Preparedness of primary health care workers and audit of primary health centres for newborn resuscitation in Port Harcourt, Rivers State, Southern Nigeria

Introduction: Nigeria still has high newborn deaths and birth asphyxia remains a major cause. Birth attendants´ readiness to perform newborn resuscitation depends largely on their competence in basic resuscitation and availability of newborn resuscitation equipment to enable the various steps outlined in resuscitation guidelines to be applied quickly and appropriately. This study aimed to assess primary health care workers´ experience of neonatal resuscitation and audit primary health centres for availability of neonatal resuscitation equipment. Methods: this descriptive cross-sectional study surveyed 106 primary health care workers (22 doctors, 84 nurses) randomly selected from 28 Primary Health Centres to document their experiences in newborn resuscitation and appraise the centres for availability of newborn resuscitation equipment. Experience in newborn resuscitation was obtained using a semi-structured questionnaire and audit was with a Proforma following on-site facility visits. Data was analysed using SPSS v20 and displayed in tables and graphs. Results: all health care workers had resuscitated newborns but only 58(57.4%) had ever used a bag and mask, 53(50%) used stethoscopes and 19(17.9%) had resuscitation protocol in their facilities. Fifteen (53.6%) health centres had functional newborn-specific bag and masks, 11(39.3%) had suction machines and 5(25%) had empty oxygen cylinders. Conclusion: primary health care workers´ experience of newborn resuscitation is very limited and some primary health centres were grossly unequipped. Neonatal resuscitation training interventions and supplies of neonatal resuscitation equipment are urgently needed.

UNICEF [10]. These courses give health workers the prerequisite training to improve competence in neonatal resuscitation and has been encouraged at all levels of healthcare [10,11].
Birth asphyxia requires simple and cost effective tools like resuscitator (bag and mask) and suction devices to prevent its occurrence [12].
Nationwide surveys that assessed emergency obstetrics and newborn services in some health facilities in Africa and Asia identified unavailability of equipment, health care workers´ ignorance and unskillfulness as setbacks to perform newborn resuscitation [13][14][15][16].
A multi-country survey by Enweronu-Laryea et al. [17] involving 12 Low and Middle Income Countries including Nigeria which aimed to grade the "bottlenecks" hindering scale up of basic newborn care and neonatal resuscitation in these countries showed that for neonatal resuscitation, lack of available bag and mask, inadequate workforce and poor service delivery were the major blocks in the health system. Sample size: the minimum sample size for this study was determined using the formula for quantitative variables for proportions [26]. Therefore, . nx =(267/(1+(267-1)))/168 = 103.
Hence a minimum of 103 HCWs was required for this study.

Selection of PHC centres: all 28 PHC Centres in Port Harcourt
Metropolis met inclusion criteria and were included.
Selection of health care workers: stratified sampling by proportionate allocation was used to randomly select primary health care workers. Both local government areas had a total of 168 HCWs.
In each PHC Centre, the workers were stratified by cadre into doctors and nurse/midwives. Each centre had two to three doctors and between two to twelve Nurse/midwives. Proportionate allocation was used to achieve the number of HCWs to be selected in each health facility and then each HCW was selected by simple random sampling by balloting. At each facility to minimise bias, the names of HCWs that met inclusion criteria were obtained from the scheduled duty roster and numbers assigned to each name. Then the required number needed to comprise the sample group as calculated by proportionate allocation formula was attained by picking at random after balloting. Health Care Management Board. Consent was obtained from each health care worker enrolled and were allowed to withdraw at any time.
All information, including personal details were handled with confidentiality.

Results
All one hundred and six health care workers who enrolled in this study completed the questionnaires, giving a completion rate of 100% and all 28 PHC centres were visited and availability and functionality of neonatal resuscitation equipment assessed.

Discussion
This study has shown that the overall experience of newborn This study therefore has identified some gaps; the limited experience of neonatal resuscitation among primary health care workers in Port Harcourt and the fact that re-stocking of neonatal equipment alone will not be sufficient. It suggests that both supplies of equipment for newborn resuscitation and training/re-training of health care workers at the community level be emphasized.
Limitation: this study did not assess the skills of the health workers with live babies or simulations, however, it is clear that even where the knowledge and skills for initiating positive pressure ventilation is available, lack of appropriate equipment may hinder progress and successful outcome during resuscitation.

Conclusion
The  Stocking Primary Health Centres with newborn resuscitation equipment alone is insufficient.

Competing interests
The authors declare no competing interests.  Table 1: socio-demographic characteristics of the health care workers