Using Helping Mothers Survive toImprove Intrapartum CareCherrie L. Evans, DrPH, CNM, Rosemary Kamunya, DC, MS, Gaudiosa Tibaijuka, MS

abstract Data from the past decade have revealed that neonatal mortality represents a growing burdenof the under-5 mortality rate. To further reduce these deaths, the focus must expand toinclude building capacity of the workforce to provide high-quality obstetric and intrapartumcare. Obstetric complications, such as hypertensive disorders and obstructed labor, aresignificant contributors to neonatal morbidity and mortality. A well-prepared workforce withthe necessary knowledge, skills, attitudes, and motivation is required to rapidly detect andmanage these complications to save both maternal and newborn lives. Traditional off-site,didactic, and lengthy training approaches have not always yielded the desired results. HelpingMothers Survive training was modeled after Helping Babies Breathe and incorporates furtherevidence-based methodology to deliver training on-site to the entire team of providers, whocontinue to practice after training with their peers. Research has revealed that significantgains in health outcomes can be reached by using this approach. In the coronavirus disease2019 era, we must look to translate the best practices of these training programs intoa flexible and sustainable model that can be delivered remotely to maintain quality services towomen and their newborns.

Jhpiego, Baltimore, Maryland

Dr Evans conceptualized the approach of the article, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Kamunya reviewed themanuscript for important programmatic content; Ms Tibaijuka reviewed and edited the manuscript for important content; and all authors approved thefinal manuscript as submitted.

DOI: https://doi.org/10.1542/peds.2020-016915M

Accepted for publication Aug 4, 2020

Address correspondence to Cherrie L. Evans, DrPH, CNM, Technical Leadership and Innovations, Jhpiego, 1615 Thames St, Baltimore, MD 21231.E-mail: cherrie.evans@jhpiego.org

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2020 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: Dr Evans directs the Helping Mothers Survive (HMS) project and is an instructional designer and expert trainer; DrKamunya supports HMS globally as an expert trainer; Ms Tibaijuka supports HMS regionally as an expert trainer and is the technical director of a largeproject in Tanzania that uses both HMS and Helping Babies Survive.

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Although progress has been made innewborn survival, much remains tobe done. Gains in child survival havemeant that newborn deaths make upa larger proportion of under-5mortality. In 2018, neonatal mortalityaccounted for 47% of under-5mortality, compared to 40% in1990.1 To achieve the SustainableDevelopment Goal 3 to decrease theneonatal mortality rate to #12 per1000 live births,2 we must look atthe maternal-infant dyad and bringincreased attention to the qualityof maternal care. Maternalcomplications play a criticalcontribution to the top 3 causes ofneonatal mortality: prematurity, birthasphyxia, and infection.1 For example,hypertensive disorders in pregnancycan result in growth restriction, fetalcompromise, and premature birth.3

Prolonged or obstructed labor, if notaddressed in a timely fashion, mayresult in birth asphyxia and fetaldemise.4 If left unmanaged, prolongedrupture of the membranes may resultin chorioamnionitis and sepsis of thenewborn.5 These complications andothers must be identified andmanaged early to achieve furtherreductions in neonatal mortality.

An appropriately trained anddeployed workforce is key toensuring the quality of maternal andnewborn health care, along withsufficient infrastructure, equipment,consumables, drugs, and robustsupply chains and referral systems.The highest attainable standard ofmental and physical health of thewoman and her newborn, a basichuman right, will never be realizedwithout a well-trained, empowered,and properly remunerated workforce.However, providers’ ability to offerquality care to women and theirnewborns is hampered in somesettings by a lack of the knowledge,skills, and confidence needed toprovide appropriate assessment,monitoring, identification, andmanagement of complications whenthey arise.6 To address these gaps, we

must intensify our efforts in both pre-service and in-service education.

INNOVATIVE TRAINING APPROACHESCAN IMPROVE PROVIDERPERFORMANCE AND HEALTH OUTCOMES

The Helping Babies Breathe (HBB)initiative provided a foundation forthe development of a new model oftraining to reduce maternal andneonatal mortality. It has succeededin improving outcomes of newbornsrequiring help to breathe at birth.7,8

Although HBB met a great trainingand supply need for newbornresuscitation, asphyxia is not the onlycause of neonatal death. To expand onthe HBB initiative and address otherknowledge and skills gaps fornewborn care, complementarynewborn modules were developed bythe American Academy of Pediatrics,including Essential Care for EveryBaby and Essential Care for SmallBabies. In addition, to address gaps inknowledge and skills for maternalcare, a series of Helping MothersSurvive (HMS) training modules weredeveloped by Jhpiego, an affiliate ofJohns Hopkins University, inpartnership with global stakeholders.HMS was purposefully designed tobuild the capacity of the entire teamof providers who care for women andtheir newborns at birth or assistthose who do, including midwives,nurses, doctors, clinical officers, andother assistants.

During development of the first HMSmodule, evidence emerged suggestingthat conventional approaches totraining that rely on workshopsconducted away from the clinicalsetting were not yielding the desiredresults. In 2016, Leslie et al9

demonstrated that traditionaltraining, even when coupled withsupportive supervision, did notmeaningfully improve the care ofpregnant women and children whowere sick. Around this time, newevidence was emerging about themost effective teaching techniques forin-service training.10 A change in

methodology and further innovationwere clearly needed to shift the off-site approach to a more holisticworkforce-capacity building approachto improve provider performance andhealth outcomes.

Recognizing the need for freshtraining approaches and cognizant ofthe fact that the same provider oftencares for both the woman and hernewborn, HMS Bleeding after Birth(BAB) was launched in 2013 toaddress postpartum hemorrhage(PPH), which is the leading cause ofmaternal death globally. HMS BABwas modeled on HBB, the firstmodule in the Helping Babies Survive(HBS) series, which recommendshands-on training and continuedskills practice after training. Tofacilitate learning specifically for PPH,the first low-cost childbirth simulatorwas developed and launched in2012.11 Implementation and researchexperience from HBB and HMS BABhighlighted that a stronger emphasiswas needed to help consolidateproviders’ skills.12 To fill this need,HMS BAB incorporated deliberatepractice after training day. Thispractice is not merely the simplerepetition of skills; rather, it issystematic, purposeful practiceundertaken with focused attentionwith the goal of improvingperformance of a particular skill. Thecombined method of short hands-onand team-based learning that isdelivered on-site and followed byongoing deliberate practice has beencalled “low dose, high frequency”(LDHF).

The LDHF training methodologyincorporated into HMS programminghas been the subject of severalresearch studies. From 2014 to 2015,HMS BAB and HBB were delivered asone-day trainings to all labor wardstaff at 125 hospitals and healthcenters in 12 districts in Uganda. HMSBAB training was provided to eachfacility first, followed by HBB training2 to 3 months later. All providerswere asked to deliberately practice

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certain skills once per week for a totalof 12 weeks after training. Two-thirdsof facilities had practice coordinatorsto facilitate this practice. Directclinical observations revealedimprovements in care practices,such as timely administration ofa uterotonic for prophylaxis,preparation of the bag and mask inadvance of birth, and breastfeedingwithin one hour. Improvements weregreater in facilities with practicecoordinators. Across all facilities,improvement in the care of womenand their newborns in the 6 monthsafter the intervention was noted bydeclines in retained placenta (47%),PPH (17%), fresh stillbirth (32%),and newborn death before discharge(62%) compared with baseline.13

Similar results regarding HMS BABtraining were found in 2 studies inTanzania resulting in a decrease inblood transfusion and near-misscases.14,15

EXPANDING THE SCOPE ANDAPPROACHES EMPLOYED BY HMS

HMS has since expanded to includea suite of 6 training modules as wellas a fresh approach to capacitybuilding (Table 1). This suite nowencompasses all basic emergencyobstetric and newborn carecompetencies that directly affectnewborn survival, including routinecare for normal and prolonged orobstructed labor and management ofpreeclampsia and eclampsia. Inparticular, HMS Essential Care forLabor & Birth (ECL&B) is thecornerstone of the suite and has thelargest potential to improve outcomesof both women and their newborns(Fig 1). Grounded in respectful care,ECL&B reinforces the importance ofmonitoring the woman and her fetusto ensure early identification ofcomplications to decrease severemorbidity and mortality.

In response to further evidencesuggesting that poor quality of care infacilities is a greater barrier to goodoutcomes than access to care,6 the

original LDHF approach has beenembedded in a quality improvementframework, with training targeted toidentified performance gaps. HMStraining is still provided on-site to thewhole team, by using hands-onlearning, and followed by deliberateskills practice, but training is alsosupported by use of videos, otherdigital tools, and qualityimprovement activities. These qualityimprovement activities are often assimple as posting referral andtransportation plans and ensuring theemergency cart is well maintained,but they also include more complexactivities, such as patient chartreviews and reordering clientservice flow.

Localizing training and education tofacilities where care is deliveredallows for problems to be solved inreal time and training updates to be

delivered where needed most. On thebasis of the World HealthOrganization’s quality of careframework,16 the HMS initiativematches training with competenciesrequired for quality care, deliverstraining to all levels of the healthsystem, and emphasizes women’sexperiences of care and humanrights–based approaches. However,training alone can only go so far toimprove outcomes; health systemgaps also must be addressed to thefullest extent possible. When trainingis deployed to address identifiedperformance gaps and is embeddedin a quality improvement framework,we have the opportunity to achievemuch greater impact. The qualityimprovement guide, “Improving Careof Mothers and Babies: A Guide forImprovement Teams,” has beendescribed in this supplement andoffers one example of how to support

TABLE 1 HMS Modules

Module Competencies

BAB Completea Active management of third stage of labor; early detection andmanagement of PPH including management of shock, manual removal ofplacenta, uterine balloon tamponade, and cervical laceration repair

Preeclampsia &Eclampsiab

Correct assessment and classification of hypertensive disorders ofpregnancy, administration of loading and maintenance doses ofmagnesium sulfate and antihypertensive medications, management ofconvulsions

ECL&Bc Respectful care and women’s choice; infection prevention; classification,management, and monitoring of labor; early identification ofcomplications; identification of poor progress of labor; supportive careduring all stages of labor and birth

Threatened Preterm BirthCared

Gestational age assessment; diagnosis of conditions leading to pretermbirth: preterm labor, preterm prelabor rupture of membranes, severepreeclampsia and eclampsia, chorioamnionitis, and antenatalhemorrhage; treatment of maternal infection; advanced care for pretermnewborns: resuscitation, safe oxygen use, thermal care, feeding support,treatment of infection

Prolonged & ObstructedLabor

Timely identification of prolonged or obstructed labor, treatment ofinfection, correct use of augmentation, rapid referral for obstructedlabor, management of shoulder dystocia, and maneuvers for breechbirth

Vacuum Assisted Birth Decision-making for client selection for vacuum delivery and correct use ofvacuum device, assessment and management of maternal and neonatalcomplications from vacuum birth

Adapted from Jhpiego. Helping Mothers Survive. 2020. Available at: https://hms.jhpiego.org/. Accessed June 2, 2020.a Jhpiego. Bleeding after Birth Complete. 2020. Available at: https://hms.jhpiego.org/bleeding-after-birth-complete/.Accessed June 2, 2020.b Jhpiego. Pre-eclampsia & Eclampsia. 2020. Available at: https://hms.jhpiego.org/pre-eclampsia_eclampsia/. AccessedJune 2, 2020.c Jhpiego. Essential Care for Labor & Birth. 2020. Available at: https://hms.jhpiego.org/essential-care-labor-and-birth/.Accessed June 2, 2020.d Jhpiego. Threatened Preterm Birth Care. 2020. Available at: https://hms.jhpiego.org/threatened-preterm-birth-care/.Accessed June 2, 2020.

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quality improvement locally.17 Thisguide is particularly relevant insettings where facility-based qualityimprovement teams are integratedwithin the health system.

NEXT STEPS

To help ensure the best possibleoutcomes for newborns and theirmothers, we must ensure thatpregnant and laboring women arecared for by a workforce that isskilled in assessment, rapididentification, and management ofcomplications. We can work towardthis goal by building the capacity ofthat workforce through this enhancedapproach to facility-based trainingusing the LDHF methodology.

HMS and HBS are open access, andthe educational strategies can beapplied to any clinical service area.Indeed, expanding this interactive,hands-on educational approach toother areas of newborn and childhealth may help continue to drivereductions in neonatal and childmortality. In particular, the HMS andHBS style of learning can and shouldbe adapted to preservice education,where it is uniquely suited tosupporting local curricula throughuse in skills laboratories. Experiencewith the 50 000 Happy Birthdaysproject in Rwanda, Ethiopia, andTanzania (which is reviewed in moredepth elsewhere in this supplement)reveals that HMS and HBS cancomplement curricula in preserviceeducation institutions in 2 importantways.18 First, the LDHF approach canbe used to strengthen the capacity ofstaff at clinical practicum sites beforethey supervise students duringclinical placements. Second, thetraining materials and methodsdeveloped for team-based, hands-onlearning can work in concert withstanding curricula by offeringstudents the opportunity for practicein skills laboratories before they areplaced in a clinical site.

FIGURE 1ECL&B action plan. BP, blood pressure; bpm, beats per minute. (Reprinted with permission fromJhpiego Corporation. Essential Care for Labor & Birth Action Plan. Baltimore, MD: Jhpiego Corpo-ration; 2019.)

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Finally, in this challenging time of thecoronavirus disease 2019 pandemic,maintaining quality services forwomen and their newborns is at risk.It is now more important than everthat the health workforce is wellprepared. We must now pivot fromusing only face-to-face training toprovide remote learning, mentorship,and support to providers globally.HMS and HBS partners are workingtogether to help meet this challengein the next phase of our worktogether.

ABBREVIATIONS

BAB: Bleeding after BirthECL&B: Essential Care for Labor &

BirthHBB: Helping Babies BreatheHBS: Helping Babies SurviveHMS: Helping Mothers SurviveLDHF: low dose, high frequencyPPH: postpartum hemorrhage

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