1. Helping Babies Breathe
a global educational program in neonatal resuscitation 1

2. 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.

3. 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

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

5. 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

6. 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

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

8. Helping Babies Breathe8

9. Action Plan Plan 9

10. 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

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

12. 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

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

14. Evaluation Formative Evaluation Content/Methodology/Educational Kenya
Pakistan

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

16. Learner pair + neonatal simulator 6:1 learner-to-facilitator ratio16

17. Graphic linkage of Action Plan, flipchart, learner workbook17

18. Flipchart image for learner and instructional guide for facilitator18

19. Peer learning/teaching19

20. Case scenarios conducted independently by learner pairs20

21. 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

22. Results

23. 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

24. 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

25. 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

26. 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 <
Learners
.17
0&
9.4
15% 9
17%
Item missed most frequently: “ventilate at 40 breaths per minute”
“watch for chest rise” 26

27. 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

28. 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

29. Helping Babies Breathe
Implementation Field Testing
India
Tanzania
Kenya
Bangladesh 29

30. Results India 30

31. Knowledge Assessment
HBB Trainers & Providers 31

32. 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

33. 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

34. 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

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

36. 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

37. 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

38. Thank You
Nalini Singhal, Calgary Canada

39. Millennium Development Goal 450
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

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

41. The World of Physicians Working
2002 41

42. The World of Physicians Working
2002 42

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