Preventing those so-called stillbirths.

Increased recognition of the disproportionately large contribution of newborn health to global child survival has fuelled efforts to address neonatal mortality in resource-limited settings. Stillbirths have not been as well studied despite the fact that more than 3 million stillbirths occur annually, a disease burden that approaches that of postnatal deaths. The poorest countries have the highest incidences with two regions, sub-Saharan Africa and south Asia, together accounting for nearly 70% of worldwide stillbirths. 1 Limited health services undeniably constitute the major determinant in perinatal mortality, but there is growing concern that high stillbirth rates in many regions are also being driven by less apparent, potentially preventable factors. Birth asphyxia, defined as the failure to establish breathing at birth, accounts for an estimated 900 000 deaths each year and is one of the primary causes of early neonatal mortality. 2 Guidelines for neonatal resuscitation, such as those endorsed by WHO and the American Academy of Pediatrics, represent a standard practice set that improves outcomes in asphyxiated newborns. These algorithms stress the importance of drying, stimulating and warming babies in distress, as well as clearing their airways. In the face of persistent apnoea or bradycardia, ventilation with the use of bag-and-mask or equivalent device is indicated, and is felt by many to constitute the critical step in managing asphyxiated infants. 3 Newborns have a remarkable ability to withstand hypoxia and many improve rapidly with timely implementation of these techniques. Few infants go on to require chest compressions or pharmaceutical administration. Despite being a relatively simple and inexpensive intervention, effective neonatal resuscitation is not universal. Translation of resuscitation principles into practice might be straightforward in health-care environments that benefit from highly-skilled and well-outfitted resuscitation teams, but is understandably difficult in settings where practitioners lack training in newborn care and where access to essential resuscitation equipment is limited. In parts of many low-income countries, for example, resuscitation algorithms may be nonexistent or inappropriate. Bulb syringes and bag-and-mask devices may be substandard or unavailable; even when present and functioning, staff may be unfamiliar with their use. Moreover, stethoscopes, which can play a crucial role in helping practitioners to recognize a live birth by detecting a heart rate, may also be either inaccessible or unused. Customary practice in some regions dictates use of a stethoscope only by doctors, who may not regularly attend deliveries. Given that perinatal asphyxia occurs with regular frequency and that health-care …