Cost analysis of large-scale implementation of the ‘Helping Babies Breathe’ newborn resuscitation-training program in Tanzania

Background: Helping Babies Breathe (HBB) has become the gold standard globally for training birth-attendants in neonatal resuscitation in low-resource settings in efforts to reduce early newborn asphyxia and mortality. The purpose of this study was to do a first-ever activity-based cost-analysis of at-scale HBB program implementation and initial follow-up in a large region of Tanzania and evaluate costs of national scale-up as one component of a multi-method external evaluation of the implementation of HBB at scale in Tanzania. Methods: We used activity-based costing to examine budget expense data during the two-month implementation and follow-up of HBB in one of the target regions. Activity-cost centers included administrative, initial training (including resuscitation equipment), and follow-up training expenses. Sensitivity analysis was utilized to project cost scenarios incurred to achieve countrywide expansion of the program across all mainland regions of Tanzania and to model costs of program maintenance over one and five years following initiation. Results: Total costs for the Mbeya Region were $202,240, with the highest proportion due to initial training and equipment (45.2$4,000,000 (around $600 per facility). Following sensitivity analyses, the estimated total for all Tanzania initial rollout lies between$2,934,793 to $4,309,595. In order to maintain the program nationally under the current model, it is estimated it would cost$2,019,115 for a further one year and $5,640,794 for a further five years of ongoing program support. Conclusion: HBB implementation is a relatively low-cost intervention with potential for high impact on perinatal mortality in resource-poor settings. It is shown here that nationwide expansion of this program across the range of health provision levels and regions of Tanzania would be feasible. This study provides policymakers and investors with the relevant cost-estimation for national rollout of this potentially neonatal life-saving intervention

Structured on-the-job training to improve retention of newborn resuscitation skills: a national cohort Helping Babies Breathe study in Tanzania

Background: Newborn resuscitation is a life-saving intervention for birth asphyxia, a leading cause of neonatal mortality. Improving provider newborn resuscitation skills is critical for delivering quality care, but the retention of these skills has been a challenge. Tanzania implemented a national newborn resuscitation using the Helping Babies Breathe (HBB) training program to help address this problem. Our objective was to evaluate the effectiveness of two training approaches to newborn resuscitation skills retention implemented across 16 regions of Tanzania. Methods: An initial training approach implemented included verbal instructions for participating providers to replicate the training back at their service delivery site to others who were not trained. After a noted drop in skills, the program developed structured on-the-job training guidance and included this in the training. The approaches were implemented sequentially in 8 regions each with nurses/ midwives, other clinicians and medical attendants who had not received HBB training before. Newborn resuscitation skills were assessed immediately after training and 4–6 weeks after training using a validated objective structured clinical examination, and retention, measured through degree of skills drop, was compared between the two training approaches. Results: Eight thousand, three hundred and ninety-one providers were trained and assessed: 3592 underwent the initial training approach and 4799 underwent the modified approach. Immediately post-training, average skills scores were similar between initial and modified training groups: 80.5 and 81.3%, respectively (p-value 0.07). Both groups experienced statistically significant drops in newborn resuscitation skills over time. However, the modified training approach was associated with significantly higher skills scores 4–6 weeks post training: 77.6% among the modified training approach versus 70.7% among the initial training approach (p-value \u3c 0.0001). Medical attendant cadre showed the greatest skills retention. Conclusions: A modified training approach consisting of structured OJT, guidance and tools improved newborn resuscitation skills retention among health care providers. The study results give evidence for including on-site training as part of efforts to improve provider performance and strengthen quality of care

Individual, maternal and household risk factors for anaemia among young children in sub-Saharan Africa: a cross-sectional study

Objective: Anaemia affects the majority of children in sub-Saharan Africa (SSA). Previous studies of risk factors for anaemia have been limited by sample size, geography and the association of many risk factors with poverty. In order to measure the relative impact of individual, maternal and household risk factors for anaemia in young children, we analysed data from all SSA countries that performed haemoglobin (Hb) testing in the Demographic and Health Surveys. Design and setting This cross-sectional study pooled household-level data from the most recent Demographic and Health Surveys conducted in 27 SSA between 2008 and 2014. Participants: 96 804 children age 6–59 months. Results: The prevalence of childhood anaemia (defined as Hb <11 g/dL) across the region was 59.9%, ranging from 23.7% in Rwanda to 87.9% in Burkina Faso. In multivariable regression models, older age, female sex, greater wealth, fewer household members, greater height-for-age, older maternal age, higher maternal body mass index, current maternal pregnancy and higher maternal Hb, and absence of recent fever were associated with higher Hb in tested children. Demographic, socioeconomic factors, family structure, water/sanitation, growth, maternal health and recent illnesses were significantly associated with the presence of childhood anaemia. These risk factor groups explain a significant fraction of anaemia (ranging from 1.0% to 16.7%) at the population level. Conclusions: The findings from our analysis of risk factors for anaemia in SSA underscore the importance of family and socioeconomic context in childhood anaemia. These data highlight the need for integrated programmes that address the multifactorial nature of childhood anaemia

Individual, maternal and household risk factors for anaemia among young children in sub-Saharan Africa: a cross-sectional study

Objective: Anaemia affects the majority of children in sub-Saharan Africa (SSA). Previous studies of risk factors for anaemia have been limited by sample size, geography and the association of many risk factors with poverty. In order to measure the relative impact of individual, maternal and household risk factors for anaemia in young children, we analysed data from all SSA countries that performed haemoglobin (Hb) testing in the Demographic and Health Surveys. Design and setting This cross-sectional study pooled household-level data from the most recent Demographic and Health Surveys conducted in 27 SSA between 2008 and 2014. Participants: 96 804 children age 6–59 months. Results: The prevalence of childhood anaemia (defined as Hb <11 g/dL) across the region was 59.9%, ranging from 23.7% in Rwanda to 87.9% in Burkina Faso. In multivariable regression models, older age, female sex, greater wealth, fewer household members, greater height-for-age, older maternal age, higher maternal body mass index, current maternal pregnancy and higher maternal Hb, and absence of recent fever were associated with higher Hb in tested children. Demographic, socioeconomic factors, family structure, water/sanitation, growth, maternal health and recent illnesses were significantly associated with the presence of childhood anaemia. These risk factor groups explain a significant fraction of anaemia (ranging from 1.0% to 16.7%) at the population level. Conclusions: The findings from our analysis of risk factors for anaemia in SSA underscore the importance of family and socioeconomic context in childhood anaemia. These data highlight the need for integrated programmes that address the multifactorial nature of childhood anaemia

Risk factors for possible serious bacterial infection in a rural cohort of young infants in central India

Abstract Background Possible serious bacterial infection (PBSI) is a major cause of neonatal mortality worldwide. We studied risk factors for PSBI in a large rural population in central India where facility deliveries have increased as a result of a government financial assistance program. Methods We studied 37,379 pregnant women and their singleton live born infants with birth weight ≥ 1.5 kg from 20 rural primary health centers around Nagpur, India, using data from the 2010–13 population-based Maternal and Newborn Health Registry supported by NICHD’s Global Network for Women’s and Children’s Health Research. Factors associated with PSBI were identified using multivariable Poisson regression. Results Two thousand one hundred twenty-three infants (6 %) had PSBI. Risk factors for PSBI included nulliparity (RR 1.13, 95 % CI 1.03–1.23), parity > 2 (RR 1.30, 95 % CI 1.07–1.57) compared to parity 1–2, first antenatal care visit in the 2nd/3rd trimester (RR 1.46, 95 % CI 1.08–1.98) compared to 1st trimester, administration of antenatal corticosteroids (RR 2.04, 95 % CI 1.60–2.61), low birth weight (RR 3.10, 95 % CI 2.17–4.42), male sex (RR 1.20, 95 % CI 1.10–1.31) and lack of early initiation of breastfeeding (RR 3.87, 95 % CI 2.69–5.58). Conclusion Infants who are low birth weight, born to mothers who present late to antenatal care or receive antenatal corticosteroids, or born to nulliparous women or those with a parity > 2, could be targeted for interventions before and after delivery to improve early recognition of signs and symptoms of PSBI and prompt referral. There also appears to be a need for a renewed focus on promoting early initiation of breastfeeding following delivery in facilities. Trial registration This trial is registered at ClinicalTrials.gov ( NCT01073475 )

Newborn Resuscitation Training in Resource-Limited Settings: A Systematic Literature Review.

CONTEXT: Birth asphyxia contributes substantially to neonatal mortality in low- and middle-income countries (LMICs). The effects of training birth attendants in neonatal resuscitation (NR) on mortality are limited by falloff of skills and knowledge over time and transference of learned skills into clinical practice. OBJECTIVE: This review examined acquisition and retention of NR knowledge and skills by birth attendants in LMICs and the effectiveness of interventions to improve them. DATA SOURCES: Medline, Cochrane, Embase, CINAHL, Bireme, and African Index Medicus databases were searched. We reviewed Web pages and reports from non-peer-reviewed (or gray ) literature sources addressing NR training in LMICs. STUDY SELECTION: Articles on acquisition and retention of NR knowledge and skills, and interventions to improve them, were limited to LMICs. RESULTS: The initial search identified 767 articles, of which 45 met all inclusion criteria. Of these, 31 articles analyzed acquisition of knowledge and skills, and 19 analyzed retention. Most studies found high acquisition rates, although birth attendants struggled to learn bag-mask ventilation. Although significant falloff of knowledge and skills occurred after training, refresher training seemed to improve retention. Results of the gray literature analysis suggest that formal, structured practice sessions improve retention. LIMITATIONS: This review did not analyze training\u27s direct impact on mortality. CONCLUSIONS: Knowledge and skills falloff is a significant barrier to the success of NR training programs and possibly to reducing newborn mortality in LMICs. Refresher training and structured practice show significant promise. Additional research is needed to implement and assess retention improvement strategies in classroom and clinical settings

Duration of solid fuel cookstove use is associated with increased risk of acute lower respiratory infection among children under six months in rural central India.

IntroductionIndia has a higher number of deaths due to acute lower respiratory infections (ALRIs) in children Methods and materialsChildren born to pregnant women participating in the Global Network for Women and Children's Health Maternal and Newborn Health Registry near Nagpur, India were followed every two weeks from birth to six months to diagnose ALRI. The number of hours per day that the child's mother spent in front of a burning solid fuel cookstove was recorded. Children of mothers using only clean cookstoves were classified as having zero hours of exposure. Odds Ratios with 95% confidence intervals were obtained from Generalized Estimating Equations logistic models that assessed the relationship of exposure to solid fuels with risk of ≥1 ALRI, adjusted for sex of the child, household smoking, wealth, maternal age, birth weight and parity.ResultsBetween August 2013 and March 2014, 302 of 1,586 children (19%) had ≥1 episode of ALRI. Results from the multivariable analysis indicate that the odds of ALRI significantly increased from 1.2 (95% CI: 0.7-2.2) for 3 hours of exposure to solid fuel cookstoves compared with no exposure (pConclusionsOur study findings indicate that increasing the time mothers spend cooking near solid fuel cookstoves while children are in the house may be associated with development of ≥1 ALRI in children <6 months

Additional file 1: Table S1. of Risk factors for possible serious bacterial infection in a rural cohort of young infants in central India

Sensitivity Analyses for Multivariable Model with Outcome of Possible Serious Bacterial Infection. (DOC 77 kb

Implementation of “Helping Babies Breathe”: A 3-Year Experience in Tanzania

Objectives: This first-ever country-level study assesses the implementation of the Helping Babies Breathe (HBB) program in 15 of Tanzania\u27s mainland regions by measuring coverage, adoption and retention of provider skills, acceptability among providers, and barriers and challenges to at-scale implementation. Methods: Longitudinal facility-level follow-up visits assessed provider resuscitation knowledge and skills in using objective structured clinical examinations and readiness of facilities to resuscitate newborns, in terms of birth attendants trained and essential equipment available and functional. Focus group discussions were held with providers to determine the acceptability, challenges, and barriers to implementation of the HBB program. Results: Immediately after HBB training, 87.1% of providers passed the objective structured clinical examination. This number dropped to 79.4% at 4 to 6 weeks and 55.8% at 4 to 6 months (P \u3c .001). Noting this fall-off in skills, the program implemented structured on-the-job training and supportive supervisory visits, which were associated with an improvement in skill retention. At long-term follow-up, \u3e90% of facilities had bag-mask devices available to all beds in the labor and delivery ward, and 96% were functional. Overall, providers were highly satisfied with the HBB program but thought that the 1-day training used in Tanzania was too short, so they would welcome additional training and follow-up visits to reinforce skills. Conclusions:The HBB program in Tanzania has gained acceptability and shown success in equipping providers with neonatal resuscitation knowledge, skills, and supplies. However, assessing the program\u27s impact on neonatal mortality has proven challenging