Standardized formal resuscitation training likely reduces neonatal mortality in low- and middle-income countries compared to no training or basic training.
This comprehensive meta-analysis synthesized data from randomized controlled trials, quasi-randomized trials, and cluster-randomized trials conducted exclusively in low- and middle-income countries (LMICs). The total sample size included 528,366 newborns across the included studies. The primary focus was on neonatal mortality, defined as death within the first 28 days of life, with specific analysis of components including mortality within 24 hours, within 7 days, and between 8 and 28 days of life. Secondary outcomes assessed included neonatal morbidity, teamwork behavior, and the acquisition and retention of knowledge and skills. The intervention of interest was standardized formal resuscitation training (SFNRT), which was compared against no formal resuscitation training, basic resuscitation training, and SFNRT plus additional components such as booster or refresher training. The follow-up period for mortality outcomes extended to the first 28 days of life.
Regarding the comparison between SFNRT and no SFNRT, the analysis included 353,527 participants for the 24-hour mortality outcome. The results indicated that SFNRT likely decreases 24-hour mortality, with a risk ratio (RR) of 0.73 (95% CI 0.66 to 0.82). For early neonatal mortality, involving 354,358 participants, SFNRT likely decreases this outcome as well, with an RR of 0.82 (95% CI 0.75 to 0.89). The certainty of evidence for these specific comparisons was moderate. However, data for neonatal mortality in the first 28 days, late neonatal mortality, and neonatal morbidities were not reported for the SFNRT versus no SFNRT comparison.
When comparing SFNRT to basic resuscitation training, the study included 3355 participants for the first 28 days mortality outcome. The evidence suggests that SFNRT may decrease mortality in the first 28 days, with an RR of 0.55 (95% CI 0.33 to 0.91). For the 24-hour mortality outcome in this comparison group of 169,331 participants, SFNRT likely decreases mortality with an RR of 0.59 (95% CI 0.51 to 0.67). Early neonatal mortality in 69,264 participants showed a likely decrease with an RR of 0.88 (95% CI 0.77 to 0.99). Conversely, for late neonatal mortality in 3274 participants, the analysis found that SFNRT may not decrease late neonatal mortality, with an RR of 0.47 (95% CI 0.20 to 1.11). The certainty of evidence for these comparisons was low.
The impact of booster training was assessed in a smaller subset of 511 participants. The evidence is very uncertain about the effect of SFNRT with boosters versus SFNRT alone on mortality in the first 28 days of life, with an RR of 1.23 (95% CI 0.46 to 3.27). Safety and tolerability data, including adverse events, serious adverse events, and discontinuations, were not reported in the included studies. The overall risk of bias of the included studies was mixed, largely due to a high risk of performance bias in all randomized controlled trials. Additionally, only a maximum of four studies provided data for each specific outcome.
Methodological limitations include the exclusive setting of LMICs, which restricts the generalizability of findings to high-income settings. The lack of reported data on neonatal morbidities and late neonatal mortality in the primary comparison group limits the scope of clinical conclusions. The very low certainty of evidence regarding booster sessions highlights the need for further research in this area. Despite these limitations, the findings suggest that implementing standardized formal resuscitation training is a viable strategy to reduce early neonatal mortality in resource-limited settings. The review had no dedicated funding, and the Cochrane review team reported no conflicts of interest.
Clinically, these results support the adoption of SFNRT over no training to improve survival within the first 24 hours and the first week of life. When upgrading from basic training, SFNRT may offer benefits for 28-day survival, though the magnitude of effect varies. The uncertain benefit of booster sessions suggests that while refresher training is often recommended, its specific impact on mortality requires further investigation. Questions remain regarding the long-term retention of skills and the specific components of training that drive these mortality reductions. Future studies should aim to report on morbidity outcomes and conduct trials in diverse geographic settings to broaden the applicability of these findings.
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