Increase in Newborns Ventilated Within the First Minute of Life and Reduced Mortality After Clinical Data-Guided Simulation Training

BackgroundThe Helping Babies Breathe (HBB) educational program focuses on training of first-level birth attendants in neonatal resuscitation skills for the first minute of life (The Golden Minute). Pre-post studies of HBB implementation in sub-Saharan Africa and Asia have shown reductions in facility-based very early neonatal mortality and stillbirth rates. However, the Global Network pre-post HBB Implementation Study (GN-HBB-IS) found no difference in day 7 perinatal mortality rates (PMR-D7) among births to women participating in the Global Network’s Maternal and Newborn Health Registry. To address potential differences in perinatal outcomes in births occurring in facilities that implemented HBB vs. all births occurring in the communities served by facilities that implemented HBB, we compared day-1 perinatal mortality rates (PMR-D1) among births occurring pre and post HBB implementation in facilities in Nagpur, India, one of the 3 sites participating in the GN-HBB-IS.MethodsWe hypothesized that there would be a 20% decrease in the Nagpur facility based PMR-D1 in the 12 months post GN HBB implementation from the pre-period. We explored pre-post differences in stillbirth rates (SBR) and day-1 neonatal mortality rates (NMR-D1).ResultsOf the 15 facilities trained for the GN-HBB-IS, 13 participated in the Nagpur HBB Facility Study (Nagpur-HBB-FS). There were 38,078 facility births in the 12 months before the GN-HBB-IS and 40,870 facility births in the 12 months after the GN-HBB-IS. There was 11% overlap between the registry births analyzed in the GN-HBB-IS and the facility births analyzed in the Nagpur-HBB-FS. In the Nagpur-HBB-FS, there was a pre-post reduction of 16% in PMR-D1 (p = 0.0001), a 14% reduction in SBR (p = 0.002) and a 20% reduction NMR-D1 (p = 0.006).ConclusionsIn the Nagpur-HBB-FS, PMR-D1, stillbirths and NMR-D1 were significantly lower after HBB implementation. These benefits did not translate to improvements in PMR-D7 in communities served by these facilities, possibly because facilities in which HBB was implemented covered an insufficient proportion of community births or because additional interventions are needed after day 1 of life. Further studies are needed to determine how to translate facility-based improvements in PMR-D1 to improved neonatal survival in the community.Trial registrationThe Global Network HBB Implementation Study (GN-HBB-IS) was registered at ClinicalTrials.gov: NCT01681017.

Globally, stillbirths account for 2.7 million infant deaths each year, with the vast majority occurring in sub-Saharan Africa and South Asia. Approximately 900,000 infants die due to birth asphyxia. The focus of the Helping Babies Breathe (HBB) program is to help the nonbreathing infant to breathe within the first minute of life, termed the "Golden Minute." To present a multinational interprofessional development program utilizing the train-the-trainer methodology for HBB to address neonatal morbidity and mortality. Involving nursing students in collaboration with established global partners provided an innovative method of professional development. Lessons learned and challenges will be shared to enhance success of future efforts. HBB train-the-trainer workshops were held to provide professional development for nurses and nursing students in 5 locations in 4 countries including Ethiopia, India, Vietnam, and Zambia. Workshop participants and the trainers participated in discussions and informal conversation to assess impact on professional development. HBB training and train-the-trainer workshops were implemented in 4 counties. Equipment and supplies were provided in these countries through several internal university grants. All 145 participants demonstrated increased knowledge and skills at the end of the workshops through the HBB check off. Collaborative teaching and cross-cultural professional skills were enhanced in student and faculty trainers. Nurses, midwives, and advance practice nurses can engage globally and contribute to closing this gap in knowledge and skills by providing train-the-trainer workshops. Developing systems to integrate the HBB program within each country's existing healthcare infrastructure promotes in-country ownership. Joining the global effort to save the lives of neonates can be a meaningful opportunity for innovative professional development projects. While HBB education has been shown to save lives, a 1-time training is insufficient. Determining how often HBB updates or refreshers are required to maintain skills is an important next step. Another direction for research is to implement this project within prelicensure nursing programs.

Aims & Objectives: Philippines has a persistently high neonatal mortality rate (14 per 1,000 live births). Helping Babies Breathe (HBB) simulation training has led to reductions in early neonatal mortality. However, data is lacking in application of skills taught in HBB such as bag valve mask (BMV) in clinical practice. In our study, HBB trainings were held for local nurses and midwives in the Philippines. Follow-up of HBB skills both at refresher training and at live deliveries in local hospitals was used to assess skill retention and application post-training. Methods: HBB trainings were held for local nurses and midwives in the Philippines over two days in August 2018. Follow-up of HBB skills was assessed in two settings: in refresher classes 12 months post-training (n=11) and at live deliveries in local hospitals 6 to 12 months post-training (n=14). Adherence to HBB skills was assesed using the validated HBB OSCE B. Results: At 12-month follow-up, passing rate for HBB OSCE B was 81%. Time to initiate BMV worsened from an average of 90.0 seconds to 135.9 seconds, with only 2 providers achieving successful BMV within the “Golden Minute” compared to 6 immediately post-training. In clinical practice, 93% of birth attendants followed HBB protocol for normal newborn care, though zero of 3 newborns received BMV when indicated. Conclusions: Some essential skills have been adopted by trainees that persist after HBB training. Future training sessions should focus on skill retention and initiation of adequate BMV within the “Golden Minute” after birth, as this skill was not observed in clinical practice.

IntroductionMost neonatal deaths occur in the first week of life, due to birth asphyxia. Helping Babies Breathe (HBB), is a simulation-based neonatal resuscitation training program to improve knowledge and skills. There is little information on which knowledge items or skill steps are challenging for the learners.MethodsWe used training data from NICHD's Global Network study to understand the items most challenging for Birth Attendants (BA) to guide future curriculum modifications. HBB training was provided in 15 primary, secondary and tertiary level care facilities in Nagpur, India. Refresher training was provided 6 months later. Each knowledge item and skill step was ranked from difficulty level 1 to 6 based on whether 91%–100%, 81%–90%, 71%–80%, 61%–70%, 51%–60% or <50% of learners answered/performed the step correctly.ResultsThe initial HBB training was conducted in 272 physicians and 516 midwives of which 78 (28%) physicians and 161 (31%) midwives received refresher training. Questions related to timing of cord clamping, management of a meconium-stained baby, and steps to improve ventilation were most difficult for both physicians and midwives. The initial steps of Objective Structured Clinical Examination (OSCE)-A i.e. equipment checking, removing wet linen and immediate skin-to-skin contact were most difficult for both groups. Midwives missed stimulating newborns while physicians missed cord clamping and communicating with mother. In OSCE-B, starting ventilation in the first minute of life was the most missed step after both initial and 6 months refresher training for physicians and midwives. At the retraining, the retention was worst for cutting the cord (physicians level 3), optimal rate of ventilation, improving ventilation & counting heart rate (midwives level 3), calling for help (both groups level 3) and scenario ending step of monitoring the baby and communicating with mother (physicians level 4, midwives 3).ConclusionAll BAs found skill testing more difficult than knowledge testing. The difficulty level was more for midwives than for physicians. So, the HBB training duration and frequency of retraining can be tailored accordingly. This study will also inform subsequent refinement in the curriculum so that both trainers and trainees will be able to achieve the required proficiency.

This study aimed to evaluate the Health care providers (nurses) performance regarding helping babies breathe during neonatal resuscitation. Research design: descriptive analytical study. Setting: The study was conducted at the delivery room of Obstetric and Gynecological Hospital affiliated to Ain Shams University Hospitals. Subjects: A purposive sample composed of 50 health care providers (nurses, assistance nurses trainee and nursing staff) who, attended and receive the baby for resuscitation at the previously mentioned setting over a 6 months period regardless of their residence, age and gender. Tools: A predesigned questionnaire sheet to assist health care providers (nurses) knowledge regarding helping baby breath and an observation checklist to assess health care providers (nurses) performance regarding helping babies breathe. Results: the study revealed that there was Almost three quarters studied sample had poor score for total knowledge, compared with less than one quarters had average score. Almost less than two thirds of the studied nurse had incompetent performance regarding helping baby breath, There was a positive correlation between total knowledge of the studied nurses and their total performance regarding helping baby breath Conclusion: Based on finding of the present study and answering research question, more than three quarters of the studied health care providers (nurses) had poor score level of knowledge regarding helping babies breathe, more than one fifth of the studied health care providers (nurses) had incompetent performance regarding helping baby breath, and there were positive correlation between total knowledge of the studied nurses and their total performance regarding helping babies breathe. Recommendation: upgrade health care providers' knowledge regarding helping babies breathe through continuous educational program. Enhance health care providers (nurses) practice according to helping babies breathe. Further researches are required involving all health care providers not only nurses about helping babies breathe at different study all over Egypt..

BackgroundHealth professionals equipped with the adequate skills of helping baby breath remain the backbone in the health system in improving neonatal outcomes. However, there is a great controversy between studies to show the proximate factors of the skills of health care providers in helping babies breathe. In Ethiopia, there is a paucity of evidence on the current status of health care provider’s skills of helping babies breathe despite the improvement in neonatal health care services. Therefore, this study intends to fill those gaps in assessing the skills of helping babies breathe and its associated factors among health professionals in public hospitals in Southern Ethiopia.MethodsA facility-based cross-sectional study was conducted among 441 health professionals from March 10 to 30, 2019. A simple random sampling method was used to select the study participants. The data were collected through pre-tested interviewer-administered questionnaire and observational checklist. A binary logistic regression model was used to identify significant factors for the skills of helping babies breathe by using SPSS version 25. The P-value < 0.05 used to declare statistical significance.ResultsOverall, 71.1% (95%CI: 66.2, 75.4%) of health professionals had good skills in helping babies breathe. Age group from 25 to 34 (AOR = 2.24; 95%CI: 1.04, 4.81), training on helping babies breathe (AOR = 2.69; 95%CI: 1.49, 4.87), well-equipped facility (AOR = 2.15; 95%CI: 1.09, 4.25), and adequate knowledge on helping babies breathe (AOR = 2.21; 95%CI: 1.25, 3.89) were significantly associated with a health professionals good skill on helping babies breathe.ConclusionsEven though a significant number of care providers had good skills in helping babies breathe, yet there is a need to further improve the skills of the provider in helping babies breathe. Hence, health facilities should be equipped with adequate materials and facilitate frequent training to the provider.

BackgroundResponding to stagnating neonatal mortality rates in Ghana, a five-year collaboration called Making Every Baby Count Initiative (MEBCI) was undertaken to improve the quality of newborn care provided around the time of birth. A multi-pronged approach was used to build health worker (HW) capacity in resuscitation, essential newborn care, and infection prevention using a curriculum built on the American Academy of Pediatric’s (AAP) Helping Babies Breathe (HBB) and Essential Care for Every Baby (ECEB) modules with an added section on infection prevention (IP).MethodsMEBCI used a training of trainer’s approach to train 3688 health workers from district-level facilities in four regions in Ghana between June 2015 and July 2017. Prior to training, HWs familiarized themselves with the learning materials. Concurrently, MEBCI worked to improve enabling environments that would sustain the increased capacity of trained health workers. Knowledge and skills gained were tested using AAP’s Knowledge checklist and validated single-scenario Objective Structured Clinical Examinations (OSCEs) tools.Findings: Majority of HWs trained were midwives (58.8%) and came from district-level hospitals (88.4%). Most HWs passed the HBB OSCE (99.9%, 3436/3440). Age of doctors was negatively associated with HBB scores (r = − 0.16, p = 0.0312). Similarly, older midwives had lower HBB scores (r = − 0.33, p value < 0.001). Initiating ventilation within the Golden Minute was challenging for HWs (78.5% passed) across all regions. Overall, the pass rate for ECEB OSCEs was 99.9% in all regions. Classify newborn for further care and communicate plan to family were frequent challenges observed in Volta Region (69.5% and 72.0% pass rate respectively). HWs less than 40 years of age performed significantly better than health workers older than 40 years (p = 0.023). Age of only paediatricians was positively associated with ECEB scores (r = 0.77, p < 0.001) while age of midwives was negatively associated with ECEB scores (r = − 0.08, p < 0.001).ConclusionMEBCI’s integrated HBB-ECEB-IP training resulted in significant mastery of the clinical knowledge and skills of HWs. Harmonization and standardization of the course delivery by trainers and having a core team to ensure training fidelity are essential to maintaining high quality while scaling a program nationally.FundingChildren’s Investment Fund Foundation (CIFF).

BackgroundTraining in neonatal resuscitation has been shown to reduce deaths related to intrapartum asphyxia. Helping Babies Breathe (HBB) is a simulation-based program focusing on training healthcare providers (HCPs) in immediate neonatal care including stimulation, initiating bag mask ventilation (BMV) in the absence of breathing by 1 min of life, and delayed (30–60 s after birth) umbilical cord clamping (DCC). Data on implementation of HBB posttraining are limited.ObjectiveTo determine time from birth to spontaneous breathing, cord clamping, and initiation of BMV in a setting where the majority of HCPs are HBB trained.MethodsTwo research nurses observed deliveries conducted in two referral hospitals. Timing included the onset of breathing, cord clamping, and initiation of BMV. Deliveries were grouped according to the mode of delivery.ResultsIn total, 496 neonates were observed; 410 (82.7%) neonates cried or had spontaneous breathing (median time 17 s) soon after birth, 25/86 (29%) of neonates not breathing responded to stimulation, 61 (12.3%) neonates required BMV, and 2 (0.4%) neonates required chest compression and/or adrenalin. Neonates delivered by cesarean section (CS) took longer to initiate first breath than those delivered vaginally (median time 19 vs. 14 s; p = 0.009). Complete data were available in 58/61 (95%) neonates receiving BMV, which was initiated in 54/58 (93%) cases within 60 s of life (the “Golden Minute”). Median time to cord clamping was 74 s, with 414 (83.5%) and 313 (63.0%) having cord clamped at ≥ 30 and ≥ 60 s, respectively. Factors associated with BMV were CS delivery [odds ratio (OR) 29.9; 95% CI 3.37–229], low birth weight (LBW) (birthweight < 2,500 g) (OR 2.47; 95% CI 1.93–5.91), and 1 min Apgar score < 7 (OR 149; 95% CI 49.3–5,021). DCC (≥ 60 s) was less likely following CS delivery (OR 0.14; 95% CI 0.02–0.99) and being LBW (OR 0.43; 95% CI 0.24–0.77).ConclusionApproximately 83% of neonates initiated spontaneous breathing soon after birth and 29% of neonates not breathing responded to physical stimulation. BMV was initiated within the Golden Minute in most neonates, but under two-thirds had DCC (≥60 s). HBB implementation followed guidelines, suggesting that knowledge and skills taught from HBB are retained and applied by HCP.

Birth asphyxia, defined as the failure to establish breathing at birth, accounts for an estimated 900,000 deaths yearly.In our projects during 2021, it ranked as the second leading cause of neonatal death, only after low birth weight/prematurity complications, and accounted for 25% of all neonatal inpatient mortality (441 out of 1768 total neonatal deaths).Helping Babies Breathe (HBB) is an evidence and skills-based educational programme developed to teach neonatal resuscitation in resource-limited settings.The programme emphasises critical steps within the "Golden Minute" after birth, including drying, stimulating, and warming babies who fail to breath at birth alongside bag-and-mask ventilation for infants who continue to experience breathing difficulties despite initial interventions.Notably, the implementation of HBB has been shown to reduce early neonatal mortality by 47% in Tanzania 1 .In collaboration, MSF Spain's medical department and learning unit developed a comprehensive training implementation plan.Their objective was to enhance basic neonatal resuscitation skills among all medical and paramedical staff involved in assisting deliveries, using the HBB programme.The final goal was to cover all target staff across MSF Spain health facilities on the assumption that a large proportion of deaths and complications related to birth asphyxia can be prevented.

BackgroundThe Golden Minute®, the first minute following birth of a newborn, is a critical period for establishing ventilation after delivery, as emphasized in the Helping Babies Breathe® and other resuscitation training programs. Previous studies have reinforced training through observers’ evaluation of this time period; although observation is useful for research, it may not be a sustainable method to support resuscitation practice in low-resource settings where few birth attendants are available. In order to reinforce resuscitation within The Golden Minute®, we sought to develop a simple mobile delivery-room timer on an Android cell phone platform for birth attendants to use at the time of delivery.MethodsWe developed and evaluated a mobile delivery room timer to document the time interval from birth to the initiation of newborn crying/spontaneous respiration or bag and mask ventilation in a convenience sample of women who delivered in five hospitals in Karnataka, India. The mobile delivery room timer is an Android cell phone-based application that recorded key events including crowning, delivery, and crying/spontaneous respiration or bag and mask ventilation. The mobile delivery room timer recorded the birth attendant verbally indicating the time of crowning, birth-(defined as when the entire baby was delivered), crying/spontaneous respiration or bag and mask ventilation. The mobile delivery room timer results were validated in a subsample by a trained observer (nurse) who independently recorded the time between delivery and initiation of crying/spontaneous respiration or bag and mask ventilation.ResultsOf the total 4,597 deliveries, 2,107 (46 %) were timed; a sample (n = 438) of these deliveries was also observed by a trained nurse. There was high concordance between the mobile delivery room timer and observed time elapsed between birth and crying/spontaneous respiration or ventilation (correlation =0.94, p < 0.0001). The majority of neonates in both groups cried/breathed spontaneously or received bag and mask ventilation by 1 min (430/438 by the timer vs. 433/438 for observer).ConclusionsWe demonstrated that a simple mobile delivery room timer application was feasible to use during delivery and provided valid observations of the time to crying/spontaneous respiration or bag and mask ventilation. This type of tool may be useful in reinforcing neonatal resuscitation training and the need to ensure spontaneous or assisted ventilation by The Golden Minute®.

BackgroundNeonatal deaths account for over 40% of all under-5 year deaths; their reduction is increasingly critical for achieving Millennium Development Goal 4. An estimated 3 million newborns die annually during their first month of life; half of these deaths occur during delivery or within 24 hours. Every year, 6 million babies require help to breathe immediately after birth. Resuscitation training to help babies breathe and prevent/manage birth asphyxia is not routine in low-middle income facility settings. Helping Babies Breathe (HBB), a simulation-training program for babies wherever they are born, was developed for use in low-middle income countries. We evaluated whether HBB training of facility birth attendants reduces perinatal mortality in the Eunice Kennedy Shriver National Institute of Child Health and Human Development’s Global Network research sites.Methods/designWe hypothesize that a two-year prospective pre-post study to evaluate the impact of a facility-based training package, including HBB and essential newborn care, will reduce all perinatal mortality (fresh stillbirth or neonatal death prior to 7 days) among the Global Network’s Maternal Neonatal Health Registry births ≥1500 grams in the study clusters served by the facilities. We will also evaluate the effectiveness of the HBB training program changing on facility-based perinatal mortality and resuscitation practices. Seventy-one health facilities serving 52 geographically-defined study clusters in Belgaum and Nagpur, India, and Eldoret, Kenya, and 30,000 women will be included. Primary outcome data will be collected by staff not involved in the HBB intervention. Additional data on resuscitations, resuscitation debriefings, death audits, quality monitoring and improvement will be collected. HBB training will include training of MTs, facility level birth attendants, and quality monitoring and improvement activities.DiscussionOur study will evaluate the effect of a HBB/ENC training and quality monitoring and improvement package on perinatal mortality using a large multicenter design and approach in 71 resource-limited health facilities, leveraging an existing birth registry to provide neonatal outcomes through day 7. The study will provide the evidence base, lessons learned, and best practices that will be essential to guiding future policy and investment in neonatal resuscitation.Trial registrationTrial registration ClinicalTrials.gov Identifier: NCT01681017

BackgroundBirth asphyxia is one of the significant causes of neonatal deaths in Pakistan. Poor newborn resuscitation skills of birth attendants are a major cause of neonatal mortality in low resource settings across the globe. This study aimed to evaluate the effectiveness of the Simulation-Based High-Frequency training of the Helping Babies Breathe for Community Midwives (CMW), in district Gujrat, Pakistan.MethodA pre-post-test interventional study design was used. The universal sampling technique was employed to recruit 50 deployed CMWs in the entire district of Gujrat. The pre-tested module and tools of Helping Babies Breathe (2nd edition) were used in the intervention. Using the High Frequency training approach, three one-day training sessions were conducted for CMWs at an interval of 2 months. During the 2 months interval, participants were monitored and supported to practice their skills at their birthing centers. Knowledge and skills were assessed before and after each session. The McNemar and Cochran’s Q tests were applied for data analysis. Participants’ feedback was also obtained at the end of each training, which was analyzed through descriptive statistics.ResultsData from 34 CMWs were analyzed as they completed all three training sessions and assessments. The results were statistically different after each training session for OSCE B (p-value < 0.05). However, for knowledge and OSCE A, significant improvement was observed after training sessions 1 and 2 only. Pairwise comparison showed that pre-assessment at training 1 was significantly different from most of the repeated measures of knowledge, OSCE A, and OSCE B. Moreover, the learners appreciated the overall training in terms of organization, content, material, assessment, and overall competency. Additionally, due to a small sample size of the CMWs, and a short time of the intervention, significant differences in morbidity and mortality outcomes could not be detected.ConclusionThe study concluded that a series of training and continuous supportive supervision and facilitation enhances Helping Babies Breathe (HBB) knowledge retention and skills. The study recommends, periodic, structured and precise HBB trainings, with ongoing quality monitoring activities through blended learning modalities would help sustain and scale-up the intervention.

Introduction: Simulation based education is an intervention that enable students to become competent in performing clinical skills. The study aimed to find out the effectiveness of simulation-based education on competencies on performing Helping Babies Breathe (HBB)and perceived self-efficacy on performing Helping Babies Breathe among nursing students. Methods: Pre-experimental study design was adopted. Total 40 nursing students of BSc third year were included. Initially, pre-intervention data was obtained and simulation-based intervention on skills practice on Helping Babies Breathe was intervene by research team members based on HBB guideline and post-intervention data was obtained after 4 weeks of intervention. Data were analysed by using descriptive and inferential statistics specifically, paired t-test and Wilcoxon test was used Results: All most all participants were able to initiate effective ventilation within a minute in post-test. The skills scores on performing all the steps of effective ventilation in post-test were increased. Specifically, there is a significant increased on skills score on initial steps of HBB after intervention with (p=0.001), birth time to initiation of effective ventilation (p= 0.002), continuing effective ventilation (p=0.005) and on overall skill competencies for performing HBB per minute (p=0.000). Regarding their perceived self-efficacy on performing HBB, score was higher on all aspects after intervention. Conclusions: Statistical significant increased scores on skills on performing Helping Babies Breathe (HBB)on post-test than pre-test signifies that simulation based education on HBB is effective on increasing skills competencies among nursing students and enhancing their perceived self-efficacy. Thus, skills practice on HBB is recommended to promote among nursing students in simulated labs.

Rationale: The Helping Babies Breathe (HBB) curriculum is an established, effective method to combat neonatal mortality worldwide. However, during the COVID-19 pandemic international travel largely ceased. In 2020 there were six HBB courses taught, compared to over 100 global trips and master training courses taught in 2019. In 2020, learners at all levels began utilizing video-based platforms for meetings, lectures, and even social activities. In the present study, we analyzed whether HBB could be modified into a video-based course. Methods: Prior to the start of the course, two HBB master trainers modified the HBB curriculum into a condensed hybrid course. Participants were randomly divided into two cohorts based on learner type;an in-person learner group and a “Zoom” learner group in a separate conference room. Participants were given a pre and post-course confidence survey consisting of 10 statements answered using a 10-point Likert scale. Responses were assigned a numerical value from zero to nine, with increasing numerical value indicating increased confidence. Data were analyzed using IBM SPSS to run Wilcoxon signed rank tests to compare pre and post-test responses. After the course, each participant completed a previously validated written knowledge check and was observed by a trained instructor on two objective structured clinical examinations (OSCE). All participants passed both the knowledge check and both OSCE's. Results: Figure 1 shows the average Likert scale score for each survey question pre-course and postcourse by learner type. Figure 1: Pre and Post HBB Course Confidence Rating by Learner Type When comparing pre-and post-course survey data among the in-person learners, all questions had a statistically significant increase in confidence (p=0.005). Among Zoom learners, there was also a statistically significant increase from pre-course to post-course confidence (p=0.005). There was no statistically significant difference between the Zoom or In Person learners' confidence in skills or knowledge (p= 0.747). Conclusions: Our data shows teaching HBB through a video-based platform is an effective alternative to in-person learning. The development of this course serves as a model for global health education, with large impacts both during and after the current pandemic. This model would reduce the monetary cost of HBB training trips, and has the potential to reach delivery providers in rural or unsafe areas that were previously inaccessible. In addition, follow up studies show that long term skill acquisition declines over time. Video-communication platforms would facilitate the implementation of frequent reassessments in areas with existing HBB infrastructure.

Globally, deaths around the time of birth are unacceptably high of which there are about 2.7 million neonatal deaths and 2.6 million stillborn annually. Perinatal mortality accounts for deaths after 28 weeks of gestation to seven days after birth. Perinatal mortality is a public health concern with a huge impact on the health, social and economic well being affecting both family and society. The burden of perinatal mortality is obvious in the low and middle-income countries, and more on the countries south of sub-Sahara Africa. East Africa being among the sub-Sahara countries is also experiencing a high rate of perinatal mortally, with Tanzania taking the lead. Almost half of stillborns are alive at the start of labor offering an opportunity for prevention. Likewise, 44% of the neonatal deaths occur on the first day of life and are predominantly the result of intrapartum events. Events during labor, including birth asphyxia (interruption of placental blood flow) account for one-quarter of the global newborn deaths. These deaths can be substantially reduced by improving quality of care around the time of labor and childbirth. The Helping Babies Breathe (HBB) curriculum, involves training to improve knowledge and skills of midwives and other birth attendants, to provide improved basic care to new-borns including timely breathing support and as a consequence to improve newborn survival as needed. It became apparent the course did not alter outcome following one day training i.e. improve survival. This pointed to the need for more frequent training. Thus the concept of frequent brief onsite simulation (FBOS) HBB training was introduced at Haydom Lutheran Hospital as part of continuous quality improvement (CQI), in an effort to reduce perinatal mortality. This became the central thrust of this thesis as described below. Aim: The aim of this thesis is to evaluate the process and impact for optimizing implementation of HBB project to improve early perinatal outcome at Haydom Lutheran Hospital, a rural referral hospital in north-central in Tanzania. Method: We conducted three studies between February 2011 and January 2017 to evaluate the process and impact of HBB project to improve early perinatal outcome. The study site was labor ward and operating theatre at Haydom Lutheran hospital. The study intervention involved implementation of FBOS training using a low fidelity manikin with the ability to provide bag/mask ventilation and feel a pulse on different simulation scenarios and also having repeated feedback. Study I was a one-year project from February 2011 through January 2012 that involved FBOS. This was a before-after prospective education intervention study in a cohort of midwives (birth attendants), pregnant women attending to give birth and their newborns. The labor management process and outcomes of birth in the first 24hrs were evaluated. The outcome of pregnancy (n=4814) was compared to a baseline period (n=4894), which was also a one-year period between February 2010 through January 2011. Secondary outcomes included care provider change in behavior i.e. frequency in resuscitation practice, labor management which involved, fetal heart rate monitoring, mode of delivery and resuscitation practice. Study II was a five years follow-up from February 2011 through January 2016. Perinatal outcome during the study period was compared to the baseline period as in study I (Feb. 2010 through Jan 2011). The study involved continuous observation to trace and document perinatal outcomes over time and evaluate the implementation process. The cohort involved 22,176 newborns and compared the outcome to the baseline (n=4894). Factors included in the analysis involved those with potential co-relationship with perinatal outcomes as interventions, administrative events and facility process. Study III was also a continuous observation to trace and document perinatal outcomes as in study II. The cohort involved a total of 31122 newborns of which intervention period was for six years from Feb 2011 through Jan 2017 with 26220 newborns and one year of baseline period (Feb 2010 through Jan 2011). Logistic regression modeling was used to construct risk-adjusted variable-life adjusted display (VLAD) and cumulative sum (CUSUM) plots to monitor changes in perinatal survival (primary outcome). Plots of unadjusted changes in perinatal risks were compared to risks adjusted plots. Results: In Study I, There was a significant reduction in early neonatal mortality rate (eNMR) from 11.1/1000 during baseline to 7.2/1000 (p0.040) after implementation of FBOS HBB training. During the period, the proportion of resuscitation through stimulation increased from 14.5% to 16.3% (p 0.016), and suction increased from 13.0% to 15.8% (p ≤ 0.0005) while the proportion receiving bag-mask ventilation (BMV) decreased from 7.3% to 5.9% (p ≤ 0.005) in Cohort 1 versus Cohort 2, respectively. In study II, the CUSUM plot in most of the period was lower than the baseline level of 2.7% with slight variation on ePMR months indicating reduction after implementation of FBOS HBB training. In the VLAD plot there was a continuous upward trend on cumulative monthly number of lives saved compared to baseline, with few fluctuations indicating that the outcome (perinatal survival) was better than in the baseline. The trend indicated continuous improvement in perinatal outcome during the five years follow-up period. The trend of outcomes had some variations in some point, which could be linked with different interventions and events of which improvement in survival linked refresher HBB training and reduced survival linked trained midwifes leaving the hospital and new recruited who have not attended FBOS HBB training. The VLAD plot showed an overall positive trend, reflecting more than 120 extra lives saved over the 5-year period. In study III, Persistent and steady increase in perinatal survival was observed following implementation of FBOS HBB training. Six years follow-up revealed 150 extra lives saved according to VLAD plot. After adjusting for the risk factors VLAD plot indicated that an estimated 250 extra lives were saved which indicate that survival was maintained even when the cohort included high risks cases indicating a further improvement in survival compared to when the risks were not considered. Conclusion: This PhD project show that optimizing the implementation of FBOS simulation training is associated with improvement on clinical practice and neonatal survival. This is the first published report that documented the important association of FBOS and reduce neonatal mortality. During the CQI, continuous evaluation in the SPC revealed that the improvement in perinatal outcome matched with the activities related to FBOS training. Additionally, the reduction on perinatal mortality was even more evident when adjusting for risks in the cohort. To conclude, optimizing implementation of HBB training has the potential to improve perinatal outcome.