Impact of CountryWide Implementation of the Neonatal Resuscitation Program

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Impact of Country-Wide Implementation of the
Neonatal Resuscitation Program
Oswaldo Revelo-Castro, MD1 Namasivayam
Ambalavanan, MD2 Carlos Ramos, MD3 Yanira
Burgos, MD3 Claudia de Alas MD3 Lorena Parada,
MD3 and Waldemar A Carlo, MD2 Hospital Nacional
de Niños, San Salvador1 University of Alabama at
Birmingham, Birmingham, AL2 and Ministerio de
Salud Pública y Asistencia Social, San Salvador,
El Salvador3
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Background Birth Asphyxia

• Birth asphyxia is defined as the inability of the
  baby to establish spontaneous normal breathing
  after birth is a leading cause of neonatal
  mortality accounting for 1 of 5 million
  deaths/year
• WHO has concluded that resuscitation is often
  not initiated or the methods used inadequate or
  wrong

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Background Neonatal Resuscitation

• Neonatal resuscitation is a simple, inexpensive,
  and cost-effective intervention according to WHO
• Resuscitation is effective in normalizing vital
  signs in about 99 of the infants requiring
  resuscitation at birth (Perlman and Riser)
• Resuscitation training is widely used in the
  developed world but has had limited dissemination
  in many developing countries

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BackgroundNeonatal Resuscitation Program (NRP)

• NRP is a train-the-trainer program for
  resuscitation skills
• NRP was developed by AAP/AHA based on ILCOR
  guidelines
• NRP has been used in many countries but there are
  no data on the effects of country-wide
  dissemination of a neonatal resuscitation
  training program

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Hypothesis

• Country-wide implementation of the standardized
  neonatal resuscitation training program
  decreases
• Overall neonatal mortality
• Neonatal mortality due to birth asphyxia in
• institutional births

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Methods

• Retrospective quasi-experimental design
• Country-wide birth/death registry for statistical
  analysis of trends
• NRP introduced progressively from 2000 to 2004
• Courses were conducted in the local language by
  certified instructors using the train-the trainer
  model.
• Most physicians and nurses in all 28 delivery
  hospitals in El Salvador became NRP-trained

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Methods NRP Training, Cumulative Number of
Trained Personnel
76
60
Number Trained
38
12
5
0
is based on total personnel
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Results Overall Neonatal Mortality Rate (per
1000 live births)
p0.02
Mortality Rate
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Results Neonatal Mortality Due to Birth
Asphyxia (per 1000 live births)
Mortality Rate
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Summary

• Country-wide implementation of the American
  Academy of Pediatrics Neonatal Resuscitation
  Program was completed over a 5 year period
• There was a statistically significant and
  clinically important decrease in overall neonatal
  mortality. This decrease was in part due to a
  reduction in neonatal mortality due to birth
  asphyxia.

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Conclusions

• Because the reduction in neonatal mortality may
  be associated with secular trends due to other
  improvements in care, controlled trials of
  neonatal resuscitation training are needed to
  confirm these findings.
• These results are based on low levels of evidence
  with data from institutional births in a single,
  relatively homogenous small country, and thus,
  well designed trials,generalizable to the
  countries with highest infant mortality need to
  be performed.
• Effective resuscitation training has the
  potential to markedly reduce neonatal mortality

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Acknowledgment

• We would like to thank to the AAP, specially to
  Executive Director Dr. Errol
  Alden, the staff (Eileen Schoen, Alejandra Lule)
  and the faculty (Dr. Waldemar Carlo
  and Dr. Susan Niermeyer) for their support to
  stablish and mantain the program in El Salvador.
• Thank you very much!

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Acknowledgment

• In our country this Program was support by
  USAID (SALSA Project).
• PAHO Washington and local Office help us to
  organize the Instructor Courses.
• Thanks!