What is known and what is new about this study?

• Neonatal resuscitation programmes are being scaled up globally, yet coverage of resuscitative interventions is not routinely tracked. Resuscitation coverage and quality measures have not yet been validated in either population-based surveys or routine facility registers.

• Challenges exist for measurement of resuscitation coverage indicators:

° Numerator: Which action during clinical resuscitation (e.g. stimulation or bag-mask-ventilation [BMV]) is both measurable and valid?

° Denominator: What is measurable and useful (e.g. live births plus fresh stillbirths or non-breathing, or non-crying babies)?

• EN-BIRTH is the first observational study (> 23,000 births) to assess validity of neonatal resuscitation coverage measurement, in both exit survey of women’s report and routine register records. Using time-stamped data, we analysed coverage and quality of neonatal resuscitation in five hospitals in Bangladesh, Nepal, and Tanzania.

Survey — what did we find and what does it mean?

• Numerator options: Survey-reported coverage of BMV (0.3–1.9%) markedly under-estimated observed coverage (0.7–7.1%). BMV had low sensitivity (< 21%) and high specificity (> 98%). Newborn stimulation was reported by < 3% of women, very much lower than observed coverage (5.2–21.0%).

• Denominator options: Crying at birth had low “don’t know” responses (< 3%) in exit survey. Compared to observed crying within a minute of birth, sensitivity was high (> 95%); however, specificity was low (< 22%). Survey-reported BMV coverage validity was consistently low for all denominators assessed.

Register — what did we find and what does it mean?

• Numerator options: Stimulation and BMV were recorded by 4 of 5 labour ward registers, yet accuracy varied between hospitals even with the same register design. BMV sensitivity ranged from 12.4–48.4% and specificity was high (> 93%). For stimulation, sensitivity was low at 7.5–40.8% and specificity was more variable (range 66.8–99.5).

• Denominators: Livebirths and fresh stillbirths were recorded in all registers. The “non-crying/non-breathing” combined denominator was only in the Bangladesh registers and could not be validated. Register-recorded BMV coverage was consistent whichever denominators was applied.

Gap analysis for quality of care and measurement

• Most newborns (71.4–94.7%) who did not respond to stimulation did receive BMV, but only 1% within the recommended 1 min after birth.

What next and research gaps?

• Population-based surveys are not likely to be useful for measuring neonatal resuscitation coverage, given low validity of exit-survey report. Additionally, household surveys would be underpowered since resuscitation is required by a small proportion of babies.

• Routine hospital registers have potential to track resuscitation coverage indicators, but implementation research is needed to standardise design and processes, including data flow to Health Management Information Systems. BMV is the most accurate numerator, true denominator measurement is complex and requires more research, including assessment of non-crying.

• Data use with feedback loops and support to frontline healthcare workers could help improve data quality and quality of care. Local clinical quality improvement and special studies are important to reduce quality gaps, particularly for timely BMV, and help meet global goals to end preventable deaths.