A Short History of Helping BabiesBreathe: Why and How, Then and NowSusan Niermeyer, MD, MPH,a George A. Little, MD,b Nalini Singhal, MD,c William J. Keenan, MDd

abstractHelping Babies Breathe (HBB) changed global education in neonatal resuscitation. Althoughrooted in the technical and educational expertise underpinning the American Academy ofPediatrics’ Neonatal Resuscitation Program, a series of global collaborations and pivotalencounters shaped the program differently. An innovative neonatal simulator, graphic learningmaterials, and content tailored to address the major causes of neonatal death in low- andmiddle-income countries empowered providers to take action to help infants in their facilities.Strategic dissemination and implementation through a Global Development Alliance spreadthe program rapidly, but perhaps the greatest factor in its success was the enthusiasm ofparticipants who experienced the power of being able to improve the outcome of babies.Collaboration continued with frontline users, implementing organizations, researchers, andglobal health leaders to improve the effectiveness of the program. The second edition of HBBnot only incorporated new science but also the accumulated understanding of how to helpproviders retain and build skills and use quality improvement techniques. Although theimplementation of HBB has resulted in significant decreases in fresh stillbirth and earlyneonatal mortality, the goal of having a skilled and equipped provider at every birth remainsto be achieved. Continued collaboration and the leadership of empowered health careproviders within their own countries will bring the world closer to this goal.

aSection of Neonatology, Department of Pediatrics, School of Medicine, University of Colorado and Colorado School of Public Health, Aurora, Colorado; bDepartments of Pediatrics andObstetrics and Gynecology, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; cSection of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta,Canada; and dDivision of Neonatal and Perinatal Medicine, Saint Louis University, St Louis, Missouri

Dr Niermeyer conceptualized and designed the review, collected data, drafted the initial manuscript, and reviewed and revised the manuscript; Drs Little, Singhal,and Keenan participated in conceptualizing and designing the review, collected data, and reviewed and revised the manuscript; and all authors approved the finalmanuscript as submitted and agree to be accountable for all aspects of the work.

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

Address correspondence to Susan Niermeyer, MD, MPH, Section of Neonatology, Department of Pediatrics, School of Medicine, University of Colorado, 13121 E 17thAve, Mail Stop 8402, Aurora, CO 80045. E-mail: susan.niermeyer@cuanschutz.edu

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: The authors are members of the American Academy of Pediatrics Helping Babies Survive Planning Group and members of theeditorial committee for the first and second editions of Helping Babies Breathe.

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THE CHALLENGE: WHY FOCUS ONRESUSCITATION AT BIRTH?

What happens in the first minutesafter birth can influence an entire life.Supporting a safe birth for eachindividual protects the health offamilies and communities, andattention to women and infantsaround birth signifies a highlydeveloped social compact andmature health system.

THE GAP IN CARE AND OUTCOMES: WHYFOCUS ON EDUCATION?

Despite the importance of care atbirth, promoting attention to theinfant has proven to be a persistentchallenge through history. Forcenturies, medical interventionfocused on the mother, without whoman infant had little to no chance ofsurvival.1 In the modern era ofobstetrics and pediatrics, the adventof the Apgar score in 1953 signaleda need to focus on the physiologictransitions of the newly born infantand the beginning of systematicinvestigation around support fortransition and recovery fromintrapartum hypoxic-ischemicevents.2 Despite physiologic researchdone in the 1960s and the emergenceof neonatal-perinatal medicine andresuscitation science in the 1970s,birth asphyxia continued to bea leading cause of neonatal mortalityin the United States and othermedically advanced countries as wellas most of the rest of the world.3

Recognition of birth asphyxia asa public health problem promptedleaders in medical research andpublic health at the United StatesChildren’s Bureau to begin an agendato improve the science and practice ofcare of the newly born infant. TheNational Institutes of Health (NIH)issued a call for research in the area,resulting not only in basic-scienceproposals but also educationalapproaches, most notably, one thatdeveloped a systematized educationalprogram on neonatal resuscitation for

health professionals. Concertedadvocacy efforts by Dr WilliamKeenan forged agreement in principleon the value of professional educationaround neonatal resuscitation andbrought support from the AmericanAcademy of Pediatrics (AAP),American Academy of FamilyPhysicians, American NursesAssociation, American Society ofAnesthesiologists, and AmericanCollege of Obstetricians andGynecologists. The educationalprogram developed at Charles R.Drew Postgraduate Medical School byRonald Bloom, MD, and CathyCropley, RN, MSN, with the awardfrom the NIH was revolutionary in itsemphasis on hands-on practice forthe development of psychomotorskills and deliberate learningstrategies that repeated consistentkey messages. Using this template asthe foundation, leaders of the AAPand the American Heart Associationjoined in to create and disseminatewhat became the NeonatalResuscitation Program (NRP).4

Beginning in 1986, the NRPincorporated the available scienceinto a standardized educationalprogram and disseminated it rapidlyand widely across hospitals in theUnited States and around the world.Although the approach contributed toeffective management of newborninfants, creating an educationalprogram also revealed the gaps inevidence and the need to include themost widely used practices whenevidence did not exist. The NRPprogressively incorporated results ofscientific evidence evaluation by theInternational Liaison Committee onResuscitation. Putting emphasis onknowledge and skills rather thanprofessional discipline as thenecessary qualification to performresuscitation enabled the NRP tochange behavior effectively and gainwide uptake.4,5 The goal of theprogram, to have a person at everybirth who was trained and equippedto initiate resuscitation, elevated the

role of nurses as an integral part ofthe perinatal team. Perhaps the mostunexpected aspect was the globaldemand for an effective educationalprogram in neonatal resuscitation.The AAP did not set out to createa global program but did try to meetthe requests for faculty support, andthe program eventually wasintroduced in over 130 countries andtranslated into 24 languages.6

Implementation outside the UnitedStates continued to emphasize theinvolvement of both nurses andphysicians; the NRP gave a voice andopportunities for leadership to nursesin low- and middle-income countries(LMIC). Successful implementation atlarge scale usually involved theMinistry of Health, together witha pediatric or neonatal professionalsociety and a university ornongovernmental organization.7 Onesuch program was Freedom of Breath,Fountain of Life, an effort begun in2004 by the Chinese Ministry ofHealth with the Chinese Center forDisease Control and Prevention incollaboration with the AAP, ChineseSocieties of Perinatal Medicine,Pediatrics and Nursing, and Johnson& Johnson Pediatric Institute.8,9 Thesteering committee quickly expandedto include midwives, who providemost of the immediate care at birth inChina but whose scope of practicehad not included neonatalresuscitation before the initiative.Implementation of the programtargeted provinces where maternaland neonatal mortality were thehighest, and thus revealed the vastrange of facility types and capabilitieswhere deliveries occurred. Thegeneral doctors, midwives, andnurses in small rural facilities made itclear that an educational program inneonatal resuscitation needed to bepractical, short, and approachable(not based on a textbook or hours ofslide lecture).

As systematic provider education andbetter management of pregnantwomen and newborns were reflected

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in improved health statistics forNorth America, the huge burden ofasphyxial mortality among infants inmuch of the rest of the world becameevident. In the United States, asphyxiaas a cause of neonatal death fell by.72% from 1979 to 1996.10 At thesame time, in global data collection,asphyxia was identified as 1 of the 3major causes of neonatal death,together with infection andprematurity or small size at birth.11

The burden of mortality weighed theheaviest in LMIC, where 99% of anestimated 4 million global neonataldeaths occurred and where stillbirthaccounted for ∼1 million lives lost peryear.12,13 In the year 2000, deaths inthe first 28 days accounted for ∼37%of total ,5 child deaths, but thisproportion was rising steadilybecause deaths in childhood weredeclining much faster than thoseduring the neonatal period, duelargely to effective efforts againstdiarrhea and pneumonia. Laggingprogress for neonates meant manycountries were not on track to meetthe 2015 Millennium DevelopmentGoals of reducing the ,5 childmortality rate by two-thirds from1990 levels.12,14

In the early 2000s, some evidence-based interventions had beenidentified to combat neonatalmortality: support for exclusivebreastfeeding, kangaroo care for lowbirth weight infants, and treatment ofperinatal infections with antibiotics;however, interventions forintrapartum hypoxic-ischemic eventshad been largely regarded asrequiring intensive care and, so, werefelt to be impractical or inaccessiblein most settings. Better clinicalalgorithms, educational methods, andtechnology for neonatal resuscitationwere recognized as global prioritiesfor research to reduce deaths frombirth asphyxia.15 Experience with themore structured algorithm of NRPdemonstrated the great value of theinitial, basic steps of resuscitation:drying, stimulation, and positive-

pressure ventilation. Concurrently,evidence evaluation was focused onthe potential effectiveness ofinitiating ventilation with room air,removing another barrier to thewidespread implementation ofneonatal resuscitation guidelines.Other lines of evidence evaluationrelating to management of theumbilical cord after birth andmaintenance of normothermia in thedelivery setting had a clearrelationship to survival and toresource-limited settings.16 It wasbecoming apparent that basicresuscitation not requiring extensiveresources could have a hugeimpact.

UNDERSTANDING THE GLOBAL NEED:HOW MUST THIS BE DIFFERENT?

Although the needs of infants areuniversal, a global educationalprogram would have to be adaptableand nimble to meet the needs ofhealth care providers. The newprogram could leverage severalfeatures that had promotedeffectiveness and uptake of NRP(Fig 1), but to be accessible toa global audience, high-priorityconcepts would have to becommunicated efficiently to manydifferent cadres of birth attendantswithout relying on text-heavy

materials or electricity. Thecurriculum must target practicalskills, but equipment to provide caredid not exist in many facilities.17

The educational program shouldempower a frontline birth attendant,often caring for both mother andinfant, to help a newborn who didnot breathe at birth.

To better understand and meet theneeds of the target audience, the AAPformed a Global Implementation TaskForce (GITF) in 2006 and inviteda broad range of stakeholders to join.AAP volunteer members and fellowsbrought extensive teachingexperience in LMIC, and severalbrought a personal perspective fromliving and working in Latin America,Asia, or Africa. Physician leaders fromLatter-day Saint Charities and the NIHGlobal Network for Women’s andChildren’s Health Research hadalready worked with the AAP to adaptNRP to a simplified format forteaching in their internationalsites. Save the Children’s SavingNewborn Lives had explored simplemouth-to-tube resuscitation deviceswith midwives in Indonesia.18

Representatives from the WorldHealth Organization (WHO) in Genevaand the Hesperian Foundation,publishers of Donde No Hay Doctor(translated as Where There Is No

FIGURE 1Features of HBB that promoted effectiveness and uptake as a result of lessons learned in thedevelopment of the NRP.

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Doctor), brought their insights intokey elements for educationalmaterials. Leadership from the UnitedStates Agency for InternationalDevelopment (USAID) offeredperspectives on implementation.Laerdal Medical, which hadsupported NRP with purpose-builtmannequins and simulators,expressed interest in designing a low-cost neonatal simulator based on oneproduced for Simply NRP. Witha philosophy of inclusivity, the AAPled this group of collaborators withdeep expertise and expressedcommitment to helping createa solution.

The International PediatricAssociation congress in Athens inAugust 2007 proved pivotal inarticulating the need for a rapidresponse and radically differenteducational approach. Several globalleaders of academic and clinicalpediatrics attended a session in whichDr George Little presented the GITFproposal. As educators and clinicians,they spoke unanimously about theneed to make the materials lesscomplex, accessible to all, andrelevant to the realities of care. In thewords of Dr Vinod Paul, from the AllIndia Institute of Medical Sciences(V.K. Paul, MD, PhD, personalcommunication, 2020), “The currentsystem of teaching neonatalresuscitation is overly complex, andat the same time misses meeting theneeds of many babies born aroundthe world. A program that targetsproviders in the low-resource settingsand focuses on core neonatalresuscitation skills should bedeveloped and scaled up. This willtransform our approach to reduceneonatal mortality worldwide.” Witha challenge issued to producea curriculum for field testing withina year, the task force literally threwaway early drafts and began to honeguiding principles for innovativeeducational materials. The missionbecame “to develop and implementan evidence-based curriculum,

adaptable to clinical and training usewherever babies are born.”

From the beginning, collaborationwith participants from the targetaudience of health care providers inLMIC helped shape programdevelopment around hands-onactivity and pictorial communication.An early prototype created to trainsite coordinators for the NIH GlobalNetwork’s First Breath trial usedcut-up and rearranged line drawingsfrom the Textbook of NeonatalResuscitation as a useful tool to guideskills practices for birth attendants inIndia, Pakistan, Zambia, theDemocratic Republic of the Congo,Guatemala, and Argentina.19 Practiceexercises had incorporatedconsideration of on-the-groundconcerns, such as availability ofadequate light, clean equipment,communication with the mother, andhelp for a single birth attendantcaring for both mother and infant. ForHelping Babies Breathe (HBB),a pictorial Action Plan replaced thewords of the traditional resuscitationalgorithm, and it became clear fromobservations in the field that anelement of time must propelsuccessful resuscitation. Rapidassessment and action in The GoldenMinute became an organizingprinciple: by one minute, an infantshould be breathing spontaneously orreceiving ventilation with bagand mask.

The 20th anniversary celebration ofthe NRP in the United States in 2006proved to be a springboard for thedevelopment of the global program.Many people, gathered to celebratethe impact of NRP on professionaleducation, neonatal outcomes, andquality of care, shared the thoughtexpressed by Wally Carlo, “When westarted the NRP, no one thought thatthere could be a person trained andequipped to provide resuscitation atevery birth in the United States. Nowthat is the standard, and it can be thesame for the rest of the world.”Progress quickly accelerated when

Laerdal Medical introduced to theGITF a low-cost, high-fidelity neonatalsimulator that showed the primaryevaluation signs of cry (squeakerbulb), breathing (pneumatic bulb forspontaneous breaths and chest risewith positive-pressure ventilation),and heart rate (another pneumaticbulb for palpable umbilical pulse).The water-filled simulator had theweight and the tone of an infant whoneeded resuscitation; every healthcare provider who was handed thesimulator felt a shiver. This wasa simulator that elicited a visceral,emotional response that could beharnessed to engage learners. Laerdalalso offered the in-kind support oftheir graphic and educationaldesigners, Anne Jorunn SvalastogJohnsen and Harald Eikland, whomade subtle points of technique,become visible and helped fashiona spare but impactful text supportingpractice change. The GITF set aboutturning a curriculum into aneducational program with repeatedtesting of the logic, feasibility, andusability of new materials.

DEVELOPMENT AND VALIDATION OFEDUCATIONAL DESIGN: HOW TO TEACHAND LEARN?

Shifting the educational paradigmrequired refining the techniques foractive learning with simulation andproducing more sophisticated graphicmaterials. HBB relies on the samescience as NRP. However, the ActionPlan used a series of icons orsymbolic illustrations to stand forwell-defined sets of evaluations,decisions, and actions that createa shared mental model for the care ofa newly born infant regardless oflanguage (Fig 2: HBB Action Plan).The words used on the Action Planwere few, chosen to be simple, andconsistent to facilitate translation anduse by low-literacy providers. Eachicon on the Action Plan correspondedto an explanatory page in botha Provider Guide and Facilitator FlipChart. Simple but lifelike drawings

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created from photographs withcomputer-aided design broughtemotion to interaction with providers

and illustrated actions step-by-step.Text was kept to a minimum, andefforts were made to use short

sentences and language at a middleschool level. The Facilitator Flip Chartnot only displayed the illustrations inlarge format for learners but alsoprovided, on the reverse side, a scriptfor the facilitator to explain,demonstrate, lead practice, checkunderstanding, and explore barriersand solutions with participants. Withevery action step, hands-on practicetook place with the simulator andequipment as well as practice ofcommunication with other providers,the mother, and her companion.Reinforcing the principle of hands-onlearning, the decision was made todeliver a simulator with a completeset of equipment and learningmaterials for each pair of participantstrained. In order that equipment usedfor training could also be used forclinical care, a new reusable bulbsuction device, the Penguin suction,was developed so that both suctionand bag-and-mask devices could bereprocessed and highly disinfected.

SHIFTING KEY BEHAVIORS ANDACTIONS: HOW TO MAKE CHANGEHAPPEN?

As important as the pedagogicaltechniques was the analysis of thesocial and behavioral changenecessary to create a change inoutcomes. Extensive systematicreviews of newborn care practicespointed to several key interventionsthat were basic but had the potentialto save lives.20 Traditionally, thesewere not part of neonatalresuscitation education, butexperience with the combineddelivery of the WHO EssentialNewborn Care Course content andneonatal resuscitation in the FirstBreath trial had revealed the clearadvantage of combining concepts ofhygiene and infection prevention,thermal support, and immediate andexclusive breastfeeding intoimmediate care at birth. In clinicaland research experience in globalsites, researchers repeatedlydocumented the consequences of

FIGURE 2Helping Babies Breathe Action Plan, First Edition (reproduced with the permission of the AAP).

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unavailable equipment, long delays inattending to an infant who was notbreathing, and administration of chestcompressions, medications, or otherinterventions without first providingadequate ventilation. A number ofbehavioral constructs and educationaldevices were incorporated to addressthese shortcomings.

� Preparation for birth: identifyinga helper, reviewing the emergencyplan, and preparing the area fordelivery and area for ventilation(testing equipment).

� Thorough drying for all infants asa first action step before andduring the initial evaluation.

� Initial evaluation for crying or notcrying as a rapid, objectiveindicator, followed immediately bya more detailed evaluation ofbreathing.

� Routine care as systematic use oflifesaving interventions: handhygiene for all present at birth,skin-to-skin care in the first hour,delayed umbilical cord clamping,and support for immediatebreastfeeding.

� The Golden Minute: prioritizinga quick response for an infant whodoes not cry immediately withdrying, with the goal of breathingspontaneously or being ventilatedby 1 minute after birth; initiationof ventilation presumptively in allexcept obviously maceratedstillborn infants.

� Emphasis on the keyinterventions: ventilation andimprovement of ventilation withomission of chest compressions,supplemental oxygen, andmedications (but with the optionto segue into a full NRP algorithmwhen available for extensiveresuscitation).

� Empowerment of the health careworkers: providing equipment andeducation simultaneously toachieve basic mastery of skillswith peer-to-peer learning in pairsand exploring existing norms and

barriers to create positive change(Fig 3).

DATA TO GUIDE EDUCATIONALDEVELOPMENT: HOW TO KNOW WHATWORKS AND WHAT DOES NOT?

Collaboration broadened as formativeevaluation shaped the developmentof the educational program at everystep. Beginning in 2008, members ofthe GITF provided feedback and betatesting as new elements wereintroduced. Digital materials weredistributed to global stakeholders,including those present at the AthensInternational Pediatric Associationcongress, for input in 2 rounds ofelectronic Delphi review. WHOtechnical consultation withheadquarters staff and global regionalrepresentatives assured importantharmonization with the Guidelines onBasic Newborn Resuscitation thenunder revision.21 WHO midwiferyadvisors and representatives of theUnited Nations Population Fundsuggested key changes, such asputting thorough drying “front andcenter” in the Action Plan as the firstaction step after birth for all infants,with evaluation of crying during andafter that. This change reconfiguredthe Action Plan and balanced care for

infants who were not breathing withessential care interventions for allinfants to avoid hypothermia,hypoglycemia, and infection.

In 2009, formal educational testingwith frontline providers in Kenya andPakistan examined not onlyeducational outcomes of knowledgeand skills but the replicability of theprogram through a train-the-trainercascade.22,23 Modifications based onthe results of field testing wereincorporated into the program, andimplementation testing began inTanzania to more fully examine thetraining cascade and clinicaloutcomes.24 Always there wasawareness of the balance betweenfurther testing to perfect theeducational program and the urgencyto release a program that couldpotentially save lives. Because of thepositive feedback and mountingexcitement among stakeholders andfrontline providers, the decision wasmade to launch HBB in mid-2010 andcontinue additional implementationtesting after release.

DISSEMINATION: HOW TO SCALE UPEDUCATION?

Dissemination and implementationon a large scale were made possible

FIGURE 3A HBB workshop in Belgaum, India, during implementation trials (reproduced with the permission ofthe AAP).

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through a Global DevelopmentAlliance (GDA) and the partnershipsforged in the process of programdevelopment. Concurrent with thefirst workshop in HBB held inWashington, DC, in June 2010,a public-private partnership wasformed with the goal of reducingmortality and morbidity from birthasphyxia through rapid disseminationand implementation of HBB. TheUSAID organized 5 founding partners:USAID and its implementing agenciesprovided connection with in-countrymaternal-newborn programming,Save the Children’s Saving NewbornLives brought strong advocacy as wellas in-country programming, theNational Institute of Child Health andHuman Development contributedongoing implementation evaluationthrough the Global Network forWomen’s and Children’s Health, theAAP supported creation of a globalfaculty and network of facilitators,and Laerdal Global Health, a newlyformed nonprofit corporation,produced and distributed educationalmaterials at cost to MillenniumDevelopment Goals targetcountries.25,26

IMPLEMENTATION: HOW TO CHANGECLINICAL OUTCOMES?

From the outset, the AAP and otherpartners in the GDA had as their goaldemonstrating the impact on clinicaloutcomes at scale. Through USAIDand Save the Children, implementingpartners trained in-country cadres offacilitators and sought to support theintegration of neonatal resuscitation,and more broadly newborn care, intonational policy and newborn plans.The AAP and Save the Childrenproduced an online Guide forImplementation of HBB as a tool forfacilitators, program managers, policymakers, and planners and made itavailable through the HealthyNewborn Network site (https://healthynewbornnetwork.org).Many other nongovernmentalorganizations, apart from the GDA,

recognized the value of HBB not onlyas an educational program but asa ready-made framework forevaluation and monitoring. Earlyimplementation trials demonstratedthat an educational workshop byitself may change skills but notbehavior in the clinical setting.27 Botheducational and implementationresearch identified the need forcontinued practice to maintaininfrequently used skills, such as bag-and-mask ventilation.22,28,29 However,with routines for low-dose, high-frequency practice in the facility, localresuscitation champions, and use ofdata for quality improvement, thefirst implementation of HBB inTanzania (Fig 4) showed a sustained47% reduction in early neonatalmortality (24 hours) and 24%reduction in fresh stillbirths.24

The first 5 years after the launch ofHBB focused on scaling up educationand yielded numerous studies thatdemonstrated the effectiveness ofHBB in reducing fresh stillbirth andearly neonatal mortality. These effectswere replicated with a high degree ofconsistency across different providergroups (midwives, physicians, and

traditional birth attendants) anddifferent settings, from single-sitestudies to multicenter, population-based trials. A meta-analysis of studiesin Tanzania, India, Kenya, and Nepaldemonstrated a 34% reduction infresh stillbirth rate (odds ratio: 0.66;95% confidence interval: 0.52–0.85)and 30% reduction in first-daymortality rate (odds ratio: 0.70; 95%confidence interval: 0.51–0.98).30 TheNational Institute for Child Healthand Human Development GlobalNetwork used population-basedperinatal registries in 3 sites in Indiaand Kenya to examine perinatalmortality.31 Although perinatalmortality did not change in theoverall registry areas (in-facility andhome births), fresh stillbirths weresignificantly reduced in facilities inwhich staff were trained in HBB. Theconsistent reduction of freshstillbirths with HBB trainingdemonstrated that timely, universalinitiation of basic resuscitationinterventions addressedmisclassification of infants who aresimply not breathing as stillborn.32,33

As experience grew with HBB, thefocus shifted to understanding better

FIGURE 4Participants and faculty at the train-the-trainer workshop for the Tanzanian implementation trial(reproduced with the permission of the AAP).

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how to help providers retain skillsand reliably improve outcomes. Manyindependent groups used theirimplementation sites in LatinAmerica, Asia, and Africa toinvestigate the role of low-dose, high-frequency practice and qualityimprovement initiatives.34–37 Low-dose, high-frequency practice (shortbursts of practice at intervals fromdaily to monthly) proved to be moreefficient than longer refreshercourses after longer intervals.38 Bothtraditional quality improvementcommittee structures and mentoringapproaches have proven effective inimproving newborn outcomes.34,38,39

Studies revealed improvement inaspects of essential newborn care atbirth as well as resuscitationinterventions, such as initiation ofventilation within one minute afterbirth.40,41 However, challengesremain because a large proportion ofinfants do not receive ventilationuntil after one minute, there ispersistent overuse of suctioning, andinterruptions in ventilation occureven when an infant is notbreathing.28,42

In 2015, stakeholders and frontlineusers of HBB, Helping Babies Survive,and Helping Mothers Surviveprograms participated in an Utsteinconsensus process to synthesize theiraccumulated experience into 10action steps to improve maternal andnewborn survival and inform thesecond edition of HBB.43 Revision ofthe materials again involved listeningto global leaders, frontline providers,program managers, and researchersthrough opportunities for onlinecomment and structured Delphireviews.44 New International LiaisonCommittee on Resuscitation evidenceevaluation on the management ofmeconium-stained amniotic fluid andumbilical cord clamping also wasincorporated into the second editionof HBB, in 2016, consistent with thepromise to help bring the mostcurrent resuscitation science to allnewborns in a timely way. The second

edition also incorporated enhancedsupport for skills practice, emphasison debriefing after resuscitation, andintegration of deliberate qualityimprovement efforts continue tomaximize the product of the formulafor survival: resuscitation science xeducational efficiency x localimplementation = survival (Fig 5).

LESSONS LEARNED AND PATHWAYFORWARD: THEN AND NOW

A decade of experience with HBB hasmade a lasting impact on familieswhose infants’ lives were saved, onproviders and facilitators who havenew skills and pride in theimprovements they have made, andon health systems that have realizedthe value of investing in the newborn.Professional associations andpartners in implementation have alsobeen changed by recognizing howthey can make valuable contributionsto global child health. Indeed, theresuscitation programs of the AAPdeliver much of their unique valuebecause practicing professionals whoare actually responsible for clinicalcare of newborns, training of healthcare providers, and evaluation ofscientific evidence dedicate their timeand talents as volunteers workingtoward a shared goal. The mission ofthe AAP itself, the health of allchildren, cannot be overestimated inits importance in providing direction,authority, and a community thatallows members to achieve what theycould not as individuals.

HBB has taught a number of lessonsthat have broad applicability to manyinterventions aimed at improving thesurvival of mothers and newborns.

� Simplicity and clarity open thedoor for change.

� Facility-based education inknowledge and skills initiateschange.

� Mentoring and empowerment ofhealth workers solidify change.

� Monitoring, data collection, anduse of data to improve caresupports continued change.

� The catalytic role of HBB spreadschange by

○ focusing not only on infants butalso their mothers duringantepartum, intrapartum, andpostnatal care;

○ demystifying interventions (eg,resuscitation and postpartumhemorrhage prevention); and

○ demystifying processes (eg, datacollection and qualityimprovement).

� Articulating a goal on behalf of allthe world’s children can drivechange.

Perhaps the greatest success of HBBhas been its role as a catalyst to bringpeople together to focus onnewborns, realize what they can do,and say to one another “we can savenewborn infants.” When frontlinehealth providers realize that, theythen ask, “What can we do next?” Inthat way, norms and standardschange.

Nevertheless, the goals of havinga skilled person at every birth andending preventable deaths ofnewborns are far from beingachieved, and, again, another globaltarget approaches for the SustainableDevelopment Goals.45 Extending thescope of education beyondresuscitation to comprehensiveessential newborn care as well ascare for small and sick newborns andredoubling the effort to increasecoverage are more important thanever.46,47 HBB is a living programwith the capacity for change, and thelessons learned can be applied to newscience and new modalities forlearning.48,49 There is fresh potentialto collaborate more widely, moreoften, and more meaningfully amongcountries and among professionaldisciplines to improve HBB andstrengthen in-country ownership ofnewborn survival programs.

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Ultimately, the vision would betransformation from an educationalprogram to an integral part of theoperational structure of health

systems, in which, clinical standards,professional expectations, and anapproach to continued learning andimprovement of quality of care all

elevate the survival and outcome ofnewborns.

ABBREVIATIONS

AAP: American Academy ofPediatrics

GDA: Global Development AllianceGITF: Global Implementation Task

ForceHBB: Helping Babies BreatheLMIC: low- and middle-income

countriesNIH: National Institutes of HealthNRP: Neonatal Resuscitation

ProgramUSAID: United States Agency for

International DevelopmentWHO: World Health Organization

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Susan Niermeyer, George A. Little, Nalini Singhal and William J. KeenanA Short History of Helping Babies Breathe: Why and How, Then and Now

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Susan Niermeyer, George A. Little, Nalini Singhal and William J. KeenanA Short History of Helping Babies Breathe: Why and How, Then and Now

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