Newborn resuscitation with bag and mask
The number of newborns not breathing/crying spontaneously within the first minute after birth for whom additional resuscitation actions (stimulation and bag and mask) were taken during a specified reference period is expressed as a percentage of the total number of live births in the same period (Singhal, et al, 2012).
The main data source for this indicator is routinely collected administrative data.
Data from routinely collected and compiled administrative data sources will provide information as recorded in medical charts/ records or registers and are entered into national and/or subnational health management information systems (HMIS).
Data from health information systems may collect information on newborn resuscitation immediately after birth among all newborns who were born at a health facility. Routinely collected administrative data and health facility statistics are the preferred data source in settings with a high utilization of health facility services and data are recorded in a manner that ensures good data quality for both the public and private health sectors. The compiled data in the national HMIS or District Health Information System (DHIS2) should include data from both public and private health sectors, especially when the private sector is a substantial source of service provision to the population. In settings where utilization of health facilities is not high (e.g., settings with a high prevalence of births occurring at home), data may suffer from incompleteness if information about women delivering outside facilities is not captured. In addition, there are often challenges in accurately measuring the numerator and the denominator when routine HMIS data are used to measure this indicator.
Key source of data: Administrative data sources include health facility and health services data abstracted from obstetric and neonatal medical records, including health services registers. Relevant information is recorded by health personnel on paper forms and/or through an electronic medical record. Information on interventions performed during birth would need to be captured in the medical chart, related to additional stimulation and administration of bag and mask ventilation for calculation of this indicator. Data from paper or electronic sources are entered or abstracted into a database or registry and are compiled and analyzed within the national and/ or subnational HMIS. The Ministry of Health (MoH) and/or National Statistical Offices (NSO) are usually responsible for the reporting of this indicator.
Indicator and calculation: The indicator is calculated as the number of newborns who were not breathing spontaneously or crying at birth for whom resuscitation (stimulation and/or bag and mask) was initiated in the facility expressed as a percentage of all live births in health facilities during the same time period.
Numerator: The number of newborns who were not breathing spontaneously or crying at birth and, subsequently, required resuscitation (stimulation and/or bag and mask) to be performed during a specified period.
Denominator: Total number of live births in facility during the same time period.
Of note, there is ongoing work to test different denominators for treatment of newborn complications. Additional guidance on appropriate denominators will be made available in future versions of this indicator reference sheet. Different denominators being tested include: (a) total number of live births in the facility; (b) total births in the facility (including stillbirths); (c) target population for coverage (i.e., including fresh stillbirths as a surrogate of intrapartum stillbirths).
Frequency of measurement: The indicator can be calculated on an annual basis or may be tracked on a more frequent and ongoing basis (e.g., monthly, quarterly), depending on facility, subnational and national processes for data entry, compilation and analysis. As a guide, the recommended frequency of measurement based on reporting level is outlined below:
- Facility level: Monthly, quarterly, or as needed based on the country and/or facility need
- Subnational (first and second administrative) level: Monthly or quarterly
- National level: Annually (data can be aggregated to provide national-level data).
Disaggregation: By sex, duration of ventilation (in minutes), level of facility and location of facility (e.g., urban, rural).
Missing values: Missing values are usually not known or not reported.
The first 28 days of life is a vulnerable time for child survival and an estimated 2.4 (uncertainty interval: 2.3, 2.7) million newborns died in 2019 (UNICEF, 2020). Although progress has been made since 1990, neonatal mortality and morbidity remains a challenge in low- and middleincome countries where there are poor health system infrastructure and critical shortages of health personnel who are able to adequately manage and provide quality care (UNICEF, 2020; Alkema, et al, 2014). Approximately 90% of newborns make a smooth transition into the world; however, the remaining may need assistance with breathing and require basic newborn resuscitation (WHO, 2012). In the instance that a newborn does not breathe or cry spontaneously at birth, basic newborn resuscitation consists of stimulation and positive pressure ventilation (PPV) with bag and mask. A very small proportion of newborns (< 1%) may require more comprehensive newborn resuscitation measures, such as chest compressions, medications and/or intubation (WHO, 2012). Highly skilled and trained health personnel are required to perform more comprehensive newborn resuscitation. As a result, programs such as Helping Babies Breathe® have been implemented in several countries worldwide to train health personnel in low- and middle-income countries on newborn resuscitation, including the appropriate and timely use of stimulation and/or bag and mask ventilation (Singhal, 2012). Timely access and appropriate delivery of newborn resuscitation is part of an essential set of evidence-based interventions aimed at global reductions in neonatal mortality and morbidity.
The neonatal period presents opportunities for reaching neonates with interventions that may be vital to newborn health and survival. Adequate resuscitative efforts and action with a bag and mask on newborns that are not born breathing/crying at the time of birth is critical to preventing neonatal mortality.
The purpose of this indicator is to monitor and track the proportion of neonates who received resuscitation actions (stimulation and bag and mask), and is a proxy measure of the health system’s functioning and its potential to provide adequate and quality care to neonates. Complementary indicators would also include measurement of health facility readiness to perform newborn resuscitation (e.g., functional equipment, supplies, medicines, and trained health personnel) and the neonatal mortality rates by cause of death to ascertain whether the burden of neonatal deaths from asphyxia is being simultaneously reduced. This indicator can be used to inform health systems planning and policy and the allocation of funds and resources for programs and interventions aimed at improving newborn health and survival.
Administrative data may suffer from poor quality such as irregularities in report generation, data duplication and inconsistencies (Abouzahr and Boerma, 2005). Reporting challenges exist at the facility level given data quality issues, including incomplete, inaccurate and lack of timely data due to insufficient capacity in the health system or inadequate system design. Collection of data for this indicator is also reliant on the inclusion of newborn resuscitation on the patient medical record and, if so, that the clinical documentation is entered into the registry to database system for national or subnational monitoring and evaluation.
Many HMIS databases or registries are event-based and only births that occur in health facilities are included. Administrative data should be interpreted with caution in settings where data quality is poor and the percentage of births at public and private sector health facilities is low, or where data from the private health sector is not compiled within the HMIS reporting.
For more information on this indicator, please see the MoNITOR indicator reference sheet developed by the World Health Organization: Who-indicators (srhr.org).
Quality, newborn health (NH)
- United Nations Inter-agency Group for Child Mortality Estimation (UN IGME). Levels and trends in child mortality: report 2020, estimates developed by the United Nations Inter-agency Group for Child Mortality Estimation. New York: United Nations Children’s Fund; 2020 (https://www.unicef.org/reports/levels-and-trends-child-mortality-report-2020)
- Alkema L, New JR, Pedersen J, You D, UN Inter-agency Group for Child Mortality Estimation; Technical Advisory Group. Child mortality estimation 2013: an overview of updates in estimation methods by the United Nations Inter-agency Group for Child Mortality Estimation. PloS One. 2014;9(7):e101112 (https://journals.plos.org/plosone/article?id=10.1371/journal. pone.0101112)
- Guidelines on basic newborn resuscitation. Geneva: World Health Organization; 2012 (https:// apps.who.int/iris/bitstream/handle/10665/75157/9789241503693_eng.pdf)
- Singhal N, Lockyer J, Fidler H, Keenan W, Little G, Bucher S, et al. Helping babies breathe: global neonatal resuscitation program development and formative educational evaluation. Resuscitation. 2012;83(1):90–6 (https://www.resuscitationjournal.com/article/S0300- 9572(11)00426-6/fulltext)
- Abouzahr C, Boerma T. Health information systems: the foundations of public health. Bull World Health Organ. 2005;83(8):578–83 (https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2626318/)