Helping Babies Breathe, second edition: A model for strengthening educational programs to increase global newborn survival

Background: Helping Babies Breathe (HBB), a skills-based program in neonatal resuscitation for birth attendants in resource-limited settings, has been implemented in over 80 countries since 2010. Implementation studies of HBB incorporating low-dose high-frequency practice and quality improvement show substantial reductions in fresh stillbirth and first-day neonatal mortality. Revision of the program aimed to further augment provider and facilitator skills and address gaps in implementation with the goal of improving neonatal survival. Methods: The Utstein Formula for Survival—Medical Science X Educational Efficiency X Local Implementation = Survival—provided a framework for the revisions. The 2015 Neonatal Resuscitation Consensus on Science and Treatment Recommendations by the International Liaison Committee on Resuscitation informed scientific updates, which were harmonized with the 2012 World Health Organization Basic Newborn Resuscitation Guidelines. Published literature and program reports, consensus guidelines on reprocessing equipment, systematic collection of suggestions from frontline users, and responses to a semistructured online questionnaire informed educational/implementation revisions. Links to maternal care were added. Draft materials underwent Delphi review and field testing in India and Sierra Leone. An Utstein-style meeting of stakeholders identified key actions for successful implementation. Results: Scientific revisions included expectant management of infants with meconium-stained amniotic fluid, limitation of suctioning, and initiating and continuing effective ventilation until spontaneous respirations. Frontline users (N=102) suggested augmented simulation methods to build confidence and competence and additional guidance for facilitators on implementation. Users identified a need for sufficient practice during the workshop, systematized ongoing practice, and enough simulators for participants. Field trials refined approaches to self-reflection, feedback and debriefing, and quality improvement. Utstein meeting stakeholders validated the importance of quality improvement and use of data to improve outcomes. Conclusions: The second edition of HBB provides a newer paradigm of learning for providers that incorporates workshop practice, self-reflection, and feedback and debriefing to reinforce learning as well as the promotion of mentorship and development of facilitators, systems for low-dose high-frequency practice in facilities, and quality improvement related to neonatal resuscitation. In 2015, an Utstein-style meeting of key stakeholders focused on previous implementation of the HBB curriculum to determine what key actions were essential for effective dissemination of educational programs for neonatal and maternal survival, such as the Helping Babies Survive and Helping Mothers Survive programs. The framework for improving survival worldwide is summarized in the Utstein Formula for Survival, based on the consensus of international experts, which states that survival is the product of medical science, educational effectiveness, and implementation (Figure 1).26,27 Although the development of the first edition of the HBB curriculum focused on the design of the educational program, adding the components of the Utstein Formula for Survival to the second edition helped provide a framework for identifying changes that resulted from an additional focus on enhanced educational effectiveness, skills retention, and the importance of coordination with national resources and leadership. The framework also identified 2 key challenges: sustainability and wide implementation. The inputs that aided the revisions are described in further detail below. The Utstein Formula of Survival Adapted with permission from Søreide et al.27 The goal of the HBB curriculum is to bring the latest in resuscitation science to low-resource settings. To that end, the 2015 ILCOR CoSTR was formed to provide a system for evaluating scientific updates.28 For the first time, the 2015 ILCOR CoSTR used the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach for evaluating evidence to rate guidelines recommendations, based on the strength of the evidence.29 The most recent changes in resuscitation processes identified by the 2015 ILCOR CoSTR review were further harmonized with the revised WHO Guidelines on Basic Newborn Resuscitation.12 During the evaluation process, the committee also reviewed the evidence supporting delayed cord clamping. New experimental evidence and human data from low-resource settings demonstrated increased neonatal morbidity and mortality with cord clamping prior to onset of respiration.30–32 Feedback from user experience revealed a frequent overreliance on suctioning, whether the infant was breathing or not; delays in the initiation of ventilation; and frequent interruptions in ventilation when the infant was not yet breathing. The committee also recognized that a single provider may often be caring for the mother–infant pair and that little evidence was available on how to co-manage the 2 patients if both were critically ill. Improved linkages between neonatal care and maternal care were made, including, for example, the preparation of oxytocin before birth. Researchers in Kenya expressed concern that improper or incomplete disinfection of resuscitation equipment was a contributing factor in spreading infection.33 They reported that non-HBB-trained personnel were often involved in reprocessing the equipment for future use, which was being done improperly, potentially affecting the safety and functionality of the equipment.33 They noted that a workable field guide did not exist that would provide recommendations about reprocessing of used resuscitation equipment. The dissemination of the HBB curriculum, as noted earlier, was global, with numerous facility-based studies of doctors, nurses, and midwives indicating that uptake of both knowledge and skills improved immediately after an HBB workshop.15,24,34–36 However, published reports also mentioned the deterioration of skills after HBB workshops, which mirrored the experiences of other resuscitation training programs.24,37,38 For the effective performance of these lifesaving skills to impact neonatal mortality and stillbirth rates, providers need to be able to perform basic resuscitation and bag-mask ventilation, if needed, within “The Golden Minute” after birth. Numerous studies since the release of the first edition of the curriculum indicate that a system of ongoing practice or refresher training can be effective for the maintenance of resuscitation skills.39 Many key lifesaving skills, such as bag-mask ventilation, require more practice time, focus, and supervision than could be provided during the usual 1-day workshop.24 While the exact frequency of practice and refresher training required to maintain proficiency for each type of provider is unknown, it is clear that ongoing low-dose high-frequency practice can improve performance and competency.18,23,25,40,41 Importantly, the incorporation of debriefings and case reviews after real-life delivery room situations, and a quick review of bag-mask ventilation in low-dose high-frequency sessions, for example, at the beginning of a shift, improved early neonatal mortality and decreased stillbirth rates in facility-based settings in Africa and Asia.18,23 Pilot testing of Helping Babies Breathe 1st Edition in Dar es Salaam, Tanzania. © 2010 Eileen Schoen/American Academy of Pediatrics. Lifesaving skills, such as bag-mask ventilation, often require more practice time, focus, and supervision than can be provided in a single-day workshop. Studies also indicated that it was important to consider past experience of the providers, as different cadres of providers such as physicians likely had some past experience with neonatal resuscitation training and simulation, whereas nurses did not.41 Furthermore, researchers noted differences between who was able to perform these skills in real-life scenarios, despite similar performances during simulation exercises. The concept of ongoing practice, even when studied in rural providers—such as village midwives and birth attendants—1 year after their initial HBB training, showed retention of basic resuscitation skills with ongoing practice and/or refresher trainings and reductions in fresh stillbirth and early neonatal mortality rates.38,42,43 Finally, additional input from frontline users also noted that the skills assessments—in particular, the objective structured clinical evaluations (OSCEs)—were cumbersome, confusing, and potentially biased. These assessments were often used in both summative and formative evaluation but were not always implemented in a learner-focused fashion, which allows learners to self-reflect and learn from their experience. After gathering information from published literature and program reports, the HBB GDA published a summary of the first 5 years of HBB implementation, with a clear message that gaps in quality of care would need to be overcome by more than just additional or continued provider training.11 To that end, USAID and WHO designed frameworks for characterizing gaps in quality of care for mothers and babies and strategies to overcome the gaps in care.44,45 The WHO framework described 6 strategic areas where evidence-based approaches could guide interventions to improve care, including the development of clinical guidelines, standards of care, effective interventions, measures of quality of care, relevant research, and capacity-building practices.45 The newly formed Quality of Care Network, linked to the WHO framework, focuses on the tenets of quality, equity, and dignity to drive quality of care and access to care for all. Themes of effective implementation included linking workshops to existing health care programs and leaders in order to promote local ownership and planning for training-of-trainers cascades, with an emphasis on early exposure through preservice education. The Utstein-style meeting formulated 10 essential action points for national dissemination and implementation of the Helping Babies Survive and Helping Mothers Survive program materials and training (Box). Reproduced from Ersdal HL, Singhal N, Msemo G, et al (2017).26 To gather additional perspectives from frontline HBB users, we developed a 59-question semistructured online survey. The invitations to participate were sent via email, and the online survey generated 102 responses. The primary respondents were physicians (65%), professionals based in North America (77%), and global HBB facilitators (93%). When asked about the most important change needed to make sure all babies receive help to breathe, respondents answered better confidence and skills in those trained (66%), rather than training greater numbers of providers (33%). When asked about the 3 most important ways to ensure that providers could perform their skills, respondents identified sufficient time for practice during the workshop (91%), enough mannequins to reach the goal ratio of 1 mannequin per 2 participants (54%), and a system for ongoing practice after the workshop (87%). To better support HBB facilitators, respondents ranked facilitating the first course with experienced trainers (68%), improving ways to assess that learners have the required skills (64%), and more instruction/practice on how to facilitate the course (51%) as their 3 highest choices. Respondents identified sufficient time for practice during workshops and a system for ongoing practice after workshops as key ways to improve provider skills. The draft materials underwent Delphi review by 20 individuals recruited from frontline users and program managers. Consistent messages from Delphi reviewers included the need to strengthen facilitator advice before, during, and after the workshop; to emphasize systems of ongoing practice and quality improvement after the workshop; and to more strongly link HBB with the Helping Mothers Survive suite of programs. Further inputs from the maternal care community suggested that elements of maternal care could be integrated within HBB, recognizing that care for the mother and baby is often the task of a single provider. A revised version of the materials underwent field testing in India and Sierra Leone. In India, experienced master trainers, familiar with the first edition materials, and novice participants were trained with the new materials. In Sierra Leone, a group of novice participants was trained to be master trainers, and then observed as they trained a group of providers. At both sites, focus group discussions were performed to obtain qualitative feedback about the new materials and the overall educational program. The interviews were audio recorded, transcribed, and then subjected to thematic analysis by independent reviewers. Ethical approval for the semistructured survey was obtained from the Cincinnati Children’s Hospital Medical Center Institutional Review Board. For the India field trial, ethical approval was obtained by the Colorado Multiple Institutional Review Board and the Institute Ethics Committee of the All India Institute of Medical Sciences, in New Delhi, India. Ethical approval for the field trial in Sierra Leone was obtained from the Committee for the Protection of Human Subjects at the Theodore Geisel School of Medicine.