Helping Babies Breathe a global educational program in neonatal resuscitation
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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
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Wall SN, et al. IJGO 2009; 107:S47
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Assessment at birth and routine care
80-90%
Drying, warmth, clearing the airway, stimulation
Bag and mask ventilation
Chest compressions, medications
3-6%
< 1
8-10%
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• Scientific evidence base
– International consensus on science (ILCOR)
– Revision every 6 years
• Harmonization with international health policy
– WHO technical expert review
– Delphi panel
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• World Health Organization
– Basic resuscitation guidelines (in revision)
– Hand washing
– Breastfeeding
– Context of ENC

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Plan
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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
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Routine Care
Drying thoroughly
Keeping warm
Evaluating crying
Checking breathing
Clamping or typing and cutting the cord
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The Golden Minute
Positioning the head
Clearing the Airway
Providing stimulation to breathe
Evaluating breathing
Initiating ventilation
Ventilating with bag and mask
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Continued ventilation with normal or slow heart rate
Improving ventilation
Evaluating heart rate
Activating the emergency plan
Support Family
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Evaluation
Formative Evaluation
Content/Methodology/Educational
• Kenya
• Pakistan

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

Learner pair + neonatal simulator
6:1 learner-to-facilitator ratio
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Graphic linkage of Action Plan, flipchart, learner workbook
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Flipchart image for learner and instructional guide for facilitator
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Case scenarios conducted independently by learner pairs
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• 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
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Results

Helping Babies Breathe
(Likert’s scale) Facilitators
Training to lead a course
Course materials
I can help baby breathe
Group will help babies breathe
Kenya
5
4.8
4.85
4.75
Pakistan
4.73
4.3
4.55
4.9
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Helping Babies Breathe
Learners
Course Content
I can use Action Plan
I can help babies breathe
Kenya
4.45
4.43
4.58
Pakistan
4.80
4.64
4.70
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Knowledge Assessment
Facilitators
Learners
Pre
Kenya
20.5
Pass: 75%
14.0
2%
Post
Kenya
22.3
Pass: 95%
19.5
54%
Post
Pakistan
20.2
Pass: 82%
19.5
52%
T-test
P < .01
P < .001
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Skills Assessment
Bag-and-mask ventilation skills
Master = 12/12 steps correct
Pre
Kenya
Post
Kenya
Post
Pakistan
Facilitators 2.0
Pass: 0%
10.5
Pass: 31%
11.8
Pass: 48%
Learners .17
0&
9.4
15%
9
17%
Item missed most frequently: “ventilate at 40 breaths per minute”
“watch for chest rise”
T-test
P < .00001
P < .00001
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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
Facilitators
OSCE A
Kenya
8.9
50%
OSCE A
Pakistan
8.36
100%
OSCE B
Kenya
19.3
70%
OSCE A
Pakistan
17.64
45%
Learners 9.1
Pass: 60%
8.32
Pass: 83%
15.8
Pass: 20%
15.6
Pass: 23%
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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.
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Helping Babies Breathe
Implementation Field Testing
India
Tanzania
Kenya
Bangladesh
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Results India
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Knowledge Assessment
HBB Trainers & Providers
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Helping Babies Breathe
Deliveries
Live Births
Still Births
Deaths at Birth
Pre-Training
Oct 2009 – Mar 2010
4173
4046
124 (3%)
3
Post Training
Mar 2010 – Oct 2010
5427
5301
123 (2.3%)
3
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Helping Babies Breathe
Body breathing at 1 minute
Resuscitation Required
Stimulation
Suction
Bag & Mask
Bag & Mask started < 1 minute
Pre Training n(%)
118 (2.8)
1218 (29.2)
666 (16)
1113 (26.7)
124 (3)
92 (2.2)
Post Training n(%)
266 (4.9)
645 (11.9)
491 (9)
594 (10)
219 (4)
144 (2.7)
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Helping Babies Breathe
Conclusions
• Better recognition of babies not breathing at birth
• Still births decreased
• Neonatal deaths remained unchanged
• Need for specific resuscitation decreased
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Helping Babies Breathe
Summary
• Program well received
• Improves knowledge
• Improves skills
• Clinical impact needs further study
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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
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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)
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Nalini Singhal, Calgary Canada

Under-5 mortality rate
Early neonatal mortality
Late neonatal mortality
Target for
MDG-4
1960 1980
Year
2000 2020
Lawn JE et al. Lancet 2005
Reduce under-5 child deaths 2/3 from 1990 levels by 2015

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

The World of Physicians Working www.worldmapper.org 2002
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The World of Physicians Working www.worldmapper.org 2002
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Regional rates of neonatal mortality
UNICEF, State of the World’s Children 2009