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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]. |
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