Zahedan University of Medical Sciences

Report from: ZAUMS Family and Reproductive Health Department
Published on: 10 May 2019

In 2017, 47% of all under-5 child deaths were among newborn infants - up from 40 % in 1990 (1). Globally 2.5 million children died in the first month of life in 2017, with about 1 million dying on the first day. A child’s risk of dying is highest in the first 28 days of life, during the neonatal period (1).

Labor, birth and the immediate postnatal period are the most critical for newborn and maternal survival (2).  Studies have shown that many newborn lives can be saved by the use of interventions that require simple technology. The majority of these interventions can be effectively provided by a single skilled birth attendant caring for the mother and the newborn. 

 Courtesy: (c) 2001-2019 Laerdal Medical

Helping Babies Breathe (HBB) is an evidence-based, hands-on educational program that was developed  by the American Academy of Pediatrics (AAP) to reduce neonatal mortality in resource-limited environments (3). The HBB program addresses the three most common causes of preventable neonatal deaths: complications during childbirth, complications from preterm birth, and neonatal infections. HBB programs are largely supported and implemented by many global partners including the US Agency for International Development (USAID), Save the Children, Laerdal Global Health, Latter-day Saint Charities, and Johnson & John​son (3).

With the launch of HBB in 2010, the Helping Babies Breathe Global Development Alliance (GDA) was formed to support an effective and widespread implementation of the program. HBB is now introduced in over 80 countries with 450,000 birth attendants trained and equipped (4).  Helping Babies Breathe teaches the initial steps of neonatal resuscitation to be accomplished within The Golden Minute to save lives and give a much better start to many babies who struggle to breathe at birth. HBB neonatal resuscitation techniques have been shown to reduce neonatal mortality by up to 47% and fresh stillbirths by 24% (5). ​​​Additionally, a smaller study in India resulted in a 48% reduction in fresh stillbirths after HBB training (6).

Revision of the program has been carried to further augment provider and facilitator skills and address gaps in implementation with the goal of improving neonatal survival. 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 (7).

According to the WHO recommendation, the HBB program can be implemented at all levels of the health system. The program, at high levels of health services, such as hospitals and treatment centers, is also considered a complementary measure but is not a replacement for the Neonatal Resuscitation Program (NRP). NRP and HBB teach both the early stages of basic neonatal resuscitation. But the NRP also teaches the use of supplemental oxygen, chest massaging, insertion of the tracheal tube, and medications.

By implementing simple interventions, the HBB program has been expected to lead to 99% improvement in babies survival. The program includes regular assessment of care at the time of birth, such as immediate and thorough drying, warming, and early initiation of breastfeeding. About 10-20% of infants who are breathless at birth are responding drying and warming up, cleaning up the airway and, if needed specific respiratory stimuli. Only a small percentage of infants (about 6-3%) need assisted bag and mask ventilation, and less than 1% need advanced resuscitation measures such as chest massage and medication. The objectives of the HBB program at the national level are: first: reducing neonatal mortality to less than 7 in 1,000 live births in accordance with the goals set forth in the Sixth Development Plan, and the second: reducing the birth complications (asphyxia at birth) to less than 11%.

The implementation of the HBB program for the first time in Iran was launched in February 2016. The first HBB Training-of-Trainers (TOT) workshop was organized by Neonatal Health Department, Iranian Ministry of Health and Medical Education.  The workshop was conducted in Zahedan University of Medical Sciences, with participation of candidate trainers from Zahedan, Zabol, Iranshahr, and Birjand universities of medical sciences. Three of the candidate trainers were selected as master trainers.  In 2017, three HBB workshops were conducted by those master trainers for 51 midwives working in safe delivery facilities and 5 midwives working in Chabahar, Saravan and Khash districts hospitals. The workshops were closely supervised by head of the Neonatal Health Department, Iranian Ministry of Health and Medical Education.

The two master trainers from ZAUMS also received refresher trainings by attending workshop on "Helping Babies Survive" and "Helping Babies Breathe" Programs that held jointly by the Ministry of Health and Medical Education, Islamic Republic of Iran and UNICEF-Iran Country Office from 19 to 22 February 2018.

In the year 2018 and 2019, after receiving the HBB training kit and equipments (donated by UNICEF- Iran Office), 6 HBB workshops were conducted at Zahedan, Iranshahr, Zabul, and Jiroft medical universities by ZAUMS master trainers. The participants included  81 midwives working in labor facilities and 5 experts from districts maternal and child health departments, 47 midwives working in delivery blocks of university and non-university hospitals, 28 gynecologists, 8 anesthetists, 5 pediatricians and 10 faculty members working in Schools of Nursing and midwifery (governmental and nongovernmental).

Pre and post training evaluation was carried out to assess the trainees" knowledge and performance and skills. Provider knowledge and performance substantially improved with HBB training. The average score of knowledge increased from 91.1% to 97.7% , and the average score for technical skills showed a substantial increase from 5.3% to 72.7%. It is noteworthy that the majority of the participants did not have the appropriate skills in performing basic neonatal resuscitation, despite having enough knowledge before attending this program, which significantly improved after completing the course.

Although HBB training significantly improves neonatal resuscitation knowledge and skills, but there is some evidence that both skills and knowledge decline over time (8). Therefore, ongoing skills practice and monitoring, more frequent retesting, and refresher trainings are needed to maintain neonatal resuscitation skills.

The trainees will be evaluated again by master trainers 12-6 months after completing the course in order to assess their retention of knowledge and skills in basic neonatal resuscitation.

The HBB training materials including: Action Plan, Facilitator flip charts, Caregivers and Parents Guidelines was first translated from English into Persian by Zahedan University of Medical Sciences in 2017. The Persian version of the HBB training materials were reviewed by Neonatal Health Department, Iranian Ministry of Health and Medical Education and  Isfahan University of Medical Sciences, and then were sent to American Academy of Pediatrics (AAP) via UNICEF-Iran for final approval.

Copyright © 2019 Zahedan University of Medical Sciences. All rights reserved. Date Updated: 10/05/2019.
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 References:

 1. World Health Organization. Newborns: reducing mortality 2019. Available from: https://www.who.int/news-room/fact-sheets/detail/newborns-reducing-mortality.

2. World  Health Organization. Newborn care at birth 2019. Available from: https://www.who.int/maternal_child_adolescent/newborns/care_at_birth/en/.

3. American Academy of Pediatrics. Helping Babies Survive 2019. Available from: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/helping-babies-survive/Pages/default.aspx.

4. Laerdal Global Health. Helping Babies Breathe 2019. Available from: https://laerdalglobalhealth.com/partnerships-and-programs/helping-babies-breathe/.

5. Msemo G, Massawe A, Mmbando D, Rusibamayila N, Manji K, Kidanto HL, et al. Newborn mortality and fresh stillbirth rates in Tanzania after helping babies breathe training. Pediatrics. 2013;131(2):e353-60.

6. Goudar SS, Somannavar MS, Clark R, Lockyer JM, Revankar AP, Fidler HM, et al. Stillbirth and newborn mortality in India after helping babies breathe training. Pediatrics. 2013;131(2):e344-52.

7. Kamath-Rayne BD, Thukral A, Visick MK, Schoen E, Amick E, Deorari A, et al. Helping Babies Breathe, Second Edition: A Model for Strengthening Educational Programs to Increase Global Newborn Survival. Glob Health Sci Pract. 2018;6(3):538-51.

8. Bang A, Patel A, Bellad R, Gisore P, Goudar SS, Esamai F, et al. Helping Babies Breathe (HBB) training: What happens to knowledge and skills over time? BMC Pregnancy and Childbirth. 2016;16(1):364.