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MDG 4: HELPING BABIES BREATHE

06/13/2010

Dr. Little of Children's Hospital at Dartmouth Hitchcock Medical Center describes the Golden Minute of neonatal resuscitation.

A pregnant woman in the Leshoto District of Tanzania describes her birthing experience, "I was pregnant again and felt labor pains. The neighbors carried me to the mission. They drove me to Korogwe hospital, where they deliver the traditional way-no plastic sheets, no gloves."

Though the Leshoto District may have limited resources including medical supplies used for neonatal care, the care providers are working toward being equipped with a different kind of resource - caregivers trained in the necessary procedures of neonatal care. In an effort to progress towards Millennium Development Goal Number 4, the American Academy of Pediatrics is targeting what the World Health Organization estimates as the cause of more than one million infant deaths, and 23 percent of neonatal deaths per year -- birth asphyxia (the inability to breathe adequately immediately after delivery).

Helping Babies Breathe (HBB) is an initiative of the American Academy of Pediatrics (AAP) in consultation with the World Health Organization (WHO), and collaborators such as the US Agency for International Development (USAID), Saving Newborn Lives/Save the Children, the Eunice Kennedy Shriver National Institute of Child Health and Development (NICHD), and a number of other global health stakeholders.

HBB is an evidence-based educational program to teach neonatal resuscitation techniques in resource-limited areas. The objective of HBB is to train birth attendants in developing countries the essential skills of newborn resuscitation, with the goal of having at least one person who is skilled in neonatal resuscitation at the birth of every baby.

It is aimed at births wherever they occur including those with a single birth attendant, and the curriculum is designed for use as part of a coordinated educational approach to early neonatal care that can be effectively combined with other curricula. HBB can be locally taught to birth attendants in diverse venues and locations and focuses on practices that all persons who care for babies at birth can learn to assist babies who do not breathe on their own. Simply taking the necessary steps of neonatal care (clearing the airway, rubbing the back) that every infant deserves can make all the difference.

A key concept of HBB is The Golden MinuteSM. Within one minute of birth, a baby should be breathing well or should be ventilated with a bag and mask. The Golden Minute identifies the steps that a birth attendant must take immediately after birth to evaluate the baby and stimulate breathing. HBB is much more than a classroom-based educational program. It is designed to change clinical practice across systems of care.

In order to impact MDG 4, medical units must be ready for ongoing training and practicing of the skills learned to help babies breathe at birth. HBB training should be considered as part of continuing practice improvements for facilitators, learners and health systems.

HBB implementation has received much thought and attention within a basic principle that it should be systems based to the greatest extent possible. Experienced program implementers suggest that the anticipated time to prepare for HBB training is 9-12 months. The preparation interval may be shorter or longer depending upon factors such as neonatal care and resuscitation programs already in place locally, the relative strength and resources of the Ministry of Health and other system factors.

Assessing the environment for program readiness including identification of local partners as well as medical facilities at all levels where training can be provided is very important. Systems and facilities should commit to "owning" training in an ongoing and sustainable fashion. Data collection, including staff support, is necessary to evaluate outcomes and improve ongoing education and clinical care. Following an initial assessment of need, planning for resource allocation through system infrastructure involving master training partners, facilitators and course leaders, and specific sites can be applied within a specific time frame.

Global partnerships are important contributors to the HBB initiative. HBB is being implemented through a public-private alliance between the American Academy of Pediatrics, the USAID, Laerdal Medical, a manufacturer and distributor of resuscitation devices, who will increase access to high-quality, affordable resuscitation kits; the NICHD, a USG agency that will lead the evaluation of the alliance in selected countries; and Save the Children, which provides global technical expertise through its Saving Newborn Lives program and will represent civil society.

USAID provides technical expertise in newborn health and will support the rollout and scale-up of the alliance through its Implementing Partner Programs: Maternal and Child Health Integrated Program (MCHIP), Health Care Improvement (HCI), HealthTech (PATH), and CORE Group.

Key principles of the Alliance include inclusiveness, supporting country ownership, encouraging integration with other maternal and child health programs, and commitment to shared goal, results, risks and recognition. Through the alliance, partners plan to initiate country-wide implementation of HBB in targeted MDG 4 countries.

Countries in the active phase of field testing (Kenya, Pakistan, Tanzania, India, and Bangladesh) have reported an overwhelming increase in community mobilization to promote the importance of attended births and education of medical care in the community. A nurse in Tanzania reports, "This is what we've been waiting for." Community leaders are recognizing the available resources and making them available to medical centers. As a result, women are empowered to take their own health, as well as the health of their child into her own hands, and encourage others to do the same.

Development of an HBB consultant, mentor and training facilitator pool is underway as is establishment of distribution channels for HBB associated education and clinical tools such as flipcharts and mannequins. Updated information about this and other aspects of HBB is available at helpingbabiesbreathe@aap.org

DR. GEORGE LITTLE OF CHILDREN'S HOSPITAL AT DARTMOUTH HITCHCOCK MEDICAL CENTER  IS ASSOCIATE EDITOR, HBB.