The effects of standardised protocols of obstetric and neonatal care on perinatal and early neonatal mortality at a rural hospital in Tanzania

Frequent brief on-site simulation training and reduction in 24-h neonatal mortality--an educational intervention study

AIM OF THE STUDY

"Helping Babies Breathe" (HBB) is a simulation-based educational program developed to help reduce perinatal mortality worldwide. A one-day HBB training course did not improve clinical management of neonates. 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.

METHODS

Before/after educational intervention study in a rural referral hospital in Northern Tanzania. Baseline data was collected from 01.02.2010 to 31.01.2011 and post-intervention data from 01.02.2011 to 31.01.2012. All deliveries were observed by research assistants who recorded information about labor, newborn delivery room management, perinatal characteristics, and neonatal outcomes. 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. Outcome measures were; delivery room management of newborns and 24-h neonatal outcomes (normal, admitted to a neonatal area, death, or stillbirths).

RESULTS

There were 4894 deliveries pre and 4814 post-implementation of frequent brief simulation training. The number of stimulated neonates increased from 712(14.5%) to 785(16.3%) (p = 0.016), those suctioned increased from 634(13.0%) to 762(15.8%) (p ≤ 0.0005). Neonates receiving bag mask ventilation decreased from 357(7.3%) to 283(5.9%) (p = 0.005). Mortality at 24-h decreased from 11.1/1000 to 7.2/1000 (p = 0.040).

CONCLUSION

On-site, brief and frequent HBB simulation training appears to facilitate transfer of new knowledge and skills into clinical practice and to be accompanied by a decrease in neonatal mortality.

Resuscitation in resource-limited settings

Intrapartum-related hypoxia leading to deaths and disabilities continues to be a global challenge, especially in resource-limited settings. Primary prevention during labour is likely to have a significant impact, but secondary prevention with focus on immediate basic stabilization at birth can effectively reduce a large proportion of these adverse outcomes as demonstrated in the resource-rich settings. Infants who fail to initiate and establish spontaneous respirations at birth often respond to early interventions such as drying, stimulation, clearing the airways, as well as bag mask ventilation applied within the first minute after birth. Simple resuscitation education such as 'Helping Babies Breathe', which focuses on the very basic steps and pays attention to comprehensive program development with local ownership and accountability, can help transfer competency into clinical practice and lead to sustainable programs impacting neonatal mortality and morbidity.

Newborn mortality and fresh stillbirth rates in Tanzania after helping babies breathe training

BACKGROUND

Early neonatal mortality has remained high and unchanged for many years in Tanzania, a resource-limited country. Helping Babies Breathe (HBB), a novel educational program using basic interventions to enhance delivery room stabilization/resuscitation, has been developed to reduce the number of these deaths.

METHODS

Master trainers from the 3 major referral hospitals, 4 associated regional hospitals, and 1 district hospital were trained in the HBB program to serve as trainers for national dissemination. A before (n = 8124) and after (n = 78 500) design was used for implementation. The primary outcomes were a reduction in early neonatal deaths within 24 hours and rates of fresh stillbirths (FSB).

RESULTS

Implementation was associated with a significant reduction in neonatal deaths (relative risk [RR] with training 0.53; 95% confidence interval [CI] 0.43-0.65; P ≤ .0001) and rates of FSB (RR with training 0.76; 95% CI 0.64-0.90; P = .001). The use of stimulation increased from 47% to 88% (RR 1.87; 95% CI 1.82-1.90; P ≤ .0001) and suctioning from 15% to 22% (RR 1.40; 95% CI 1.33-1.46; P ≤ .0001) whereas face mask ventilation decreased from 8.2% to 5.2% (RR 0.65; 95% CI 0.60-0.72; P ≤ .0001).

CONCLUSIONS

HBB implementation was associated with a significant reduction in both early neonatal deaths within 24 hours and rates of FSB. HBB uses a basic intervention approach readily applicable at all deliveries. These findings should serve as a call to action for other resource-limited countries striving to meet Millennium Development Goal 4.