Helping Babies Survive global impact of educational programs in resuscitation and essential newborn care Susan Niermeyer, MD, MPH, FAAP University of Colorado, Aurora, Colorado, USA American Academy of Pediatrics
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Helping Babies Surviveglobal impact of educational programs in resuscitation and essential newborn care
Susan Niermeyer, MD, MPH, FAAPUniversity of Colorado, Aurora, Colorado, USA
American Academy of Pediatrics
Conflict of interest
• No financial relationships to disclose
Helping Babies Survive global impact of educational programs
• Helping Babies Breathe: content, educational design, innovative models and equipment
• Implementation and impact
• New initiatives to improve neonatal survival and quality of care
Neonatal Resuscitation Program
Transferability….to more than 120 countries
Sites of implementation of NRP around the world
Where newborns are dying
Lawn JE Lancet 2014 www.thelancet.com/series/everynewborn
Under-5 child mortality45% of deaths occur in the neonatal period
2.7 million neonatal deaths and 2.6 million stillbirths per year worldwide
WHO, Levels and Trends in Child Mortality, 2015
Helping Babies Survive addressing 3 major causes of neonatal mortality
SevereInfections
Intrapartum-related complications
Complications from low weight and preterm birth
Every Newborn Action Planreducing neonatal mortality < 10/1000 live births
0
10
20
30
40
50
60
70
80
90
100
1990 1995 2000 2005 2010 2015 2020 2025 2030 2035
Mo
rtal
ity
rate
(p
er
1,0
00
live
bir
ths)
2000-2012AAR = 2.7%
Proposed NMR target: National NMR of 10 or lessGlobal NMR of 7
2000-2012 AAR = 3.8%Global U5MR
Global NMR
APR target: National U5MR of 20 or lessGlobal U5MR of 15
AAR = 4.3%
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
Singhal et al. Resuscitation 2012; 83:90
Educational design: case scenario exercises
Educational design: in-facility training
Helping Babies Breatheimplementation in 77 countries
The Formula for Survival
patient survival is the product of three important factors
Søreide E et al. Resuscitation 2013;84:1487-93
Medical
Science
Educational
Efficiency
Local
ImplementationSurvival
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 practiceobservations 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 for debriefing
• Midwife “champion” at each delivery site
Impact of low-dose, high-frequency practiceHaydom 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 Mduma E et al. Resuscitation 2015; 93:1 + 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
fresh stillbirth
neonatal death
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
Ashish KC et al. BMC Pediatrics 2012; 12:159
Nepal: HBB as a framework for changepre-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
Nepal: HBB as a framework for change
KC Ashish et al. Pediatrics in press
Nepal: HBB as a framework for improved survival
KC Ashish et al. Pediatrics in press
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
Essential Care for Every BabyAction Plan
Essential Care for Every Babymaterials
Essential Care for Every BabyParent Guide
Essential Care for Every Babycommunication and quality improvement
Thukral et al. BMC Pediatrics 2015; 15:71
Essential Care for Every BabyBreast model – breastfeeding, expression, skin-to-skin care
Ethiopia Field Testing with WHO – Addis Abbaba, May 2014
Essential Care for Small BabiesAction Plan
Essential Care for Small Babiescontinuous skin-to-skin care
Weight 1.6 kgRealistic size and proportions for preterm babySupports training in
• proper breastfeeding positioning and attachment• correct nasogastric tube placement• cup and nasogastric tube feeding• continuous skin-to-skin care
Essential Care for Small Babiespreterm simulator
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 to activities through the improvement cycle
Helping Babies Survive addressing 3 major causes of neonatal mortality
SevereInfections
Intrapartum-related complications
Complications from preterm birth
HBB: Basic resuscitation
ECSB: Continuous skin-to-skin careAlternative feeding methodsHygieneRecognition of problems
ECEB:Hygiene, cord careSkin-to-skin contactExclusive breastfeedingRecognition of danger signs, antibiotic treatment
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,
debriefing, case reviews
• Monitoring, data collection and utilization of data document and support continued change
• Catalytic role of HBS spreads change– Focusing attention on babies (and their mothers)– Demystifying interventions (resuscitation, thermal care)– Demystifying a process (quality improvement)
www.helpingbabiesbreathe.org/docs/HBB-Report-2010-2015.pdf
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