Interpretation
In our study, 87.5% of HW had attended at least one training in neonatal resuscitation, and 70% of the HW performed resuscitations on a regular basis. Despite this, our findings documented challenges in adherence to NR guidelines, stressing that NR programmes cannot stand alone. Transfer of competencies learned during training into clinical practice remains a key challenge. A study from Nepal using HBB with a quality improvement cycle showed improved adherence to NR guidelines.37 They attribute their success to a multifaceted intervention involving local leadership, multidisciplinary quality improvement teams, daily debriefings, root-cause analysis of poor NR performance and development of inclusive quality improvement goals.37 In addition, a systematic review from 2020 of the HBB programme from its initiation in 2010 found a reasonable translation of knowledge and skills. 38 Yet, few studies have documented the transfer of knowledge into clinical practice reflected in neonatal outcomes. 38 39 A HBB review on the effect on intrapartum-related stillbirths and neonatal mortalities found mixed results on mortality reduction, which further supports that training with frequent refreshers could aid in preserving knowledge and skills.39 Thus, there is a need to re-think traditional training and, to a greater extent, support the implementation of learned knowledge and skills into clinical practice.
Videos can help to recognise and monitor essential areas of improvement and aid intervention design. The insights from the videos could not have been obtained by any other means. Direct observations by research assistants could provide some structured observations about NR but cannot provide a real-time recording of NR for analysis and understanding of the actual challenges. Furthermore, direct observations generate a number of ethical issues where an observer should be a trained clinician in order to observe such a complex clinical situation as NR, but a trained clinician should obviously intervene in life-threatening situations. Many studies, both from high-resource settings and a few from low-resource settings, support videos to understand the quality of care. 20 24-32 Video recordings are beneficial for understanding NR, and our study from Pemba proved that video recordings are also beneficial to understand gaps in the quality of recommended essential newborn care and emphasizes the need for improved post-natal care of healthy newborns to prevent morbidity and mortality. 40 41 Similarly, a study from Nepal reports that emphasis on post-natal care is paramount to sustain gains in survival after resuscitation and NR programmes.23
Our findings stress the need to prioritise effective PPV since oxygenation and reduction of shunts are the key interventions to reverse hypoxia. 15 Our results are consistent with previous studies from LMIC in Nepal, Mozambique, and Uganda who found unsustained ventilation and delays in establishing ventilation. 20 26 28 31 32 42 The 2021 European Resuscitation Guidelines recommend the omission of suction even for newborns born in thick meconium as it delays ventilation and there is an absence of evidence of benefit.16 It has been argued that the suction device should be removed from the resuscitation table and observations from our study support this as critical time is diverted to suctioning instead of ventilation. 26 The AMANHI study attributed perinatal asphyxia as the leading cause of death responsible for more than 47% of neonatal deaths in Pemba. 34. In addition, the Zanzibari Ministry of Health reports birth asphyxia as the leading cause of death in children under 13 years, accounting for 25.2 % of deaths.43
Lastly, we report an NMR of 23.6 per 1000 live births, with more than 90% of the deaths occurring within the first 24 hours. Our one-day neonatal mortality is higher than most of the literature, suggesting that the overall neonatal mortality rate in Pemba could be much higher than we report. 3-5 12 The NMR in our study is slightly higher than the official numbers from the Zanzibari Ministry of Health and the AMANHI-study group. 34 44
Challenges in provision of quality of care according to guidelines have many reasons beyond the capacity of HWs, including structural barriers such as lack of human resources, lack of equipment and logistical challenges. Maaløe et al. recommend local adaptation of guidelines, so they are achievable and contextualised to the setting.45 In addition, there is a need to understand the barriers to adhere to the guidelines, such as HBB and similar NRP, to succeed and translate into improvements in knowledge and skills and improve neonatal outcomes. Novel technology such as mHealth tools are widely available. A study showed that the Safe Delivery App aids knowledge and skill retention with a non-significant reduction of perinatal mortality, and mHealth solutions such as this could be part of the solution. 46