INTRODUCTION

Neonatal mortality is defined as death occurring within the first 28 days of life; the term encompasses early and late mortality, occurring within the first 7 days and between 7 and 28 days, respectively ¹. In 2016, the World Health Organization (WHO) estimated that, 2.6 million infants died in the world within the first month of life; of them, 1 million died on the first day and 1 million died within the next six days ². In 2015, in high income countries like Germany, Australia, Finland, Iceland, Singapore and the United States, or in low income countries like Cuba, neonatal mortality ranged between 0.9 and 3.5 for every 1000 live births. In contrast, in Latin American, frequency ranged between 8.5 and 13.5 in 1000 live births in Costa Rica and Colombia, respectively ³. According to the Epidemiological Bulletin (Boletín epidemiológico) of the Colombian National Institute of Health, the main causes of neonatal death in Colombia are pre- maturity (24%), other causes (22.5%) and neonatal asphyxia (22.2) ⁴.

Neonatal asphyxia is defined as oxygen deprivation or reduction in neonatal organ perfusion; in the majority of cases (90%) this condition originates in events taking place before or during childbirth. However, there is a non-negligible proportion of neonates who die from cardiopulmonary failure or neurological impairment during the postpartum period ⁵. Asphyxia may result in hypoxic-ischemic encephalopathy, high rates of neurological sequelae and multiple organ damage, leading to increased healthcare costs not only for the system but for the family as well ⁶. At present, this condition is still a clinical challenge given the significant associated mortality rate ⁷.

Although neonates are physiologically equipped to adapt to their environment in response to stimuli, either chemical (changes in arterial oxygen pressure), neurological (respiratory center stimuli), sensory (touch, drying), thermal (going from a warm fluid to a dry and cooler environment) or mechanical (going through the birth canal) ⁸, it is also true that birth is one of the most decisive and sensitive moments for the viability of the neonate ⁹; and although 90% of the neonates do not need any help to take their first breath, close to 10% need some form of support ¹⁰. Consequently, healthcare professionals who participate during this critical event should have the knowledge and skills required to ensure that the neonate can adapt adequately to the extra-uterine environment, and to respond effectively in the event additional interventions are required to initiate breathing within the first minute after birth ^11-13.

to the Helping Babies Breathe consists of a logical sequence of steps designed to respond to the needs of the neonate at the time of birth, helping it to adapt. These include providing warmth, drying it thoroughly, suctioning the airway if needed, checking for breathing or crying, and cutting the umbilical cord. In vigorous term babies, these steps may be carried out on top of the mother’s abdomen, promoting skin contact to create warmth and initiate early bonding. However, in cases in which breathing is not established after performing the initial steps, positive pressure ventilation is provided immediately so as not to delay the onset of breathing and avoid the consequences of asphyxia. All this must be done within the first minute of life ¹⁴. This first minute strategy, also known as “Helping Babies Breathe,” (HBB) was first implemented in 2010 with the aim of training midwives as well as physicians in rural settings and birthing units in these steps ^15,16. Goudar et al. ¹⁷ evaluated the effectives of this strategy in reducing fetal demise and mortality before neonatal discharge. Using a before-and-after design in which they included 4187 neonates before the training and 5411 after the training, they found that cases of fetuses that did not respond adequately to neonatal resuscitation, considered as recent fetal demises (fetuses that did not initiate cardiac activity and were not macerated) went down from 3 to 2.3% (OR = 0.6; 95% CI: 0.59-0.98), although mortality before discharge was 0.1% during the two time periods. On the other hand, Msemo et al. ¹⁸ report that, after implementing training in the HBB strategy in eight hospitals in Tanzania during a period of 6 to 9 months, they found a substantial reduction in the frequency of neonatal deaths in the first 24 hours (RR=0.53; 95% CI: 0.43- 0.65) and in the proportion of recent fetal demises (RR = 0.76; 95% CI; 0.64-0.90); and in terms of the resuscitation steps, the use of stimulation and suctioning increased from 47 to 88% and from 15 to 22%, respectively.

Given that the implementation of the Helping Babies Breathe strategy requires a trained multidis- ciplinary team, the Colombian Ministry of Health and Social Protection, with the support of the Colombian Society of Neonatology and the regional health secretariats, has implemented since 2012 a series of workshops designed to train healthcare professionals involved in childbirth ¹⁹.

Little is known regarding the result of the implementation of this strategy in terms of compliance, acceptability, feasibility, relevance, costs, coverage, sustainability, or safety and efficacy ²⁰.

Hence the objective of this study of determining compliance with the Helping Babies Breathe strategy among professionals and medical interns providing care in the delivery room of a general, intermediate complexity institution.

MATERIALS AND METHODS

RESULTS

Overall, 151 neonates were finally included in the study (Figure 1); in the sampled population, there was a larger frequency of male neonates (56%), with an average birth weight of 3252 g (standard deviation [SD] ± 481); the average gestational age in the study population was 39 weeks (SD ± 1.27). Apgar scores were 8 at 1 minute and 9 at 5 minutes in 50% of the neonates, with 1% having an Apgar score between 1-3, 25% between 4-7, and 74% more than 8 (Table 1).

Figure 1 Distribution of neonates included in the study on adherence to the Helping Babies Breathe strategy in a Level II institution in Cali (Colombia), June-August, 2017 

Mothers of the neonates recognized themselves as being of mestizo ethnicity in 87% of cases; 8 out of 10 were living in free union; 40% had completed secondary education and only close to 3% had technical training; 90% lived in the urban area, and 87% belonged to the subsidized health insurance regime (Table 2).

In terms of the staff that executed the Helping Babies Breathe strategy, the majority (53%) were interns, followed by pediatricians (43%) and gynecologists (4%), the latter two having an average experience in the area of 7 years (SD ±6).

When adherence to the Helping Babies Breathe was evaluated by physician level of training, adherence among gynecologists was found to be 33.3% (95% CI: 4.3-77.7), and 65.6 (95% CI: 53.8-78.4) and 75.3% (95% CI: 64.8-85.1) among pediatricians and interns, respectively. As relates to the Helping Babies Breathe steps, highest compliance was found for positive pressure ventilation when there was poor response to initial stimulation (100%; 95% CI: 30-100) and for the availability and readiness of medical devices (98%; 95% CI: 94.3-99.5). Steps for which low compliance was found were placing the cap on the neonate’s head (64.9%; 95% CI: 56.7-72.4), followed by “skin-to-skin” contact between mother and baby (65%; 95% CI: 55.9-74.4) (Table 3).

Regarding time elapsed between the last training in neonatal resuscitation and the time of the study, 74% had received training more than 6 months before (64% more than one year before).

DISCUSSION

The initial few hours after birth are critical for neonatal survival ²¹. For this reason, knowing and correctly implementing strategies such as the “Helping Babies Breathe” is of the essence. The results found in this study show a 69% overall adherence Helping Babies Breathe strategy - 75.3% for interns, 65.6% for pediatricians and 33.3% for gynecologists- showing that adherence was inadequate. In terms of performing the steps comprised in the Helping Babies Breathe strategy, those with highest compliance were giving positive pressure ventilation when there was poor response, and having medical devices readily available; steps with the lowest compliance where placing the cap on the baby’s head and placing mother and baby in skin-to-skin contact.

Our results were superior to those reported by Lindback et al. ²², who found, after observing the resuscitation process in 1827 neonates through a video camera in a tertiary hospital in Nepal, that the healthcare staff failed to comply with most of the steps included in the neonatal resuscitation guidelines. They are also superior to those of Gelbart et al. ²³, who reported that more than 50% of the birth attendants in a referral hospital in Melbourne, Australia, failed to follow some of the guidelines for the initial approach and resuscitation of the neonate.

Regarding the steps comprised in the strategy, Pérez et al.²⁴, in the context of research conducted in two rural health centers in Nicaragua which assessed compliance with certain neonatal care practices before and after the implementation of the “Helping Babies Breathe” initiative, found that, before the implementation, attendants failed to comply with the step of skin-to-skin contact, while after the implementation, adherence was greater than 56%. On the other hand, when assessing umbilical cord care, they found 85% compliance after the intervention, similar to the figure reported in this study.

This finding adds to the report by Shikuku et al. ²⁵ in a total of 138 neonatal resuscitations carried out in the delivery room of the General Regional Hospital in Kakamega county in Kenia where they found adequate provision of bag and mask ventilation in 100% of cases of failed response to initial stimulation and airway maintenance. A warm environment was maintained in 71% of cases. It was found that warm babies were associated with survival in the first hour of life (OR = 3.3; 95% CI: 1.2-8.8).

As relates to the strengths of this study, it is important to highlight that a pilot test was performed before the observation exercise with the aim of verifying the relevance of the checklists implemented. Moreover, the use of random sampling minimizes the possibility of selection bias.

As far as weaknesses are concerned, it is important to mention that the number of obstetricians and gynecologists included was low, deliveries were not discriminated by attendance hours, and there was no follow-up of the neonates after the first minute. Additionally, considering that nurses and residents did not act as the main leaders in the care of the neonates included in the study, compliance by these healthcare professionals was not measured.

CONCLUSIONS

Results pertaining to the degree of adherence by healthcare staff point to the need of setting up continuing education and evaluation processes for the application of this proven strategy in institutions providing childbirth care services.