Approximately 85% of newborns breathe spontaneously at birth and another 5–10% will start breathing with just physical stimulation (drying and rubbing) (1–3). This implies that most newborns will do well with routine care of drying them and maintaining warmth. Conversely, less than 10% of deliveries will require some assistance with breathing. The recommended form of assisting any infant with poor respiratory effort is through providing positive pressure ventilation using a bag mask resuscitator. If bag mask ventilation (BMV) is started promptly, most babies will respond and initiate breathing immediately. In those who do not breath despite 30–60 s of BMV, the heart rate is assessed and chest compressions are recommended if the heart rate is less than 60 beats per minute (bpm) and adrenalin if the heart rate is < 60 bpm despite 30–60 s of chest compressions (4). It is reported that of the total deliveries, less than 1% of patients will need chest compressions and/or adrenalin (1, 2, 5, 6).

At the time of birth, the umbilical cord is clamped thereby removing the placental circulation. The clamping of the cord is considered to be delayed, if it occurs at or more than 30–60 s (7) from the time of delivery of the baby, using ≥ 30 s for preterm and term (8, 9) and some recommended ≥ 60 s for term infants (10, 11). A meta-analysis reported that delayed clamping of the cord is associated with a number of benefits including less incidence of intraventricular hemorrhage, less incidence of necrotizing enterocolitis, and less need for blood transfusion in preterm infants (12); while in term infants, it is associated with less incidence of iron deficiency anemia at 6 months of age (13). The International Liaison Committee on Resuscitation (ILCOR) and the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommend to delay cord clamping for at least 30 s in newborns who do not require resuscitation at birth (14, 15).

The Helping Babies Breathe (HBB) program is a simulation-based training program. It trains the healthcare providers (HCPs) on the resuscitation of the neonate focusing on ensuring that babies who are not breathing are assisted with BMV by the first minute of life. The steps of resuscitation in the HBB program include suctioning if there is meconium, drying the infant, checking if the baby is crying or breathing, delaying clamping of the cord, keeping the baby warm, and starting BMV, if the baby is not breathing within the first minute of life (Golden Minute) (16, 17). The implementation of this training program has been associated with a reduction in early neonatal mortality rates (ENMRs) and fresh stillbirth rate (FSBR) (18, 19).

Several hospitals in the Eastern Cape, South Africa, escalated training of their HCP on immediate care of newborns at birth using HBB from 2016. But for any program to be successful, it needs proper implementation. Training on a certain skill using simulation requires that a follow-up is made to assess whether the individual is applying the skill appropriately in a real-life situation. The objective of this study was to assess the condition of newborn infants at birth and the implementation of skills or procedures recommended in the HBB training program, in a setting where the majority of HCP were trained in this program.

The main findings in this study are that 83% of neonates started breathing spontaneously soon after birth and this increased to 87% with physical stimulation. Approximately a third (29%) of neonates who were not breathing at birth started breathing spontaneously after physical stimulation. Less than 1% required advanced resuscitation (chest compressions and/or adrenalin). The median time for neonates to start breathing spontaneously from the time of birth was 17 s. Deliveries conducted in this setting where HCPs were trained in the HBB program resulted in 98% of neonates breathing spontaneously or receiving BMV by 1 min of life. Neonates who were born by cesarean section and those with low birth weight were more likely to require BMV and, therefore, were less likely to have delayed cord clamping.

The time to onset of spontaneous respiration in this report was longer than the 10 s observed in a study by Ersdal et al. (20). The proportion of neonates who required BMV in this study is higher than that of 3–6% reported in a meta-analysis looking at the annual number of all the newborns requiring assistance to breath (1, 2), but similar to that reported in a study conducted in Tanzania (20, 21). The possible reason for the longer time to the initiation of spontaneous respiration and a high proportion of babies requiring respiratory support is that the centers where this study was conducted are referral centers and, therefore, are more likely to be delivering high-risk pregnancies. This is supported by the high cesarean section and preterm rates of 66.8 and 48.4%, respectively, in this study. Preterm births and emergency cesarean section have been associated with the need for positive pressure ventilation at birth (22). The proportion of cesarean sections that were performed as emergencies was not recorded in this study. The high proportion of a need for assistance with breathing highlights the importance of having a person with knowledge and skill in basic neonatal resuscitation as taught in HBB, especially for deliveries from high-risk pregnancies.

Though not all the neonates who were not breathing by 1 min received BMV, it was encouraging that 98% of babies were breathing or being ventilated by the “Golden Minute.” This suggests that HBB training enhanced the knowledge and skills of healthcare workers on immediate care of newborn babies and that the goal of making sure that each neonate should be breathing or being assisted to breathe by 1 min was achieved in most deliveries. An association between retention of skills from the HBB training and a positive result in terms of starting BMV within the Golden Minute for those newborns who fail to initiate spontaneous breathing has been reported previously (23). The American Heart Association recommends that each delivery must be attended by a HCP who is skilled, whose sole responsibility is to look after the newborn at birth, so that there are no delays in initiation of resuscitation (15). Delays in initiating positive pressure ventilation are associated with an increase in mortality, with delays of 30 s increasing the risk of mortality or prolonged hospitalization by 12–16% (3, 21).

The ILCOR guidelines suggest that cord clamping should be delayed in neonates who do not require resuscitation (14, 24). The WHO also recommends delayed cord clamping, with the cord being clamped after 1 min–3 min after birth (25). The HBB program recommends that in babies who are crying and/or breathing spontaneously at birth, clamping of the cord should be delayed (16, 17). Overall, approximately two-thirds of neonates had cord clamped at 60 s or longer, with the median time to cord clamping of 74 s, while more than 80% had delayed cord clamping if one uses 30 s or longer to define delay. Cesarean section and infants with low birth weight were found to be less likely to have delayed cord clamping. These factors were also found to be associated with the need for BMV and under such circumstances, the cord was clamped earlier because the HCP wanted to initiate resuscitation and avoid delays. It has been reported previously that neonates who require resuscitation at birth have their cords clamped earlier (20). On the univariate analysis, midwives were more likely to be the ones who performed delayed cord clamping than doctors, supporting that training of midwives in HBB is critical in improving the quality of immediate care of neonates at birth. The most likely reason for doctors not performing as midwives is that they tend to rotate between departments; therefore, some of them might have forgotten what they were trained during HBB. The better performance of midwives in implementing delayed cord clamping compared to doctors has been observed before (26). After adjusting for cesarean section deliveries, the advantage of midwives in performing cord clamping was lost, suggesting that this intervention was not performed very well by both the categories of HCP, even if midwives did better than doctors. In order to improve on delaying cord clamping in neonates who need resuscitation, the setting at the delivery room or operating theater will need to be reorganized to allow initiating BMV while cord clamping is delayed. In developed countries, bed designs that allow initiating resuscitation at the mothers bedside are being explored (27).

The strength of this study is that the settings in which the study was conducted managed high-risk pregnancies and, therefore, presented HCPs with opportunities to implement all the steps taught in the HBB program, as they got exposed to different clinical scenarios. This allowed the study to have a high number of events where HCPs could be assessed. The limitations of the study are that not all the deliveries were observed, as there were limited resources to provide research nurses to observe deliveries at night and during the weekends. Secondly, there is no data on the performance of the interventions taught in HBB before the implementation of this training in order to assess the impact of training on HBB in performing these interventions.

In a setting where training in the immediate care of the newborn was implemented using the HBB program, HCPs implemented the interventions in immediate care according to the steps of the HBB training program. This highlights that knowledge and skills taught during HBB were retained by most HCPs. More than 10% of neonates required some form of assistance soon after birth highlighting the importance of training in HBB, since not providing the necessary basic interventions such as physical stimulation and BMV may have resulted in the deaths of these neonates. It is known that training in basic neonatal resuscitation can reduce neonatal mortality by a third; therefore, the HBB program should be implemented globally especially in low- and middle-income countries where the rate of intrapartum deaths is high.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation on request.

This study was reviewed by the Walter Sisulu University Human Ethics Research Committee. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements instead verbal consent was obtained.

All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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