Nigerian Journal of Paediatrics

An audit of some health facilities and equipment for neonatal resuscitation in south south Nigeria

Niger J Paediatr 2016; 43 (3): 197 – 200

ORIGINAL

Oloyede IP

An audit of some health facilities and

Udo PA

equipment for neonatal resuscitation

in south-south Nigeria

DOI:http://dx.doi.org/10.4314/njp.v43i3.8

Accepted: 19th April 2016

Abstract : Background: Neonatal

while three (11.5%) were private

Mortality rates continue to be

facilities. Of the government

Oloyede IP

(

)

high in spite of the general decline

owned facilities four were primary

Udo PA

in under-5 mortality rates in Nige-

health facilities (17.3%), 18 were

Department of Paediatrics,

University of Uyo Teaching Hospital,

ria. Available evidence has shown

secondary (78.4%), while only one

Uyo Akwa Ibom State, Nigeria.

that the availability of a skilled

(4.3%) was a tertiary health facil-

Email: isooloyede@yahoo.com

birth attendant and equipment for

ity. Most of the health facilities

basic neonatal resuscitation is

had annual deliveries, annual new-

necessary for the prevention of

born resuscitation and birth as-

early neonatal death which ac-

phyxiated babies in the 1-500

counts for majority of neonatal

range. All the Paediatricians were

mortality. This audit was , there-

in the tertiary health facility. Only

fore , carried out to identify the

three (11.5%) facilities had bag

quantity and quality of equipment

and mask and radiant warmer, re-

available for basic neonatal resus-

spectively, while only five (19.2%)

citation in some health facilities in

had radiant warmers.

southern Nigeria.

Conclusion: Equipment for basic

Methods: This was a cross sec-

neonatal resuscitation is grossly

tional questionnaire based study.

deficient in some health facilities

Data was obtained from health

in southern Nigeria. Therefore ,

care workers from 26 health fa-

urgent efforts should be made by

cilities who attended Neonatal

the stakeholders involved in the

resuscitation training workshops

delivery of child health services to

from June 2010 to November

provide basic resuscitation equip-

2012. Information obtained in-

ment to health facilities. This will

cluded type of health facility, ob-

contribute to a reduction in the

stetric and paediatric services

neonatal mortality rate in Nigeria.

provided and human and material

resources available for neonatal

Keywords: Neonatal, Resuscita-

resuscitation.

tion, Basic, Resuscitation, Equip-

Results: Twenty-three (88.5%)

ment.

were government owned facilities

Introduction

powerful interventions- vaccines, treatment for pneumo-

nia, diarrhoea, malaria and nutritional supplements and

The child survival indices of 2012 especially the under-5

bed nets target the leading cause of death for older chil-

dren. When it comes to the leading causes of newborn

mortality rate has shown substantial improvement over

the 1990 values. These improvements, however, have

deaths- prematurity, birth asphyxia and infection, simple

not been equitable over geographical regions and across

affordable tools to prevent and treat are often not avail-

the age ranges. In Nigeria, the significant improvement

able at all or not available in the right formulations for

newborns. Newborn deaths may therefore represent the

seen in the 2012 values over the 1990 values in under

five mortality rates (u-5MR) and infant mortality rates

final frontier for child survival. Identifying the facilities,

(IMR) (124/1000 live births vs 213/1000 live births and

public and private where large numbers of the most vul-

78/ 1000 live births vs 126/1000 live births , respec-

nerable women are delivering babies especially in the

tively) is not appreciable for the neonatal mortality rate

fifteen countries including Nigeria where 80% of mater-

(NMR) (39/1000 live births vs 42/1000 live births).

1,2

nal and newborn deaths are concentrated and investing

This further goes to buttress the fact that most of the

heavily in the quality of care provided in these facilities

is of utmost importance and will maximise impact.

improvements in the under-5 mortality rate is due to a

fall in the post neonatal mortality rates. Older children

have enjoyed the greater gains partly because the most

Neonatal care provided within the first few minutes of

198

life plays a major role in the reduction of neonatal mor-

102 per 1000 live births. These values are a lot higher

bidity and mortality. Internationally there is now con-

than the WHO recommended values. Most (>60%) of

siderable consensus on how newborn resuscitation

the births occur outside the health facility. There are 405

should be provided. It is believed that in 95% of cases,

health facilities in Akwa Ibom State; 361 are primary,

49 are secondary, with one tertiary health facility.

when it is required resuscitation should be possible with

only a minimum of equipment and without access to

We conducted neonatal resuscitation training (NRT)

intensive care skills or facilities.

7,8

Immediate newborn

using the American Academy of Paediatrics (AAP)

assessment and stimulation includes immediate assess-

training manual in conjunction with the State Ministry

ment, warming, drying and tactile stimulation at birth.

of Health, Akwa Ibom State with participants drawn

Basic resuscitation is defined as airway clearing

from 26 health facilities from the three senatorial dis-

(suctioning if required), head positioning and positive

tricts of the state. The participants were doctors and

pressure ventilation via bag and mask. Basic resuscita-

nurses from the primary through the tertiary health care

tion s has been shown to reduce neonatal mortality rate

facilities. The training occurred from June 2010 to

by 20% generally and preterm mortality in particular has

November 2012.

been reduced by 5%. However, in low income countries,

particularly in South Asia and sub-Saharan Africa,

The facilitators had been trained and certified in the

which account for over two thirds of the world’s neona-

NRT train-the trainers program of the AAP conducted

tal deaths, resuscitation is not available for the major-

by the Paediatric Association of Nigeria (PAN) in col-

ity of newborns who are born either at poorly staffed

laboration with the Latter day Saint’s Charities. The

and equipped first-level health facilities, or at home (60

studies were approved by the ethical committee of the

million births annually), where birth attendants may lack

University of Uyo Teaching Hospital

skills or may perform practices that delay effective ven-

A train-the-trainer educational programme utilized vari-

tilation. Given these challenges, achieving high cover-

ous teaching methods for participants learning including

age with basic neonatal resuscitation should be priori-

clinical practice sessions and demonstrations with man-

tized as advanced resuscitation is infrequently required

nequins and case scenarios to train health professionals.

and may have limited additional mortality impact in low

Two-day training programmes were held for not more

resource settings. To ensure a high proportion of all

than 60 participants at a time. These trainings were held

resuscitation episodes are appropriately managed clearly

biannually.

a large majority of providers must be trained.

How-

ever , the availability, accessibility and correct function-

The neonatal resuscitation course content included an in

ing of basic resuscitation equipment is still a missing

depth hands on training in basic knowledge and skills

essential pre-requisite for the successful training and

including initial resuscitation steps, bag and mask venti-

resuscitation itself in many settings. The provision of

lation, chest compression, endotracheal intubation,

resuscitation devices to help babies breathe is one of the

medications, ethics and end of life care. Mannequins

cost effective and evidence based but often overlooked

were used for the hands – on demonstrations and each

commodities for newborn health.

participant was encouraged to practice the skills taught

and observed. The training lasted for two days. Partici-

This audit of neonatal resuscitation equipments in health

pants filled a pre-training questionnaire indicating the

facilities in the state was , therefore , conducted as part of

annual number of deliveries and number of asphyxiated

a series of training of health workers in the state in neo-

babies in their facility, their resuscitation practices and

natal resuscitation using the American Academy of Pae-

the human and material resources available in their cen-

diatrics training manual on neonatal resuscitation. It is

tre for neonatal resuscitation. The list of equipments was

hoped that the outcome of this audit will help our health

derived from the neonatal resuscitation textbook of the

policy makers to prioritize equipment supply for neona-

American Academy of Paediatrics and adapted to our

local context. This was to enable us assess the prepar-

tal resuscitation to health facilities in the short term and

in the long term assist our trained health workers in re-

edness of the facilities for resuscitation and to assess if

suscitation, therefore improving our neonatal heath indi-

the participants had the equipments to work with after

ces and reducing neonatal deaths.

the training.

Data analysis

Methodology

The statistical package STATA (Stata Corp TX USA)

was used to analyze the data. Results were summarized

Akwa Ibom State is one of the states in south-south

as means and standard deviations and presented in ta-

Nigeria. It has borders with Abia, Cross River, Rivers

bles. A p-value of <0.05 was taken as statistically sig-

State and Cameroon. It is among the most recently cre-

nificant.

ated states in the nation. It has three senatorial districts

with 31 local government areas. It has a population of

3,902,051.

Most of the urban dwellers are civil ser-

vants, while the indigenous occupation of the people is

Results

farming and fishing. It has an infant mortality rate of 66

per 1000 live births and an under-five mortality rate of

Twenty-six health facilities were assessed for material

199

and human resources for neonatal resuscitation. Seven

asphyxiated babies in the 1-500 range. The tertiary

(26.9%) of the health facilities were in the Eket senato-

health facility was the only facility with greater than

rial district, 11 (42.3%) in Ikot Ekpene senatorial district

2000 deliveries per annum (precisely 5000-6000 births).

and Eight (30.8%) of the facilities were located in Uyo

The distribution of health professionals especially pae-

Senatorial district. Twenty-three (88.5%) were govern-

diatricians was quite low in the health facilities as

ment owned facilities while three (11.5%) were private

shown in table 4.

facilities. Of the government owned facilities four were

primary health facilities (17.3%), 18 were secondary

Table 3: Distribution of annual deliveries, new born resuscita-

(78.4%), while only one (4.3%) was a tertiary health

tion and birth asphyxia in some facilities in southern Nigeria

facility. Table 1 shows that most of the health facilities

Parameter

Fre-

quency

provide some level of obstetric care, while table 2 shows

None

501-

1001-

1501-

>2000

that neonatal intensive care is not provided by most of

500

1000

1500

2000

the health facilities.

Annual deliveries

Newborn resuscita-

tion

Table 1 : Spectrum of obstetric services provided by some

Asphyxiated babies

Health facilities in Southern Nigeria

‡

Services

Obstetric

ANC*

†

Yes

Table 4: Distribution of healthcare professionals in some

facilities in southern Nigeria

Health pro-

None

1-10

11-20

21-30

31-

41-50

>50

*Antenatal Care; ǂCaesarean Section; †Family Planning;

fessionals

‡Vaginal delivery

Skilled birth

attendants

Table 2: Spectrum of paediatric services provided by some

Midwives

Med officers

health facilities in Southern Nigeria

Obstetrician

NIC

‡

Services

POP*

PIP

Routine

Immunization

Paediatrician

NB care

†

Anaesthetist

Yes

The distribution of equipments for basic neonatal resus-

citation especially bag and mask (11.5%), radiant

*Paediatric Outpatient; Paediatric Inpatient; New-born;

†

warmer (11.5%) and pre-warmed towels (19.2%) were

‡

Neonatal Intensive Care

very poor in the health facilities as shown in table 5. On

the other hand , most facilities seemed to have the drugs

Table 3 shows that most of the health facilities had an-

required for advanced resuscitation as shown in table 6.

nual deliveries, annual newborn resuscitation and birth

Table 5: Distribution of basic newborn resuscitation equipments in some health facilities in southern Nigeria

Equipment

Neonatal

Suction

Stethoscope

Suction

Timers

Radiant

Pre-warmed

bag/mask

machine

catheter

warmer

towels

Yes (%)

3 (11.5)

19 (73.1)

24(92.3)

14 (53.8)

6 (23.1)

3(11.5)

5 (19.2)

No (%)

23 (88.5)

7 (26.9)

2 (7.7)

12 (46.2)

20 (76.9)

23(88.5)

21 (80.8)

owned with a highlight on the disparities among differ-

Table 6: Distribution of advanced newborn resuscitation

ent local governments in the state. Our results show a

equipment in some health facilities in southern Nigeria

general dearth of basic resuscitation equipment in our

Equipments

Yes (%)

No (%)

health facilities especially in the primary and secondary

Oxygen cylinders

14 (53.8)

12(46.2)

healthcare facilities. These results provide a possible

Oxygen concentrators

6 (23.1)

20 (76.9)

explanation for our inability to effectively bring down

Neonatal laryngoscope

2 (7.7)

24 (92.3)

the neonatal mortality rate in our country. This corrobo-

Endotracheal tubes

2 (7.7)

24 (92.3)

rates the already known fact that majority of new-borns

Nasogastric tube

20 (76.9)

6 (23.1)

are born either at poorly staffed and equipped first-level

Meconium aspirator

2 (7.7)

24 (92.3)

Umbilical catheter

2 (7.7)

24 (92.3)

health facilities, or at home. With the relatively low gov-

Resuscitaire

2 (7.7)

24 (92.3)

ernment funding of health of less than 5% of the Gross

0.9% saline

26 (100)

0 (0)

Development Product , and an increasing reliance on

10% D/W

22 (84.6)

4 (15.4)

household out-of- pocket expenditure for health, it is not

Adrenaline

25 (96.2)

1 (3.8)

surprising that provision of basic resuscitation equip-

8.4% Sodium bicarbonate

13 (50)

ment and skilled health personnel in the health facilities

Whole blood

17 (65.4)

9 (34.6)

are very poor. However, the availability of drugs (84-

100%) which are needed for advanced newborn resusci-

tation point to organisational and management deficien-

cies related to weak, fragmented and inconsistent link-

Discussion

ages between the different stakeholders in the delivery

of child health services. Moreover , the high burden of

The distribution of health facilities in the state is reflec-

annual deliveries in the tertiary centre compared to that

tive of that of the nation with 88.5% being government

seen in the primary and secondary centres likely results

200

from a combination of poverty, societal and cultural

different stakeholders that deliver child health services

factors which constitute barriers to accessing healthcare

on the provision of basic neonatal resuscitation equip-

in rural communities. In addition, this maybe an indica-

ment. This is particularly important in the absence of

tor of non-functional primary and secondary healthcare

high-technology innovations that are available in the

facilities or a lack of confidence in the operation of the

high income countries for the tertiary prevention and

treatment of neonatal encephalopathy.

primary and secondary health services by the populace.

In addition,

Our results also point to the inequalities in accessing

there is need for interventional studies in our setting to

healthcare at the different levels especially in the distri-

define strategies to overcome this challenges in order to

bution of health personnel where majority are found in

drive policy changes. Furthermore , there is an urgent

the tertiary institution. This brings up the need for staff

need to strengthen the Primary and Secondary health

recruitment to fill up the established posts in the periph-

care system to provide comprehensive and competitive

ery and the provision of essential equipment for basic

basic neonatal resuscitation services by encouraging

new-born resuscitation.

community ownership through informed decision mak-

ing and accountability of resources allocated to neonatal

The major limitation of this study was the fact that the

resuscitation services.

self-reported questionnaires used may give some room

for recall bias but considering the poor record keeping

Conflict of interest: None

prevalent in our setting it was difficult to get data from

Funding: None

an alternative source.

Acknowledgements

Conclusion

The authors wish to thank Akwa Ibom State Ministry of

Health for funding two of the training sessions and Nes-

In conclusion, basic neonatal resuscitation equipment is

tle Nutrition Institute Africa for funding one of the train-

largely unavailable in health facilities in South-south

ing sessions. We also acknowledge the help of Dr

Nigeria which may partly explain the prevailing high

Udeme Ekrikpo in Data Analysis.

infant mortality rate in this region.

We , therefore , recommend collaboration among the

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