654 - Evaluation of resuscitation care in clinical practice through observations: formative implementation research for understanding the contributors to the “know-do” gap in bag-mask ventilation

Publication Number: 3633.654

Amy Mackay, University of Alabama School of Medicine, Birmingham, AL, United States; Albert Manasyan, University of Alabama School of Medicine, Birmingham, AL, United States; Rachel L. Benz, UAB, Birmingham, AL, United States; Jyoti Lakhwani, Centre for Infectious Disease Research in Zambia, Lusaka, Lusaka, Zambia; Rodia M. Mwiinga, University Teaching Hospital-Zambia, Lusaka, Lusaka, Zambia; Janet Turan, University of Alabama at Birmingham, Birmingham, AL, United States; Olakunle Alonge, University of Alabama at Birmingham School of Public Health, Birmingham, AL, United States; Waldemar Carlo, University of Alabama, Birmingham, AL, United States

Background: Early, effective, and continuous bag-mask ventilation (BMV) can be lifesaving for newborns not breathing at birth. A "know-do" gap persists in low-resource settings where providers have been trained in BMV, but adoption and effectiveness are inconsistent. A better understanding of the current contributors to BMV practices is necessary to co-design implementation strategies.

Objective: To explore the hypothesis that experience level, environmental factors, and translation of training to clinical practice contribute to the "know-do" gaps in BMV

Design/Methods: At the national tertiary referral teaching hospital in Lusaka, Zambia, where the annual delivery volume is ~9,500 births and 59% were cesarean sections in 2023, we collected data on the training and experience levels of providers working in labor and delivery (N=50). We then conducted direct observations using a structured checklist in a convenience sample of births (N=501), focusing on preparation before deliveries, resuscitation care performed at the time of birth, and delivery information (Figure 1). Descriptive statistics were reported by computing frequencies and percentages for categorical variables, as well as medians and interquartile ranges or means and standard deviations for continuous variables.

Results: Of the providers observed, 48/50 were college-educated midwives and 2/50 were registered nurses. 24/50 (48%) have less than 3 years of experience in delivery care. 28/50 (56%) had completed the Essential Newborn Care Course 1 and 2 (Table 1). Before delivery, providers consistently located the BMV device and placed it within 3 meters of the resuscitation area, and tested its functionality (99.8% and 99.4%, respectively). 59/501 (12%) of newborns received BMV with a median timing of 1 minute 16 seconds after birth (Q1: 01:02, Q3: 01:40), which was comparable between providers with less than 1 year and more than 5 years of experience. 59 of 142 liveborns not breathing by 30 seconds after birth, and 59 of 65 liveborns still not breathing by 60 seconds after birth, received BMV (Table 2). 0/5 (0%) of fresh stillbirths received BMV.

Conclusion(s): 41.5% of livebirths who did not breathe by 30 seconds after birth received BMV. BMV was initiated at a median time of 1 minute and 16 seconds after birth, and no fresh stillbirths received BMV. Improving the provision of BMV within the golden minute to newborns not breathing at birth and fresh stillbirths is needed. Further contributors to BMV practices will be explored to inform the co-design of a package of implementation strategies aimed at improving BMV practices.

Figure 1: Newborn Delivery Observation Guide
Observation guide for documentation of preparation for deliveries, early newborn care and delivery information. Three observers staffed the labor ward during the week, doing day and night shifts. Trained observers were nurses who received orientation to the observation duties, practiced with both simulated resuscitations, and received feedback on the quality of observation data entry.

Table 1: Midwife and Nurse Training and Experience Levels, n = 50


Table 2: Delivery Room Observations, n = 501 birth observations
1 - Stethoscope, umbilical cord palpation, pulse oximetry