Abstract: We identified two community-based and three manikin-based trials that assessed the effect of SFNRT compared with no SFNRT. Very low quality evidence from one study suggested improvement in acquisition of knowledge (RR 5.96, 95% CI 3.60 to 9.87) and skills (RR 170, 95% CI 10.8 to 2711) and retention of knowledge (RR 3.60, 95% CI 2.43 to 5.35) and the other study suggested improvement in resuscitation and behavioural scores. We identified three community-based cluster-randomised trials in developing countries comparing SFNRT with basic resuscitation training (Early Newborn Care). In this setting, there was moderate quality evidence that SFNRT decreased early neonatal mortality (typical RR 0.88, 95% CI 0.78 to 1.00; 3 studies, 66,162 neonates) and when analysed by the approximate analysis method (typical RR 0.85, 95% CI 0.75 to 0.96; RD -0.0044, 95% CI -0.0082 to -0.0006; NNTB 227, 95% CI 122 to 1667). Low quality evidence from one trial showed that SFNRT may decrease 28-day mortality (typical RR 0.55, 95% CI 0.33 to 0.91) but the effect on late neonatal mortality was more uncertain (typical RR 0.47, 95% CI 0.20 to 1.11). None of our a priori defined neonatal morbidities were reported. We did not identify any randomised studies in the developed world. We identified two trials that compared SFNRT with team training to SFNRT. Teamwork training of physician trainees with simulation may increase any teamwork behaviour (assessed by frequency) (MD 2.41, 95% CI 1.72 to 3.11) and decrease resuscitation duration (MD -149.54, 95% CI -214.73 to -84.34) but may lead to little or no difference in Neonatal Resuscitation Program (NRP) scores (MD 1.40, 95% CI -2.02 to 4.82; 98 participants, low quality evidence). We identified two trials that compared SFNRT with booster courses to SFNRT. It is uncertain whether booster courses improve retention of resuscitation knowledge (84 participants, very low quality evidence) but may improve procedural and behavioural skills (40 participants, very low quality evidence). We identified two trials on decision support tools, one on a cognitive aid that did not change resuscitation scores and the other on an electronic decision support tool that improved the frequency of correct decision making on positive pressure ventilation, cardiac compressions and frequency of fraction of inspired oxygen (FiO2) adjustments (97 participants, very low quality evidence). SFNRT compared to basic newborn care or basic newborn resuscitation, in developing countries, results in a reduction of early neonatal and 28-day mortality. Randomised trials of SFNRT should report on neonatal morbidity including hypoxic ischaemic encephalopathy and neurodevelopmental outcomes. Innovative educational methods that enhance knowledge and skills and teamwork behaviour should be evaluated.

Plain-language summary: We searched for studies that evaluated the effectiveness of newborn resuscitation programmes in April 2014 and updated in March 2015 and found five community-based studies (187,080 deliveries) and nine mannequin-based studies (626 newborns). Moderate quality evidence from three studies suggested that training in newborn resuscitation probably decreases newborn deaths in the first seven days after birth. Low quality evidence from one study suggested that newborn resuscitation training may decrease newborn deaths in the first 28 days after birth. All three studies were performed in low-income settings and their findings may have limited applicability to high-income settings. We also found that teaching teamwork in addition to resuscitation training may improve team behaviour and decrease time for resuscitation (two studies, low quality evidence) but the effect on performance on resuscitation was uncertain. It is uncertain whether resuscitation programmes increase learners' knowledge and skills immediately and knowledge at six months because the quality of evidence was very low. Similarly, whether boosters to neonatal resuscitation help in retaining knowledge or performing resuscitation appropriately remain uncertain (the quality of evidence was very low). Also, whether visual or electronic aids for helping making decisions during resuscitation, improve resuscitation performance was uncertain (one study did not show effect but one electronic decision support tool with prompts improved resuscitation performance) (low quality evidence). We strongly encourage future studies to report outcomes related to long-term health, such as brain injury due to lack of oxygen, fits and long-term brain development. Effective methods to enhance teamwork behaviour, learning and retention of resuscitation knowledge and skills are needed.