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International Perspectives: Birth-Associated Neonatal Encephalopathy:
Postresuscitation Care in West African Newborns
Article  in  NeoReviews · September 2018
DOI: 10.1542/neo.19-9-e507
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International Perspectives
Birth-Associated Neonatal Encephalopathy:
Postresuscitation Care in West African Newborns
Christabel C. Enweronu-Laryea, MRCP, MSc,* Julien-Didier Adedemy, MD, FWACP,†
Ikechukwu R. Okonkwo, MBBS, FWACP,‡ Anne C.C. Lee, MD, MPH,x Nicola J. Robertson, MBChB, PhD{**
*Department of Child Health, University of Ghana School of Medicine and Dentistry, Accra, Ghana;
†Department of Mother and Child, Faculty of Medicine, University of Parakou, Benin;
‡Department of Child Health, University of Benin Teaching Hospital, Edo State, Nigeria;
xDepartment of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA;
{Neonatology, Institute for Women’s Health, University College London, United Kingdom;
**Division of Neonatology, Sidra Medicine, Doha, Qatar
Education Gaps
1. Clinicians caring for newborns in low-resource settings need to recognize
that several local and complex dynamics influence the burden of perinatal
asphyxia in West Africa.
2. Appropriate use of clinical scores/tools may improve diagnostic accuracy
of birth-associated neonatal encephalopathy.
3. Therapeutic hypothermia without an effective package of intensive
monitoring and care may not be safe.
4. Prevention, early diagnosis, andmanagement of secondary causes of brain
injury are critical for improving health outcomes.
Abstract
The West African subregion has the highest burden of neonatal mortality
globally and the neonatal mortality rate is decreasing very slowly.
A high proportion of newborn deaths are preventable and improved
quality of care can reduce long-term morbidity in survivors. Perinatal
asphyxia is the major cause of death and disability in term infants in the
subregion. Neonatal resuscitation training programs have reduced
AUTHOR DISCLOSURE Drs Enweronu-Laryea, stillbirths and early neonatal mortality but the overall effect on survival
Adedemy, Okonkwo, Lee, and Robertson
have disclosed no financial relationships to discharge, population-based perinatal mortality, and long-term
relevant to this article. This commentary impairment is uncertain. Gaps in the health system and quality of
does not contain a discussion of an
postresuscitation care for affected newborns may defeat gains from global
unapproved/investigative use of a
commercial product/device. efforts to improve care around the time of birth. The aim of this review
is to discuss the current situation of postresuscitation care of term infants
ABBREVIATIONS
with presumed birth-associated neonatal encephalopathy in West Africa.
HBB Helping Babies Breathe
NE neonatal encephalopathy Limitations in diagnosing and treating affected infants and feasible
NRT neonatal resuscitation training interventions to improve acute and postdischarge care are discussed.
PA perinatal asphyxia
Vol. 19 No. 9 SEPTEMBER 2018 e507
Objectives After completing this article, readers should be able to:
1. Describe the burden and causes of birth-associated neonatal
encephalopathy in West Africa.
2. Recognize limitations in diagnosis and appropriate management of
neonatal encephalopathy in West Africa.
3. Review feasible community and facility-based interventions to reduce
death and disability of newborns with encephalopathy in West Africa.
INTRODUCTION skilled providers, vital registration systems are relatively
weak, and health systems face many challenges. (1)(3)(4)
The West African subregion is composed of 17 low- and Efforts by countries to improve maternal-newborn health
low-middle income countries with an estimated 350 mil- outcomes have resulted in a significant increase in facility-
lion people of great diversity in culture, language, religion, based antenatal and delivery services. (4) However, there
and colonial legacy (Fig). It has the highest burden of are still major gaps in the quality of services provided
neonatal mortality globally. (1)(2) Available data on major around the time of birth, and preventable birth complica-
causes of neonatal deaths and disability are estimates tions, especially perinatal asphyxia (PA), remain a major
because about half of all births still occur at home without cause of death and disability. (5)(6)
Figure. United Nations subregions of Africa andWest Africa. Printed with permission from the United Nations: West Africa, Map No. 4533, October 2014,
United Nations (http://www.un.org/Depts/Cartographic/map/profile/westafrica.pdf).
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PA occurs when there is interruption of blood flow and linkages and standards in the health system undermine
gas exchange to the fetus around the time of birth. Sig- maternal-newborn services; transportation is a major con-
nificant interruption results in hypoxic brain injury and straint to emergency obstetric care in rural communi-
neonatal encephalopathy (NE). The “golden minute”—the ties. (17)(18) Ambulance services, where they exist, are
first minute after birth—provides a crucial window of not equipped for transportation of sick newborns. Infants
opportunity for skilled essential care to reduce death who require postresuscitation care may not receive effec-
and disability. (7) Standardized neonatal resuscitation tive respiratory support during transportation to referral
training (NRT) programs such as Helping Babies Breathe centers and this increases the risk of secondary brain
(HBB) have significantly improved resuscitation skills injury.
of frontline providers and reduced deaths on the first Published country data on the burden of PA in the
day after birth. (8)(9)(10) Although HBB may reduce subregion are mostly estimates based on inadequate health
intrapartum-related neonatal mortality by 30% in low- information systems. In 2010, modeled estimates of
resource settings, the overall effect of NRT on survival population-level data on rates of adverse outcome related
to discharge, population-based perinatal mortality, and to intrapartum events showed an estimated 198,000 intra-
long-term impairment is uncertain. (7)(11)(12) Improving partum stillbirths, 129,000 intrapartum-related neonatal
the quality of care beyond the time around birth may save deaths, and 173,000 incident cases of NE (Table 1). (6)
more lives and reduce severe disability. Unpublished 2017 data from 16 neonatal referral centers
InWest Africa, many births still occur at the community in the Republic of Benin, Ghana, and Nigeria show that PA
and primary health facility level, often without a skilled accounted for 30% (range, 14%–58%) of term newborn
provider or 1 skilled provider attending to both the mother admissions and 20% (range, 11%–36%) of all neonatal
and newborn. (4) Newborns who require assistance with admissions. According to World Health Statistics 2015
breathing or have a weak or no cry at birth may not from the World Health Organization, intrapartum-related
receive effective resuscitative care. However, with govern- complications among live-born infants caused 8% to 13%
ment investments in community-based health services, the of deaths in children younger than 5 years in West African
HBB program is making inroads into intrapartum care at countries. (19)
all levels of health service delivery. (13) Consequently, an Survivors of PA in high-income countries have a high
increasing number of successfully resuscitated newborns risk of impaired neurodevelopmental outcome. (20) Little
are being referred to higher-level facilities for postresus- is known about long-term morbidity among survivors of
citation care. This review describes the situation in West PA in low-resource settings. (21) Low quality of postresus-
Africa and suggests options that may reduce the burden of citation care has been described in this region and thismay
birth-associated NE and improve hospital-based postre- increase the risk of severe neurodevelopmental impair-
suscitation care for affected term newborns. ment in survivors. (22)
THE BURDEN OF PA DIAGNOSIS OF BIRTH-ASSOCIATED NE
The burden of PA reflects the quality of maternal-newborn NE has been described as a clinical syndrome of impaired
health services; underlying factors for inadequate services neurologic function often accompanied by difficulty with
in the subregion have been described. (3) In Africa, the initiating and sustaining respiration around the time of
West Africa subregion has the poorest indices for facility- birth. (23) Although maternal, placental, and fetal risk
based maternal care; about 50% of births still occur at factors predispose newborns to NE, intrapartum-related
home with 20% occurring with no person present and acute hypoxic ischemia is the underlying cause in 50% to
only 35% attended by a physician or nurse/midwife. (14) 80% of cases in high-income countries and this proportion
Inequalities in access to health care and wealth contribute may be higher in low-resource settings. (24) Antenatal
significantly to giving birth with no one present, and inflammation including chorioamnionitis is common in
Nigeria accounts for a significant proportion of the global low-resource settings; this inflammation may potentiate
burden. (15) the effects of hypoxia on brain injury and significantly
Facility-based skilled delivery is inversely correlated to increase the risk for term encephalopathy. (25)
early neonatal deaths and varies widely between and within The criteria for attributing a birth-associated hypoxic-
countries, from 7.2% in rural Burkina Faso to 78% in ischemic event as the underlying cause of NE have evolved
Senegal. (16) Overall, limited resources and inadequate since 1996 but the cornerstone criterion remains the
Vol. 19 No. 9 SEPTEMBER 2018 e509
TABLE 1. IR Outcomes of NE in West Africa: Estimates for the Year 2010
NE SURVIVORS
MODERATE- NE SURVIVORS
IR NEONATAL NE NE NEONATAL NE SURVIVORS SEVERE MILD
COUNTRY INCOME BIRTHS NMR DEATHS CASES DEATHS (POSTNEONATAL) IMPAIRMENT IMPAIRMENT
Benin LIC 350,300 31.8 3,126 3,967 1,051 2,915 840 708
Burkina Faso LIC 713,200 37.9 7,280 9,322 2,470 6,852 1,973 1,665
Cameroon LMC 709,900 33.5 6,666 8,404 2,227 6,177 1,779 1,501
Cape Verde LMC 10,300 14.4 24 61 8 53 15 13
Cote d’Ivoire LMC 673,100 40.5 9,301 2,465 6,836 1,969 1,661
Gambia LIC 65,900 31.3 596 737 195 542 156 132
Ghana LMC 769,700 28 6,054 7,867 2,085 5,782 1,665 1,405
Guinea LIC 389,900 37.9 4,079 5,102 1,352 3,750 1,080 911
Guinea-Bissau LIC 58,200 40.1 640 796 211 585 169 142
Liberia LIC 153,700 34.1 1,478 1,843 488 1,354 390 329
Mali LIC 714,100 47.7 8,485 11,260 2,984 8,276 2,383 2,011
Mauritania LMC 116,800 39 1,202 1,565 415 1,150 331 280
Niger LIC 754,900 32.4 6,500 8,691 2,303 6,388 1,840 1,552
Nigeria LMC 6,300,000 40 69,240 86,636 22,959 63,678 18,339 15,474
Senegal LMC 465,400 27.2 3,674 4,650 1,232 3,417 984 830
Sierra Leone LIC 226,400 45.5 2,708 3,437 911 2,526 728 614
Togo LIC 193,400 32.4 1,731 2,225 590 1,636 471 397
IR¼intrapartum-related; LIC¼low income country; LMC¼low middle income country; NE¼neonatal encephalopathy; NMR¼neonatal mortality rate. Source:
Lee et al.(6)
presence of severe metabolic acidosis (pH <7.0 and base commodities for effective intrapartum monitoring are
deficit ‡12 mmol/L) with early signs of moderate or severe limited; available tools, particularly the partograph and
encephalopathy. Other minor criteria include a sentinel Apgar scoring, are often not used appropriately or inter-
obstetric hypoxic-ischemic event, abnormal fetal heart rate preted accurately; and clinical encephalopathy scoring is
patterns, low Apgar score, abnormal findings on neuro- infrequently used. (27)(28) Integrated perinatal care is not
imaging, and multisystem organ complications. NE is standard practice and newborns referred for postresusci-
an evolving disorder and no single test or clinical tool is tation care arrive with inadequate information about peri-
diagnostic. (26) natal events.
Acid-base measurements and neuroimaging are not usu- The Thompson score, first described in a South African
ally available at the point of care in West Africa. Currently, population, is a sensitive early clinical scoring system that
birth-associated NE is diagnosed when a newborn who has been shown to be sensitive at predicting either ab-
required resuscitative care at birth presents with abnormal normal amplitude-integrated electroencephalographic
neurologic findings (especially a clinical seizure). Perinatal or findings or moderate-severe encephalopathy. (29)(30) In
birth asphyxia is still the most commonly used terminology. Senegal, the modified Sarnat and Sarnat score has been
Almost all cases are presumed to be intrapartum-related and used to diagnose cases of intrapartum-related NE among
other causes of encephalopathy that present around the time of newborns referred with PA. (31) These approaches suggest
birth are largely underdiagnosed. that it is feasible to diagnose NE without expensive tech-
Several factors undermine accurate diagnosis of birth- nology. The scoring tools are easy to use and can be applied
associated NE in the subregion. The skilled workforce and as early effective screening tools for birth-associated NE
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in low-resource settings. Accurate diagnosis of intrapartum-
related NE is essential before application of specific thera- TABLE 2. Checklist for Perinatal Risk Factors
pies because routine application of therapeutic hypothermia for Birth-Associated Neonatal
may not be safe in the prevailing circumstances in West Encephalopathy and Related Events
Africa. Training and supervision of front-line clinicians
Maternal factors
about the appropriate use of the partograph (or electronic
monitoring where available), Apgar score, encephalopathy Chorioamnionitis
scoring tools, and checklists (Table 2) to capture intrapartum Maternal fever >100.4ºF (38ºC)
events and other clinical data may improve the diagnostic Prolonged rupture of membranes >18 hours
accuracy of birth-associated NE. • Antibiotics given
• Antibiotics not given
MANAGEMENT OF BIRTH-ASSOCIATED NE:
Prolonged hypoxia
CURRENT PRACTICE
Prolonged low blood pressure
There is no specific treatment for birth-associated NE, Cardiovascular collapse
but therapeutic hypothermia reduces death and disability
Obstetric complications
when included as part of a package of neonatal intensive
care. (32) However, the safety and efficacy of therapeutic Umbilical cord prolapse
hypothermia in low-resource settings is uncertain. (33) In Rupture of the uterus
the West African subregion, the neonatal intensive care Severe antepartum hemorrhage
package is limited to tertiary centers and a few nontertiary
• Placental abruption
hospitals. In addition to basic newborn care the package
includes oxygen therapy, intravenous drugs and infusions • Placenta previa
including blood products, phototherapy, gavage feeding, Placental insufficiency
and noninvasive respiratory support. Very few centers • Postdates
provide mechanical ventilation. Human resources are • Scanty liquor
severely limited and certified neonatal nurses are rare.
Fetal factors
Laboratory and radiologic services may not be accessible
at the point of care and basic monitoring devices such Abnormal fetal heart rate pattern
as pulse oximeters are very limited. • Persistent fetal tachycardia >160 beats/min >10 min
Effective care of newborns with NE requires a well- • Persistent fetal bradycardia <110 beats/min >10 min
organized system that provides timely and appropriate
• Absent baseline variability
supportive care. In rural settings, affected infants may not
receive skilled postresuscitation assessment before dis- • Recurrent late deceleration
charge; it is not uncommon for cases to be referred on the • Recurrent variable deceleration
second or third day of age because of poor feeding or Infant status at birth
seizures. None of the countries in West Africa have Inadequate or weak spontaneous respiratory effort
specific national guidelines for referral of infants for
Weak or absent cry
postresuscitation care. In the few countries with national
guidelines for clinical care, the information is scanty and Resuscitation provided
not updated, and some institutional guidelines are not • Stimulation or simple oxygen therapy
evidence-based. (34) • Bag and mask resuscitation
In West Africa, clinicians would generally not provide
• Endotracheal intubation
extra warmth to affected infants during the first 3 days
after birth; this practice is described as passive cooling in
some countries. For infants with seizures, phenobarbital
is the first-line anticonvulsant and phenytoin, where avail- appropriate treatment of clinically diagnosed seizures. All
able, is the second-line agent. Some tertiary centers use centers that provide an intensive care package provide
midazolam infusion for intractable seizures. Concerns postdischarge follow-up care for about 6 to 24 months but
about respiratory depression from anticonvulsants limit the content and quality of the service is variable because
Vol. 19 No. 9 SEPTEMBER 2018 e511
there are no national standards. It is not uncommon for rural communities, as advocates for reducing PA and
families to seek rehabilitation care from spiritual and severe disability will reduce cultural barriers to care seek-
traditional healers after discharge and only return for ing. The tradition of restricting pregnancy-related infor-
hospital care when there is severe disability. mation to only women needs to change. Community
Evidence-based guidelines and clinical pathways may health services should create opportunities to educate
reduce variability in practice and improve quality of ser- men about PA; the “School for Husbands” in Niger is a
vices during the acute and rehabilitation stages of care. (35) program worth emulating. (41) Where limited access or
(36) Limited capacity to continuously monitor body tem- cultural resistance to facility-based care is a constraint,
perature and oxygen therapy is a major constraint. Infants integrating traditional birth attendants into the health
undergoing facilitated endogenous cooling, so-called pas- system should be considered because this approach has
sive cooling, are at risk for severe hypothermia, hypoxia, or improved maternal-newborn outcome in Sierra Leone
hyperoxia, which may worsen brain injury. Clinical obser- and other African countries. (42)
vation, the only method available for diagnosing seizures,
is known to be highly inaccurate with low sensitivity;
underdiagnosis of seizures increases the risk for brain Improve Referral Systems and Integrate Care
damage while overdiagnosis may lead to unnecessary and No single referral system can meet the needs of all com-
toxic treatments. (37) munities; lessons can be learned from diverse approaches
to improve referral systems for emergency maternal-new-
born care. (43) Rural community efforts and social media
RECOMMENDATIONS TO IMPROVE HEALTH platforms are bridging some gaps in maternal services.
OUTCOMES These approaches can be extended to newborns when
Reductions in stillbirths and early neonatal deaths from intrauterine transfer is not possible. Adequate oxygen
improved intrapartum care and neonatal resuscitation pro- therapy and respiratory support should be provided
grams may lead to an increase in the population of children throughout the journey from the labor room to the neo-
and adults with severe disabilities and this has socioeco- natal unit. Every birthing place should have a newborn
nomic implications for society. (21)(38) Effective implemen-
tation of low-cost approaches could prevent some cases of TABLE 3. Content of Newborn Transport Kit
NE, improve the quality of resuscitative and postresuscita-
tion care, and enhance postdischarge rehabilitation services. Bag and mask equipment (appropriate sizes)
(27)(39) This section provides general recommendations Portable suction device and accessories
that can be adapted to local circumstances. Oxygen: Small oxygen cylinder with blender, oxygen delivery tube
with face mask or nasal prongs
Community Engagement Pulse oximeter
Of the 3 major causes of neonatal death, PA is the least
Thermometer
understood by communities in West Africa. Cultural be-
Glucometer
liefs and myths about pregnancy and birth-associated
injuries affect health-seeking behavior for facility-based Stethoscope
delivery and postdischarge rehabilitative care. Improving Intravenous cannula sizes 24G, 26G
the health literacy of mothers and families about the risk Syringes and needles: 2 mL, 5 mL
and socioeconomic consequences of PA and benefits of
Intravenous infusion set
acute and rehabilitative care is critical to reducing the
burden of disease. (27)(39) An increasing number of Nasogastric tube sizes 5–8F
women in the subregion are receiving antenatal care ser- Intravenous infusions: D10W, normal saline
vices in health facilities; this offers an opportunity for Thermal care: Cot sheets, blankets, cap
providers to improve the health literacy of mothers and
Medications: Epinephrine, phenobarbital, naloxone, calcium
communities on birth-associated injuries. gluconate 10%
Effective community engagement has the potential to Hygiene supplies: Gloves, alcohol wipes, diapers, cotton wool
significantly reduce demand-side barriers to facility-based
Other advanced equipment and supplies depending on available
care. (40) Engaging traditional, political, and religious expertise
leaders, as well as social groups of women and men in
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transport kit (Table 3) containing appropriate sizes of bag brain injury and use of affordable and durable diagnostics,
and mask and other supplies. If an ambulance or other including simple amplitude-integrated electroencephalog-
forms of vehicular transport service exist, efforts should be raphy devices to improve the diagnosis of seizures, espe-
made to equip them to meet basic needs, especially respi- cially in tertiary centers. Affordable and durable pulse
ratory care, of sick newborns. oximeters and acid-base measurement equipment may
Formal communication between obstetric and pediatric improve the quality of care and health outcomes. Other
services should extend beyond monthly or quarterly peri- options for anticonvulsant therapy for NE need to be con-
natal mortality meetings, and providers of neonatal care sidered because phenobarbital and phenytoin may not
need to engage with rehabilitation service providers. Effec- effectively treat neonatal seizures. (47)
tive communication and collaboration between depart- Facilitated endogenous cooling (ie, passive cooling) is
ments is essential. An integrated approach to perinatal currently standard practice in most West African coun-
care may improve diagnostic capacity and management tries. Central cooling, the endogenous physiologic re-
for affected infants. (36)(44) Hospitals that offer compre- sponse to asphyxia, was observed in infants in 1958 by
hensive obstetric care should have a pediatric team respon-
Burnard and Cross and recently in a pilot randomized trial
sible for the newborn around the time of birth. Limited
in Uganda. (48)(49) The cooling response may be exag-
human resources pose amajor handicap at district hospitals
gerated and prolonged in infants with severe NE. It is
where most births occur; many facilities may have 1 medical
unclear whether this endogenous cooling response is as
officer or pediatrician responsible for all neonatal and pedi-
neuroprotective as therapeutic hypothermia; also, the ef-
atric cases. However, a pediatric team of skilled nurses/
fect of antenatal inflammation on endogenous cooling is
midwives equipped with guidelines and checklist (Table 2)
unknown. Concerted efforts should focus on reducing sec-
could provide this service under the supervision of a single
physician. ondary brain injury until local randomized trials provide
evidence for other therapies.
Good-Quality Clinical Care
Many facility-based birth attendants in the subregion have FUTURE INTERVENTIONS AND RESEARCH
not received NRT, and basic resuscitation equipment is not
available at the point of care. (45) With central government Countries need to adopt continuous quality improvement
support, national pediatric/neonatal societies have the initiatives and use available resources more efficiently.
pivotal role of formulating national guidelines, training Tertiary institutions or countries should consider joining
birth attendants, and possibly instituting a national NRT established neonatal networks. Collaborative networks pro-
program. Advocacy for essential equipment and supplies vide opportunities for improving standards, learning, re-
for newborn services is vital. Other approaches to improv- search collaborations, data-driven quality improvement,
ing essential care and resuscitation around the time of and more. Ethiopia has recently joined the Vermont
birth have been described. (46) Oxford Network and other countries can learn from Ethio-
Infants with birth-associated NE are at high risk of having pia’s experience. The West African Health Organization
a secondary brain injury from secondary hypoxia and hyper- should recognize and prioritize the burden of birth-
oxia, hypocapnia and hypercapnia, untreated and prolonged associated NE, advocate for improved neonatal services,
seizures, sepsis, hyperthermia, and excessive (<91.4°F and possibly facilitate a regional collaborative neonatal
[33°C]) and prolonged cooling (>72 hours). Lessons can network.
be learned from high-income countries over the last de-
cade, with neonatal neurocritical care emerging as a culture
change toward a “brain-focused” approach to mitigate sec- TABLE 4. Future Needs and Direction for
ondary brain injury, rapid recognition of complications and Improving Care
seizures, consistent use of protocols, and use of experienced
teams. There is an urgent need for a culture change in the • National center of excellence that provides an intensive care
package including neurocritical care to scale up national training
practice of neonatology inWest Africa, including a culture of
•
teamwork and continuous quality improvement in the orga- Affordable effective technologies and drugs for accurate diagnosisand management of neonatal seizures
nization and practice of neonatal care.
• Improved capacity for effective rehabilitative care especially at
A culture change in West African neonatal care will district level
require basic training in measures to prevent secondary
Vol. 19 No. 9 SEPTEMBER 2018 e513
Parenteral levetiracetam, commonly used for neonatal 2. GBD 2015 Child Mortality Collaborators. Global, regional, national,
seizures in high-income countries is expensive and not avail- and selected subnational levels of stillbirths, neonatal, infant, and
under-5 mortality, 1980-2015: a systematic analysis for the Global
able in the subregion. Safer, effective, and affordable drugs for Burden of Disease Study 2015. Lancet. 2016;388(10053):1725–1774
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ducting randomized clinical trials using newer anticonvul- newborn and child health (MNCH) and health systems research
sants for newborns in the subregion should be explored. boundaries: conducive and limiting health systems factors to
improving MNCH outcomes in West Africa. Health Res Policy Syst.
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marized in Table 4. neonatal encephalopathy incidence and impairment at regional
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SUMMARY 7. Lee AC, Cousens S, Wall SN, et al. Neonatal resuscitation and
immediate newborn assessment and stimulation for the
• There are major gaps in the health system of West prevention of neonatal deaths: a systematic review, meta-analysis
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• Expensive technologies are not required to reduce the 8. The American Academy of Pediatrics. http://www.
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high burden of death and disability; engaging commu-
9. Hoban R, Bucher S, Neuman I, Chen M, Tesfaye N, Spector JM.
nities and improving timely access to quality maternal-
‘Helping babies breathe’ training in sub-saharan Africa:
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• New technologies and therapies will improve the diag- 2013;59(3):180–186
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11. Bellad RM, Bang A, Carlo WA, et al; HBB Study Group. A pre-post
• Quality improvement interventions should address the study of a multi-country scale up of resuscitation training of
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