Background: Substantial health care resources are expended on standardised formal neonatal resuscitation training (SFNRT) programmes, but their effectiveness has not been proven. Objectives: To determine whether SFNRT programmes reduce neonatal mortality and morbidity, improve acquisition and retention of knowledge and skills, or change teamwork and resuscitation behaviour. Methods: We searched CENTRAL, MEDLINE, PREMEDLINE, EMBASE, CINAHL, Web of Science and the Oxford Database of Perinatal Trials, ongoing trials and conference proceedings in April 2015, and included randomised or quasi-randomised trials that reported at least one of our specified outcomes. Results: SFNRT in low- and middle-income countries decreased early neonatal mortality [risk ratio (RR) 0.85 (95% CI 0.75-0.96)]; the number needed to treat for benefit [227 (95% CI 122-1,667; 3 studies, 66,162 participants, moderate-quality evidence)], and 28-day mortality [RR 0.55 (95% CI 0.33-0.91); 1 study, 3,355 participants, low-quality evidence]. Decreasing trends were noted for late neonatal mortality [RR 0.47 (95% CI 0.20-1.11)] and perinatal mortality [RR 0.94 (95% CI 0.87-1.00)], but there were no differences in fresh stillbirths [RR 1.05 (95% CI 0.93-1.20)]. Teamwork training with simulation increased the frequency of teamwork behaviour [mean difference (MD) 2.41 (95% CI 1.72-3.11)] and decreased resuscitation duration [MD -149.54 (95% CI -214.73 to -84.34); low-quality evidence, 2 studies, 130 participants]. Conclusions: SFNRT in low- and middle-income countries reduces early neonatal mortality, but its effects on birth asphyxia and neurodevelopmental outcomes remain uncertain. Follow-up studies suggest normal neurodevelopment in resuscitation survivors.

The fourth Millennium Development Goals (MDG-4) commits to reducing mortality in children aged younger than 5 years of age [1]. Neonatal deaths account for a significant proportion of deaths in children less than 5 years. It is estimated that 2.76 million neonates died worldwide in 2013, and the most common causes were preterm birth complications, birth asphyxia and neonatal sepsis [2]. The vast majority of these neonatal deaths (98%) occurred in the middle- and low-income countries where asphyxia accounted for approximately one quarter of all the deaths [3]. It is estimated that approximately 10% of all newborns require some assistance at birth and less than 1% require extensive resuscitation [4]. However, although early neonatal depression is common, it is difficult to predict prior to birth, and the need for resuscitation may be anticipated in only 50% of cases [5]. Therefore, the universal presence of personnel adequately prepared to perform resuscitation is an important first step in newborn resuscitation.

There are significant variations in the presence of skilled personnel at newborn resuscitation. In South Asia and sub-Saharan Africa, only about one third of women deliver in the presence of a skilled birth attendant [6]. In the developed world, debate continues around the area of planned home births. A recent meta-analysis has found that there is a tripling of neonatal mortality in planned home deliveries [7]. Some of this increase has been attributed to inadequate training in newborn resuscitation [7].

In the past, there has been great variation in neonatal resuscitation practices, but this has been addressed recently with the introduction of standardised formal neonatal resuscitation training (SFNRT) programmes. Numerous neonatal resuscitation programmes exist, including the NRP (Neonatal Resuscitation Programme), NLS (Neonatal Life Support) and ENLS (European Neonatal Life Support). The NRP was introduced in 1987 in the US, and there are now over 24,000 NRP instructors in the US and over two million people trained in NRP. It is now taught in over 140 countries worldwide. In the middle- and low-income countries, resuscitation programmes often form a part of an overall newborn care intervention package [8], and an SFNRT has been specifically developed as part of this package, Helping Babies Breathe (HBB). Since its launch in 2010, the HBB has been introduced in 77 countries and well over 160,000 birth attendants have been trained and equipped [9]. ILCOR (the International Liaison Committee on Resuscitation) [4] presents scientific statements, addresses consensus on cardiopulmonary resuscitation science statements and prepares treatment recommendations for resuscitation, including the newborn infant.

While neonatal resuscitation training programmes may differ both in their content and format, they generally include a theoretical knowledge-based component and a practical, skill-based component. Standardised programmes have a fixed content and course set for the programme, and formal standardised programmes are defined by the intended and focused teaching session as opposed to teaching at the bedside or during resuscitation.

The purpose of neonatal resuscitation education is to translate the science of resuscitation into a training programme, allowing transfer of the knowledge and skills of resuscitation into improved clinical practice with the ultimate goal being to reduce neonatal morbidity and mortality. Therefore, every resuscitation education programme should be rigorously evaluated to verify that it is both valid and effective. In addition, substantial health care resources are expended on standardised, formal resuscitation training programmes. Our primary aim was to determine the effectiveness of SFNRT programmes in reducing mortality and morbidity in the newborn infant. Our secondary aim was to determine the effect of SFNRT on changing health care provider behaviour, acquisition of knowledge and skills, and retention of knowledge and skills.

Procedures

The guidelines from the Cochrane Neonatal Review Group (CNRG; http://neonatal.cochrane.org/) were applied. We followed the PRISMA guidelines for reporting systematic reviews and meta-analyses [10] and the GRADE methodology to evaluate evidence as low-, moderate- and high-quality evidence [11]. We included randomised, cluster-randomised or quasi-randomised trials of SFNRT programmes to train health care professionals caring for newborns at delivery.

Definitions

We defined SFNRT broadly as programmes which include the essential elements of teaching and testing resuscitation skills by instructors who are certified by a national or international body that oversees resuscitation. Resuscitation programmes may include content in addition to the essential elements (such as behavioural training or boosters), use any instructional format (didactic vs. simulation) and may include single or multiple sessions. Resuscitation programmes may use lecture- or video-based didactics, teaching skills in interactive sessions using mannequins and simulation based on real-life scenarios using low- or high-fidelity mannequins, or be virtual or computer based.

Our primary outcome was neonatal mortality, which was defined as death in the first 28 days of life. Subgroup categories for neonatal mortality were early neonatal mortality (death in the first 7 days of life) and late neonatal mortality (death between 8 and 28 days of life). We also derived data for the outcomes of stillbirths (fresh stillbirths) and perinatal deaths (stillbirths + deaths in the first 7 days of life). Stillbirths will be defined as babies born after 6 months of gestation without any movement, spontaneous breathing or heartbeat during or after the delivery [12] and fresh stillbirths as stillbirths with absence of maceration [13].

Secondary outcomes were measures of neonatal morbidity, changes in health care professional and resuscitation team behaviour, and acquisition and retention of knowledge and skills. Neonatal morbidity was defined as follows:

(i) Hypoxic ischaemic encephalopathy - moderate to severe encephalopathy defined using a combination of clinical and biochemical parameters. This is defined as follows: in infants >36 weeks of gestation, either cord or arterial pH <7 or base deficit >16 within the 1st h of life OR if there is no blood gas, or cord/arterial pH 7-7.15 and base deficit between 10 and 16, then additional criteria of a history of an acute perinatal event and Apgar scores <5 at 10 min OR need for mechanical ventilation at 10 min of age [14];

(ii) In view of unavailability of biochemical measures of defining hypoxic ischaemic encephalopathy in low- and middle-income countries, we also used the WHO definition of birth asphyxia, namely failure to initiate or sustain normal breathing at birth, as determined by the birth attendant [15];

(iii) Low Apgar scores defined as a 10-min Apgar score <5;

(iv) Seizure: electroencephalographically confirmed seizure within 72 h of birth;

(v) Hypothermia (defined as a temperature <36°C) on admission to the neonatal unit [16];

(vi) Admission to the neonatal unit in randomised infants including those requiring resuscitation;

(vii) Meconium aspiration syndrome - defined as respiratory distress in an infant born through meconium-stained amniotic fluid whose symptoms cannot be otherwise explained [17];

(viii) Neurodevelopmental outcome at 18-24 months as assessed by a validated tool.

We also evaluated change in health care professional and resuscitation team behaviour, and acquisition and retention of knowledge and skills. Our search strategy and databases searched are attached in the online supplementary file (available at www. karger.com/doi/10.1159/000443875).

Data Collection and Analysis

Review authors (M.P. and E.M.D.) independently assessed the titles and the abstracts of studies identified by the search strategy for eligibility for inclusion. Two authors separately extracted, assessed and coded all data for each included study. We used the standardised review methods of the CNRG to assess the methodological quality of the studies. We performed statistical analysis according to the recommendations of the CNRG and used the statistical package RevMan 5.3 [18] as recommended by the Cochrane handbook [19]. We used the fixed-effect model for meta-analyses. In cluster-randomised trials (CRTs) that were analysed appropriately at the cluster level using the intra-cluster coefficient (ICC), the summary estimate was used to generate the natural logarithm of the risk ratio (RR) and the standard error of the logarithm of RR, entered in RevMan and meta-analysed using the generic inverse-variance method. In CRTs that were not analysed at the cluster level, where the ICC was available, we calculated the design effect using the ICC and adjusted the sample size for analyses. If the ICC was not available, we used an assumed ICC from similar trials [ICC from [12] or [20]] or performed approximate analysis as recommended [19]. When the ICC could not be assumed due to variability in the study design or outcome, we summarised the results without meta-analysis. We assessed heterogeneity of treatment effects between trials using the I2 statistics to check the appropriateness of pooling data and performing meta-analysis. Meta-analysis was deferred if heterogeneity was high (>75%).

The inclusion process from the search strategy to inclusion of articles into our review is outlined in the PRISMA flow diagram (fig. 1). Details on the 14 included studies are reported in table 1 and the 29 excluded studies with reasons for exclusion in table 2. Two studies presented as abstracts (Campbell and Finan [21] and Yamada et al. [22]) and 1 ongoing study (Bang et al. [23]) are awaiting classification as no data were available and thus not included. Methodological assessment of the studies included was performed along established guidelines [19]. Risk of bias in included studies is reported in table 3.

Table 1

Characteristics of the studies included

Characteristics of the studies included
Characteristics of the studies included
Table 2

Studies excluded

Studies excluded
Studies excluded
Table 3

Risk of bias

Risk of bias
Risk of bias
Fig. 1

PRISMA flow diagram detailing study inclusion. Fourteen studies met the inclusion criteria and 8 studies were included in data synthesis by meta-analysis.

Fig. 1

PRISMA flow diagram detailing study inclusion. Fourteen studies met the inclusion criteria and 8 studies were included in data synthesis by meta-analysis.

Close modal

Effects of Neonatal Resuscitation Training on Neonatal Mortality, Stillbirth and Neonatal Complications

In community-based CRTs, where birth attendants were randomised to SFNRT in addition to basic resuscitation training, the estimated RR showed a reduction in early neonatal mortality: RR 0.88 (95% CI 0.78-1.00). Using the approximate analysis method [19], the estimated RR was 0.85 (95% CI 0.75-0.96) and the risk difference was -0.0044 (95% CI -0.0082 to -0.0006), which implies a number needed to treat for benefit of 227 (95% CI 122-1,667; 3 CRTs, 66,162 participants, moderate-quality evidence; fig. 2a).

Fig. 2

a Forest plot of studies reporting RRs with 95% CIs for early neonatal mortality. Derived from approximate analyses method where the sample size is reduced by the design effect (dependent on ICC and mean size of the cluster) and using the Mantel-Haenszel (M-H) method and a fixed-effect model for meta-analyses. RevMan 5.3 was employed for the analyses and generation of forest plots. b Forest plots of subgroup analysis of traditional birth attendants who were trained and attended deliveries, reporting RR with 95% CIs for early neonatal mortality. The generic inverse-variance (IV) method was used with a fixed-effect model. RevMan 5.3 was used for the analyses and generation of forest plots.

Fig. 2

a Forest plot of studies reporting RRs with 95% CIs for early neonatal mortality. Derived from approximate analyses method where the sample size is reduced by the design effect (dependent on ICC and mean size of the cluster) and using the Mantel-Haenszel (M-H) method and a fixed-effect model for meta-analyses. RevMan 5.3 was employed for the analyses and generation of forest plots. b Forest plots of subgroup analysis of traditional birth attendants who were trained and attended deliveries, reporting RR with 95% CIs for early neonatal mortality. The generic inverse-variance (IV) method was used with a fixed-effect model. RevMan 5.3 was used for the analyses and generation of forest plots.

Close modal

For every 227 deliveries occurring in a setting where health care workers have been trained in SFNRT, there is 1 fewer neonatal death. We downgraded the quality of evidence from high to moderate quality as the participants were not blinded to the intervention and also due to inconsistency in the direction of the effects across studies (heterogeneity, I2 = 71%). Studies by Carlo et al. [20,24] did not report a decrease in neonatal mortality, whereas Gill et al. [12], who included only traditional birth attendants, showed a significant decrease in early neonatal mortality in the intervention group. In subgroup analyses, training of traditional birth attendants in neonatal resuscitation decreased early neonatal mortality: RR 0.79 (95% CI 0.65-0.95; 3 CRTs, 27,673 participants, moderate-quality evidence; fig. 2b). One CRT [12] reported no differences in late neonatal mortality in 3,274 neonates [RR 0.47 (95% CI 0.20-1.11); 1 study, low-quality evidence] but a decreased neonatal mortality at 28 days in 3,355 neonates [RR 0.55 (95% CI 0.33-0.91); 1 study, low-quality evidence]. Studies by Opiyo et al. [25] and Xu et al. [26] reported on mortality or morbidity but not as defined in our protocol, and hence they were not included in the meta-analyses.

Resuscitation behaviour related to the use of bag mask ventilation by health care providers was reported in 3 CRTs that enrolled 29,664 neonates, but heterogeneity was high (I2 = 95%) and meta-analysis was deferred. The quality of evidence was downgraded to low as the participants were not blinded to the intervention and due to the inconsistent effects across studies. A significant increase in the use of bag mask ventilation was reported by Carlo et al. [20] in 2010 [RR 1.18 (95% CI 1.04-1.33)] and Gill et al. [12] in 2011 [RR 29.50 (95% CI 9.39-92.65)], but was not significant in another study by Carlo et al. [24] in 2010 [RR 0.85 (95% CI 0.63-1.15)].

We also performed a meta-analysis on stillbirths and perinatal deaths by the approximate analysis method. Carlo et al. [13] did not include a definition of stillbirths in their study although they define fresh stillbirth as absence of maceration. Gill et al. [12] defined stillbirth, but data on fresh stillbirths were not separately available. There was no significant difference in the rate of fresh stillbirths when SFNRT was compared with early newborn care, RR 1.05 (95% CI 0.93-1.20; fig. 3) or in the rate of all stillbirths [RR 1.04 (95% CI 0.93-1.15); 3 CRTs, 62,366 births, moderate-quality evidence]. Perinatal mortality showed a decreasing trend with borderline statistical significance [RR 0.94 (95% CI 0.87-1.00); 3 CRTs, 62,152 live births, moderate-quality evidence; fig. 4]. None of the trials reported the following relevant outcomes related to neonatal morbidity: neonatal outcomes of hypoxic ischaemic encephalopathy, low Apgar scores (<5) at 10 min, seizure, hypothermia, admission to the neonatal unit, meconium aspiration syndrome, long-term neurodevelopmental outcome at 2 years or mortality during initial hospitalisation.

Fig. 3

Forest plots of studies reporting RRs with 95% CIs for stillbirths. Derived from approximate analyses method where the sample size is reduced by the design effect (dependent on ICC and mean size of the cluster) and using the Mantel-Haenszel (M-H) method and a fixed-effects model for meta-analyses. RevMan 5.3 was used for the analyses and generation of forest plots.

Fig. 3

Forest plots of studies reporting RRs with 95% CIs for stillbirths. Derived from approximate analyses method where the sample size is reduced by the design effect (dependent on ICC and mean size of the cluster) and using the Mantel-Haenszel (M-H) method and a fixed-effects model for meta-analyses. RevMan 5.3 was used for the analyses and generation of forest plots.

Close modal
Fig. 4

Forest plots of studies reporting RRs with 95% CIs for perinatal deaths. Derived from approximate analyses method where the sample size is reduced by the design effect (dependent on ICC and mean size of the cluster) and using the Mantel-Haenszel (M-H) method and a fixed-effect model for meta-analyses. RevMan 5.3 was used for the analyses and generation of forest plots.

Fig. 4

Forest plots of studies reporting RRs with 95% CIs for perinatal deaths. Derived from approximate analyses method where the sample size is reduced by the design effect (dependent on ICC and mean size of the cluster) and using the Mantel-Haenszel (M-H) method and a fixed-effect model for meta-analyses. RevMan 5.3 was used for the analyses and generation of forest plots.

Close modal

Teamwork Behaviour and Resuscitation Duration after Teamwork Training

Two randomised trials by Thomas et al. [27,28] reported teamwork behaviour in 130 participants after supplementing SFNRT with teamwork training. Teamwork behaviours, information sharing, inquiry, assertion, teaching and advising, managing workload and vigilance were assessed by observations of the frequency or duration. Inquiry, information sharing, assertion, teaching and advising were measured as rates (behaviours/min), whereas workload management and vigilance were measured as a percentage of simulation time.

Teamwork training increased the frequency of ‘any teamwork behaviour' (reported as behaviours/min): mean difference (MD) 2.41 (95% CI 1.72-3.11; fig. 5). Heterogeneity was low (I2 = 0%). Components of teamwork behaviour that increased after teamwork training were (MD) information sharing [0.84 behaviours/min (95% CI 0.55-1.13)], inquiry [0.29 behaviours/min (95% CI 0.15-0.43)] and managing workload [9.93% of simulation time (95% CI 6.14-13.73)]. Teamwork behaviour related to teaching or advising [0.08 behaviours/min (95% CI -0.01 to 0.16)], assertion [0.68 behaviours/min (95% CI 0.33-1.03)] and vigilance [0.20% of simulation time (95% CI -0.13 to 0.53)] did not significantly increase after teamwork training. We downgraded the quality of evidence to low as evidence was from only 2 studies from a single institution, unclear allocation concealment and imprecision of the estimate with wide CIs. Two randomised trials [27,28] reported on the duration to complete resuscitation in 130 participants after teamwork training with SFNRT, and the estimated MD showed a decrease in resuscitation duration: MD -149.54 s (95% CI -214.73 to -84.34; fig. 6). We downgraded the quality of evidence to low as evidence was from only 1 study from a single institution, unclear allocation concealment and imprecision of the estimate with wide CIs.

Fig. 5

Forest plot of studies reporting MD with 95% CIs for teamwork behaviour. Subgroups of teamwork behaviour with versus without teamwork training were compared. The inverse-variance (IV) method was used with a fixed-effect model. RevMan 5.3 was used for the analyses and generation of forest plots.

Fig. 5

Forest plot of studies reporting MD with 95% CIs for teamwork behaviour. Subgroups of teamwork behaviour with versus without teamwork training were compared. The inverse-variance (IV) method was used with a fixed-effect model. RevMan 5.3 was used for the analyses and generation of forest plots.

Close modal
Fig. 6

Forest plot of studies reporting MD with 95% CIs for resuscitation duration (in s) with or without teamwork training. The inverse-variance (IV) method was used with a fixed-effect model. RevMan 5.3 was used for the analyses and generation of forest plots.

Fig. 6

Forest plot of studies reporting MD with 95% CIs for resuscitation duration (in s) with or without teamwork training. The inverse-variance (IV) method was used with a fixed-effect model. RevMan 5.3 was used for the analyses and generation of forest plots.

Close modal

One randomised trial [28] reported on NRP performance scores in 98 participants after teamwork training with SFNRT. The estimated MD in the NRP scores between the intervention and the control groups was 1.40 (95% CI -2.02 to 4.82). We downgraded the quality of evidence to low as evidence was from only 1 study from a single institution, unclear allocation concealment and imprecision of the estimate with wide CIs.

Resuscitation Knowledge, Skills and Resuscitation Performance Scores

In the CRT by Dunn et al. [29], which included 166 participants, the proportion of participants who scored more than 80% on an evaluation of their knowledge of neonatal resuscitation by means of a multiple-choice examination increased after training from 36 to 91%, compared to 15% in the controls. None of the subjects scored 100% on the skills before the test (using structured evaluation of a mock code involving a mannequin), but 100% of the intervention group did so after the test. Eighty-five percent of the intervention group and 23% of controls passed the knowledge multiple-choice test with a score of 80% or more. None of the participants in either group passed the skill test (mock code) 6 months after the SFNRT. In the other CRT by Xu et al. [26], the mean knowledge acquisition scores (SD) were 9.2 (1.2) in the intervention group and 8.4 (1.5) in the control group (p < 0.0001). Both CRTs were incorrectly analysed at the level of the individual and hence not included in the meta-analysis. The quality of evidence was rated very low because of unit of analysis error and evidence available from only 2 studies. In randomised studies, Lee et al. [30] and Rubio-Gurung et al. [31 ]reported on resuscitation scores and team scores. We are awaiting more data to be considered for inclusion in the meta-analyses.

Two trials [32,33] reported the effect of NRP boosters on retention of knowledge and skills. One trial [17] evaluated ‘hands on' and video boosters on knowledge and skill retention in 187 participants and found no differences in knowledge retention after hands on booster [MD 7.00 (95% CI -2.87 to -16.87)], video booster [MD 4.00 (95% CI -9.72 to 17.72)] or any booster [MD 5.50 (95% CI -4.37 to 15.37)]. There were no significant differences in skill retention after ‘hands on' booster [MD 5.00 (95% CI -3.18 to 13.18)], video booster [MD 6.00 (95% CI -1.16-13.16)] or any booster [MD 5.48 (95% CI -1.07 to 12.03)]. Another trial [19] reported on the knowledge and skill retention after a simulation booster 7-10 months after NRP and assessed 15-18 months after NRP. The study found increases in procedural skills (scores of 18.8 vs. 16.2, p = 0.02) and behaviour (scores of 71.6 vs. 68.1, p = 0.02) but not in knowledge scores (scores of 71.6 vs. 68.1, p = 0.57). We downgraded the quality of evidence for boosters to very low as evidence was from only 2 studies and also the high risk of selection, performance and attrition biases.

Two trials reported on decision support tools during resuscitation [34,35]. In a randomised study of a cognitive aid (poster) during a resuscitation scenario, Bould et al. [34] reported no differences in resuscitation technical scores [median 20.3, interquartile range (IQR) 18.3-21.3, range 15.0-24.3 with intervention vs. median 18.2, IQR 15-20.5, range 10.7-25.3 with control] or scores of Anaesthetists' Non-Technical Skills (median 10.2, IQR 9.5-11, range 7.2-13.7 with intervention vs. median 9.3, IQR 7.8-10.3, range 5.3-14 with control). Fuerch et al. [35] randomised 65 participants to an electronic decision support tool with prompts and reported that positive pressure ventilation was performed correctly more frequently (94-95% with intervention vs. 55-80% with control, p < 0.0001) as well as cardiac compressions (82-93% with intervention vs. 71-81% with control, p < 0.0001); FiO2 was adjusted three times more frequently in the intervention group compared to the control group.

Meta-analyses of data from 3 community-based CRTs suggest that SFNRT results in a reduction in early neonatal mortality in the low- and middle-income countries, where birth attendants had previously received training in basic newborn care. These well-designed, large, community-based studies provide moderate-quality evidence supporting the efficacy of newborn resuscitation training programmes in improving neonatal outcomes. The greatest reduction in mortality was seen in the community where births were attended by SFNRT-trained traditional birth attendants. All three studies are from low- and middle-income countries, where baseline neonatal mortality rates are high, and so these findings cannot be directly extrapolated to high-income countries, where neonatal mortality is already much lower, and where resuscitation training programmes are considered the standard of care and required for accreditation of training in newborn care.

The classification of a birth as a live birth or a stillbirth can be affected by training in neonatal care programmes, which can influence the denominator in the calculation of mortality rates in the perinatal period. In 2010, Carlo et al. [20] showed a marked reduction in stillbirth rates, as babies previously thought to be stillborn were then recognised to be depressed but to have a potential for survival after the introduction of the Early Newborn Care programme. Recently, the HBB programme has also reported a similar occurrence [36]. Our meta-analysis of the 3 CRTs of SFNRT in this review did not show differences in fresh stillbirths or all stillbirths (both fresh and macerated) after SFNRT compared to the Early Newborn Care programme. Absence of differences in stillbirths may be because the universal introduction of the Early Newborn Care programme had already achieved appropriate designation of stillbirths.

We report in this review that for every 227 births attended by personnel trained in NRP there was 1 neonatal death less - an important finding. If 1 trained attendant attends 1,000 births per year, then there will be 4 deaths prevented, resulting in a significant reduction in neonatal mortality. This figure translates into 80 fewer deaths over 20 years: 1 training course, 8 refresher courses resulting in 80 fewer deaths (32 h spent on mandatory courses, which translates into almost 3 deaths prevented per hour spent on the course). This is an astonishing figure, and in those parts of the world with the highest perinatal mortality, such as sub-Saharan Africa [37], major impacts on neonatal mortality are possible. We estimate that if every birth was attended by personnel trained in SFNRT, then 140,000 lives would be saved annually.

As there were no data analysable on neonatal morbidities, we cannot be certain from this review that there was no increase in morbidity associated with the increase in survival. If a substantial number of survivors had morbidities, especially permanent morbidities, then the burden imposed on low-income countries by introducing SFNRT could be large. However, recently reported follow-up cohort studies suggest normal neurodevelopment in resuscitation survivors. Carlo et al. [38] have reported that resuscitated children from a low-income country did not have an excess of neurologic or developmental morbidity to 12 months of age and a second observational study has come to the same conclusion; the large majority of infants who required resuscitation at birth had normal development up to 36 months of age [39].

In view of the clear benefit, lack of harm and good long-term outcomes of resuscitated infants, it may not be reasonable to continue to perform other studies of SFNRT compared to no training. The efficacy and cost benefits of SFNRT may vary by setting, health care provider and by whether the health care providers are already trained in basic newborn care, and therefore future studies may be needed to address these issues. In contrast, different methods of training providers, and different interventions and equipment are certainly worth comparing in prospective randomised trials. Assessment of methods to reduce cost and increase efficacy of training programmes will be important to allow wider dissemination of SFNRT in low- and middle-income countries.

Despite the importance of SFNRT, there is a paucity of high-quality evidence regarding methods of teaching the programmes. We could find no evidence from randomised trials that simulation-based training was preferable to non-simulation-based SFNRT, and the evidence from randomised trials suggests that high-fidelity simulation was no more effective than low-fidelity simulation [40]. This is important considering the financial costs of high-fidelity training. Retention of knowledge and skills is poor, and there are little reliable data about how to improve retention. Further studies of effective ways of teaching and maintaining skills in neonatal resuscitation are needed in order to further increase the impact of these programmes.

The precise composition of the programmes has also not been well studied. New programmes, such as HBB (http://www.helpingbabiesbreathe.org/about.html), with a reduced requirement for very advanced skills, seem effective from before/after studies and are tailored to the environment in which many deliveries occur. However, the individual components of such programmes warrant investigation, since training different ways to administer positive pressure breaths, as one example, could have a big influence on the effectiveness of a programme. Resuscitation devices are central to neonatal resuscitation in low- and middle-income countries, and have been named as 1 of 4 commodities for saving newborn lives in a recent UN report. The design, durability, availability and costs of current resuscitation devices pose significant barriers to the dissemination of newborn resuscitation. The bag mask devices, currently available, consist of many parts, making them difficult to disassemble and clean. Consideration should be given to alternative bag masks, such as the Laerdal Global Health ‘upright' bag mask, which was designed to be easier to use, easier to clean due to fewer parts and cheaper than standard devices [41]. The upright stance of the device, in addition to a new mask with a thicker and broader top surface, was designed to make it easier to hold the device correctly and enable a better mask seal. In a recent mannequin-based randomised controlled trial, expiratory volumes were higher, mask leakage lower and mean airway pressure slightly higher with upright bag mask versus a standard resuscitator [42]. An alternative airway device, the uncuffed, gel laryngeal mask airway, is currently being investigated in comparison to the bag mask in low-resource settings in a randomised controlled trial [43]. The training mannequins also need further enhancement and innovation, but still remain low-cost simulators with adequate fidelity. Our experience in Sudan led us to examine the NeoNatalie mannequin in 3 modalities, showing that the mannequin filled with water or half water/air were the best configurations as assessed by user preference (‘most realistic') and ease of ventilation [44]. The mannequin filled with air (one of the modalities recommended by the manufacturers) was not deemed realistic and was difficult to ventilate by neonatal doctors and nurses.

Of course, in the 3 community-based programmes that reported neonatal mortality, participants could not be blinded to the SFNRT intervention. We also observed high heterogeneity among the studies for the proportion of physician-attended deliveries and whether there was an observed change in resuscitation behaviour (use of assisted ventilation by face mask). The reasons for this high heterogeneity may be due to the differences in the neonatal population and the higher clinical risk in physician-attended deliveries. In 2011, Gill et al. [12] enrolled all neonates irrespective of birth weight, Carlo et al. [24] analysed only infants with very low birth weight and Carlo et al. [20] included neonates >1,500 g. Enrolment of neonates with varying birth weights may be associated with varying risk that can partially contribute to this heterogeneity. High heterogeneity was also observed in the assessment of resuscitation behaviour of bag mask ventilation, which could be attributed to the risk status of the neonates enrolled or the varying skills of the trained birth attendants. All the 3 community-based CRTs ensured good follow-up data with loss to follow-up <5%. Components of teamwork behaviour from the 2 studies [27,28] that evaluated teamwork training as an adjunct to SFNRT showed high heterogeneity, which is difficult to explain considering the homogeneity of the physician trainees enrolled in these studies. Evidence from 1 study [33] evaluating knowledge and skill retention was downgraded to very low because of unclear allocation concealment, absence of blinding to intervention and a high risk for attrition bias.

We strove to decrease biases in the review process. Three authors performed the literature search using an inclusive search strategy and combined their results. Our search strategy identified randomised clinical trials reporting neonatal outcomes only from low- and middle-income countries but none from high-income countries. In the trials identified, additional data were obtained from the authors [12,20,27] and could not be obtained for 1 study [29].

Our review is the first systematic review and meta-analysis of randomised trials investigating resuscitation training in the newborn. Five previous reviews addressed resuscitation training and outcomes [45,46,47,48,49], but only 3 included newborn resuscitation [47,48,49]. Lee et al. [47] included both observational studies (n = 20), quasi-randomised (n = 2) and randomised trials (n = 2), and found that neonatal resuscitation training in health care facilities reduced term intrapartum deaths [RR 0.70 (95% CI 0.59-0.84)]. Jabbour et al. [45] included all life support courses, including adult, paediatric and newborn resuscitation courses, and found a reduction in mortality after resuscitation training [odds ratio 0.28 (95% CI 0.22-0.37)]. However, this review was published in 1996 when there were no randomised controlled trials of newborn resuscitation training. Mileder et al. [49] reviewed simulation-based neonatal and infant resuscitation teaching. They identified 13 randomised controlled trials with 832 participants. However, due to distinct differences in research objectives and varying outcome assessment, the authors chose not to conduct a meta-analysis. Included trials suggested that simulation-based resuscitation education can enhance trainees' cognitive, technical and behavioural skills as well as self-confidence. Meaney et al. [46] reviewed resuscitation training in all age groups, including the newborn, children and adults, also in observational studies and concluded that newborn resuscitation training decreased mortality.

In conclusion, SFNRT of birth attendants, in addition to basic newborn care, results in a reduction in early neonatal mortality (moderate-quality evidence) and mortality in the first 28 days after birth (low-quality evidence) in low- and middle-income countries. Teamwork training in addition to SFNRT in physician trainees during simulation improved teamwork behaviour and decreased resuscitation duration in the short term (low-quality evidence). Boosters after neonatal resuscitation training did not enhance knowledge and skill retention (very-low-quality evidence). Further investigation in educational methods that facilitate acquisition and retention of knowledge and skills related to newborn resuscitation is essential to improve training and neonatal outcomes. Randomised comparisons of different SFNRT programmes (e.g. simulation vs. didactic- or skill-based SFNRT) are feasible and may help to identify the most optimal method for training health care providers. Future studies evaluating SFNRT should report on newborn morbidity outcomes, including hypoxic ischaemic encephalopathy and long-term neurodevelopment.

We acknowledge the help of all investigators in sharing data from their studies that made the meta-analysis possible. We are also grateful to the CNRG Editorial Board for their insightful comments and critiques that have enhanced the review.

Dr. Dempsey received salary support from the Health Research Board (Ireland) to undertake this review.

1.
Waage J, Banerji R, Campbell O, Chirwa E, Collender G, Dieltiens V, Dorward A, Godfrey-Faussett P, Hanvoravongchai P, Kingdon G, Little A, Mills A, Mulholland K, Mwinga A, North A, Patcharanarumol W, Poulton C, Tangcharoensathien V, Unterhalter E: The Millennium Development Goals: a cross-sectoral analysis and principles for goal setting after 2015 Lancet and London International Development Centre Commission. Lancet 2010;376:991-1023.
2.
Liu L, Oza S, Hogan D, Perin J, Rudan I, Lawn JE, Cousens S, Mathers C, Black RE: Global, regional, and national causes of child mortality in 2000-13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet 2015;385:430-440.
3.
Lawn JE, Cousens S, Zupan J; Lancet Neonatal Survival Steering Team: 4 million neonatal deaths: when? where? why? Lancet 2005;365: 891-900.
4.
International Liaison Committee on Resuscitation: The International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: neonatal resuscitation. Pediatrics 2006;117:e978-e988.
5.
Chance GW, Hanvey L: Neonatal resuscitation in Canadian hospitals. CMAJ 1987;136:601-606.
6.
Knippenberg R, Lawn JE, Darmstadt GL, Begkoyian G, Fogstad H, Walelign N, Paul VK; Lancet Neonatal Survival Steering Team: Systematic scaling up of neonatal care in countries. Lancet 2005;365:1087-1098.
7.
Wax JR, Lucas FL, Lamont M, Pinette MG, Cartin A, Blackstone J: Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010;203:243.e1-243.e8.
8.
Narayanan I, Rose M, Cordero D, Faillace S, Sanghvian T: The Components of Essential Newborn Care. Basics Support for Institutionalizing Child Survival Project (Basics II). Arlington, United States Agency for International Development, 2004.
9.
HBB: Helping Babies Breathe Global Development Alliance: Global Newborn Health Conference. Johannesburg, http://www.laerdalglobalhealth.com/doc/2503/Helping-Babies-Breathe-Global-Development-Alliance, 2013.
10.
Moher D, Liberati A, Tetzlaff J, Altman DG, Group P: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009;151:264-269, W264.
11.
Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter Y, Schunemann HJ: What is ‘quality of evidence' and why is it important to clinicians? BMJ 2008;336:995-998.
12.
Gill CJ, Phiri-Mazala G, Guerina NG, Kasimba J, Mulenga C, MacLeod WB, et al: Effect of training traditional birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): randomised controlled study. BMJ 2011;342:d346.
13.
Carlo WA, McClure EM, Chomba E, Chakraborty H, Hartwell T, Harris H, Lincetto O, Wright LL: Newborn care training of midwives and neonatal and perinatal mortality rates in a developing country. Pediatrics 2010;126:e1064-e1071.
14.
Shankaran S, Laptook AR, Ehrenkranz RA, Tyson JE, McDonald SA, Donovan EF, et al: Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. N Engl J Med 2005;353:1574-1584.
15.
WHO: Guidelines on Basic Newborn Resuscitation. Geneva, WHO, 2012, http://apps.who.int/iris/bitstream/10665/75157/1/9789241503693_eng.pdf.
16.
de Almeida M, Guinsburg R, Sancho G, Rosa I, Lamy Z, Martinez F, da Silva R, Ferrari L, de Souza Rugolo L, Abdallah V, Silveira R; Brazilian Network on Neonatal Research: Hypothermia and early neonatal mortality in preterm infants. J Pediatr 2014;164:271.e1-275.e1.
17.
Cleary GM, Wiswell TE: Meconium-stained amniotic fluid and the meconium aspiration syndrome. An update. Pediatr Clin North Am 1998;45:511-529.
18.
Review Manager (RevMan) (Computer Program) Version 5.3. Copenhagen, The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
19.
Higgins JPT, Green S: Cochrane Handbook for Systematic Reviews of Interventions, version 5.1.0). London, The Cochrane Collaboration, http://handbook.cochrane.org, 2011.
20.
Carlo WA, Goudar SS, Jehan I, Chomba E, Tshefu A, Garces A, Parida S, Althabe F, McClure EM, Derman RJ, Goldenberg RL, Bose C, Krebs NF, Panigrahi P, Buekens P, Chakraborty H, Hartwell TD, Wright LL, First Breath Study Group: Newborn-care training and perinatal mortality in developing countries. N Engl J Med 2010;362:614-623.
21.
Campbell DM, Finan E: Impact of video-debriefing following simulated neonatal resuscitation in inter-professional teams. Paediatr Child Health 2014;14:116.
22.
Yamada NK, Fuerch JH, Halamek LP: Impact of standardized communication techniques on errors during simulated neonatal resuscitation. Am J Perinatol 2016;33:385-392.
23.
Bang A, Bellad R, Gisore P, Hibberd P, Patel A, Goudar S, Esamai F, Goco N, Meleth S, Derman RJ, Liechty EA, McClure E, Carlo WA, Wright LL: Implementation and evaluation of the Helping Babies Breathe curriculum in three resource limited settings: does Helping Babies Breathe save lives? A study protocol. BMC Pregnancy Childbirth 2014;14:116.
24.
Carlo WA, Goudar SS, Jehan l, Chomba E, Tshefu A, Garces A, Parida S, Althabe F, McClure EM, Derman RJ, Goldenberg RL, Bose C, Hambidge M, Panigrahi P, Buekens P, Chakraborty H, Hartwell TD, Moore J, Wright LL; First Breath Study Group: High mortality rates for very low birth weight infants in developing countries despite training. Pediatrics 2010;126:e1072-e1080.
25.
Opiyo N, Were F, Govedi F, Fegan G, Wasunna A, English M: Effect of newborn resuscitation training on health worker practices in Pumwani Hospital, Kenya. PLoS One 2008;3:e1599.
26.
Xu T, Wang H, Gong L, Ye H, Yu R, Wang D, Wang L, Feng Q, Lee HC, McGowan JE, Zhang T: The impact of an intervention package promoting effective neonatal resuscitation training in rural China. Resuscitation 2014;85:253-259.
27.
Thomas EJ, Taggart B, Crandell S, Lasky RE, Williams AL, Love LJ, Sexton JB, Tyson JE, Helmreich RL: Teaching teamwork during the neonatal resuscitation program: a randomized trial. J Perinatol 2007;27:409-414.
28.
Thomas EJ, Williams AL, Reichman EF, Lasky RE, Crandell S, Taggart WR: Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations. Pediatrics 2010;125:539-546.
29.
Dunn S, Niday P, Watters NE, McGrath P, Alcock D: The provision and evaluation of a neonatal resuscitation program. J Contin Educ Nurs 1992;23:118-126.
30.
Lee MO, Brown LL, Bender J, Machan JT, Overly FL: A medical simulation-based educational intervention for emergency medicine residents in neonatal resuscitation. Acad Emerg Med 2012;19:577-585.
31.
Rubio-Gurung S, Putet G, Touzet S, Gauthier-Moulinier H, Jordan I, Beissel A, Labaune JM, Blanc S, Amamra N, Balandras C, Rudigoz RC, Colin C, Picaud JC: In situ simulation training for neonatal resuscitation: an RCT. Pediatrics 2014;134:e790-e797.
32.
Bender J, Kennally K, Shields R, Overly F: Does simulation booster impact retention of resuscitation procedural skills and teamwork? J Perinatol 2014;34:664-668.
33.
Kaczorowski J, Levitt C, Hammond M, Outerbridge E, Grad R, Rothman A, Graves L: Retention of neonatal resuscitation skills and knowledge: a randomized controlled trial. Fam Med 1998;30:705-711.
34.
Bould MD, Hayter MA, Campbell DM, Chandra DB, Joo HS, Naik VN: Cognitive aid for neonatal resuscitation: a prospective single-blinded randomized controlled trial. Br J Anaesth 2009;103:570-575.
35.
Fuerch JH, Yamada NK, Coelho PR, Lee HC, Halamek LP: Impact of a novel decision support tool on adherence to Neonatal Resuscitation Program algorithm. Resuscitation 2015;88:52-56.
36.
Goudar SS, Somannavar MS, Clark R, Lockyer JM, Revankar AP, Fidler HM, Sloan NL, Niermeyer S, Keenan WJ, Singhal N: Stillbirth and newborn mortality in India after Helping Babies Breathe training. Pediatrics 2013;131:e344-e352.
37.
Bhutta ZA, Black RE: Global maternal, newborn, and child health - so near and yet so far. N Engl J Med 2013;369:2226-2235.
38.
Carlo WA, Goudar SS, Pasha O, Chomba E, Wallander JL, Biasini FJ, McClure EM, Thorsten V, Chakraborty H, Wallace D, Shearer DL, Wright LL; Brain Research to Ameliorate Impaired Neurodevelopment-Home-Based Intervention Trial Committee and the National Institute of Child Health and Human Development Global Network for Womenʼs and Childrenʼs Health Research Investigators: Randomized trial of early developmental intervention on outcomes in children after birth asphyxia in developing countries. J Pediatr 2013;162:705.e3-712.e3.
39.
Wallander JL, Bann C, Chomba E, Goudar SS, Pasha O, Biasini FJ, McClure EM, Thorsten V, Wallace D, Carlo WA: Developmental trajectories of children with birth asphyxia through 36 months of age in low/low-middle income countries. Early Hum Dev 2014;90:343-348.
40.
Finan E, Bismilla Z, Whyte HE, Leblanc V, McNamara PJ: High-fidelity simulator technology may not be superior to traditional low-fidelity equipment for neonatal resuscitation training. J Perinatol 2012;32:287-292.
41.
Coffey PS, Saxon EA, Narayanan I, DiBlasi RM: Performance and acceptability of two self-inflating bag-mask neonatal resuscitator designs. Respir Care 2015;60:1227-1237.
42.
Thallinger M, Ersdal HL, Ombay C, Eilevstjonn J, Stordal K: Randomised comparison of two neonatal resuscitation bags in manikin ventilation. Arch Dis Child Fetal Neonatal Ed 2015, Epub ahead of print.
43.
Randomized Clinical Trial Assessing Laryngeal Mask Airway versus Face-Mask Ventilation in Neonatal Resuscitation (LMAvsFMV). ClinicalTrials.Gov identifier: NCT02042118, 2016.
44.
Hawkes GA, Malik Y, Livingstone V, Dempsey EM, Ryan CA: End user bag-mask ability and perceptions of two infant resuscitation mannequins. Acta Paediatr 2016;105:281-285.
45.
Jabbour M, Osmond MH, Klassen TP: Life support courses: are they effective? Ann Emerg Med 1996;28:690-698.
46.
Meaney PA, Topjian AA, Chandler HK, Botha M, Soar J, Berg RA, Nadkarni VM: Resuscitation training in developing countries: a systematic review. Resuscitation 2010;81:1462-1472.
47.
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.
48.
Opiyo N, English M: In-service training for health professionals to improve care of the seriously ill newborn or child in low and middle-income countries (review). Cochrane Database Syst Rev 2015;5:CD007071.
49.
Mileder LP, Urlesberger B, Szyld EG, Roehr CC, Schmolzer GM: Simulation-based neonatal and infant resuscitation teaching: a systematic review of randomized controlled trials. Klin Padiatr 2014;226:259-267.
50.
Duran R, Aladag N, Vatansever U, Sut N, Acunas B: The impact of neonatal resuscitation program courses on mortality and morbidity of newborn infants with perinatal asphyxia. Brain Dev 2008;30:43-46.
51.
Patel D, Piotrowski ZH, Nelson MR, Sabich R: Effect of a statewide neonatal resuscitation training program on Apgar scores among high-risk neonates in Illinois. Pediatrics 2001;107:648-655.
52.
Patel D, Piotrowski ZH: Positive changes among very low birth weight infant Apgar scores that are associated with the Neonatal Resuscitation Program in Illinois. J Perinatol 2002;22:386-390.
53.
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;21:29-33.
54.
Chomba E, McClure EM, Wright LL, Carlo WA, Chakraborty H, Harris H: Effect of WHO newborn care training on neonatal mortality by education. Ambul Pediatr 2008;8:300-304.
55.
Boo NY: Neonatal resuscitation programme in Malaysia: an eight-year experience. Singapore Med J 2009;50:152-159.
56.
Ashish KC, Malqvist M, Wrammert J, Verma S, Aryal DR, Clark R, Naresh PK, Vitrakoti R, Baral K, Ewald U: Implementing a simplified neonatal resuscitation protocol - Helping Babies Breathe at birth (HBB) - at a tertiary level hospital in Nepal for an increased perinatal survival. BMC Pediatr 2012;12:159.
57.
Msemo G, Massawe A, Mmbando D, Rusibamayila N, Manji K, Kidanto HL, Mwizamuholya D, Ringia P, Ersdal HL, Perlman J: Newborn mortality and fresh stillbirth rates in Tanzania after Helping Babies Breathe training. Pediatrics 2013;131:e353-e360.
58.
Duran R, Aladağ N, Vatansever U, Küçükuğurluoğlu Y, Süt N, Acunaş B: Proficiency and knowledge gained and retained by pediatric residents after neonatal resuscitation course. Pediatr Int 2008;50:644-647.
59.
Durojaiye L, O'Meara M: Improvement in resuscitation knowledge after a one-day paediatric life-support course. J Paediatr Child Health 2002;38:241-245.
60.
Ergenekon E, Koc E, Atalay Y, Soysal S: Neonatal resuscitation course experience in Turkey. Resuscitation 2000;45:225-227.
61.
Ersdal HL, Vossius C, Bayo E, Mduma E, Perlman J, Lippert A, Soreide E: A one-day ‘Helping Babies Breathe' course improves simulated performance but not clinical management of neonates. Resuscitation 2013;84:1422-1427.
62.
Lopez-Herce J, Carrillo A, Rodriguez A, Calvo C, Delgado MA, Tormo C: Paediatric life support instructors courses in Spain. Spanish Paediatric and Neonatal Resuscitation Group. Resuscitation 1999;41:205-209.
63.
Nadler I, Sanderson PM, Van Dyken CR, Davis PG, Liley HG: Presenting video recordings of newborn resuscitations in debriefings for teamwork training. BMJ Qual Saf 2011;20:163-169.
64.
Singhal N, McMillan DD, Yee WH, Akierman AR, Yee YJ: Evaluation of the effectiveness of the standardized neonatal resuscitation program. J Perinatol 2001;21:388-392.
65.
Skidmore MB, Urquhart H: Retention of skills in neonatal resuscitation. Paediatr Child Health 2001;6:31-35.
66.
Trevisanuto D, Ibrahim SA, Doglioni N, Salvadori S, Ferrarese P, Zanardo V: Neonatal resuscitation courses for pediatric residents: comparison between Khartoum (Sudan) and Padova (Italy). Paediatr Anaesth 2007;17:28-31.
67.
Trevisanuto D, Ferrarese P, Cavicchioli P, Fasson A, Zanardo V, Zacchello F: Knowledge gained by pediatric residents after neonatal resuscitation program courses. Paediatr Anaesth 2005;15:944-947.
68.
Tan S, Batey N, Sharkey D: Cardiac compression quality deteriorates with increasing compression rate during preterm resuscitation simulations: a new preterm simulation trainer. Arch Dis Child 2014;99:A71.
69.
Walker D, Cohen S, Fritz J, Olvera M, Lamadrid-Figueroa H, Cowan J, Hernandez D, Dettinger JC, Fahey JO: Team training in obstetric and neonatal emergencies using highly realistic simulation in Mexico: impact on process indicators. BMC Pregnancy Childbirth 2014;14:367.
70.
Mathai SS, Adhikari KM, Rajeev A: Comparison of training in neonatal resuscitation using self inflating bag and T-piece resuscitator. Med J Armed Forces India 2015;71:19-23.
71.
Cavaleiro AP, Guimaraes H, Calheiros F: Training neonatal skills with simulators? Acta Paediatr 2009;98:636-639.
72.
Curran VR, Aziz K, O'Young S, Bessell C: Evaluation of the effect of a computerized training simulator (ANAKIN) on the retention of neonatal resuscitation skills. Teach Learn Med 2004;16:157-164.
73.
Hubballi JG, Sumitra LA, Raddi SA: Randomized control trial to evaluate the effectiveness of Helping Babies Breathe programme on knowledge and skills regarding neonatal resuscitation among auxiliary nurse midwives students. Int J Nurs Educ 2014;6:146-151.
74.
Deindl P, Schwindt J, Berger A, Schmolzer GM: An instructional video enhanced bag-mask ventilation quality during simulated newborn resuscitation. Acta Paediatr 2015;104:e20-e26.
75.
Senarath U, Fernando DN, Rodrigo I: Effect of training for care providers on practice of essential newborn care in hospitals in Sri Lanka. J Obstet Gynecol Neonatal Nurs 2007;36:531-541.

This paper is based on a Cochrane review first published in The Cochrane Library 2015, Issue 9. DOI:10.1002/14651858.CD009106.pub2.

Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.