South African Health Care Provider Perceptions of Barriers to Effective Neonatal Resuscitations in Delivery Settings

Monday, 9 November 2015

Valerie Ann Clary-Muronda, MSN-Ed, RNC-OB
MUSC College of Nursing, Medical University of South Carolina, Cherry Hill, NJ, USA

The purpose of this qualitative study is to explore the facilitators and barriers to effective neonatal resuscitation for neonatal care providers in South Africa from their South African contexts, to identify potential areas for improvement in the study setting, an area in which improvement has occurred in the past decade, but has not met expectations, despite interventions.  

The rationale underlying this inquiry is the need to develop an understanding of factors that affect neonatal resuscitation from the standpoints of healthcare providers from their specific cultural contexts for the discovery of significant issues at multiple levels of care delivery that may remain undiscovered in strictly quantitative research.   Additionally, this preliminary exercise can provide useful information regarding constructivist grounded theory (CGT) as an appropriate means of qualitative inquiry in this cultural context.

Specific Aims:

Aim 1: Using semi-structured in-depth qualitative interviews with three health care providers at the University of Johannesburg, South Africa, identify facilitators and barriers to effective neonatal resuscitation upon delivery, and categorize themes that may be consistent with those in a different setting.

 Aim 2: Using a constructivist grounded theory approach, perform initial, focused open coding with constant comparative analysis, and then theoretical coding of data employing categorizing and memo writing to identify intermediate categories from coded data and final theoretical concepts.

 Aim 3: Generate theory from the perspectives of participants from their South African contexts regarding neonatal resuscitation and to collect preliminary data to determine the utility of constructivist grounded theory as a means to explore more extensive observational comparisons, and testable hypotheses for future research.

Expected Results:  The results will reveal useful information identifying multiple level factors affecting neonatal resuscitation that will guide future hypotheses and interventions with the aim of improving neonatal outcomes.

Conclusion/Implications: Findings from this study will address a critical element of the neonatal resuscitation process, the multiple level factors affecting neonatal resuscitation as experienced by neonatal resuscitation providers from their situational and cultural contexts, while addressing the Millennium Development Goal 4 which calls for a two-thirds reduction in under five mortality by the year 2015 (2). 


Global estimates of neonatal deaths range from 2.9 million deaths to 3.6 million deaths per year, with the majority occurring due to lack of appropriate resuscitation upon birth (1). Worldwide, there is a call by the WHO for a two-thirds reduction in childhood mortality rates by 2015. In 2013, 6.3 million children under the age of five died, with the highest risk of death for a child being in the first 28 days of life (2). Preterm birth, intra partum related complications such as asphyxia or apnea (20%), and infections constitute the major causes of death in the neonatal period (2). Some of the highest neonatal mortality rates are in sub-Saharan Africa, where neonatal mortality rates have improved in the past 15 years, though less in the countries with the highest NMR (3). Although the United States possesses some of the highest level of resources in neonatal resuscitation (NR), such technological advances have not translated to better outcomes than other high resource countries. NMR in the United States are high when compared to other developed countries, with the US ranking 26th with NMR more than twice as high as such rates in Finland, Japan, Portugal, and Sweden (4). Interprofessional collaboration in neonatal resuscitation is necessary in various settings, both high resource settings and lower resource settings for the best outcomes. However, various multiple factors at the individual, interpersonal, environmental, policy, and societal levels can impede or facilitate effective resuscitation in delivery settings. Cost effective interventions such as resuscitation education can significantly reduce neonatal mortality rates, however, some barriers to intervention implementation may exist (3). This qualitative study employing constructivist grounded theory will use qualitative interviews to categorize themes that emerge from interview data to identify the facilitators and barriers to effective NR as described by the participants. The information from this qualitative study will provide the foundation for interventions addressing multiple level factors that impede effective resuscitation efforts that may significantly improve neonatal outcomes. Additionally, information from this study may provide insight to barriers to effective NR that may be common in low, moderate, and high resource settings.

Neonatal Resuscitation and Simulation-Based Training:  While most neonates require only tactile stimulation, drying, and clearing of the airway, 10% of neonates will require some assistance with breathing at birth, with approximately 1% requiring extensive resuscitation (5). Timely intervention within the first moments of life can reduce the likelihood of birth asphyxia, which contributes to a 27-30% of neonatal deaths in resource-limited countries (6). In resource limited countries, several factors contribute to the lack of improvement of neonatal outcomes over the past 15 years, such as other higher national health priorities, localized training efforts, lack of training for midwives, lack of essential equipment, and failure to initiate resuscitation steps in a timely manner (6).  Simulation-based learning programs such as the WHO Essential Newborn Care course, and the Helping Babies Breathe Course, may reduce early neonatal mortality and improve neonatal outcomes worldwide (6, 7) but are still being evaluated without positive outcomes (8). One study by Ersdal et al. (1) in Tanzania revealed that sporadic simulation based training may not lead into improvements in clinical practices and outcomes.  In the United States, the American Academy of Pediatric Neonatal Resuscitation Program (NRP) provides providers with comprehensive information and skills for neonatal resuscitation to providers. However, studies show that NRP training does not necessarily translate to excellent performance in neonatal resuscitation (9). Simulation based training is potentially an excellent means to promote collaboration across the disciplines, and low cost simulators such as NeoNatalie (approx. $50) provides an opportunity for practicing and evaluating core neonatal resuscitation competencies (10). However, simulation based learning is a teaching strategy that is in its infancy and needs to be adapted to settings with differing resources internationally. Moreover, researchers are still developing methods to evaluate the effectiveness and transferability of simulation based learning in neonatal resuscitation to clinical areas. Acknowledgement of the existing barriers and facilitators to effective neonatal resuscitation is a first step to developing sustainable interventions that take into the multiple level systemic issues as experienced by clinicians.

Many barriers exist to effective neonatal resuscitation efforts, regardless of the setting. Barriers at the individual, interpersonal, environmental, community, societal, and policy levels can impede effective neonatal resuscitative efforts in low, moderate, and high resource settings, negatively impacting clinical outcomes. Examination of facilitators and barriers to effective neonatal resuscitation as experienced by care providers at multiple levels is essential to develop sustainable training programs that are more likely to make a positive impact on patient outcomes. This preliminary study takes an exploratory approach to examining the multi-level factors affecting effective neonatal resuscitation in this setting to provide useful information to to guide the formation of a sustainable intervention program. It is unclear how the variations of birth attendants (11) appropriate technology (12), and less success with simulated interventions (1) documented in sub-Saharan countries affect this South African site, which is not low resource.  Additionally, this preliminary description will provide the basis for comparing and contrasting themes to determine their relationship to those in different settings.

An integrative review providing information about measurement instruments for assessing effective teamwork and collaboration in neonatal resuscitation in delivery room resuscitations in high resource settings found that few studies with well-documented psychometrics assess interprofessional collaboration and teamwork in neonatal teams with diverse skills. Moreover, many of the existing studies have been done within the discipline of medicine, although most delivery room NRs occur in interprofessional teams, often without a physician team member. Even fewer of the studies reviewed considered the multiple level factors affecting effective resuscitative efforts in the delivery room, raising the following questions for further exploration about neonatal resuscitation:

  • What are the perceptions of facilitators and barriers to neonatal resuscitation in delivery room settings as identified by the health care professionals responsible for NR?
  • What multiple level supports can improve NR in delivery room settings as identified by health care professionals who provide neonatal resuscitation?
  • What (if any) are the similarities in facilitators and barriers to NR in the delivery room in low, moderate, and higher resource settings?

Answering these key questions is paramount for the development of sustainable interventions (and appropriate measures to assess their effectiveness) that can be applicable in various resource settings for improvement of neonatal outcomes. Since neonatal resuscitation guidelines and recommendations are internationally standardized, assessment of facilitators and barriers to effective implementation of these standards is necessary in different settings for significant improvements of neonatal outcomes to occur, particularly in areas that have shown less improvement in neonatal outcomes in the last decade.