Update on Helping Babies Breathe...10 steps for Helping Babies and Mothers Survive inLMIC 1. Secure...
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Update on Helping Babies Breathe Through an equity lens Susan Niermeyer, MD, MPH University of Colorado School of Medicine Colorado School of Public Health RESUSCITATION – It’s about time 12 th International Spark of Life Conference
Transcript of Update on Helping Babies Breathe...10 steps for Helping Babies and Mothers Survive inLMIC 1. Secure...
Update on Helping Babies BreatheThrough an equity lens
Susan Niermeyer, MD, MPHUniversity of Colorado School
of MedicineColorado School of Public Health
RESUSCITATION – It’s about time12th International Spark of Life Conference
Financial Disclosures
• No relevant financial relationships with any commercial interests.
Conflict of Interest• Dr. Niermeyer is a Senior Medical Advisor for Newborn
Health, USAID. The views and opinions expressed in this presentation are those of the author and not necessarily the views and opinions of the United States Agency for International Development.
Susan Niermeyer
Outside Lhasa, Tibet
Rukunjiri District Hospital, Uganda
Frogmore Cottage or Lindo Wing, St. Mary’s Hospital, London ?
site for a royal birth
Resources for neonatal resuscitation
Resources for neonatal resuscitation
Photo (right): Lynsey Addario, Dying to Give Birth
Objectives• Become aware of global inequalities in access to care at birth
• Describe the impact of education on care at birth and survival in low- and middle-income countries
• Discuss the need for strengthening systems to achieve the goals of the Every Newborn Action Plan
• Explore the potential for advocacy to accelerate change
Births assisted by a skilled birth attendantby country, 2011-2016
https://data.unicef.org/topic/maternal-health/delivery-care/# - January 2018
Births assisted by a skilled birth attendantcountries with > 90% coverage
Births assisted by a skilled birth attendantcountries with > 80% coverage
Births assisted by a skilled birth attendantcountries with > 70% coverage
Births assisted by a skilled birth attendantcountries with > 60% coverage
Births assisted by a skilled birth attendantcountries with > 50% coverage
Births assisted by a skilled birth attendantcountries with > 40% coverage
Births assisted by a skilled birth attendantcountries with > 30% coverage
Births assisted by a skilled birth attendantcountries with > 20% coverage
Births assisted by a skilled birth attendantcountries with > 10% coverage
Relationship of access to care and mortality
Proportion of deliveries with skilled attendant
Mat
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Maternal mortality Neonatal mortality
Adegoke AA et al. BJOG 2009
Content of care, not just contact
Newborns who had• Immediate initiation of
breastfeeding• Weight at birthExperienced ↓ likelihood of death on days 0-1 and 2- 27
Amouzou A et al. J Global Health 2017
Regional disparities in rates of neonatal mortality
UN Inter-agency group for child mortality estimation (UN IGME). Levels & Trends in Child Mortality 2017
Central and Southern Asia
Sub-Saharan Africa
Western Asia and Northern Africa
Eastern Asia and South-Eastern Asia
Latin America and the Caribbean
Oceania
North America and Europe
Australia and New Zealand
Deaths per 1000 live births0 10 20 30 40
Sub-national disparities in access
Causes of unequal access to care• Geographic isolation
o Mountains, rivers, roads• Urban/rural variation in service density• Socioeconomic status• Membership in ethnic minority groups
o Cultural beliefso Language
• Disrespect by care providers• Natural disasters/epidemic outbreaks• Conflict
Demographic and Health Survey, Ghana
Delivery in Health Facility - Ghana, 2014
Sub-national disparities in access
Causes of unequal access to care• Geographic isolation
o Mountains, rivers, roads• Urban/rural variation in service density• Socioeconomic status• Membership in ethnic minority groups
o Cultural beliefso Language
• Disrespect by care providers• Natural disasters/epidemic outbreaks• Conflict
Infant mortality by indigenous status
The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples: 2015, AIHW
Effects of exposure to armed conflict on pregnancy
Keasley J et al. BMJ Glob Health 2017
Perinatal stress• ↑Low birth weight• +/- Stillbirth• +/- Prematurity
↑ stillbirth↑ early neonatal mortality
Destruction of local infrastructure• Disruptions in food, water, power,
sanitation• Hospitals as targets of attacks• Outmigration of health personnel
and administrative management
Causes of neonatal and under-5 child death46% of all deaths occur in the neonatal period
UN Inter-agency group for child mortality estimation. Levels & Trends in Child Mortality 2017
2.6 million neonatal deaths per year with global average NMR 19/1000 live births
Preterm birth complications 16%
Intrapartum-related events 11%
Severe infection + pneumonia 10%
Helping Babies Breathe (HBB)
Drying to provide stimulation of breathing and prevent
hypothermia
Delayed umbilical cord clamping to promote
cardiovascular stability
Immediate initiation of breastfeeding to avoid
hypoglycemia
Clearing the airway only if necessary
Specific stimulation to breathe
Ventilation within one minute after birth, The Golden Minute
Improved ventilation
Immediate skin-to-skin contact to prevent hypothermia and promote
breastfeeding
Segue to advanced resuscitation when available
Helping Babies Breathe, 2nd edition
• Focus on basic interventions and The Golden Minute
• Pictorial materials• Active learning with low-tech, high-
fidelity simulator• Simultaneous delivery of training and
equipment for clinical care• Low-dose, high frequency refresher• Quality improvement
Kamath-Rayne BD et al. Pediatr Res 2017; doi: 10.1038/pr.2017.48
Helping Babies Survive implementation in > 80 countries from 2010-2018
hbs.aap.org
52 programs led and coordinated by national governments30 integrated maternal/newborn programs
> 500,000 health providers trained and equipped by GDA
Helping Babies Breathe effectiveness in reducing fresh stillbirths and first-day mortality
Dol J. JBI Database of Sys Rev and Impl Rep 2018
Fresh stillbirth
First-day mortality
Quality improvement cyclesdata monitoring and skills reinforcement
Nepal – daily handover board
• Daily bag and mask skills check
• Use of self-evaluation checklist
• Preparation for resuscitation before every birth
• Attendance at weekly review meetings
• Peer evaluation after each resuscitation
KC A et al. BMC Pediatrics 2017; 17:103
Nepal: Impact of training, practice, quality improvement
KC A et al. Pediatrics 2016; 137 (6):e2 0150117
intrapartum stillbirth
1st day mortality
10 steps for Helping Babies and Mothers Survive in LMIC
1. Secure Ministry of Health buy-in
2. Form a working group for planning, training and monitoring
3. Develop national roll-out plan for pre-service and in-service
training, in both public and private sector
4. Provide learning materials & equipment at time of training
5. Identify and support local leaders and champions
6. Establish Low Dose High Frequency refresher training
7. Establish facility level quality improvement teams
8. Monitor performance
9. Establish a system for reporting and feedback
10. Engage health providers, families and the broader community
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.10178073
Best practice implementation to improve survival
Key lessons from Helping Babies Breathe
• Simplicity and clarity open the door for change
• Facility-based skills training initiates change
• Practice, mentoring and empowerment of health workers solidify change
• Catalytic role of initiative spreads change• Focusing attention on babies (and their mothers)
• Demystifying interventions (resuscitation, thermal care)
• Demystifying a process (quality improvement)
• Monitoring, data collection and utilization of data document and support continued change
Ending preventable newborn and child deathsEvery Newborn Action Plan (ENAP)
Lawn JE et al. Lancet 2014 Every Newborn
A Promise Renewed target: National U5MR of 20 or less
Every Newborn target: National NMR of 10 or less
National NMR and stillbirth rates 10 or less
Strengthening systems to achieve the goals of the Every Newborn Action Plan
Decide to seek care
Reach care
Obtain appropriate level of care
3 Delays model of access to care at birth
Access to antenatal, intrapartum, referral care
Ssebunya R, Matovu JKB. BMC Preg Childbirth 2016
Access to new technology for prevention
Moyo fetal monitor
Clinical trials.gov NCT02790554
Access to timely and safe surgical intervention
UAM – Universal Anesthesia Machine
educational programs
WHOEssential Newborn Care educational materials
Advocacy to accelerate change
Tibet – women’s committees
Tanzania – women councillors
India – female village health workers
Advocacy to accelerate change
Strategies
Outcomes
Improving equity in care at birth and survivalEducationLife-saving essential skillsGlobally accepted educational packagesMultiple cadres of providers
SystemsTransportationCommunication Regionalization
AdvocacyBy allFor allEverywhere
