Silent stories of midwives: Midwives’ experiences, attitudes and beliefs on neonatal resuscitation that affect their clinical skills and very early neonatal death in Sub Saharan Africa

Jan Becker

doi:10.25907/00777

Globally, almost three million neonates die every year during the first month of life. Of this number, 99 per cent originate from low- and middle-income countries. In Tanzania, over 40,000 neonates die every year, of which those who fail to breathe at birth account for 30 per cent of deaths which are related to intrapartum-related hypoxia (birth asphyxia). The majority can be saved through basic timely skilled resuscitation. The Helping Babies Breathe® (HBB) program is an evidence-based course, which was developed to provide neonatal resuscitation techniques and skills for areas with limited resources. HBB was employed in Tanzania in 2009 and led to a 47% reduction in birth asphyxiated mortality rates. However, the HBB program is not sustainable. Observational research in Tanzanian facilities showed that, despite training in HBB, many midwives failed to initiate any resuscitation or were continuing to use antiquated resuscitation practices that are harmful. This study explores midwives’ experiences, attitudes, and feelings regarding neonatal resuscitation and gains insight into what empowers midwives to perform timely, skilled neonatal resuscitation after training. The study also aims to explore the midwives’ stories, solutions and insights into the enablers and inhibitors of successful neonatal resuscitation, as optimal neonatal resuscitation reduces perinatal asphyxia and prevents very early neonatal death (VEND). Midwives with experience in neonatal resuscitation and VEND at an acute Tanzanian labour ward were individually interviewed either face to face or via online platforms like Zoom, along with written interviews. Multiple interview platforms were utilised to overcome Covid 19 restrictions on travel. The transcribed audio files were analysed utilising thematic analysis. Midwives felt that the HBB champion program should be expanded to mentor midwives regarding the resuscitation of neonates. The midwives believed this training would be crucial to imparting practical neonatal resuscitation skills. Midwives suggested that brief ‘classroom’ teaching of fundamental bag and mask skills then ensure it was expanded into training on practical skills. Skills and training best learned practically in the labour ward at the birth of the neonate. Moreover, midwives stated that committing to respectfully caring for the mothers as if they were family encourages better decisions and birth preparation. However, midwives were overwhelmed by the lack of staff and supplies available for managing the 50–100 births which included complex cases per day, which impeded their ability to provide optimal care to both the mother and neonate. Very Early Neonatal Deaths caused the midwives deep sadness and internal struggle, with spirituality and resilience used to cope and find sense in the high numbers of neonatal deaths. Additionally, midwives cited neglect and lack of adequate intrapartum fetal monitoring by some colleagues whose attitude of indifference was a contributor to VEND. Midwives reported that focusing on solutions, rather than blame, stimulated effective teamwork. Further, midwives emphasised, they must unlearn outdated practices (e.g., deep long suctioning) and learn new practices like bag and mask ventilation as first line immediate care at birth. Some midwives stated that a lack of confidence and fear overrode their desire to learn and perform neonatal resuscitation skills. Many midwives felt that their behaviour and beliefs changed after observing a successful resuscitation using the bag and mask and conducting Hands-on-training (‘HOT’) resus” training at the beside. The ‘Champion’ midwife training program for neonatal resuscitation focused on the midwives being unequivocally centred on the neonates breathing within one minute after birth – hence the neonate’s ‘champion’. The Champion program created pride and collective self-efficacy in the mastery of skilled neonatal resuscitation resulting in less neonates being admitted to the unit for birth asphyxia related conditions. Focusing on vigilant intrapartum fetal monitoring can assist midwives in being adequately prepared for an unwell neonate at birth. Formal, low-dose training two to three times per week and mentorship in the ward, builds confidence and proficiency in the midwives’ neonatal resuscitation skills. Moreover, observing and managing successful resuscitations at the bedside during a real emergency creates behavioural and attitudinal changes in midwives whilst building confidence and mastery.

Silent stories of midwives: Midwives’ experiences, attitudes and beliefs on neonatal resuscitation that affect their clinical skills and very early neonatal death in Sub Saharan Africa

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