Introduction

Neonatal period is exactly the first four weeks of life, the most critical episode for a newborn’s viability and survival. Approximately 130 million newborns are born annually worldwide, and 2.3 million of them died within the first 28 days in 20211,2,3. Unfortunately, the majority of neonatal deaths occur in low- and middle-income countries4. Neonatal asphyxia accounts for about a quarter of neonatal mortalities all around the world5, not only bringing about death but also leading to neurological sequelae, ranging from untreatable cognitive impairments to motor problems6. In 2022, the neonatal mortality rate in Iran was reported to be 7.6 deaths per thousand live births7.

About 10% of babies require basic support to start breathing; however, 1% require complete resuscitation5,8. The Neonatal Resuscitation Program (NRP) is an essential educational course designed for healthcare providers, playing a critical role in improving the survival rate of newborns. A report indicated that approximately 30% of neonatal resuscitations are either missed or performed improperly. Challenges in this area have been most prominent at the level of intubation9. Neonatal resuscitation involves teamwork, requiring at least two skilled healthcare providers. Reports have highlighted that a lack of coordination during group efforts contributes to 2% of perinatal deaths, emphasizing the importance of effective collaboration in this critical procedure10,11. World Health Organization (WHO) reported that the main reason for misdiagnosis or failure to recognize neonates in need of resuscitation, in both developed and developing countries, is the insufficiency in healthcare professionals’ training process12. Adequate knowledge about resuscitation plays a critical role in early diagnosis and proper management of high-risk newborns. Additionally, it can decrease the complications and sequelae in newborns with life-threatening states11,13. Studies have reported a lack of sufficient knowledge and appropriate practice in neonatal resuscitation among different levels of medical staff14,15.

Data about the current status and healthcare providers’ knowledge of neonatal resuscitation in developing countries are limited16,17. Thus, we designed this research to provide a national scheme of neonatal resuscitation in Iran and an overview of factors affecting the outcome, including the availability and shortcomings of equipment and human resources.

Materials and methods

This was a cross-sectional descriptive study conducted in 674 hospitals in Iran, from June 2020 to January 2022. All hospitals in which there was a possibility of delivery (live births and stillbirths) and resuscitation were recruited (census). Health centers, private hospitals, social welfare hospitals, educational hospitals, and hospitals affiliated with charity or governmental organizations were included.

Instrument development and validation

We designed a checklist based on the American standardized program of NRP 202018. The checklist was reviewed by neonatologists and data analysts. The final checklist consisted of 62 multiple-choice or short-response questions (See Supplementary File). Data on the number of live births, stillbirths and neonatal deaths were gathered from annual report of the national office of neonatal health from registries.

Data sources and collection

An electronic copy of the final version of the questionnaire was sent to all the above-mentioned hospitals. A team of healthcare providers in each hospital were asked to complete the online questionnaire precisely with final data in two weeks, including neonatologists, neonatology fellows, pediatricians, pediatrics residents, gynecologists, gynecology residents, NICU or neonatal ward nurses, and midwives. An assessment team was responsible in each hospital for reporting the records. Also, an online video clip was provided beforehand to instruct how to complete the form and ensure all items were interpreted correctly by the respondents.

In the first step, neonatal wards and the NICU settings were evaluated by assessing the availability of healthcare professionals. Thereafter, the personnel were asked to state their attitudes towards the reasons for the shortcomings. We classified the answers in four categories: Labor shortage, insensitivity of officials, poor follow-up of department head, and insufficient remuneration.

Also, the composition of the resuscitation team was studied in deliveries with high or low risk for resuscitation. High-risk deliveries are identified by a set of perinatal risk factors that increase the likelihood of resuscitation: Low birth weight, preterm labor, chorioamnionitis, pre-eclampsia, prolonged rupture of membranes, placental abruption, prolonged labor, meconium-stained amniotic fluid, multiple pregnancy, and fetal distress19.

Furthermore, the organization of NRP workshops was investigated in hospitals. Hospital regulations regarding compulsory attendance in these courses were also determined.

We also inquired about consultations between gynecologists and the pediatric and neonatology departments regarding the viability of deliveries. Additionally, we examined when the pediatric department was notified about high-risk or low-risk deliveries. We broke down the notification time into four stages: when pregnant women are admitted to the hospitals, once they enter the delivery room, after birth if the newborn is unstable and requires resuscitation, and after CPR has been initiated by the delivery room staff.

Some special tasks assigned to the resuscitation team included recording the exact time and progression of resuscitation events, caring for the newborn immediately after birth in the delivery room, and informing the parents about the progression and level of neonatal resuscitation. We assessed the availability of resuscitation equipment. Participants were asked about their perspectives on the causes of shortages in facilities and their proposed solutions to address the issues.

We also measured the average duration of resuscitation for neonates with asystole across the country (based on the estimations of the respondent teams at each hospital) and also in hospitals with different delivery rates. Moreover, there are special circumstances in resuscitative attempts that require critical decisions, such as newborns ≤ 500 g, multiple anomalies, and gestational age ≤ 24 weeks. The rate of non-resuscitation in such situations were also recorded.

Statistical analysis

In the next step, data were entered into Excel sheets based on the type of hospitals, educational or non-educational. We also divided them into three groups based on the annual number of hospital deliveries (≤ 1000, 1000–3000, and ≥ 3000). Finally, data were analyzed by SPSS version 20.0 (SPSS Inc., Chicago, IL). Descriptive statistics were used to describe the percentage responses to each question and, mean, standard deviation (SD), and median were reported for live births and mortality rates. In cases where data were missing, valid percent has been calculated, and the number of missing values were reported. In order to estimate the impact of professional availability, neonatal ward or NICU availability, and organization of NRP educational courses, we compared the neonatal mortality rates in these settings. The neonatal mortality rate was calculated by dividing the number of neonatal deaths within 28 days by the number of live births (per 1000 live births) in 2021. The same analysis was done using Point Biserial Correlation. To examine the association between the death rate and the availability of healthcare providers and ward/NICU facilities, we performed a multiple linear regression analysis. The dependent variable was the death rate, while the independent variables pediatric resident, pediatrician, neonatology fellow, neonatologist, and ward/NICU were entered simultaneously into the model. All differences were considered significant as the entire study population were recruited. The study was approved by Shahid Beheshti University of Medical Sciences ethics committee (Number: IR.SBMU.MSP.REC.1399.013). The study was conducted with adherence to “STROBE” guideline for cross-sectional studies and Declaration of Helsinki.

Results

Hospital characteristics

In this survey, 674 hospitals were studied, of which 629 (93.3%) were non-educational. Among non-educational hospitals, 60.7% (N = 382) were health centers, 20.2% (N = 127) were private hospitals, 9.5% (N = 60) were social welfare hospitals, 7.5% (N = 45) were governmental organization-affiliated hospitals, and 2.4% (N = 15) were charity-affiliated hospitals.

Table 1 shows the distribution of educational and non-educational hospitals based on the number of annual deliveries. Taken together, the number of hospitals with ≤ 1000, 1000–3000, and ≥ 3000 deliveries per year was 337, 232, and 105, respectively. Among non-educational hospitals, the number of hospitals with ≤ 1000, 1000–3000, and ≥ 3000 deliveries per year was 330, 217, and 82, respectively. In these hospitals, the number of deliveries per year was mostly under 3000 (87.0%, N = 547). However, in educational hospitals, approximately half had a report of deliveries more than 3000 (51.1%, N = 23).

Table 1 Number of annual deliveries based on the type of the non-education hospital.
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Birth outcomes by hospital type

Table S1 presents the distribution of live births, stillbirths, and neonatal deaths by hospital type. As shown in the table, educational hospitals had the highest mean number of live births (Mean = 3587.6), stillbirths (Mean = 64.4), and death within the first 28 days (Mean = 15.5). Among non-educational hospitals, charity-affiliated hospitals had the highest mean number of live births (Mean = 2803.1) and stillbirths (Mean = 15.3), while health centers had the highest mean (2.3) of death within 28 days.

Neonatal wards and NICU availability

Our study reported that 120 hospitals (17.8%) had neither neonatal ward nor NICU with only one of these being educational. Table 2 shows the details of neonatal wards and NICU settings based on hospital annual delivery rates. The presence of neonatal wards and NICU settings by hospital type is also demonstrated in Table S2.

Table 2 Percentage of hospitals with neonatal wards and NICU settings based on annual delivery rate of hospitals.
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Healthcare providers and professional availability

A neonatologist was available in only 32.5% (N = 219) of hospitals. The separate percentages of availability of different levels of healthcare providers based on annual delivery rates of hospitals are provided in Table S3. We conducted the same assessment based on the type of hospitals. Table S4 shows available professionals separately reported according to hospitals’ type classification. Figure 1 shows the distribution of different levels of pediatric physicians across the country.

Fig. 1
figure 1

This figure illustrates the distribution of pediatric physicians across the provinces of Iran. For each category of physician, we calculated a presence ratio, defined as the number of physicians of a given type in each province divided by the number of hospitals in that province. This ratio represents the average density of that specialist per hospital. For example, in Alborz province, there were 5 neonatologists across 12 hospitals, corresponding to 0.42 neonatologists per hospital. In East Azarbaijan province, there were 27 pediatricians across 30 hospitals, corresponding to 0.90 pediatricians per hospital. Thus, the color gradient in Fig. 1 reflects these ratios, with darker blue denoting higher physician density and darker red denoting lower density. Nationally, there were a total of 219 neonatologists, 15 neonatology fellows, 613 pediatricians, and 45 pediatric residents distributed across 674 hospitals. These totals correspond to overall average presence ratios of approximately 0.32 neonatologists, 0.02 fellows, 0.91 pediatricians, and 0.07 residents per hospital, respectively. Figure 1, therefore, depicts the provincial variation around these national averages, highlighting areas of relative undersupply and oversupply of pediatric physicians.

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Table S.5 illustrates personnel attitudes towards the reasons for lack of professionals in different types of hospitals. The participants could have chosen more than one reason. Labor shortages and insufficient wages have been the two most common reasons in all types of hospitals, respectively.

Resuscitation team composition

Composition of the resuscitation team has been studied in different hospitals, as shown in Table 3. It shows the composition of resuscitation team classified based on the situation of newborn into high or low risk. Neonatologists had no participation during low risk deliveries.

Table 3 Composition of resuscitation team in different types of hospitals.
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Note

The variances in the percentages of physicians between S.2 and Table 3 arise because they might work shifts at different hospitals not included in the personnel listings.

In general, trained midwives and nurses had the highest rate of cooperation in all circumstances. Anesthesiologists did not attend low-risk deliveries in charity-affiliated hospitals. Neonatologists had the highest cooperation percentage in educational (55.6%, N = 25) and charity-affiliated (40.0%, N = 6) hospitals during high-risk deliveries, respectively.

NRP workshop participation

The NRP workshops statistics are provided in Table S6. As shown, 40% of educational hospitals (N = 18) have held one resuscitation workshop each year, and 57.8% of them (N = 26) have held several workshops a year.

Based on annual deliveries, 62.0% of hospitals (N = 209) with ≤ 1000 annual deliveries, 54.7% (N = 127) with 1000–3000 annual deliveries, and 47.62% (N = 50) with ≥ 3000 annual deliveries held only one workshop per year. In 26.1% (N = 88), 44.0% (N = 102), and 49.5% (N = 52) of hospitals, several workshops were held per year for those with ≤ 1000, 1000–3000, and ≥ 3000 annual deliveries, respectively. Other hospitals did not hold routine workshops.

Table S6 is a brief comparison of hospitals’ resuscitation workshops and attendance requirements based on hospital type.

Notification, consultation Practices, and resuscitation Documentation

According to our survey, 12 hospitals (1.78%) neither inform the pediatric and neonatology departments about low-risk deliveries nor do they even notify them about high-risk deliveries.

Further details of notification and consultation are summarized in Table S7. Other details on resuscitation routines are available in Table S8.

Table S9 illustrates the notification times at each type of hospital. Notification after the commencement of CPR was reported only in 4 hospitals. In about half of the cases (49.8%, N = 336), paediatric and neonatal units are informed of a high-risk pregnancy at the time of admission. Table S10 shows the details of resuscitation attendance routines in different types of hospitals.

In case of high-risk pregnancies, in all hospital types, more than half of centers had a routine of 4 skilled members. In 17.4% of hospitals (N = 117), no one was responsible for the documenting events progression during resuscitation. In 37.5% (N = 273) and 41.2% (N = 278) of hospitals, briefing and debriefing meetings were held, respectively.

Table S11 shows details of physicians tasks in resuscitation. In the majority of hospitals, pediatricians are primarily responsible for informing parents, performing umbilical catheter insertion, and leading intubation efforts, with the exception of educational hospitals where pediatric residents are more extensively involved in intubation procedures and neonatologists in informing parents and umbilical catheter insertion.

Facility and equipment availability

As it is shown in Table 4, none of the hospital types have full (100%) facility coverage. Temperature adjustment was not available in 129 (19.1%) delivery rooms. Oxygen is provided with the highest percentage by central oxygen in all types of hospitals. Furthermore, 31 hospitals had neither pulse oximetry nor EKG monitoring (4.6%). Shortages were reported for all critical resuscitation drugs. Table S12 provides details of critical facilities availability for neonatal resuscitation based on the annual delivery rates of hospitals. Overall, the percentage of equipment availability was higher in hospitals above 3000 deliveries per year (except for compressed air which was more available in hospitals with less than 1000 deliveries per year).

Table 4 Facilities of neonatal resuscitation and primary protocols based on hospital types.
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Causes of shortcomings and proposed solutions

Table S13 outlines the personnel’s attitude towards the reasons for shortcomings and their proposed solutions. The highest reported reason for shortcomings in all hospitals was the percentage of the budget deficit, except in private hospitals where inadequate national provision of equipment took precedence. Reporting to superior in-charge authorities was consistently identified as the primary solution to address these shortcomings.

Resuscitation duration and do not resuscitate cases

The estimation of neonatal resuscitation time reported by staff is shown in Table S14. In approximately half (49.52%) of the hospitals with more than 3000 deliveries per year, the mean neonatal resuscitation time was 20 min. The mean reported neonatal resuscitation time across the country was 25.8 min.

Table S15 presents data on the percentage of Do Not Resuscitate (DNR) cases in various types of hospitals. Overall, in 61.9% (N = 417), 46.1% (N = 311), and 61.6% (N = 415) of hospitals, newborns under 500 g, with multiple anomalies, and with gestational age less than 24 weeks, were not resuscitated, respectively.

Impact of interventions on neonatal mortality

We evaluated the impact of availability of professionals, NICU or Neonatal wards, and NRP attendance compulsory rules on mean neonatal mortality rate. Table 5 provides details of this association. The neonatal mortality rate was reduced by the availability of pediatricians, mandating NRP workshops, and equipping the hospital with NICU or neonatal wards.

Table 5 Association between neonatal mortality rate mean and availability of professionals, NICU or Neonatal, and NRP attendance compulsory rules.
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A multiple linear regression analysis was conducted to assess the relationship between the availability of healthcare providers and ward/NICU facilities with death rate (defined as the number of deaths per total live births).

Among the predictors, the standardized coefficients indicated that pediatric residents (β = 0.162) and neonatology fellows (β = 0.194) had the strongest positive associations with death rate and were positive predictors. In contrast, the negative coefficient for ward/NICU availability was negative (β = −0.080), suggesting a potential protective effect, i.e., facilities with ward or NICU availability were related to lower death rates.

In terms of unstandardized coefficients, the direction of effect implies that for each one‑unit increase in the number of pediatric residents, the death rate would increase by 0.002 units, and each additional neonatology resident would increase the death rate by 0.004 units. The effect of neonatologists was minimal, with a one-unit increase raising the death rate by 7.059 × 10 − 57.059 × 10 − 5 units. Conversely, the presence of a pediatric ward or NICU was associated with a 0.001‑unit reduction in the mortality rate. Overall, while higher numbers of pediatric and neonatology trainees correlated with increased mortality, the availability of ward or NICU facilities showed an inverse association with death rates.

Discussion

This cross-sectional descriptive study was designed to illustrate the status of neonatal resuscitation and the availability of related facilities in hospitals of Iran. To our knowledge, this study represents the largest report of neonatal resuscitation in Iran to date. In our study, 674 hospitals were recruited, of which 45 were educational (had pediatric residency programme). Educational hospitals, likely reflecting their referral status, reported the highest average rates of live births, stillbirths, and neonatal deaths, whereas health centers documented the highest absolute numbers in these categories. Analysis of service capacity revealed substantial deficiencies in both equipment and trained healthcare providers, underscoring the urgent need for targeted interventions by health policymakers.

Our study reported that 17.8% of hospitals had neither a neonatal ward nor a NICU. Our analysis revealed that the absence of these facilities was associated with a higher mean neonatal mortality rate. A previous study in sub-Saharan Africa and South Asia also showed that improved facilities and advanced care could reduce neonatal mortality20.

Our survey found that only 32.5% of hospitals had a neonatologist available, indicating a significant lack across all hospital types, including those with NICUs. Surprisingly, hospitals with neonatologists or neonatology fellows had higher neonatal mortality rates. The regression analysis confirmed an unexpected positive association between the number of pediatric residents and neonatology fellows and higher mortality rates. In the context of Iran, neonatologists, neonatal fellows, and pediatric residents are typically concentrated in larger, urban hospitals or those with advanced NICU facilities, similar to healthcare systems in other countries with high healthcare resources. The presence of pediatricians, however, correlated with lower neonatal mortality rates. This observation may be explained by the fact that severe cases are often referred to hospitals with pediatric professionals, leading to a higher concentration of neonatal deaths in these facilities. A study by Goodman et al. in 2002 also found no link between the availability of neonatologists and lower risk of neonatal mortality, suggesting a potential risk of over-diagnosis and over-treatment in advanced facilities21. Another explanation is that, according to NRP guidelines, the training and experience of the individual performing resuscitation are more critical than their professional title (whether pediatrician, neonatologist, nurse, or another trained provider).

According to our data, 64 hospitals had no mandatory policy on staff attendance at NRP workshops. Our analysis revealed that neonatal mortality rate was lower in hospitals with mandate for attendance. In a study conducted in Mongolia, they found that NRP workshops were effective in improving knowledge and skills. This was particularly true for midwives compared with doctors22. Based on our survey, trained nurses and midwives have the highest rate of cooperation and attendance at low and high risk deliveries in Iran. Therefore, these trainings can improve the care.

One of the most important weaknesses identified in neonatal care for situations requiring resuscitation is the lack of effective and consistent communication between obstetric and neonatal/pediatric teams in many hospitals. This finding highlights the critical role of interdisciplinary collaboration, as effective communication between these specialties is just as essential for preparedness and coordination during emergencies as having appropriate knowledge and equipment23.

There were shortages and deficiencies throughout the country, including equipment essential for resuscitation, such as oxygen blender, T-piece resuscitator, pulse oximetry, EKG monitoring, laryngeal mask, umbilical catheter, etc. Overall in our study, the percentage of equipment availability was higher in hospitals above 3000 deliveries per year. Critical drugs shortages were reported nationwide, which could seriously affect the final outcome of neonatal resuscitation. Among different medications, epinephrine was the only one that was almost available in all types of hospitals. The results can be compared with a study by Alemayehu Eshetu et al.24 in NICUs of a resource-limited setting, where they found inadequate equipment for neonatal resuscitation. The most frequently missing drug was bicarbonate, which was also lacking in many hospitals in Iran.

There is strong evidence supporting the importance of early care, including temperature regulation, early nasal CPAP (continuous positive airway pressure), and ventilatory devices that can improve respiratory outcomes25,26,27. Prevention of hypothermia in the first minutes of life reduces the mortality and morbidity rate of newborns, particularly in preterm neonates. Various interventions from environmental temperature regulation to the use of warmers, plastic bags, head coverings, etc. would help achieve a temperature of 23–25 °C28. The efficiency of normal plastic bags in preventing thermal loss in preterm infants is undeniable29. Unfortunately, even a normal plastic bag was missing in 53% of delivery rooms of Iran hospitals. A study by Narayanan et al.30 in 2019 in Uganda, Indonesia and India showed that essential equipment for basic neonatal care was available in all facilities. For example, self-inflating bags were available in all centers, in contrast to Iran where they were not available in some centers. SpO2 and heart rate are two indices that could help the resuscitation team to achieve a real-time reporting of their effort during resuscitation31. According to our analysis, 31 hospitals in Iran had neither pulse oximetry nor EKG monitoring. Equipping hospitals with pulse oximetry improves outcomes by providing immediate newborn status reports and guiding decision-making during resuscitation and oxygen prescription32.

The heterogeneity of practical routines in different hospitals, mainly caused by different available facilities and equipment, would seriously interfere with the purpose of medical training. This issue has also been remarked in previous articles from different countries31. Lack of primary and essential resuscitative equipment would result in the failure of implementing skills, as the staff cannot put their acquired knowledge and skills into practice33.

This study provides a comprehensive national overview of neonatal resuscitation and resources in Iran, distinguishing it from previous research that has typically focused on single hospitals, selected provinces, or specific components of neonatal care. By integrating data from 674 hospitals—educational and non‑educational—this study captures the full heterogeneity of hospital characteristics, workforce distribution, resuscitation team composition, equipment availability, and NRP training practices. However, some limitations should be considered for this survey. The study focused on assessing neonatal resuscitation routines and identifying factors contributing to unsuccessful resuscitations, but it did not delve into the detailed clinical outcomes or circumstances surrounding each neonatal death. The neonatal mortality data reported in this study do not exclusively reflect deaths directly related to resuscitation efforts and equipment. Other complex factors contributing to neonatal mortality, such as pre-existing medical conditions, complications during pregnancy, congenital anomalies, or newly developed medical conditions such as infections, were not separately explored. Moreover, team composition varied across hospitals, which may have influenced the responses received. We were unable to assess the performance, skill level, or adherence to resuscitation protocols among the staff responsible for neonatal resuscitation. Another limitation was the inclusion of referral hospitals, where neonates often have more severe conditions (inherent bias), impacting the generalizability of the findings to broader healthcare settings.

Conclusion

In this study, we tried to give a general picture of the status of neonatal resuscitation and stabilization status in hospitals in Iran. The shortage of staff and equipment was reported throughout the country. Around a fifth of hospitals had neither a neonatal ward nor a NICU. The lack of neonatologist was also reported all over the country. Our study demonstrated the importance of providing facilities, implementing workshops, and updating the staff by educating the acquired knowledge and skills. These are the clues that would aid us to improve our neonatal resuscitation system step by step, basically.