Neonatal resuscitation training program in Malaysia: results of the first 2 years

Train the Trainer in Bleeding Control: A Two-Year Pilot Study in Low-Income and Middle-Income Countries

INTRODUCTION

Traumatic hemorrhage represents a major cause of mortality in low-income and middle-income countries (LMICs). Thus, LMICs can benefit from improvements to prehospital hemorrhage management. One strategy is implementation of a bleeding control course using the "train the trainer" model (TTT) to increase course availability. The Stop the Bleed (STB) campaign provides laypeople with basic knowledge and skills of hemorrhage control. While the feasibility and success of the STB course have been demonstrated in the United States, course dissemination in LMICs has been slower and its feasibility using the TTT model has not been established.

MATERIALS AND METHODS

From December 2017 to January 2019, instructors from the International Surgical Health Initiative conducted seven surgical humanitarian trips and taught 10 index 1-h STB training sessions across six LMICs. LMIC instructors were encouraged to continue providing STB courses following departure of the visiting instructors. Course data were collected from sign-in sheets and analyzed using Microsoft Excel.

RESULTS

Ten index courses conducted by United States-trained STB experts trained 35 LMIC instructors over 2 y. Six of 35 offered 12 additional courses, certifying 323 new trainees, an 823% increase from the initial cohort. Overall, implementation of the TTT model yielded 22 STB courses in six LMICs, producing 358 new trainees.

CONCLUSIONS

This pilot study shows the STB TTT model was feasible and effective in expanding bleeding control trainer capacity in four of six LMICs. Use of the TTT model in LMICs may represent a means to increase STB course availability and is one strategy to improve prehospital hemorrhage control in LMICs.

Faculty Development Approaches for Life Support Courses: A Scoping Review

The aim of this scoping review initiated by the Education, Implementation and Teams Task Force of the International Liaison Committee on Resuscitation was to identify faculty development approaches to improve instructional competence in accredited life support courses. We searched PubMed, Ovid Embase, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials to identify studies published from January 1, 1966 to December 31, 2021 on approaches to improve faculty development for life support courses. Data on participant characteristics, interventions, design, and outcomes of included studies were extracted. Of the initially identified 10 310 studies, we included 20 studies (5 conference abstracts, 1 short communication, 14 full-length articles). Among them, 12 studies aimed to improve instructors/candidates' teaching ability in basic life support courses. A wide variety of interventions were identified. The interventions were categorized into 4 themes: instructor qualification/training (n=9), assessment tools (n=3), teaching skills enhancement (n=3), and additional courses for instructors (n=5). Most studies showed that these interventions improved specific teaching ability or confidence of the instructors and learning outcomes in different kinds of life support courses. However, no studies addressed clinical outcomes of patients. In conclusion, the faculty development approaches for instructors are generally associated with improved learning outcomes for participants, and also improved teaching ability and self-confidence of the instructors. It is encouraged that local organizations implement faculty development programs for their teaching staff of their accredited resuscitation courses. Further studies should explore the best ways to strengthen and maintain instructor competency, and define the cost-effectiveness of various different faculty development strategies.

Simulation-Based Education in the Training of Newborn Care Providers-A Malaysian Perspective

Simulation-based education (SBE) is increasingly used as an education tool to improve learning for healthcare providers. In newborn care practice, SBE is used in the Neonatal Resuscitation Program (NRP) and training in procedural skills. The NRP is a mandatory course in Malaysia for all house officers (interns) and medical officers (residents) during their pediatric rotation. Almost 30,000 of NRP providers have been trained over the last 5 years. The recent establishment of the Allied Healthcare Center of Excellence (AHCoE), an organization dedicated to promoting SBE, and Malaysian Society for Simulation in Healthcare (MaSSH) aims to enhance the integration of SBE into the healthcare training curriculum and set up a local healthcare simulation educator training program. Our experience in implementing SBE necessitated that we made several important choices. As there was no strong evidence to favor high-fidelity over low-fidelity simulation, and because simulation centers can be very costly to set up with limited resources, we chose SBE mainly in the form of low-fidelity and in situ simulation. We also identified an important developmental goal to train Malaysian instructors on structured debriefing, a critical activity for learning in SBE. Currently, debriefing is often carried out in our centers at an ad hoc basis because of time limitation and the lack of personnel trained. Finally, we aim to implement SBE further in Malaysia, with two axes: (1) the credentialing and recertification of physicians and nurses, and (2) the education of lay caregivers of high-risk infants before discharge from the neonatal intensive care unit.

Exploring Factors Influencing Practice of Neonatal Resuscitation with Bag and Mask in Ethiopia: Analysis from 2016 National Emergency Obstetric and Newborn Care Survey

Background

Globally, more than 7 million children die under the age of five and the highest proportion of death is during the first 28 days of life. For babies who do not breathe at birth, neonatal resuscitation is critical in reducing intra-partum related neonatal deaths by 30%. Yet, there is a dearth of studies on the provision of neonatal resuscitation in Ethiopia. So, this study aimed to assess health facilities provision of neonatal resuscitation with bag and mask and its factors among asphyxiated newborns.

Materials and Methods

Data used were from the Ethiopian 2016 Emergency Obstetric Newborn Care survey, conducted in 3,804 health facilities providing maternal and newborn health services. The analysis included neonatal resuscitation with bag and mask in the previous 3 months before the survey. Descriptive statistics, simple and multivariable regression analyses were performed using SPSS-21 version.

Results

The analysis findings show that 72.2% of the health facilities were providing neonatal resuscitation with bag and mask. The result showed that hospitals (adjusted odds ratio (AOR): 3.90; 95% confidence interval (CI) [2.05, 7.49]), health-care providers not trained in neonatal resuscitation (AOR: 0.64; 95% CI [0.42, 0.99]) and availability of essential equipment (AOR: 1.32; 95% CI [1.15, 1.51]) were more likely to practice neonatal resuscitation.

Conclusion

Overall practice of health facilities on neonatal resuscitation with bag and mask was at 72.2%. Type of facility, providers trained in neonatal resuscitation and availability of essential equipments were independently affecting the practice of neonatal resuscitation. Incorporating competency-based training, refresher training, and clinical mentorship will improve the practice.

Healthcare Professionals' Knowledge of Neonatal Resuscitation in Ethiopia: Analysis from 2016 National Emergency Obstetric and Newborn Care Survey

Background

Birth asphyxia, which accounts for 31.6% of all neonatal deaths, is one of the principal causes of neonatal mortality in Ethiopia. Adequate knowledge of newborn resuscitative procedures plays an important role in early diagnoses and suitable management. However, there are limited data on healthcare professionals' knowledge about neonatal resuscitation. Thus, this study aimed to determine the knowledge of healthcare professionals about neonatal resuscitation and factors affecting it.

Methods

Data from the Ethiopian 2016 national Emergency Obstetric and Newborn Care survey of 3,804 health facilities that provided maternal and newborn health services were analyzed. We have included 3804 healthcare providers, who attended the largest number of deliveries in the last month prior to the survey, and assessed their knowledge of neonatal resuscitation. It was also determined whether certain factors were associated with healthcare providers' knowledge through linear regression method.

Result

The overall knowledge score of the healthcare providers about neonatal resuscitation ranged from 12 to 24 out of 37 items (with mean score of 18.4 (±5.47) and mean score percentage of 49%). The findings showed that providers trained on neonatal resuscitation (β=2.65, 95% CI: 0.65, 4.62; p <0.00), facilities that had guideline of neonatal resuscitation (β=2.50, 95% CI: 0.60, 3.52; p =0.01), and availability of essential equipment (β=0.95, 95% CI: 0.44, 1.45; p =0.02) were significantly associated with sufficient knowledge of neonatal resuscitation in Ethiopia.

Conclusion

Overall knowledge of neonatal resuscitation was insufficient. Trained healthcare providers, having guideline on neonatal resuscitation, and availability of essential equipment were significantly associated with knowledge of neonatal resuscitation. Competency and simulation-based in-service training and refresher training complemented by supportive supervision and mentorship are helpful ways to put up providers capability to perform neonatal resuscitation.

The train the trainer model for the propagation of resuscitation knowledge in limited resource settings: A systematic review

BACKGROUND

The Train the Trainer (TTT) model is increasingly used in limited resource settings as a mechanism to disseminate resuscitation knowledge and skills among providers. Anecdotally, however, many resuscitation programs that use this model fail to achieve sustainability.

OBJECTIVE

We aim to systematically review the literature to describe the evidence for the TTT method of knowledge dissemination for resuscitation courses in limited resource settings.

METHODS

We conducted a systematic review of the literature in accordance with PRISMA guidelines of the PubMed, Cochrane Library, MEDLARS online (MEDLINE), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases.

RESULTS

Eleven manuscripts met inclusion criteria, the majority (7/11) focused on neonatal resuscitation. We found strong evidence for the TTT model for imparting knowledge and skills on providers, however, little evidence exists for the impact of these programs on patient outcomes or long term sustainability. Facilitators associated with successful programming include the use of language and resource appropriate materials, support from the Ministry of Health of the country, and economic support for supplies and salaries.

CONCLUSION

While the TTT model of programming for the dissemination of resuscitation education is promising, further research is necessary especially relating to sustainability and impact on patient outcomes. Familiarity with the local environment, language, culture, resources and economic realities prior to the initiation of programming is key to success.

The burden of hypoxic-ischaemic encephalopathy in Malaysian neonatal intensive care units

INTRODUCTION

This study aimed to determine the incidence of hypoxic-ischaemic encephalopathy (HIE) and predictors of HIE mortality in Malaysian neonatal intensive care units (NICUs).

METHODS

This was a retrospective study of data from 37 NICUs in the Malaysian National Neonatal Registry in 2012. All newborns with gestational age ≥ 36 weeks, without major congenital malformations and fulfilling the criteria of HIE were included.

RESULTS

There were 285,454 live births in these hospitals. HIE was reported in 919 newborns and 768 of them were inborn, with a HIE incidence of 2.59 per 1,000 live births/hospital (95% confidence interval [CI] 2.03, 3.14). A total of 144 (15.7%) affected newborns died. Logistic regression analysis showed that the significant predictors of death were: chest compression at birth (adjusted odds ratio [OR] 2.27, 95% CI 1.27, 4.05; p = 0.003), being outborn (adjusted OR 2.65, 95% CI 1.36, 5.13; p = 0.004), meconium aspiration syndrome (MAS) (adjusted OR 2.16, 95% CI 1.05, 4.47; p = 0.038), persistent pulmonary hypertension of the newborn (PPHN) (adjusted OR 4.39, 95% CI 1.85, 10.43; p = 0.001), sepsis (adjusted OR 4.46, 95% CI 1.38, 14.40; p = 0.013), pneumothorax (adjusted OR 4.77, 95% CI 1.76, 12.95; p = 0.002) and severe HIE (adjusted OR 42.41, 95% CI 18.55, 96.96; p < 0.0001).

CONCLUSION

The incidence of HIE in Malaysian NICUs was similar to that reported in developed countries. Affected newborns with severe grade of HIE, chest compression at birth, MAS, PPHN, sepsis or pneumothorax, and those who were outborn were more likely to die before discharge.

Using routine health data and intermittent community surveys to assess the impact of maternal and neonatal health interventions in low-income countries: A systematic review

BACKGROUND

There is a need to provide increased evidence on effective interventions to reduce maternal and neonatal mortality in low- and middle-income countries (LMICs).

OBJECTIVES

To summarize the breadth of knowledge on using routine data (Routine Health Information Systems [RHIS] and Intermittent Community Surveys [ICS]) for well-designed maternal and neonatal health evaluations in LMICs.

SEARCH STRATEGY

We searched reports and articles published in Embase, Medline, and Google scholar. Selection criteria Studies were considered for inclusion if they were carried out in LMICs, using RHIS or ICS data with experimental or quasi-experimental design.

DATA COLLECTION AND ANALYSIS

A form was used to collect information on indicators used for interventions' impact assessment. Descriptive statistics and multiple correspondence analyses were then performed.

MAIN RESULTS

Of the 1201 publications identified, 46 studies met the inclusion criteria. Most of these were using RHIS data (n=40), mainly extracted from health facility registers (n=34), and non-controlled before and after design (n=30). The indicators, which were mostly reported, were related to the use of healthcare services (n=36) and maternal/neonatal health outcomes (n=31). Few studies used ICS data (n=6) or indicators of severity (n=2).

CONCLUSION

RHIS and ICS data should be increasingly used for impact studies on maternal and neonatal health in LMICs.

Global report on preterm birth and stillbirth (4 of 7): delivery of interventions

BACKGROUND

The efficacious interventions identified in the previous article of this report will fail unless they are delivered at high and equitable coverage. This article discusses critical delivery constraints and strategies.

BARRIERS TO SCALING UP INTERVENTIONS

Achieving universal coverage entails addressing major barriers at many levels. An overarching constraint is the lack of political will, resulting from the dearth of preterm birth and stillbirth data and the lack of visibility. Other barriers exist at the household and community levels, such as insufficient demand for interventions or sociocultural barriers; at the health services level, such as a lack of resources and trained healthcare providers; and at the health sector policy and management level, such as poorly functioning, centralized systems. Additional constraints involve weak governance and accountability, political instability, and challenges in the physical environment.

STRATEGIES AND EXAMPLES

Scaling up maternal, newborn and child health interventions requires strengthening health systems, but there is also a role for focused, targeted interventions. Choosing a strategy involves identifying appropriate channels for reaching high coverage, which depends on many factors such as access to and attendance at healthcare facilities. Delivery channels vary, and may include facility- and community-based healthcare providers, mass media campaigns, and community-based approaches and marketing strategies. Issues related to scaling up are discussed in the context of four interventions that may be given to mothers at different stages throughout pregnancy or to newborns: (1) detection and treatment of syphilis; (2) emergency Cesarean section; (3) newborn resuscitation; and (4) kangaroo mother care. Systematic reviews of the literature and large-scale implementation studies are analyzed for each intervention.

CONCLUSION

Equitable and successful scale-up of preterm birth and stillbirth interventions will require addressing multiple barriers, and utilizing multiple delivery approaches and channels. Another important need is developing strategies to discontinue ineffective or harmful interventions. Preterm birth and stillbirth interventions must also be placed in the broader maternal, newborn and child health context to identify and prioritize those that will help improve several outcomes at the same time. The next article discusses advocacy challenges and opportunities.

Delivering interventions to reduce the global burden of stillbirths: improving service supply and community demand

BACKGROUND

Although a number of antenatal and intrapartum interventions have shown some evidence of impact on stillbirth incidence, much confusion surrounds ideal strategies for delivering these interventions within health systems, particularly in low-/middle-income countries where 98% of the world's stillbirths occur. Improving the uptake of quality antenatal and intrapartum care is critical for evidence-based interventions to generate an impact at the population level. This concluding paper of a series of papers reviewing the evidence for stillbirth interventions examines the evidence for community and health systems approaches to improve uptake and quality of antenatal and intrapartum care, and synthesises programme and policy recommendations for how best to deliver evidence-based interventions at community and facility levels, across the continuum of care, to reduce stillbirths.

METHODS

We systematically searched PubMed and the Cochrane Library for abstracts pertaining to community-based and health-systems strategies to increase uptake and quality of antenatal and intrapartum care services. We also sought abstracts which reported impact on stillbirths or perinatal mortality. Searches used multiple combinations of broad and specific search terms and prioritised rigorous randomised controlled trials and meta-analyses where available. Wherever eligible randomised controlled trials were identified after a Cochrane review had been published, we conducted new meta-analyses based on the original Cochrane criteria.

RESULTS

In low-resource settings, cost, distance and the time needed to access care are major barriers for effective uptake of antenatal and particularly intrapartum services. A number of innovative strategies to surmount cost, distance, and time barriers to accessing care were identified and evaluated; of these, community financial incentives, loan/insurance schemes, and maternity waiting homes seem promising, but few studies have reported or evaluated the impact of the wide-scale implementation of these strategies on stillbirth rates. Strategies to improve quality of care by upgrading the skills of community cadres have shown demonstrable impact on perinatal mortality, particularly in conjunction with health systems strengthening and facilitation of referrals. Neonatal resuscitation training for physicians and other health workers shows potential to prevent many neonatal deaths currently misclassified as stillbirths. Perinatal audit systems, which aim to improve quality of care by identifying deficiencies in care, are a quality improvement measure that shows some evidence of benefit for changes in clinical practice that prevent stillbirths, and are strongly recommended wherever practical, whether as hospital case review or as confidential enquiry at district or national level.

CONCLUSION

Delivering interventions to reduce the global burden of stillbirths requires action at all levels of the health system. Packages of interventions should be tailored to local conditions, including local levels and causes of stillbirth, accessibility of care and health system resources and provider skill. Antenatal care can potentially serve as a platform to deliver interventions to improve maternal nutrition, promote behaviour change to reduce harmful exposures and risk of infections, screen for and treat risk factors, and encourage skilled attendance at birth. Following the example of high-income countries, improving intrapartum monitoring for fetal distress and access to Caesarean section in low-/middle-income countries appears to be key to reducing intrapartum stillbirth. In remote or low-resource settings, families and communities can be galvanised to demand and seek quality care through financial incentives and health promotion efforts of local cadres of health workers, though these interventions often require simultaneous health systems strengthening. Perinatal audit can aid in the development of better standards of care, improving quality in health systems. Effective strategies to prevent stillbirth are known; gaps remain in the data, the evidence and perhaps most significantly, the political will to implement these strategies at scale.

Using mnemonics and visual imagery to teach the new neonatal resuscitation program

Mnemonics have long been used to help learners remember facts in various disciplines of medicine. With the introduction of the revised Neonatal Resuscitation Program (NRP), it is vital for learners to know and remember important changes to the NRP curricula. While teaching the new curricula, we found that learners appeared confused, being unable to provide the correct sequence of answers to the questions posed during the assessment phase of the course. Mnemonics were developed to aid memory recall and optimize resuscitation skills.