Helping babies breathe (HBB) training: What happens to knowledge and skills over time?

Abstract

Background Millennium Development Goal 4 called for a two-thirds re- duction in mortality of children under 5 years of age from 1990 rates by 2015 [1]. Between 1990 and 2013 under five mortality decreased from 12.7 to 6.3 million annual deaths, but the Millennium Development Goal was not met because the neonatal mortality rate decreased by only 40%, from 4.7 to 2.8 million, during this same time period. Because the de- cline in neonatal mortality was slower than the decline in post neonatal mortality, neonatal mortality represents an in- creasing proportion of the under five deaths (~45%). At current rates, it will be over 150 years before African new- borns have the same chance of survival as a baby born today in Europe or North America [2]. Hence, attention is increas- ingly focusing on reducing neonatal mortality in order to achieve sustainable progress toward future global goals [2–6]. The three leading causes of neonatal mortality worldwide are prematurity (36%), birth asphyxia (23%), and infections (23%) [3]. Neonates who survive birth asphyxia may have such long-term consequences as cerebral palsy, epilepsy, and learning disabilities [7]. An additional 1.2 million intra- partum stillbirths are not included in neonatal mortality rates [3]. Neonatal resuscitation has the potential to prevent perinatal mortality caused by intrapartum related asphyxia for almost two million babies annually [3]. However to be successful, birth attendants (BAs) must be trained to per- form appropriate and adequate neonatal resuscitation in the critical first minutes after birth. The Neonatal Resuscitation Program (NRP) has been the standard of care for resuscitating newborns since 1987 [8, 9]. First Breath, the first controlled resuscitation trial, used simplified versions of NRP and essential new- born care to train BAs in low and middle income coun- tries and demonstrated that essential newborn care, including resuscitation training, significantly reduced still births without increasing the early neonatal mortal- ity rate [10]. Subsequently the American Academy of Pediatrics (AAP), in collaboration with global partners, including Laerdal Medical and The Eunice Kennedy Shriver National Institute of Child Health and Human Develop- ment (NICHD) Global Network for Women’s and Children’s Health Research (Global Network), developed Helping Babies Breathe (HBB), a simulation-based curricu- lum to train facility BAs in resuscitation, in resource limited settings [11–14]. HBB focuses on the initial steps of resuscitation, in- cluding immediate drying of the baby, providing warmth and additional stimulation to breathe, followed by bag and mask ventilation (BMV) if needed, within the first 60 seconds after birth (The Golden MinuteTM ). HBB training materials use multiple approaches (color, graphic icons outlining three simple care paths, and il- lustrations depicting the key elements of skills); draw at- tention to critical decision points; and stress the need to initiate ventilation no later than the end of the first mi- nute after birth [15]. Teaching materials include a Learner Workbook, Facilitator Flip Chart, a neonatal simulator (NeoNatalieTM ) that allows trainers to manipulate cardinal evaluation signs (crying, breathing, heart rate), and an Ac- tion Plan that uses these evaluation signs to guide decision- making and management of the newborn who may range from a healthy wailing newborn to one who needs extra at- tention before crying and breathing well, or one who needs BMV and advanced care. Cohort studies suggest that BAs at various skill levels [14, 16–24] can be trained to effectively resuscitate newborns using the HBB methods; however, less is known about the durability of knowledge and skills and the need for re- training [14, 16, 20, 23]. We recently conducted a study of the effect of HBB training on perinatal survival in three sites of the NICHD Global Network, two sites in India and one in western Kenya [25]. The primary outcomes of the study have already been published [26]. Here we evaluate the effect of HBB training on neonatal resuscitation skills and knowledge, as well as retention of knowledge and skills by physicians and nurses who attended deliveries in facil- ities. The objectives were to evaluate (1) baseline know- ledge and skills of BAs; (2) change in knowledge and skills after HBB training; (3) retention of skills and knowledge until refresher training; (4) the effect of refresher training on knowledge and skills of the BAs: and (5) factors asso- ciated with loss of skills before refresher training. Methods This study was conducted in Global Network sites in Belgaum and Nagpur, India, and Eldoret, Kenya, areas covered by a prospective, population-based registry which was established in 2008 and included all pregnancy and neonatal outcomes through 42 days postpartum in defined geographic catchment areas. The training intervention was delivered in selected health facilities that provided 24-h coverage for deliveries 7 days/week, served a population that had a minimum perinatal mortality rate of 30 per 1000 registry deliveries in the pre-study period, Bang et al. BMC Pregnancy and Childbirth (2016) 16:364 Page 2 of 12 and delivered 40% of the total registry births in the three sites. The study protocol detailing the design was pub- lished previously [25].