Controversy- Implementing Basic Neonatal Resuscitation at Community Level

1. When The Baby Doesn’t Breathe, and There Is No Skilled Birth AttendantAnnie Clark, URC Sr. QI Advisor MNCH

2. Controversy- Implementing Basic Neonatal Resuscitation at Community Level • Issues with maintaining equipment & skills among non-SBAs given rare need for ventilation • Cost of intervention compared to coverage concern • Given the relatively small effect size, the infrequent occurrence, and the challenges of methodology and data collection, difficult to demonstrate benefit in a trial • Some country Ministries do not permit training of non-SBAs in ventilation (i.e. Uganda)

3. Controversy- Implementing Basic Neonatal Resuscitation at Community Level On the other hand, there may be a role: • in some high mortality settings where most births occur at home • skilled attendance is not achievable in the foreseeable future • alternative cadres already attend the majority of deliveries • case load per attendant is high enough to justify the training, equipment inputs and skill maintenance

4. 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-Lee, et al. BMCPH 2011 • 24 studies found that reported the impact of neonatal resuscitation training on mortality outcomes: 16 studies in facilities, and 8 studies in community settings • Delphi panel of 18 experts estimated that immediate newborn assessment and stimulation would reduce both intrapartum-related and preterm deaths by 10% • Facility-based resuscitation would prevent a further 10% of preterm deaths • Community-based resuscitation would prevent further 20% of intrapartum-related and 5% of preterm deaths.

5. LUNESP Study Results • Among 3,497 deliveries, mortality in the first 24 hours of life was significantly lower for those delivered by trained non-SBAs -- 7.8 deaths per 1,000 live births, compared to 19.9 per 1,000 births for the non-trained group. • Deaths due to birth asphyxia reduced by 63 percent among infants delivered by the trained non-SBAs

6. Basic neonatal resuscitation effect on stillbirths in community-based studies • In the First Breath study, the stillbirth rate was reduced by 31% after the intervention • In the SEARCH study, the fresh stillbirth rate was 32% lower during the period of bag-mask compared to tube-mask resuscitation(p< 0.09). • In the LUNESP study, there was no significant effect of the intervention on stillbirth rate.

7. Conclusions reached by TWG based on findings reported by the Community Based Newborn Care Project (CBNCP) in Nepal • Very low “capture rate” by Female Community Health Visitors (FCHVs) and Health Facilities. Data quality acceptable. • Issues with maintaining equipment & skills among FCHVs given rare practice • Cost of intervention compared to coverage is of concern • Low rates of service provision call viability of intervention (particularly bag-and-mask) into question • As institutional delivery rate increases, need for Birth Aasphyxia management at community level may further decline

8. Individuals and Projects Taking Initiativeswithout HBB GDA Guidance-Example Casa Colibri

9. What will the HBB GDA Partners Recommend Regarding Newborn Resuscitation at Community Level? 1) No recommendation for NB resuscitation at community level 2) Advocate teaching first five steps (dry, warm, position, suction, stimulate) only 3) Respond per request of MoH 4) Advocate mouth-to-mouth ventilation when no alternative available (counsel re: associated theoretical risks) 5) Advocate simple tube and mask ventilation 6) Advocate bag and mask ventilation 7) Conduct further research 8) Other