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Table 5 Barriers to Evidence-Based Practices in Neonatal Resuscitation Before and After Training

From: The power of practice: simulation training improving the quality of neonatal resuscitation skills in Bihar, India

Barrier

Before training

After training

Initial resuscitation

 Knowledge

“They were not knowing ok there is a need to stimulate... and they were not knowing ok why they need to dry the baby.”

“So much suctioning is there… with the help of drying or stimulating the baby can be saved, but in spite of that they used to go for suctioning… like if baby didn’t cry means ok get… sucker, get sucker.”

 Traditional Practices

“They’ll hold the baby upside down, they will shake the baby here and there, they’ll beat the baby… but… the proper stimulation they were not aware [that] they should rub the baby back or they should flick [the feet].”

 

 Equipment

“They used to dry the baby but… not with a clean or dry cloth.”

“Baby was [asphyxiated with] thick meconium… suction, all the thing[s] [were] not available and we don’t know where they are.”

 Focus on Later Management

 

“[Mentees] think that if the baby is not crying, they have to take [the baby] immediately to the warmer, so they forget the stimulation part.”

Measurement of heart and respiratory rates

 Knowledge

“Actually before… [mentees] were not knowing ok heart rate and respiration[s] are two different things… then we started teaching them anatomy. Respiration- this is the work of lungs… and heart rate- this is the work of heart.”

 

 Skill

 

“[Mentees] don’t have timers to see or… just for name sake they see… or they don’t see it properly… the counting goes here and there. They don’t get it accurately.”

 Equipment

 

“Some sisters [are] having trouble while checking the heart rate because… watch is not available.”

 Focus on Later Management

“The goal is the baby should cry. [Mentees] don’t see for the respiration rate or for the heart rate, they just see that the baby cries… keep on stimulating so that the baby cries.”

“Until [mentees] see the baby [cry], they will give bag and mask, bag and mask. In between… check heart rate, respiratory rate, they were not doing.”

 Role of MD

“[Mentees] said… ‘what’s heart rate? How do we check that? That’s doctor’s thing, they do that with the stethoscope.’”

 

PPV with chest rise

 Knowledge

“They were not knowing about the PPV. If any of the [mentees] knew, she was not knowing the correct rhythm… how much time you need to do, how you need to. She only knew ok we need to do.”

 

 Skill

“[Mentees] just pump [the Ambu bag]… according to the baby[‘s] size they don’t use the [correct] mask. Whatever mask they get, they will connect that and they will pump it.”

“[Mask] seal is not good for most of the time… and the rhythm also. Some of the mentees, they forget the [ventilation] rhythm also.”

 Traditional Practices

“Before… in some facilities [mentees] were giving mouth to mouth ventilation… that time they didn’t know how to use bag and mask ventilation.”

“PPV they are doing but they have more belief in oxygen. If we will put the oxygen… baby will be crying they believe only.”

 Equipment

 

“In some PHC we don’t have zero [size] mask… we have only one number mask, so it is not as effective, because in preterm baby we can’t use the big one.”

 Role of MD

“Before training [mentees] were not doing [PPV]… they didn’t know how to use bag and mask ventilation. They only know… we can’t use, doctor has to do.”

 

Urgency

 Knowledge

“Actually they are not aware what is the effect [of delay]. Until we… know what is the effect, we will not take precaution.”

“[Mentees] can’t… understand when [the neonates] need resuscitation or not. Sometimes they identify very well but… sometime[s] they waiting for… crying… It’s not proper timing.”

 Skill

“To cut the cord, to take the baby to the NBCC, and to start [the] resuscitation, it will take more than 5 min they were telling.”

“It will take time, especially drying the baby, wiping it, stimulating it, clamping… the cords.”

 Traditional Practices

“Because their old practice is like... they… will wait, they’ll tell, ‘Baby will cry now, sister this is normal baby will cry now.’”

“They are thinking it might be crying… they are waiting for some time. But when we are there we are telling them not crying so go fast!”

 Equipment

 

“Golden minute… [mentees] don’t have articles for clamping or… they search for suctioning, for mucus extractor… availability is not there in the PHC, so they go outside to get.”

 Facility Layout

 

“NBCC is in another room… this is labor room, so next to labor room is NBCC, so that takes [mentees] more than a minute to take the baby from labor room to NBCC.”

 Maternal Management

“For one to two to three minutes [mentees] will wait… because [until] the placenta is removed, they will concentrate on that. Ok, the placenta is removed, after that they see, ok, baby is not crying. Then they will start with the Ambu.”

 

 Human Resources

 

“Sometimes only one staff is there for delivery… she will be taking care of the mother and then baby is not crying...”

  1. PPV Positive pressure ventilation, PHC Primary health center, NBCC Newborn care corner