The World Health Organization (WHO) reported that between 1990 and 2003, mortality of children under five years old fell from 12.7 million to 6.3 million. During the same time, the proportion of deaths that occurred in the neonatal period (the first 28 days) actually increased from 37 percent to about 44 percent. Global recognition of this gap has motivated many in the field of neonatal care to scale up effective and affordable interventions to address the primary causes of neonatal mortality: asphyxia, low birth weight, and infection. Among those leading the effort to improve newborn survival worldwide is Susan Niermeyer, MD, MPH, FAAP, professor of Pediatrics, Section of Neonatology at the University of Colorado School of Medicine and professor of Epidemiology at the Colorado School of Public Health, both located on the CU Anschutz Medical Campus.
Susan Niermeyer, senior investigator at the Colorado School of Public Health's Center for Global Health is one of the chief architects of Helping Babies Survive (HBS), comprehensive trainings designed to improve neonatal survival by combining evidence-based resuscitation practices with adult education and implementation science. HBS, an initiative of the American Academy of Pediatrics, is composed of three distinct one to two day trainings, Helping Babies Breathe, Essential Care for Every Baby, and Essential Care for Small Babies. Helping Babies Breathe (HBB) was developed first, because it focuses on risks present at the moment of birth. Dr. Niermeyer explains, “HBB really is the cornerstone because it prepares health workers to act at birth to help babies who are not breathing spontaneously or effectively on their own. It also establishes the whole educational methodology and learning system [of the later trainings].”
Thinking back to the initial phases of HBB development, Dr. Niermeyer recalls the early objectives, “Our main goal was to demystify resuscitation because the global health community had a vision of resuscitation as intensive care. Those of us teaching neonatal resuscitation internationally knew that very simple steps could be very effective. We wanted to present these steps in a way that was accessible, scientifically valid, and supportive of the same care that a baby would get anywhere else in the world.”
Five years of implementation activities in 80 countries have generated an abundance of new information and data along the way. Teaching experiences in the field, feedback from local partners, and meetings with ministries of health and in-country leadership have all inspired changes in the HBB curriculum. These influences, along with new clinical guidelines from ILCOR (International Liaison Committee on Resuscitation), resulted in the development of Helping Babies Breathe, 2nd Edition. Dr. Niermeyer elaborates, “The original program was developed simultaneously with the WHO Basic Neonatal Resuscitation guidelines that came out in 2012, but there are new 2015 ILCOR guidelines, so we made some scientific changes based on those recommendations. We also formally surveyed a number of frontline users in-country through a web survey about a year ago when we started ramping up the revisions. We heard that people wanted more support for course facilitators, and wanted more clear guidance on how they could follow up the training workshop itself. We also collated lots of comments that came in through the website.”
In addition to this feedback, the second edition of HBB is informed by three distinct scientific disciplines. “There are three bodies of research and evidence that we used in creating and updating this program,” Niermeyer explains. “One is resuscitation science, and what you need to do to take care of newborns to prevent them from dying. There is a truly global body of scientists working on this. Then there is a body of educational research that is really about active learning, adult learning, and the value of hands-on simulation, feedback, and debriefing. The third big area is implementation science. What happens after the workshop? The whole HBS suite is a tool for quality improvement teams to apply what they have learned to address specific gaps in their facilities.” This focus on quality improvement teaches HBB learners how to implement changes in their hospitals and clinics and track results after changes have been made.
For Dr. Niermeyer, the quality improvement piece was a new and exciting challenge in her own career. “It was very interesting to me to move into quality improvement. We worked to de-jargonize quality improvement so it could become a seamless part of everyday clinical practice even in low- and middle-income countries. Quality improvement is wonderful and rewarding. If you instill the appreciation that the data you collect every day can actually be used to improve your patient’s care, it can increase your job satisfaction,” she explains. To encourage adoption of this behavior, new skills-practice activities and data collection guidance are included in the 2nd edition HBB learning materials. The idea is to get learners to think critically about the standard procedures in their facility by asking questions like, “If a suction device is used [to clear a baby’s airway], is it disinfected before being used again?” For the facilitators teaching the course, there is also expanded educational advice and teaching tips to emphasize key points and reinforce specific skills. Dr. Niermeyer and colleagues created a detailed guide to describe each of the changes made to the training, and where these changes are reflected in the printed materials. This is no small task considering the HBB curriculum has been translated into 26 languages!
To encourage awareness and dissemination of the program, all course materials are available online. Similarly, there is an opportunity for in-country health authorities to work with the American Academy of Pediatrics to translate and adapt materials to fit local contexts. Adaptations may include exchanging pictures in the flip charts for ones that are more culturally appropriate, or adjusting certain recommendations to align with national newborn care strategies issued by the ministry of health. Mentorship of in-country champions like program managers, HBB master trainers, and academicians allows the HBB program to assimilate with clinical practices across several systems. Strong emphasis is placed on conducting HBS trainings to complement and support national policies, service standards, and training programs. “In countries where there is a central ministry of health and a strong national health program, these changes need to work their way through the system to become the operational guidelines,” Dr. Niermeyer explains. “More than anything, we have tried to make sure that these programs are integrated with a health system’s policies. Many countries adopt newborn protocols or guidelines, and HBS trainings have really filled a need in many countries by adapting to specific policies that may exist in Nepal but not in Guatemala, for instance. The basic steps in care really remain the same but they may be accomplished by different people or in different ways. Ultimately, though, the HBS suite supplies a scientifically valid framework that countries can build upon,” she continues.
The next five-year implementation cycle will bring new challenges and lessons. Dr. Niermeyer plans to explore the use of mobile platforms like cell-phone and tablet-based systems that facilitate knowledge maintenance, and encourage data collection to enhance quality improvement efforts. Another objective is to increase coverage and sustainability by working with the in-country professional associations and academic institutions to include HBB in midwifery, nursing, and medical school curricula. “This program has reached 80 countries, but have 100% of the providers in these countries been trained? No.” she states. Dr. Niermeyer plans to continue updating the HBB curriculum in correspondence with ILCOR’s guidelines. She says, “One of our commitments from early on was to bring the same science that was rolling out in the developed world to developing areas on the same five year cycle. We kept that commitment.”
