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Glob Health Sci Pract. 2018 Oct 4;6(3):538-551. doi: 10.9745/GHSP-D-18-00147. Print 2018 Oct 3.

Helping Babies Breathe, Second Edition: A Model for Strengthening Educational Programs to Increase Global Newborn Survival.

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Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA, and Perinatal Institute and Global Child Health, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.
Latter-day Saint Charities, Salt Lake City, UT, USA.
Division of Life Support, American Academy of Pediatrics, Itasca, IL, USA.
World Hope International, Alexandria, VA, USA and Freetown, Sierra Leone.
Division of Neonatology, Saint Louis University, St. Louis, MO, USA.
Division of Neonatology, University of Calgary, Alberta, Canada.
Division of Neonatology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
Section of Neonatology, University of Colorado School of Medicine, Aurora, CO, USA.



Helping Babies Breathe (HBB), a skills-based program in neonatal resuscitation for birth attendants in resource-limited settings, has been implemented in over 80 countries since 2010. Implementation studies of HBB incorporating low-dose high-frequency practice and quality improvement show substantial reductions in fresh stillbirth and first-day neonatal mortality. Revision of the program aimed to further augment provider and facilitator skills and address gaps in implementation with the goal of improving neonatal survival.


The Utstein Formula for Survival-Medical Science X Educational Efficiency X Local Implementation = Survival-provided a framework for the revisions. The 2015 Neonatal Resuscitation Consensus on Science and Treatment Recommendations by the International Liaison Committee on Resuscitation informed scientific updates, which were harmonized with the 2012 World Health Organization Basic Newborn Resuscitation Guidelines. Published literature and program reports, consensus guidelines on reprocessing equipment, systematic collection of suggestions from frontline users, and responses to a semistructured online questionnaire informed educational/implementation revisions. Links to maternal care were added. Draft materials underwent Delphi review and field testing in India and Sierra Leone. An Utstein-style meeting of stakeholders identified key actions for successful implementation.


Scientific revisions included expectant management of infants with meconium-stained amniotic fluid, limitation of suctioning, and initiating and continuing effective ventilation until spontaneous respirations. Frontline users (N=102) suggested augmented simulation methods to build confidence and competence and additional guidance for facilitators on implementation. Users identified a need for sufficient practice during the workshop, systematized ongoing practice, and enough simulators for participants. Field trials refined approaches to self-reflection, feedback and debriefing, and quality improvement. Utstein meeting stakeholders validated the importance of quality improvement and use of data to improve outcomes.


The second edition of HBB provides a newer paradigm of learning for providers that incorporates workshop practice, self-reflection, and feedback and debriefing to reinforce learning as well as the promotion of mentorship and development of facilitators, systems for low-dose high-frequency practice in facilities, and quality improvement related to neonatal resuscitation.

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