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Aim: In Ghana, institutional delivery has been emphasized to improve maternal and newborn outcomes. The Making Every Baby Count Initiative, a large coordinated training effort, aimed to improve newborn outcomes through government engagement and provider training across four regions of Ghana. Two newborn resuscitation training and evaluation approaches are described for front line newborn care providers at five regional hospitals. Methods: A modified newborn resuscitation program was taught at the Greater Accra Regional Hospital (GARH) and evaluated with real-time resuscitation observations. A programmatic shift, led to a different approach being utilized in Sunyani, Koforidua, Ho and Kumasi South Regional Hospitals. This included Helping Babies Breathe (HBB) and Essential Care for Every Baby (ECEB) training followed by objective structured clinical examinations (OSCE) with manikins at fixed intervals. Data was collected on training outcomes, fresh stillbirth and institutional newborn mortality rates. Results: Training was conducted for 412 newborn care providers. For 120 staff trained at GARH, resuscitation observations and chart review found improvements in conducting positive pressure ventilation. For 292 providers that received HBB and ECEB training, OSCE pass rates exceeded 90%, but follow-up decreased from 98% to 84% over time. A decrease in fresh stillbirth and institutional newborn mortality occurred at GARH (p < 0.05), but not in the other four regional hospitals. Conclusion: Newborn resuscitation training is warranted in low-resource settings; however, the optimal training, monitoring and evaluation approach remains unclear, particularly in referral hospitals. Although, mortality reductions were observed at GARH, this cannot be solely attributed to newborn resuscitation training.
Ghana is a West African country with a health system comprised of community-based health centers at the lowest level, district hospitals at the intermediate level, and regional hospitals and teaching hospitals at the highest level. Neonatal resuscitation training was conducted in five regional hospitals for healthcare workers directly involved in childbirth and newborn care, primarily midwives, neonatal nurses, nurse anesthetists and doctors, using two methodologies described below. Initially, structured observations of real-time midwife resuscitation practices were conducted using a modified AHA/AAP NRP integrated skills station performance checklist.13 Observations were conducted six to nine months before and following training in the labor ward and obstetric theatre by NRP certified healthcare providers from the United States (US) familiar with the local setting. The training content, adapted from the NRP 6th Edition, included: Principles of Resuscitation, Initial Steps of Resuscitation, Use of Resuscitation devices for Positive-Pressure Ventilation (PPV), and Chest Compressions.13,18 Six US based NRP instructors (one neonatologist, one neonatology fellow, one pediatrician, and three registered labor and delivery nurses) visited Ghana for 10–14 days at 3- to 4-month intervals to conduct observations, training, supportive supervision and bedside mentoring. Each NRP training was a one-day, 4-h session at the GARH. A pilot course was delivered in September 2014 to determine appropriateness for this setting. In January 2015, seven training sessions were conducted over two weeks with one additional session in December 2015 for newly hired or previously untrained midwives. Training was context specific, addressing pre-training performance gaps identified through the structured observations. At the beginning and end of each session, participants completed a 20-question multiple choice examination provided in the NRP textbook.13 During training, participants had opportunities to practice resuscitation techniques on mannequins including drying and stimulation, clearing the airway, providing PPV with a self-inflating bag, administering chest compressions, and coordinating chest compressions with PPV. Hands-on coaching was given to each participant to facilitate learning. In addition, two motivated labor ward midwives were trained to become neonatal resuscitation instructors at the GARH. Data were collected on resuscitation provided for GARH delivered newborns with Apgar scores of 0–3 and neonatal intensive care unit (NICU) admissions for birth asphyxia. We concentrated on newborns with Apgar scores of 0–3, because these would have uniformly required PPV. Data were manually extracted from logbooks and patient folders or electronically extracted via a Microsoft Access database. Electronic data were inputted by local data collectors employed by the GHS, unaffiliated with the training program and validated. The MEBCI program targeted the Ashanti, Brong Ahafo, Eastern and Volta regions, which included the Kumasi South, Sunyani, Koforidua and Ho Regional Hospitals, respectively. A detailed assessment was conducted in each facility prior to training evaluating available equipment and medications, treatment protocols, laboratory services, staffing, infection prevention measures, waste management and delivery data. This information provided a baseline for facility readiness to implement training. Furthermore, training materials were provided to trainees for review. Training in HBB, ECEB and infection prevention was conducted systematically in a conference center over five days according to the following schedule: HBB (1.5 day), ECEB (2 days), infection prevention (1 day) and implementation planning (0.5 days). A written pre- and post-test were administered including 17 questions for HBB, 25 for ECEB and 8 for infection prevention. Each training session included 24 multidisciplinary trainees divided into four groups with one trainer per group. The training team included five physicians, midwives and nurses from England and the US and six master trainer midwives from the GHS. Training sessions were conducted during May (two sessions), July (four sessions) and September (four sessions) 2016 and January (two sessions) 2017. Following short dedicative presentations, hands on practice with manikins and role playing were incorporated. Trainees were immediately evaluated with standardized OSCEs in HBB and ECEB and were re-tested with the same scenarios in their respective hospitals at 4–6 weeks, 5–6 months and 12–13 months following training. Follow-up assessments were done by individuals unaffiliated with the training but familiar with the training program. At each follow-up visit, equipment and supply availability, cleaning techniques, hand-washing capability and delivery documentation were recorded and shared with hospital management. An allotment of resuscitation equipment was also dispensed at each regional hospital. Course participant and assessment score data were maintained using Excel 2013 (Version 15) and results were grouped by hospital. An external evaluator collected information on institutional deliveries, newborn deaths, fresh and macerated still births through manual extraction from logbooks and patient folders. Results with each training approach were analyzed using Chi-squared, paired t-test or a test of binomial proportions, as appropriate, with p < 0.05 as significant. Institutional review board approval was granted by Cincinnati Children’s Hospital Medical Center, Wake Forest University Health Sciences, and the GHS.
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