Relationships between Socioeconomic Factors, Health Systems Factors, Clinical Factors and Advanced Neonatal Resuscitation Interventions in Alberta, Canada
Creators: Pickett, Breanna A
Publisher: name: University of Alberta Library
Year: 2024

<p>BackgroundThe Neonatal Resuscitation Program (NRP) is an educational program that outlines best practice, adopted across Canada. Neonatal resuscitation focuses on establishing effective ventilation; thus, the primary focus at birth is ensuring the newborn receives proper breathing interventions if necessary. Approximately 10% of newborns require resuscitation at birth, with 1% receiving advanced neonatal resuscitation interventions (ANRI) defined as endotracheal intubation for positive pressure ventilation, chest compressions, epinephrine administration, or a combination of interventions. The existing literature focuses primarily on clinical factors associated with any form of neonatal resuscitation with minimal research on non-clinical factors.ObjectivesThis thesis aims to 1) present a scoping review to understand this literature gap pertaining to Canada and other high-income countries, 2) describe neonatal resuscitation trends in Alberta, Canada using a population-based administrative dataset, and 3) examine possible relationships between non-clinical (maternal socioeconomic status (SES), maternal remoteness of residence, hospital level of service (LoS)) and clinical risk factors with advanced neonatal resuscitation interventions.Methods/DesignFirst, a scoping review was conducted on the database MEDLINE by Ovid to highlight current literature on neonatal resuscitation in relation SES (maternal) and remoteness (maternal residence, access to care, hospital rural/urban location and hospital LoS). Studies were included based on the criteria of; all neonates, resuscitation at birth and addressing on of the topics of interest. Second, a descriptive study was conducted on all live births ≥34 weeks gestational age in Alberta, Canada from 2000-2020 using retrospective, population-based administrative data. We aimed to 1) describe trends in neonatal resuscitation interventions and neonatal outcomes over 21 years and multiple editions of NRP, and 2) compare ANRI rates between hospitals of different LoS and rural/urban location. Maternal SES was categorized into quintiles based on the Pampalon material deprivation index. Maternal remoteness of residence was categorized by k-means clustering of values from the Statistics Canada Remoteness Index. Hospitals (n=97) were categorized based on availability of obstetrics and pediatrics supports and subcategorized by population and proximity to metropolitan centres. Finally, a multivariable logistic regression analysis was performed on this dataset to examine relationships between non-clinical factors (maternal SES, maternal remoteness of residence, hospital LofS of delivery site), clinical factors, and a binary outcome of any ANRI (yes/no). ResultsThe scoping review resulted in ten articles. Six articles discussed hospital LoS including hospital preparedness, hospital delivery volume, healthcare provider comfort and skills and resuscitation interventions. Three articles discussed telehealth and transfers between tertiary centers and community hospitals regarding neonatal resuscitation. One article discussed SES and a variety of neonatal outcomes. In the descriptive study, 966,475 births were included. Most occurred in hospitals with level 2 (56.6%) or level 3 (21.5%) NICUs. ANRI rates were: intubation for ventilation (0.8%), chest compression (0.2%), epinephrine (0.02%), any ANRI (0.95%). Other findings include: 1) as hospital LoS increased, intubation rates increased and chest compressions rates decreased, 2) no pattern was observed between rural/remote sites of similar LoS, and 3) compared with previous, advanced interventions decreased in infants born &gt;=41 weeks with NRP® 7th Edition.In the regression analysis, maternal SES does not appear to influence the need for receiving ANRI. Maternal remoteness of residence showed no clear pattern on the odds of needing ANRI. Level 3 delivery sites had the lowest odds of performing ANRI, despite caring for higher risk patients. Some clinical factors increased odds for infants to receive ANRI, including: general anesthesia (OR:4.89, 95% CI: 4.47-5.34), emergency c-section compared (OR: 1.45, 95% CI: 1.30-1.62), maternal age &lt;20 (OR:1.32, 95% CI: 1.18-1.47). Gestational age shows an increased odds of requiring ANRI in the form of a U-shaped trend, with the lowest odds at 38 and 39 weeks.ConclusionThere is a literature gap surrounding maternal SES and remoteness of maternal residence related to neonatal resuscitation in high-income countries. The descriptive study demonstrated higher chest compression rates and lower intubation rates with lower hospital LoS, which is concerning. When accounting for clinical risk factors, maternal SES did not appear to significantly influence ANRI, which is accounted for mostly by known clinical risk factors, with some differences due to hospital LoS. Further work is needed to understand these relationships to inform quality improvement for all newborns in Canada. </p>