Facility and care provider emergency preparedness for neonatal resuscitation in Kano, Nigeria.

INTRODUCTION: The knowledge, attitude, and practice of emergency neonatal resuscitation are critical requirements in any facility that offers obstetric and neonatal services. This study aims to conduct a needs assessment survey and obtain individual and facility-level data on expertise and readiness for neonatal resuscitation. We hypothesize that neonatal emergency preparedness among healthcare providers in Kano, Nigeria is associated with the level of knowledge, attitudinal disposition, practice and equipment availability at the facility level.
METHODS: A semi-structured, self-administered questionnaire was administered to a cross-section of health providers directly involved with neonatal care (n = 112) and attending a neonatal resuscitation workshop in Kano state. Information regarding knowledge, attitude, practice and facility preparedness for neonatal resuscitation was obtained. Bloom's cut-off score and a validated basic emergency obstetric and neonatal care assessment tool were adopted to categorize outcomes. Multivariable logistic regression was employed to determine independent predictors of knowledge and practice.
RESULTS: Almost half (48% and 42% respectively) of the respondents reported average level of self-assessed knowledge and comfort during resuscitation. Only 7% (95% CI:3.2-13.7) and 5% (95% CI:2.0-11.4) of health providers demonstrated good knowledge and practice scores respectively, with an overall facility preparedness of 46%. Respondents' profession as a physician compared to nurses and midwives predicted good knowledge (aOR = 0.08, 95% CI: 0.01-0.69; p = 0.01), but not practice.
CONCLUSION: Healthcare provider's knowledge and practice including facility preparedness for emergency neonatal resuscitation were suboptimal, despite the respondents' relatively high self-assessed attitudinal perception. Physicians demonstrated higher knowledge compared to other health professionals. The low level of respondents' awareness, practice, and facility readiness suggest the current weak state of secondary health systems in Kano.

Introduction

Each year, approximately 136 million babies are born, with an estimated 10% requiring some form of basic support at birth, and 3–6% needing active resuscitation [1,2]. Over 90% of neonatal deaths occur in low and middle-income countries of Sub-Saharan Africa (SSA) and southeast Asia [2,3], with a quarter of these deaths related to intrapartum events. Nigeria is among the top three contributors to the global burden of infant mortality [3], with a neonatal mortality rate (NMR) that has stagnated between 37 and 41 per 1000 live births over the past three decades. The high rates of neonatal mortality in Nigeria have been linked to a lack of access to quality emergency services, including resuscitation at birth [4,5]. This finding is partly attributable to the paucity of skilled personnel—Nigeria has a workforce of only 476 Pediatricians [6], and a health worker to patient ratio of 20/10,000, which is below the World Health Organization (WHO) recommendation of 23/10,000 [7]. Kano State, the most populated state in Nigeria, has the highest burden of NMR in the country, at 69 per 1000 live births. Evident NMR disparity exists in the State linked to sociodemographic indices and is worst among infants born to young mothers with no education, low wealth index quintile, male gender, high birth order and birth interval of less than 2 years. Infants born in rural areas are 54% more likely to die than their urban counterparts [8]. Reports from 6 African countries showed that among health workers, the knowledge of neonatal resuscitation was poor, ranging between 2%–12% [1]. In addition, only 8%-22% of the surveyed facilities had appropriate resuscitation equipment [1]. It remains unclear whether these findings are the same in Nigeria, a country with similar demographics, the most populous in Africa with a high fertility rate, that was not included in the study.

The intrapartum transition of the new-born requires meticulous proficiency in the immediate and emergent care provided at birth and is key to a favorable neonatal outcome. A recent meta-analysis reported a 37% reduction in intrapartum asphyxia-related deaths with neonatal resuscitation training (NRT) [9]. To avert the projected annual global death of 2.8 million neonates, 80% of which will likely occur in SSA and southeast Asia [3]; and achieve the proposed Sustainable Development Goal target of reducing preventable neonatal deaths to at least 12 deaths per 1,000 live births by 2030, concerted efforts are needed to strengthen and accelerate the availability of emergency NRT [10]. For NRT to be impactful, the cognitive knowledge and attitude towards it, technical know-how and equipment availability to support proficiency are essential. As a first step, obtaining reliable data for evaluating key action areas that need support is necessary.

We hypothesize that neonatal emergency preparedness among healthcare providers in Kano, Nigeria may be associated with the level of knowledge, attitudinal disposition, practice and equipment availability at the facility level. To our knowledge, there is no published research on the status of emergency preparedness for neonatal resuscitation in the most populous state in Africa’s most populated country. We, therefore, conducted a needs assessment survey to obtain individual and facility-level data on the level of expertise and readiness for neonatal resuscitation. Our multi-center findings will help inform policy to delineate areas that need support and enhance service delivery.

Methodology

Study site

This survey was conducted in secondary health facilities in Kano, the capital of Kano state in northwest Nigeria (estimated population: 13 million) [11]. The State has 44 local government areas (LGAs), each divided into wards totaling 484. Health services are provided via three tiers of government: primary health care provided by the local government, secondary health care by the state government, and tertiary care supported by the federal government. Private facilities provide different services at various community levels. The state has 1350 primary health facilities and 40 secondary health centers spread across the LGAs. Only 33 secondary health facilities have a maternity unit and conduct deliveries. The total fertility rate in Kano is 6.5 and only 19.2% of deliveries take place in a health facility [12].

Study design

A descriptive cross-sectional survey was conducted during a two-day NRT workshop in November 2020.

Sampling

The State Ministry of Health organized a two-day neonatal resuscitation workshop for healthcare providers in secondary health centers of the state. The training was conducted in two batches. A master health facility list was used to identify the centers that offer obstetric and newborn services and invitations were sent to participants through the state ministry of health and management board. Two participants were invited from each of the 33 secondary facilities that conduct deliveries. The remaining participants were drawn from the two Pediatric secondary health centers within Kano metropolis (Hasiya Bayero Pediatric Hospital and Khalifa Isyaka Rabiu Pediatric Hospital). Using each center’s work rota, a convenience sample was used for the selection process, inviting only staff that were off duty to eliminate the risk of staff shortage on active duty during the training period. The diversity of the participants including doctors, nurses, and midwives added strength to the sample and reduced selection bias. Only healthcare providers who were directly involved in neonatal care were invited and participation in the survey was voluntary.

Sample size estimation

With a power of 80%, 95% confidence level, a desired level of precision of 0.05 and 3% prevalence of healthcare workers with good knowledge of neonatal resuscitation obtained from a similar study in North-eastern Nigeria [13], and a non-response rate of 10%, we determined a minimum sample size of 98 healthcare workers. To increase precision, all healthcare workers (112) who were present at the training were included in the study.

Study population

The study population was comprised of medical officers, nurses and midwives working in the operating room, delivery, newborn, and Pediatric wards of government-owned secondary health centers in Kano, Nigeria. We excluded any healthcare provider who was not directly involved in labor/delivery and newborn care, and those who did not provide consent, a pre-requisite for inclusion.

Consent

Participants were informed about the survey at the beginning of the workshop before the commencement of the training, and written consent was obtained from each participant before inclusion in the survey.

Data collection instrument

A literature review of methods and data collection instruments used for NRT needs assessment was conducted. A semi-structured questionnaire was developed from core components of the neonatal resuscitation algorithm [14,15] and standardized questions from similar studies [16-18] pertinent to our practice. The questionnaire was self-administered and completed before the start of the training to ensure efficiency, anonymity and reduce response bias. It comprised a total of 51 questions divided into five sections covering information on sociodemographic/work-related characteristics, knowledge of neonatal resuscitation, practical skills, self-reported readiness, and facility-related preparedness. The final questions used were consensually reviewed, edited, and validated, and were pretested among 12 neonatal health care providers consisting of nurses and doctors in a tertiary institution.

Outcome variables

The outcome variables considered were four, namely: knowledge; self-reported preparedness and attitude; practice; and facility preparedness for neonatal resuscitation. The knowledge on neonatal resuscitation was assessed using 12 elements on the questionnaire, eliciting information on the appropriate sequence of resuscitation, initial steps and airway management, indications for ventilation and chest compression, rate of ventilation, indications for oxygen use and targeted oxygen saturation, when to use drugs, and the indicators of adequate resuscitation. Self-reported preparedness and attitude were evaluated using four questions. Two questions elicited self-assessed knowledge and opinion regarding facility preparedness for neonatal resuscitation with a 6-level Likert-type scale. Other questions enquired about the participants’ attitude during resuscitation, specifically the need to call for help and how soon the request was made, and their comfort level during resuscitation.

The practice of the respondents was assessed using 15 items on resuscitation technique and everyday practice, e.g., partograph use to predict the need for resuscitation, the number of staff that participate during resuscitation, neonatal temperature regulation, routine umbilical cord care practice, expertise in umbilical catheterization, etc. Facility level preparedness was audited with 8 questions in three domains: availability of essential and priority resuscitation equipment, and on-the-job staff training. The first two domains had questions on available equipment for neonatal resuscitation and the third domain covered the presence of neonatal resuscitation guidelines and equipment checklist.

Explanatory variables

Demographic information included age, sex, the profession of the participant (physician, nurse, or midwives), unit/ward of practice, years of experience in the specified ward, number of deliveries conducted, and neonatal resuscitation events performed by the respondents during the preceding year; and whether the respondent had received NRT in the past. Other information captured the availability of advanced equipment and certain emergency medical facilities/services, the total number of deliveries and deaths within 24 hours and the number of staff dedicated to neonatal care.

Scoring of responses

One point was allocated for each correct response and zero was allocated to a wrong or ‘don’t know’ response. For each section, the mean score was calculated as a percentage of the total for that section (12 points equivalent to 100% for knowledge and 15 points equivalent to 100% for practical skills). Bloom’s cut-off [19] of 80% was adopted to categorize knowledge and practice. A score of ≥9.6 was considered good knowledge and a score of ≥12 was considered good practice.

The WHO method of assessing facility service availability and readiness for basic emergency obstetric and neonatal care (BEmONC) [20] was used to evaluate facility-related level of preparedness for neonatal resuscitation. Three domains with 29 indicators were assessed namely: staff and training domain comprising of two indicators; essential equipment and drugs domain consisting of 15 indicators; and priority equipment domain consisting of 12 indicators. A composite score was created for the indicators in the assessed domains, with each item per domain scored as one if available and zero if absent. The scores were tallied to obtain a total score for each domain and converted to a percentage. The expected target was 100%, so each domain was allocated 33.3% of the overall score. The readiness of a facility to provide optimal neonatal resuscitation was calculated by adding the percentage proportions of the three domains. An overall score of 50% [20,21] was considered as the cut-off for a well-equipped and prepared facility.

Data privacy and quality assessment

Paper forms were used to collect data anonymously, and these were distributed at the beginning of the training before didactic sessions began. All questionnaires were checked for completeness, correctness, clarity, and consistency by the investigators immediately after collection from participants. The completed forms were kept in a secured institutional unit accessible only to other investigators on request.

Data analysis

All analyses were conducted using STATA 15.0 (STATA Corp, College Station, TX, USA). Proper coding and categorization of data were done, and these were rechecked for completeness and accuracy. Frequencies and percentages were described for categorical variables, mean (with standard deviation, SD) was reported for age and median with interquartile range (IQR) for years of experience. Univariate analysis was conducted to identify variables associated with knowledge and practice of neonatal resuscitation. All variables were considered a priori confounding variables for both knowledge and practice of neonatal resuscitation as identified by previous literature [18,22-25]. Independent variables with p<0.10 at the bivariate level were included in the multivariate analysis. To generate adjusted odds ratios, a forward selection approach to modelling was employed, and a parsimonious model was built with retention of those variables that changed the odds ratio by at least 10%. A p-value <0.05 was considered statistically significant.

Ethics approval

Ethical approval was obtained from the Kano State Ministry of Health research ethics committee (Ref: MOH/Off/797/T.I/2111). Signed consent was obtained from all the respondents and participation was voluntary. All provisions of the Helsinki declaration were respected.

Results

A total of 112 participants responded to the survey and 111 were included for analysis Fig 1. The age of participants ranged between 20 to 56 years (mean ± SD: 34.6 ± 8.4 years). Approximately half of the respondents (51%, n = 56) work in the delivery room while less than half (46%, n = 50) of the respondents had previous NRT. Approximately 46% (n = 23) received the training in the preceding 3 years. The participants’ years of work experience ranged from one year to 32 years (median [IQR]: 5 [2,10] years). Other characteristics are presented in Table 1. Overall, the median participants’ self-reported monthly number of deliveries and neonatal deaths within 24 hours of delivery in the facilities were 150 (IQR: 60–250) and 5 (IQR: 2,10) respectively.

Fig 1

Schematic representation of the respondents from secondary health facilities in Kano, Nigeria during neonatal resuscitation training.

Table 1

Characteristics of the respondents.

Variable	Frequency N = 111	Percent (%)
Age in years (*5)
20–29	30	28.3
30–39	51	48.1
40–49	15	14.2
50–59	10	9.4
Sex (*0)
Male	45	40.5
Female	66	59.5
Profession (*0)
Doctor	42	37.8
Nurse	44	39.6
Midwife	25	22.5
Ward (*0)
Neonatal	15	13.5
Labor/Delivery	56	50.5
Operating Theatre	9	8.1
Pediatrics	26	23.4
Multiple wards	5	4.5
Work experience in years (*0)
1–5	63	56.8
More than 5	48	43.2
Received NRT (*2)
Yes	50	45.9
No	59	54.1
Deliveries attended in the preceding year (*4)
Less than 10	29	27.1
10 or more	78	72.9
Neonates resuscitated in the preceding year (*2)
≤10	57	52.3
>10	52	47.7

NRT- Neonatal Resuscitation Training.

*—Missing numbers.

Knowledge and attitude towards neonatal resuscitation

Almost half of the respondents (48%, n = 51) reported an average level of self-assessed knowledge towards neonatal resuscitation, while only 9 (9%) and 3 (3%) believed they had poor and excellent knowledge respectively. However, when knowledge was measured objectively, only 8 participants (7%, 95% CI:3.2–13.7) had good knowledge. Respondents’ profession was the only factor identified as a predictor of good knowledge; nurses and midwives were 92% less knowledgeable than physicians (aOR = 0.08, 95% CI: 0.01–0.69; p = 0.01). Age, gender, ward, years of work experience, previous NRT, number of deliveries attended, and neonates resuscitated were not predictive of knowledge Table 2. Comparing the knowledge of neonatal resuscitation between participants from the 33 secondary health centres that conduct deliveries (n = 66, mean score 50.4 ±12.9, 95% CI 47.2–53.6) and participants from the two paediatric hospitals within Kano metropolis (n = 45, mean score 51.1±12.1, 95% CI 47.5–54.8), there was no significant difference between the scores (p = 0.76). The majority of respondents (43%, n = 45) self-reported average level of comfort with their newborn resuscitation practice. Furthermore, most respondents (88%, n = 93) often felt the need to call for help during resuscitation, with 75 (77%) making the request as soon as the need is identified, while 10 (10%) ask for assistance only when in the theatre.

Table 2

Factors associated with knowledge and practice of neonatal resuscitation.

Knowledge					Practice
Factor	Crude OR* (95% CI)	P-Value	Adjusted ORa (95% CI)	P-Value	Crude ORb (95% CI)	P-Value	Adjusted ORc (95% CI)	P-Value
Age (in years)
≤35	Reference		Reference		Reference		Reference
>35	0.28 (0.03–2.45)	0.19	0.24 (0.03–2.19)	0.21	0.35 (0.04–3.26)	0.32	0.29 (0.03–2.73)	0.13
Gender
Male	Reference				Reference
Female	0.68 (0.16–2.9)	0.61	0.84 (0.18–3.84)	0.60	0.32 (0.56–1.83)	0.18	0.51 (0.08–1.80)	0.47
Profession
Doctor	Reference		Reference		Reference		Reference
Nurse/Midwife	0.07 (0.01–0.62)	0.002	0.08 (0.01–0.69)	0.01	0.28 (0.05–1.62)	0.14	0.46 (0.07–2.84)	0.10
Ward
Neonatal/Pediatrics	Reference				Reference
Labor/Operating theatre	1.63 (0.30–8.79)	0.54	1.83 (0.03–10.06)	0.55	0.29(0.05–1.68)	0.15	0.35 (0.06–2.09)	0.25
Multiple	4.88 (0.36–66.41)		4.11 (0.29–57.62|)		-		-
Work experience (in years)
1–5	Reference	0.26	Reference	0.31	Reference	0.15	Reference	0.19
>5	0.41 (0.08–2.14)		0.40 (0.78–2.08)		0.25 (0.03–2.19)		0.23 (0.03–2.08)
Deliveries attended to in the preceding year
≤10	Reference	0.50	Reference	0.57	Reference	0.73	Reference	0.82
>10	0.59 (0.13–2.66)		0.63 (0.14–2.85)		0.73 (0.13–4.21)		1.24 (0.21–7.34)
Neonates resuscitated in the last year
≤10	Reference	0.49	Reference	0.50	Reference	0.91	Reference	0.95
>10	0.64 (0.14–2.81)		0.60 (0.13–2.71)		1.10 (0.21–5.72)		1.05 (0.20–5.65)
Previous NRT
Yes	Reference		Reference		Reference	0.09		0.16
No	0.48 (0.11–2.12)	0.33	0.99 (0.21–4.90)	0.99	0.16 (0.02–1.38)		0.20 (0.02–1.90)
Knowledge of neonatal resuscitation
Poor					Reference	0.51	Reference	0.45
Good					2.18 (0.21–22.53)		2.67 (0.20–35.15)

Adjusted for profession, age and previous NRT.

Adjusted for previous Neonatal Resuscitation Training (NRT).

c Adjusted for gender, profession, ward, years of experience and previous NRT.

Practice during neonatal resuscitation

Only 5% (95% CI:2.0–11.4) of the respondents (n = 6) had good neonatal resuscitation practices. After adjusting for the effect of previous NRT, no factor was found to be independently associated with good practice Table 2. There was, however, a statistically significant difference (p = 0.03) between the practice scores of participants from the 33 secondary health centers that conduct deliveries (n = 66, mean score 50.6 ±15.0, 95% CI 46.9–54.3) and participants from the two pediatric hospitals (n = 45, mean score 57.0±12.1, 95% CI 52.4–61.6) included in the survey.

Facility preparedness for neonatal resuscitation

On the self-assessed level of facility readiness, slightly over a third of respondents (38%, n = 40) believed their facilities to be averagely ready, while 28 (28%) felt their facilities were poorly prepared. The overall neonatal resuscitation preparedness index was 45.8%, with each of the three domains assessed having less than 50% average score for the measured indicators. The facility readiness based on a 33.3% proportionate contribution of each domain for staff and training was 13.2%, for essential equipment and drugs were 17.5% and for priority equipment was 15.1%.

None of the facilities had 100% availability of any indicator (equipment, drugs, and training) of readiness, including advanced equipment and emergency services, Table 3. Only a third of the facilities had an equipment checklist. Gloves (81.1%, n = 90) and stethoscopes (90.1%, n = 101) were mentioned as the most available essential and priority equipment, respectively.

Table 3

Indicators of readiness to provide neonatal resuscitation in secondary health facilities in Kano (N = 111).

Staff and training	Availability (N)	Percent (%)
Resuscitation guidelines	52	46.8
Equipment checklist	36	32.4
Essential equipment and drugs
Gloves	90	81.1
Normal saline	88	79.3
Ambu bag	86	77.5
Suction bulb	85	76.6
Cord ties	78	70.3
Scissors	77	69.4
10% DW	71	64.0
Clock	54	48.7
Adrenaline	45	40.5
Nasogastric tubes	36	32.4
Towels/Cloths	33	29.7
Infant warmer	30	27.0
Resuscitation table	29	26.2
Sodium bicarbonate	13	11.7
Polythene bags	11	9.9
Priority Equipment
Stethoscope	101	90.1
Syringes	88	79.3
Oxygen concentrator	87	78.4
Suction device	81	73.0
Pulse oximeter	68	61.3
Glucometer	54	48.7
Incubator	49	44.1
100% oxygen	37	33.3
Endotracheal tube	13	11.7
Transport Incubator	10	9.0
Laryngoscope	9	8.1
Continuous Positive Airway Pressure Ventilation	6	5.4
Advanced equipment
Ventilator	15	13.5
ECG monitor	5	4.5
Laryngeal mask airway	3	2.7
Blood gas analyzer	1	0.9
Emergency services
Backup generator or Solar	92	82.9
Electricity	73	65.8
Ambulance	67	60.4
Communication system with referral centers	36	32.4

N-Total number of respondents.

Discussion

We found that the level of knowledge and practice of neonatal resuscitation among healthcare providers in secondary health facilities in Kano to be poor, with only 7% and 5% of respondents demonstrating good knowledge and practice, respectively. Similarly, the overall facility-level preparedness for neonatal resuscitation was inadequate at 18%. These findings imply that the quality of neonatal resuscitation provided at secondary health centers in the state requires significant improvement. Both long-term neurobehavioral and cognitive development of children are associated with the quality of immediate care provided in the first few hours of life. The low utilization of delivery services including lack of antenatal care, delayed hospital presentation during labor, preference for unorthodox obstetric care and home deliveries hinders timely obstetric service demand [4] and worsens neonatal outcome. This may be linked with poverty, lack of insight, and community perceived facility inadequacy in providing quality obstetric services. Failure to improve community health-seeking behaviors and the standard of healthcare practice through continuous retraining and re-evaluation and ensuring availability of essential equipment for optimal service delivery could worsen neonatal and child health indices in the state.

The finding of low level of knowledge and practice among respondents despite almost half (46%) of them having had prior NRT was unexpected. This finding could be due to the lack of regular facility audits to ensure an up-to-date level of comprehension and practice [26] of the healthcare providers. Another reason could be the dearth of frequent standardized formal NRTs, which have been shown to reduce early neonatal death [27], change providers’ behavior, level and retention of knowledge and practice [28]. The majority of our respondents (47%) were trained in the preceding 3 years. There is no clear recommendation regarding the number of NRTs per year to maintain practice [1].

The proportion of doctors with good knowledge of resuscitation was higher than other healthcare providers (p = 0.01). This finding likely affected the general quality of service offered, as the majority (62%) of the workforce are nurses and midwives. The prevalence of good knowledge and practice of neonatal resuscitation is similar to reports from Gombe in northern Nigeria [13], probably because of similar demographics, although the majority of the facilities surveyed in Gombe were primary health facilities with a few referral centers. In Ghana, the prevalence of good knowledge was 1.9%, [29] slightly lower than this study; however, in that study, all the respondents were midwives as opposed to this study that included physicians. In contrast, studies from western Nigeria (95%) [22] and Ethiopia (53.8%) [23] with nurse participants only showed much higher prevalence rates than our study. This disparity may be associated with the difference in the survey tool used, with fewer and less technical questions assessed in the two studies.

Although only 7.2% of the respondents had good knowledge, this finding did not affect the overall outcome of practice at 5.4%. As most of the respondents’ knowledge is poor, it is unlikely that the small proportion with adequate knowledge will have a meaningful impact on the overall quality of practice. Similarly, the identified paucity of equipment in all the centers may have contributed to the pervasive poor practice, since good practice cannot be achieved without the availability of the necessary tools for service delivery. This finding is similar to reports from other developing countries [13,30]. Western Nigeria [22], however, reported a higher level of practice than our study at 49.7%. The score criterion for adequate knowledge was less than the measure used in the current study.

Overall, facility readiness to offer neonatal resuscitation services including availability of equipment was poor, with a preparedness index of 46%, signifying that approximately 16 of the 35 secondary health centers achieved the minimum of 50% readiness score to offer resuscitation service. This finding is higher than the 29.5% obtained in Tanzania [20], a similar low resource country. The latter study, however, had a larger sample size, including private hospitals and dispensaries, with both obstetric and neonatal service readiness evaluated. Further, in the staff and training domain, availability of trained staff contributed to the better outcome for the latter study, which in the current study was not significantly associated with knowledge (p = 0.99) or practice (p = 0.16), and thus was not included in our domain assessment. Similar to audit reports from southern Nigeria on neonatal resuscitation preparedness and equipment availability [31], the shortage of basic consumables and vital resuscitation equipment from our study is also a major concern. This finding poses a considerable challenge in optimal service delivery, contributing to intervention delays, poor quality of practice and consequently high neonatal mortality [8].

On self-assessed reports of knowledge and facility preparedness, few respondents (9% and 32%, respectively) believed they had a below-average level of knowledge and preparedness. Ninety percent of the participants, however, reported above-average comfort level during resuscitation. This finding, compared with the participants’ low scores on the objective assessment of knowledge and practice of NRT confirms that most of the healthcare providers lack insight into their level of individual and facility preparedness for neonatal resuscitation. This is a significant barrier to self-motivated learning, improvement, and capacity building.

A strength of this study is that it was a multicenter survey of a sample of respondents from all the secondary health centers in the state. This design provides a diverse representation from all the centers to permit inferences as to the current state of neonatal emergency service delivery in Kano, the largest city in northern Nigeria. In addition, all cadres of health providers directly involved with newborn resuscitation participated, thus improving the generalizability of the data and allowing targeted interventions to improve neonatal care and reduce mortality.

A limitation of the study is the lack of inclusion of primary and tertiary health centers in the state. The resources required to do this were not available and limiting the design to secondary health centers only would not significantly affect the results, as many deliveries take place there due to referrals from primary health centers, which are not equipped to offer such services. Direct observation of respondent’s practice during resuscitation would have enhanced the accuracy and objectivity of the results. However, with the correspondingly low level of knowledge and practice obtained from the survey responses, it is unlikely that the findings would have been considerably different.

Conclusion

Our finding of an alarming substandard level of knowledge and practice in neonatal preparedness among healthcare providers in secondary facilities in Kano, Nigeria indicates weakness of the existing emergency neonatal preparedness system. Doctors showed relatively higher knowledge of neonatal resuscitation compared to other health professionals. This underscores the urgent need for intensified training and retraining of health care providers. We also recommend the provision of essential and priority equipment in all facilities to curtail the lack of facility preparedness and improve neonatal outcomes.

Data collection instrument.

(PDF)

Click here for additional data file.

20 Aug 2021

PONE-D-21-11467

Facility and care provider emergency preparedness for neonatal resuscitation in Kano, Nigeria.

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

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Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: • Facility and care provider emergency preparedness for neonatal resuscitation in Kano, Nigeria.

• Abstract

• Abstract should be written in sections of introduction, method, result and conclusion.

• Under abstract it better to define first what mean by emergency preparedness for neonatal resuscitation rather than neonatal resuscitation.

• On line 23, why you proposed an hypothesis “We hypothesize that the high prevalence of asphyxia-related morbidity…”? While your title was preparedness for neonatal resuscitation? This is the same comment for introduction section.

• On line 33, include the confidence interval for the result of Healthcare provider’s knowledge, skills and facility preparedness.

• On line 37, what do you mean by weak state and what is your base line to say this?

• On line 55 to 57, you stated that “Even among health workers, the knowledge of neonatal resuscitation is poor, ranging between 2%–12%.[1] In addition, only 8%-22% of surveyed facilities have appropriate resuscitation equipment.[1]”, if these are known, why you study again?

• On line 77, you stated as your study will help for policy maker. Do you think that a single site cross sectional study can be influence policy makers?

• On line 105 to 109, why you used prevalence of knowledge only for sample calculation, while there are also practices and facility preparedness? Again your sample is different with abstract section (111 Vs 98 and 112 under result section), why this difference?

• On lone 108, you said that, “To increase precision, all healthcare workers who were

• 109 present at the training were included in the study.”, so why sample calculation is necessary in this case if you were collect data from all them?

• On line 114, you excluded those who did not provide consent. Do you think that unable to give consent is exclusion criteria? If yes, who were none respondents?

• On line 117, you used a semi-structured, self-administered questionnaire. Do you think that it is appropriate method self-administrated questionnaire for knowledge and practice? Why not you used interview administered?

• You are using skill, practice and proficiency exchangeable. Therefore, try to use one of it throughout the document.

• Under your analysis section include the p-value you used to select variable for multivariate analysis.

• Under table 1, check male sex is 405%?

• On line 209, you included attitude. But, there were not stated in the introduction or in method section about attitude. Why this happened/from where attitude came? Even no under operational definition and under measurement.

• On line 227, you said that level of practices…, is it a level? If yes, how much level is there?

• In discussion section, try to limit your discussion to your main objectives only.

• Try to copy edit for punctuation (most of your full stop is before your citation bracket in throughout the document).

Reviewer #2: The manuscript presents an analysis of provider and facility readiness for neonatal resuscitation in Kano state, Nigeria. The issue examined is very pertinent to address the variable and often slow progress toward global neonatal mortality targets. Limitations in the design of the research restrict its validity and generalizability, though the findings are illustrative of barriers encountered widely.

Abstract: The abstract accurately describes the study. The degree of precision in the percentages reported for adequate knowledge, practice, and facility preparedness could be reduced to whole numbers.

Introduction: It is very pertinent to highlight that Kano State has the highest NMR and thus the highest burden, as the most populous state. It might be useful to characterize the area further (urban/rural, geographic or political/social challenges).

Reference 9 presents a Delphi review that estimated the mortality reduction with neonatal resuscitation to be around 30%. More recent systematic reviews and meta-analyses provide information from actual trials (e.g. Dol J 2018).

While the hypothesis that poor neonatal emergency preparedness contributes to the high prevalence of asphyxia-specific mortality is valid, later discussion of the very low rate of in-facility delivery in the state reveals another major factor contributing to the burden. Addressing this aspect would give a more complete picture of the needs.

Methods: In the description of participants, it should be made clear that this was a convenience sample. Did the selection criteria for attending the workshop skew the participants toward those with low knowledge and skills, or perhaps did it skew toward more experienced clinical leadership?

In the sample size estimation, it is not clear what difference (of 10%) was being measured.

The data collection instrument regarding essential equipment and drugs inquired about several medications that are no longer recommended by ILCOR (International Liaison Committee on Resuscitation) for acute neonatal resuscitation (calcium, bicarbonate, naloxone).

The reliability of data on total number of deliveries and deaths within 24 hours and staff numbers would seem low if based on report from non-supervisory personnel.

What was the basis for considering a facility readiness score of 50% as sufficient to qualify a facility as well-equipped and prepared?

Results: The percentages of respondents could be rounded to whole numbers.

Discussion: When comparing the results to findings of other studies, there is frequent speculation on cause of differences – e.g. “In Ghana….mainly because all respondents were midwives…”. The demographic differences can be highlighted, but causation should not be implied. On page 19, “Western Nigeria reported…..probably because the score criterion….” and “….in Tanzania….probably because the latter study….” should be similarly revised.

The first paragraph of page 20 regarding strengths of the study over-estimates the strength of the design, as it was not a representative sample, nor was self-report validated by observation or triangulation. This paragraph should be revised or omitted.

The role of low utilization of health facilities for delivery should also be highlighted in the discussion. This may be linked to the inadequate knowledge, skills, and equipment in the facilities.

Conclusion: The conclusion appropriately highlights the value of information gained in the study.

Figures and Tables: Figure 2 adds little to the results as presented in the text, and it could be omitted.

References: References are current and complete.

Reviewer #3: PLOS ONE REVIEW COMMENTS

Many thanks for the opportunity to review this manuscript addressing an important topic that is key to improving newborn outcomes in a developing country. Neonatal resuscitation is key to the achievement of maternal and newborn health SDG targets on neonatal mortality globally. Overall, the manuscript is well written, paying attention to the existing literature and relating to the current findings. A few specifics comments to be addressed or clarified are as below

Abstract – nicely written and succinct

Introduction

- Line 47 “……one-fourth of these deaths…..” revise to …..a quarter of these deaths ….

- Line 55 – 57 “Even among health workers, the knowledge of neonatal resuscitation is poor, ranging between 2%–12%.[1] In addition, only 8%-22% of surveyed facilities have appropriate resuscitation equipment”…….please clarify whether these are global or Nigerian statistics

Methods

Study site

- Private hospitals were not included as part of the study. Does this mean they do not conduct any births since they were not included in the study? Refer to this related survey about Nigerian health care system at https://www.shopsplusproject.org/sites/default/files/resources/SHOPS%20Nigeria%20Private%20Sector%20Health%20Census_6.15.2014%20FINAL.pdf

- Any information on the proportion of births conducted in the three levels of health facilities would be useful to provide the context

Data collection

- How were study participants recruited/informed about the study?

- When and how were the study participants consented to participate in the study?

- When was the structured interview questionnaire administered?

- Who collected the data/administered the structured questionnaire?

Results

- Line 193: Age of participants is better presented by median given the age ranges and distribution

- Line 194 “The majority of the respondents (50.5%, n = 56)…..” this is just half the population and not the majority

- It would be useful to know if there were any differences in knowledge/skills scores between participants (66 from secondary hospitals + 45 from paediatric hospitals)

- Table 3: Bicarbonate….write the chemical name in full e.g. sodium bicarbonate

Discussion

- Well written and relates to other studies in the field to explain any similarities, variations and meanings of the findings

- Page 19, line 307 – 312: “On self-assessed reports of knowledge and facility preparedness, few respondents (8.5% and 32.4%) believed they had a below-average level of knowledge and preparedness, with 90% of the respondents reporting an above-average comfort level during resuscitation. This confirms that the majority of the healthcare providers lack insight into their deficient preparedness both at the individual and facility level, which is a significant barrier for self-motivated learning, improvement and capacity building.” This statement is confusing and unclear. Authors to review and clarify for ease of understanding

**********

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Reviewer #1: Yes: Yitagesu Sintayehu

Reviewer #2: No

Reviewer #3: Yes: DUNCAN N SHIKUKU

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Submitted filename: PLoS ONE preparedness for neo resus Nigeria.docx

Click here for additional data file.

4 Oct 2021

Responses to reviewers’ comments

Thank you for considering our manuscript for publication in PLOS One. We have addressed the concerns raised by the reviewers in the table below.

Reviewer #1 comments

Abstract should be written in sections of introduction, method, result and conclusion.

Response: Done

Under abstract it better to define first what mean by emergency preparedness for neonatal resuscitation rather than neonatal resuscitation

Response: Done. The sentence has been modified to fit the context.

On line 23, why you proposed an hypothesis “We hypothesize that the high prevalence of asphyxia-related morbidity…”? While your title was preparedness for neonatal resuscitation? This is the same comment for introduction section.

Response: This has been changed to “We hypothesize that poor neonatal emergency preparedness among healthcare providers in Kano, Nigeria may be associated with the dearth of knowledge, poor attitudinal disposition, lack of good practice and equipment shortage at the facility level.”

On line 33, include the confidence interval for the result of healthcare provider’s knowledge, skills and facility preparedness

Response: Confidence intervals added.

On line 37, what do you mean by weak state and what is your base line to say this?

Response: The basis for this conclusion is from the low level of knowledge, skills and facility preparedness found in our study, which were below the pre-specified reference cut-off values used.

On line 55 to 57, you stated that “Even among health workers, the knowledge of neonatal resuscitation is poor, ranging between 2%–12%.[1] In addition, only 8%-22% of surveyed facilities have appropriate resuscitation equipment.[1]”, if these are known, why you study again?

Response:The cited study was done in 6 African countries (Egypt, Ghana, Kenya, Rwanda, Tanzania, and Uganda). It is unclear if findings will be similar in Nigeria, a country with similar demographics that was not included in the cited study.

On line 77, you stated as your study will help for policy maker. Do you think that a single site cross sectional study can be influence policy makers?

Response:The study participants were drawn from all the secondary health centres in the state, hence can be described as a multi-centre survey with the potential to inform policy decisions.

On line 105 to 109, why you used prevalence of knowledge only for sample calculation, while there are also practices and facility preparedness? Again your sample is different with abstract section (111 Vs 98 and 112 under result section), why this difference?

Response: Two other sample sizes were computed using prevalence of healthcare workers with good resuscitation practices and prevalence of facility preparedness from a similar setting, however, a lower sample size was obtained in both cases. Therefore, the power analysis for prevalence of knowledge was used for this study.

The sample size has been corrected in the abstract to 112. One participant had incomplete records and was excluded from the final analysis, hence, 111 were finally included. In the methods, 98 was the minimum sample calculated. However, all participants that provided consent were included in analysis, which will improve the precision of the findings

On line 108, you said that “To increase precision, all healthcare workers who were 109 present at the training were included in the study.”, so why sample calculation is necessary in this case if you were collect data from all them?

Response: Sample calculation was necessary to obtain the minimum sample required to avoid a type II error and for objective extrapolation of results. Including all the 112 survey participants may improve the precision of results and is unlikely to impact negatively on the findings.

On line 114, you excluded those who did not provide consent. Do you think that unable to give consent is exclusion criteria? If yes, who were none respondents?

Response: Voluntary participation is an ethical pre-requisite for inclusion. Only one participant declined to take part in the survey.

On line 117, you used a semi-structured, self-administered questionnaire. Do you think that it is appropriate method self-administrated questionnaire for knowledge and practice? Why not you used interview administered?

Response: The questionnaire was self-administered to ensure anonymity and reduce response bias. Further, all the participants were literate and could respond to the survey appropriately based on instructions provided. The interviewer to participants ratio was also low, making interviewer administration less efficient and timely.

You are using skill, practice and proficiency exchangeable. Therefore, try to use one of it throughout the document

Response:Thank you. Done.

Under your analysis section include the p-value you used to select variable for multivariate analysis

Response: P-value used to include independent variables in the multivariate analysis now included

Under table 1, check male sex is 405%?

Response: We apologise for the typo. The correct number is 40.5% (now corrected).

On line 209, you included attitude. But, there were not stated in the introduction or in method section about attitude. Why this happened/from where attitude came? Even no under operational definition and under measurement.

Response: This information has been added to the abstract, introduction and methods section (outcome variables) to reflect the findings.

On line 227, you said that level of practices…, is it a level? If yes, how much level is there?

Response:This phrase has been modified to practice during neonatal resuscitation.

In discussion section, try to limit your discussion to your main objectives only.

Response: Thank you. Done

Try to copy edit for punctuation (most of your full stop is before your citation bracket in throughout the document).

Response: Thank you. Done

Reviewer #2 comments

The abstract accurately describes the study. The degree of precision in the percentages reported for adequate knowledge, practice, and facility preparedness could be reduced to whole numbers.

Response:Done

Introduction: It is very pertinent to highlight that Kano State has the highest NMR and thus the highest burden, as the most populous state. It might be useful to characterize the area further (urban/rural, geographic or political/social challenges).

Response:More detail has been added characterizing neonatal mortality in the state based on urban/rural, geographic, or political/social challenges.

Reference 9 presents a Delphi review that estimated the mortality reduction with neonatal resuscitation to be around 30%. More recent systematic reviews and meta-analyses provide information from actual trials (e.g. Dol J 2018).

Response:This has been changed to a more recent systematic review. (https://doi.org/10.1136/bmjpo-2017-000183)

While the hypothesis that poor neonatal emergency preparedness contributes to the high prevalence of asphyxia-specific mortality is valid, later discussion of the very low rate of in-facility delivery in the state reveals another major factor contributing to the burden. Addressing this aspect would give a more complete picture of the needs.

Response:Done, see lines 468-484 on the recised manuscript with track changes

Methods: In the description of participants, it should be made clear that this was a convenience sample. Did the selection criteria for attending the workshop skew the participants toward those with low knowledge and skills, or perhaps did it skew toward more experienced clinical leadership? Response:Convenience sample has been stated as the method of sampling.“Using each centre’s work rota, a convenience sample was used for the selection process, inviting only staff that were off duty to eliminate the risk of staff shortage on active duty during the training period. Response:The diversity of the participants including doctors, nurses, and midwives added strength to the sample and reduced selection bias”

In the sample size estimation, it is not clear what difference (of 10%) was being measured.

Response: Sample size parameters corrected. “difference (of 10%)” was a typographical error

The data collection instrument regarding essential equipment and drugs inquired about several medications that are no longer recommended by ILCOR (International Liaison Committee on Resuscitation) for acute neonatal resuscitation (calcium, bicarbonate, naloxone).

Response:Calcium and naloxone have been removed. Sodium bicarbonate, however, although discouraged during brief CPR may be useful during prolonged arrest after adequate ventilation is established and there is no response to other therapies. Information regarding its availability in the surveyed facilities to assess level of preparedness may still be useful (DOI: 10.1111/apa.15754 )

The reliability of data on total number of deliveries and deaths within 24 hours and staff numbers would seem low if based on report from non-supervisory personnel.

Response: We agree, but this is a survey looking at participants’ self-reported knowledge, among other things. The findings therefore reflect the perception of the respondents. In the results section, this detail has been revised to reflect self-reported monthly deaths and deliveries

What was the basis for considering a facility readiness score of 50% as sufficient to qualify a facility as well-equipped and prepared?

Response:The score was determined using the WHO approach, and facility preparedness indicators identified according to the WHO Service Availability and Readiness Assessment (SARA) Manual (https://apps.who.int/iris/bitstream/handle/10665/149025/WHO_HIS_HSI_2014.5_eng.pdf?sequence=1isAllowed=y)

Results: The percentages of respondents could be rounded to whole numbers.

Response:Done

Discussion: When comparing the results to findings of other studies, there is frequent speculation on cause of differences – e.g. “In Ghana….mainly because all respondents were midwives…”. The demographic differences can be highlighted, but causation should not be implied. On page 19, “Western Nigeria reported…..probably because the score criterion….” and “….in Tanzania….probably because the latter study….” should be similarly revised.

Response:Done

The first paragraph of page 20 regarding strengths of the study over-estimates the strength of the design, as it was not a representative sample, nor was self-report validated by observation or triangulation. This paragraph should be revised or omitted.

Response: The paragraph has been revised.

The role of low utilization of health facilities for delivery should also be highlighted in the discussion. This may be linked to the inadequate knowledge, skills, and equipment in the facilities

Response:Done, see lines 468-484 or the revised manuscript with track changes

.

Figures and Tables: Figure 2 adds little to the results as presented in the text, and it could be omitted. Response:Figure 2 has now been removed

Reviewer #3

- Line 47 “……one-fourth of these deaths…..” revise to …..a quarter of these deaths ….

Response:Done

- Line 55 – 57 “Even among health workers, the knowledge of neonatal resuscitation is poor, ranging between 2%–12%.[1] In addition, only 8%-22% of surveyed facilities have appropriate resuscitation equipment”…….please clarify whether these are global or Nigerian statistics

Response:This has been modified to “Reports from 6 African countries showed that even among health workers, the knowledge of neonatal resuscitation was poor, ranging between 2%–12%.[1] In addition, only 8%-22% of the surveyed facilities had appropriate resuscitation equipment.[1] It still remains unclear whether these findings are the same in Nigeria, a country with similar demographics, the most populous in Africa with a high fertility rate, that was not included in the study.

Private hospitals were not included as part of the study. Does this mean they do not conduct any births since they were not included in the study? Refer to this related survey about Nigerian health care system athttps://www.shopsplusproject.org/sites/default/files/resources/SHOPS%20Nigeria%20Private%20Sector%20Health%20Census_6.15.2014%20FINAL.pdf

Response:The focus of our survey were Kano state government-owned secondary health care centres, hence the lack of inclusion of private facilities.

Any information on the proportion of births conducted in the three levels of health facilities would be useful to provide the context

Response:Unfortunately, this information is not available.

How were study participants recruited/informed about the study?

Response:Invitations were sent to participants through the Kano State Ministry of Health Management Board.

When and how were the study participants consented to participate in the study?

Response:Participants were informed about the survey at the beginning of the workshop before commencement of the training Written consent was obtained from each participant before inclusion in the study.

When was the structured interview questionnaire administered?

Response:The questionnaire was self-administered and completed before the start of the training to ensure efficiency, anonymity and reduce response bias

Who collected the data/administered the structured questionnaire?

Response:The questionnaire was self-administered and completed before the start of the training to ensure efficiency, anonymity and reduce response bias.

Line 193: Age of participants is better presented by median given the age ranges and distribution

Response:The data for age of the participants was normally distributed, hence our choice of mean as measure of reporting.

Line 194 “The majority of the respondents (50.5%, n = 56)…..” this is just half the population and not the majority

Response:This has been changed to “approximately half of the respondents….”

It would be useful to know if there were any differences in knowledge/skills scores between participants (66 from secondary hospitals + 45 from paediatric hospitals)

Response:Differences in knowledge and skills scores by type of hospital added.

Table 3: Bicarbonate….write the chemical name in full e.g. sodium bicarbonate

Response:Done

Page 19, line 307 – 312: “On self-assessed reports of knowledge and facility preparedness, few respondents (8.5% and 32.4%) believed they had a below-average level of knowledge and preparedness, with 90% of the respondents reporting an above-average comfort level during resuscitation. This confirms that the majority of the healthcare providers lack insight into their deficient preparedness both at the individual and facility level, which is a significant barrier for self-motivated learning, improvement and capacity building.” This statement is confusing and unclear. Authors to review and clarify for ease of understanding

Response:This has been reviewed to “Few respondents (9% and 32%, respectively) believed they had a below-average level of knowledge and preparedness. Ninety percent of the participants, however, reported above-average comfort level during resuscitation. This finding, compared with the low participants’ scores on objective assessment of knowledge and practice of NRT confirms that most of the healthcare providers lack insight into their level of individual and facility preparedness for neonatal resuscitation. This is a significant barrier for self-motivated learning, improvement, and capacity building”

Additional remarks

Authors are encouraged to further clarify outcome variables and provide the questionnaire used in this study as supplementary file.

Response:Done

Authors should explain whether this questionnaire was anonymous or not?

Response:The questionnaire was self-administered and completed anonymously (Lines 243-244 and 328 of the revised manuscript with track changes)

Authors should provide unidentified raw data of the study. PLOS journals require that authors make all data underlying the findings described in their manuscript fully available, with exception when ethical or legal restrictions prohibit public sharing of data. Authors may upload their data to a public repository or include their data as a Supporting Information file. If data cannot be made public, all restrictions and information necessary for submitting data requests should be outlined in the Data Availability statement, which will be published at the top of the article.

Response:Our data contain potentially identifying and sensitive participant information and therefore cannot be made publicly accessible without permission from the Ethics Review Committee of Kano State Ministry of Health. All data requests should be directed to Mr. Nasir Tafida, Secretary, Research Ethics Review Board, Kano State Ministry of Health, Post office road, Kano Nigeria

Email: nasirtafida438@gmail.com

Phone: +234 (0)8022759125

Authors are encouraged to include and discuss the following relevant and recent publication "Briggs, D. C., Eneh, A. U. (2020). Preparedness of primary health care workers and audit of primary health centres for newborn resuscitation in Port Harcourt, Rivers State, Southern Nigeria. The Pan African Medical Journal, 36, 68. https://doi.org/10.11604/pamj.2020.36.68.22164".

Response:Done, see line 543-545

Please state whether you validated the questionnaire prior to testing on study participants. Please provide details regarding the validation group within the methods section.

Response:Lines 257-259: The final questions used were consensually reviewed, edited, and validated, and were pretested among 12 neonatal health care providers consisting of nurses and doctors in a tertiary institution.

In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Response:Our data contain potentially identifying and sensitive participant information and therefore cannot be made publicly accessible without permission from the Ethics Review Committee of Kano State Ministry of Health. All data requests should be directed to Mr. Nasir Tafida, Secretary, Research Ethics Review Board, Kano State Ministry of Health, Post office road, Kano Nigeria

Email: nasirtafida438@gmail.com

Phone: +234 (0)8022759125

Submitted filename: Response to reviewers.docx

Click here for additional data file.

29 Nov 2021

PONE-D-21-11467R1Facility and care provider emergency preparedness for neonatal resuscitation in Kano, Nigeria.PLOS ONE

Dear Dr. Usman,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Authors have adequately addressed most reviewers' and editorial comments. Just minor comments remain.Please submit your revised manuscript by Jan 13 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

In the conclusion: “The low level of respondents’ awareness, practice, and facility readiness demonstrates the current weak state of secondary health systems in Kano”. Conclusion has to be based on study findings. Since this study didn’t investigate the “state of secondary health systems in Kano”, authors are encouraged to revise this sentence (reducing its strength/certainty) (e.g., replacing demonstrates by suggests or indicates).

In the abstract: “Respondents’ designation predicted good knowledge (aOR=0.08, 95% CI: 0.01–0.69; p= 0.01), but not practice”. Authors should better define/specify “designation” (e.g., physicians versus nurses/midwives).

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Reviewer #1: All comments have been addressed

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Reviewer #1: Yes

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Reviewer #1: Yes

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Reviewer #1: No

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Reviewer #1: Yes

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Reviewer #1: (No Response)

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Reviewer #1: Yes: Yitagesu Sintayehu

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11 Dec 2021

Thank you for considering our manuscript for publication in PLOS One. We have addressed the concerns raised by the reviewers below.

1) In the conclusion: “The low level of respondents’ awareness, practice, and facility readiness demonstrates the current weak state of secondary health systems in Kano”. Conclusion has to be based on study findings. Since this study didn’t investigate the “state of secondary health systems in Kano”, authors are encouraged to revise this sentence (reducing its strength/certainty) (e.g., replacing demonstrates by suggests or indicates).

Response:The conclusion has been revised to reflect the study findings and the word demonstrates has been changed to suggest and indicates in the abstract conclusion and main conclusion respectively.

2) In the abstract: “Respondents’ designation predicted good knowledge (aOR=0.08, 95% CI: 0.01–0.69; p= 0.01), but not practice”. Authors should better define/specify “designation” (e.g., physicians versus nurses/midwives).

Response:The designation has been better specified by including physicians versus nurses/midwives to describe it.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

17 Dec 2021

PONE-D-21-11467R2Facility and care provider emergency preparedness for neonatal resuscitation in Kano, Nigeria.PLOS ONE

Dear Dr. Usman,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Specifically, in the conclusion/results "Respondents’ designation predicted good knowledge (aOR=0.08, 95% CI: 0.01–0.69; p= 0.01). In order to provide the readers with meaningful information, authors should specify "designation" (e.g.,physicians versus nurses/midwives).

Please submit your revised manuscript by Jan 31 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Elsayed Abdelkreem, MD, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

20 Dec 2021

Specifically, in the conclusion/results "Respondents’ designation predicted good knowledge (aOR=0.08, 95% CI: 0.01–0.69; p= 0.01). In order to provide the readers with meaningful information, authors should specify "designation" (e.g.,physicians versus nurses/midwives).

Response:The word designation has been changed to profession for clarity and further specified by including physicians versus nurses/midwives to describe it in the abstract, methods, results and conclusion.

Submitted filename: Response to reviewers copy.docx

Click here for additional data file.

26 Dec 2021

Facility and care provider emergency preparedness for neonatal resuscitation in Kano, Nigeria.

PONE-D-21-11467R3

Dear Dr. Usman,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Elsayed Abdelkreem, MD, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

30 Dec 2021

PONE-D-21-11467R3

Facility and care provider emergency preparedness for neonatal resuscitation in Kano, Nigeria.

Dear Dr. Usman:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Elsayed Abdelkreem

Academic Editor

PLOS ONE