The Health Agenda, Volume 2. Issue 3. July, 2014
EDITORIAL Basic Neonatal Resuscitation Trainings: Need of the Hour Author: Akash Bang Corresponding author: Dr. Akash Bang Associate Professor, Dept. of Pediatrics Mahatma Gandhi Institute of Medical Sciences Sewagram, Maharashtra 442102 Mail ID:
[email protected] “The measure of a civilization is how it treats its weakest members,” said Mahatma Gandhi. In any society, who can be a weaker member than an unarmed, defenceless, vulnerable newborn? And if the neonatal mortality figures are anything to go by, we sure do not stand a very good chance in the race for a developed civilization. Throughout the period 1990-2009, India has been the country with the largest number of neonatal deaths. (1) Millennium Development Goal (MDG)-4, which calls for a two-thirds reduction in mortality risks of children under five years of age between 1990 and 2015, has brought about a lot of focus and attention towards the under five deaths. (2) However, traditionally the main focus of studies of childhood mortality has been the infant and under-five mortality rates; and neonatal mortality (deaths below 28 days of age) has received limited attention. Even in the international public health policies and programs, neonatal deaths do not seem to have received the attention they deserve, especially in lower income countries. (1, 2) Why neonatal deaths are important? Years back, in 2003, the Lancet series on child survival published a world map wherein red dots were placed on the map, each red dot corresponding to 5000 child deaths. (3) One shuddered with pain and horror to see India completely painted red. To me, it almost symbolized red blood of the dying children that drowned India! MDG-4 requires a two-thirds reduction in the under-five mortality from 1990. All efforts at reducing the under-5 mortality must have adequate emphasis on neonatal mortality because neonatal deaths alone account for about 40% of all childhood deaths. (1,2) In 2009, India contributed a 19.6% share to the
global live births, but accounted for 27.8% of the global neonatal mortality - almost zero improvement over the 1990 status when India accounted for 29.5% of global neonatal mortality and 19.8% of global live births. (1) Thus every third to fourth newborn dying in the world is an Indian! Around 900,000 newborns die every year in India. (1) This roughly translates into two newborn deaths every minute. Isn’t it an absolutely horrifying thought that by the fifteen minutes or so that one takes to finish reading this small piece, thirty newborns would already have died somewhere in India? Hence, a key component in reduction of under-5 mortality would be reducing neonatal mortality by identifying the causes and tackling them. Why do newborns die? Child survival programs have typically focused on diseases affecting post-neonatal age group like pneumonia, malaria, diarrhoea, and vaccine preventable diseases. (1,4) Neonatal mortality reduction will require a specific focus on the epidemiology, causes and appropriate interventions. Prematurity (28%), infections (26%), and birth asphyxia (23%) are the three topmost causes of neonatal mortality worldwide. (5) Birth asphyxia, thus, kills almost 200,000 newborns every year in India. Asphyxia, to some extent, is unique because it operates only in few minutes immediately after birth. Thus, unlike other causes of neonatal deaths, it provides a rare but very narrow window of opportunity. If appropriate actions are taken in this narrow timeframe - essentially the first few seconds of life - this big chunk of neonatal deaths is largely preventable. Page | 77
The Health Agenda, Online ISSN No: 2320-3749
Bang A: Basic Neonatal Resuscitation Trainings: Need of the hour
What are the effects of asphyxia? There is another aspect of asphyxia which is probably even more worrying. Unlike neonatal deaths, which are very diligently recorded and include newborns with signs of life at birth that could not survive; many hospitals and birthing places do not keep detailed records of fresh still births. Fresh still births are fetuses that die just before or during the birth process and hence show no signs of life immediately after birth. Thus in a depressed and asphyxiated baby, in the absence of respiratory efforts, the heart rate noted immediately at birth would be probably the only clinically detectable sign that would tell a neonatal death (live born but died immediately) from a fresh still birth. Due to various social, legal and moral pressures and stigma that surround a neonatal death, misclassifications of neonatal deaths as fresh still births are bound to happen either deliberately or unknowingly. This is quite obvious from studies which show that efforts focussed to decrease the neonatal mortality decreases still birth rates either instead of, or in addition to, the neonatal mortality. (6,7) National still birth estimates for India calculated in 2011 from the data collected from nationally representative surveys and various studies suggested that around 600,000 still births occur every year in India. (8) Out of these, approximately 30% are attributed to the intra-partum causes, mostly birth asphyxia. However, the data regarding fresh still births are not standardized and there is a gross under reporting. Thus the total mortality due to birth asphyxia includes many more still births and thus far exceeds the reported “asphyxia specific neonatal mortality”. The ill effects of birth asphyxia don’t stop at this. Mortality is just a small “tip of the iceberg” representation of the havoc caused by asphyxia. Worldwide, more than 1 million children who survive birth asphyxia every year go onto suffer cerebral palsy, learning disorders and other disabilities. (9) Birth asphyxia, thus, in addition to causing mortality in form of fresh still births and neonatal deaths, also cripples children and thus increases morbidity. So the problem is right
here, in front of us, staring in our eyes and we just can’t adopt an ostrich attitude trying to ignore it! Is there a solution? Of course, there is a solution to the problem. Unlike other causes of neonatal mortality, birth asphyxia is a problem that operates in just first few minutes after birth. So the solution is ensuring that every newborn gets its first breath in the “first golden minute” of life - either it starts breathing on its own, or is provided some assistance in form of neonatal resuscitation. For this, we need to ensure that every birth is attended by a person who is trained in basic neonatal resuscitation. Conversely, whoever is likely to attend a birth in the capacity of a health personnel, needs to be identified and trained in basic neonatal resuscitation, which consists of simple steps that include preparations for birth; assessment of the newborn at birth to decide whether it is breathing well on its own or needs assistance; initial steps viz. providing warmth, clearing airway as necessary, thorough and vigorous drying, and stimulation to start breathing; and finally, positive pressure ventilation by bag and mask, if needed. These simple steps constituting the basic neonatal resuscitation can be learnt by any health care personnel and are sufficient to manage almost 99% of newborns since advanced resuscitative measures like chest compression and medications are known to be required in hardly 1% of the births. (10) Neonatal Resuscitation Trainings and their impact Resuscitation training using a standard national program began in the United States with the 1987 publication of the American Academy of Pediatrics (AAP) Neonatal Resuscitation Program. Later, AAP in partnership with its global partners came out with “Helping Babies Breathe (HBB)”, a new training program aimed to train the birth attendants to resuscitate neonates wherever they are born. (11) Thus HBB was one of the first attempts to demystify the resuscitation process, and take the most basic, simple and most commonly required skills of basic neonatal resuscitation to the lowest ranks of birth attendants. Page | 78
The Health Agenda, Volume 2. Issue 3. July, 2014
Indian Academy of Pediatrics (IAP) and Government of India came out with a similar training program on the lines of HBB called “Navjaat Shishu Suraksha Karyakram (NSSK)” in government and “Basic Neonatal Care and Resuscitation Program (BNCRP)” in private sector. The Neonatal Resuscitation Program First Golden Minute Project of IAP aims to train 200,000 birth attendants through a network of trainers from its own members and partner organizations. (12) Studies have evaluated the impact of neonatal care and resuscitation training for physicians, nurses, and other birth attendants on their skills and knowledge and have suggested that birth attendants at different levels of skill can be trained to effectively resuscitate newborns. (1315) Though HBB training improved both knowledge and skills; the improvement was most marked in skills. The percent of trainees passing the skills test increased from 4% pretraining to 97% post-training and nurses fared just as well as physicians. (16) Whether this improvement in the resuscitation skills during the training sessions also reflects in real world and translates into a drop in the neonatal mortality and fresh still births remains to be seen. In past, female community health workers trained with a mixed package of management of asphyxia, pre-term birth and neonatal infections in addition to home visits for health education to women and monitoring neonates brought down the case fatality in neonates with severe asphyxia from 39 to 20% (p
