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Neonatal resuscitation and Immediate Newborn Assessment and Stimulation

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More Intervention Effect Estimate Summaries

Lee AC, Cousens S, Wall SN, Niermeyer S, Darmstadt GL, Carlo WA, Keenan WJ, Bhutta ZA, Gill C, Lawn JE. Neonatal resuscitation and immediate newborn assessment and stimulation for the prevention of neonatal deaths: a systematic review, meta-analysis and Delphi estimation of mortality effect. BMC Public Health 2011; 11(Suppl 3): S12.


  • Roughly 10 million (5-10%) of babies born annually require help to establish breathing at birth (1-6).
  • Each year 814,000 neonatal deaths (7) result from intrapartum-related events in term babies, previously referred to as “birth asphyxia” (8), and 1.03 million from complications of prematurity, such as respiratory distress syndrome) (9).
  • Immediate newborn assessment and stimulation includes immediate assessment, warming, drying and tactile stimulation of the newborn at birth.  
  • Basic newborn resuscitation is defined as airway clearing (suctioning if required), head positioning and positive pressure ventilation via bag and mask.  
  • Advanced newborn resuscitation is not addressed in this paper.
  • Increased momentum for scale up of neonatal resuscitation in low-middle income countries has resulted from the release of a simplified resuscitation algorithm and training package led by the American Academy of Pediatrics (, evidence that neonatal resuscitation with room air is effective, and a consortium of implementing partners.

Intervention Effects

Immediate Newborn Assessment and Stimulation

  • Because the quality of evidence is low, a Delphi panel of 18 experts was convened to estimate effect size
  • 10% reduction in intrapartum-related deaths (range 0-25%, IQR 5-15%)
  • 10% reduction in preterm deaths (range 0-20%, IQR 5-15%)

Basic Neonatal Resuscitation Training on Intrapartum-related Neonatal Deaths in Facilities

  • 30% reduction in intra-partum-related neonatal deaths (RR: 0.70, 95% CI 0.59-0.84) – 3 studies (moderate quality of evidence) - this estimate was used for the effect of facility-based basic neonatal resuscitation training (additional to assessment and stimulation alone).
  • 38% (RR: 0.62, 95% CI 0.41-0.94) reduction in early neonatal mortality (within 7 days of birth)

Basic Neonatal Resuscitation Training on Preterm Mortality Effect in Facilities

  • Because the quality of evidence is low, a Delphi panel of 18 experts was convened to estimate effect size
  • 10% reduction in preterm deaths from neonatal resuscitation, in addition to immediate assessment and stimulation (range 4-30%, IQR 10-20%)

Basic Neonatal Resuscitation (in addition to assessment and stimulation) on Neonatal Mortality in the Community

  • Because the quality of evidence is low, a Delphi panel of 18 experts was convened to estimate effect size
  • 20% reduction intrapartum-related mortality from basic neonatal resuscitation (range 10-50%, IQR 15-25%)
  • 5% reduction in preterm mortality from basic neonatal resuscitation (range 1-40%, IQR 5-10%)

Intervention Recommendation

  • There is evidence from facility-based studies in low and middle-income countries that neonatal resuscitation training reduces neonatal mortality from intrapartum-related events (i.e. “birth asphyxia”) by 30%, potentially saving 93,700 each year just by addressing missed opportunities for current facility births, and up to 192,000 babies at 90% coverage (10), only considering the effect on intrapartum-related neonatal deaths.

References from Lee Paper Cited Here

  1. Wall SN, Lee AC, Niermeyer S, English M, Keenan WJ, Carlo W, Bhutta ZA, Bang A, Narayanan I, Ariawan I, et al. Neonatal resuscitation in low-resource settings: what, who, and how to overcome challenges to scale up? Int J Gynaecol Obstet. 2009;107(Suppl 1):S47-62–S63-44.
  2. Deorari AK, Paul VK, Singh M, Vidyasagar D. Impact of education and training on neonatal resuscitation practices in 14 teaching hospitals in India. Ann Trop Paediatr. 2001;21(1):29–33. 
  3. Zhu XY, Fang HQ, Zeng SP, Li YM, Lin HL, Shi SZ.  The impact of the neonatal resuscitation program guidelines (NRPG) on the neonatal mortality in a hospital in Zhuhai, China. Singapore Med J. 1997;38(11):485–487. 
  4. World Health Organization. The World Health Report 2005- make every mother and child count. Geneva, Switzerland: World Health Organization; 2005. 
  5. Bang AT, Bang RA, Baitule SB, Reddy HM, Deshmukh MD.  Management of birth asphyxia in home deliveries in rural Gadchiroli: the effect of two types of birth attendants and of resuscitating with mouth-to-mouth, tube-mask or bag-mask. J Perinatol. 2005;25(Suppl 1):S82–91. 
  6. Textbook of Neonatal Resuscitation. 5. American Academy of Pediatrics; 2006. 
  7. Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, Jha P, Campbell H, Walker CF, Cibulskis R, Eisele T, Liu L, Mathers C. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet. 2010;375(9730):1969–1987. 
  8. Lawn JE, Lee AC, Kinney M, Sibley L, Caro WA, Paul VK, Pattinson R, Darmstadt GL. Two million intrapartum-related stillbirths and neonatal deaths: where, why, and what can be done? Int J Gynaecol Obstet. 2009;107(Suppl 1):S5-18–S19.
  9. Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? Where? Why? Lancet 2005, 365(9462): 891-900.
  10. Lawn J, Kinney M, Lee AC, Chopra M, Donnay F, Paul V, Bateman M, Bhutta Z, Darmstadt GL. Reducing intrapartum-related deaths and disability: can the health system deliver? International Journal of Gynecology and Obstetrics 2009. (10)

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