Assessing Midwives' Knowledge and Practice in Neonatal Resuscitation: Gaps and Transfer of Knowledge to Reduce Mortality

Introduction The neonatal period is a crucial time for the survival, growth, and development of newborns. Despite advances in medical science, neonatal mortality rates remain a significant public health issue, and midwives play a critical role in reducing neonatal deaths through the use of evidence-based practices and appropriate neonatal resuscitation techniques. However, studies have shown that healthcare workers, including midwives, may not possess adequate knowledge in neonatal resuscitation, leading to adverse outcomes. This study aims to explore the current state of neonatal care and the role of midwives in neonatal resuscitation, with a focus on training and the transfer of knowledge into practice. It is essential to assess the level of knowledge of midwives in neonatal resuscitation and their ability to transfer this knowledge into action to reduce neonatal mortality rates. Objectives The objective of this study was to assess the level of knowledge and practice of midwives in neonatal resuscitation, identify gaps in their knowledge and practice, and evaluate their ability to transfer this knowledge into action to reduce neonatal mortality rates. Methods This study is a cross-sectional, descriptive study conducted in six governmental teaching hospitals located in Khartoum city, with a total sample size of 57 midwives who work in the labor and operation rooms of the hospitals. The questionnaire comprised sections on sociodemographics (5 questions), knowledge assessment (14 questions), and neonatal resuscitation practices (21 questions). The sampling technique used was total coverage. Result This study included 57 female participants, primarily aged 51–60 years with a one-year diploma level of education. Of those surveyed, 49.1% performed neonatal resuscitation weekly. Participants demonstrated strong knowledge and practice in preparing for birth, but some gaps were identified in equipment usage and identification band placement. Resuscitation skills were generally lacking, with poor performance in ambo bagging and chest compression. Conclusion This study on Sudanese midwives' neonatal resuscitation knowledge and practices reveals room for improvement in equipment use, identification, and resuscitation skills. Demographic factors affect CPR knowledge and practice.


Introduction
Te neonatal period, which extends from birth to the frst 28 days of life, is a critical time for the survival, growth, and development of newborns [1].Immediate care of newborns after birth is crucial for their well-being.Good care during pregnancy, labor, and delivery is the frst step in ensuring good newborn care.However, unsafe practices and behaviors related to the immediate care of newborns still exist, leading to adverse outcomes [2].Despite advances in medical science, neonatal mortality rates have either stagnated or continued to rise in many countries [1].Midwives play a vital role in reducing neonatal mortality, and training them in neonatal resuscitation is provided through various programs [3].However, efective transfer of knowledge about neonatal resuscitation into practice is not easy, and there are gaps in the application of these skills.Rapid assessment can generally identify newborns who require resuscitation [4].Tis study aims to explore the current state of neonatal care and the role of midwives in neonatal resuscitation with a focus on training and transfer of knowledge into practice.
Neonatal mortality remains a global concern and a signifcant public health issue.Healthcare providers, especially midwives, play a critical role in preventing neonatal deaths through evidence-based practice and appropriate neonatal resuscitation techniques [5].However, studies have shown that healthcare workers, including midwives, may not have adequate knowledge in neonatal resuscitation [6,7].Tis lack of knowledge can lead to an increase in neonatal deaths worldwide, especially due to birth asphyxia [8].Terefore, it is essential to assess the level of knowledge of midwives in neonatal resuscitation and their ability to transfer this knowledge into action to reduce neonatal mortality rates.
Te study conducted among midwives in neonatal resuscitation yielded insightful fndings regarding the knowledge and practices of these healthcare professionals in Khartoum, Sudan.Despite the presence of adequate knowledge and adherence to certain practices, areas requiring improvement were identifed, such as the need for enhanced equipment utilization, attention to identifcation band details, and improvement in ambo bagging and chest compression skills.In addition, the study revealed the impact of demographic and experiential factors on CPR knowledge and practice profciency.Tese results underscore the importance of targeted CPR training programs tailored to address specifc factors infuencing neonatal resuscitation quality, ultimately aiming to improve maternal and child healthcare outcomes in Sudan.

Study Design and
Setting.Tis study was a crosssectional, descriptive study conducted in six governmental teaching hospitals located in Khartoum city.Te research was carried out over a period of ten months, from October 2019 to July 2020.

Study Population.
Te research involved all midwives employed in the labor and operation rooms of the teaching hospitals in Khartoum city, regardless of their full-time or part-time status.Tis encompassed a total of six governmental teaching hospitals.Midwives involved in obstetric care were included, while those working in other departments such as village midwives and sister midwives were excluded.Additionally, midwives working in private hospitals in Khartoum city and those on vacation were also excluded from the study, along with individuals who declined to participate.

Sampling.
Te sample size for the study was determined to be 57 midwives, which represented the total number of midwives in the six governmental teaching hospitals in Khartoum city.To obtain the sample, total coverage was used as the sampling technique.

Data Collection.
Data was gathered through an interviewer-administered questionnaire, which was meticulously crafted to evaluate midwives' knowledge, practices, and observational skills concerning neonatal resuscitation.Te comprehensive 40-question survey encompassed various sections focusing on sociodemographic details, knowledge assessment, and practical applications related to neonatal resuscitation.
Te questionnaire design included 5 questions dedicated to gathering essential background information on the midwives, 14 questions aimed at assessing their comprehension of neonatal resuscitation topics, and 21 questions exploring their hands-on implementation of resuscitation techniques and protocols.
To ensure the questionnaire's reliability and validity, a pilot study was conducted to fne-tune its content and structure.In addition, the questionnaire underwent scrutiny by a panel of experts to confrm its appropriateness for assessing midwives' knowledge and practices in neonatal resuscitation.
Scoring and analysis of the questionnaire responses were meticulously carried out, with the knowledge section scores based on the accuracy of responses and the practices section scores refecting the profciency in applying neonatal resuscitation techniques in line with established guidelines.
Beyond the initial pilot study, internal consistency of the questionnaire was further evaluated using statistical methods like Cronbach's alpha to ensure the coherence and alignment of questions within each section.Te questionnaire administration took place within hospital settings during midwives' break times, minimizing disruption to their routine duties.Analysis of the collected data was performed using SPSS version 25, with frequencies calculated for both independent variables (e.g., age, educational level, and experience) and dependent variables.Chi-square tests were employed for in-depth data analyses, contributing to a robust evaluation of midwives' knowledge and practices in neonatal resuscitation.

Ethical Considerations.
Te study received written ethical approval from the Sudan Medical Specialization Board Ethical Committee.Written ethical clearance was also obtained from the Khartoum State Ministry of Health, and written permission was obtained from the administrative authorities of the teaching hospitals where the study was conducted.Verbal and written consent was obtained from all participants individually.

Patient and Public Involvement.
Tere was no direct involvement of patients or the public in this study.

Result
A total of 57 participants were included in the study, with 49.1% belonging to the age group of 51-60 years.All participants were female, and 73.7% were married.80% of the participants had a one-year diploma level of education, and 22.6% of the midwives worked in Saad Abualilaa and Soba 2 Nursing Research and Practice teaching maternity hospitals.38% of the participants had attended courses for NRPs (Neonatal Resuscitation Programs).43.8% of the participants had between 21 and 30 years of experience in obstetrics and gynecology, and 49.1% performed neonatal resuscitation on a weekly basis (see Tables 1 and 2 for more details).
Regarding knowledge, 81.7% of the participants mentioned that they prepare for birth by identifying a helper and making an emergency plan.All participants ensured that the delivery area was clean, warm, and well lit.91.8% washed their hands before touching the baby and helped the mother wash her hands before breastfeeding her baby orally.82.5% assisted a baby in breathing if necessary, and 96.6% dried the baby thoroughly.98.2% carried out suction of the fuid from the mouth, while 91.2% began ventilation if the newborn baby was quiet, limp, not crying, and did not respond to steps to stimulate breathing and suction.66.7% agreed with the recommended rate for ventilating a newborn infant as 20 breaths per minute (see Tables 3 and 4 for more details).
Regarding practice, 50.9% of the participants used all necessary equipment and instruments that were in good working order, ready, available, clean, and sterile.56.1% did not wear a sterile gown, and 54.4% wore sterile gloves.71.9% used a clean mask.98.2% wiped the eyes and face when the head was delivered using sterile cotton material, while 96.5% dried the babies while assessing their breathing.None of the midwives who applied the identifcation bands included all the necessary details, and none of them placed at least two identifcation bands on the baby's wrist and mother's wrist.87.7% of them were administered vitamin K.
Regarding skin-to-skin contact, 29.7% of the participants mentioned that the advantage of skin-to-skin contact is bonding.91.2% of the participants answered that if the baby is breathing well; they place him/her in skin-to-skin contact with the mother's abdomen and cover the body (see Table 5 for more details).
In terms of resuscitation, 76.4% called for help when they had a baby not breathing well after 30 seconds postdelivery.63.2% clamped the cord approximately 2-3 minutes after birth or after cessation of cord pulsations.All participants tied the cord frmly about 2 fngers (3-4 cm) from the baby's abdomen and cut the cord 1 cm away from the tie.Only 19.3% thought that cleaning of the airway by suction is necessary, and all started suctioning through the mouth.94.7% answered that the baby did not need ambo bagging, while 5.3% of babies needed extensive resuscitation using ambo bagging and chest compression.Te performance of midwives in ambo bagging and chest compression was poor.93% thought the baby did not require chest compression, and 5.3% of those who performed ambo bagging performed poorly (see Table 6 for more details).
Te study found signifcant associations between demographic and experiential factors and CPR knowledge and practice.Age, education level, type of courses attended, years of experience, and frequency of performing CPR are all factors that infuence CPR knowledge and practice.Te fndings suggest that educators can improve CPR training and education programs by targeting specifc groups based on these factors, as well as by identifying and addressing potential barriers to CPR knowledge and practice (see Table 7 for more details).

Discussion
Te study conducted a comprehensive analysis of the demographic and experiential factors infuencing CPR knowledge and practice among midwives, yielding crucial insights that can enhance resuscitation training programs.Of the 57 participants, it was noted that a signifcant portion indicating that more experienced healthcare professionals often exhibit higher profciency in clinical skills such as neonatal resuscitation [9].Given that a majority of the participants were in the advanced stages of their careers, their accumulated experience likely contributed to their high profciency levels measured in this study.
Te marital status and educational level also emerged as signifcant factors.A predominant 73.7% of the participants were married, and 80% had achieved a one-year diploma level of education.Tis demographic profle may refect broader trends seen in healthcare, where personal and professional life choices signifcantly impact career development and specialization [10].Furthermore, the predominance of diploma-educated individuals highlights the necessity for continuous professional development to ensure that midwives remain updated on the latest protocols and procedures in neonatal care [11].
An important observation from the study is the participation rate in various educational courses.Approximately 38% had attended Neonatal Resuscitation Programs (NRPs), which correlate strongly with improved clinical outcomes in neonatal emergencies.Prior research has established that continuous education, particularly in specialized courses like NRP, signifcantly enhances the efectiveness of healthcare workers in emergency situations [12,13].Tis underscores the necessity of integrating such programs into regular training schedules for midwives.
Te study also brought forth detailed knowledge and practice assessments.An impressive 81.7% of the  Nursing Research and Practice participants prepared by identifying a helper and making an emergency plan, and 91.8% adhered to hygiene protocols by washing their hands before intervening with the newborn [14].Tese practices parallel fndings from international studies which emphasize the importance of preparedness and hygiene in reducing neonatal morbidity and mortality [15].High adherence to these protocols indicates a robust baseline of practical knowledge among the sample population, which is critical in ensuring the success of neonatal resuscitation procedures.
In terms of application, it was observed that 50.9% of the participants used all necessary equipment and 96.5% dried the babies while assessing their breathing.Te meticulous adherence to drying and assessing breathing refects best practice guidelines as recommended by global health authorities such as the World Health Organization (WHO) [16].However, the discrepancy observed in the usage of sterile gowns and gloves, with 56.1% and 45.6%, respectively, not adhering to the guidelines, indicates areas needing improvement.Tis inconsistency could potentially compromise the sterility of resuscitation environments and expose newborns to infections.
Te data also indicate a gap in the implementation of identifcation protocols.None of the midwives included all necessary details on the identifcation bands, and no midwife placed two identifcation bands on the baby's and mother's wrists [17,18].Tis practice is critical to prevent misidentifcation, and the current shortfall identifed by the study suggests an immediate need for procedural reinforcement in this area.
Importantly, the study's fndings on resuscitation practices reveal that a large proportion, 76.4%, did not call for help when a baby was not breathing well after 30 seconds.Tis can be potentially harmful as prompt action is crucial in neonatal resuscitation to prevent hypoxic damage [19].Te results show that while a number of participants have high theoretical knowledge, there may be gaps in practical application, especially under high-pressure conditions.
Te observed low rate of good performance in ambu bagging and chest compressions (only 5.3% refecting good performance) is particularly concerning.Previous studies have shown that hands-on practice and simulation-based training are essential in improving these skills among healthcare providers [20].Te fndings here reiterate the need for more frequent and rigorous practical training sessions to enhance the profciency of midwives in performing efective resuscitation measures [21].
Finally, the study draws signifcant attention to the associations between demographic factors, years of experience, frequency of CPR performance, and levels of knowledge and practice.Tese fndings suggest the necessity for targeted interventions in educational programs, highlighting the importance of continuous learning and practice tailored to the specifc needs identifed within diferent demographic groups.Regular assessment and refresher courses may bridge the knowledge-practice gap observed [22,23].
Te current situation in Sudan regarding CPR, particularly neonatal resuscitation, highlights the need for targeted training programs to enhance midwives' profciency in life-saving techniques.Te study's implications emphasize the importance of continuous professional development and hands-on training to improve neonatal resuscitation outcomes [24].Conducting research in specifc hospital settings in Khartoum allows for a focused examination of practices and knowledge among midwives in urban healthcare settings, ofering insights that can be utilized to tailor interventions for improved maternal and child healthcare.
In conclusion, this study provides valuable insights into the factors infuencing CPR knowledge and practice among midwives and ofers actionable information to enhance training programs.Emphasizing continuous professional development, adherence to best practices, and the integration of frequent hands-on training can signifcantly improve neonatal resuscitation outcomes.Tese improvements will contribute towards better neonatal care and lower infant morbidity and mortality rates, aligning with global healthcare goals.

Study Limitations.
One limitation of the study is the small sample size of 57 participants, which may restrict the generalizability of the fndings to a larger population of midwives.In addition, the study's focus on specifc hospitals in Khartoum limits the generalizability of the results to other healthcare settings.Te reliance on self-reporting through questionnaires and interviews may introduce response bias, and the lack of a comparative analysis and limited scope of assessment restrict the ability to assess the efectiveness of interventions or benchmark against other healthcare professionals.Tese limitations were identifed and acknowledged to provide a transparent and comprehensive interpretation of the study fndings.Nonetheless, further research with larger sample sizes and more diverse participant groups is warranted to address these limitations and enhance the validity and generalizability of the fndings.

Conclusion
In conclusion, this study provides valuable insights into the knowledge and practices of midwives in Sudan regarding neonatal resuscitation.Although many midwives displayed adequate knowledge and adherence to certain practices, there remains room for improvement in areas such as the use of necessary equipment, identifcation band details, and ambo bagging and chest compression skills.Te study also highlights the infuence of demographic and experiential factors on CPR knowledge and practice.

Recommendations
We recommend the development of targeted CPR training and education programs that address demographic and experiential factors to improve the overall quality of neonatal resuscitation in Sudan.In addition, eforts should be made to address potential barriers to CPR knowledge and practice, such as limited resources or lack of support.By implementing these recommendations, we can enhance Nursing Research and Practice the outcomes for newborns requiring resuscitation and ultimately improve the quality of maternal and child healthcare in Sudan.

Table 1 :
Demographic characteristics of the participants, N � 57.

Table 2 :
Type of courses attended by studied participants, N � 57.

Table 5 :
Practice assessment (part A) distribution among study participants, N � 57.

Table 6 :
Practice assessment (part B) distribution among studied participants, N � 57.Ties the cord frmly about 2 fngers (3-4 cm) from the baby's abdomen and cuts the cord 1 cm away from the tie

Table 7 :
Chi-square test and p value distribution among studied participants, N � 57.