Helping Babies to Breathe Wherever They Are Born

Denver, CO—“Helping Babies Breathe,” a life-saving program from the American Academy of Pediatrics, is reaching underserved neonatal populations around the globe.

At the Association of Women’s Health, Obstetric and Neonatal Nurses 2011 annual convention, Susan Niermeyer, MD, MPH, Professor of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Denver, described the program she heads up, which is aimed at protecting neonates during “the golden minute” of life.

Accentuating the huge disparity between the most and the least developed countries, Dr Niermeyer noted that 98% of babies who die are born in low- to middle-income countries. “Even within countries, there are health disparities wherever you look, down to the level of the community,” she said.

Globally, inadequate coverage and quality of intrapartum care is a characteristic of 60 million births that occur within homes each year. The consequences of acute intrapartum events are often neonatal encephalopathy and long-term impairment, and for 814,000 newborns, death.

Almost half of these neonatal deaths occur in the first 24 hours, “the time of lowest coverage with skilled attention” in the developing world, she said. This is most often the result of preterm birth, severe infections, or asphyxia. Mechanical problems of labor and placental insufficiency are frequent reasons for a baby to be born not breathing, she added.

It has been especially hard to intervene against asphyxia. In countries such as Kenya, for example, more than 50% of births occur in the home, only 22% are managed by an attendant trained in neonatal resuscitation, and only 7% have the benefit of resuscitation equipment.

 www.helpingbabiesbreathe.org. Helping Babies Breathe is also on Facebook and linked on the Healthy Newborn Network." src="/sites/default/files/imgvol3no5pg10.png" style="width: 399px; height: 270px;" /> 
Master trainers in Tanzania invite everyone to follow the latest developments with
Helping Babies Breathe on the website, www.helpingbabiesbreathe.org. Helping Babies
Breathe is also on Facebook and linked on the Healthy Newborn Network.

Figure This neonatal simulator is purpose-built with crying, breathing, and heart rate
(umbilical cord pulse). The mannequin ships flat, but when filled with 2 liters of warm
water, it has the weight, the warmth, and the tone of a baby who needs help to breathe.

Strong evidence indicates that resuscitation training could prevent many of these complications, “but there has not been a readily available tool that can be taken around the world,” Dr Niermeyer said.

A Systematic Problem

Neonatal complications in the acute intrapartum period represent a “systematic problem” that begins at the household and community level and extends to the highest level of the healthcare system. Delays in seeking care are common. “A crucial first step is for mothers to decide they can benefit from going to facilities to deliver,” she said.

Second, transportation to such centers often is lacking; and third, highquality care may be lacking as well. In general, in-facility births do offer better care and should be the primary target for interventions, she said.

“However, the whole system must be impacted to make meaningful improvements in neonatal survival,” she added.

Interventions That Work

In helping newborns to breathe, at least 80% of the effort should be aimed at proper assessment and routine intrapartum care. Ten percent should be aimed at infants who need drying, warming, clearing the airway, and stimulation. About 6% should be directed toward aid with bag and mask ventilation, and 1% toward those requiring chest compressions and medications.

“We translated this information into a program that emphasizes basic steps that will be effective in most situations,” Dr Niermeyer said. “A huge part is to draw attention to the moment of birth as the time of greatest risk: the golden minute, when a simple intervention can be life-saving if it is timely and is done correctly.”

The Helping Babies Breathe program, supported by scientific evidence, is harmonized with international health policy and has been evaluated formally for content and methodology by field testing in Kenya, Pakistan, Tanzania, India, and Bangladesh.

The program is aimed at attendants who are the sole person at the birth responsible for the baby, “which is the reality in most countries,” she pointed out. “Even having a single person at the delivery is a luxury for many women.” The program is based on visual imagery, using simple pictorial aids and flip charts that are linked to an action plan geared to the 5th- or 6th-grade learning level. The facilitator starts by teaching that most babies cry at birth, and one who does not cry needs help to breathe. This progresses to skill building using a hands-on approach with the use of a neonatal simulator that has the weight and tone of a baby needing resuscitation (Figure).

The simulator is not only “a powerful learning paradigm” for attendants, but is also something of a “selling point” to women who are skeptical about delivering in a facility. A nurse in Kenya claimed to have nothing to convince families to come into the facility to deliver, but after training on the simulator, she can attest to the potential for a safer birth there. “For the first time, this moves her community to a more modern level of neonatal care delivery,” Dr Niermeyer said.

The program is being implemented in 25 countries. Outcomes data are just emerging, showing improved survival and health status for births attended by persons trained in this program. In Tanzania, where more than 7000 deliveries have occurred after the training of traditional birth attendants, neonatal deaths within 24 hours have been reduced by 54%. In India, with more than 5000 posttraining deliveries, neonatal deaths have not changed but stillbirths have been reduced by 27%, she reported.

“We think these are encouraging results,” Dr Niermeyer said. “Training does make a difference in important outcomes.”