Effect of a statewide neonatal resuscitation training program on apgar scores among high-risk neonates in Illinois

Objective. The national Neonatal Resuscitation Program (NRP), started in 19 87, provided training to hospital delivery room personnel to standardize kn owledge and skills to reduce neonatal morbidity and mortality and increase successful resuscitation during the first few critical minutes after birth. The Apgar score continues to be used as the best established index of imme diate postnatal health. The purpose of this study was to evaluate the impac t of the NRP instruction in Illinois hospitals by examining Apgar scores am ong high-risk infants who are likely to benefit from the NRP. Methods. A retrospective 3-time period cohort design was used (before the i ntroduction of the NRP, 1985-1988; transition when NRP training occurred, 1 989-1990; and after NRP training was completed at least once for some deliv ery room personnel in each Illinois hospital, 1991-1995). Illinois computer ized birth certificate files on a selected group of 636 429 high-risk neona tes provided information on Apgar scores and maternal characteristics. The American Academy of Pediatrics provided instructor lists to determine when NRP training started and when it was fully implemented in Illinois. Illinoi s Department of Public Health provided data to categorize hospitals into le vels based on type and intensity of neonatal services (Level I, II, II+, II I). High-risk neonates were defined as meeting 1 of the following criteria: maternal age <20 years old or >35 years old, birth weight <2500 g or >4000 g, presence of a maternal medical risk factor, and no prenatal care or pre natal care started after the first trimester. Several exclusion criteria were applied including the following: birth reco rds with missing data, multiple birth or congenital anomaly, and hospital i nformation that indicate no birth deliveries in 1 of the 11 study years or delivery outside of a hospital. One-minute and 5-minute Apgar scores were d ivided into categories for analysis (0-3, 4-6, 7-10). No change or a decrea se in a low (0-6) 1-minute Apgar when compared with the 5-minute Apgar was a primary measure to evaluate effect of NRP resuscitation. Variables examin ed included the following: race/ethnicity, maternal age, level of education , presence of maternal medical risk factor, trimester started prenatal care , complications of labor and delivery, and a low birth weight. Analysis con sisted of chi (2) tests, relative risk calculations, and logistic regressio n to reveal independent associations with no change in low 1-minute Apgar s core or continued low (0-6) 5-minute Apgar. Results. A total of 636 429 hig h-risk birth records was selected for detailed analyses out of 2 077 533 bi rths in Illinois between 1985 and 1995 for 193 hospitals. The number of act ive NRP instructors in Illinois changed dramatically during the study perio d; for example, 1 to 6 between 1987 and 1988 to 1096 to 1242 between 1991 a nd 1995. The percentage of neonates reported to have low (<7) 1-minute Apga r score decreased in 1991 to 1995 overall and for each of 4 hospital levels . Overall and by hospital level, there was a statistically significant lowe r proportion of high-risk newborns who showed a decrease or no change in th eir 5-minute Apgar scores after the NRP instruction. After adjusting for se veral maternal characteristics, logistic regression analysis revealed that high-risk newborns with a low 1-minute Apgar were more likely to increase t heir 5-minute Apgar after the NRP instruction in 1991 to 1995. Additional a nalyses indicated that very low birth weight and low birth weight newborns benefited the most from NRP instruction. Conclusion. Although previous research has shown that the NRP instruction i mproves knowledge and skill among health care personnel in the delivery roo m, both short-term and long-term, there has been little evidence to demonst rate NRP impact on infant morbidity. Several strategies were used in this s tudy to control for bias and to adjust for secular trends in decreased infa nt morbidity during the study period. This study demonstrated sufficient su pport for the hypothesis that a significant improvement occurred among neon ates in their Apgar score after the NRP instruction in Illinois. Empirical support is provided for the clinical effectiveness of NRP instruction.