Helping Babies Breathe a global educational program in neonatal resuscitation 1

Helping Babies Breathe A baby’s first cry is one of the most anticipated and welcome sounds in all the world. But in much of the world, when there is no cry – hopes are dashed. Too many times there is no one with the knowledge or the skills or the equipment to help…and a baby dies. This baby in Lesotho was born in a such a center and did not survive.

Target of Helping Babies Breathe 1.02 million stillbirths due to asphyxia 830,000 neonatal deaths due to asphyxia Lawn JE et al. IJGO 2009; 107:S5 3

Circumstances at Birth Wall SN, et al. IJGO 2009; 107:S47 4

Need for help to breathe at birth Drying, warmth, clearing the airway, stimulation Bag and mask ventilation Chest compressions, medications Assessment at birth and routine care 80-90% 8-10% 3-6% < 1 5

Evidence base and Evaluation Scientific evidence base International consensus on science (ILCOR) Revision every 6 years Harmonization with international health policy WHO technical expert review Delphi panel 6

Helping Babies Breathe World Health Organization Basic resuscitation guidelines (in revision) Hand washing Breastfeeding Context of ENC

Helping Babies Breathe 8

Action Plan Plan 9

Helping Babies Breathe Preparation for Birth Identifying a helper and reviewing the emergency plan Preparing the are for delivery Hand washing Preparing and area for ventilation and checking equipment 10

Helping Babies Breathe Routine Care Drying thoroughly Keeping warm Evaluating crying Checking breathing Clamping or typing and cutting the cord 11

Helping Babies Breathe The Golden Minute Positioning the head Clearing the Airway Providing stimulation to breathe Evaluating breathing Initiating ventilation Ventilating with bag and mask 12

Helping Babies Breathe Continued ventilation with normal or slow heart rate Improving ventilation Evaluating heart rate Activating the emergency plan Support Family 13

Evaluation Formative Evaluation Content/Methodology/Educational Kenya Pakistan

Helping Babies Breathe Training of Master Trainers Training of a facilitator and learners

Learner pair + neonatal simulator 6:1 learner-to-facilitator ratio 16

Graphic linkage of Action Plan, flipchart, learner workbook 17

Flipchart image for learner and instructional guide for facilitator 18

Peer learning/teaching 19

Case scenarios conducted independently by learner pairs 20

Helping Babies Breathe Course assessment All HBB training participant Master Trainers & Facilitators after teaching Knowledge assessment Multiple Choice Questionnaire (pre- and post-training) Skills and Performance assessment Bag-and-mask skills assessment (pre and post) OSCE A (post only) OSCE B (post only) Qualitative assessment Focus Group Discussions 21

Results

Helping Babies Breathe (Likert’s scale) Facilitators Kenya Pakistan Training to lead a course 5 4.73 Course materials 4.8 4.3 I can help baby breathe 4.85 4.55 Group will help babies breathe 4.75 4.9 23

Helping Babies Breathe Learners Kenya Pakistan Course Content 4.45 4.80 I can use Action Plan 4.43 4.64 I can help babies breathe 4.58 4.70 24

Knowledge Assessment Pre Kenya Post Pakistan T-test Facilitators 20.5 Pass: 75% 22.3 Pass: 95% 20.2 Pass: 82% P < .01 Learners 14.0 2% 19.5 54% 52% P < .001 25

Skills Assessment Bag-and-mask ventilation skills Master = 12/12 steps correct Pre Kenya Post Pakistan T-test Facilitators 2.0 Pass: 0% 10.5 Pass: 31% 11.8 Pass: 48% P < .00001 Learners .17 0& 9.4 15% 9 17% Item missed most frequently: “ventilate at 40 breaths per minute” “watch for chest rise” 26

Performance Assessment Objective Structured Clinical Evaluation (OSCE post-HBB training only) OSCE A (11 items) pass = 3 critical items and 80% overall OSCE B (22 items) pass = 9 critical items and 80% overall OSCE A Kenya Pakistan OSCE B Facilitators 8.9 50% 8.36 100% 19.3 70% 17.64 45% Learners 9.1 Pass: 60% 8.32 Pass: 83% 15.8 Pass: 20% 15.6 Pass: 23% Most common items missed in OSCE A for both Facilitators and Learners = “Evaluate breathing” and “Position and clear airway.” Mixed causes for failure of OSCE B by Facilitators; Most common items missed by Learners = “Selects appropriate sized mask” and “Ventilates at 40 breaths/mins.” 27

Conclusions from Phase I Helping Babies Breathe Increases knowledge of immediate care at birth and interventions to help babies who do not breathe. Improves bag-and-mask ventilation (BMV) skills. Improves the ability of birth attendants in the resource-limited setting to manage both simple (OSCE A) and complicated (OSCE B) cases of newborns who do not breathe spontaneously. 28

Helping Babies Breathe Implementation Field Testing India Tanzania Kenya Bangladesh 29

Results India 30

Knowledge Assessment HBB Trainers & Providers 31

Helping Babies Breathe Pre-Training Oct 2009 – Mar 2010 Post Training Mar 2010 – Oct 2010 Deliveries 4173 5427 Live Births 4046 5301 Still Births 124 (3%) 123 (2.3%) Deaths at Birth 3 32

Helping Babies Breathe Pre Training n(%) Post Training Body breathing at 1 minute 118 (2.8) 266 (4.9) Resuscitation Required 1218 (29.2) 645 (11.9) Stimulation 666 (16) 491 (9) Suction 1113 (26.7) 594 (10) Bag & Mask 124 (3) 219 (4) Bag & Mask started < 1 minute 92 (2.2) 144 (2.7) 33

Helping Babies Breathe Conclusions Better recognition of babies not breathing at birth Still births decreased Neonatal deaths remained unchanged Need for specific resuscitation decreased 34

Helping Babies Breathe Summary Program well received Improves knowledge Improves skills Clinical impact needs further study 35

Helping Babies Breathe Sustainability Simple Evidence based Low-cost and effective Easy to integrate Hands on Empowers the learner Higher level of learning Promotes life long learning 36

Helping Babies Breathe Babies acknowledge the support of American Academy of Pediatrics (AAP) United States Agency for International Development (USAID) Laerdal Medical Laerdal Foundation for Acute Medicine Saving Newborn Lives (SNL) Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD) World Health Organization (WHO) 37

Thank You Nalini Singhal, Calgary Canada

Millennium Development Goal 4 50 100 150 Global mortality per 1000 births 1960 1980 2000 2020 Year Under-5 mortality rate Late neonatal mortality Early neonatal mortality Target for MDG-4 Lawn JE et al. Lancet 2005 Reduce under-5 child deaths 2/3 from 1990 levels by 2015

Global causes of neonatal death UNICEF 2007 Lee ACC, et al. Int J Epidemiol (inpress)

The World of Physicians Working www.worldmapper.org 2002 41

The World of Physicians Working www.worldmapper.org 2002 42

Regional rates of neonatal mortality UNICEF, State of the World’s Children 2009