Understanding Barriers to Neonatal Resuscitation in a Hospital in Haiti

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BACKGROUND: Neonatal mortality is a major problem in developing countries, accounting for 41% of child mortality. Approximately one quarter of these deaths are attributed to birth asphyxia. Although estimates suggest that 99% of asphyxia-related deaths can be prevented with neonatal resuscitation, in many settings, interventions to improve resuscitation have not led to decreases in mortality. OBJECTIVES: This study aimed to develop an understanding of neonatal resuscitation practices at a hospital in Haiti. Specific objectives were: to identify current resuscitation practices at the time of delivery; to characterize provider experiences with newborn care and resuscitation; and to identify perceived barriers to effective resuscitation. METHODS: This mixed methods study collected data through delivery observations and semi-structured individual interviews with health care providers. RESULTS: Fifty-one (32.9%) of the 155 newborns in this study were not breathing at birth. Of these, 45 (88.2%) were successfully resuscitated, 11.8% by drying and stimulation, 19.6% by stimulation and airway clearing, 39.2% by a combination of drying, stimulation, and airway clearing, and 17.6% by bag-mask ventilation with or without chest compressions. Six of the newborns (11.8%) died. The average time to newborn assessment for all deliveries was 16 seconds, and to bag-mask ventilation was 3.2 minutes. In the interviews, most providers described feeling competent to perform resuscitation, although bag-mask ventilation technique was considered challenging. The most salient barriers to resuscitation included personnel shortages, resource shortages, inadequate space, and poorly organized communication systems. CONCLUSIONS: This investigation found a higher proportion of newborns in need of resuscitation than global estimates suggest. The systemic nature of the barriers to neonatal resuscitation highlighted by this study suggest that addressing the need for personnel, equipment, space, and solid communication systems will be essential to making improvements in neonatal resuscitation and consequently reducing neonatal morbidity and mortality. Training, particularly training that is embedded in a system of ongoing mentorship, is also important, but given the extent to which systemic barriers prevent providers from putting into practice the skills they already have, further training alone will be insufficient to overcome the barriers revealed in this study.