National Scaling Up of Helping Babies
Breathe Initiatives in Bangladesh
Dr. Sayed Rubayet
Project Manager, HBB and SNL
Save the Children in Bangladesh
Presentation Outline
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Background
National scale up strategy
Evaluation design
Results to date
Quality improvement process
Plans for sustainability
Lessons learned
Background:
Facts of Neonatal Health in Bangladesh
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Delivery at health facility -29%
Delivery attended by a skilled
provider -32%
Neonatal death per year is
83,000 *
Neonatal mortality rate:
32/1000 live births
Neonatal deaths - 60% of all <5
deaths
Source: * Bangladesh-specific mortality estimates (Liu et
al. 2012, BDHS 2011
Causes of Newborn Mortality in Bangladesh
Data source: Bangladesh-specific mortality estimates (Liu et al. 2012).
Background of National Scale-up of HBB in
Bangladesh
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2010 - HBB Pilot Study conducted in Bangladesh
Dissemination seminar on HBB Pilot Study was held on
September 2010
The Honorable Minister, MOH&FW was encouraged seeing the
findings of the study and
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Instructed to take initiatives to scale-up the HBB interventions nationwide
and
Requested development partners for necessary support.
Series of national stakeholders’ consultation workshops
held on to develop HBB Scale-up strategy and plan after
dissemination
National HBB scale-up plan developed, approved by MOH
and forwarded to USAID and UNICEF for support in
April 2011
National Scale-up Plan
Capacity Building
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Training on NB resuscitation including primary management of birth asphyxia
and basic ENC to all SBAs (from highest level service provider to community
level) of Bangladesh (public sector)
Equip all the facilities of public health sector and cSBAs with resuscitator
(neonatal bag & mask with sucker)
Quality Assurance
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Supervision and monitoring of training
MIS system strengthening and evaluation of the HBB scale-up activities
Sustainability
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Incorporate in National Health Sector Program
Incorporate HBB protocol in all relevant in-service and pre-service
curriculum
Capacity building of the facilities for training & refreshers training
Routine refreshers training for retention of skills and utilization of the NB
resuscitation capacity
Background of National Scale-up of HBB in
Bangladesh
Institutional Arrangement
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Funding Arrangement
MOH&FW (Cash and kind)
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UNICEF
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Laerdal Foundation
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Children
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Adaptation of training materials
Organize training in all level
Monitoring and supervision
UNICEF
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through Save the
Nationwide Implementation, supervision,
monitoring and Evaluation
Ensure Logistics
BSMMU
Children
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Overall implementation
TAX/VAT of offshore procurement
MCHIP/Save the Children
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USAID through
MCHIP/Save the
MOH&FW (DGFP, DGHS)
Equipment for district implementing
maternal and NB projects,
Supervision and monitoring
ICDDRB
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Evaluation of HBB scale-up activities
HBB Scale-up Partners in Bangladesh
Summary of HBB Training Plan
Period
Jun 11Sep 11
Oct 11Sep 12
Oct 12Sep 13
District/
City
Corp’n
Training on HBB Curriculum
Training of Trainers
Batch
Trainers
Batch
Doctors
Nurse/
Paramedics
13
11
210
168
507
1583
1028
2908
33
30
598
513
1546
4929
3096
8863
24
19
370
319
1126
2934
1764
5454
70
60
1178
1000
3179
9446
5888
17225
CSBA
Total
Total
Step-wise HBB scale-up plan
Total 11 steps
Each Step
TOT- Doctors from
Medical College Hosp (if any),
District Hospital, District
Health and FP Office and
Upazila Health Complexes
7-8 batches
6 districts
•2 days TOT in BSMMU
• Trainer return
and provide training to
district and upazila SBAs
Training starts immediately after TOT
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Medical College Hosp – 30 doctors and 40 nurses
District Hospital- 6-8 doctors and 10+ nurses
MCWC- all doctors and FWV
UHC- 5-7 Medical Officer and all Nurses
All FWVs and CSBAs
Plan of System Evaluation of Scaling-up of HBB Intervention
in Facility and Community Settings in Bangladesh
 Research Questions
 What proportion of deliveries are
attended by a skilled provider in
health facilities as well as in the
community?
 In what proportion of deliveries
attended by the skilled providers:
– Were they equipped with
bag-mask, suction device,
etc?
– They applied the resuscitation
techniques appropriately?
 What proportion of HBB-trained
birth attendants retain key skill
elements of newborn resuscitation
after-training?
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 Measurements
 Observation of deliveries to assess
delivery, newborn care practices and
asphyxia management; availability of
equipments
 Review of facility delivery records to
obtain total number of deliveries
 Post-HBB training assessment of
skills during monthly
retraining/practice sessions
 Interview of recently delivered
women at an end-of-project
household survey to assess coverage
of skilled birth attendants in
deliveries in the community
Key assumptions, sample size and operation plan of
HBB evaluation
Facility component
Community component
Intervention
Comparison
Intervention
Comparison
% of deliveries attended by SBAs
100%
100%
50%
10%
% of newborn received optimum
quality of resuscitation
80%
50%
80%
10%
Number of newborn requiring
resuscitation
43
43
32
16
Actual number of deliveries to
observe
953 (Baseline and
in each quarter)
953 (Baseline and
in each quarter)
709
(Post HBB training
target)
355
(Post HBB training
target)
Facility
Community
Baseline
1st quarter
2nd quarter
3rd quarter
3 months
3 months
3 months
3 months
Baseline
Follow-up data collection
3 months
9 months
HH Survey
2 months
Results to date
Status of HBB Implementation - Training
Type
Target Trained Percentage
completed
Trainers
1178
763
65%
Doctors
3179
1300
41%
Nurse/
Paramedics
9446
4731
50%
CSBA
5888
2599
44%
Total
19691
9393
48%
70
33
47%
District
Step 1 districts completed
Step 2 districts completed
Step 3 districts completed
Step 4 districts completed
Step 5 districts will be completed 20 July
Training and equipping
• Use for training and refreshers
• Kept in all facilities from UHC and
above for refreshers training
Mannequin (NeoNatalie-Laerdal)
• Provided to use for training and refreshers
• Provided to all facilities &
CSBAs for newborn resuscitation
• Arrangement be taken to made
them readily available in all facilities. Resuscitator & Suction device
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Training and equipping
Action plan – for training and
hanged in delivery sites of the
facilities
Flipchart- for training
and kept in facilities for
refreshers training
Learner Workbookprovided to all trainee
Status of HBB Implementation – Equipment
Distribution
Type of Facilities
Neonatalie
Complite
No. Facility
Bag & Musk
with Sucker
Medical Colleges Hospital
10
24
39
District Hospital
29
32
67
Maternal and Child Welfare
Center
30
30
64
Upazila Health Complexes
193
357
337
1386
-
1386
46
-
113
-
-
2599
1694
443
4595
Union Health and Family
Welfare Center
NGOs Facilities
Community SBA
Total
Incorporation of HBB Protocol in Different
Curriculum
• HBB Scale-up plan have the component to incorporate
the HBB protocol in different pre-service and in-service
curriculum.
• Following curriculum already decided to incorporate the
protocol.
1.
2.
3.
4.
5.
MBBS Curriculum
Diploma and Degree course of Nursing
Midwifery Training Curriculum
FWV training Curriculum
Private Paramedics Training Curriculum
• Initiatives also taken to incorporate in CSBA curriculum
• Standard Operation Procedure (SOP) for Newborn
Health Care in Primary and Secondary level facilities
Quality Improvement
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National Level (DGHS, DGFP BSMMU and SC )
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Divisional Level Health and FP officials
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Joint monitoring visit and follow-up of divisional officials visit
Usually 1 district/division in each phase, so feasible for divisional
level to organize monitoring visit
District Health and FP officials will visit each batch as resource
person
UHFPO/UFPO/RMO coordinate the training of their
upazila/facilities
MNCH, MNH, MNCS and MaMoni and other similar program
will provide support for supervision and supervise in the project
area
Standard checklist will be used for supervision and monitoring
Quality Improvement (Cont.)
Supervision and monitoring of training
 90%
session are expected to be supervised/monitored by District
level DGHS and DGFP officials
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 50%
83% sessions observed by district level Health/FP managers
sessions will be monitored /supervised by BSMMU officials
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Monitoring visits with checklist (179 out of 416 sessions) training- 43% of
sessions)
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QA through direct observation of master trainers (59 out of 416 - 14% of
sessions)
 15%
sessions are expected to be supervised by national and
divisional level DGHS/DGFP official
HBB Training Quality Assurance Checklist
HBB Training Supervision and Monitoring Checklists
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Quality Improvement- Refreshers training
Refreshers training introduced
through routine system
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SBA describe the experience of
resuscitation to others in the
monthly meeting if any newborn
was resuscitated
1/3rd of SBAs practice with the
manikins and bag & mask under
observation of their trained
supervisor as a routine practice
The supervisors take brief test
and record it in a card given
during training
All SBA have to practice and
record his/her performance in
the record card by every 3rd
month
Steps
A. Prepares for birth
B. Dries thoroughly
C. Clears airway and stimulates
breathing if baby is not crying*
Identifies a helper
Prepares the area for delivery
Cleans hands
Prepares an area for ventilation
Checks equipments
Dries the baby thoroughly
Removes wet cloth
Keeps warm
Positions head and clears airway
Stimulates breathing by rubbing the
back
Cuts cord and moves to area for
ventilation
Apply the mask to make a firm seal
D. Ventilates with bag and mask if
baby is not breathing
Starts ventilation within Golden
Minute
(started at _________ seconds)
Ventilates at 40 breaths/min (30-50
acceptable)
(_________breaths per minute)*
Looks for chest movement *
Head: reapply mask and reposition
head
E. Improve ventilation if chest does
Mouth: clear secretions and open the
not move*
mouth
Bag: squeezes the bag harder
Complet
e
Plans for sustainability
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HBB program incorporated in the Health Population Nutrition Sector
Development the Program (HPNSDP) 2011-2016 and its Operation Plans
(OP) of the MNC&AH (DGHS) and MCR&AH (DGFP)
Curriculums and Newborn SOP incorporated the protocol
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Refreshers training introduced through routine system
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Developing a video for refreshers training and distribution to all the
facilities are under way
Regular review meeting in directorates are going way.
MIS incorporation under process,
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A Technical Sub-Committee on Finalization of Newborn Indicator have
been formed and are working
DGFP is now piloting HBB related indicators
Surveillance activities are planned
Lessons learned
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Rapid scaling-up of an public health intervention became
possible due to the
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Political Commitment
Systemic Linear Approach
Technical Capacity
Partnership and
Fund Availability
Still the Challenges of HBB Scale-up are
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Retention of skill
Monitoring of implementation and outcome and linking with routine
system
Cleaning of the Equipment
Sabina Yasmin with her baby who was
resuscitated with bag & mask on 23rd
November at Mohammadpur UHC.
Dr Subol Chandra Borman , RMO
resuscitating a newborn baby at Jointapur
UHC on 7th December.