Reduction in Perinatal Mortality after Implementation of HBB Training at a District Hospital in Mali

A hybrid approach to skill retention following neonatal resuscitation training: Assessing effectiveness

 Perinatal death, a global health problem, can be prevented with simple resuscitation interventions that help the baby breathe immediately at birth. Latter-day Saint Charities (LDSC) and Safa Sunaulo Nepal (SSN) implemented a program to scale-up Helping Babies Breathe (HBB) training in Karnali Province, Nepal from January 2020-February 2021. The interventions were implemented using a hybrid approach with on-site mentoring in the pre/post COVID period combined with remote support and monitoring during the COVID period. This paper reports overall changes in newborn outcomes in relation to the unique implementation approach used. A prospective cohort design was used to compare outcomes of birth cohorts in 16 public health facilities in the first and last three months of program implementation. Results showed significant decreases in intrapartum stillbirths (23%), and neonatal deaths within (27%) and after (41.3%) 24 hours of life. The scale-up of HBB training resulted in 557 providers receiving training and mentoring support during the program period, half trained during the COVID period. Increased practice sessions, review meetings and debriefing meetings were reported during the COVID period compared to pre/post COVID period. The evaluation is suggestive of the potential of a hybrid approach for improved perinatal outcomes and scaling-up of newborn resuscitation trainings in health system facing disruptions.

Scale Up of Neonatal Resuscitation Training and Skill Retention in Five Provinces of Nepal

To reduce neonatal mortality attributable to intrapartum hypoxic events, Latter-days Saint Charities (LDSC) and Safa Sunaulo Nepal (SSN) implemented a neonatal resuscitation training, scale-up, and skill retention program. This article reports on the LDSC/SSN dissemination program and newborn outcomes associated with its implementation. To evaluate the program, we used a prospective cohort design to compare outcomes of birth cohorts in 87 health facilities preimplementation and postimplementation of the facility-based training. A paired T-test was used to determine whether baseline and endline values were significantly different. Resuscitation training began with trainers from 191 facilities attending Helping Babies Breathe (HBB) training-of-trainer (ToT) courses. Thereafter, 87 facilities from five provinces received active mentoring, scale-up assistance (6389 providers trained), and skill retention support. The LDSC/SSN program was associated with decreases in the number of intrapartum stillbirths in all provinces except Bagmati. Neonatal deaths within 24 hours of birth decreased significantly in Lumbini, Madhesh, and Karnali provinces. Morbidity associations, as defined by sick newborn transfers, decreased significantly in Lumbini, Gandaki, and Madhesh provinces. The LDSC/SSN model of neonatal resuscitation training, scale-up, and skill retention has the potential to significantly improve perinatal outcomes. It could potentially guide future programs in Nepal and other resource-limited settings.

Impact of accredited advanced life support course participation on in-hospital cardiac arrest patient outcomes: A systematic review

Aim

Advanced life support courses have a clear educational impact; however, it is important to determine whether participation of one or more members of the resuscitation team in an accredited advanced life support course improves in-hospital cardiac arrest patient survival outcomes.

Methods

We searched EMBASE.com, Medline, Cochrane and CINAHL from inception to 1 November 2022. Included studies were randomised or non-randomised interventional studies assessing the impact of attendance at accredited life support courses on patient outcomes. Accredited life support courses were classified into 3 contexts: Advanced Life Support (ALS), Neonatal Resuscitation Training (NRT), and Helping Babies Breathe (HBB). Existing systematic reviews were identified for each of the contexts and an adolopment process was pursued. Appropriate risk of bias assessment tools were used across all outcomes. When meta-analysis was appropriate a random-effects model was used to produce a summary of effect sizes for each outcome.

Results

Of 2714 citations screened, 19 studies (1 ALS; 7 NRT; 11 HBB) were eligible for inclusion. Three systematic reviews which satisfied AMSTAR-2 criteria for methodological quality, included 16 of the studies we identified in our search. Among adult patients all outcomes including return of spontaneous circulation, survival to discharge and survival to 30 days were consistently better with accredited ALS training. Among neonatal patients there were reductions in stillbirths and early neonatal mortality.

Conclusion

These results support the recommendation that accredited advanced life support courses, specifically Advanced Life Support, Neonatal Resuscitation Training, and Helping Babies Breathe improve patient outcomes.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Epidemiology of neonatal mortality: a spatial and multilevel analysis of the 2019 mini-Ethiopian demographic and health survey data

BACKGROUND

Sub-Saharan African countries are a high-burden region of neonatal mortality and showed slow progress in its reduction. In developing countries, as long as the current trend of mortality persists, achieving a sustainable development target for neonatal mortality would be challenging. The aim of this study was to detect significant geographic areas and identify community and individual-level predictors of neonatal mortality in Ethiopia to draw attention to a policy.

METHODS

A weighted total sample of 24,136 mothers from the 2019 mini-Ethiopian demographic and health survey data were included in the analysis. Global Moran's I statistics was run to check the clustering of neonatal mortality and then kriging interpolation was done to predict the magnitude of neonatal mortality in Ethiopia. In addition, SaTScan analysis was also executed to identify hot spot clusters of neonatal mortality. Finally, a multilevel mixed-effect logistic regression model was used to identify community and individual-level predictors of early neonatal and neonatal mortality.

RESULTS

The lifetime early neonatal and neonatal mortality among mothers in Ethiopia was 5.08 (95% CI: 4.13-6.03) and 6.54 (5.55, 7.52) per 1000 births respectively. Neonatal mortality was spatially clustered in the country and the SaTScan analysis identified significant hotspot areas of neonatal mortality in the Amhara and Afar regions and some areas of the Somali and Oromia regions. Its predicted magnitude was > 8 per 1000 births in wide areas of the Amhara and Benishangul regions. A multilevel mixed-effect logistics regression analysis identified that a lower level of maternal education, being a twin neonate, and being a male neonate were predictors of both early neonatal and neonatal mortality. Whereas, the younger age of mothers predicted neonatal mortality.

CONCLUSIONS

Neonatal mortality in Ethiopia is geographically clustered and sociodemographic and obstetric factors played a significant role. Policy direction should focus on evidence-based practices like midwives-led community and facility-based continuum of care from preconception to postnatal periods to possibly reduce neonatal mortality.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimising pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Effect of the Helping Babies Breathe Program on Newborn Outcomes: Systematic Review and Meta-Analysis

Background and objectives: In low- and middle-income countries, the leading cause of neonatal mortality is perinatal asphyxia. Training in neonatal resuscitation has been shown to decrease this cause of mortality. The program "Helping Babies Breathe" (HBB) is a program to teach basic neonatal resuscitation focused on countries and areas with limited economic resources. The aim of the study was to determine the effect of the implementation of the HBB program on newborn outcomes: mortality and morbidity. Material and Methods: A systematic review was carried out on observational studies and clinical trials that reported the effect of the implementation in low- and middle-income countries of the HBB program on neonatal mortality and morbidity. We carried out a meta-analysis of the extracted data. Random-effect models were used to evaluate heterogeneity, using the Cochrane Q and I2 tests, and stratified analyses were performed by age and type of outcome to determine the sources of heterogeneity. Results: Eleven studies were identified. The implementation of the program includes educational strategies focused on the training of doctors, nurses, midwives, and students of health professions. The poled results showed a decrease in overall mortality (OR 0.67; 95% CI 0.57, 0.80), intrapartum stillbirth mortality (OR 0.62; 95% CI 0.51, 0.75), and first-day mortality (OR 0.70; 95% IC 0.64, 0.77). High heterogeneity was found, which was partly explained by differences in the gestational age of the participants. Conclusions: The implementation of the program HBB in low- and medium-income countries has a significant impact on reducing early neonatal mortality.

Do in-service training materials for midwifery care providers in sub-Saharan Africa meet international competency standards? A scoping review 2000-2020

BACKGROUND

Levels of maternal and neonatal mortality remain high in sub-Saharan Africa, with an estimated 66% of global maternal deaths occurring in this region. Many deaths are linked to poor quality of care, which in turn has been linked to gaps in pre-service training programmes for midwifery care providers. In-service training packages have been developed and implemented across sub-Saharan Africa in an attempt to overcome the shortfalls in pre-service training. This scoping review has aimed to summarize in-service training materials used in sub-Saharan Africa for midwifery care providers between 2000 and 2020 and mapped their content to the International Confederation of Midwives (ICM) Essential Competencies for Midwifery Practice.

METHODS

Searches were conducted for the years 2000-2020 in Cumulative Index of Nursing and Allied Health Literature, PubMed/MEDLINE, Social Science Citation Index, African Index Medicus and Google Scholar. A manual search of reference lists from identified studies and a search of grey literature from international organizations was also performed. Identified in-service training materials that were accessible freely on-line were mapped to the ICM Essential Competencies for midwifery practice.

RESULTS

The database searches identified 1884 articles after removing duplicates. After applying exclusion criteria, 87 articles were identified for data extraction. During data extraction, a further 66 articles were excluded, leaving 21 articles to be included in the review. From these 21 articles, six different training materials were identified. The grey literature yielded 35 training materials, bringing the total number of in-service training materials that were reviewed to 41. Identified in-service training materials mainly focused on emergency obstetric care in a limited number of sub-Saharan Africa countries. Results also indicate that a significant number of in-service training materials are not readily and/or freely accessible. However, the content of in-service training materials largely met the ICM Essential Competencies, with gaps noted in the aspect of woman-centred care and shared decision making.

CONCLUSION

To reduce maternal and newborn morbidity and mortality midwifery care providers should have access to evidence-based in-service training materials that include antenatal care and routine intrapartum care, and places women at the centre of their care as shared decision makers.

Prioritizing Health Care Strategies to Reduce Childhood Mortality

IMPORTANCE

Although child mortality trends have decreased worldwide, deaths among children younger than 5 years of age remain high and disproportionately circumscribed to sub-Saharan Africa and Southern Asia. Tailored and innovative approaches are needed to increase access, coverage, and quality of child health care services to reduce mortality, but an understanding of health system deficiencies that may have the greatest impact on mortality among children younger than 5 years is lacking.

OBJECTIVE

To investigate which health care and public health improvements could have prevented the most stillbirths and deaths in children younger than 5 years using data from the Child Health and Mortality Prevention Surveillance (CHAMPS) network.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used longitudinal, population-based, and mortality surveillance data collected by CHAMPS to understand preventable causes of death. Overall, 3390 eligible deaths across all 7 CHAMPS sites (Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa) between December 9, 2016, and December 31, 2021 (1190 stillbirths, 1340 neonatal deaths, 860 infant and child deaths), were included. Deaths were investigated using minimally invasive tissue sampling (MITS), a postmortem approach using biopsy needles for sampling key organs and fluids.

MAIN OUTCOMES AND MEASURES

For each death, an expert multidisciplinary panel reviewed case data to determine the plausible pathway and causes of death. If the death was deemed preventable, the panel identified which of 10 predetermined health system gaps could have prevented the death. The health system improvements that could have prevented the most deaths were evaluated for each age group: stillbirths, neonatal deaths (aged <28 days), and infant and child deaths (aged 1 month to <5 years).

RESULTS

Of 3390 deaths, 1505 (44.4%) were female and 1880 (55.5%) were male; sex was not recorded for 5 deaths. Of all deaths, 3045 (89.8%) occurred in a healthcare facility and 344 (11.9%) in the community. Overall, 2607 (76.9%) were deemed potentially preventable: 883 of 1190 stillbirths (74.2%), 1010 of 1340 neonatal deaths (75.4%), and 714 of 860 infant and child deaths (83.0%). Recommended measures to prevent deaths were improvements in antenatal and obstetric care (recommended for 588 of 1190 stillbirths [49.4%], 496 of 1340 neonatal deaths [37.0%]), clinical management and quality of care (stillbirths, 280 [23.5%]; neonates, 498 [37.2%]; infants and children, 393 of 860 [45.7%]), health-seeking behavior (infants and children, 237 [27.6%]), and health education (infants and children, 262 [30.5%]).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, interventions prioritizing antenatal, intrapartum, and postnatal care could have prevented the most deaths among children younger than 5 years because 75% of deaths among children younger than 5 were stillbirths and neonatal deaths. Measures to reduce mortality in this population should prioritize improving existing systems, such as better access to antenatal care, implementation of standardized clinical protocols, and public education campaigns.

Effect of Training Healthcare Providers in Helping Babies Breathe Program on Neonatal Mortality Rates

BACKGROUND

Training in the Helping Babies Breathe (HBB) Program has been associated with a reduction in early neonatal mortality rate (ENMR), the neonatal mortality rate (NMR), and fresh stillbirth rate (FSBR) in low- and middle-income countries (LMICs). This program was implemented in five different healthcare facilities in the Oliver Reginald Tambo (ORT) District, South Africa from September 2015 to December 2020.

OBJECTIVE

To determine and compare the FSBR, ENMR, and NMR between 2015 before initiation of the program (baseline) and subsequent years up to 2020 following the implementation of facility-based training of HBB in five hospitals in ORT District.

METHODS

Records of perinatal statistics from January 2015 to December 2020 were reviewed to calculate FSBR, ENMR, and NMR. Data were collected from the five healthcare facilities which included two district hospitals (Hospital A&B), two regional hospitals (Hospital C&D), and one tertiary hospital (Hospital E). Comparisons were made between pre- (2015) and post- (2016-2020) HBB implementation periods. Differences in changes over time were also assessed using linear regression analysis.

RESULTS

There were 19,275 births in 2015, increasing to 22,192 in 2020 with the majority (55.3%) of births occurring in regional hospitals. There were significant reductions in ENMR (OR-0.78, 95% CI 0.70-0.87) and NMR (OR-0.81, 95% CI 0.73-0.90), but not in FSBR, in the five hospitals combined when comparing the two time periods. Significant reduction was also noted in trends over time in ENMR (r ² = 0.45, p = 0.001) and NMR (r ² = 0.23, p = 0.026), but not in FSBR (r ² = 0.0, p = 0.984) with all hospitals combined. In looking at individual hospitals, Hospital A (r ² = 0.61, p < 0.001) and Hospital E (r ² = 0.19, p = 0.048) showed a significant reduction in ENMR over time, but there were no significant changes in all mortality rates for Hospitals B, C, and D, and for the district or regional hospitals combined.

CONCLUSION

There was an overall reduction of 22% and 19% in ENMR and NMR, respectively, from pre- to post-HBB implementation periods, although there were variations from year to year over the 5-year period and, across hospitals. These differences suggest that there were other factors that affected the perinatal/neonatal outcomes in the hospital sites in addition to the implementation of training in HBB.

Assessing the effectiveness of newborn resuscitation training and skill retention program on neonatal outcomes in Madhesh Province, Nepal

Intrapartum events leading to asphyxia at birth are among the leading causes of neonatal morbidity and mortality in Nepal. In response to this, the Nepal Ministry of Health and Population adopted Helping Babies Breathe (HBB) as a tool to improve neonatal resuscitation competencies. The effectiveness of HBB trainings has been well established. However, challenges remain in maintaining skills over time. Safa Sunaulo Nepal (SSN), with support from Latter-day Saint Charities (LDS Charities) designed an initiative for scaling up newborn resuscitation training and skills maintenance over time. This paper reports on the implementation of the SSN model of newborn resuscitation trainings and skill retention, and the changes in perinatal outcomes that occurred after the program. The program built capacity among facility-based trainers for the scale up and maintenance of resuscitation skills in 20 facilities in Madhesh Province, Nepal. A single external Mentor coached and assisted the facility-based trainers, provided general support, and monitored progress. Prospective outcome monitoring tracked changes in health metrics for a period of 14 months. Data was gathered on the neonatal health outcomes of 68,435 vaginal deliveries and 9,253 cesarean sections. Results indicate decreases in neonatal deaths under 24 hours of life (p<0.001), intrapartum stillbirths (p<0.001), and the number of sick newborns transferred from the maternity unit (p<0.001). During the program, facility-based trainers taught resuscitation skills to 231 medical personnel and supported ongoing skill retention. The SSN model for newborn resuscitation training and skills retention is a low-cost, evidence-based program focusing on facility-based trainers who are mentored and supported to scale-up and sustain resuscitation skills over time. Findings from the report are suggestive that the model had a substantial influence on critical neonatal outcomes. Future programs focused on improving neonatal outcomes may benefit by incorporating program elements of SSN model.

Optimizing initial neonatal resuscitation to reduce neonatal encephalopathy around the world

One million two hundred thousand neonatal lives are lost each year due to intrapartum-related events; 99% of these deaths occur in low- and lower middle-income countries. Neonates exposed to intrapartum-related events present with failure to breathe at birth. Quick and effective delivery room management of these neonates is critical in the prevention of brain injury. Given the prominent role of lung aeration in the cardiopulmonary transition at birth, the mainstay of neonatal resuscitation is effective ventilation. Basic neonatal resuscitation focuses on simple stimulation, airway positioning and clearing, and bag-mask ventilation. Although principles for basic neonatal resuscitation remain the same for high- and low-resource settings, guidelines may differ based on available human and material resources. Formal training in basic resuscitation reduces intrapartum-related neonatal mortality in low-resource settings. However, there remain opportunities to improve provider performance for increased impact with other strategies such as regular practice and continuous quality improvement.

Implementation of the Helping Babies Breathe Training Program: A Systematic Review

CONTEXT

Helping Babies Breathe (HBB) is a well-established neonatal resuscitation program designed to reduce newborn mortality in low-resource settings.

OBJECTIVES

In this literature review, we aim to identify challenges, knowledge gaps, and successes associated with each stage of HBB programming.

DATA SOURCES

Databases used in the systematic search included Medline, POPLINE, Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Health Sciences Literature, African Index Medicus, Cochrane, and Index Medicus.

STUDY SELECTION

All articles related to HBB, in any language, were included. Article quality was assessed by using the Grading of Recommendations Assessment, Development, and Evaluation framework.

DATA EXTRACTION

Data were extracted if related to HBB, including its implementation, acquisition and retention of HBB knowledge and skills, changes in provider behavior and clinical care, or the impact on newborn outcomes.

RESULTS

Ninety-four articles met inclusion criteria. Barriers to HBB implementation include staff turnover and limited time or focus on training and practice. Researchers of several studies found HBB cost-effective. Posttraining decline in knowledge and skills can be prevented with low-dose high-frequency refresher trainings, on-the-job practice, or similar interventions. Impact of HBB training on provider clinical practices varies. Although not universal, researchers in multiple studies have shown a significant association of decreased perinatal mortality with HBB implementation.

LIMITATIONS

In addition to not conducting a gray literature search, articles relating only to Essential Care for Every Baby or Essential Care for Small Babies were not included in this review.

CONCLUSIONS

Key challenges and requirements for success associated with each stage of HBB programming were identified. Despite challenges in obtaining neonatal mortality data, the program is widely believed to improve neonatal outcomes in resource-limited settings.