Neonatal resuscitation programme in Malaysia: an eight -year experience

Original Article Singapore Me J 2009; 50 (2) : 152 Neonatal resuscitation programme in Malaysia: an eight -year experience Boo N Y ABSTRACT Introuction: The neonatal resuscitation programme (NRP) publishe by the American Acaemy of Paeiatrics an American Heart Association as launche in Malaysia in 1996. 3,000 4th eition 3r eition This stuy aime to reie the outcome of NRP in Malaysia uring the first eight years. Department of Paeiatrics, Clinical School, International Meical Uniersity, Jalan Rasah, Seremban 70300, Malaysia Boo NY, FRCP Professor Corresponence to: Prof Nem-Yun Boo Tel: (60) 6 767 7798 Fax: (60) 6 767 7709 Email: nemyun boo @imu.eu.my Methos: Information on basic emographical ata an training actiities of N RP proiers ere collecte prospectiely from NRP instructors from all oer Malaysia uring the eight years folloing the inception of the NRP. The national perinatal an neonatal mortality ata uring the fie-year perio before an eight years folloing implementation of the NRP ere compare. Results: During the eight years folloing the launch, 14,575 personnel ere traine. 40 percent of NRP-certifie personnel orke in areas here eliery serices ere proie, iz. labour room, operation theatre, obstetric ar, emergency epartment an maternal an chil health clinic. There ere ery fe NRP-certifie proiers orking in emergency epartments an most of them ere meical assistants. Most of the proiers orking in neonatal intensie care units (NICUs) an labour rooms ere nurses hile those in paeiatric ars ere octors. All NRP-certifie octors orking in NI CUs an labour rooms obtaine full certificates. Only 80 percent of NRP-certifie nurses in these to areas obtaine full certificates. There as further serial ecrease in perinatal mortality an neonatal mortality rates in Malaysia uring the years folloing the launch of the NRP programme. Conclusion: The launch of the Malaysian NRP as associate ith further improement in perinatal an neonatal mortality rates. Keyors: neonatal mortality rates, neonatal resuscitation programme Singapore Me J 2009;50(2): 152-159 1,000. 0 Fig. I Number of personnel traine using the thir an fourth eitions of the Neonatal Resuscitation Programme textbooks in Malaysia, 1996-2004. INTRODUCTION The neonatal resuscitation programme (NRP) is a systematic training programme for perinatal caregiers eelope jointly by the American Heart Association (AHA) an the American Acaemy of Paeiatrics (AAP).''"2' The training proie by the NRP consists of both theoretical an practical aspects of neonatal resuscitation, coering areas in the initial steps of resuscitation, bag an mask entilation, cariac compression, enotracheal intubation an meication. The primary goals of the NRP are to ensure that at least one person skille in neborn resuscitation is in attenance at eery eliery an an aitional skille person is reaily aailable to assist shoul the nee arise. (1,2) With the support of the Ministry of Health of Malaysia an the Faculty of Meicine at the Uniersiti Kebangsaan Malaysia, the NRP as launche by the Perinatal Society of Malaysia as a national training programme for perinatal health professionals in September 1996. Both the NRP textbook an instructors' training manual ere translate into the Malay language. Initially, 37 core instructors (ith a minimum of to from each of the 13 states in Malaysia) ere traine.(3) When a ne ersion (fourth

Singapore Me J 2009; 50 (2) : 153 Table I. Demographic an outcome ariables of health personnel ho complete the neonatal resuscitation programme (NRP) in Malaysia, 1996-2004. Variables 3r eition of NRP n = 8,302 (%) 4th eition of NRP n = 6,272 (%) Males 1,329 (16.0) 960 (15.3) Profession Doctors 2,287 (27.6) 2,028 (32.4) Nurses 5,681 (68.5) 3,936 (62.8) Meical assistants 225 (2.8) 179 (2.9) Meical stuents 106 (1.03) 121 (1.9) Full certificate 6,242 (75.2) 5,247 (83.7) Leel of training receie Proier 7,387 (89.0) 5,559 (88.6) Instructor 915 (11.0) 713 (11.4) Language use uring training Malay 2,142 (25.8) 2,507 (40.0) English 5,969 (71.9) 3,759 (59.9) Malay & English 191 (2.3) 6 (0.1) Place of ork Labour room 2,001 (24.3) 913 (15.9) Operation theatre 196 (2.4) 110(1.9) Obstetric ar 465 (5.6) 630 (11.0) Maternal an chil health clinic 843 (10.2) 647(11.3) Emergency epartment 273 (3.3) 252 (4.4) Neonatal intensie care unit 1,240 (15.0) 829 (14.5) Special care nursery 797 (9.7) 548 (9.6) Paeiatric ar 1,434 (17.4) 1,111 (19.4) Others 994 (12.1) 695 (12.1) Unknon 59 (0.7) 537 (8.6) Table II. Relationship beteen lie births, neonatal resuscitation programme -certifie personnel an perinatal mortality rates in Malaysia beteen 1990 an 2004. Annual lie births Personnel certifie each year Annual lie births/nrp personnel traine yearly Perinatal mortality rates* Still birth rates* Neonatal mortality rates# 1991 511,527 o o 12.0 5.8 8.1 1992 528,475 o o 12.0 5.9 7.9 1993 541,887 o o 11.7 5.8 7.5 1994 537,654 o o 10.8 5.2 7.1 1995 539,295 o o 9.7 4.5 6.8 1996 544,302 198 2,749 9.1 4.3 6.0 1997 540,486 1,567 344.9 9.0 4.4 6.0 1998 524,696 2,064 254.2 7.9 3.9 5.2 1999 521,870 1,940 269.0 7.3 3.8 4.5 2000 530,012 1,377 384.9 7.5 3.7 5.0 2001 494,795 1,201 412.0 6.1 3.3 4.5 2002 482,629 2,006 240.6 6.3 3.8 3.5 2003 473,104 1,979 239.0 6.3 3.7 3.2 2004 463,241 2,244 206.0 6.8 4.1 3.8 NRP: Neonatal resuscitation programme * per 1,000 births per 1,000 lie births eition) of the NRP became aailable in 2000,(2) the NRP textbook an its test questions ere also translate into the Malay language ith permission from the AHA an AAP Retraining of the national an state NRP instructors as carrie out in August an October 2001. As the Malaysian NRP has been in existence for eight years, this stuy aime to etermine the number of personnel traine in Malaysia, an hether this programme ha any impact on the Malaysian perinatal an early neonatal mortality rates. METHODS This as a prospectie obserational stuy carrie out oer an eight -year perio beteen September 6, 1996 an December 31, 2004. Information on basic emographical ata an training actiities of each NRP proier ere collecte an submitte prospectiely by their instructors to a national secretariat for issuance of official certificates upon completion of training.i3' Each successful proier as issue a full certificate hen he passe both the ritten an practical tests of all the

Singapore Me J 2009; 50 (2) : 154 996 1998 2000 2002 2004 996 1998 2000 2002 2004 Ambulance personnel Meical stuents Fig. 2 Frequency istribution of personnel traine each year accoring to their profession in arious health facilities. NICU: neonatal intensie care unit; SCN: special care nursery; MCHC: maternal an chil health clinics. lessons in the training course. A partial certificate as issue to proiers ho passe the ritten an practical tests of the first four lessons an ere able to assist in enotracheal intubation uring the practical test of the fifth lesson. Instructors ere successful proiers ho ere further traine to conuct NRP training courses. These ata of NRP-certifie proiers ere compile prospectiely an analyse against the national an state perinatal an neonatal mortality ata compile by the Malaysian Statistics Department an the Information an Documentation System Unit of the Ministry of Health of Malaysia. (4-7) RESULTS During this 81/4 -year perio, 8,302 health personnel ere traine base on the thir eition of the NRP textbook,» an 6,272 base on the fourth eition (Fig. 1).(2) Except for the first year (1996), more than 1,200 personnel ere traine each year. More than 95% of certifie NRP proiers ere nurses or octors (Table I). More than 75% of these proiers obtaine full certificates. They constitute 98% of octors, 70% of nurses, 80% of meical assistants, 20% of ambulance personnel an 100% of meical stuents traine. Only 11% of the certifie personnel ere further traine as instructors.

Singapore Me J 2009; 50 (2) : 155 Perlis Keah Pulau Pinang Perak rr o. A 'ioß!.055 Bra A1! -200 Kuala Lumpur Selangor Negeri Sembilan Malacca Johor Kelantan Terengganu -200 1.2 /1..ee Saraak Sabah gra W.P. Labuan 996 1998 2000 2002 2004 SIE -200 Instructors, Proiers Fig. 3 Number of instructors an proiers traine in the neonatal resuscitation programme in the 13 states an to feeral territories of Malaysia, 1996-2004. Among them, 51% ere octors, 45% ere nurses an 4% ere meical assistants. More than 40% of NRP-certifie personnel orke in areas here elieries took place, iz. labour rooms, operation theatres, obstetric ars, emergency epartments an maternal an chil health clinics (MCHC) (Table I). There ere ery fe NRP-certifie proiers orking in emergency epartments an most of them ere meical assistants (Fig. 2). Most of the proiers orking in the NICUs (64%) an the labour rooms (75.8%) ere nurses. All NRP-certifie octors an only 80% of NRP-certifie nurses orking in the NICUs an labour rooms obtaine full certificates. Although NRP training actiities ere carrie out in all the states an feeral territories uring the eight years, the leel of actiities arie accoring to location (Fig. 3). Seen states (Pulau Pinang, Perak, Selangor, Johor, Saraak, Terengganu, Pahang) an the feeral territory of Kuala Lumpur consistently traine a large number of proiers uring the eight years. There as a ramatic increase in the number of proiers traine folloing the launch of the fourth eition of the NRP in one of the rural

Singapore Me J 2009; 50 (2) : 156 Perlis Keah Pulau Pinang Perak g 300 200 Ó Z 100' Meet Kuala Lumpur Selangor Negeri Sembilan Malacca ' y7200' \ Johor Kelantan Terengganu Pahang WR Labuan 7m. Profession: Doctors Nurses 1 Meical assistants Ambulance personnel 2 Meical stuents Fig. 4 Relationship beteen the number of personnel traine an their profession in each of the 13 states an to feeral territories of Malaysia, 1996-2004. states (Kelantan). In the state of Sabah, the NRP training actiities seeme to hae fizzle out Except for four states (Perak, Negeri Sembilan, Kelantan an Saraak), all other states an feeral territories i not train as many instructors uring the last to years (2003-2004). While most of the states traine octors an nurses, only fie states (Perak, Negeri Sembilan, Johor, Kelantan, Saraak) traine a small number of meical assistants an one state (Saraak) traine meical stuents (Fig. 4). Although both the English an Malay languages ere use as the meia of instruction (Table I), an increasingly higher proportion (z4o%) of NRP courses as conucte in the Malay language uring the secon half of the eight - year perio, especially in the states of Perak, Kelantan, Terengganu an Sabah (Fig. 5). This as particularly marke in the MCHCs here, by the year 2004, more than 60% of their NRP-certifie staff ere traine ith the Malay language as the meium of instruction (Fig. 6). The ratio of annual lie births per NRP-certifie proier in Malaysia improe serially uring the eight years since the launch of the NRP (Table II). Before the launch of the Malaysian NRP, there as an

Singapore Me J 2009; 50 (2) : 157 Perlis Keah Pulau Pinang Perak C 2-2001 Kuala Lumpur Selangor Negeri Sembilan Malacca c 300 o a 200 á 200 1 Saraak Sabah WR Labuan i 300 200 1001 996 998 2000 2002 2004 1996 998 2000 2002 2004 Language use: Malay English Mixture of Malay an English Fig. 5 Relationship beteen the number of personnel traine in neonatal resuscitation an the meium of instruction in each of the 13 states an to feeral territories of Malaysia, 1996-2004. annual ecrease in the per natal mortality rates (PMR) an stillbirth rates (SBR) since 1993, an an annual ecrease in neonatal mortality rates (NMR) since 1991. Folloing the launch of the NRP, there as further ecrease in the PMR an the NMR, but not the SBR in Malaysia (Fig. 7). DISCUSSION A reie of the literature publishe beteen 1995 an February 2007 shoe that this is the first report on the finings of a national NRP conucte in a systematic manner oer a number of years. A number of countries or regions hae reporte on the finings of their efforts in initiating either a national or regional NRP, an for only a short perio of time.i814i Our ata shoe that it is possible to successfully organise an ongoing national NRP using the eucational materials esigne by the AAP an AHA,''"2i by a non -goernment organisation (the Perinatal Society of Malaysia) that orke closely ith a goernment organisation (the Ministry of Health, Malaysia). With careful planning at the onset of the programme, e ere able to systematically collect a

Singapore Me J 2009; 50 (2) : 158 600 NICUs SCNs Paeiatric ars T 500 a Z 200 100 600 Labour rooms Operation theatres Obstetric ars 500 a p 300 z 200 100 600 Emergency epartments MCHCs Others 500 á Z 200 100 {... Language use: entati A AAg AAtrA Malay English Mixture of Malay an English Fig. 6 Relationship beteen the number of personnel traine an the meia of instruction in each ork area in Malaysia beteen 1996 an 2004. NICU: neonatal intensie care unit; SCN: special care nursery; MCHC: maternal an chil health clinics. substantial amount of useful ata to help us continue to run the programme an, to a certain extent, to etermine its impact on NMRs in Malaysia. That our ata shoe further improement only of the NDR an PMR, but not the SBR, since the launch of the Malaysian NRP (Fig. 2) suggests that the Malaysian NRP has a positie impact on perinatal an neonatal care in this country. A large number of meical an health personnel of arious categories ere traine uner the Malaysian NRP uring these eight years, coering arious areas here neonatal resuscitation serices ere neee. Hoeer, it is not certain hat percentage of the personnel orking in NICUs, labour rooms, operation theatres, emergency epartments, an MCHCs ere certifie, as this ata as not simultaneously collecte. Base on the original objectie of the NRP, the proportion of certifie personnel in attenance of eliery shoul be 100%. The small number of NRP certifie personnel in some areas, such as emergency epartments an ambulance serices, suggests that this objectie might not hae been fully met A substantial proportion of certifie personnel ere traine using the Malay ersion of the textbooks, especially beteen the years of 2002 an 2004. This suggests that ha the English language been use as

Singapore Me J 2009; 50 (2) : 159 14 12-10 o Q 8- a 6-4- 2 1991 1993 1995 1992 1994 FIR - - - - Stillbirth rates NDR Fig.7 Perinatal mortality rates (PMR),stillbirth rates an neonatal eath rates (NDR) in Malaysia beteen 1991 an 2004, before an after the launch of the Malaysian neonatal resuscitation programme (NRP). Note:ertical line inicates the year (1996) hen the Malaysian NRP as launche. the sole meium of instruction, a large number of health personnel might not hae been traine. This as particularly obious in the MCHCs an in some of the states of Malaysia, such as Kelantan an Perak, here the primary language of communication is Malay. Our results suggest that for the NRP to continue to be use extensiely all oer Malaysia, future ersions of the programme shoul be translate into the Malay language until a large proportion of the health personnel are conersant in of the English language. Although there are 17 meical schools in Malaysia, the majority (except for one meical school in Saraak) i not inclue the NRP in their curriculum. As meical stuents are not the front -liners in the proision of neonatal resuscitation for perinatal serices, it is not certain hether there is any isaantage if meical stuents are not traine in the NRP until after they hae grauate. ACKNOWLEDGEMENT This project as fully fune by the Perinatal Society of Malaysia. REFERENCES 1. 2. 3. Bloom RS, Cropley C, es. Textbook of Neonatal Resuscitation. Elk Groe Village, IL: American HeartAssociation an American Acaemy of Paeiatrics, 1994. Kattinkel J, e. Textbook of Neonatal Resuscitation. 4th e. Elks Groe Village, IL: American Heart Association an American Acaemy of Paeiatrics, 2000. Boo NY, Pong KM. Neonatal resuscitation training program in Malaysia: results of the first 2 years. J Paeiatr Chil Health 2001; 37:118-24. 4. Department of Statistics, Malaysia. Vital Statistics Malaysia 2003. Kuala Lumpur: Jabatan Perangkaan Malaysia. 5. Department of Statistics, Malaysia. Vital Statistics Malaysia 2000 (special eition). Kuala Lumpur: Jabatan Perangkaan Malaysia. 6. Department of Statistics, Malaysia. States an istrict ata bank, Malaysia 2005. 7. Department of Statistics, Malaysia. States an istrict ata bank Malaysia 2004. 8. Couper ID, Thurley JD, Hugo JF. The neonatal resuscitation training project in rural South Africa. Rural Remote Health 2005; 5:459. 9. Vakriloa L, Elleau CH, Slunchea B. [French-Bulgarian program "Resuscitation of the neborn in a eliery room", results an perspecties]. Akush Ginekol (Sofila) 2005; 44: 35-40. Bulgarian. 10. Deorari AK, Paul VK, Singh M, Viyasagar D. The national moement of neonatal resuscitation in Inia. J Trop Peiatr 2000; 46:315-7. 11. Patel D, Piotroski ZH, Nelson MR, Sabich R. Effects of a stateie neonatal resuscitation training program on Apgar scores among high -risk neonates in Illinois. Peiatrics 2001; 107:648-55. 12. Ergenekon E, Koc E, Atalay Y, Soysal S. Neonatal resuscitation course experience in Turkey. Resuscitation 2000; 45:225-7. 13. Ryan CA, Ahme S, Abullah H, McCarthy -Clark L, Malone A. Dissemination an ealuation of AAP/AHA Neonatal Resuscitation Program in Irelan. Ir Me J 1998; 91:51-2. 14. Zhu XY, Fang HQ, Zeng SP, et al. The impact of the neonatal resuscitation programme guielines (NRPG) on the neonatal mortality in a hospital in Zhuhai, China. Singapore Me J 1997; 38:485-7.