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Survive & Thrive annotated bibliography

The Survive & Thrive GDA final report presented an impresive overview of peer-reviewed articles on the Helping Mothers Survive and Helping Babies Survive Educational Programs. Find the annotated bibliography in the report or in the list bellow bellow.


Evans, C. L., Bazant, E., Atukunda, A. Peer-assisted learning to sustain provider performance after onsite, low-dose, high-frequency training and practice to prevent and treat postpartum hemorrhage and neo- natal asphyxia: 2018. A pragmatic cluster randomized trial in Uganda.

This cluster-randomized trial in 125 facilities in 12 districts of Uganda provided facility-based training in HMS BAB and HBB to >700 providers. Three approaches to facilitating simulation-based, peer practice were compared. Uterotonic provision within one minute of birth increased and remained high in all groups, but was greater in the groups with support for ongoing practice. Simulated skills maintenance for postpartum hemorrhage prophylaxis remained high across all study groups 7 to 8 months after the intervention however skills for newborn bag-and-mask ventilation remained high only in the full intervention group. For all groups combined, incidence of postpartum hemorrhage and retained placenta declined 17% and 47%, respectively and fresh stillbirths and newborn death prior to discharge decreased by 34% and 62%, respectively, from baseline and remained reduced 6-9 months post- implementation.

Egenberg, S., Karlsen, B., Massay, D., et al. (2017). “No patient should die of PPH just for the lack of training!” Experiences from multi-professional simulation training on postpartum hemorrhage in northern Tanzania: a qualitative study. BMC Medical Education, 17:119.

The study utilized qualitative methods to examine the effect of multi-professional simulation training on PPH on providers’ perceptions. After the second of two simulation training at two hospitals in northern Tanzania, ten focus group discussions comprising 42 nurse midwives, doctors, and medical attendants, were carried out. The key finding was the perceived importance of team training as learning feature, and the perception of improved ability to use a teamwork approach to PPH.

Egenberg, S., Masenga, G., Bru, L. E., et al. (2017). Impact of multi-professional, scenario-based training on postpartum hemorrhage in Tanzania: a quasi-experimental, pre- vs. post-intervention study BMC Pregnancy and Childbirth, 17:287.

This quasi-experimental, pre-vs. post-interventional study involved on-site multi-professional, scenario-based PPH training, conducted in a two-week period in October 2013 and another 2 weeks in November 2014 in a rural hospital in Tanzania. Results showed a 47% reduction in blood transfusion.

Egenberg,, S., Øian, P., Eggebø,T. M., Arsenovic, M. G. and Bru, L. E. (2017). Changes in self-efficacy, collective efficacy and patient outcome following interprofessional simulation training on postpartum haemorrhage. Journal of Clinical Nursing, 26(19-20), 3174-3187

The study contributes to new knowledge on how simulation training with BAB through mastery and vicarious experiences, verbal persuasion and psychophysio- logical state might enhance postpartum haemorrhage-specific self-efficacy and collective efficacy levels and thereby predict team performance. The significant reduction in severe postpartum haemorrhage after training, indicated by reduction in ≥5 units of blood transfusions, corresponds well with the improvement in collective efficacy,

Nelissen, E., Ersdal, H., Mduma, E., et al. (2017). Clinical performance and patient outcome after simulation-based training in prevention and management of postpartum haemorrhage: an educational intervention study in a low-resource setting. BMC Pregnancy and Childbirth, 17:301.

This study examined changes in PPH before and after BAB training. Three thousand six hundred twenty-two births before and 5824 births after intervention were included. The incidence of PPH (500–1000 ml) significantly reduced from 2.1% to 1.3% after training. The proportion of women who received oxytocin as part of management of PPH increased significantly (before training 43. 0%, after training 61.2%).

Dustan R. Bishanga, John Charles, Gaudiosa Tibaijuka, Rita Mutayoba, et al. (2018) Improvement in the active management of the third stage of labor for the prevention of postpartum hemorrhage in Tanzania: a cross-sectional study. BMC Pregnancy and Childbirth. 18:223.

The quality of PPH prevention increased substantially in facilities that implemented competency-based training and quality improvement interventions, with the most dramatic improvement seen at lower-level facilities. As Tanzania continues with efforts to increase facility births, it is imperative that the quality of care also be improved by promoting use of up- to-date guidelines and ensuring regular training and mentoring for health care providers so that they adhere to the guidelines for care of women during labor. These measures can reduce maternal and newborn mortality.


Nathan, L. M., et al. (2016). Retention of skills 2 years after completion of a postpartum hemorrhage simulation training program in rural Rwanda. International Journal of Gynecology & Obstetrics, 134(3), 350-353.

A quasi-experimental pre–post intervention study enrolled eleven generalist physicians in rural Rwanda. Participants underwent initial simulation training including pre- and post-training testing in February 2012. Simulation drills to assess skill retention were conducted on eight physicians in March 2014. Results showed simulation training to be effective for teaching postpartum hemorrhage- management skills to generalist physicians in rural areas and skills are retained for at least 2 years.

Nelissen, E., Ersdal, H., Mduma, E., Evjen-Olsen, B., et al. (2016). Helping Mothers Survive Bleeding After Birth: retention of knowledge, skills, and confidence nine months after obstetric simulation-based training. BMC Pregnancy and Childbirth, 15:190.

In 2012, 89 providers were trained in a half day BAB course onsite in Tanzania. Nine months later, 36 providers were retested for knowledge and skills retention. Training resulted in an immediate increase in knowledge, skills, and confidence. While knowledge and simulated basic delivery skills decayed after nine months, confidence and simulated obstetric emergency skills were largely retained. These findings indicate a need for continuation of training.


Egenberg, S., Øian, P., Bru, L. E., Sautter, M., Kristoffersen, G., Eggebø,T. M. (2015). Can inter- professional simulation training influence the frequency of blood transfusions after birth? Acta Obstetricia et Gynecologica Scandinavica, 94(3), 316–323.

This study examined whether inter-professional simulation training for PPH could influence the rate of blood transfusion after birth in a large, urban Norwegian hospital. A significant reduction in red blood cell transfusions, curettages, and uterine artery embolization after introduction of mandatory simulation training on management of postpartum hemorrhage. In 2009, 20.8% of women with estimated blood loss >500mL received transfusion vs. 12.3% in 2011.


Evans, C. L. and Johnson, P. (2014). Response to Nelissen et al, Helping mothers survive bleeding after birth: an evaluation of simulation-based training in a low-resource setting. Acta Obstetricia et Gynecologica Scandinavica, 93(6), 610-610.

Evans, C. L., Johnson, P., Bazant, E., Bhatnagar, N., Zgambo, J., Khamis, A. R. (2014). Competency-based training “Helping Mothers Survive: Bleeding after Birth” for providers from central and remote facilities in three countries. International Journal of Gynecology & Obstetrics, 126(3), 286–290.

In response to the Nelissen study in 2012, Jhpiego responded outlining the changes based on learning from the Tanzania experience. In the Nelissen study, trainers had little or no experience as trainers beyond simple orientation to the materials. As a result, trainer preparation was reinforced and training time was increased whereby the BAB agenda was increased to one full day.


Nelissen, E., Ersdal, H., Østergaard, D., Mduma, E., Broerse, J., Evjen-Olsen, B., et al. (2013). Helping mothers survive bleeding after birth: an evaluation of simulation-based training in a low-resource setting. Acta Obstetricia et Gynecologica Scandinavica, 93(3), 287-295.

In 2013 a total of 155 skilled and semiskilled birth attendants participated in training in India, Malawi, and Zanzibar, Tanzania. Knowledge and confidence were assessed before and after training. Skills and acceptability were assessed after training. The proportion of attendants with passing knowledge scores increased significantly. Post training pass rates ranged from 83% to 89%.


Gomez, P., Nelson, A., Asiedu, A., Addo, E., Agbodza, D., Allen, C., & Effah, F. (2018). Accelerating newborn survival in Ghana through a low-dose, high-frequency health worker training approach: a cluster randomized trial. BMC Pregnancy and Childbirth, 18:72.

From 2014 to 2017, authors conducted a cluster-randomized trial in 40 hospitals in Ghana to assess the effect of a low- dose, high frequency (LDHF) training approach on long-term evidence-based skill retention among skilled birth attendants (SBAs) and impact on adverse birth outcomes. The LDHF approach resulted in a sustained decrease in facility-based newborn mortality and intrapartum stillbirths, and retained knowledge and skills among SBAs after a year.

Massawe, A., Kidanto, H. L., Moshiro, R., Majaliwa, E., Chacha, F., Shayo, A., Mdoe, P., Ringia, P., Azayo, M., Msemo, G., & Mduma, E., Ersdal, H., & Perlman, J. (2018). A care bundle including antenatal corticosteroids reduces preterm infant mortality in Tanzania a low resource country. PloS One, 13(3), e0193146.

Together with the refresher course in a timely manner will ensure that the participants are better prepared to meet neonatal emergencies in low-income countries like Nepal where most deliveries occur at homes by traditional birth attendants. This study concluded that HBB training on NeoNatalie newborn simulator significantly improved the knowledge of the participants.

Moshiro, R., Ersdal, H., Mdoe, P., Kidanto, H., & Mbekenga, C. (2018). Factors affecting effective ventilation during newborn resuscitation: a qualitative study among midwives in rural Tanzania. Global Health Action, 11(1), 1423862.

Interviews with eight midwives in Tanzania were analyzed to provide insight on barriers and facilitators to effective bag mask ventilation. Based on midwives’ experiences, improvement efforts should focus on labor monitoring, birth preparedness, accurate assessment and high-quality and frequent simulation training.

Tabangin, M., Josyula, S.,Taylor, K.,Vasquez, J., & Kamath- Rayne, B. (2018). Resuscitation skills after Helping Babies Breathe training: a comparison of varying practice frequency and impact on retention of skills in different types of providers. International health. 10(3): 163-171.

The goal of this study was to determine retention of resuscitation skills by different cadres of providers using the approved HBB Spanish translation in a rural clinic and community hospital in Honduras. Assessments showed rapid loss of resuscitation skills occurs after an initial training. Repeated practice leads to retention of skills in all types of providers. Further investigation is warranted to determine the clinical correlation of neonatal outcomes after HBB training.

Alwy F, Pembe AB, Hirose A, Morris JL, Leshabari S, Marrone G, Hanson C. (2018) Effect of the competency-based Helping Mothers Survive Bleeding after Birth (HMS BAB) training on maternal morbidity: A cluster-randomized trial in 20 districts in Tanzania. Submitted to PLOS One.

331 providers were trained in HMS BAB in a randomized controlled trial in Tanzania. A statistically significant reduction of PPH near-misses was found among women who suffered PPH in the intervention district compared to comparison districts. There was also a significant decrease in long-term case fatality in PPH near-miss cases in intervention facilities. The intervention also increased the proportion of women with PPH who received intravenous uterotonic. This study suggests that the decrease in morbidity and mortality from postpartum hemorrhage where the intervention occurred demonstrates that HMS BAB addresses an important deficit in knowledge and skills surrounding PPH.

Emma Williams, Eva Bazant, Sam Holcombe, Innocent Atukunda, Rose Namugerwa, Cherrie Evans (2018) ‘Let us … again, practice so that skill does not disap- pear’: Mixed methods evaluation of simulator-based practice for midwives in Uganda. Submitted to Human Resources for Health

A trial in 125 facilities in Uganda compared three strategies of support for LDHF provider practice to improve retention of provider skills in prevention and treatment of postpartum hemorrhage and neonatal asphyxia after facility-based BAB and HBB training. Practice log data indicated that simulator- based practice sessions occurred more frequently in facilities where one or two peer practice coordinators helped schedule and lead the practice sessions compared to facilities without coordinators. Where practice occurred more fre- quently, better clinical practice was directly observed.


Arlington, L., Kairuki, A., Isangula, K., Meda, R.,Thomas, E.,Temu, A., Mponzi,V., Bishanga, D., Msemo, G., Azayo, M., & Nel-son, B. (2017). Implementation of “Helping Babies Breathe”: A 3-year experience in Tanzania. Pediatrics, 139(5). e20162132

This first-ever country-level study assesses results from the 3-year national rollout of the HBB program in Tanzania by measuring coverage, adoption and retention of provider skills, acceptability among providers, and barriers and challenges to at-scale implementation. The program was successful in equipping providers with life-saving newborn resuscitation skills and equipment; however, assessing impact on mortality requires greater efforts.

Eblovi, D., Kelly, P., Afua, G., Agyapong, S., Dante, S., & Pellerite, M. (2017). Retention and use of newborn resuscitation skills following a series of Helping Babies Breathe trainings for midwives in rural Ghana. Global Health Action, 10(1), 1387985, DOI: 10.1080/16549716.2017.1387985

Authors conducted two 2-day HBB trainings and 2-day refresher courses one year later for 48 midwives from rural Ghana in order to assess the impact of HBB trainings on skill retention and 24-hour neonatal mortality. Evaluations of trainee skills suggest that skills diminish less quickly when supplemented by refresher courses. Analysis of delivery data indicates the training likely prevented deaths to due birth asphyxia.

Ersdal, H. L., Singhal, N., Msemo, G., Ashish, K. C., Data, S., Moyo, N.T., & Niermeyer, S. (2017). Successful implementation of Helping Babies Survive and Helping Mothers Survive programs – An Utstein formula for newborn and maternal survival. PloS One, 12(6), e0178073.

This paper provides users of HBS and HMS programs with a 10-point list of essential implementation action steps designed to promote successful national implementation of HBS/ HMS. The list evolved through an Utstein consensus process, involving a broad spectrum of international experts, and can be used to guide processes in low-resourced countries. Successful implementation of HBS and HMS training programs require country-led commitment, readiness, and follow-up to create local accountability and ownership. Each country has to identify its own gaps and define realistic service delivery standards and patient outcome goals depending on available financial resources for dissemination and sustainment.

K.C., A., Bergström, A., Chaulagain, D., Brunell, O., Ewald, U., Gurung, A., Eriksson, L., Litorp, H., Wrammert, J., Grönqvist, E., & Edin, P., Le Grange, C., Lamichane, B., Shrestha, P., Pokharel, A., Pun, A., Singh, C., Målqvist, M. (2017). Scaling up quality improvement intervention for perinatal care in Nepal (NePeriQIP); study protocol of a cluster randomised trial. BMJ Global Health, 2(3), e000497.

Describes the proposed Nepal Perinatal Quality Improvement Project (NePeriQIP) that builds on previous research on implementation of HBB-QI cycle and will add to scarce evidence base on how to scale up interventions within existing health systems.

K.C., A., Wrammert, J., Nelin,V., Clark, R., Ewald, U., Peterson, S., & Målqvist, M. (2017). “Evaluation of Helping Babies Breathe Quality Improvement Cycle (HBB-QIC) on retention of neonatal resus-citation skills six months after training in Nepal.” BMC Pediat-rics 17:1, 103.

This article describes the impact of a multifaceted implementation strategy for HBB, as a quality improvement cycle (HBB-QIC).This HBB-QIC intervention took place at a tertiary hospital in Nepal, and findings show that health workers who practiced bag-and-mask skills, prepared for resuscitation before every birth, used self-evaluation check- lists, and attended weekly review meetings were more likely to retain their neonatal resuscitation skills. Further studies are required to evaluate HBB-QIC in primary care settings.

Kamath-Rayne, B. D., Josyula, S., Rule, A. R. L., & Vasquez, J. C. (2017). Improvements in the delivery of resuscitation and newborn care after Helping Babies Breathe training. Journal of Perinatology, 37, 1153-1160.

In a rural Honduran community hospital, HBB training resulted in improvements in basic neonatal resuscitation and postnatal care practices such as skin-to-skin care, breast-feeding and delayed cord clamping. Authors suggest that further improvements may require focused quality improvement initiatives for hospitals to sustain high quality care.

Leader, A., Cadet, C., Lazala, D., Roa, W., Arroyo, O., & Jensen, L. (2017). Collaborative implementation Strategy for newborn Resuscitation and Essential Care training in the Dominican Republic. Frontiers in Public Health, 5.

This study details the design and implementation of a comprehensive newborn health initiative including HBS programs. The initiative featured a combined HBB/ECEB program with integrated quality improvement (QI) systems. The initiative was implemented through a partnership of a multidisciplinary team of technical experts and the Ministry of Health. Using a train-the-trainer model, the initiative aimed to provide ongoing program monitoring, reinforcement, and mentor- ship. Assessing the cognitive, affective, behavioral, and clinical outcomes, this study concludes that partnerships fostering collaborative training interventions contribute essential clinical resources to local providers. Further, they empower providers to better care for their patients and promote the training and supervision of their colleagues, and strengthen the local health care system, ultimately improving the quality of care, and support improved health outcomes.

Perlman, J. M., Msemo, G., Ersdal, H., & Ringia, P. (2017). Designing and Implementing the Helping Babies Breathe Program in Tanzania. Journal of Pediatric Intensive Care, 6(01), 028-038.

Introduction of the HBB program in eight study sites in Tanzania was associated with a significant reduction in early newborn mortality (ENM) and fresh stillbirth (FSB).This reduction is attributed to early basic interventions, including drying and stimulation of the newly born (key principals of the HBB curriculum), and was effective for both the term and preterm infant. Maintaining competencies in the basic skills, including application of bag-mask ventilation is enhanced by high-frequency, low-dose simulation-based training. Instilling a sense of ownership and self-efficacy at all levels is critical to success. However to further reduce both ENM and later deaths in the first week, focus has to include enhanced monitoring of events during labor (fetal heart rate) as well as reducing the burden of premature mortality (infants of 28 to 35 week estimated gestational age), through the administration of a package of interventions.

Rule, A., Maina, E., Cheruiyot, D., Mueri, P., Simmons, J., & Kamath-Rayne, B. (2017). Using quality improvement to decrease birth asphyxia rates after Helping Babies Breathe” training in Kenya. Acta Paediatrica. 106(10): 1666-1673.

A Neonatal Task Force was formed at a rural referral hospital in Kenya to improve local perinatal outcomes and data collection. In combination with HBB training, improvement of staff communication, ongoing refresher training, retention of skilled staff, and other interventions, hypoxic-ischaemic encephalopathy decreased by 50% over 10 months. Authors conclude that focused QI can sustain and advance gains in neonatal outcomes post-HBB training.

Seto,T.,Tabangin, M.,Taylor, K., Josyula, S.,Vasquez, J., & Kamath-Rayne, B. (2017). Breaking Down the Objective Structured Clinical Examination: An Evaluation of the Helping Babies Breathe OS-CEs. Simulation in Health- care, 12(4), 226-232.

Objective structured clinical examinations (OSCEs) are clinical performance assessments that evaluate learners’ skills in simulated scenarios. The aims of this study were (1) to evaluate the validity and reliability of the OSCEs used in the HBB curriculum, (2) to conduct an itemized analysis of the OSCEs to identify specific deficits in knowledge and performance.

As summative and formative assessments of performance in simulated neonatal resuscitation, the HBB OSCEs are effective because most learners were able to perform the skills correctly after an HBB workshop. Based on the results, the authors recommend changes to future editions of HBB, including the following: simplification of multistep items to single tasks, use of a global rating scale, provision of additional scenarios, and specific instructions to raters on how to grade OSCEs and promote self-reflection to enhance debriefings/ feedback.

Wilson, G. M., Ame, A. M., Khatib, M. M., Rende, E. K., Hartman, A. M., & Blood-Siegfried, J. (2017). Helping Babies Breathe implementation in Zanzibar,Tanzania. International Journal of Nursing Practice. 24:3; e12561

Implementation of HBB in rural Zanzibar was effective using the train-the-trainer implementation strategy combined with follow-up over time. Observations revealed that HBB skills and knowledge were carried over into practice. Authors suggest that applying key strategies such as mentoring, allocation of reusable supplies, observations with supportive feedback and focus group discussions when implementing HBB can result in improved clinical practice.

Wrammert, J., KC, A., Ewald, U., & Målqvist, M. (2017). Improved postnatal care is needed to maintain gains in neonatal survival after the implementation of the Helping Babies Breathe initiative. Acta Paediatrica, 106(8):1280-1285. doi: 10.1111/apa.13835

The aim of this study was to describe the timing and causes of neonatal in-hospital deaths before and after HBB training at a maternity health facility in Nepal. A prospective cohort study was conducted at the facility between July 2012 and September 2013.The causes of 299 neonatal deaths and the day of death, up to 27 days, were collected before and after the training course. Deaths caused by intrapartum-related complications were reduced from 51% to 33%.The authors conclude the continuum of postnatal care for newborn infants needs to be strengthened after Helping Babies Breathe training, to maintain the gains in neonatal survival on the day of delivery.


Arabi, A., Ibrahim, S., Ahmed, S., Abdalla, M., & Rayan, C. (2016). Original Articles Introducing Helping Babies Breathe (HBB) Programme into rural Sudan: An interim report. Khartoum Medical Journal, 8(1). 1048-1057

This study examined the impact of HBB training on resuscitation skills of Sudanese village midwives and perinatal outcomes. HBB training and peer-peer skills practice was associated with improvements in newborn resuscitation and perinatal outcomes. HBB training combined with peer-peer skills practice could have immense benefits if expanded nationally.

Arabi, A., Ibrahim, S., Ahmed, S., MacGinnea, F., Hawkes, G., Dempsey, E., & Ryan, C. (2016). Skills retention in Sudanese village midwives 1 year following Helping Babies Breathe training. Archives of Disease in Childhood, 101:439-442.

In this prospective intervention study to evaluate newborn resuscitation competencies, Sudanese village midwives’ performances in the HBB OSCE B were recorded prior to, 3 and 12 months following HBB training. OSCE assessments showed that participants absorbed and sustained HBB skills for at least a year, and regular, low intensity, manikin-based skills training with peers may have helped sustain face-mask ventilation.

Chaudhury, S., Arlington, L., Brenan, S., Kairuki, A., Meda, A., Isangula, K., Mponzi,V., Bishanga, D.,Thomas, E., Msemo, G., Azayo, M., Molinier, A., & Nelson, B. (2016). Cost analysis of large-scale implementation of the ‘Helping Babies Breathe’ newborn resuscitation-training program in Tanzania. BMC Health Services Research, 16(1), 681, DOI: 10.1186/s12913-016-1924-2

This study shows that HBB implementation is a relatively low-cost intervention with potential for high impact on perinatal mortality in resource-poor settings, and that nation- wide expansion of the program across the range of health provision levels and regions of Tanzania would be feasible. The article provides policymakers with the relevant cost-estimation for national rollout of this potentially neonatal life-saving intervention.

Isangula, K., Kassick, M., Kairuki, A., Meda, R.,Thomas, E., Temu, A., Msemo, G., Azayo, M., & Nelson, B. D. (2016). Provider experiences with the large-scale ‘Helping Babies Breathe’ training programme in Tanzania. Paediatrics and International Child Health, 38(1): 46-52.

This article describes the results of 222 focus group discussions with HBB-trained providers across 15 regions of Tanzania. Overall, the HBB program was well received. Participants reported increased knowledge, skills and confidence, and that the equipment simplified resuscitation. Addressing the main challenges cited, particularly training duration, may increase provider satisfaction.

K.C., A., Wrammert, J., Clark, R. B., Ewald, U.,Vitrakoti, R., Chaudhary, P., Pun, A., Raajmakers, H., & Målqvist, M. (2016). Reducing perinatal mortality in Nepal using Helping Babies breathe. Pediatrics, 137(6): e20150117.

The authors developed and implemented a quality improvement cycle (QIC) at a tertiary hospital in Nepal to improve adherence to HBB protocol and reduce perinatal mortality. The HBB QIC reduced intrapartum stillbirth and first-day neonatal mortality and was associated with improvements in providers’ adherence to neonatal resuscitation protocols.

Kassick, M. E., Chinbuah, M. A., Serpa, M., Mazia, G.,Tang, A. M., Sagoe-Moses, I., & Engmann, C. (2016). Evaluating a novel neonatal-care assessment tool among trained delivery attendants in a resource-limited setting. Inter- national Journal of Gynecology & Obstetrics, 135(3), 285-289.

In this cross-sectional study, ECEB-trained healthcare providers from 12 district hospitals in Ghana completed a 21-item OSCE tool to assess neonatal care competency. The OSCE tool demonstrated substantial reliability and the providers exhibited satisfactory performance. The OSCE tool could be useful in similar settings and could have potential for up-scaled use in assessing neonatal-management skills.

Reisman, J., Arlington, L., Jensen, L., Louis, H., Suarez- Rebling, D., & Nelson, B. D. (2016). Newborn resusci- tation training in resource-limited settings: a systematic literature review. Pediatrics, 138(2), e20154490.

This systematic literature review examined acquisition and retention of NR knowledge and skills by birth attendants in low-and middle-income countries. Authors conclude that knowledge and skills falloff over time is a significant barrier to success of neonatal resuscitation programs. Refresher training and structured practice can prevent this decline.

Xu,T., Niermeyer, S., Lee, H. C., Simon, W. M.,Yue, Q., Gong, L., & Wang, H. (2016). International Perspectives: Reducing Birth Asphyxia in China by Implementing the Neonatal Resuscitation Program and Helping Babies Breathe Initiative. NeoReviews, 17(8), e425-e434.

This article details China’s dual approach to address birth asphyxia using the Neonatal Resuscitation Program (NRP) and Helping Babies Breathe. As a large and rapidly developing country, China has geographic- and resource-related challenges to improving clinical care to reduce neonatal mortality. While both NRP and HBB use the same evidence base, these two programs target differently-resourced facility settings. This article illustrates how NRP and HBB can be implemented in countries where needs and resources vary regionally and locally. The introduction and implementation of NRP and HBB in China have already shown substantial benefits in a relatively short amount of time. The authors provide a number of lessons learned and detail future steps to better achieve reductions in neonatal mortality in China.


Mduma, E., Ersdal, H., Svensen, E., Kidanto, H., Auestad, B., & Perlman, J. (2015). Frequent brief on-site simulation training and reduction in 24-h neonatal mortality – an educational intervention study. Resuscitation, 93, 1-7.

The objective was to assess the impact of frequent brief (3–5 min weekly) on-site HBB simulation training on newborn resuscitation practices in the delivery room and the potential impact on 24-h neonatal mortality. A newborn simulator was placed in the labor ward and frequent brief HBB simulation training was implemented on-site; 3-min of weekly paired practice, assisted by local-trainers. Local trainers also facilitated 40-min monthly re-trainings. The researchers reported that the number of neonates receiving stimulation increased, as did those who received suctioning. Neonates receiving bag mask ventilation decreased as did 24-hourmortality.The study concludes that on-site, brief and frequent HBB simulation training appears to facilitate transfer of new knowledge and skills into clinical practice and is accompanied by a decrease in neonatal mortality.

Reisman, J., Martineau, N., Kairuki, A., Mponzi,V., Meda, A. R., Isangula, K. G.,Thomas, E., Plotkin, M., Chan, G., Davids, L., Msemo, G., Azayo, M., & Nelson, B. (2015). Validation of a novel tool for assessing newborn resuscitation skills among birth attendants trained by the Helping Babies Breathe program. International Journal of Gynecology & Obstetrics, 131(2), 196-200.

This prospective cross-section study of the OSCE tool was conducted among HBB-trained birth attendants in five regions of Tanzania. The best OSCE performances were recorded among participants from facilities with high annual birth volumes. The simplified OSCE tool could facilitate implementation of national-level HBB programs.

Seto,T. L.,Tabangin, M. E., Josyula, S.,Taylor, K. K.,Vasquez, J. C., & Kamath-Rayne, B. D. (2015). Educational outcomes of Helping Babies Breathe training at a community hospital in Honduras. Perspectives on Medical Education, 4(5), 225-232.

This study evaluated the acquisition of knowledge and skills following HBB training and correlation of learner characteristics to performance at a community hospital in Honduras. When evaluated immediately after workshop, HBB training resulted in significant gains in neonatal resuscitation knowledge and skills. Further studies are necessary to determine how to sustain HBB knowledge and skills over time.

Somannavar, M. S., Goudar, S. S., Revankar, A. P., Moore,J. L., McClure, E. M., Destefanis, P., DeCain, M., Goco, N., & Wright, L. L. (2015). Evaluating time between birth to cry or bag and mask ventilation using mobile delivery room timers in India: the NICHD Global Network’s Helping Babies Breathe Trial. BMC Pediatrics, 15(1), 93.

Researchers developed and evaluated a mobile delivery room timer to document the time interval from birth to the initiation of newborn crying/spontaneous respiration or bag and mask ventilation in five hospitals in Karnataka, India. The mobile delivery room timer is a cell phone-based application that recorded key events including crowning, delivery, and crying/spontaneous respiration or bag and mask ventilation. There was high concordance between the mobile delivery room timer and observed time elapsed between birth and crying/spontaneous respiration or ventilation. The researchers concluded this type of tool may be useful in reinforcing neo- natal resuscitation training and the need to ensure spontaneous or assisted ventilation by The Golden Minute.

Thukral, A., Lockyer, J., Bucher, S. L., Berkelhamer, S., Bose, C., Deorari, A., Esamai, F., Faremo, S., Keenan, W., McMillan, D., & Niermeyer, S. (2015). Evaluation of an educational program for essential newborn care in resource-limited settings: Essential Care for Every Baby. BMC Pediatrics, 15(1), 71.

This study focused on Essential Care for Every Baby (ECEB), assessing the overall design of the course; the ability of facilitators to teach the course; and the knowledge and skills acquired by the learners. Testing occurred at 2 global sites, one in Kenya and one in India. Data from a facilitator evaluation survey, a learner satisfaction survey, a multiple-choice question (MCQ) examination, performance on two objective structured clinical evaluations (OSCE), and pre- and post-course confidence assessments were analyzed using descriptive statistics. Pre-post course differences were examined. Comments on the evaluation form and post-course group discussions were analyzed to identify potential program improvements. Findings indicate ECEB program was highly acceptable, demonstrated improved confidence, improved knowledge and developed skills.


Bang, A., Bellad, R., Gisore, P., Hibberd, P., Patel, A., Goudar, S., Esamai, F., Goco, N., Meleth, S., Derman, R., Liechty, E., McClure, E., Carlo, W., & Wright, L. (2014). Implementation and evaluation of the Helping Babies Breathe curriculum in three resource limited settings: does Helping Babies Breathe save lives? A study proto- col. BMC Pregnancy and Childbirth, 14(1), 116.

The study evaluates the effect of a HBB/ENC training and a QI and monitoring package on perinatal mortality using a large multicenter common design and approach in 71 resource-limited health facilities, leveraging an existing birth registry to provide neonatal outcome data through day 7.The study provides the evidence base, lessons learned, and best practices that will be essential to guiding future policy and investment in neonatal resuscitation.

Bondoe, C., Wraynee, A. B., Riner, M. E., Allam, E., & Stephenson, E. (2014). Helping Babies Breathe: Providing an evidence-based education intervention at a tertiary referral hospital in Liberia. Journal of Nursing Education and Practice, 4(9), 119-127.

In this study the Helping Babies Breathe program was provided to students and staff at the teaching and referral hospital in Liberia. Results showed a significant increase in neonatal knowledge as well as attainment of skills by staff and students. It is expected that full implementation will include establishing agency procedures, supervision, and support to staff in the delivery room and will ultimately result in lower neonatal mortality due to asphyxia. Similar institutions seeking to implement the HBB program should fully support the initial training initiative and plan for ongoing implementation support. Preparing nurses and midwives as certified trainers can make this valuable lifesaving knowledge and skill available to those delivering babies under high risk conditions in low resource areas.

Hubballi, J., Sumitra, L., & Raddi, S. (2014). Randomized control trial to evaluate the effectiveness of Helping Babies Breathe programme on knowledge and skills regarding neonatal resuscitation among auxiliary nurse midwives students. International Journal of Nursing Education, 6(1), 146.

The findings of the study showed that Helping Babies Breathe program is effective to improve the knowledge and skill regarding neonatal resuscitation among experimental group of Auxiliary Nurse Midwives (ANM) students. Findings revealed that Helping Babies Breathe program was effective to improve knowledge and skill of subjects under study. There was no gain in knowledge and skill regarding neonatal resuscitation among control group of ANM students.

Lindbäck, C., K.C., A., Wrammert, J.,Vitrakoti, R., Ewald, U., & Målqvist, M. (2014). Poor adherence to neonatal resuscitation guidelines exposed; an observational study using camera surveillance at a tertiary hospital in Nepal. BMC Pediatrics, 14(1), 233.

CCD-cameras recorded the resuscitations taking place and CCD-observational record forms were completed for each case. The resuscitation routines were then assessed and compared with existing guidelines. To evaluate the reliability of the observational form, 50 films were randomly selected and two independent observers completed two sets of forms for each case. The results were then cross-compared. During the study period 1827 newborns were taken to the resuscitation table, and more than half of them (53.3%) were noted as not crying prior to resuscitation. Suction was used in almost 90% of newborns brought to the resuscitation table, whereas bag- mask ventilation was only used in less than 10%.The chance to receive ventilation with bag-and-mask for a newborn not crying when brought to the resuscitation table was higher for boys, low birth weight babies and babies that were delivered by caesarean section.

Little, G. A., Keenan, W. J., Singhal, N., & Niermeyer, S. (2014). International perspectives: Helping Babies Breathe: Evolution of a global neonatal resuscitation program for resource-limited areas. Neoreviews, 15(9), e369-e380.

This review of HBB provides readers with insight into the strategic assessment of global neonatal mortality that led to development of the program, how that assessment shaped the educational program as a catalyst for change, and how a global public–private alliance has promoted HBB implementation and continues to strive for sustainable improvement in newborn health.

Maharjan, U., Rajbanshi, L., & Dhungana, G. (2014). Effectiveness of Helping Babies Breathe (HBB) training on knowledge for Health Professionals and Medical Students at Chitwan Medical College. Journal of Chit- wan Medical College, 4(8): 17-19.

The educational effectiveness of HBB training on newborn simulator, knowledge of trainees from Doctors, Nurses and Medical Students was evaluated before and after training. Participants underwent a 2 day training course of 5 hours each. A post course practical skills evaluation was performed on a Neonatalie Newborn Simulator.

Vossius, C., Lotto, E., Lyanga, S., Mduma, E., Msemo, G., Perlman, J., & Ersdal, H. (2014). Cost-effectiveness of the Helping Babies Breathe program in a missionary hospital in rural Tanzania. PloS One, 9(7), e102080.

Authors analyzed the cost effectiveness of HBB at Haydom Lutheran Hospital (HLH) in rural Tanzania. Costs per life saved were USD 233, while they were USD 4.21 per life year gained. Costs for maintaining the program were USD 80 per life saved and USD 1.44 per life year gained. Authors conclude that HBB is a low-cost intervention, and implementation in HLH has been highly cost effective. To facilitate further global implementation of HBB, a cost-effectiveness analysis including government, urban hospitals and district facilities is necessary.


Julia Bluestone, Peter Johnson, Judith Fullerton, Catherine Carr, Jessica Alderman James BonTempo. (2013) Effective in-service training design and delivery: evi- dence from an integrative literature review. Human Resources for Health 2013, 11:51

A review of education and training literature was conducted between May and June 2011 to identify effective training approaches. The evidence suggests using multiple interactive techniques including clinical simulation with skills practice and feedback was identified as the most effective approach. Didactic techniques using passive instruction, such as reading or lecture, were found to have little or no impact on learning outcomes. Repetitive interventions, rather than single interventions, were shown to be superior. Workplace learning improved skill acquisition and performance.

Ersdal, H. L., & Singhal, N. (2013). Resuscitation in re- source-limited settings. Seminars in Fetal and Neonatal Medicine, 18(6): 373-378

Authors describe the need to reduce global perinatal mortality and effectively address intrapartum-related hypoxia leading to death and disability, especially in resource-limited settings. Based on an analysis of current science and educational programs, authors suggest that simple resuscitation education such as ‘Helping Babies Breathe’ can help transfer competency into clinical practice and lead to sustainable programs impacting neonatal mortality and morbidity.

Ersdal, H. L.,Vossius, C., Bayo, E., Mduma, E., Perlman, J., Lippert, A., & Søreide, E. (2013). A one-day “Helping Babies Breathe” course improves simulated perfor- mance but not clinical management of neonates. Resuscitation, 84(10): 1422-1427.

This report documents the long-term impact of a one-day HBB training on practical skills and management strategies among providers in a rural Tanzanian hospital. When providers simulated “Routine Care” and “Neonatal Resuscitation” seven months after HBB training, skills and performance were significantly better. By contrast, neonatal management in the delivery room during the corresponding time period did not improve and in fact was worse. Thus, less newborn infants were stimulated and the time to initiate face mask ventilation was longer. Subsequently, measures were taken (short HBB re-trainings delivered regularly and frequently with local mentoring) to improve the transfer of acquired knowledge and skills into clinical practice. Further research is necessary to explore the impact of these measures on performance and patient outcome. More focus on early stimulation and discussions around local implementation should be prioritized during HBB training.

Goudar, S., Somannavar, M., Clark, R., Lockyer, J., Revankar, A., Fidler, H., Sloan, N., Neirmeyer, S., Keenan,W., & Singhal, N. (2013). Stillbirth and newbor mortality in India after Helping Babies Breathe training. Pediatrics, 131(2), e344-e352.

This study evaluated the effectiveness of HBB training in reducing stillbirth (SB), and pre-discharge and neonatal mortality (NMR) in Southern India. A total of 599 birth attendants from rural, district and urban facilities were trained in HBB, and au- thors found that the training systematically improved provider knowledge and performance. Assessments also showed that HBB training reduced SB without increasing NMR, indicating that resuscitated infants survived the neonatal period.

Hoban, R., Bucher, S., Neuman, I., Chen, M.,Tesfaye, N., & Spector, J. M. (2013). Helping Babies Breathe training in sub-Saharan Africa: educational impact and learner impressions. Journal of Tropical Pediatrics, 59(3), 180-186.

This study sought to characterize knowledge changes and resuscitation skills after national-level HBB training in Ethiopia, the factors correlated with successful training, and trainee perceptions. Assessments showed that the HBB training improved neonatal resuscitation knowledge and was well-received by participants. A lower trainer-to-trainee ration was associated with improved knowledge scores.

Msemo, G., Massawe, A., Mmbando, D., Rusibamayila, N., Manji, K., Kidanto, H., & Perlman, J. (2013). New- born mortality and fresh stillbirth rates in Tanzania after helping babies breathe training. Pediatrics, 131(2), e353-e360.

The objectives of this study were to determine if implementation of HBB would enhance basic skills of birth attendants and reduce early neonatal mortality and fresh stillbirth rates. Results of the study demonstrated that implementation of the HBB program in 8 hospitals in Tanzania was associated with a sustained 47% reduction in early neonatal mortality within 24 hours and a 24% reduction in fresh stillbirths after 2 years.

Musafili, A., Essén, B., Baribwira, C., Rukundo, A., & Persson, L. Å. (2013). Evaluating Helping Babies Breathe: training for healthcare workers at hospitals in Rwanda. Acta Paediatrica, 102(1): e34-e38.

This study of 118 trainees found that Helping Babies Breathe training significantly improved the knowledge of healthcare personnel from three hospitals in Rwanda. Retesting 3 months later showed that knowledge was retained but, skills dropped to unsatisfactory levels in that period of time. The authors suggest educational training programs should include continuing field experiences to assist health workers in retaining knowledge and sustaining practical skills.


Ersdal, H. L., Mduma, E., Svensen, E., & Perlman, J. (2012). Birth asphyxia: a major cause of early neonatal mortality in a Tanzanian rural hospital. Pediatrics, 129(5), e1238-e1243.

Global estimates on the presumed causes of neonatal deaths have remain unchanged over the past decade, so the objective of this study was to determine the presumed causes of neonatal death within the first 24 hours in a rural hospital in northern Tanzania. Over 1 year, 4720 infants were born and evaluated. Observational findings indicate that most cases of early neonatal mortality were related to birth asphyxia (BA), and the 5-minute Apgar score is a poor surrogate of BA. Reducing perinatal mortality requires a multifaceted approach with attention to issues related to BA, prematurity and low birth weight.

Ersdal, H. L., Mduma, E., Svensen, E., & Perlman, J. M. (2012). Early initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries: a prospective descriptive observational study. Resuscita- tion, 83(7), 869-873.

The objectives of this observational study at a rural hospital in Tanzania were to describe normal transitional respiratory adaption at birth and to assess the importance of initiating basic resuscitation within the first minutes after birth as it relates to neonatal outcome. Results demonstrated that the majority of lifeless babies were in primary apnea and responded to stimulation/suctioning and/or face mask ventilation (FMV). Infants who required FMV were more likely to die particularly when ventilation was delayed or prolonged.

Ersdal, H. L., Mduma, E., Svensen, E., Sundby, J., & Perl- man, J. (2012). Intermittent Detection of Fetal Heart Rate Abnormalities Identify Infants at Greatest Risk for Fresh Stillbirths, Birth Asphyxia, Neonatal Resuscitation, and Early Neonatal Deaths in a Limited-Resource Setting: A Prospective Descriptive Observational Study at Haydom Lutheran Hospital. Neonatology, 102: 235–242.

The objective of this observational study was to determine the value of routine intermittent fetal heart rate (FHR) monitoring during labor in the detection of FHR abnormalities. Authors observed and recorded labor information for 10,271 deliveries at Haydom Lutheran Hospital in Tanzania. Assessments showed that intermittent detection of an absent or abnormal FHR using a fetal stethoscope is associated with fresh stillbirth, increased need for resuscitation, birth asphyxia and neonatal death in a limited resource setting. This supports the well-established hypothesis that an abnormal FHR is an important indicator of fetal stethoscope is associated with fresh stillbirth, increased need for resuscitation, birth asphyxia and neonatal death in a limited resource setting. This supports the well-established hypothesis that an abnormal FHR is an important indicator of fetal compromise. Moreover, the findings indicate a significant association between an abnormal FHR and labor complications.

K.C., A., Målqvist, M., Wrammert, J.,Verma, S., Aryal, D. R., Clark, R., KC, N.,Vitrakoti, R., Baral, K. & Ewald, U. (2012). Implementing a simplified neonatal resuscitation protocol-helping babies breathe at birth (HBB)-at a tertiary level hospital in Nepal for an increased perinatal survival. BMC Pediatrics, 12(159).

To provide a scalable strategy to improve the health workers performance in simplified neonatal resuscitation to reduce intrapartum death has been a global research priority. In low resource healthcare setting with multiple and complex factors determining the performance of health worker, identifying a specific solution to improve performance would be crucial. The HBB initiative has previously been shown to be feasible and acceptable to health workers. The focus on assisted breathing and the “golden minute” harbor an expectation also for improved results in relation to mortality and morbidity. This has however not been demonstrated. The results from this research study will therefore be of importance for policy makers at all levels and have implications for future neonatal resuscitation guidelines globally.

Singhal, N., Lockyer, J., Fidler, H., Keenan, W., Little, G., Bucher, S., Qadir, M. & Niermeyer, S. (2012). Helping Babies Breathe: global neonatal resuscitation program development and formative educational evaluation. Resuscitation, 83(1), 90-96.

This article describes the outcome of a formative evaluation of the HBB educational program at two test sites (Kenya and Pakistan). Participants demonstrated high satisfaction with the program, high self-efficacy and gain in knowledge and skills. Mastery of ventilation skills and integration of skills into case management may not be achievable in the classroom setting without additional practice, continued learning, and active mentoring in the workplace. These findings were used to revise program structure, materials and assessment tools.

Little, G. A., Keenan, W. J., Niermeyer, S., Singhal, N., & Lawn, J. E. (2011). Neonatal nursing and helping babies breathe: an effective intervention to decrease global neonatal mortality. Newborn and Infant Nursing Reviews, 11(2), 82-87.

This article describes the global neonatal death problem and the need to expand effective interventions to decrease neonatal mortality in limited-resource settings. Authors note that HBB is a highly suitable intervention to improve neonatal survival. Authors also point out that neonatal nursing must serve an essential role in standard setting, education and implementation of any bedside change in care of the newly born infant, and that international nursing and medical organizations should critically evaluate HBB and consider being actively involved in efforts that use HBB to decrease neonatal mortality.