three, or poor if only two or less steps were performed. It is important to note that neonates who did not respond to care in the initial steps during resuscitation proceeded to the subsequent levels of resuscitation. Therefore, the quality of care was computed for each of the four principle steps as the number of neonates kept reducing from one level of care to the next.
Descriptive statistics of HCPs’ characteristics using frequencies and percentages were computed. Since the dependent variable (quality of care) was ordered, the ordered logistic regression model was used to compare the QoC scores with the HCPs characteristics. This was carried out for each of the four specific principle areas of resuscitation applied. Chest compressions assessment was not analysed in this study as the decision to initiate chest compressions depends on variables not easily determined by the observer and very few resuscitations require chest compressions [
The study protocols were approved by the Makerere University, School of Health Sciences Institutional Review Board (IRB) [SHSREC REF: 2015 – 028], Moi University/Moi Teaching and Referral Hospital (MTRH) Institutional Research and Ethics Committee (IREC) [FAN: IREC 1608], and the Kakamega County General Hospital Ethics and Research Committee [ERC no. 9/04/2016].
Informed written consent was obtained from the HCPs prior to enrolment to participate in the study. There was apprehension on the side of HCPs on repercussions in case of identification of incorrect practices or poor skills. However, they were assured that the records would not bear any identification apart from the study code. In addition, there was strict observation of confidentiality at all levels of the study. To avoid change in practices and alteration of results, HCPs noted to have poor skills were given confidential individual feedback at the end of the 3–5 rounds of observations to protect the interests of the newborns.
The mean age of HCPs was 32.8 years (SD ± 7.0) with a range of 24 years to 50 years. Majority of HCPs (89.3%) were aged 25 years and above. Nurses/midwives were the majority cadre (71.4%) providing newborn resuscitation. Over half of HCPs (53.6%) providing newborn resuscitation care were registered diploma holders. Two-thirds of nurses/midwives (65%) were registered diploma holders and one-third (35%) were bachelor degree (graduate) nurses. Most of the HCPs (89.3%) had worked in the maternity ward providing NR care for more than a year. Eighteen HCPs (64.3%) reported ever attending a formal NR training. These training courses included Helping Babies Breathe (
Background characteristics of HCPs with the distribution of newborns resuscitated at KCGH.
HCP characteristics | Frequency |
Percentage (%) | Newborns resuscitated |
Percentage (%) |
---|---|---|---|---|
|
||||
<25 years | 3 | 10.7 | 15 | 10.9 |
>25–50 years | 25 | 89.3 | 123 | 89.1 |
|
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Male | 8 | 28.6 | 38 | 27.5 |
Female | 20 | 71.4 | 100 | 72.5 |
|
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Nurses/midwives | 20 | 71.4 | 100 | 72.5 |
Medical officers | 4 | 14.3 | 20 | 14.5 |
Anaesthetists | 3 | 10.7 | 13 | 9.4 |
Clinical officers | 1 | 3.6 | 5 | 3.6 |
|
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Diploma | 15 | 53.6 | 73 | 52.9 |
Bachelor degree | 13 | 46.4 | 65 | 47.1 |
|
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Yes | 18 | 64.3 | 88 | 63.8 |
No | 10 | 35.7 | 50 | 36.2 |
|
|
|||
<6 months | 6 | 33.3 | 30 | 34.1 |
≥Over 12 months | 12 | 66.7 | 58 | 65.9 |
|
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Yes | 25 | 89.3 | 123 | 89.1 |
No | 3 | 10.7 | 15 | 10.9 |
|
|
|||
Past 6 months | 9 | 36.0 | 45 | 32.6 |
>6–12 months | 6 | 24.0 | 30 | 21.7 |
>12 months | 10 | 40.0 | 48 | 34.8 |
|
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<1 year | 3 | 10.7 | 15 | 10.9 |
>1 year–5 years | 17 | 60.7 | 83 | 60.1 |
≥5 years | 8 | 28.6 | 40 | 29.0 |
Importantly, all the HCPs who participated in the study had at least undergone either a formal NR training or received the initial routine orientation offered to new staffs joining the maternity unit on a number of emergency obstetrics and neonatal care skills, for example, basic neonatal resuscitation, manual removal of the placenta, and maternal resuscitation at the hospital.
Nurses provided NR for the majority of the newborn babies (72.5%). Diploma holder HCPs cared for over half of the newborn babies (52.9%). Healthcare providers who had undergone a NR training cared for the majority of the newborn babies (63.8%); however the training mostly occurred over a year ago prior to this study (65.9%). Importantly, HCPs who had worked for less than a year in the unit cared for the least (10.9%) whereas those with over 1-year experience in maternity cared for the remainder (89.1%) (Table
Helping Babies Breathe (HBB) NR action plans and guidelines were displayed at the resuscitation area. No immediate newborn care and warm chain charts were observed in the unit.
Most of the NR equipment, two resuscitaires equipped with electric warmers; oxygen source (two oxygen cylinders, oxygen flow meters, and oxygen tubing); suction devices (electric suction machine and coloured suction bulbs); ambu bags; preterm and term face masks; and a wall clock were available, functional, and accessible at the resuscitation station. However, only one clean dry towel was present in each delivery pack.
Almost all resuscitation cases (
Overall mean scores indicated that airway clearance for baby with no breathing after stimulation at birth was the most commonly performed principle NR step (mean score 0.80, SD ± 0.33) while bag and mask ventilation was the least (mean 0.74, SD ± 0.38) performed (Figure
Mean scores for the main steps in neonatal resuscitation at KCGH.
Nurses were the commonly identified helpers before the resuscitation with over half (
A few inappropriate stimulation practices observed during the resuscitations included vigorously rubbing the baby’s back and chest (
Less than half (
Chest compressions with effective breaths were performed for 20 (83.3%) newborns who had poor or no breathing with a low heart rate (less than 60 beats per minute) after improved BMV. One effective breath for every three chest compressions for a minute was administered. Airway, breathing, and heart rate were reassessed every 1-2 minutes during this cardiopulmonary resuscitation. Compressions were stopped after establishment of an improved heart rate (increased pulsation or more than 60 beats per minute) and breathing was supported by providing supplemental oxygen. Twenty-one (87.5%) of the newborns required and were commenced on supplemental oxygen through the nasal catheters after both BMV and chest compressions as per the national guidelines (Table
Performance mean scores for each of the neonatal resuscitation steps.
Step in NR | Observations | Mean score (0-1) | SD (±) |
---|---|---|---|
Preparation for resuscitation | |||
Preparation for resuscitation area | 138 | 0.88 | 0.32 |
Check NR equipment availability | 138 | 0.88 | 0.33 |
Check NR equipment functioning | 138 | 0.88 | 0.33 |
Identify a helper | 138 | 0.52 | 0.5 |
|
|
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Drying/stimulation |
|||
Baby dried thoroughly by gently rubbing the back | 138 | 0.88 | 0.32 |
Wet cloth removed | 138 | 0.69 | 0.46 |
Baby kept warm | 138 | 0.71 | 0.46 |
|
|
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Airway clearance |
|||
Looked into airway | 123 | 0.98 | 0.13 |
If meconium, suctioning done before stimulation | 57 | 0.4 | 0.49 |
Airway cleared with suction bulb if unresponsive | 123 | 1 | 0 |
Baby’s head in neutral position | 123 | 0.83 | 0.38 |
|
|
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Bag and mask ventilation for |
|||
|
|||
|
66 | 1.00 | 0.00 |
|
66 | 0.55 | 0.5 |
|
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HCP call for help | 30 | 0.87 | 0.35 |
Correct mask size used during BMV | 30 | 0.83 | 0.37 |
Chest movements observed with each ventilation | 30 | 0.63 | 0.49 |
BMV rate within 30–50 breaths/minute | 30 | 0.60 | 0.50 |
Baby’s HR checked at 1 min | 30 | 0.73 | 0.45 |
|
|
||
Advanced |
|||
Effective breath with chest compressions | 24 | 0.83 | 0.38 |
Supportive oxygen | 24 | 0.88 | 0.34 |
|
|
Ordered logistic regression of the QoC scores with HCPs’ characteristics.
HCP characteristics |
|
|
95% CI |
---|---|---|---|
Drying/stimulation | |||
Professional cadre | |||
Doctors (ref) | |||
Nurses | 0.81 | 0.203 | −0.438–2.065 |
C/Officer |
|
0.521 | −3.904–1.977 |
Anesthetists | 1.51 | 0.127 | −0.429–3.451 |
NR training | |||
No (ref) | |||
Yes | 0.325 | 0.555 | −0.755–1.404 |
Maternity experience | |||
<1 year (ref) | |||
1–5 years | 1.860 |
|
0.626–3.093 |
>5 years | 1.566 |
|
−0.087–3.219 |
Support supervision | |||
No (ref) | |||
Yes |
|
0.123 | −4.018–0.480 |
|
|||
Airway maintenance | |||
Professional cadre | |||
Doctors (ref) | |||
Nurses | |
0.568 | −3.071–1.685 |
C/Officer | 0.347 | 1.000 | −18953–18954 |
Anesthetists | 16.135 | 0.997 | −9029–9061 |
NR training | |||
No (ref) | |||
Yes | 0.492 | 0.525 | −1.027–2.012 |
Maternity experience | |||
<1 year (ref) | |||
1–5 years | 1.887 |
|
0.469–3.305 |
>5 years | 2.493 |
|
0.127–4.859 |
Support supervision | |||
No (ref) | |||
Yes | −16.199 | 0.997 | −10014–9982 |
|
|||
Initial BMV | |||
Professional cadre | |||
Doctors (ref) | |||
Nurses |
|
|
−4.732–0.056 |
C/Officer |
|
0.990 | −3173–3134 |
Anesthetists |
|
0.100 | −6.163–0.541 |
NR training | |||
No (ref) | |||
Yes |
|
0.742 | −1.797–1.280 |
Maternity experience | |||
<1 year (ref) | |||
1–5 years | 0.341 | 0.681 | −1.283–1.964 |
>5 years | 0.221 | 0.852 | −2.105–2.546 |
Support supervision | |||
No (ref) | |||
Yes |
|
0.992 | −3170–3137 |
|
|||
Advanced BMV | |||
Professional cadre | |||
Doctors (ref) | |||
Nurses |
|
0.997 | −7047–7016 |
C/Officer |
|
1.000 | −14917–14917 |
NR training | |||
No (ref) | |||
Yes | 1.956 | 0.148 | −0.694–4.606 |
Maternity experience | |||
<1 year (ref) | |||
1–5 years | 0.992 | 0.434 | −1.492–3.477 |
>5 years |
|
0.377 | −5.097–1.928 |
Support supervision | |||
No (ref) | |||
Yes |
|
1.000 | −11121–11116 |
Overall, the QoC scores were high (good) for airway clearance (83%), fair for drying/stimulation & advanced BMV (60%), and poor for the initial BMV commencement within the Golden minute (45%). For those who did not establish breathing after initial BMV, all the recommended five steps were performed in over half (60%) of the newborns (Figure
Quality of care scores for the 4 principle steps in neonatal resuscitation. BMV: bag and mask ventilation.
Ordered logistic regression illustrated that HCPs with 1–5 years maternity experience providing NR services (drying/stimulation) of good quality was almost twice more than for HCPs with less than a year maternity experience when the other variables in the model were held constant (
Newborn resuscitation is an essential skill that all HCPs involved in the delivery process must have. The basic essential NR equipment for provision of newborn warmth, airway maintenance, and ventilation was available, accessible, and functional at the resuscitation station. At least two sets of equipment were available in case of multiple births, or for other births occurring at the same time, or in case one set does not function as recommended [
Years worked in maternity were shown to be associated with good quality scores for drying and airway maintenance and positioning during NR. With longer periods of practice within the high risk referral hospital in the same maternity unit, the HCPs clinically practice and enhance their self-efficacy and competence in NR skills with improved neonatal outcomes [
Ironically, our findings show no statistically significant association between the HCPs’ previous NR training and quality of NR care at the key principle resuscitation steps. Besides, completion of resuscitation training does not imply that an individual is competent to perform NR as demonstrated by the American Heart Association (AHA) neonatal resuscitation programme (NRP) [
Cleaning and decontamination of NR equipment skills/practices were good among the HCPs. Adequate infection prevention supplies for NR would prevent infections among resuscitated neonates due to their immature immunity [
HCPs performed strongly during the preparation for resuscitation steps to ensure that the newborns at risk receive the emergency attention immediately without delays after delivery. However, identifying a helper before the resuscitation commences was below expectations indicating that there is a weakness among HCPs in recognizing that every baby is at risk of birth asphyxia as recommended [
Keeping the newborns warm was a key missing step in early neonatal care among a good number of newborns. It was surprising that some HCPs forget to remove the wet cloth used for drying the newborn. This predisposes the newborns to heat loss through convection leading to hypothermia [
Checking the airway for secretions and clearance of obstructive secretions for babies who fail to initiate spontaneous breathing after drying was done for almost all newborns who did not respond after drying as recommended [
Inappropriate positioning of the baby’s airway, turning baby upside down, and hyperextending the jaw were observed in a considerable number of newborns. These harmful practices have also been reported in previous studies conducted in the country [
Bag and mask ventilation was initiated for all newborns who did not establish breathing after drying and airway clearance (with secretions). This shows that HCPs clearly recognize the indication for bag and ventilation in newborns without or gasping respirations as recommended [
This study conspicuously revealed that nurses/midwives (whether diploma or degree holders) who provide the majority of the primary NR were poor (delayed initiating BMV; ventilation rate not within the recommended 30–50 breaths/minute; inconsistent monitoring of the heart rate; BMV provided ineffective as more babies required reevaluation and reapplication of the bag and mask to achieve ventilation) in initial BMV NR skill compared to the doctors (
Most HCPs called for help from other colleagues in the unit in cases of failed initial BMV. This is an important step in the collaborative management in a hospital. Calling for help from more experienced colleagues and other cadres trained in NR helps increases the likelihood of survival of the neonate. This help could include assistance with BMV, airway maintenance, and checking of heart rate that determines the continuation or stoppage of the NR [
This study further demonstrated an existing gap in knowledge and skill on the rate of bag and mask ventilation and the implication of observable chest rise with each ventilation as recommended [
Encouragingly, many newborns with poor or gasping breathing after unsatisfactory BMV were provided with chest compressions and/or supplemental oxygen. This indicates that HCPs understand the importance of the priority of giving adequate ventilation by bag and mask before commencing on chest compressions and/or supplemental oxygen. Importantly, if ventilation is performed correctly, chest compressions are rarely indicated (1 in 1000) [
Therefore, clearly to improve the quality of care provided during NR, efforts must address both the healthcare providers and the health facilities.
Conducting direct observations allowed us to see what HCPs exactly do rather than relying on what they say they did. Secondly, conducting multiple observations (3–5) allowed us to eliminate possible anxiety that could be associated with direct observations on the part of the HCP being observed and give a true representation of the HCP. Using research assistants from the same maternity unit helped us to minimize the expected Hawthorn’ effect with direct observations.
There was a risk of the observer to feel compelled to assist during the resuscitation and bias since the research assistants were recruited from the antenatal ward of the hospital. This was minimized by training of the RAs to understand the study procedures and supervision. The HCPs knew why the researchers were there. As a result, a change in behaviour due to the researchers’ presence was anticipated. The assumption was that, after a few minutes, the HCP would become accustomed to the researchers presence and function in a more natural fashion, but further capturing the events more than once in a resuscitation offered an opportunity to minimize this risk. This is a major drawback of the observation studies; however, this helped to observe the “where” and “when” of the ongoing process/situation/behaviour wanted not relying on reported information. Inconsistent evaluation of the heart rate by use of stethoscope for monitoring response to resuscitative interventions by the HCP was negated by observing the immediate outcomes of resuscitation, for example, change in skin colour, active withdrawal/crying, and active motion by the newborn. Few HCPs involved in resuscitation were observed a multiple times to achieve the sample size of the resuscitation observations. Therefore, our results should be interpreted in light of the small sample size.
This study has implications both at the health facility level and the government level for the fight against neonatal mortality due to birth asphyxia. A few newborns miss out on the most important step: being kept warm adequately and this could result in further neonatal deaths precipitated by hypothermia. Secondly, many newborns with birth asphyxia are denied the vital ventilation within the Golden minute and this could be a signal for other sequelae associated with birth asphyxia. Caring for newborns with meconium in airway, a predictor of birth asphyxia is still poor. Health facilities should invest more in ensuring that the initial steps of drying, warmth, airway maintenance, and BMV within the Golden minute are perfectly performed to prevent more newborns proceeding to later stages of resuscitation that are associated with less survival.
The hospital is prepared in both healthcare providers and equipment to provide NR. However, training in neonatal resuscitation for HCPs is poorly spaced allowing deterioration of key skills in maintaining the warm chain, airway maintenance, ventilation, and circulation. Conspicuously, inappropriate practices are still performed by all the HCPs irrespective of cadre. Healthcare providers need cost-effective initial and regular refresher NR training and clinical mentorship with a focus on skills retention at least every year.
The authors declare that they have no conflicts of interest regarding the publication of this paper.
Duncan N. Shikuku conceived the idea, developed the proposal, participated in data collection, analysis, and report writing, and drafted the manuscript. Benson Milimo was involved in proposal development, review of data collection instruments, final report, and the manuscript. Elizabeth Ayebare was involved in proposal development, review of data collection instruments, final report, and the manuscript. Peter Gisore was involved in proposal development, review of data collection instruments, and the manuscript. Gorrette Nalwadda was involved in proposal development, review of methods, and data collection instruments, supervised the analysis plan and final report, and reviewed the manuscript. All authors have read and approved the manuscript.
Author 1 (Duncan N. Shikuku) thanks the INTRA-ACP Mobility Scholarship Scheme for funding his M.S. postgraduate programme in Makerere University, Uganda. The authors sincerely thank the mothers and newborns, administration, staff, and research assistants at Kakamega County General Hospital for allowing and participating in the study. The authors acknowledge Professor Dan Kaye for his oversight and expert guidance on data analysis and interpretation.