Helping Babies Survive educational programs to improve

neonatal survival

Susan Niermeyer, MD, MPH, FAAP University of Colorado, Aurora, Colorado, USA

Helping Babies Survive more than just a workshop

• Content, educational design, innovative models and equipment

• Ongoing practice for mastery of skills • Facility-based improvement activities to

change behavior and outcomes

Helping Babies Survive addressing 3 major causes of neonatal mortality

Severe Infections

Intrapartum-related complications

Complications from preterm birth

3.8 million neonatal deaths and 3.2 million stillbirths per year worldwide

Helping Babies Breathe

Helping Babies Breathe

• Action Plan • Facilitator Flip Chart • Learner Workbook • Neonatal Simulator • Bag and Mask • Suction Device

materials

Educational design: key principles

• Effectiveness of basic steps,

not intensive care

• Graphic Action Plan and learning materials

• Purpose-built neonatal simulator for skill-building and practice

• Empowerment of birth attendants to change performance and outcomes

Educational design: practice in pairs

Educational design: case scenario exercises

Educational design: in-facility training

Essential Care for Every Baby Action Plan

Essential Care for Every Baby materials

Essential Care for Every Baby Provider Guide – review and quality improvement

Essential Care for Every Baby Provider Guide – exercises with communication skills

Essential Care for Every Baby Parent Guide

Essential Care for Every Baby Breast model – breastfeeding, expression, skin-to-skin care

Ethiopia Field Testing with WHO – Addis Abbaba, May 2014

Essential Care for Small Babies Action Plan

Essential Care for Small Babies Provider Guide – review and quality improvement

Weight 1.6 kg Realistic size and proportions for preterm baby Supports training in

• proper breastfeeding positioning and attachment • correct nasogastric tube placement • spoon, cup and nasogastric tube feeding • continuous skin-to-skin care

Essential Care for Small Babies Preterm simulator

Helping Babies Survive addressing 3 major causes of neonatal mortality

Severe Infections

Intrapartum-related complications

Complications from preterm birth

HBB: Basic resuscitation

ECSB: Continuous skin-to-skin care Alternative feeding methods Hygiene Recognition of problems

ECEB: Hygiene, cord care Skin-to-skin contact Exclusive breastfeeding Recognition of danger signs, antibiotic treatment

The Formula for Survival

patient survival is the result of three equally important factors

Søreide E et al. Resuscitation 2013;84:1487-93

Medical Science

Educational Efficiency

Local Implementation

Survival

Confronting the challenges of change

• After training, providers want to make change – but an individual cannot make change alone

• Change means taking risks – keeping old practices is safe – avoids criticism and

possible failure

• There are many things that need change – confronting them all is overwhelming

HBB: Change in skills but not clinical practice observations at Haydom Hospital, Tanzania

Sept 2009 Nov 2010

Scenario (video analysis)

N= 39 N=27

Routine care (% pass) 41 74*

Bag-mask (% pass) 18 74^

Delivery room (observation)

N=2745 N=3116

Stimulation (%) 17.7 14.1*

BMV (%) 8.4 7.5

Time to BMV (sec) 76+54 89+76*

* p<0.05 ^ p<0.0001 Ersdal HL et al. Resuscitation 2013; 84:1422

April 2010 HBB training

Facility-based training, mentored practice

• Routinized practice of skills

• Simulators in the delivery room

• Midwife “champion” at each delivery site

Impact of low-dose, high-frequency practice Haydom Hospital, Tanzania

Sept 2009 Nov 2010 Feb 2010- Jan 2011

Feb 2011- Jan 2012

Clinical outcomes

Fresh stillbirth (per 1000 live births)

16.0 14.4*

Death < 24 hours (per 1000 live births)

11.1 7.2*

Delivery room (obs) N=2745 N=3116 N=4876 N=4734

Stimulation (%) 17.7 14.1* 14.4 16.0 *

BMV (%) 8.4 7.5 7.2 5.7 +

Time to BMV (%) 76+54 89+76* 89+72 97+74

* p < 0.05 + p =0.03 Ersdal HL et al. Resuscitation 2013; 84:1422

April 2010 HBB training February 2011 LDHF practice

Msemo G et al. Pediatrics 2013; 131:e353

Tanzania: change in survival

Nepal: HBB as a framework for quality improvement

Plan

Do Study

Act

27

• Identify objective for implementing HBB

• Develop measurement system to assess change (performance, mortality)

• Collect and analyze data • Meet weekly to review

progress and challenges

Ashish KC et al. BMC Pediatrics 2012; 12:159

Are all babies dried thoroughly immediately after birth?

Do all babies have the airway cleared for visible secretions or obstruction only?

Is umbilical cord clamping delayed for at least 1 minute?

Are all babies placed skin-to-skin with the mother after drying?

Do all babies who do not breathe after stimulation receive bag and mask ventilation by 1 minute?

Is equipment prepared and checked before every delivery?

Using the Action Plan to create change

Nepal: HBB as a framework for outcomes pre-HBB N=9630 post-HBB N=1385

86% 14% 95% 5%

41% received suction, stim, O2

none ventilated by 1 min

18% received suction, stim, O2

Honduras: observation and improvement cycles impact clinical performance

Pre-HBB (N=14)

Post –HBB (N=65)

Drying/stimulation of non-breathing baby

30 % 94 % *

Unnecessary suction 42 15 +

Delayed cord clamping 86 97

Skin-to-skin care 44 79 +

Breastfeeding before 30 min 50 72

* p <0.01 + p < 0.05

Kamath-Rayne BD et al. PAS 2014

Improving care of mothers and babies

• Facilitator Flipchart – introduction to improvement for every provider

• Provider Guide – questions to improve care in your facility and what to monitor (process and outcome)

• Improvement Workbook – team exercises and guide through the improvement cycle

Key lessons from Helping Babies Survive

• Simplicity and clarity open the door for change • Facility-based skills training initiates change • Mentoring and empowerment of health workers

solidifies change – Practice in pairs, in situ practice, LDHF refreshers,

mentoring • Catalytic role of HBS spreads change

– Focusing attention on babies (and their mothers) – Demystifying interventions (resuscitation, thermal care) – Demystifying a process (quality improvement)

• Monitoring, data collection and utilization of data document and support continued change

www.helpingbabiesbreathe.org

www.helpingbabiesbreathe.org/docs/HBB-Report-2010-2015.pdf

HBB: Tanzania Ersdal HL, Mduma E, Svensen E, Sundby J, Perlman J. Intermittent detection of fetal heart rate abnormalities identify infants at greatest risk for fresh stillbirths, birth asphyxia, neonatal resuscitation, and early neonatal deaths in a limited-resource setting: a prospective descriptive observational study at Haydom Lutheran Hospital. Neonatology. 2012;102(3):235-242. Ersdal HL, Mduma E, Svensen E, Perlman J. Birth asphyxia: a major cause of early neonatal mortality in a Tanzanian rural hospital. Pediatrics. 2012;129(5):e1238-1243. Ersdal HL, Mduma E, Svensen E, Perlman JM. Early initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries: a prospective descriptive observational study. Resuscitation. 2012;83(7):869-873. Ersdal HL, Vossius C, Bayo E, Mduma E, Perlman J, Lippert A. Soreide E. A one-day "Helping Babies Breathe" course improves simulated performance but not clinical management of neonates. Resuscitation. 2013;84(10):1422-1427. Msemo G, Massawe A, Mmbando D, Rusibamayila N, Manji K, Kidanto HL, Mwizamuholya D, Ringia P, Ersdal HL, Perlman J. Newborn mortality and fresh stillbirth rates in Tanzania after helping babies breathe training. Pediatrics. 2013;131(2):e353-360. Mduma, E., Ersdal, H., Svensen, E., Kidanto, H. L., Auestad, B., & Perlman, J. (2015). Frequent brief on-site simulation training and reduction in 24-h neonatal mortality - An educational intervention study. Resuscitation. doi: http://dx.doi.org/10.1016/j.resuscitation.2015.04.019 HBB: Kenya and Rwanda Hoban R, Bucher S, Neuman I, Chen M, Tesfaye N, Spector JM. 'Helping babies breathe' training in sub-saharan Africa: educational impact and learner impressions. Journal of Tropical Pediatrics. 2013;59(3):180-186. Musafili A, Essen B, Baribwira C, Rukundo A, Persson LA. Evaluating Helping Babies Breathe: training for healthcare workers at hospitals in Rwanda. Acta Paediatrica. 2013;102(1):e34-38.

HBB: India, Nepal, Honduras Goudar SS, Somannavar MS, Clark R, Lockyer JM, RevankarAP, Fidler HM, Sloan NL, Niermeyer S, Keenan WJ, Singhal N. Stillbirth and newborn mortality in India after helping babies breathe training. Pediatrics. 2013;131(2):e344-352. Ashish KC, Malqvist M, Wrammert J, Verma S, Aryal DR, Clark R Naresh PK, Vitrakoti R, Baral K, Ewald U. Implementing a simplified neonatal resuscitation protocol-helping babies breathe at birth (HBB) - at a tertiary level hospital in Nepal for an increased perinatal survival. BMC Pediatrics. 2012;12:159. Seto TL, Tabangin ME, Josyula S, Taylor KK, Vasquez JC, Kamath-Rayne BD. Educational outcomes of Helping Babies Breathe training at a community hospital in Honduras. Perspectives in Medical Education, available on-line 9 September 2015, DOI 10.1007/s40037-015-0214-8

HBB: Global Singhal N, Lockyer J, Fidler H, Keenan W, Little G, Bucher S, Qadir M, Niermeyer S. Helping Babies Breathe: global neonatal resuscitation program development and formative educational evaluation. Resuscitation. 2012;83(1):90-96. Steele C. Helping babies breathe around the world. JOGNN - Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2013;42(2):243-246. Wall SN, Lee AC, Carlo W, Goldenberg R, Niermeyer S, Darmstadt GL, Keenan W, Bhutta SA, Perlman J, Lawn JE. Reducing intrapartum-related neonatal deaths in low- and middle-income countries-what works? Seminars in Perinatology. 2010;34(6):395-407. Little, G. A., Keenan, W. J., Singhal, N., & Niermeyer, S. Helping Babies Breathe: Evolution of a global neonatal resuscitation program for resource-limited areas. NeoReviews, 2014;15(9), e369-380. Niermeyer S. From the Neonatal Resuscitation Program to Helping Babies Breathe: Global impact of programs in neonatal resuscitation. Seminars in Fetal and Neonatal Medicine 2015, available on-line 8 August 2015 http://dx.doi.org.hsl-ezproxy.ucdenver.edu/10.1016/j.siny.2015.06.005.

ECEB and ECSB Thukral, A., Lockyer, J., Bucher, S. L., Berkelhamer, S., Bose, C., et al. (2015). Evaluation of an educational program for essential newborn care in resource-limited settings: Essential Care for Every Baby. BMC Pediatrics. 2015;15:71. Berkelhamer S, Bose C, Bucher S, Campbell-Yeo M, McMillan D, Niermeyer S, Singhal N. Essential Care for Small Babies (ECSB) Improves Knowledge, Performance and Confidence in Caring for Small Babies (poster 2935.676). Pediatric Academic Societies’ Meeting. April 26, 2015, San Diego, CA.

Selected references