Course: Helping Babies Breathe (HBB) is a new evidence-based neonatal resuscitation education curriculum specifically designed for low resource countries

Goal:Describe efficacy of teaching HBB in the real-world setting of Maseru, Lesotho

Background: •First hour & day are critical times in newborn survival, 60-70% of neonatal deaths occur within 24 hrs1,2

•Common causes of neonatal death3:•Birth asphyxia•Infection•Prematurity

• ~27-30% of neonatal deaths are from birth asphyxia or failure to initiate and sustain breaths at birth4

•Lesotho: •Population ~2 million5

•Infant mortality 91/1000 live births (2010) 6

Course: Helping Babies Breathe (HBB) is a new evidence-based neonatal resuscitation education curriculum specifically designed for low resource countries

Goal:Describe efficacy of teaching HBB in the real-world setting of Maseru, Lesotho

Background: •First hour & day are critical times in newborn survival, 60-70% of neonatal deaths occur within 24 hrs1,2

•Common causes of neonatal death3:•Birth asphyxia•Infection•Prematurity

• ~27-30% of neonatal deaths are from birth asphyxia or failure to initiate and sustain breaths at birth4

•Lesotho: •Population ~2 million5

•Infant mortality 91/1000 live births (2010) 6

Knowledge, Skills, and Use of Neonatal Resuscitation in Lesotho, Before and After Participation in a Helping Babies Breathe Train-the-Trainer Program

Jennifer Werdenberg MD*~, Rebecca Hoban MD MPH+, Acacia Cognata MD MSPH*, Asad Moten BS#, Norma Perez DO**, Lineo Thahane*~ MD, Edith Mohapi, MD*~, Elizabeth Montgomery MD MPH*~^

*Baylor College of Medicine Dept. of Pediatrics, ~Baylor International Pediatric AIDS Initiative (BIPAI); +Tufts U. Dept. of Pediatrics, Section of Neonatology; # Harvard-MIT School of Bioengineering; **UT-H Dept. of Pediatrics, Section of Infectious Diseases; ^Baylor College of Medicine, Dept. of Pediatrics, Section of Retrovirology & Global Health

Methods:•Evaluation of improved knowledge via:

•Pre- and post-testing of knowledge via 16-question multiple-choice questionnaire (MCQ)

•Pre- and post-test bag-mask ventilation (BMV) skills assessed using 7-item validated checklist

•Post-training objective structured clinical exams (OSCE) utilizing case-based neonatal scenarios

•OSCE #1: scenario required learner to perform stimulation & suctioning on mannequin

•OSCE #2: scenario required full resuscitation of mannequin with BMV & heart rate checks

•Post-course qualitative survey

•Evaluation of knowledge retention and dissemination of course by trainers via:•3-8 and 9-12 month follow-up post-test (remaining data will be collected 9-12

months after course) •9-12 month survey (remaining data will be collected 9-12 months after course)

Methods:•Evaluation of improved knowledge via:

•Pre- and post-testing of knowledge via 16-question multiple-choice questionnaire (MCQ)

•Pre- and post-test bag-mask ventilation (BMV) skills assessed using 7-item validated checklist

•Post-training objective structured clinical exams (OSCE) utilizing case-based neonatal scenarios

•OSCE #1: scenario required learner to perform stimulation & suctioning on mannequin

•OSCE #2: scenario required full resuscitation of mannequin with BMV & heart rate checks

•Post-course qualitative survey

•Evaluation of knowledge retention and dissemination of course by trainers via:•3-8 and 9-12 month follow-up post-test (remaining data will be collected 9-12

months after course) •9-12 month survey (remaining data will be collected 9-12 months after course)

Learner characteristics (n = 17)•15/17 (88%) of learners are nurse midwives•13/17 (76%) work in community-level clinic or health center •4/17 (24%) work at a district, regional, or national hospital •17/17 (100%) report previous use of BMV, although not all report previous training•5/17 (29%) had been trained on a simulator before this course

Learner characteristics (n = 17)•15/17 (88%) of learners are nurse midwives•13/17 (76%) work in community-level clinic or health center •4/17 (24%) work at a district, regional, or national hospital •17/17 (100%) report previous use of BMV, although not all report previous training•5/17 (29%) had been trained on a simulator before this course

Quantitative Results:

•Comparison of post-test knowledge MCQ taken immediately after the course and 3-8 mo after the course revealed no significant change in score, p >0.01.

Qualitative results:•Learners report confidence that they could save lives at birth and teach these skills to others•Learners report plans to train others within 6 months

Conclusions:•Newborn resuscitation knowledge significantly improved and was retained 3 months after course•Bag-mask ventilation skills significantly improved after HBB course•Post-training OSCE scores indicate learner competency to perform basic neonatal resuscitation

[1] Lawn, JE, Lee ACC, Kinney M, et al. Two million intrapartum-related stillbirths and neonatal deaths: where, why and what can be done? Int J Gynaecol Obstet. 2009; 07(suppl 1)S5-S18, S19 [2] Kruger C, Niemi M, Espeland H et al. The effects of standardised protocols of obstetric and neonatal care on perinatal and early neonatal mortality at a rural hospital in Tanzania. Int Health 2012;4(1):55-62 [3] Black RE, Cousens S, Johnson HL, et al; Child Health Epidemiology Reference Group of WHO and UNICEF. Global, regional and national causes of child mortality in 2008: a systematic analysis. Lancet. 2010;375(9730)1969-1987 [4] Mwaniki MK, Atieno M, Lawn JE, Newton CR. Long term neurodevelopmental outcomes after intrauterine and neonatal insults: a systematic review. Lancet. 2012;379 (9814)445-452 [5] Department of economic and social affairs population division (2009) world population prospects table A1 2008 revision. UN Retrieved 3/12/2009 [6] Lesotho MOH annual joint review report 2011

Quantitative Results:

•Comparison of post-test knowledge MCQ taken immediately after the course and 3-8 mo after the course revealed no significant change in score, p >0.01.

Qualitative results:•Learners report confidence that they could save lives at birth and teach these skills to others•Learners report plans to train others within 6 months

Conclusions:•Newborn resuscitation knowledge significantly improved and was retained 3 months after course•Bag-mask ventilation skills significantly improved after HBB course•Post-training OSCE scores indicate learner competency to perform basic neonatal resuscitation

[1] Lawn, JE, Lee ACC, Kinney M, et al. Two million intrapartum-related stillbirths and neonatal deaths: where, why and what can be done? Int J Gynaecol Obstet. 2009; 07(suppl 1)S5-S18, S19 [2] Kruger C, Niemi M, Espeland H et al. The effects of standardised protocols of obstetric and neonatal care on perinatal and early neonatal mortality at a rural hospital in Tanzania. Int Health 2012;4(1):55-62 [3] Black RE, Cousens S, Johnson HL, et al; Child Health Epidemiology Reference Group of WHO and UNICEF. Global, regional and national causes of child mortality in 2008: a systematic analysis. Lancet. 2010;375(9730)1969-1987 [4] Mwaniki MK, Atieno M, Lawn JE, Newton CR. Long term neurodevelopmental outcomes after intrauterine and neonatal insults: a systematic review. Lancet. 2012;379 (9814)445-452 [5] Department of economic and social affairs population division (2009) world population prospects table A1 2008 revision. UN Retrieved 3/12/2009 [6] Lesotho MOH annual joint review report 2011

Test performed Pre-test # correct avg % correct Post-test mean % correct p-value

Knowledge MCQ (of 16) 12.6 +/ - 1.5 79% 15.7 +/ - 0.5 98% <0.01BMV skills (of 7) 3.7 +/ - 1.4 53% 6.2 +/ - 0.8 89% <0.01

OSCE#1 (of 13) 11.3 +/ - 1.4 87%OSCE#2 (of 18) 16.4 +/ - 1.2 91%

Knowledge MCQ @ 3- months (n = 7) 15 +/- 1.2 94% <0.03

* Immediate post- test n=17

• [1] Lawn, JE, Lee ACC, Kinney M, et al. Two million intrapartum-related stillbirths and neonatal deaths: where, why and what can be done? Int J Gynaecol Obstet. 2009; 07(suppl 1)S5-S18, S19

• [2] Kruger C, Niemi M, Espeland H et all. The effects of standardised protocols of obstetric and neonatal care on perinatal and early neonatal mortality at a rural hospital in Tanzania. Int Health 2012;4(1):55-62

• [3] Black RE, Cousens S, Johnson HL, et al; Child Health Epidemiology Reference Group of WHO and UNICEF. Global, regional and national causes of child mortality in 2008: a systematic analysis. Lancet. 2010;375(9730)1969-1987

• [4] Mwaniki MK, Atieno M, Lawn JE, Newton CR. Long term neurodevelopmental outcomes after intrauterine and neonatal insults: a systematic review. Lancet. 2012;379 (9814)445-452

• [5] Department of economic and social affairs population division (2009) world population prospects table A1 2008 revision. UN Retrieved 3/12/2009

• [6]Lesotho MOH annual joint review report 2011