Original Paper
Neonatology 2018;114:294–302
Effect of a Low-Dose/High-Frequency
Training on Real-Life Neonatal
Resuscitation in a Low-Resource Setting
Maria Elena Cavicchiolo a, b Francesco Cavallin c Federica Bertuola d
Damiano Pizzol b Giulia Segafredo b Olivier Manzungu Wingi e
Liviana Da Dalt a Giovanni Putoto b Daniele Trevisanuto a
a Department of Woman’s and Child’s Health, University of Padua, Padua, Italy; b Doctors with Africa CUAMM, Padua,
Italy; c Independent Statistician, Solagna, Italy; d Neonatal Intensive Care Unit, San Bortolo Hospital, Vicenza, Italy;
e Paediatric Department, Beira Central Hospital, Beira, Mozambique
Keywords
Education · Low-resource setting · Neonatal resuscitation ·
Training · Video recording
Abstract
Background: As intrapartum-related events represent a
quarter of all neonatal deaths, education on neonatal resus-
citation is a critical priority. Objective: To assess the impact
of a low-dose/high-frequency neonatal resuscitation train-
ing on clinical practice of midwives in a low-resource setting.
Methods: Eight months after a modified Neonatal Resuscita-
tion Program (NRP) course, we implemented a low-dose/
high-frequency training for midwives at Beira Central Hospi-
tal, Mozambique. The training lasted 6 months and included
weekly practice sessions. Fifty consecutive resuscitations af-
ter the low-dose/high-frequency training were compared
with those registered before (n = 50) and after (n = 50) par-
ticipation in the adapted NRP course using video recording.
Results: All 150 neonates received the initial steps; 103 re-
quired bag-mask ventilation and 41 required chest compres-
sions. The scores for initial steps, bag-mask ventilation and
chest compressions improved after the course (p < 0.0001,
© 2018 S. Karger AG, Basel
E-Mail karger@karger.com
www.karger.com/neo
Received: February 23, 2018
Accepted after revision: May 24, 2018
DOI: 10.1159/000490370 Published online: July 16, 2018
p = 0.005 and p = 0.03) and did not change after the low-
dose/high-frequency training (p = 0.34, p = 0.99 and p =
0.30). The low-dose/high-frequency training decreased the
total time of the procedure (p < 0.0001) and anticipated start
time of airway suctioning and tactile stimulation (p = 0.003
and p < 0.0001), but had no effect on the time of initiation
of bag-mask ventilation (p = 0.30). Conclusions: In a low-
income setting, a low-dose/high-frequency training after
participation in an adapted NRP course contributed to im-
proving the initiation and times of some procedures. How-
ever, many aspects of neonatal resuscitation remained poor.
Low-dose/high-frequency training should focus on improv-
ing the prevention of thermal loss, face mask ventilation and
heart rate assessment. © 2018 S. Karger AG, Basel
Introduction
About 2.6 million newborn babies die annually, ac-
counting for 44% of deaths of children younger than 5
years [1]. Approximately 99% of these deaths occur in
low-resource settings [2]. According to the World Health
165.123.34.86 - 7/17/2018 1:41:59 PM
Daniele Trevisanuto
Department of Woman’s and Child’s Health, University of Padua
University of Pennsylvania
Azienda Ospedaliera di Padova
Via Giustiniani 3, IT–35128 Padua (Italy)
Downloaded by:
E-Mail daniele.trevisanuto @ gmail.com
Organization, intrapartum-related events (previously
called “birth asphyxia”) represent a quarter of all neonatal
deaths [2]. Therefore, training programs in neonatal re-
suscitation for all health workers who are involved in the
management of the newborn at birth are a critical prior-
ity to improve neonatal survival [3]. Neonatal resuscita-
tion has gathered considerable attention, with the Neona-
tal Resuscitation Program (NRP) [4] and Helping Babies
Breathe (HBB) [5] being taught in over 100 countries. De-
spite increasing information on resuscitation training in
low-resource settings [6, 7], the most efficient and effec-
tive ways for health care workers to acquire and maintain
neonatal resuscitation skills are still undefined [8]. In ad-
dition, incorrect, ineffective or dangerous forms of prac-
tice are actually widespread [1, 9].
According to previous studies, knowledge and technical
skills improve immediately after participation in NRP
courses or HBB trainings, but they may deteriorate as early
as 3–6 months later [10–12]. In situ simulation and low-
dose/high-frequency training have been demonstrated to
be effective in high-resource settings [13], and encouraging
results have been reported in low-resource settings [14–17].
Our previous study in a low-resource setting showed im-
proved clinical performance of midwives after participation
in an adapted NRP course, while the quality and timing of
resuscitations remained below the recommended stan-
dards [18]. Therefore, we offered a low-dose/high-frequen-
cy training in order to maintain and reinforce the practical
skills learned during the NRP course. The present study
aimed to assess the impact of this low-dose/high-frequency
neonatal resuscitation training on clinical practice.
Methods
Setting
This study describes the follow-up evaluation of a previous ed-
ucational intervention conducted at Beira Central Hospital (prov-
ince of Sofala, Mozambique), where about 4,500 deliveries occur
every year. Beira Central Hospital is the referral hospital for a geo-
graphical area that covers about 7 million people [18].
Patients
All neonates who needed resuscitation at birth were included
in the study. Resuscitation was defined as any intervention pro-
vided by health care workers: initial steps in order to initiate spon-
taneous breathing; bag-mask ventilation (BMV); and/or chest
compressions (CC). Lack of parental consent was the only exclu-
sion criterion.
Study Design
At Beira Central Hospital, midwives are responsible for the im-
mediate postnatal care of all neonates, including resuscitation. The
Low-Dose/High-Frequency Training and
Real-Life Neonatal Resuscitation
available equipment consists of gloves, clean towels, a wall suction
device, suction catheters, a suction bulb, a self-inflating bag in
combination with two face masks (size 0 and 1) and an oxygen
source. Neonatal resuscitation was based on the NRP 6th edition
algorithm with the exclusion of use of pulse oximetry, intubation
and medications [19]. The adapted NRP course was chosen be-
cause the NRP algorithm was already in use and known by the
midwives involved in neonatal resuscitation at Beira Central Hos-
pital.
On January 31, 2014, all 16 midwives (median age: 30 years;
median experience in the delivery room: 7 years) who were respon-
sible for immediate postnatal management of the newborns at Bei-
ra Central Hospital participated in an adapted NRP course. Par-
ticipant performance was objectively assessed before and after the
course using video recording and a composite score [18].
About 8 months after the adapted NRP course, we implement-
ed a low-dose/high-frequency training focused on maintaining
and improving the skills that were acquired during the course. The
low-dose/high-frequency training lasted 6 months and consisted
of weekly 3-h practical sessions on resuscitation held by a local in-
structor using a manikin (Neonatal Resuscitation Baby; Laerdal,
Stavanger, Norway). Each midwife of the unit attended 4–5 ses-
sions during the 6-month training. The content of the sessions
consisted of continuous repetition of manual skill stations (initial
steps including equipment preparation, prevention of heat loss,
airway, stimulation and assessment; BMV; and CC) and scenarios
guided and supervised by the same expert midwife, who was
trained in the NRP [19]. During the session, participant perfor-
mance was not scored, but incorrect procedures and inadequate
techniques were appropriately discussed with and corrected by the
instructor.
After the training, 50 resuscitations were video recorded and
evaluated using a predefined composite score [20] by the skilled
neonatologist who evaluated the videos in the original study [18].
Two points were awarded for every correct decision and for every
procedure that was performed properly. One point was awarded if
the intervention was delayed or the technique for a given proce-
dure was inadequate. No points were awarded for indicated pro-
cedures that were omitted or for performed procedures that were
not indicated. The sum of the awarded points was divided by the
total possible points for that level of resuscitation (initial steps,
BMV and CC) to obtain a percent score. When a step was antici-
pated due to skipping of the previous step, the first step was scored
0 and the following one was scored 2. When a step was delayed
despite skipping the previous step, the first step was scored 0 and
the following one was scored 1. This approach allowed discrimi-
nating these different scenarios, thus leading to a more detailed
score for the entire performance.
The starting time and duration of the procedures, as well as the
maternal and neonatal data, were also recorded.
Video Recording
Video recording was performed as described in a previous
study [18]. Briefly, the interventions were recorded using a web-
cam for video monitoring (ENXDVR-4C; Encore Electronics;
www.encore-usa.com), consisting of one fixed camera installed
above the radiant warmers both in the delivery room and in the
operating room. The image was zoomed to show only the newborn
and the hands of the resuscitation team. Parents, obstetric proce-
dures and faces of the caregivers were not visible. All videos were
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Table 1. Maternal and neonatal characteristics

Before course After course After low-dose/ p value

high-frequency training

Number of resuscitations 50 50 50 –
Maternal characteristics
Age, years 23 (19–29) 23 (19–28) 25 (19–30) 0.43
Antenatal visits 4 (3–6) 4 (3–6) 4 (3–6) 0.99
Previous pregnancies 3 (1–4) 2 (1–3) 1 (0–3) 0.0001
First pregnancy 17 (34) 21 (42) 24 (48) 0.39
HIV infection 10 (20) 12 (24) 18 (36) 0.17
Mode of delivery 0.39
Caesarean section 23 (46) 28 (56) 21 (42)
Vaginal delivery 27 (54) 22 (44) 29 (58)
Amniotic fluid 0.35
Clear 39 (78) 33 (66) 39 (78)
Meconium stained 11 (22) 17 (34) 11 (22)
Complications 32 (64) 36 (72) 19 (38) 0.002
Placental abruption 0 4 3 –
Eclampsia/preeclampsia 12 16 6
Dystocia 6 10 2
Uterine rupture 2 0 0
Other 8 0 8
Neonatal characteristics
Male:female ratio 32:18 35:15 32:18 0.79
Birth weight, g 2,800 (2,200–3,000) 2,950 (2,500–3,300) 2,830 (2,100–3,350) 0.17
Gestational age, weeks 38 (35–40) 38 (37–40) 39 (37–40) 0.66
Apgar score at 1′ 5 (1–7) 4 (3–6) 5 (3–6) 0.18
Apgar score at 5′ 6 (2–8) 6 (4–7) 6 (5–7) 0.07
Deaths 13 (26) 14 (28) 3 (6) 0.007

Data are expressed as n (%) or median (IQR).

stored on a hard disk and sent to the coordinating centre (Univer-
sity of Padua). In order to protect the identities of the subjects and
the data, all data about resuscitation dates and locations were re-
moved, and the shipment was insured.
Statistical Analysis
The same sample size as in the previous study was selected in
order to compare the outcomes between three equally sized
groups (50 resuscitations each) [18]. Continuous data are ex-
pressed as median and interquartile range (IQR). The study out-
comes were compared between the three groups using the Krus-
kal-Wallis test (continuous outcomes) or Fisher’s test (categorical
outcomes), followed by pairwise comparisons with Benjamini-
Hochberg adjustment for multiple endpoints. Maternal and neo-
natal characteristics were compared between the three groups us-
ing the Kruskal-Wallis test or Fisher’s test with a descriptive pur-
pose. All tests were two-sided, and a p value <0.05 was considered
statistically significant. The statistical analysis was performed us-
ing R 3.3.2 (R Foundation for Statistical Computing, Vienna, Aus-
tria) [21].
Results
Patients
After the low-dose/high-frequency training, 50 out of
501 (9.9%) neonates were resuscitated from May 1 to June
2, 2015, and were included in the analysis (low-dose/
high-frequency training; LT group). The maternal and
neonatal characteristics were compared with those of the
previous two groups (before the course [BC group] and
after the course [AC group]) (Table 1). The LT group had
more primiparous mothers, fewer complications and a
low number of deaths. All 150 neonates received the ini-
tial steps of resuscitation; 103 of them received BMV and
41 received CC.
Primary Outcomes
Overall, the scores for initial steps, BMV and CC im-
proved after the course (p < 0.0001, p = 0.005 and p = 0.03,
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100
Score, %
Fig. 1. Total scores before and after the
course, as well as after the low-dose/high-
frequency training, for the three levels (ini-
tial steps, bag-mask ventilation, and chest
compressions) of resuscitation. NRP, Neo-
natal Resuscitation Program.
respectively) [18], and they did not change after the low-
dose/high-frequency training (p = 0.34, p = 0.99 and p =
0.30, respectively) (Fig. 1).
The specific items of the initial steps are shown in Fig-
ure 2. Head positioning and drying of the infant improved
after the course (p = 0.03 and p = 0.005, respectively) and
did not change after the low-dose/high-frequency train-
ing (p = 0.41 and p = 0.44, respectively). Uncovering of
the infant did not change after the course (p = 0.92) but
improved after the low-dose/high-frequency training
(p = 0.003). Suction, stimulation and heart rate assess-
ment changed after the low-dose/high-frequency train-
ing (p = 0.02, p < 0.0001 and p < 0.0001, respectively).
The specific items of BMV are shown in Figure 3. Start
of positive pressure ventilation with room air improved
after the course (p = 0.002) and did not change after the
low-dose/high-frequency training (p = 0.30). Correct face
mark positioning improved after the course (p < 0.0001),
but then impaired (p = 0.005). Correct ventilatory rate
and heart rate detection after 30 s did not change after the
course (p = 0.91 and p = 0.28, respectively), but improved
after the low-dose/high-frequency training (p = 0.03 and
p = 0.03, respectively). Chest movements did not change
over time (p = 0.53).
The specific items of CC are shown in Figure 4. The
method of compression and the rate/depth of compres-
sion showed an increasing proportion of correct proce-
dures (both p = 0.01), but the limited sample size pre-
vented us from identifying any statistically significant
Low-Dose/High-Frequency Training and
Real-Life Neonatal Resuscitation
Color version available online
80 ■ Before NRP
course
60 ■ After NRP
course
40
■ After low-dose/
high-frequency
training
20
0
Initial Bag-mask Chest
steps ventilation compressions
p < 0.0001 p = 0.01 p = 0.003
pairwise comparisons (BC vs. AC: p = 0.15 and p = 0.10;
AC vs. RT: p = 0.49 and p = 0.54). The rate of ventilation
and the coordination with ventilation improved after the
course (p = 0.03 and p = 0.02, respectively) and did not
change after the low-dose/high-frequency training (p =
0.43 and p = 0.33, respectively).
Timing of Interventions
The starting time and the duration of each interven-
tion did not adhere to the times recommended by the
NRP algorithm (Fig. 5). The total time of the procedure
was similar before and after the course (p = 0.89), but
it decreased after the low-dose/high-frequency training
(p < 0.0001). The time elapsed from birth to starting re-
suscitation decreased after the course (p = 0.03) and did
not change after the low-dose/high-frequency training
(p = 0.39). The starting time and duration of airway suc-
tioning were similar before and after the course (p = 0.15
and p = 0.40), but they decreased after the low-dose/high-
frequency training (p = 0.003 and p = 0.04). The starting
time of tactile stimulation was similar before and after the
course (p = 0.70), but it decreased after the low-dose/
high-frequency training (p < 0.0001). The duration of tac-
tile stimulation was longer after the course (p = 0.02) and
did not change after the low-dose/high-frequency train-
ing (p = 0.95). The starting time of BMV seemed to de-
crease after the course (p = 0.08) and did not change after
the low-dose/high-frequency training (p = 0.57), with
similar durations in the three groups (p = 0.14).
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 Color version available online
■ Yes ■ Yes, not correct ■ No

100

80

60
Score, %

40

20

0
BC AC LT BC AC LT BC AC LT BC AC LT BC AC LT
Equipment preparation Newborn positioning Head positioning Suction Drying
p = 0.08 p = 0.27 p = 0.02 p = 0.001 p < 0.0001

100

80

60
Score, %

40

20

0
BC AC LT BC AC LT BC AC LT BC AC LT
Remove wet linen Uncovering newborn Stimulation HR assessment
p = 0.99 p = 0.0001 p = 0.0001 p < 0.0001

Fig. 2. Detailed scores before (BC) and after (AC) the course, as well as after the low-dose/high-frequency train-
ing (LT), for the initial steps of resuscitation. HR, heart rate.

Color version available online

■ Yes ■ No

100

80

60
Score, %

40

20

0
BC AC LT BC AC LT BC AC LT BC AC LT BC AC LT

Start PPV in room air Correct FM positioning Correct ventilatory rate Chest movements HR detection (after 30 s)
p < 0.0001 p < 0.0001 p = 0.01 p = 0.62 p = 0.03

Fig. 3. Detailed scores before (BC) and after (AC) the course, as well as after the low-dose/high-frequency train-
ing (LT), for bag-mask ventilation. PPV, positive pressure ventilation; FM, face mask.
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100
80
60
Score, %
40
20
0
BC AC LT BC AC LT
Correct method Correct frequency
(2 fingers/2 thumbs) and depth
p = 0.01 p = 0.01
Fig. 4. Detailed scores before (BC) and after (AC) the course, as well as after the low-dose/high-frequency train-
ing (LT), for chest compressions (CC). HR, heart rate.
Discussion
This study evaluated the impact of a low-dose/high-
frequency training after participation in an adapted NRP
course on clinical practice of midwives in a low-resource
setting. Our results showed that the low-dose/high-fre-
quency training contributed to improving the initiation
and duration of some procedures, but many aspects of
neonatal resuscitation remained below the recommend-
ed standards.
Improving delivery room management of asphyxiated
neonates in middle- and low-resource countries, where
nearly all intrapartum-related events occur, is urgently
needed. In Mozambique, a sub-Saharan African country,
neonatal deaths account for 35% of the estimated 85,000
deaths of children under 5 years [22]. A previous study in
the same setting reported only partial improvements in
quality and time of execution of midwife performances
after participation in an adapted NRP course [18]. These
findings were consistent with previous studies adopting
different training programmes [6, 23]. Ersdal et al. [6]
showed that 1-day HBB training courses in Tanzania im-
proved performance in simulated scenarios several
months after training, but it did not translate into im-
proved delivery room management. Bellad et al. [23]
showed that HBB training was not associated with con-
sistent improvements in mortality rates among all neo-
Low-Dose/High-Frequency Training and
Real-Life Neonatal Resuscitation
Color version available online
■ Yes ■ No
BC AC LT BC AC LT BC AC LT
Correct ventilatory Correct CC/ HR assessment
frequency ventilation ratio (3:1)
p = 0.003 p < 0.0001 p = 0.77
nates ≥1,500 g in India and Kenya. The implementation
of quality improvement interventions and low-dose/
high-frequency training including in situ simulation may
facilitate the transfer of new knowledge/skills into clinical
practice, thereby reducing perinatal mortality in Tanza-
nia, Nepal and Sudan [7, 15, 24].
According to these experiences, we planned to per-
form a low-dose/high-frequency training held by a skilled
local instructor. Although the phases of “initial steps,”
“BMV” and “CC” remained stable over time, some inter-
ventions significantly improved after the low-dose/high-
frequency training. Our results show some benefits on the
practice of prevention of thermal loss, stimulation, and
quality of CC. It is noteworthy that some ineffective and
dangerous forms of practice, such as continuous and re-
peated suction, did not change after the training. The is-
sue with continued suctioning was previously observed
after HBB training [6], and was deemphasized in the sec-
ond edition [5]. The poor achievement of chest rise in all
resuscitations suggests that effective ventilation was not
reliably accomplished. Along with stimulation, high-
quality BMV is one of the most important interventions,
but several studies reported that learning to provide BMV
was more difficult than other aspects of newborn resusci-
tation for birth attendants [16, 17].
In addition to poor-quality BMV, we observed a very
high rate of CC, although the percentage of patients re-
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 Color version available online
■ Recommended ■ Before course
■ After course ■ After low-dose/high-frequency training Time, s

0 30 60 90 120 150 180 210 240 270 300 330 360 390
Airway
suctioning

0 30 60 90 120 150 180 210 240 270 300 330 360 390
Tactile
stimulation

0 30 60 90 120 150 180 210 240 270 300 330 360 390
Bag-mask
ventilation

0 30 60 90 120 150 180 210 240 270 300 330 360 390
Chest
compressions

Fig. 5. Initiation times and durations of the procedures. The data are expressed as medians.

ceiving CC decreased over time. These findings are in
agreement with anecdotal observations by many experi-
enced clinicians and educators who were involved in the
design of HBB, resulting in a focus on ventilation rather
than CC in resource-limited settings [5]. Low proficiency
with BMV immediately after training suggests that edu-
cational programmes should emphasize the learning of
such a technique, including methods for improving ven-
tilation when it is initially ineffective.
Our data show a lower mortality rate after the low-dose/
high-frequency training, but this is likely associated with
hospital-level quality improvements (including interven-
tions regarding infrastructure, equipment and clinical pro-
tocols) that were implemented after the NRP course [25].
Heart rate assessment was not performed in about 90%
of the procedures after the low-dose/high-frequency
training, thus reflecting a limited impact of the training
on this milestone of neonatal resuscitation.
The definition of a “golden minute” clearly explains
the importance of the time elapsed immediately after
birth and, as a consequence, highlights the importance of
resuscitative intervention times. Interestingly, the most
relevant result of our training concerned the times of the
interventions. Our data suggest a trend for a reduction in
the times of initiation and duration of all procedures after
the low-dose/high-frequency training, despite the fact
that the initiation times remained longer than the recom-
mended times. Of note, the low-dose/high-frequency
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training did not reduce the time till starting positive pres-
sure ventilation, suggesting that further educational in-
terventions should focus on this aspect. While an assess-
ment of each procedure per se (i.e., suction, stimulation,
face mask positioning, ventilatory rate assessment, etc.)
concerns technical skills, shortening procedure times in-
volves non-technical skills. The recent literature under-
lines the crucial role of non-technical over technical skills
in emergencies [26]. In other words, performing the ad-
equate procedure is essential, but understanding the pri-
ority and time of the intervention is crucial. Low-dose/
high-frequency training showed encouraging results, but
the ideal approach and frequency remain to be demon-
strated [27].
The strength of our study is the objective assessment/
comparison of data on resuscitations collected at three
specific time points: before and after participation in an
adapted NRP course and after a 6-month period of low-
dose/high-frequency training. Unlike in other experienc-
es where external trainers gave the training, a local skilled
midwife had the full responsibility for the low-dose/high-
frequency training. By using video recordings and a pre-
defined score, we were able to evaluate in depth every
aspect of the resuscitative intervention and to individual-
ize the strengths and weaknesses of our teaching ap-
proach.
Our research has some limitations. First, the training
was based on an adapted NRP course because the NRP
algorithm was already in use at Beira Central Hospital
and was known by the participants; therefore, different
teaching programmes such as the HBB package [5] may
have led to different results. Second, only one assessor
scored the videos; however, the evaluation was performed
using a prespecified and detailed scoring system to facili-
tate the assessment [18]. In addition, intrarater variabil-
ity was not assessed. Third, although the video assessment
yielded objective data, it could not provide information
on the heart rate of the patients. Thus, the appropriate-
ness of the manoeuvres and times of interventions did not
take into account the heart rate values but was limited to
the presence of apnoea and/or gasping. Fourth, the level
of clinical performance was not evaluated before starting
the retraining period; thus, the effect of the low-dose/
high-frequency training could have been influenced by
the other “educational factors” during the period elapsed
between the adapted NRP course and the low-dose/high-
frequency training.
Conclusions
In a low-income setting, a low-dose/high-frequency
training after participation in an adapted NRP course
contributes to improving the initiation and times of re-
suscitation procedures. However, many aspects of neona-
tal resuscitation remain poorly performed. Continuous
refresher trainings should focus on improving the pre-
vention of thermal loss, face mask ventilation and heart
rate assessment.
Acknowledgments
We thank Associazione Pulcino, Italy, for supporting the study
and providing funds for the video cameras.
Statement of Ethics
The study protocol was approved by the National Committee
of Bioethics (Ref. No. 315/CNBS/13; November 1, 2013) and by the
Minister of Health of the Republic of Mozambique (Ref. No. 08/
GMS/002/2014; January 7, 2014). Parental consent to record neo-
natal delivery room management and to use the data was obtained
before every delivery. Written informed consent was given by the
parents and caregivers for the clinical records to be used in this
study. All information, including informed consent and all the ma-
terial used in the study, was written in Portuguese in a clearly un-
derstandable form.
Disclosure Statement
The authors have no conflicts of interest to disclose.

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DOI: 10.1159/000490370
University of Pennsylvania
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