Helping Babies Breathe: A Nursing Intervention to Improve Global Health in Hyderabad, India

Monday, 30 October 2017: 9:50 AM

Cheryl Riley, DNP1
Llewelyn Prater, PhD1
Raghava Kavalla, MPH2
(1)Louise Herrington School of Nursing, Baylor University, Dallas, TX, USA
(2)Neonatal-perinatal fellowship at Tufts in Boston, Tufts, Metford, MA, USA

An estimated 135 million infants and children die globally each year and of these approximately 3 million infants die within the first 28 days of life (UNICEF, 2012: Campbell-Yeo et al., 2014). There is significant disparity in infant mortality both between and within countries (Kinney, Wang, Foreman, et al., 2012). The majority of neonatal deaths occur in Africa and south Asia. Infant mortality has been listed as a public health priority and was part of Millennium Development Goal 4—to reduce under-5 child mortality by two- thirds between 1990 and 2015 (Lawn, et al., 2012); and now a major part of Sustainable Development Goal 3 - to reduce by two-thirds between 2015 and 2030.

Stillbirths account for 3 million infants who die worldwide each year and many of these infants can be saved with low cost, low-tech care (WHO, 2012). Among live born infants, infections, preterm birth, and birth asphyxia are the leading causes of under-5 child mortality worldwide (WHO, 2012). Birth asphyxia, “failure to establish breathing at birth” is responsible for 900,000 infant deaths per year world-wide (Lawn, Shi buya, & Stein, 2005). A major advance in the prevention and management of birth asphyxia has been the use of the Helping Babies Breathe (HBB) program. Since the roll out of HBB, approximately 300,000 health care providers have been trained and equipped to provide resuscitation in 77 countries (Kak, et al., 2015).

Hyderabad, located in the state of Telangana, India continues to have one of the highest Infant Mortality Rate (IMR) in southern India. For every 1,000 live births in the state, as many as 41 percent of infants die, according to the Government of India’s survey known as the Sample Registration System (SRS 2012; Baseerat, 2013). Institutional deliveries in India have risen from 26% to 39%, and nearly half of the women now have their births attended by skilled health personnel. This is important because birth attended by skilled providers is associated with improved outcomes in maternal and newborn health at delivery and during the postnatal period (Prasad & Dasgupta 2013).

The adaptation of HBB in resource poor countries has been challenged by differences in language, infrastructure and culture. In India, there has been a reduction in the overall maternal and child mortality rate, however the percentage of those neonatal deaths has increased from 41% in 1990 to 56% in 2012 (Choudhary, Saxena & Thakre, 2014). The reason for this may be the fact that India is a complex country with demographic and cultural diversity. There are disparities between rural and urban areas, rich and poor, male and female along with regional ethnic differences (Boone et al., 2007). Infants born in rural areas are twice as likely to die as those born in urban settings and female infants have a higher mortality rate than males.

This University has a proven track record of promoting nurse capacity in India through educational workshops, hands on training using low-tech simulators, faculty development, and collaborative research since 2010. The team has developed a mutually beneficial relationship with key stakeholders at the Neonatal Intensive Care and Emergencies (NICE) hospital and foundation, a nonprofit foundation in Hyderabad, India. The foundation is dedicated towards improving maternal health and reducing infant and child mortality. They strive to provide quality healthcare to the poorest, the neglected, and the most deserving in their society. Saving lives has always been NICE Foundation’s ultimate goal (NICE, 2012). The mission of the NICE foundation and this University are congruent; both are dedicated to provide care to underserved populations. A Memorandum of Understanding was signed in 2013.

The Knowledge to Action (KTA) translational framework guided development and implementation of the HBB workshop. Knowledge translation (KT) frameworks are methods used to close the gap between knowledge and practice (Straus et al. 2009). In the KTA framework the focus is on the interaction between the researcher and the stakeholders rather than a hierarchical model of learning from teacher to learner. This framework is congruent with capacity building. Demonstration and feedback strategies using a simulation model of learning were added to the KTA framework to promote the uptake of the new behavior using an active participatory teaching strategy that allowed for observation and auditing HBB skills using different scenarios. The goal of this training was to provide knowledge and hands on training using the NeoNatalie™ (a low tech simulator) to the nurses and nurse midwives at the hospital and the rural clinic. HBB is a learner centered educational methodology used to develop necessary skills to provide infants with the best care possible in a timely manner. Pictorial flip charts, posters, and hands on training utilizing the NeoNatalie™ were incorporated. Each skill was first demonstrated, then the learners in dyads would role-play being the health care provider and the mother, then they would change roles. At each practice the learners started with the beginning skills and then the new content was added. This program focuses on the first minute of life and the importance of initiate breathing within that time frame (HBB, 2014).

A pre/post test methodology was used including a skill check off. There was a significant difference in both knowledge and skills attainment. A policy and procedure was developed in collaboration with the nurses, midwives and administration to incorporate mock codes to provide frequent, small dose refreshers on HBB.