1. Background
The neonatal period, defined as the first 28 days of life, is the most vulnerable phase for newborn survival (1). Approximately 2.3 million neonatal deaths occur globally each year, with the highest burden in sub-Saharan Africa and South Asia (2). In Morocco, the neonatal mortality rate was 11.1 deaths per 1,000 live births in 2021 (1).
Neonatal resuscitation (NR) is a critical intervention for reducing neonatal mortality. The International Liaison Committee on Resuscitation (ILCOR) emphasizes evidence-based guidelines, effective provider training, and regular skills practice as essential components of high-quality resuscitation (2). Nevertheless, substantial gaps in NR knowledge and practice persist among healthcare providers, particularly in low- and middle-income countries (3).
2. Objectives
In this context, the aim of the present study was to assess NR knowledge and self-reported practices among midwives and nurses at a public university hospital in central Morocco.
3. Methods
3.1. Study Design and Setting
This descriptive cross-sectional study was conducted at the Mother and Child Hospital of a public university in central Morocco between March and May 2024.
3.2. Participants and Sampling
The study population comprised midwives and nurses working in the delivery room and the pediatric emergency department. The inclusion criteria were: 1) current employment in the relevant department; 2) direct involvement in neonatal care; and 3) provision of written informed consent. Administrative staff without clinical duties were excluded. All eligible healthcare providers who met the inclusion criteria were invited to participate, and 46 consented.
3.3. Data Collection Instrument
Data were collected using a structured, self-administered questionnaire adapted from a previously validated instrument used in Egypt (3) and based on the latest American Heart Association (AHA) and American Academy of Pediatrics (AAP) Neonatal Resuscitation Program (NRP) guidelines. The content and face validity of the French version were confirmed. Internal consistency reliability was acceptable (Cronbach's alpha = 0.78 for the knowledge subscale and 0.74 for the practice subscale).
The final instrument consisted of 39 items covering sociodemographic characteristics, NR knowledge, and self-reported practices. Knowledge and practice were scored separately. Each correct response received 1 point, and incorrect or uncertain responses received 0 points. Scores were converted to percentages and categorized as low (< 60%), moderate (60% - 80%), or good (> 80%).
3.4. Data Collection Procedure
The principal investigator distributed anonymous questionnaires during scheduled shifts. Completed questionnaires were returned directly to the investigator to ensure confidentiality.
3.5. Statistical Analysis
Data were analyzed using IBM SPSS Statistics version 25.0. Analyses included frequencies, means, standard deviations, independent-samples t tests, and chi-square tests. Statistical significance was set at P < 0.05.
3.6. Ethical Considerations
Ethical approval was obtained from the Institutional Ethics Committee (Approval No. 103/2024). Written informed consent was obtained from all participants. All data were anonymized and handled confidentially.
4. Results
4.1. Participants' Characteristics
A total of 46 midwives and nurses participated in this study. Participants' sociodemographic and professional characteristics are presented in Table 1.
Table 1.Sociodemographic and Professional Characteristics of Midwives and Nurses (N = 46) a
| Variables and Categories | No. (%) |
|---|---|
| Professional categories | |
| Midwife | 26 (56.5) |
| Generalist nurse | 17 (36.6) |
| Emergency nurse | 3 (6.5) |
| Gender | |
| Female | 40 (87.0) |
| Male | 6 (13.0) |
| Age (y) | |
| < 25 | 21 (45.7) |
| 25 - 30 | 19 (41.3) |
| > 30 | 6 (13.0) |
| Neonatology experience (y) | |
| < 2 | 5 (10.9) |
| 2 - 5 | 20 (43.5) |
| 5 - 10 | 13 (28.3) |
| > 10 | 8 (17.3) |
| Initial NR training | |
| Yes | 34 (73.9) |
| No | 12 (26.1) |
| Continuous NR training | |
| Yes | 21 (45.7) |
| No | 25 (54.3) |
| NR use (last 3 months) | |
| 0 - 5 times | 12 (26.1) |
| 6 - 10 times | 13 (28.3) |
| > 10 times | 21 (45.7) |
a Abbreviation: NR, neonatal resuscitation.
4.2. Knowledge of Neonatal Resuscitation
Overall NR knowledge was suboptimal (Table 2). Participants who had received continuous training (n = 21) had a significantly higher mean knowledge score (72.4%, SD = 11.2) than those without continuous training (n = 25; mean = 61.8%, SD = 13.5; P = 0.008).
Table 2.Knowledge Level of Neonatal Resuscitation Among Midwives and Nurses (N = 46)
| Knowledge level | No. (%) |
|---|---|
| Low (< 60%) | 17 (36.9) |
| Moderate (60% - 80%) | 23 (50.0) |
| Good (> 80%) | 6 (13.0) |
4.3. Self-reported Practices
Self-reported NR practices varied across domains (Table 3). Similarly, participants with continuous training had significantly higher practice scores (70.1%, SD = 10.8) than those without continuous training (60.7%, SD = 12.3; t = 2.51; P = 0.016; Cohen's d = 0.76).
Table 3.Self-Reported Neonatal Resuscitation (NR) Practices Among Midwives and Nurses a
| Practice item | Correct response | No. (%) |
|---|---|---|
| Preparation | ||
| Equipment for every birth | All items listed | 28 (60.9) |
| Staff in delivery room | At least 1 qualified provider | 36 (78.3) |
| NR team for critical birth | At least 2 qualified providers | 35 (76.1) |
| Warming method < 32 weeks | Polyethylene bag | 10 (22.0) |
| Initial steps | ||
| Correct NR sequence | Warm-dry-stimulate-position-PPV | 43 (93.5) |
| Good adaptation: color | Pink | 46 (100.0) |
| Good adaptation: tone | Tonic, limbs flexed | 43 (93.5) |
| Preterm infant not breathing | Place on radiant warmer | 20 (43.5) |
| Correct head position | Neutral/sniffing | 25 (54.3) |
| Suction technique | Mouth then nose | 32 (69.6) |
| Stimulation method | Gentle tactile stimulation | 32 (69.6) |
| If no breathing after stimulation | Start PPV | 42 (91.3) |
| PPV | ||
| PPV indications | Apnea/gasping or HR < 100 bpm | 36 (78.3) |
| PPV preparation | All steps correct | 41 (89.1) |
| Mask fitting precautions | Avoid pressure on eyes/neck | 29 (63.0) |
| Appropriate mask size | Correct mask | 40 (87.0) |
| CC | ||
| Initiate chest compressions | HR < 60 bpm | 42 (91.3) |
| Compression depth | One-third AP diameter | 24 (52.2) |
| CC:PPV ratio | 3:1 | 31 (67.4) |
| Adrenaline route | Umbilical vein | 17 (37.0) |
a Abbreviations: PPV, positive pressure ventilation; HR, heart rate; CC, chest compression.
5. Discussion
This study evaluated neonatal resuscitation (NR) knowledge and self-reported practices among midwives and nurses in a tertiary hospital in Morocco. The findings revealed important gaps in both knowledge and practice, particularly in advanced resuscitation procedures, consistent with reports from other low- and middle-income countries (3, 4).
Participants who had received continuous training demonstrated significantly better knowledge and practices, consistent with findings from other studies and supporting international recommendations for regular refresher training to maintain NR competency (2, 5). Similarly, as reported in other studies, the identified deficiencies in thermoregulation, chest compressions, and medication administration highlight the need for simulation-based education that combines theoretical instruction with repeated hands-on practice (4, 6, 7).
This study is limited by its single-center design, relatively small sample size, and reliance on self-reported practices. Nevertheless, it provides valuable baseline evidence on NR competency among Moroccan midwives and nurses and underscores the need to strengthen both pre-service and continuing education programs.
5.1. Conclusions
This study demonstrated suboptimal neonatal resuscitation (NR) knowledge and self-reported practices among midwives and nurses in a Moroccan tertiary hospital, with notable deficiencies in thermoregulation, chest compressions, and medication administration. Continuous training was associated with significantly better competency, highlighting the importance of ongoing education.
These findings support the implementation of regular simulation-based NR training and the integration of standardized NR education into pre-service and continuing professional development programs. Further multicenter studies are needed to generate nationally representative evidence and inform neonatal care policies in Morocco.
