Using Helping Mothers Survive to Improve Intrapartum Care Cherrie L

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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 Threatened Preterm Birth Gestational age assessment; diagnosis of conditions leading to preterm coordinators. Across all facilities, Cared birth: preterm labor, preterm prelabor rupture of membranes, severe improvement in the care of women preeclampsia and eclampsia, chorioamnionitis, and antenatal and their newborns in the 6 months hemorrhage; treatment of maternal infection; advanced care for preterm after the intervention was noted by newborns: resuscitation, safe oxygen use, thermal care, feeding support, declines in retained placenta (47%), treatment of infection Prolonged & Obstructed Timely identification of prolonged or obstructed labor, treatment of PPH (17%), fresh stillbirth (32%), Labor infection, correct use of augmentation, rapid referral for obstructed and newborn death before discharge labor, management of shoulder dystocia, and maneuvers for breech (62%) compared with baseline.13 birth Similar results regarding HMS BAB Vacuum Assisted Birth Decision-making for client selection for vacuum delivery and correct use of training were found in 2 studies in vacuum device, assessment and management of maternal and neonatal complications from vacuum birth Tanzania resulting in a decrease in blood transfusion and near-miss Adapted from Jhpiego. Helping Mothers Survive. 2020. Available at: https://hms.jhpiego.org/. Accessed June 2, 2020. a Jhpiego. Bleeding after Birth Complete. 2020. Available at: https://hms.jhpiego.org/bleeding-after-birth-complete/. 14,15 cases. Accessed June 2, 2020. b Jhpiego. Pre-eclampsia & Eclampsia. 2020. Available at: https://hms.jhpiego.org/pre-eclampsia_eclampsia/. Accessed June 2, 2020. EXPANDING THE SCOPE AND c Jhpiego. Essential Care for Labor & Birth. 2020. Available at: https://hms.jhpiego.org/essential-care-labor-and-birth/. APPROACHES EMPLOYED BY HMS Accessed June 2, 2020. d Jhpiego. Threatened Preterm Birth Care. 2020. Available at: https://hms.jhpiego.org/threatened-preterm-birth-care/. HMS has since expanded to include Accessed June 2, 2020. a suite of 6 training modules as well as a fresh approach to capacity original LDHF approach has been delivered where needed most. On the building (Table 1). This suite now embedded in a quality improvement basis of the World Health encompasses all basic emergency framework, with training targeted to Organization’s quality of care obstetric and newborn care 16 identified performance gaps. HMS framework, the HMS initiative competencies that directly affect training is still provided on-site to the matches training with competencies newborn survival, including routine whole team, by using hands-on required for quality care, delivers care for normal and prolonged or learning, and followed by deliberate training to all levels of the health obstructed labor and management of skills practice, but training is also system, and emphasizes women’s preeclampsia and eclampsia. In supported by use of videos, other experiences of care and human particular, HMS Essential Care for digital tools, and quality rights–based approaches. However, Labor & Birth (ECL&B) is the improvement activities. These quality training alone can only go so far to cornerstone of the suite and has the improvement activities are often as improve outcomes; health system largest potential to improve outcomes simple as posting referral and gaps also must be addressed to the of both women and their newborns transportation plans and ensuring the fullest extent possible. When training (Fig 1). Grounded in respectful care, emergency cart is well maintained, is deployed to address identified ECL&B reinforces the importance of but they also include more complex performance gaps and is embedded monitoring the woman and her fetus activities, such as patient chart in a quality improvement framework, to ensure early identification of reviews and reordering client we have the opportunity to achieve complications to decrease severe service flow. much greater impact. The quality morbidity and mortality. improvement guide, “Improving Care In response to further evidence Localizing training and education to of Mothers and Babies: A Guide for suggesting that poor quality of care in facilities where care is delivered Improvement Teams,” has been facilities is a greater barrier to good allows for problems to be solved in described in this supplement and outcomes than access to care,6 the real time and training updates to be offers one example of how to support

Downloaded from www.aappublications.org/news by guest on September 27, 2021 S220 EVANS et al quality improvement locally.17 This guide is particularly relevant in settings where facility-based quality improvement teams are integrated within the health system.

NEXT STEPS To help ensure the best possible outcomes for newborns and their mothers, we must ensure that pregnant and laboring women are cared for by a workforce that is skilled in assessment, rapid identiﬁcation, and management of complications. We can work toward this goal by building the capacity of that workforce through this enhanced approach to facility-based training using the LDHF methodology.

HMS and HBS are open access, and the educational strategies can be applied to any clinical service area. Indeed, expanding this interactive, hands-on educational approach to other areas of newborn and child health may help continue to drive reductions in neonatal and child mortality. In particular, the HMS and HBS style of learning can and should be adapted to preservice education, where it is uniquely suited to supporting local curricula through use in skills laboratories. Experience with the 50 000 Happy Birthdays project in Rwanda, Ethiopia, and Tanzania (which is reviewed in more depth elsewhere in this supplement) reveals that HMS and HBS can complement curricula in preservice education institutions in 2 important ways.18 First, the LDHF approach can be used to strengthen the capacity of staff at clinical practicum sites before they supervise students during clinical placements. Second, the training materials and methods FIGURE 1 developed for team-based, hands-on ECL&B action plan. BP, blood pressure; bpm, beats per minute. (Reprinted with permission from learning can work in concert with Jhpiego Corporation. Essential Care for Labor & Birth Action Plan. Baltimore, MD: Jhpiego Corpo- ration; 2019.) standing curricula by offering students the opportunity for practice in skills laboratories before they are placed in a clinical site.

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 146, number s2, October 2020 S221 Finally, in this challenging time of the 4. Miyoshi Y, Matsubara K, Takata N, Oka Y. 12. Reisman J, Arlington L, Jensen L, Louis coronavirus disease 2019 pandemic, Baby survival in Zambia: stillbirth and H, Suarez-Rebling D, Nelson BD. maintaining quality services for neonatal death in a local hospital Newborn resuscitation training in women and their newborns is at risk. setting. BMC Pregnancy Childbirth. resource-limited settings: a systematic 2019;19(1):90 literature review. Pediatrics. 2016; It is now more important than ever 138(2):e20154490 that the health workforce is well 5. Johnson CT, Farzin A, Burd I. Current prepared. We must now pivot from management and long-term outcomes 13. Evans CL, Bazant E, Atukunda I, et al. using only face-to-face training to following chorioamnionitis. Obstet Peer-assisted learning after onsite, low- provide remote learning, mentorship, Gynecol Clin North Am. 2014;41(4): dose, high-frequency training and 649–669 and support to providers globally. practice on simulators to prevent and treat postpartum hemorrhage and HMS and HBS partners are working 6. Kruk ME, Gage AD, Arsenault C, et al. neonatal asphyxia: a pragmatic trial in together to help meet this challenge High-quality health systems in the Sustainable Development Goals era: 12 districts in Uganda. PLoS One. 2018; in the next phase of our work 13(12):e0207909 together. time for a revolution. [published correction appears in Lancet Glob 14. Egenberg S, Masenga G, Bru LE, et al. Health. 2018;6(11):e1162]. Lancet Glob Impact of multi-professional, scenario- Health. 2018;6(11):e1196–e1252 ABBREVIATIONS based training on postpartum 7. Perlman JM, Msemo G, Ersdal H, Ringia hemorrhage in Tanzania: a quasi- BAB: Bleeding after Birth P. Designing and implementing the experimental, pre- vs. post-intervention ECL&B: Essential Care for Labor & Helping Babies Breathe program in study. BMC Pregnancy Childbirth. 2017; Birth Tanzania. J Pediatr Intensive Care. 2017; 17(1):287 HBB: Helping Babies Breathe 6(1):28–38 15. Nelissen E, Ersdal H, Mduma E, et al. HBS: Helping Babies Survive 8. Mduma E, Ersdal H, Svensen E, Kidanto Clinical performance and patient HMS: Helping Mothers Survive H, Auestad B, Perlman J. Frequent brief outcome after simulation-based LDHF: low dose, high frequency on-site simulation training and training in prevention and management PPH: postpartum hemorrhage reduction in 24-h neonatal mortality–an of postpartum haemorrhage: an educational intervention study. educational intervention study in a low- Resuscitation. 2015;93:1–7 resource setting. BMC Pregnancy REFERENCES Childbirth. 2017;17(1):301 9. Leslie HH, Gage A, Nsona H, Hirschhorn 1. United Nations Inter-agency Group for LR, Kruk ME. Training and supervision 16. World Health Organization. Quality, Child Mortality Estimation. Levels & did not meaningfully improve quality of Equity, Dignity: The Network to Improve Trends in Child Mortality: Report 2019. care for pregnant women or sick Quality of Care for Maternal, Newborn – Estimates Developed by the UN Inter- children in Sub-Saharan Africa. Health and Child Health Strategic Objectives. Agency Group for Child Mortality Aff (Millwood). 2016;35(9):1716–1724 Geneva, Switzerland: World Health Organization; 2018 Estimation. New York, NY: United 10. Bluestone J, Johnson P, Fullerton J, ’ Nations Childrens Fund; 2019 Carr C, Alderman J, BonTempo J. 17. Ehret DEY, Patterson JK, KC A, Worku B, 2. United Nations. Goal 3: ensure healthy Effective in-service training design and Kamath-Rayne BD, Bose CL. Helping lives and promote well-being for all at delivery: evidence from an integrative Babies Survive programs as an impetus all ages. Available at: https:// literature review. Hum Resour Health. for quality improvement. Pediatrics. sustainabledevelopment.un.org/sdg3. 2013;11:51 2020;146(suppl 2). e2020016915J Accessed June 2, 2020 11. Laerdal Medical. MamaNatalie birthing 18. West F, Bokosi M. Helping Babies 3. Hodgins S. Pre-eclampsia as underlying simulator. Available at: https://www. Survive and empowering midwives and cause for perinatal deaths: time for laerdal.com/us/products/simulation- nurses to provide quality newborn action. Glob Health Sci Pract. 2015;3(4): training/obstetrics-pediatrics/ care. Pediatrics. 2020;146(suppl 2). 525–527 mamanatalie/. Accessed June 2 2020 e2020016915N

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Downloaded from www.aappublications.org/news by guest on September 27, 2021 Using Helping Mothers Survive to Improve Intrapartum Care Cherrie L. Evans, Rosemary Kamunya and Gaudiosa Tibaijuka Pediatrics 2020;146;S218 DOI: 10.1542/peds.2020-016915M

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