Use of mask ventilation and oxygen supplementation in German delivery rooms from 2008 to 2022

Lung aeration is the most important objective of resuscitative interventions in neonates born with absent or inadequate spontaneous breathing. International resuscitation guidelines have primarily recommended the use of mask ventilation, with either a flow-inflating or self-inflating bag or a T-piece device.1, 2 The standard approach was 100% oxygen at birth.1 A major change occurred in 2010, when international consensus guidelines on neonatal resuscitation recommended starting mask ventilation with room air rather than pure oxygen. This was based on evidence for improved outcomes in term and near-term infants.2, 3 A study we published in early 2024 reported that the proportion of neonates born with a 5-min Apgar score of less than seven or an umbilical arterial cord blood pH of < 7.10 has increased substantially in Germany over the past 15 years.4 However, it was not clear whether more infants received postnatal support due to their clinical condition at birth. Population-based data on the incidence of neonatal resuscitative interventions in a high-resource setting have been lacking. This observational cohort study on delivery room interventions in Germany from 2008 to 2022 aimed to investigate the frequencies and temporal trends in the use of basic neonatal resuscitation interventions, particularly mask ventilation and supplemental oxygen administration. The preterm birth rate was analysed during the same period, as resuscitative interventions are required more frequently for preterm infants.2, 5 The study analysed mandatory federal quality assurance data on perinatal health in Germany provided by aQua Institute (Göttingen, Germany) until 2014 and by the Institute for Quality and Transparence in Healthcare (IQTIG, Berlin, Germany) in 2015–2022. Joinpoint regression analysis was conducted to investigate temporal trends in mask ventilation and oxygen supplementation shortly after birth, using Joinpoint Regression Program, Version 5.0.2 (National Cancer Institute, MD, USA). The chi-square test compared the frequencies of these interventions and the preterm birth rate between 2008–2010 and 2020–2022 and risk ratios (RR) were calculated using R, Version 4.3.1 (The R Foundation for Statistical Computing, Vienna, Austria). Ethical committee approval was not required as de-identified aggregate data was used. There were 10 696 831 live births in German hospitals from 2008 to 2022 and data on postnatal resuscitation interventions were available for 10 662 430 (99.68%) infants. Overall, mask ventilation and oxygen supplementation were provided for 2.96% and 3.91%, respectively. There were contrasting trends between the two interventions. The frequency of postnatal mask ventilation increased from 2008 to 2019 by an annual percent change (APC) of 4.60 (95% confidence interval (CI) of 3.95 to 5.88), then plateaued from 2019 to 2022 (APC −2.69, 95% CI −10.75 to 1.09) (Figure 1). Oxygen supplementation decreased notably between 2008 and 2012 (APC −7.23, 95% CI −11.01 to −5.21) and further decreased, at a slower pace, between 2012 and 2022 (APC −2.05, 95% CI −2.70 to −1.13). Between 2008–2010 and 2020–2022, the frequency of mask ventilation increased significantly from 2.29% to 3.39% (RR 1.485, 95% CI 1.468–1.502, p < 0.0001). The use of supplementary oxygen decreased from 5.03% to 3.32% (RR 0.661, 95% CI 0.654–0.667, p < 0.0001) during the same time. The proportion of live births that were preterm decreased from 8.95% in 2008–2010 to 7.66% in 2020–2022 (RR 0.856, 95% CI 0.851–0.862, p < 0.0001). Overall, just under 3% of neonates received mask ventilation, which was comparable with the positive pressure ventilation rates in a monocentric, unselected cohort in Norway.5 The frequency of mask ventilation has increased significantly since 2008, in parallel with increases in the number of infants born with a 5-min Apgar < 7 and those with an umbilical artery pH < 7.10.4 These findings reinforce the evidence that more infants have been born in a poor clinical condition in Germany during the last 15 years. This appears surprising, given that the preterm birth rate has decreased during the same period and those infants require postnatal resuscitative interventions more frequently.2, 5 The trend towards more mask ventilation may be explained by maternal morbidity and maternal age, socioeconomic parameters or changes in obstetric practices, such as fetal monitoring, delivery mode or postnatal care policies or coding. The decreased frequency of postnatal oxygen supplementation observed throughout the study period may have reflected the ongoing transformation in neonatal resuscitation practices, driven by the 2010 guideline changes.2 Although it was not possible to differentiate between 100% oxygen administration and oxygen supplementation using blenders, there was a clear downward trend in the overall rate of oxygen supplementation after birth. The increasing use of postnatal mask ventilation emphasises the importance of appropriate training in this technique for all healthcare professionals caring for neonates at birth. This may include simulation trainings with manikins or feedback devices, such as respiratory function monitors. This study assessed current rates and recent trends in basic neonatal resuscitative interventions in a large, unselected population in a high-income setting. Further investigations are required to evaluate which neonates required neonatal resuscitation interventions and why. Vinzenz Boos: Conceptualization; investigation; data curation; formal analysis; methodology; visualization; writing – original draft; writing – review and editing. Christoph Bührer: Conceptualization; investigation; writing – review and editing. Open access funding provided by Universitat Zurich. This study did not receive any specific funding. None.