Does the Helping Babies Breathe Programme impact on neonatal resuscitation care practices? Results from systematic review and meta-analysis

Stakeholders' Perspectives on the "Helping Babies Breathe" Program Situation in Nepal Following the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic impacted healthcare systems, including resuscitation training programs such as Helping Babies Breathe (HBB). Nepal, a country with limited healthcare resources, faces challenges in delivering effective HBB training, managing deliveries, and providing neonatal care, particularly in remote areas.

AIMS

This study assessed HBB skills and knowledge postpandemic through interviews with key stakeholders in Nepal. It aimed to identify strategies, adaptations, and innovations to address training gaps and scale-up HBB.

METHODS

A qualitative approach was used, employing semistructured interviews about HBB program effectiveness, pandemic challenges, stakeholder engagement, and suggestions for improvement.

RESULTS

The study encompassed interviews with 23 participants, including HBB trainers, birth attendants, officials, and providers. Thematic analysis employed a systematic approach by deducing themes from study aims and theory. Data underwent iterative coding and refinement to synthesize content yielding following 5 themes: (1) pandemic's impact on HBB training; (2) resource accessibility for training postpandemic; (3) reviving HBB training; (4) impacts on the neonatal workforce; and (5) elements influencing HBB training progress.

CONCLUSION

Postpandemic, healthcare workers in Nepal encounter challenges accessing essential resources and delivering HBB training, especially in remote areas. Adequate budgeting and strong commitment from healthcare policy levels are essential to reduce neonatal mortality in the future.

Delayed and Interrupted Ventilation with Excess Suctioning after Helping Babies Breathe with Congolese Birth Attendants

There is a substantial gap in our understanding of resuscitation practices following Helping Babies Breathe (HBB) training. We sought to address this gap through an analysis of observed resuscitations following HBB 2nd edition training in the Democratic Republic of the Congo. This is a secondary analysis of a clinical trial evaluating the effect of resuscitation training and electronic heart rate monitoring on stillbirths. We included in-born, liveborn neonates ≥28 weeks gestation whose resuscitation care was directly observed and documented. For the 2592 births observed, providers dried/stimulated before suctioning in 97% of cases and suctioned before ventilating in 100%. Only 19.7% of newborns not breathing well by 60 s (s) after birth ever received ventilation. Providers initiated ventilation at a median 347 s (>five minutes) after birth; no cases were initiated within the Golden Minute. During 81 resuscitations involving ventilation, stimulation and suction both delayed and interrupted ventilation with a median 132 s spent drying/stimulating and 98 s suctioning. This study demonstrates that HBB-trained providers followed the correct order of resuscitation steps. Providers frequently failed to initiate ventilation. When ventilation was initiated, it was delayed and interrupted by stimulation and suctioning. Innovative strategies targeting early and continuous ventilation are needed to maximize the impact of HBB.

Newborn resuscitation simulation training and changes in clinical performance and perinatal outcomes: a clinical observational study of 10,481 births

BACKGROUND

Annually, 1.5 million intrapartum-related deaths occur; fresh stillbirths and early newborn deaths. Most of these deaths are preventable with skilled ventilation starting within the first minute of life. Helping Babies Breathe is an educational program shown to improve simulated skills in newborn resuscitation. However, translation into clinical practice remains a challenge. The aim was to describe changes in clinical resuscitation and perinatal outcomes (i.e., fresh stillbirths and 24-h newborn deaths) after introducing a novel simulator (phase 1) and then local champions (phase 2) to facilitate ongoing Helping Babies Breathe skill and scenario simulation training.

METHODS

This is a 3-year prospective before/after (2 phases) clinical observational study in Tanzania. Research assistants observed all deliveries from September 2015 through August 2018 and recorded labor/newborn information and perinatal outcomes. A novel simulator with automatic feedback to stimulate self-guided skill training was introduced in September 2016. Local champions were introduced in October 2017 to motivate midwives for weekly training, also team simulations.

RESULTS

The study included 10,481 births. Midwives had practiced self-guided skill training during the last week prior to a real newborn resuscitation in 34% of cases during baseline, 30% in phase 1, and 71% in phase 2. Most real resuscitations were provided by midwives, increasing from 66% in the baseline, to 77% in phase 1, and further to 83% in phase 2. The median time from birth to first ventilation decreased between baseline and phase 2 from 118 (85-165) to 101 (72-150) s, and time pauses during ventilation decreased from 28 to 16%. Ventilations initiated within the first minute did not change significantly (13-16%). The proportion of high-risk deliveries increased during the study period, while perinatal mortality remained unchanged.

CONCLUSIONS

This study reports a gradual improvement in real newborn resuscitation skills after introducing a novel simulator and then local champions. The frequency of trainings increased first after the introduction of motivating champions. Time from birth to first ventilation decreased; still, merely 16% of newborns received ventilation within the first minute as recommended. This is a remaining challenge that may require more targeted team-scenario training and quality improvement efforts to improve.

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.

Peer Learning and Mentorship for Neonatal Management Skills: A Cluster-Randomized Trial

BACKGROUND

Clinical knowledge and skills acquired during training programs like Helping Babies Breathe (HBB) and Essential Care for Every Baby (ECEB) decay within weeks or months. We assessed the effect of a peer learning intervention paired with mentorship on retention of HBB and ECEB skills, knowledge, and teamwork in 5 districts of Uganda.

METHODS

We randomized participants from 36 Ugandan health centers to control and intervention arms. Intervention participants received HBB and ECEB training, a 1 day peer learning course, peer practice scenarios for facility-based practice, and mentorship visits at 2 to 3 and 6 to 7 months. Control arm participants received HBB and ECEB training alone. We assessed clinical skills, knowledge, and teamwork immediately before and after HBB/ECEB training and at 12 months.

RESULTS

Peer learning (intervention) participants demonstrated higher HBB and ECEB skills scores at 12 months compared with control (HBB: intervention, 57.9%, control, 48.5%, P = .007; ECEB: intervention, 61.7%, control, 49.9%, P = .004). Knowledge scores decayed in both arms (intervention after course 91.1%, at 12 months 84%, P = .0001; control after course 90.9%, at 12 months 82.9%, P = .0001). This decay at 12 months was not significantly different (intervention 84%, control 82.9%, P = .24). Teamwork skills were similar in both arms immediately after training and at 12 months (intervention after course 72.9%, control after course 67.2%, P = .02; intervention at 12 months 70.7%, control at 12 months 67.9%, P = .19).

CONCLUSIONS

A peer learning intervention resulted in improved HBB and ECEB skills retention after 12 months compared with HBB and ECEB training alone.

The effect of neonatal resuscitation training based on a serious game simulation method on nursing students' knowledge, skills, satisfaction and self-confidence levels: A randomized controlled trial

BACKGROUND

Although students are well prepared theoretically, they lack real-life practical skills because they have not faced an adequate number of emergencies such as neonatal resuscitation.

OBJECTIVES

This study was conducted with the objective of determining the impact of integrating serious game simulation (SGS) into neonatal resuscitation training on the neonatal resuscitation related knowledge, skills, satisfaction with training, and self confidence in learning of nursing students.

DESIGN

The study is a randomized controlled, pre-test post-test design and single-blind study.

SETTINGS AND PARTICIPANTS

This study was conducted on 90 undergraduate nursing students (SGS based training group = 45, control group = 45) enrolled in the fifth semester at the Faculty of Nursing.

METHODS

The students were allocated with simple randomization method to intervention and control groups. The training program prepared on the basis of neonatal resuscitation algorithm used a neonatal resuscitation serious game simulation method. At the same time, the serious game simulation method was used as a pre-test and post-test skill assessment tool. Support was obtained from a statistician in evaluation of the data and the data were analyzed using the SPSS (Statistical Package for Social Sciences) for Windows 25.0 program.

RESULTS

Post-test measurements indicated a statistically significant positive difference in the ventilation and chest compression performing skills of the intervention group compared to the control group (p = .011, p = .020, respectively). A considerable increase was found in the knowledge and skills level of both groups, after the neonatal resuscitation training (p < .05). The score averages of the Student Satisfaction and Self-Confidence in Learning Scale and its sub-dimensions were high for both groups.

CONCLUSIONS

It was concluded that the serious game simulation application used in neonatal resuscitation training was effective in raising the students' ventilation and compression performing skills.

Silent voices of the midwives: factors that influence midwives' achievement of successful neonatal resuscitation in sub-Saharan Africa: a narrative inquiry

BACKGROUND

In Tanzania, birth asphyxia is a leading cause of neonatal death. The aim of this study was to identify factors that influence successful neonatal resuscitation to inform clinical practice and reduce the incidence of very early neonatal death (death within 24 h of delivery).

METHODS

This was a qualitative narrative inquiry study utilizing the 32 consolidated criteria for reporting qualitative research (COREQ). Audio-recorded, semistructured, individual interviews with midwives were conducted. Thematic analysis was applied to identify themes.

RESULTS

Thematic analysis of the midwives' responses revealed three factors that influence successful resuscitation: 1. Hands-on training ("HOT") with clinical support during live emergency neonatal resuscitation events, which decreases fear and enables the transfer of clinical skills; 2. Unequivocal commitment to the Golden Minute® and the mindset of the midwife; and. 3. Strategies that reduce barriers. Immediately after birth, live resuscitation can commence at the mother's bedside, with actively guided clinical instruction. Confidence and mastery of resuscitation competencies are reinforced as the physiological changes in neonates are immediately visible with bag and mask ventilation. The proclivity to perform suction initially delays ventilation, and suction is rarely clinically indicated. Keeping skilled midwives in labor wards is important and impacts clinical practice. The midwives interviewed articulated a mindset of unequivocal commitment to the baby for one Golden Minute®. Heavy workload, frequent staff rotation and lack of clean working equipment were other barriers identified that are worthy of future research.

CONCLUSIONS

Training in resuscitation skills in a simulated environment alone is not enough to change clinical practice. Active guidance of "HOT" real-life emergency resuscitation events builds confidence, as the visible signs of successful resuscitation impact the midwife's beliefs and behaviors. Furthermore, a focused commitment by midwives working together to reduce birth asphyxia-related deaths builds hope and collective self-efficacy.

What Helping Babies Breathe knowledge and skills are formidable for healthcare workers?

INTRODUCTION

Most neonatal deaths occur in the first week of life, due to birth asphyxia. Helping Babies Breathe (HBB), is a simulation-based neonatal resuscitation training program to improve knowledge and skills. There is little information on which knowledge items or skill steps are challenging for the learners.

METHODS

We used training data from NICHD's Global Network study to understand the items most challenging for Birth Attendants (BA) to guide future curriculum modifications. HBB training was provided in 15 primary, secondary and tertiary level care facilities in Nagpur, India. Refresher training was provided 6 months later. Each knowledge item and skill step was ranked from difficulty level 1 to 6 based on whether 91%-100%, 81%-90%, 71%-80%, 61%-70%, 51%-60% or <50% of learners answered/performed the step correctly.

RESULTS

The initial HBB training was conducted in 272 physicians and 516 midwives of which 78 (28%) physicians and 161 (31%) midwives received refresher training. Questions related to timing of cord clamping, management of a meconium-stained baby, and steps to improve ventilation were most difficult for both physicians and midwives. The initial steps of Objective Structured Clinical Examination (OSCE)-A i.e. equipment checking, removing wet linen and immediate skin-to-skin contact were most difficult for both groups. Midwives missed stimulating newborns while physicians missed cord clamping and communicating with mother. In OSCE-B, starting ventilation in the first minute of life was the most missed step after both initial and 6 months refresher training for physicians and midwives. At the retraining, the retention was worst for cutting the cord (physicians level 3), optimal rate of ventilation, improving ventilation & counting heart rate (midwives level 3), calling for help (both groups level 3) and scenario ending step of monitoring the baby and communicating with mother (physicians level 4, midwives 3).

CONCLUSION

All BAs found skill testing more difficult than knowledge testing. The difficulty level was more for midwives than for physicians. So, the HBB training duration and frequency of retraining can be tailored accordingly. This study will also inform subsequent refinement in the curriculum so that both trainers and trainees will be able to achieve the required proficiency.

Simulation in neonatal care: towards a change in traditional training?

Simulation has traditionally been used in neonatal medicine for educational purposes which include training of novice learners, maintaining competency of health care providers, and training of multidisciplinary teams to handle crisis situations such as neonatal resuscitation. Current guidelines recommend the use of simulation as an education tool in neonatal practice. The place of simulation-based education has gradually expanded, including in limited resource settings, and is starting to show its impact on improving patient outcomes on a global basis. Over the past years, simulation has become a cornerstone in clinical settings with the goal of establishing high quality, safe, reliable systems. The aim of this review is to describe neonatal simulation training as an effective tool to improve quality of care and patient outcomes, and to encourage the use of simulation-based training in the neonatal intensive care unit (NICU) for not only education, but equally for team building, risk management and quality improvement.

CONCLUSION

Simulation is a promising tool to improve patient safety, team performance, and ultimately patient outcomes, but scarcity of data on clinically relevant outcomes makes it difficult to estimate its real impact. The integration of simulation into the clinical reality with a goal of establishing high quality, safe, reliable, and robust systems to improve patient safety and patient outcomes in neonatology must be a priority.

WHAT IS KNOWN

• Simulation-based education has traditionally focused on procedural and technical skills. • Simulation-based training is effective in teaching non-technical skills such as communication, leadership, and teamwork, and is recommended in neonatal resuscitation.

WHAT IS NEW

• There is emerging evidence for the impact of simulation-based training on patient outcomes in neonatal care, but data on clinically relevant outcomes are scarce. • Simulation is a promising tool for establishing high quality, safe, reliable, and robust systems to improve patient safety and patient outcomes.

A Randomised Controlled Study of Low-Dose High-Frequency In-Situ Simulation Training to Improve Newborn Resuscitation

Positive pressure ventilation of the non-breathing newborn is a critical and time-sensitive intervention, considered to be the cornerstone of resuscitation. Many healthcare providers working in delivery units in high-resource settings have little opportunity to practise this skill in real life, affecting their performance when called upon to resuscitate a newborn. Low-dose, high-frequency simulation training has shown promise in low-resource settings, improving ventilation performance and changing practice in the clinical situation. We performed a randomised controlled study of low-dose, high-frequency simulation training for maintenance of ventilation competence in a multidisciplinary staff in a busy teaching hospital in Norway. We hypothesised that participants training according to a low-dose, high-frequency protocol would perform better than those training as they wished. Our results did not support this, although the majority of protocol participants were unable to achieve training targets. Subgroup analysis comparing no training to at least monthly training did identify a clear benefit to regular simulation practice. Simulated ventilation competence improved significantly for all participants over the course of the study. We conclude that frequent, short, simulation-based training can foster and maintain newborn ventilation skills in a multidisciplinary delivery unit staff in a high-resource setting.

High-Frequency, Low-Dose Education to Improve Neonatal Outcomes in Low-Resource Settings: A Cluster Randomized Controlled Trial

BACKGROUND

Annually 2.5 million infants die in the first 28 days of life, with a significant regional distribution disparity. An estimated 80% of those could be saved if neonatal resuscitation were correctly and promptly initiated. A barrier to achieving the target is the knowledge and skills of healthcare workers.

PURPOSE

The objective of this cluster randomized trial was to assess the improvement and retention of resuscitation skills of nurses, midwives, and birth attendants in 2 birth centers serving 60 villages in rural India using high-frequency, low-dose training.

RESULTS

There was a significant difference (P < .05) between the groups in the rate of resuscitation, with 18% needing resuscitation in the control group and 6% in the intervention group. The posttest scores for knowledge retention at the final 8-month evaluation were significantly better in the intervention group than in the control group (intervention group mean rank 19.4 vs control group mean rank 10.3; P < .05). The success rate of resuscitation was not significantly different among the groups.

IMPLICATIONS FOR PRACTICE

Improved knowledge retention at 8 months and the lower need for resuscitation in the intervention group support the efficacy of the high-frequency, low-dose education model of teaching in this setting.

IMPLICATIONS FOR RESEARCH

Replication of these findings in other settings with a larger population cohort is needed to study the impact of such intervention on birth outcomes in low-resource settings.

Analysis of maternal and newborn training curricula and approaches to inform future trainings for routine care, basic and comprehensive emergency obstetric and newborn care in the low- and middle-income countries: Lessons from Ethiopia and Nepal

Program managers routinely design and implement specialised maternal and newborn health trainings for health workers in low- and middle-income countries to provide better-coordinated care across the continuum of care. However, in these countries details on the availability of different training packages, skills covered in those training packages and the gaps in their implementation are patchy. This paper presents an assessment of maternal and newborn health training packages to describe differences in training contents and implementation approaches used for a range of training packages in Ethiopia and Nepal. We conducted a mixed-methods study. The quantitative assessment was conducted using a comprehensive assessment questionnaire based on validated WHO guidelines and developed jointly with global maternal and newborn health experts. The qualitative assessment was conducted through key informant interviews with national stakeholders involved in implementing these training packages and working with the Ministries of Health in both countries. Our quantitative analysis revealed several key gaps in the technical content of maternal and newborn health training packages in both countries. Our qualitative results from key informant interviews provided additional insights by highlighting several issues with trainings related to quality, skill retention, logistics, and management. Taken together, our findings suggest four key areas of improvement: first, training materials should be updated based on the content gaps identified and should be aligned with each other. Second, trainings should address actual health worker performance gaps using a variety of innovative approaches such as blended and self-directed learning. Third, post-training supervision and ongoing mentoring need to be strengthened. Lastly, functional training information systems are required to support planning efforts in both countries.

Evaluating the implementation of helping babies survive program to improve newborn care conditiona

BACKGROUND

The main reason of newborn mortalities in low- and middle-income countries is due to the lack of skilled caregivers in providing essential care for babies. The aim of the present study was to evaluate the implementation of helping babies survive (HBS) program to improve newborn care condition in Isfahan, Iran.

MATERIALS AND METHODS

This quasi-experimental study was conducted in the labor and midwifery wards of Shahid Beheshti Hospital in Isfahan. Convenience sampling method was used for all healthy newborns who weighed >1500 g. First, the samples were selected for the control group. Then, the Helping Babies Breathe and Essential Care for Every Baby training courses were held over for ward nurses and midwives. Then, the samples of the intervention group were selected. The research tools consisted of demographic characteristic questionnaire, caregiver performance evaluation checklist, and breastfeeding registration checklist. SPSS software version 16 was used for data analysis.

RESULTS

A total of 130 newborns were divided into control (n = 65) and intervention groups (n = 65). The average time of umbilical cord clamping increased from 13.85 to 61.48 s, and the average duration of skin-to-skin contact between mother and baby increased from 11.75 to 60.47 min. The mean of early initiation of breastfeeding improved during the 1^st h and the 1^st day of the birth. The rate of neonatal hypothermia in the intervention group decreased sharply.

CONCLUSION

The implementation of the HBS program can positively impact newborn care condition.

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.

C. A, Wrammert J, Brunell O, Basnet O, Malqvist M. Effect of a scaled-up quality improvement intervention on health workers' competence on neonatal resuscitation in simulated settings in public hospitals: A pre-post study in Nepal

Background

Helping Babies Breathe (HBB) training improves bag and mask ventilation and reduces neonatal mortality and fresh stillbirths. Quality improvement (QI) interventions can improve retention of neonatal resuscitation knowledge and skills. This study aimed to evaluate the effect of a scaled-up QI intervention package on uptake and retention of neonatal resuscitation knowledge and skills in simulated settings.

Methods

This was a pre-post study in 12 public hospitals of Nepal. Knowledge and skills of trainees on neonatal resuscitation were evaluated against the set standard before and after the introduction of QI interventions.

Results

Altogether 380 participants were included for knowledge evaluation and 286 for skill evaluation. The overall knowledge test score increased from 14.12 (pre-basic) to 15.91 (post-basic) during basic training (p < 0.001). The knowledge score decreased over time; 15.91 (post-basic) vs. 15.33 (pre-refresher) (p < 0.001). Overall skill score during basic training (16.98 ± 1.79) deteriorated over time to 16.44 ± 1.99 during refresher training (p < 0.001). The proportion of trainees passing the knowledge test increased to 91.1% (post-basic) from 67.9% (pre-basic) which decreased to 86.6% during refresher training after six months. The knowledge and skill scores were maintained above the set standard (>14.0) over time at all hospitals during refresher training.

Conclusion

HBB training together with QI tools improves health workers’ knowledge and skills on neonatal resuscitation, irrespective of size and type of hospitals. The knowledge and skills deteriorate over time but do not fall below the standard. The HBB training together with QI interventions can be scaled up in other public hospitals.

Trial registration

This study was part of the larger Nepal Perinatal Quality Improvement Project (NePeriQIP) with International Standard Randomised Controlled Trial Number, ISRCTN30829654, registered 17^th of May, 2017.

Performance of health workers on neonatal resuscitation care following scaled-up quality improvement interventions in public hospitals of Nepal - a prospective observational study

BACKGROUND

High-quality resuscitation among non-crying babies immediately after birth can reduce intrapartum-related deaths and morbidity. Helping Babies Breathe program aims to improve performance on neonatal resuscitation care in resource-limited settings. Quality improvement (QI) interventions can sustain simulated neonatal resuscitation knowledge and skills and clinical performance. This study aimed to evaluate the effect of a scaled-up QI intervention package on the performance of health workers on basic neonatal resuscitation care among non-crying infants in public hospitals in Nepal.

METHODS

A prospective observational cohort design was applied in four public hospitals of Nepal. Performances of health workers on basic neonatal care were analysed before and after the introduction of the QI interventions.

RESULTS

Out of the total 32,524 births observed during the study period, 3031 newborn infants were not crying at birth. A lower proportion of non-crying infants were given additional stimulation during the intervention compared to control (aOR 0.18; 95% CI 0.13-0.26). The proportion of clearing the airway increased among non-crying infants after the introduction of QI interventions (aOR 1.23; 95% CI 1.03-1.46). The proportion of non-crying infants who were initiated on BMV was higher during the intervention period (aOR 1.28, 95% CI 1.04-1.57) compared to control. The cumulative median time to initiate ventilation during the intervention was 39.46 s less compared to the baseline.

CONCLUSION

QI intervention package improved health workers' performance on the initiation of BMV, and clearing the airway. The average time to first ventilation decreased after the implementation of the package. The QI package can be scaled-up in other public hospitals in Nepal and other similar settings.

Implementation of a contextually appropriate pediatric emergency surgical care course in Uganda

BACKGROUND

Low- and middle-income countries like Uganda face a severe shortage of pediatric surgeons. Most children with a surgical emergency are treated by nonspecialist rural providers. We describe the design and implementation of a locally driven, pilot pediatric emergency surgical care course to strengthen skills of these providers. This is the first description of such a course in the current literature.

METHODS

The course was delivered three times from 2018 to 2019. Modules include perioperative management, neonatal emergencies, intestinal emergencies, and trauma. A baseline needs assessment survey was administered. Participants in the second and third courses also took pre and postcourse knowledge-based tests.

RESULTS

Forty-five providers representing multiple cadres participated. Participants most commonly perform hernia/hydrocele repair (17% adjusted rating) in their current practice and are least comfortable managing cleft lip and palate (mean Likert score 1.4 ± 0.9). Equipment shortage was identified as the most significant challenge to delivering pediatric surgical care (24%). Scores on the knowledge tests improved significantly from pre- (55.4% ± 22.4%) to postcourse (71.9% ± 14.0%, p < 0.0001).

CONCLUSION

Nonspecialist clinicians are essential to the pediatric surgical workforce in LMICs. Short, targeted training courses can increase provider knowledge about the management of surgical emergencies. The course has spurred local surgical outreach initiatives. Further implementation studies are needed to evaluate the impact of the training.

LEVEL OF EVIDENCE

V.

Neonatal resuscitation: EN-BIRTH multi-country validation study

BACKGROUND

Annually, 14 million newborns require stimulation to initiate breathing at birth and 6 million require bag-mask-ventilation (BMV). Many countries have invested in facility-based neonatal resuscitation equipment and training. However, there is no consistent tracking for neonatal resuscitation coverage.

METHODS

The EN-BIRTH study, in five hospitals in Bangladesh, Nepal, and Tanzania (2017-2018), collected time-stamped data for care around birth, including neonatal resuscitation. Researchers surveyed women and extracted data from routine labour ward registers. To assess accuracy, we compared gold standard observed coverage to survey-reported and register-recorded coverage, using absolute difference, validity ratios, and individual-level validation metrics (sensitivity, specificity, percent agreement). We analysed two resuscitation numerators (stimulation, BMV) and three denominators (live births and fresh stillbirths, non-crying, non-breathing). We also examined timeliness of BMV. Qualitative data were collected from health workers and data collectors regarding barriers and enablers to routine recording of resuscitation.

RESULTS

Among 22,752 observed births, 5330 (23.4%) babies did not cry and 3860 (17.0%) did not breathe in the first minute after birth. 16.2% (n = 3688) of babies were stimulated and 4.4% (n = 998) received BMV. Survey-report underestimated coverage of stimulation and BMV. Four of five labour ward registers captured resuscitation numerators. Stimulation had variable accuracy (sensitivity 7.5-40.8%, specificity 66.8-99.5%), BMV accuracy was higher (sensitivity 12.4-48.4%, specificity > 93%), with small absolute differences between observed and recorded BMV. Accuracy did not vary by denominator option. < 1% of BMV was initiated within 1 min of birth. Enablers to register recording included training and data use while barriers included register design, documentation burden, and time pressure.

CONCLUSIONS

Population-based surveys are unlikely to be useful for measuring resuscitation coverage given low validity of exit-survey report. Routine labour ward registers have potential to accurately capture BMV as the numerator. Measuring the true denominator for clinical need is complex; newborns may require BMV if breathing ineffectively or experiencing apnoea after initial drying/stimulation or subsequently at any time. Further denominator research is required to evaluate non-crying as a potential alternative in the context of respectful care. Measuring quality gaps, notably timely provision of resuscitation, is crucial for programme improvement and impact, but unlikely to be feasible in routine systems, requiring audits and special studies.

Simulation for intrapartum care: from training to novel device innovation

Improving maternal and perinatal care is a global priority. Simulation training and novel applications of simulation for intrapartum care may help to reduce preventable deaths worldwide. Evaluation studies have published details of the effectiveness of simulation training for obstetric emergencies, exploring clinical and non-clinical factors as well as the impact on patient outcomes (both maternal and neonatal). This review summarized the many uses of simulation in obstetric emergencies from training to assessment. It also described the adaption of training in low-resource settings and the evidence behind the equipment recommended to support simulation training. The review also discussed novel applications for simulation such as its use in the development of a new device for assisted vaginal birth and its potential role in Cesarean section training. This study analyzed the financial implications of simulation training and how this may impact the delivery of such training packages, considering that simulation should be developed and utilized as a key tool in the development of safe intrapartum care in both emergency and non-emergency settings, in innovation and product development.

Identifying the know-do gap in evidence-based neonatal care practices among informal health care providers-a cross-sectional study from Ujjain, India

Background

More than a quarter of global neonatal deaths are reported from India, and a large proportion of these deaths are preventable. However, in the absence of robust public health care systems in several states in India, informal health care providers (IHCPs) with no formal medical education are the first contact service providers. The aim of this study was to assess the knowledge of IHCPs in basic evidence-based practices in neonatal care in Ujjain district and investigated factors associated with differences in levels of knowledge.

Methods

A cross-sectional survey was conducted using a questionnaire with multiple-choice questions covering the basic elements of neonatal care. The total score of the IHCPs was calculated. Multivariate quantile regression model was used to look for association of IHCPs knowledge score with: the practitioners’ age, years of experience, number of patients treated per day, and whether they attended children in their practice.

Results

Of the 945 IHCPs approached, 830 (88%) participated in the study. The mean ± SD score achieved was 22.3 ± 7.7, with a median score of 21 out of maximum score of 48. Although IHCPs could identify key tenets of enhancing survival chances of neonates, they scored low on the specifics of cord care, breastfeeding, vitamin K use to prevent neonatal hemorrhage, and identification and care of low-birth-weight babies. The practitioners particularly lacked knowledge about neonatal resuscitation, and only a small proportion reported following up on immunizations. Results of quantile regression analysis showed that more than 5 years of practice experience and treating more than 20 patients per day had a statistically significant positive association with the knowledge score at higher quantiles (q75^th and q90th) only. IHCPs treating children had significantly better scores across quantiles accept at the highest quantile (90^th).

Conclusions

The present study highlighted that know-do gap exists in evidence-based practices for all key areas of neonatal care tested among the IHCPs. The study provides the evidence that some IHCPs do possess knowledge in basic evidence-based practices in neonatal care, which could be built upon by future educational interventions. Targeting IHCPs can be an innovative way to reach a large rural population in the study setting and to improve neonatal care services.

Increased perinatal survival and improved ventilation skills over a five-year period: An observational study

Background and aim

The Helping Babies Breathe program gave major reductions in perinatal mortality in Tanzania from 2009 to 2012. We aimed to study whether this effect was sustained, and whether resuscitation skills changed with continued frequent training.

Methods

We analysed prospective data covering all births (n = 19,571) at Haydom Lutheran Hospital in Tanzania from July 2013 –June 2018. Resuscitation training was continued during this period. All deliveries were monitored by an observer recording the timing of events and resuscitation interventions. Heart rate was recorded by dry-electrode ECG and bag-mask-ventilation by sensors attached to the resuscitator device. We analyzed changes over time in outcomes, use of resuscitation interventions and performance of resuscitation using binary regression models with the log-link function to obtain adjusted relative risks.

Results

With introduction of user fees for deliveries since 2014, the number of deliveries decreased by 30% from start to the end of the five-year period. An increase in low heart rate at birth and need for bag-mask-ventilation indicate a gradual selection of more vulnerable newborns delivered in the hospital over time.

Despite this selection, newborn deaths <24 hours did not change significantly and was maintained at an average of 8.8/1000 live births. The annual reductions in relative risk for perinatal death adjusted for vulnerability factors was 0.84 (95%CI 0.76–0.94).

During the five-year period, longer duration of bag-mask ventilation sequences without interruption was observed. Delivered tidal volumes were increased and mask leak was decreased during ventilation. The time to initiation or total duration of ventilation did not change significantly.

Conclusion

The reduction in 24-hour newborn mortality after introduction of Helping Babies Breathe was maintained, and a further decrease over the five-year period was evident when analyses were adjusted for vulnerability of the newborns. Perinatal survival and performance of ventilation were significantly improved.

A Short History of Helping Babies Breathe: Why and How, Then and Now

Helping Babies Breathe (HBB) changed global education in neonatal resuscitation. Although rooted in the technical and educational expertise underpinning the American Academy of Pediatrics' Neonatal Resuscitation Program, a series of global collaborations and pivotal encounters shaped the program differently. An innovative neonatal simulator, graphic learning materials, and content tailored to address the major causes of neonatal death in low- and middle-income countries empowered providers to take action to help infants in their facilities. Strategic dissemination and implementation through a Global Development Alliance spread the program rapidly, but perhaps the greatest factor in its success was the enthusiasm of participants who experienced the power of being able to improve the outcome of babies. Collaboration continued with frontline users, implementing organizations, researchers, and global health leaders to improve the effectiveness of the program. The second edition of HBB not only incorporated new science but also the accumulated understanding of how to help providers retain and build skills and use quality improvement techniques. Although the implementation of HBB has resulted in significant decreases in fresh stillbirth and early neonatal mortality, the goal of having a skilled and equipped provider at every birth remains to be achieved. Continued collaboration and the leadership of empowered health care providers within their own countries will bring the world closer to this goal.

Achieving Country-Wide Scale for Helping Babies Breathe and Helping Babies Survive

Helping Babies Breathe (HBB) was piloted in 2009 as a program targeted to reduce neonatal mortality (NM). The program has morphed into a suite of programs termed Helping Babies Survive that includes Essential Care for Every Baby. Since 2010, the HBB and Helping Babies Survive training programs have been taught to >850 000 providers in 80 countries. Initial HBB training is associated with a significant improvement in knowledge and skills. However, at refresher training, there is a knowledge-skill gap evident, with a falloff in skills. Accumulating evidence supports the role for frequent refresher resuscitation training in facilitating skills retention. Beyond skill acquisition, HBB has been associated with a significant reduction in early NM (<24 hours) and fresh stillbirth rates. To evaluate the large-scale impact of the growth of skilled birth attendants, we analyzed NM rates in sub-Saharan Africa (n = 11) and Nepal (as areas of growing HBB implementation). All have revealed a consistent reduction in NM at 28 days between 2009 and 2018; a mean reduction of 5.34%. The number of skilled birth attendants, an indirect measure of HBB sustained rollout, reveals significant correlation with NM, fresh stillbirth, and perinatal mortality rates, highlighting HBB's success and the need for continued efforts to train frontline providers. A novel live newborn resuscitation trainer as well as a novel app (HBB Prompt) have been developed, increasing knowledge and skills while providing simulation-based repeated practice. Ongoing challenges in sustaining resources (financial and other) for newborn programming emphasize the need for innovative implementation strategies and training tools.

Development and Impact of Helping Babies Breathe Educational Methodology

The educational pedagogy surrounding Helping Babies Breathe (HBB) has been transformative in going beyond a curriculum focused only on basic neonatal resuscitation; indeed, it created the framework for an educational program that has served as a model for replication for other impactful programs, such as the Helping Mothers Survive and other Helping Babies Survive curricula. The tenets of HBB include incorporation of innovative learning strategies such as small group discussion, skills-based learning, simulation and debriefing, and peer-to-peer learning, all of which begin the hard work of changing behaviors that may eventually affect health care systems. Allowing for adaptation for local resources and culture, HBB has catalyzed innovation in the development of simplified, pictorial educational materials, in addition to low-tech yet realistic simulators and adjunct devices that have played an important role in empowering health care professionals in their care of newborns, thereby improving outcomes. In this review, we describe the development of HBB as an educational program, the importance of field testing and input from multiple stakeholders including frontline workers, the strategies behind the components of educational materials, and the impact of its pedagogy on learning.

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.

Novel modified Peyton's approach for knowledge retention on newborn life support training in medical students

AIM

We sought to improve retention of neonatal resuscitation skills by modifying step 3 through additional functional verbalisation in Peyton's four-step approach (P4S).

METHODS

Newborn life support (NLS) training was performed in a simulation-based setting. In contrast to the traditional approach, students taught with the modified approach were requested to explain every step of their performance in Peyton's step 3. A total of 123 students were allocated into both experimental groups. Students were then assessed by megacode on day four (initial assessment) and 6 months (follow-up assessment).

RESULTS

Both groups showed similar scorings in the initial, follow-up assessment and in mean change. On initial megacode, time to start with initial inflation and post-resuscitation care was significantly faster in the control group. All showed a significant loss of performance irrespective of modification in step 3 in the follow-up assessment. Only time until start with post-resuscitation care shows a significant group difference in mean change between initial and follow-up with increasing time in the control and decreasing time span in intervention group.

CONCLUSION

Both methods showed equal levels of knowledge acquisition and long-term decline in NLS performances. Verbalisation in step 3 influenced speed of applied NLS performance.

Not Crying After Birth as a Predictor of Not Breathing

BACKGROUND

Worldwide, every year, 6 to 10 million infants require resuscitation at birth according to estimates based on limited data regarding "nonbreathing" infants. In this article, we aim to describe the incidence of "noncrying" and nonbreathing infants after birth, the need for basic resuscitation with bag-and-mask ventilation, and death before discharge.

METHODS

We conducted an observational study of 19 977 infants in 4 hospitals in Nepal. We analyzed the incidence of noncrying or nonbreathing infants after birth. The sensitivity of noncrying infants with nonbreathing after birth was analyzed, and the risk of predischarge mortality between the 2 groups was calculated.

RESULTS

The incidence of noncrying infants immediately after birth was 11.1%, and the incidence of noncrying and nonbreathing infants was 5.2%. Noncrying after birth had 100% sensitivity for nonbreathing infants after birth. Among the "noncrying but breathing" infants, 9.5% of infants did not breathe at 1 minute and 2% did not to breathe at 5 minutes. Noncrying but breathing infants after birth had almost 12-fold odds of predischarge mortality (adjusted odds ratio 12.3; 95% confidence interval, 5.8-26.1).

CONCLUSIONS

All nonbreathing infants after birth do not cry at birth. A proportion of noncrying but breathing infants at birth are not breathing by 1 and 5 minutes and have a risk for predischarge mortality. With this study, we provide evidence of an association between noncrying and nonbreathing. This study revealed that noncrying but breathing infants require additional care. We suggest noncrying as a clinical sign for initiating resuscitation and a possible denominator for measuring coverage of resuscitation.

Community-based in situ simulation: bringing simulation to the masses

Simulation-based methods are regularly used to train inter-professional groups of healthcare providers at academic medical centers (AMC). These techniques are used less frequently in community hospitals. Bringing in-situ simulation (ISS) from AMCs to community sites is an approach that holds promise for addressing this disparity. This type of programming allows academic center faculty to freely share their expertise with community site providers. By creating meaningful partnerships community-based ISS facilitates the communication of best practices, distribution of up to date policies, and education/training. It also provides an opportunity for system testing at the community sites. In this article, we illustrate the process of implementing an outreach ISS program at community sites by presenting four exemplar programs. Using these exemplars as a springboard for discussion, we outline key lessons learned discuss barriers we encountered, and provide a framework that can be used to create similar simulation programs and partnerships. It is our hope that this discussion will serve as a foundation for those wishing to implement community-based, outreach ISS.

Effect of a scaled-up neonatal resuscitation quality improvement package on intrapartum-related mortality in Nepal: A stepped-wedge cluster randomized controlled trial

BACKGROUND

Improving quality of intrapartum care will reduce intrapartum stillbirth and neonatal mortality, especially in resource-poor settings. Basic neonatal resuscitation can reduce intrapartum stillbirth and early neonatal mortality, if delivered in a high-quality health system, but there is a dearth of evidence on how to scale up such evidence-based interventions. We evaluated the scaling up of a quality improvement (QI) package for neonatal resuscitation on intrapartum-related mortality (intrapartum stillbirth and first day mortality) at hospitals in Nepal.

METHODS AND FINDINGS

We conducted a stepped-wedge cluster randomized controlled trial in 12 hospitals over a period of 18 months from April 14, 2017, to October 17, 2018. The hospitals were assigned to one of four wedges through random allocation. The QI package was implemented in a stepped-wedge manner with a delay of three months for each step. The QI package included improving hospital leadership on intrapartum care, building health workers' competency on neonatal resuscitation, and continuous facilitated QI processes in clinical units. An independent data collection system was set up at each hospital to gather data on mortality through patient case note review and demographic characteristics of women using semi-structured exit interviews. The generalized linear mixed model (GLMM) and multivariate logistic regression were used for analyses. During this study period, a total of 89,014 women-infant pairs were enrolled. The mean age of the mother in the study period was 24.0 ± 4.3 years, with 54.9% from disadvantaged ethnic groups and 4.0% of them illiterate. Of the total birth cohort, 54.4% were boys, 16.7% had gestational age less than 37 weeks, and 17.1% had birth weight less than 2,500 grams. The incidence of intrapartum-related mortality was 11.0 per 1,000 births during the control period and 8.0 per 1,000 births during the intervention period (adjusted odds ratio [aOR], 0.79; 95% CI, 0.69-0.92; p = 0.002; intra-cluster correlation coefficient [ICC], 0.0286). The incidence of early neonatal mortality was 12.7 per 1,000 live births during the control period and 10.1 per 1,000 live births during the intervention period (aOR, 0.89; 95% CI, 0.78-1.02; p = 0.09; ICC, 0.1538). The use of bag-and-mask ventilation for babies with low Apgar score (<7 at 1 minute) increased from 3.2% in the control period to 4.0% in the intervention period (aOR, 1.52; 95% CI, 1.32-1.77, p = 0.003). There were two major limitations to the study; although a large sample of women-infant pairs were enrolled in the study, the clustering reduced the power of the study. Secondly, the study was not sufficiently powered to detect reduction in early neonatal mortality with the number of clusters provided.

CONCLUSION

These results suggest scaled-up implementation of a QI package for neonatal resuscitation can reduce intrapartum-related mortality and improve clinical care. The QI intervention package is likely to be effective in similar settings. More implementation research is required to assess the sustainability of QI interventions and quality of care.

TRIAL REGISTRATION

ISRCTN30829654.