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Using Helping Mothers Survive to Improve Intrapartum Care Cherrie L

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Using Helping Mothers Survive to Improve Intrapartum Care Cherrie L Using Helping Mothers Survive to Improve Intrapartum Care Cherrie L. Evans, DrPH, CNM, Rosemary Kamunya, DC, MS, Gaudiosa Tibaijuka, MS abstract Data from the past decade have revealed that neonatal mortality represents a growing burden of the under-5 mortality rate. To further reduce these deaths, the focus must expand to include building capacity of the workforce to provide high-quality obstetric and intrapartum care. Obstetric complications, such as hypertensive disorders and obstructed labor, are significant contributors to neonatal morbidity and mortality. A well-prepared workforce with the necessary knowledge, skills, attitudes, and motivation is required to rapidly detect and manage these complications to save both maternal and newborn lives. Traditional off-site, didactic, and lengthy training approaches have not always yielded the desired results. Helping Mothers Survive training was modeled after Helping Babies Breathe and incorporates further evidence-based methodology to deliver training on-site to the entire team of providers, who continue to practice after training with their peers. Research has revealed that significant gains in health outcomes can be reached by using this approach. In the coronavirus disease 2019 era, we must look to translate the best practices of these training programs into a flexible and sustainable model that can be delivered remotely to maintain quality services to women and their newborns. Jhpiego, Baltimore, Maryland Dr Evans conceptualized the approach of the article, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Kamunya reviewed the manuscript for important programmatic content; Ms Tibaijuka reviewed and edited the manuscript for important content; and all authors approved the final manuscript as submitted. DOI: https://doi.org/10.1542/peds.2020-016915M Accepted for publication Aug 4, 2020 Address correspondence to Cherrie L. Evans, DrPH, CNM, Technical Leadership and Innovations, Jhpiego, 1615 Thames St, Baltimore, MD 21231. E-mail: [email protected] 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 Evans directs the Helping Mothers Survive (HMS) project and is an instructional designer and expert trainer; Dr Kamunya supports HMS globally as an expert trainer; Ms Tibaijuka supports HMS regionally as an expert trainer and is the technical director of a large project in Tanzania that uses both HMS and Helping Babies Survive. Downloaded from www.aappublications.org/news by guest on September 27, 2021 SUPPLEMENT ARTICLE PEDIATRICS Volume 146, number s2, October 2020:e2020016915M Although progress has been made in must intensify our efforts in both pre- methodology and further innovation newborn survival, much remains to service and in-service education. were clearly needed to shift the off- be done. Gains in child survival have site approach to a more holistic meant that newborn deaths make up INNOVATIVE TRAINING APPROACHES workforce-capacity building approach a larger proportion of under-5 CAN IMPROVE PROVIDER to improve provider performance and mortality. In 2018, neonatal mortality PERFORMANCE AND HEALTH OUTCOMES health outcomes. accounted for 47% of under-5 The Helping Babies Breathe (HBB) Recognizing the need for fresh mortality, compared to 40% in initiative provided a foundation for training approaches and cognizant of 1990.1 To achieve the Sustainable the development of a new model of the fact that the same provider often Development Goal 3 to decrease the training to reduce maternal and cares for both the woman and her neonatal mortality rate to #12 per neonatal mortality. It has succeeded newborn, HMS Bleeding after Birth 1000 live births,2 we must look at in improving outcomes of newborns (BAB) was launched in 2013 to the maternal-infant dyad and bring requiring help to breathe at birth.7,8 address postpartum hemorrhage increased attention to the quality Although HBB met a great training (PPH), which is the leading cause of of maternal care. Maternal and supply need for newborn maternal death globally. HMS BAB complications play a critical resuscitation, asphyxia is not the only was modeled on HBB, the first contribution to the top 3 causes of cause of neonatal death. To expand on module in the Helping Babies Survive neonatal mortality: prematurity, birth the HBB initiative and address other (HBS) series, which recommends asphyxia, and infection.1 For example, knowledge and skills gaps for hands-on training and continued hypertensive disorders in pregnancy newborn care, complementary skills practice after training. To can result in growth restriction, fetal newborn modules were developed by facilitate learning specifically for PPH, compromise, and premature birth.3 the American Academy of Pediatrics, the first low-cost childbirth simulator Prolonged or obstructed labor, if not including Essential Care for Every was developed and launched in addressed in a timely fashion, may Baby and Essential Care for Small 2012.11 Implementation and research result in birth asphyxia and fetal Babies. In addition, to address gaps in experience from HBB and HMS BAB demise.4 If left unmanaged, prolonged knowledge and skills for maternal highlighted that a stronger emphasis rupture of the membranes may result care, a series of Helping Mothers was needed to help consolidate in chorioamnionitis and sepsis of the Survive (HMS) training modules were providers’ skills.12 To fill this need, newborn.5 These complications and developed by Jhpiego, an affiliate of HMS BAB incorporated deliberate others must be identified and Johns Hopkins University, in practice after training day. This managed early to achieve further partnership with global stakeholders. practice is not merely the simple reductions in neonatal mortality. HMS was purposefully designed to repetition of skills; rather, it is systematic, purposeful practice An appropriately trained and build the capacity of the entire team undertaken with focused attention deployed workforce is key to of providers who care for women and with the goal of improving ensuring the quality of maternal and their newborns at birth or assist performance of a particular skill. The newborn health care, along with those who do, including midwives, fi combined method of short hands-on sufficient infrastructure, equipment, nurses, doctors, clinical of cers, and and team-based learning that is consumables, drugs, and robust other assistants. delivered on-site and followed by supply chains and referral systems. During development of the first HMS ongoing deliberate practice has been The highest attainable standard of module, evidence emerged suggesting called “low dose, high frequency” mental and physical health of the that conventional approaches to (LDHF). woman and her newborn, a basic training that rely on workshops human right, will never be realized conducted away from the clinical The LDHF training methodology without a well-trained, empowered, setting were not yielding the desired incorporated into HMS programming and properly remunerated workforce. results. In 2016, Leslie et al9 has been the subject of several However, providers’ ability to offer demonstrated that traditional research studies. From 2014 to 2015, quality care to women and their training, even when coupled with HMS BAB and HBB were delivered as newborns is hampered in some supportive supervision, did not one-day trainings to all labor ward settings by a lack of the knowledge, meaningfully improve the care of staff at 125 hospitals and health skills, and confidence needed to pregnant women and children who centers in 12 districts in Uganda. HMS provide appropriate assessment, were sick. Around this time, new BAB training was provided to each monitoring, identification, and evidence was emerging about the facility first, followed by HBB training management of complications when most effective teaching techniques for 2 to 3 months later. All providers they arise.6 To address these gaps, we in-service training.10 A change in were asked to deliberately practice Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 146, number s2, October 2020 S219 certain skills once per week for a total TABLE 1 HMS Modules of 12 weeks after training. Two-thirds Module Competencies of facilities had practice coordinators BAB Completea Active management of third stage of labor; early detection and to facilitate this practice. Direct management of PPH including management of shock, manual removal of clinical observations revealed placenta, uterine balloon tamponade, and cervical laceration repair improvements in care practices, Preeclampsia & Correct assessment and classification of hypertensive disorders of b such as timely administration of Eclampsia pregnancy, administration of loading and maintenance doses of magnesium sulfate and antihypertensive medications, management of a uterotonic for prophylaxis, convulsions preparation of the bag and mask in ECL&Bc Respectful care and women’s choice; infection prevention; classification, advance of birth, and breastfeeding management, and monitoring of labor; early identification of within one hour. Improvements were complications; identification of poor progress of labor; supportive care greater in facilities with practice during all stages of labor and birth
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