Lessons Learned From Helping Babies Survive in Humanitarian Settings Ribka Amsalu, MD,a,b Catrin Schulte-Hillen, MPH,c Daniel Martinez Garcia, MD, MPH,d Nadia Lafferty, MBChB, MRCPCH,e Catherine N. Morris, MPH,a Stephanie Gee, MPH,c Nadia Akseer, PhD,g Elaine Scudder, MA,a Samira Sami, DrPH,f Sammy O. Barasa, BScN,h Hussein Had, MSc,i Maimun Farah Maalim, MD,j Seidou Moluh, MD,c Sara Berkelhamer, MDk

abstract Humanitarian crises, driven by disasters, conflict, and disease epidemics, have profound effects on society, including on people’s health and well-being. Occurrences of conflict by state and nonstate actors have increased in the last 2 decades: by the end of 2018, an estimated 41.3 million internally displaced persons and 20.4 million refugees were reported worldwide, representing a 70% increase from 2010. Although public health response for people affected by humanitarian crisis has improved in the last 2 decades, health actors have made insufficient progress in the use of evidence-based interventions to reduce neonatal mortality. Indeed, on average, conflict-affected countries report higher neonatal mortality rates and lower coverage of key maternal and newborn health interventions compared with non–conflict-affected countries. As of 2018, 55.6% of countries with the highest neonatal mortality rate ($30 per 1000 live births) were affected by conflict and displacement. Systematic use of new evidence-based interventions requires the availability of a skilled health workforce and resources as well as commitment of health actors to implement interventions at scale. A review of the implementation of the Helping Babies Survive training program in 3 refugee responses and protracted conflict settings identify that this training is feasible, acceptable, and effective in improving health worker knowledge and competency and in changing newborn care practices at the primary care and hospital level. Ultimately, to improve neonatal survival, in addition to a trained health workforce, reliable supply and health information system, community engagement, financial support, and leadership with effective coordination, policy, and guidance are required.

aDepartment of Global Health, Save the Children, Washington, District of Columbia; bUniversity of California San Francisco, San Francisco, California; cPublic Health Section, United Nations High Commissioner for Refugees, Geneva, Switzerland; dMedical Department, Médecins Sans Frontières, Geneva, Switzerland; eMedical Department, Médecins Sans Frontières, Barcelona, Spain; fDepartment of International Health and Center for Humanitarian Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; gCentre for Global Child Health, Hospital for Sick Children, Toronto, Canada; hDepartment of Nursing, Kenya Medical Training College, Machakos, Kenya; iSave the Children, Garowe, Puntland, Somalia; jGardo General Hospital, Puntland, Somalia; and kDepartment of Pediatrics, University of Washington, Seattle, Washington

Dr Amsalu conceptualized the study and drafted the initial manuscript; Ms Schulte-Hillen, Ms Gee, Mr Moluh, Mr Barasa, Ms Morris, Mr Had, and Dr Maalim contributed to the design of the study, collected data, conducted the data analysis, and drafted the case examples; Dr Akseer conducted the data analysis; Drs Sami, Garcia, Lafferty, and Ms Scudder contributed to the design of the study; Dr Berkelhamer conceptualized the study; and all authors reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work. DOI: https://doi.org/10.1542/peds.2020-016915L Accepted for publication Aug 4, 2020 Address correspondence to Ribka Amsalu, MD, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, CA 94143. E-mail: [email protected]

Downloaded from www.aappublications.org/news by guest on September 27, 2021 SUPPLEMENT ARTICLE PEDIATRICS Volume 146, number s2, October 2020:e2020016915L INTRODUCTION ($30 per 1000 live births) can be global capacities to respond to needs, fi Globally, major advances for classi ed as experiencing political and challenges in mitigating the fl fl improving newborn health have been instability or con ict in the last consequences of con ict on health achieved, including generating the decade (Table 1) on the basis of the systems. In addition, although the fl 9 evidence base, developing national Uppsala Con ict Data Program. An evidence base for newborn health has ecological analysis using national expanded since the Lancet series in strategies and action plans, and 10,11 reducing neonatal mortality.1,2 survey data from low- and middle- 2005 and there are several However, in countries affected by income countries, with methodology guidelines for humanitarian settings fi 12,13 humanitarian crises and political and de nition presented by Akseer that promote newborn health, 7 fl fi instability, newborn outcomes et al, found that con ict-affected there is insuf cient capacity in the continue to lag behind.2 countries on average have worse use of evidence-based interventions – fl Humanitarian crises, driven by NMRs compared with non con ict- to reduce neonatal mortality in the fi disasters, conflict, and disease affected countries (Fig 1). Indeed, humanitarian eld, and most epidemics, have profound effects on there continues to be a gap in organizations self-report as not ’ coverage of interventions during providing essential newborn care society, including on people s health 14 and well-being. The magnitude and pregnancy, childbirth, and postnatal services. fl severity of humanitarian crises have period between con ict-affected and – fl Authors of a 2014 evaluation of increased in the last decade. By the non con ict-affected countries 7 reproductive health services for end of 2018, an estimated 41.3 (Fig 1). refugees and IDPs in South Sudan, the million internally displaced persons Several factors have contributed to Democratic Republic of the Congo (IDPs) and 20.4 million refugees were this divergence, including an increase (DRC), and Burkina Faso found that 3 reported worldwide, which is nearly in severity and scale of conflict and out of 5 hospitals and only 5 out of 58 a 70% increase from 2010.3,4 Conflict, humanitarian crises in the last health centers were providing by its very nature, diminishes decade, overstretched national and essential newborn care services.15 Of national accountability, governance, economic growth, and resources available for social services.2,5 In TABLE 1 Occurrence of Conflict and Internal Displacement due to Conflict in 18 Counties With the addition, the impact of a crisis on Highest NMR health systems can be severe because of the destruction of health facilities, Country Neonatal Mortality UCDP: Episodes and Intensity of IDPs in This per 1000 Live Armed Conflict,b 2010–2017 Country,c 2018 shortage of skilled health workers, Births,a 2018 disruption of supply chain systems, Pakistan 42 High-intensity conflict, war 119 000 and restrictive working and Central African 41 Minor-intensity conflict 641 000 5,6 operational environments. Republic South Sudan 40 High-intensity conflict, war 1 869 000 Although occurrences of extreme Somalia 38 High-intensity conflict, war 2 648 000 weather events, earthquakes, and Afghanistan 37 High-intensity conflict, war 2 598 000 disease epidemics have also increased Guinea Bissau 37 dd in the last decade, for the purposes of Nigeria 36 High-intensity conflict, war 2 216 000 Lesotho 35 dd this Pediatrics article, we have Chad 34 Minor-intensity conflict 90 000 focused on the lessons learned in the Côte d’Ivoire 34 Minor-intensity conflict 302 000 implementation of the Helping Babies Sierra Leone 33 d 3000 Survive (HBS) training in contexts of Mali 33 Minor-intensity conflict 120 000 d conflict and displacement. Mauritania 33 Minor-intensity conflict Djibouti 32 dd Comoros 32 dd Guinea 31 dd NEONATAL SURVIVAL IN SETTINGS OF Benin 31 d 3500 CONFLICT AND DISPLACEMENT Equatorial Guinea 30 dd Neonatal mortality, defined as death UCDP, Uppsala Conflict Data Program. 8 in the first 28 days of life, has a NMR: deaths ,1 mo per 1000 live births. 2018 estimates by UN Inter-Agency Group for Child Mortality Estimation. fl b UCDP: unit of analysis events: an instance of fatal organized violence using armed force by organized actor. Minor- declined in both con ict-affected and intensity conflict: between 25 and 999 battle-related deaths in a given year. High-intensity conflict, war: at least non–conflict-affected countries from 1000 battle-related deaths in a given year. 2000 to 2018.7,8 However, 55.6% of c Internal Displacement Monitoring Center: Global report on internal displacement in 2019. Number of displaced persons due to conflict up to December 2018. the countries with the highest d No conflict documented by UCDP in the reporting period of 2010–2017.9 No data of displacement due to conflict reported neonatal mortality rates (NMRs) in the report.3

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 146, number s2, October 2020 S209 in humanitarian settings share within the Somali state of Puntland in lessons learned from their use of one 2016, Save the Children, in such training: the American Academy coordination with the Puntland of Pediatrics HBS program. Ministry of Health (MoH), conducted a feasibility and effectiveness study of The HBS training program comprises the Newborn Health in Humanitarian 3 components: Helping Babies Settings Field Guide13 that included Breathe (HBB),19 Essential Care for providing an 8-day HBS training to Every Baby (ECEB),20 and Essential providers.24 Supplemental modules Care for Small Babies (ECSB).21 HBB on maternal health, intrapartum care, FIGURE 1 provides a simplified neonatal , fl fl supportive supervision, and health NMR ( 1 month), con ict versus noncon ict, resuscitation algorithm and skills- 1990–2017. Pooled mortality trends compare information systems were included to based training on the initial steps of conflict-affected (red line) and non–conflict- address reported gaps in participants’ affected (blue line) low- and middle-income newborn resuscitation. ECEB covers experiences. In the Bossaso study, countries. Shaded area indicates 95% un- immediate newborn care for all fl fi researchers found that HBS training certainty interval. "Con ict" country is de ned infants at birth including thermal as one with a mean battle-related mortality was effective in improving knowledge care, breastfeeding, monitoring for rate of at least 10 per million for each decade and skill of health workers. between 1990–2017 (ie, 1990–1999, 2000–2009, signs of complications, and Subsequently, Save the Children, in 2010–2017), else "Non-conflict." Reprinted with predischarge care; ECSB builds on collaboration with the MoH, permission from Akseer N, Wright J, Tasic H, ECEB with a focus on low birth et al. Women, children and adolescents in conducted a 14-day HBS master fl weight (LBW) infants and specialized con ict countries: an assessment of inequal- trainer course for 29 MoH-employed ities in intervention coverage and survival. BMJ care for these infants. All 3 programs doctors and nurses in Garowe, the Glob Health. 2020;5(1): e002214. are designed to train master trainers capital city of Puntland, in 2019. (via a training of trainers) who can use the materials to cascade training. the health centers that failed to provide adequate neonatal Results resuscitation in Burkina Faso and the EXPERIENCE WITH HBS IN The Bossaso study found that DRC, the majority reported a lack of HUMANITARIAN SETTINGS: CASE providers’ knowledge improved from equipment as the main reason for not EXAMPLES pre- to post-training with a mean 1 providing the service: two-thirds did Somalia, 2016–2020 difference in score of 11.9% (95% not have a resuscitation bag and confidence interval [CI] 7.2 to 16.6; Context infant face masks in the DRC.15 P , .001), skills in newborn Similarly, in recent studies in South Somalia has experienced 3 decades of resuscitation improved from pre- to Sudan and Somalia, researchers have protracted humanitarian crises post-training with a mean difference found low baseline coverage of driven by climate shock and conflict, in score of 165.1% (95% CI 53.4 to essential newborn care practices.16,17 which have led to an estimated 2.6 76.7; P , .001), and learned skills Program staff from the United million IDPs.3 The prolonged were retained at the 18-month Nations (UN), nongovernmental instability has created a shortage of follow-up from post-training with organizations (NGOs), and skilled health workers, low coverage a mean score difference of 10.4 (95% governmental agencies reported that of health services, and fragile health CI 26.6 to 7.4; P = .903).24 In the inadequate funding, a lack of trained governance. Somalia’s indicators are Garowe master trainer course, the personnel, and high staff turnover among the highest globally, with knowledge and skills, as measured by were the top 3 barriers to a maternal mortality ratio of 692 the pre-post training evaluation, implementation of newborn health deaths per 100 000 live births in improved among the 29 participants programs in humanitarian settings.18 2019 and an NMR of 38 deaths per (Table 2). 1000 live births in 2018.8,22 The top 3 To address the gap in health worker causes of neonatal death in 2015 capacity, national ministries, the UN, were birth asphyxia and trauma Lessons Learned NGOs, and faith-based organizations (38.6%), infection (28.3%), and The lessons learned from Somalia tend to rely on in-service trainings. In prematurity (21.1%).23 were the importance of the alignment the area of newborn health, there are of HBS program to the MoH policies, few well-designed skill-based Capacity Building Approach integrated maternal and newborn trainings for low-resource settings. In Recognizing gaps in the provision of health training, and cascading this review, organizations that have newborn care at the primary health knowledge and skills at the health implemented newborn care programs facility level in the city of Bossaso facility level.

Downloaded from www.aappublications.org/news by guest on September 27, 2021 S210 AMSALU ET AL TABLE 2 Mean Pre-training and Post-training Knowledge and Skill Performance Scores in Garowe Garowe master training, such Master Training, Puntland, Somalia (N = 29) consultancy will not be needed there Module Assessment Pre-training Mean Post-training Mean Mean P in the future. (SD) (SD) Difference Mean (SD) Chad, Cameroon, and Niger, HBB Knowledge test 67.3 (20.2) 82.8 (13.7)a 15.5 (16.3) ,.001 2018–2019 OSCE-Ab skill 49.2 (20.3) 77.4 (15.9) 28.2 (22.8) ,.001 performance Context OSCE-Bc skill 29.3 (15.8) 72.1 (19.2) 42.9 (22.7) ,.001 Recognizing the need to strengthen performance maternal and newborn health ECEB Knowledge test 66.1 (16.2) 79.7 (14.7) 13.6 (13.0) ,.001 OSCE-Ad skill 52.4 (20.1) 92.0 (11.0)a 39.6 (22.4) ,.001 services, the Saving Newborn Lives performance in Refugee Settings project was OSCE-Be skill 40.8 (26.5) 85.4 (24.9)a 44.6 (34.1) ,.001 started by United Nations High performance Commissioner for Refugees (UNHCR), , ECSB Knowledge test 67.9 (16.1) 82.1 (12.1) 14.2 (10.7) .001 with support from the Bill and OSCE-Af skill 59.2 (17.6) 87.3 (16.7)a 28.1 (16.0) ,.001 performance Melinda Gates Foundation and OSCE-Bg skill 52.9 (22.4) 90.7 (12.7)a 37.9 (18.0) ,.001 together with the respective MoHs performance and NGOs in Chad, Cameroon, and OSCE, Objective Structured Clinical Evaluations. Niger in 2018–2019. These countries a Test in which $70% of participants had $80% correct answer or performance. were selected because they have b Term infant stimulation. weak health and human development c Preterm bag and mask resuscitation. d Normal birth weight infant ECEB. indicators and are cumulatively e LBW infant ECEB. hosting nearly 1 million refugees and f fi LBW infant with complication, classi cation, monitor. asylum seekers. In 2018, the national g LBW infant feeding with a nasogastric tube.20 NMRs were 34, 27, and 25 per 1000 live births in Chad, Cameroon, and The endorsement and full have the HBS materials translated Niger, respectively.8 The project engagement of the MoH into the Somali language. aimed to improve maternal and throughout the process was HBS was implemented in an newborn health care provision essential. Several factors facilitated integrated maternal and newborn through strengthening essential the MoH’s acceptance of the HBS health training approach, which was maternal and neonatal interventions curriculum, including the necessary because of limited existing and reinforcing quality family preliminary results of the Bossaso knowledge and skills for maternal planning services in refugee settings. study, promising results from health. Such an integrated approach Providing quality health services in previous studies in African highlighted the importance of the refugee camp settings faces countries, acknowledgment of the continuum of care and teamwork numerous constraints because camps challenges and gaps faced in when managing complications that are often located in remote, border providing newborn health care in might arise during childbirth. regions, and many have security Puntland, and the long-standing Introduction of new equipment, such restrictions. Staff shortages and high partnership between the MoH and as a resuscitation table with an turnover of key health staff is Save the Children. overhead heater, was not as common, and limited financial successful because of the delay in HBS was feasible and easy to resources may result in a lack of assembly and a lack of familiarity contextualize. The use of regular training for staff as well as with using the equipment.24 complementary materials, including a lack of access to essential 25 medications and supplies. Global Health Media Project videos, The cascade training was done at practical training exercises using health facility level. In both the simulated case scenarios, and paired Bossaso study and Garowe master Capacity Building Approach participation for peer support, training, participants were Across the 3 countries, the project assisted facilitators in instructing empowered with training materials covered 29 health facilities in total: participants with variable baseline and manikins to continue learning 21 health centers in refugee sites and knowledge and skills. To make HBS within their facilities and to teach 8 referral district hospitals. A baseline training materials more accessible for their peers in the same care practice. assessment was completed in 2018 to the future, Save the Children Although subject matter experts from assess needs, identify gaps, and coordinated with the American Kenya and Uganda facilitated the HBS determine priorities for project Academy of Pediatrics and MoH to trainings in the Bossaso study and activities. Specific to neonatal

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 146, number s2, October 2020 S211 resuscitation, in Cameroon and Chad, of the more effective bag and mask eclampsia). Trainings also included only half or fewer health facilities had resuscitation. a module on integrated management a resuscitation bag and mask for term of childhood illnesses (for ages 0–2 The baseline findings signaled that infants available (50% and 33%, months) that was focused on the beyond training, there was a need for respectively) (Table 3); for all 3 assessment and management of sick context-specific clinical tools and countries, a size 0 mask for neonates because this was identified guidance, procurement of essential resuscitation of preterm infants was as limited in the HBS modules. supplies and medical equipment, rarely available (ranging from 13% to infrastructure improvements, 20% of facilities). Oxygen was not Results technical support and monitoring, available at the assessed health and an increased awareness of the LDHF training was implemented in facilities in Niger and Chad, and it was importance of providing neonatal 29 health facilities. Overall, 118 found in only 30% of health facilities health programs among management- sessions were conducted on HBB in Cameroon. Advanced respiratory level staff. Importantly, the project and complemented with sessions on support such as continuous positive targeted capacity building of all ECEB and ECSB. Over the course of airway pressure (CPAP) or equipment relevant staff involved in maternal the 15 months during which these for intubation was not available. and newborn care, including doctors, trainings were cascaded, a total of Moreover, the presence of basic midwives, nurses, and nurse aides. 16 326 mother-infant pairs received resuscitation equipment in a health care at the 29 health facilities facility did not mean that it was The project applied a low-dose high- (Fig 2). In terms of the impact on actually used because some frequency (LDHF), competence- newborn survival, low NMRs at equipment was found locked in building approach, which has been baseline (potentially due to fi of ces rather than in the delivery evaluated in other settings to underreporting) made it difficult to room, and in some cases, midwives promote maximum retention of assess changes in this indicator, stated that they did not use it because clinical knowledge and skills and although trends seem encouraging. 26 of lack of knowledge. At baseline, the improve attitudes. The initial step Health facilities increased and majority of maternity staff (64% in involved 7 master trainer sessions: 3 sustained the availability of essential fi Cameroon, 67% in Chad, and 55% in in the rst year and 4 in the second supplies, medications, and clinical Niger) reported that they had never year. Each master trainer session guidelines. received training in neonatal lasted for 10 to 12 days, and 45 resuscitation (Table 3). When asked health workers were trained overall. Lessons Learned to demonstrate resuscitation The second step involved the rollout The key lessons learned can be techniques to be used for an apneic of training by master trainers in their categorized into 3 broad themes: infant, they described that newborns own facility (Table 4). The training training implementation, monitoring were held upside down by the feet curriculum included modules from and communication, and creating an and slapped on the back, alcohol was the 3 HBS programs (HBB, ECEB, and enabling environment. rubbed on the skin to stimulate ECSB) and 2 Helping Mothers Survive breathing, and mouth-to-mouth training modules (bleeding after birth Related to training, we found that the resuscitation was administered in lieu complete, and preeclampsia and selection of master trainers should ideally follow strict selection criteria to include individuals with adequate TABLE 3 Baseline Availability of Neonatal Resuscitation Equipment and Trained Health Workers at knowledge and experience in Health Facilities in Chad, Cameroon, and Niger in 2018 maternal and newborn health, Chad (n =15 Cameroon (n =10 Niger (n =5 experience in facilitating trainings, Health Health Health and direct involvement in the health Facilities) Facilities) Facilities) facility and project for maximum – Resuscitation bag and mask (size 1 term), % 33 50 100 success. Poor language proficiency, Resuscitation bag and mask (size 0 – 13 20 20 preterm), % low levels of knowledge and skills in Suction device, % 33 60 40 maternal and newborn health, lack of Oxygen,a % 0 30 0 motivation, and poor communications a CPAP, %000skills were some of the challenges Resuscitation area with heat source (radiant 74020that impacted rollout. Trainee groups warmer or other), % Health workers who never trained in neonatal 67 (12) 64 (14) 55 (42) that included both doctors and resuscitation,b %(n) midwives were favorable, facilitating a CPAP and oxygen when available were at hospital level. team dynamics during the training as b A sample of health workers were asked if they have received newborn training in the last year, .1 y ago, or never. well as the clinical practices at the

Downloaded from www.aappublications.org/news by guest on September 27, 2021 S212 AMSALU ET AL TABLE 4 Number of Health Workers Trained by Location and by HBS Module From 2018 to 2019 Ongoing communication and support No. Health Workers Who Total No. Health %of for trainers have been keys to Received Training Workers Target Met success. One WhatsApp group per Chad country was established to include HBB 91 144 63 trainers, local UNHCR public health ECEB 118 189 62 officers, and a UNHCR reproductive ECSB 100 160 63 health officer in Geneva. WhatsApp is Cameroon HBB 154 268 57 a free platform owned by Facebook, ECEB 138 239 58 Inc. It allows users to send text ECSB 133 234 57 and voice messages and video and Niger voice calls and share images and HBB 36 53 68 documents (www.whatsapp.com). ECEB 46 63 73 ECSB 18 18 100 These groups serve as key tools for communication and peer support among trainers who are dispersed health facility after training facilities were equipped with training throughout remote areas of the completion. Respectful and patient- materials and visual aids to allow country. The trainers share the centered care was an important topic staff to organize training sessions in progress of trainings, challenges and that was well received and integrated a continuous fashion according to successes, and new clinical into the care approaches. their own needs. Doing so facilitated guidelines. Difficult clinical cases are regular skills and drills practices and often discussed among the group in The LDHF approach created a critical repetition of modules as needed, for real time. The group motivates one mass of providers that learned skills example, with new staff, at no another, provides practical and and acquired knowledge at the same additional costs. At times, master emotional support, and reduces pace, allowing an improvement in trainers struggled to balance clinical feelings of isolation. clinical practice. The availability of duties with the time required for During implementation, a monitoring master trainers and training training preparation and the and supervision checklist was materials at each site was necessary scenario-based simulation exercise. In completed every 3 months, capturing because travel between facilities addition to technical knowledge and information on the training sessions was not always feasible because of skills improvement, the training held, health outcomes, emergency security or logistic constraints. approach improved team dynamics, obstetric and newborn care signal This required significant upfront teamwork, and the attitudes toward functions performed, and the investment to ensure that health patients. availability of medications, supplies, and clinical guidelines. These tools served as a monitoring tool for the project and provided a simple framework for supervisory visits, particularly for managers without a strong background in maternity care or pediatrics. It also served as an advocacy tool for the frontline midwife when working with supervisors and UNHCR public health officers, highlighting critical gaps in supplies or equipment. In addition, it allowed for more detailed understanding of the health outcomes for neonates beyond those provided in the standard UNHCR health information system such as neonatal FIGURE 2 morbidities and mortalities Maternal and newborn data from October 2018 to December 2019. Data were extracted from project- disaggregated by type. specific monitoring tools Saving Maternal and Newborn Lives project of UNHCR. Neonatal death (0–28 days) and maternal death are based on death at health facility level or as reported by Sustainable change in practice from community health workers. training requires an enabling

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 146, number s2, October 2020 S213 environment that prioritizes maternal resource-limited and humanitarian the least adopted clinical practices in and newborn health. The lack of basic settings, along with coaching tools to the Somalia study.17 Job aids such as resuscitation equipment found during help facilities meet standards. QI checklists to determine readiness for the baseline assessment highlighted initiatives could also contribute to discharge and the inclusion of the lack of awareness and/or implementation research. practical sessions on how to counsel prioritization of life-saving neonatal and educate mothers might interventions among health HBB contribute to translating knowledge managers. Recognizing the vital role Humanitarian crises affect countries and skills gained in ECEB training of management staff in establishing with varying levels of health care into practice. standards of care, additional capacity and qualifications. In its use operational guidance has been of the HBB program since 2012, ECSB developed, including webinars on Médecins Sans Frontières has Care for LBW infants is an area that neonatal health for managers and identified a challenge in the needs more evidence in humanitarian a short primer on assessing health acceptance of the HBB algorithm in settings. Inclusion of hands-on facility readiness to perform neonatal certain contexts. Although 99% of practice in the care for LBW infants resuscitation and related minimum newborns who “do not breathe at (in addition to scenario-based standards of care. birth” recover with stimulation and trainings), procurement of necessary bag and mask ventilation, the medical supplies, and improvement remaining 1% require advanced in functionality in labor room or FUTURE DIRECTIONS: TECHNICAL resuscitation.27 The lack of technical maternity wards and pediatric CONSIDERATIONS guidance for infants who need units to admit LBW infants with Monitoring Impact advanced resuscitation can be complications might all be useful in a hindrance to HBB implementation transferring learnings to practice and Although health agencies include in contexts where precrisis capacity, building the confidence of health maternal and newborn mortality, as was the case in Iraq, was high and workers. stillbirth, and coverage of maternal standard of care included specialized and newborn services in their routine newborn care. In such contexts, IMPLEMENTATION CONSIDERATIONS: monitoring and health information HBB is too simplistic, whereas fi A FUTURE DIRECTION NEEDS TO systems, such data are dif cult to comprehensive advanced collect, both at the health facility CONSIDER IMPLEMENTATION ISSUES resuscitation algorithms, such as INCLUDING THE FOLLOWING and community level, and are often those provided by the European delayed and incomplete in Resuscitation Council or Neonatal Low Baseline Knowledge and Skill humanitarian contexts. Furthermore, Resuscitation Program are too Means the Need for Flexibility in the the health data collected are complex.28 In such settings, in the Training Schedule and Approach patchwork in nature, small scale, absence of standard advanced Security considerations (shorter fi and dif cult to merge and provide resuscitation algorithms, working hours, travel restrictions), a comprehensive overview. Quality resuscitation is conducted in an ad language barriers, and variable levels improvement (QI) initiatives, or more hoc manner.28 To standardize care of experience in newborn health fi funding, are dif cult to advocate for and ensure that the latest evidence is mandate flexibility in training in the absence of accurate, timely, and practiced, the development and approaches and the duration of systematic data. Future endeavors inclusion of a simplified advanced training. A rigid training curriculum need to look at operationally simple resuscitation algorithm, as an shown to work well in stable settings approaches to measuring stillbirths optional addition to the current HBB, might not be effective in and neonatal mortality in addition to could be considered in contexts a humanitarian context. The reinforcing coverage measurements. where appropriate resources and contextualized approach taken in qualified personnel are available to these case studies worked well and QI safely provide such care. Obstetric allowed staff to absorb the new skills QI initiatives in humanitarian health drills and management of and knowledge directly applicable to responses need to be inclusive of HBS intrapartum fetal hypoxia should also their working environments. The with a set of indicators that can be be included in training approaches. LDHF model was indispensable and is tracked overtime to measure success worth considering for future capacity and impact. Health organizations can ECEB building. Additional contextualization help in the development and The reassessment of newborns and such as the availability of HBS operationalization of a measurable the provision of predischarge materials in local languages, the standard of care for all patients in education and care were noted to be procurement of manikins and

Downloaded from www.aappublications.org/news by guest on September 27, 2021 S214 AMSALU ET AL supplies before trainings (in sufficient directly rather than at the district or should be placed on scaling up HBS quantity per health facility to allow at provincial levels. Such direction and ensuring comprehensive care for repeat simulated practices), and should be considered in scaling up newborns with complications such as supportive supervision facilitated HBS, especially given the changing neonatal sepsis, pneumonia, and skills retention at a high level should paradigm of humanitarian crises, respiratory distress, as well as be encouraged. leading to more protracted crises, a simplified advanced resuscitation Newborn resuscitation is a time- more communities residing in algorithm that can complement HBB sensitive clinical emergency noncamp situations, travel when feasible. intervention that requires providers restrictions, and high staff turnover. to act immediately, systematically, This facility-level cascading was also ACKNOWLEDGMENTS fi instrumental in changing team and with con dence. In health This article is the collaborative work facilities with a low number of dynamics and in changing clinical practice in the health facility. of colleagues working in various deliveries, events requiring newborn organizations that have advocated for, resuscitation are less frequent, and However, such an approach requires a master trainer and training supplies supported, or implemented newborn extra investment is required to retain care program in humanitarian fi including manikins for each health pro ciency in skill. This requires settings including Save the Children; access to practice and training facility, which is a costly upfront investment. To address high staff UNHCR; Médecins Sans Frontières; materials at each health facility and Kenya Medical Training College; the use of frequent skill drills. turnover among responders and decrease dependency on external Gardo Hospital, Puntland, Somalia; Cognitive and psychomotor skills Johns Hopkins University Bloomberg depreciate over time; similar to consultants, investing in local master trainers allowed for a sustainable School of Public Health; Hospital for practice by paramedics on Sick Children, Toronto, Canada; and cardiopulmonary resuscitation approach. Improving neonatal survival needs to be a responsibility the University at Buffalo, New York. techniques, such should be the case We are thankful for their contribution for HBB. of the health cluster or sector coordination lead to ensure that all and dedication to newborn health. Integration of Maternal and Newborn agencies that support or deliver Health Trainings community, primary, or hospital Newborn care in humanitarian health care are competent and ABBREVIATIONS settings is often the responsibility of capable in implementing newborn CI: confidence interval health staff in the maternity unit and health care programs. Therefore, to CPAP: continuous positive airway labor ward instead of the achieve scale, the national ministries, pressure responsibility of specialized neonatal health cluster, and partner agencies DRC: Democratic Republic of the or pediatric staff. HBS should be need to prioritize investment in the Congo a shared responsibility among those HBS training as soon as is feasible ECEB: Essential Care for who work in both child and maternal after an emergency. Every Baby health. Therefore, it is critical that ECSB: Essential Care for Small health staff in pediatrics, labor wards, Babies CONCLUSIONS and maternity units receive training HBB: Helping Babies Breathe on HBS and that QI for maternal and Neonatal mortality is increasingly HBS: Helping Babies Survive child health includes newborn concentrated in settings of conflict IDP: internally displaced person indicators. In the case study and instability. In such settings, we LBW: low birth weight examples, the approach taken was to find that HBS is feasible to LDHF: low-dose high-frequency combine HBS with maternal health implement, often accepted by MoH: Ministry of Health and intrapartum care modules, and as ministries and partner agencies, NGO: nongovernmental such, integrated delivery models are effective in improving the knowledge organization encouraged for future trainings. and skills of health personnel, and NMR: neonatal mortality rate effective in improving newborn care. QI: quality improvement Achieving Scale To improve newborn survival, the UN: United Nations In the case studies, the focus was on global community needs to place UNHCR: United Nations High having master trainers responsible greater focus on the specialized needs Commissioner for within each facility to cascade of newborns in humanitarian settings. Refugees trainings within their health facilities Therefore, attention and advocacy

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 146, number s2, October 2020 S215 PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2020 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: Dr Berkelhamer is a current member of the American Academy of Pediatrics Helping Babies Survive Planning Group. The other authors have indicated that they have no potential conflicts of interest to disclose

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Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 146, number s2, October 2020 S217 Lessons Learned From Helping Babies Survive in Humanitarian Settings Ribka Amsalu, Catrin Schulte-Hillen, Daniel Martinez Garcia, Nadia Lafferty, Catherine N. Morris, Stephanie Gee, Nadia Akseer, Elaine Scudder, Samira Sami, Sammy O. Barasa, Hussein Had, Maimun Farah Maalim, Seidou Moluh and Sara Berkelhamer Pediatrics 2020;146;S208 DOI: 10.1542/peds.2020-016915L

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Downloaded from www.aappublications.org/news by guest on September 27, 2021 Lessons Learned From Helping Babies Survive in Humanitarian Settings Ribka Amsalu, Catrin Schulte-Hillen, Daniel Martinez Garcia, Nadia Lafferty, Catherine N. Morris, Stephanie Gee, Nadia Akseer, Elaine Scudder, Samira Sami, Sammy O. Barasa, Hussein Had, Maimun Farah Maalim, Seidou Moluh and Sara Berkelhamer Pediatrics 2020;146;S208 DOI: 10.1542/peds.2020-016915L

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