1. Every Newborn Action Plan, & Ending Preventable Neonatal Mortality Martha Goedert CNM, FNP, PhD

2. RESOURCES http://www.helpingbabiesbreathe.org/facil itatortools.html http://www.helpingbabiesbreathe.org/facil itatortools.html http://www.helpingbabiesbreathe.org/facil itatortools.html http://www.helpingbabiesbreathe.org/facil itatortools.html Do exam, post test and be prepared for quiz in class http://www.helpingbabiesbreathe.org/doc s/facilitatortools/hbb/HBB%20Knowledge %20Check.pdf Do exam, post test and be prepared for quiz in class http://www.helpingbabiesbreathe.org/doc s/facilitatortools/hbb/HBB%20Knowledge %20Check.pdf http://www.helpingbabiesbreathe.org/doc s/facilitatortools/hbb/HBB%20Knowledge %20Check.pdf http://www.helpingbabiesbreathe.org/doc s/facilitatortools/hbb/HBB%20Knowledge %20Check.pdf

3. Credits, always in teams Credits to HBB teams I have worked with around the globe, especially to the Haiti training team & Barry and Sandra Anderton Credits to HBB teams I have worked with around the globe, especially to the Haiti training team & Barry and Sandra Anderton I am also thankful for health care providers in Mali, Uganda, Kenya, Tanzania and Haiti who have mastered skills to save babies and help them breathe. I am also thankful for health care providers in Mali, Uganda, Kenya, Tanzania and Haiti who have mastered skills to save babies and help them breathe.

4. Resources and funding http://internationalresources.aap.org/ http://internationalresources.aap.org/ http://internationalresources.aap.org/ –(create an account, it is free, and you will find all of your teaching supplies here) (click on international link at top of webpage, upper right side) http://www2.aap.org/sections/ich/i_catch. htm (funding applications) http://www2.aap.org/sections/ich/i_catch. htm (funding applications) http://www2.aap.org/sections/ich/i_catch. htm http://www2.aap.org/sections/ich/i_catch. htm http://www.helpingbabiesbreathe.org/ http://www.helpingbabiesbreathe.org/ http://www.helpingbabiesbreathe.org/

5. 74% reduction in neonatal mortality in the last decade 40% of childhood deaths occur during the neonatal period 40% of childhood deaths occur during the neonatal period TNZ has reduced its neonatal mortality from 81/1000 in 2008, to 21/1000 in 2013 (goal was: 19/1000 NMR) TNZ has reduced its neonatal mortality from 81/1000 in 2008, to 21/1000 in 2013 (goal was: 19/1000 NMR)

6. Neonatal Mortality Rates

8. Tanzania Skilled birth attendance is at 51%.

9. Figure 7 The Lancet 2014 384, 1215-1225DOI: (10.1016/S0140-6736(14)60919-3) Copyright © 2014 Elsevier Ltd Terms and Conditions Terms and Conditions Terms and Conditions

10. Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality Prof Wim Van Lerberghe, PhD, Prof Zoe Matthews, PhD, Endang Achadi, DrPH, Chiara Ancona, MD, James Campbell, MPH, Amos Channon, PhD, Luc de Bernis, MD, Prof Vincent De Brouwere, PhD, Vincent Fauveau, PhD, Helga Fogstad, MHA, Marge Koblinsky, PhD, Jerker Liljestrand, PhD, Abdelhay Mechbal, MPH, Susan F Murray, PhD, Tung Rathavay, MPH, Helen Rehr, MSc, Fabienne Richard, PhD, Petra ten Hoope-Bender, MBA, Sabera Turkmani, MPH Prof Wim Van Lerberghe, PhD, Prof Zoe Matthews, PhD, Endang Achadi, DrPH, Chiara Ancona, MD, James Campbell, MPH, Amos Channon, PhD, Luc de Bernis, MD, Prof Vincent De Brouwere, PhD, Vincent Fauveau, PhD, Helga Fogstad, MHA, Marge Koblinsky, PhD, Jerker Liljestrand, PhD, Abdelhay Mechbal, MPH, Susan F Murray, PhD, Tung Rathavay, MPH, Helen Rehr, MSc, Fabienne Richard, PhD, Petra ten Hoope-Bender, MBA, Sabera Turkmani, MPH The Lancet The Lancet Volume 384, Issue 9949, Pages 1215-1225 (September 2014) DOI: 10.1016/S0140-6736(14)60919-3 Copyright © 2014 Elsevier Ltd Terms and Conditions Terms and Conditions Terms and Conditions

11. 143 Million Births

12. 1 Million Deaths Neonatal Asphyxia 4 Million Neonatal Deaths in the world

13. LABELED FRESH “STILLBORN” 1 Million Additional Deaths

14. Survive But Develop Cerebral Palsy Or Other Disability After Neonatal Asphyxia Neonatal Asphyxia 1 Million Newborns

15. Facility Readiness and Access to Newborn Resuscitation in Tanzania

16. 3 Causes of Neonatal Death asphyxia (31%) asphyxia (31%) preterm complications (24%) preterm complications (24%) infections (20%). infections (20%).

17. 1,198,300 Births/year 3,287 babies/day in Tanzania http://www.unicef.org/infobycountry/tanzania _statistics.html

18. Tanzanian Birth Rate 39.7 births/1000

19. Vulnerable Pregnant Teens

21. Social Justice, our work to do, must target all of the predictors! SEE THE PREVIOUS SLIDE, INDICATORS Gross national income per person, this is the wealth of each person in TNZ Gross national income per person, this is the wealth of each person in TNZ Life expectancy Life expectancy Literacy Literacy Total primary school enrollment Total primary school enrollment

22. Asphyxia Leads To Severe Disability Neonatal Death Rate 21/1000 1 in 4 die from birth asphyxia

24. The impact study of HBB conducted among 80,000 births over two years in Tanzania reported a significant reduction of early newborn mortality (within the first day of life) by 47 percent and fresh stillbirth by 24 %

25. 156 babies die each day at birth in Tanzania each year, 40% are preventable

27. 5,880 may be preventable with correct management for Neonatal Asphyxia 16 preventable deaths/day

28. Dawes Foetal and Neonatal Physiology. Year Book Medical Publishers Inc; 1968. Pathophysiologic Cardio-Pulmonary Consequences of Asphyxia

29. The First Golden Minute Birth Attendants with Simple Skills + Simple Equipment Simple Equipment Could Save 90% Of the Non-Breathing Newborns

31. The question? Why do you think we, as health care professionals are not resuscitating babies when we are trained and able? Why do you think we, as health care professionals are not resuscitating babies when we are trained and able?

32. Research from IMCI Siri Langea,,Aziza Mwisongob, Ottar Mæstada (2014).Why don't clinicians adhere more consistently to guidelines for the Integrated Management of Childhood Illness (IMCI)? Social Science and Medicine, 104: 56-63. doi:10.1016/j.socscimed.2013.12.020 Siri LangeaAziza MwisongobOttar Mæstada doi:10.1016/j.socscimed.2013.12.020

33. Clinicians in Tanzania perform 28.4 percent of the relevant IMCI assessment tasks. Clinicians in Tanzania perform 28.4 percent of the relevant IMCI assessment tasks. Lack of knowledge is not a binding constraint for improved performance. Lack of knowledge is not a binding constraint for improved performance. Clinicians have weak belief in the importance of following the guidelines. Clinicians have weak belief in the importance of following the guidelines. Physical and/or cognitive “overload” result in lack of capacity to concentrate. Physical and/or cognitive “overload” result in lack of capacity to concentrate. Many clinicians feel unappreciated due to poor remunerations and get demotivated. Many clinicians feel unappreciated due to poor remunerations and get demotivated.

34. Inverted Pyramid of Neonatal Resuscitation Medications ChestCompressions Positive-Pressure Ventilation Ventilation Initial Steps: Drying, Warmth, Clearing the Airway, Stimulation Assessment at Birth and Simple Newborn Care All infants Kenya: 118,625 Kenya : 11,862 Kenya : 11,862 Kenya: 1,186 Kenya: 1,186 Wall, Lee, Niermeyer et al. IJGO 2009 143 million babies born Approx 10 million babies Approx 6 million babies < 1.4 million babies

35. The First Golden Minute TrainedEquippedPresent

36. Every birth should be attended by someone trained in newborn resuscitation Our Goal

37. How could this be accomplished in Tanzania ?

40. Reason Women Birth at Home Distance to nearest health facility Distance to nearest health facility Financial barriers Financial barriers Cultural, traditional and religious reasons Cultural, traditional and religious reasons Attitude of health care workers concerning poor women and abuse by HCW Attitude of health care workers concerning poor women and abuse by HCW Do not have clothing for the baby, underwear, etc. Do not have clothing for the baby, underwear, etc. Stigma: ‘feel they are not clean enough’ Stigma: ‘feel they are not clean enough’ report by Country Director of African Medical Research Foundation (AMREF) report by Country Director of African Medical Research Foundation (AMREF)

41. Health Care Work Force: Health Care Work Force: Nurses and Midwives: 0.79/1000 Tanzania Nurses and Midwives: 0.79/1000 Tanzania Physicians: 0.14/1000 Tanzania Physicians: 0.14/1000 Tanzania

42. The Perfect Solution Train New Practitioners With Midwifery or Physician Skills Place them Throughout Country Accessible birthing facilities Culturally Competent

43. However education is a lengthy process for training midwives and physicians who deliver babies The Need for Help is Now

44. Capacity of Training Programs Rural Distribution Attrition Obstacles to Overcoming Shortage

45. Is There Another Solution ?

46. Train all Birth Attendants in Basic Newborn Resuscitation?

47. BeMONC Signal Functions Seven Essential Competencies for Basic Midwifery Seven Essential Competencies for Basic Midwifery Newborn resuscitation is one of the seven essential competencies for basic midwifery

48. Helping Babies Breathe ®

49. Helping Babies Breathe Curricular Concept Pictorial Limited Text Hands On Performance Frequent Skills Practice Simplest Steps “Possible” The Golden Minute

50. Helping Babies Breathe Sustainability Simple and evidence- basedSimple and evidence- based Low-cost and effectiveLow-cost and effective Easy to integrate with other essential parts of NB careEasy to integrate with other essential parts of NB care

51. Flipchart Workbook Simulator

52. Routine Care Clearing the airway if meconium present Drying infant Recognize crying Keeping warm Cutting the umbilical cord Encouraging breastfeeding

53. The Golden Minute ® Recognizing infant not crying Positioning head Clearing the airway Stimulating Recognizing breathing Initiating ventilation by 1 minute

54. A Possible Solution Train 100 Master Trainers Each Trainer Then Trains 5 others / Year 3 Years = 1500 health care providers are trained in infant resuscitation

55. You will become experts as you teach

56. “The greatest human accomplishments are not the result of great deeds by a few men, but by the small deeds of many done with great love.” A very wise person has said:

57. Tanzania 2015-2016

58. Our Motivation Our Motivation 50% of adverse outcomes are 50% of adverse outcomes are preventable with better care 1 in 12 labors is associated with adverse outcome (be proactive) CEMACH – Saving Mothers Lives; Nielsen at al, Obstet Gynecol

59. Childbirth Simulators

60. Midwifery simulations

61. Shoulder Dystocia Simulation

62. Consider the cost for safer births 50% reduction in cord pH <7 50% reduction in cord pH <7 23% reduction in adverse outcomes 23% reduction in adverse outcomesHOW? Sim teams that work together, train together..... at their birth site Sim teams that work together, train together..... at their birth site Simulation-based training.... clinical, communication and team skills (all staff)..... ideally within their own units Simulation-based training.... clinical, communication and team skills (all staff)..... ideally within their own units

63. Recommendations Units should organise 'fire drills' to improve the management of rare obstetric emergencies Units should organise 'fire drills' to improve the management of rare obstetric emergencies Including teamwork training Including teamwork training CESDI –Annual Report.– Why Mothers Die. CEMACH – Saving Mothers Lives CNST level &. To Err is Human: Building a Safer Health System.

64. Improved Team Work Team Working Team Working –Reduced demands and inquiries during emergent drill Training & Working in Teams Improves Team Working in real clinical emergencies Training & Working in Teams Improves Team Working in real clinical emergencies –Shoulder dystocia –PPH –Pre-eclampsia –Breech –Newborn resuscitation and treatment sepsis

65. Irish philosopher Edmund Burke “The only thing necessary for the triumph [of evil] is for good men to do nothing.”

66. References World Health Organization and UNICEF. (2015). A Promise Renewed. Geneva, Switzerland: WHO Press. http://www.apromiserenewed.org/wp- content/uploads/2016/01/APR-Report- 2015-e-version.pdf World Health Organization and UNICEF. (2015). A Promise Renewed. Geneva, Switzerland: WHO Press. http://www.apromiserenewed.org/wp- content/uploads/2016/01/APR-Report- 2015-e-version.pdf http://www.apromiserenewed.org/wp- content/uploads/2016/01/APR-Report- 2015-e-version.pdf http://www.apromiserenewed.org/wp- content/uploads/2016/01/APR-Report- 2015-e-version.pdf http://www.helpingbabiesbreathe.org/mas terTrainers.html http://www.helpingbabiesbreathe.org/mas terTrainers.html http://www.helpingbabiesbreathe.org/mas terTrainers.html http://www.helpingbabiesbreathe.org/mas terTrainers.html http://www.everybeatmatters.org/ http://www.everybeatmatters.org/ http://www.everybeatmatters.org/ http://apps.who.int/globalatlas/