International Perspectives: Helping Babies Breathe: Evolution of a Global

Neonatal Resuscitation Program for Resource-Limited Areas

George A. Little, William J. Keenan, Nalini Singhal and Susan Niermeyer
Neoreviews 2014;15;e369
DOI: 10.1542/neo.15-9-e369

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Author Disclosure
Drs Little, Keenan, Singhal, and
Niermeyer have disclosed no financial
relationships relevant to this article.
This commentary does not contain
a discussion of an unapproved/
investigative use of a commercial
product/device.
Abbreviations
GDA: Global Development Alliance
GITF: Global Implementation Task
Force
HBB: Helping Babies Breathe
MDG: Millennium Development
Goals
NRP: Neonatal Resuscitation
Program
TOT: Training of trainers
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international perspectives
Helping Babies Breathe: Evolution
of a Global Neonatal Resuscitation
Program for Resource-Limited Areas
George A. Little, MD,* William J. Keenan, MD,† Nalini Singhal, MD,‡ and Susan Niermeyer,
MD, MPHx
Abstract
Helping Babies Breathe (HBB) is a global neonatal resuscitation program
for resource-limited areas. This review of HBB provides readers with in-
sight into the strategic assessment of global neonatal mortality that led
to development of the program, how that assessment shaped the educa-
tional program as a catalyst for change, and how a global public–private
alliance has promoted HBB implementation and continues to strive for sus-
tainable improvement in newborn health.
Helping Babies Breathe (HBB) was (from 2010–2013) saw rapid geographic
released in June 2010 after 4 years dissemination and implementation in
of development that included peer 72 countries (Fig 2) with creation of
review and formative educational national plans for resuscitation in 18
field testing. The present HBB pro- countries.
gram includes a clinical curriculum
based on global evidence, innovative Strategic Assessment of the
educational design, and purpose-built Problem: How to Impact
educational and clinical equipment, Neonatal Mortality?
including a low-cost neonatal simu- In 2000, United Nations member
lator to enhance skill development. states adopted 8 Millennium Devel-
An Action Plan (Fig 1) serves as opment Goals (MDG) for alleviating
a pictorial foundation for under- global poverty to be met by 2015. Of
standing the flow of evaluation and the three health-related goals, two di-
decision and the action steps dur- rectly target maternal and child health
ing stabilization/resuscitation after (MDG 4 and 5). By the mid-2000s,
birth. HBB is being disseminated MDG 4 had helped bring into focus
globally through training-of-trainers several key facts:
(TOT) cascades. Field trials in Africa
• Global reduction in child mortality
and South Asia have demonstrated
was not proceeding rapidly enough
effectiveness of the intervention in de-
to meet the 2015 goal of reducing
creasing not only neonatal death but also
the under-5 child mortality rate by
fresh stillbirths. (1)(2) The first 3 years
two-thirds from 1990 levels. (3)(4)
• Neonatal mortality was the single
*Department of Pediatrics, Geisel School of Medicine largest cause of under-5 mortality,
at Dartmouth, Hanover, NH.
†
Department of Pediatrics, St Louis University, accounting for >40% of deaths.
St Louis, MO. Furthermore, this fraction was
‡
Department of Pediatrics, University of Calgary, becoming proportionately larger
Calgary, Alberta, Canada.
x
Department of Pediatrics, University of Colorado, because neonatal deaths were not
Aurora, CO. decreasing at the same pace as
NeoReviews Vol.15 No.9 September 2014 e369
international perspectives

deaths of older infants and chil-

dren were in response to efforts di-
rected at causes such as pneumonia
and diarrhea (Fig 3). (5)
• Neonatal deaths occurred pre-
dominantly on the day of birth,
and 98% occurred in low- and
middle-income countries. (3)(6)
• Deaths due to intrapartum-related
events were a major cause of neona-
tal mortality, and failure to establish
or sustain effective breathing (as-
phyxia) accounted for many deaths
in the first day. (7)(8)
In 2010, there were an estimated
7.7 million deaths of children aged
<5 years; 3.1 million were neonatal
deaths, with 50% occurring in the
first 24 hours after birth. (5) Of all
neonatal deaths, w800,000 were caused
primarily by intrapartum-related events
(asphyxia). Globally, approximately one
in four neonatal deaths (<28 days) and
up to 60% of early deaths (<24 hours)
were attributable to intrapartum-related
events in some regions. (9)
In addition to the nearly 1 million
neonatal deaths from intrapartum-
related causes, estimates in 2010 sug-
gested a nearly equal number of fresh
stillbirths. (10) Although some of
these infants truly had no heart rate
at the time of birth, estimates sug-
gested that a substantial proportion
were simply “still at birth,” not macer-
ated, not moving, not breathing,
showing no obvious signs of life, but
potentially responsive to resuscitation.
(7)(11) The majority of the estimated
350,000 maternal deaths occurred
during the same 24 hours immediately
after birth. (12) Attendance at delivery
by a person or persons trained not
only in midwifery and maternal life-
saving skills but also in neonatal re-
Figure 1. Action Plan for Helping Babies Breathe. Note the prominent Golden Minute
suscitation thus became the major
in the upper right (first minute after birth and yellow zone) defining a time-based
standardized intervention from routine care (green zone) for babies who do not focus for intervention to save lives on
breathe after thorough drying immediately after birth. the day of birth. (13)(14)
To achieve the goal of having a
birth attendant trained in neonatal

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Figure 2. Cumulative sites of implementation of Helping Babies Breathe to July 2013. Countries shaded in green have national
plans for neonatal resuscitation.
resuscitation at every delivery, a
training program would have to over-
come several major challenges (13):
• Education would need to become
more focused on skills and perfor-
mance rather than the didactic,
classroom-based teaching tech-
niques used previously. Even pre-
viously trained, experienced birth
attendants in active service would
need further experience with hands-
on practice of skills.
• Education would need to be deliv-
ered simultaneously with afford-
able equipment proven effective
for clinical care. Many previous in-
itiatives had provided education or
equipment, but seldom have the
two been available together at
the same time and place to permit
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actual application of new knowl-
edge while using new equipment.
• Education would need to reach new
cadres of birth attendants. In many re-
gions, the proportion of births occur-
ring in facilities was low, and staffing
was inadequate to meet the demands
of existing in-facility deliveries.
Two major initiatives for perinatal
health in the 1970s and 1980s in the
United States informed the program-
matic approach to the solution. To-
ward Improving the Outcome of
Pregnancy in 1976 advanced multidis-
ciplinary promotion of systematic, re-
gional perinatal care and education
targeted at improving maternal and
neonatal outcomes. (15) The Neona-
tal Resuscitation Program (NRP) of
the American Academy of Pediatrics
(AAP) and American Heart Association
international perspectives
originated in 1987 from a curriculum
designed in response to a National In-
stitute of Child Health and Human
Development request for proposals
to improve neonatal respiratory out-
comes through innovative population-
based educational initiatives. NRP was
unique in its time because it emphasized
development of psychomotor skills for
neonatal resuscitation as well as cogni-
tive understanding of the physiologic
basis for interventions. Dissemination
utilized the AAP district and chapter
structure as the framework for a TOT
cascade that rapidly reached hospitals
and providers across the United States.
The systematic implementation strat-
egy encouraged creation of multidisci-
plinary teams (eg, nursing, medicine,
respiratory therapy) of hospital-based
instructors to achieve standardized
NeoReviews Vol.15 No.9 September 2014 e371
international perspectives

Figure 3. Neonatal mortality rate (NMR) and under 5 mortality (U5M) trajectories 1990 to 2035. Note increasing proportion of
NMR with time.
ARR[annual rate reduction; MDG 4[Millennium Development Goal 4 2015 target. Source: UNICEF State of the World’s Children 2012. The United Nation’s
Interagency Group for Child Mortality Estimation, Levels, and Trends in Child Mortality: Report 2011. Team analysis from 2035 onward based on straight-line ARR
reduction from UNICEF numbers, 1990 to 2035.

change in practice at delivery facilities
across the entire population of the
United States. (16)
NRP continues to be a dynamic
program under the stewardship of an
AAP steering committee of member
volunteers, representatives of allied
organizations such as the Canadian
Pediatric Society, and program staff
committed to evidence-based quality
improvement. The scientific evidence
base of NRP derives from the Consen-
sus on Science and Treatment Recom-
mendations developed by the neonatal
subgroup of the International Liaison
Committee on Resuscitation. Program-
matic and scientific updates drive the
release of a new edition of NRP on a
5-year cycle; therefore, advances in
methods for knowledge translation
and resuscitation science are rapidly
transmitted to professionals caring for
newborns at delivery.
After its US release, NRP quickly
expanded beyond the boundaries of
the United States as pediatricians
and public health officials from other
countries recognized that this tool
could be used to meet needs within
their own environment. NRP was
clearly understandable so that one in-
structor could make a difference imme-
diately in his or her facility. Through
partnerships among academic insti-
tutions, professional associations,
and ministries of health, the pro-
gram established a national presence
in many middle-income countries.
By 2009, NRP had been taught in
>130 countries with >24 official
translations (www.aap/nrp/interna-
tional). The success of NRP in these
settings was derived from the follow-
ing: local ownership and leadership;
multidisciplinary professional asso-
ciation commitment; involvement
of governing bodies, especially the
Ministry of Health; and financial
support from government, inter-
national organizations, nongovern-
mental organizations, and commercial
sponsors.
Despite the success of NRP, it be-
came clear that a mis-match existed
between available recommendations,
guidelines, and educational programs
and the needs where neonatal mortality
was the highest, resources were severely
constrained, and many births occurred
outside medical facilities. Neonatal
resuscitation was widely viewed as
equivalent to intensive care medicine.
There was concern that one reason

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for the lack of progress in reducing
newborn deaths globally was the mis-
taken notion that expensive, high-tech
approaches were necessary. Of note, in-
fluential leaders in global child health
pointed out that three-fourths of an-
nual neonatal deaths could be averted
with low-tech, low-cost interven-
tions. (17) Specifically, estimates sug-
gested that death from asphyxia, or
intrapartum-related events, could be
reduced by 30% in term infants, and
preterm mortality reduced by 5% to
10%, through neonatal resuscitation
at an estimated cost of $208 per life
saved. (13)
Response to the Problem:
Development of HBB 2006–
2010
In 2006, the AAP charged a Global
Implementation Task Force (GITF)
with development of a curriculum
for neonatal resuscitation in resource-
limited environments. The mission
of the GITF was to develop and im-
plement an evidence-based curriculum
adaptable to clinical and training use
wherever infants are born. The AAP
sought to include as many individuals
and organizations as possible with a
global role in training, advocacy, and
research on neonatal resuscitation
(Table 1).
A consensus emerged from early
GITF meetings that the HBB educa-
tional program should be constructed
de novo. It would emphasize develop-
ment of skills necessary to empower
a first-level birth attendant, often car-
ing for both mother and infant, to help
a newborn who did not breathe at
birth. Pivotal input received at global
forums for midwifery, obstetrics, and
pediatrics further shaped the content
and methods of the program.
A small editorial group (the authors
of this article) worked for >1 year
to transform the NRP resuscitation
algorithm into a clear Action Plan
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for immediate care after birth. Figure
4 is the 2006 NRP flow diagram and
Fig 5 from the GITF 2006 minutes is
an early draft rendition of what
evolved to become the pictorial final
Action Plan seen in Fig 1.
As can be noted in the timeline of
HBB developmental milestones (Table
2), the interval from 2006 to 2008 in-
cluded evolution of program content
and structure as well as recognition of
opinions from international stakehold-
ers that included cautionary advice in
the form of concern about complexity.
The entire GITF reviewed and beta-
tested educational materials while
an expanded group of global stake-
holders developed implementation
plans.
Management of dynamic impera-
tives was necessary from late 2008
until the HBB launch in June 2010.
A shared awareness among stakehold-
ers that global neonatal outcome sta-
tistics were in many countries falling
short of MDG 4 goals argued for im-
mediate program release. However,
this imperative was balanced by con-
cerns for safety and possible risk of lack
of outcome improvement or even re-
gression as a result of moving ahead
with an untested intervention. There
was strong conviction that content
and methods would benefit from field
testing. Leadership concluded that for-
mative evaluation of the educational
component with input from actual user
groups was necessary. In late 2008, a
process for field testing that included
evaluation of the training materials
and TOT cascade, as well as the per-
formance and satisfaction of facilita-
tors and learners, was put in place.
Although study subjects were satisfied
with the HBB program and gained
self-efficacy and skills, they also dem-
onstrated the need for additional prac-
tice if bag and mask ventilation was
to be mastered and practice routines
changed. The 2009 and early 2010
field studies allowed findings to be peer
international perspectives
Precursors of
Table 1.
HBB and Their
Champions
NICHD Global Network
First Breath–Wally Carlo, Linda
Wright
Latter Day Saint Charities
Simplified NRP curriculum–Rob
Clark
World Health Organization
Basic Newborn Resuscitation
Guidelines and Integrated
Management of Pregnancy and
Childbirth (IMPAC)–Martin
Weber, Jelka Zupan
International Liaison Committee on
Resuscitation
Neonatal evidence evaluation to
meet needs of resource-limited
settings–Jeff Perlman, Nalini
Singhal
Hesperian Foundation
Donde No Hay Doctor/A Book for
Midwives–Susan McCallister
NRP/AAP Section on Perinatal
Pediatrics
Global NRP dissemination–William
Keenan, Susan Niermeyer,
George Little, Dharmapuri
Vidyasagar, Jonathan Spector
Laerdal Medical
Neonatal resuscitation
mannequins/simulators and
ventilation devices–Tore Laerdal
AAP¼American Academy of Pediatrics
HBB¼Helping Babies Breathe
NICHD¼National Institute of Child
Health and Human Development
NRP¼Neonatal Resuscitation Program
reviewed and integrated into revised
program materials, improved equip-
ment, and more practical assessment
tools before release. (18)
HBB Programmatic
Innovations
HBB has three basic and innovative
components: a resuscitation curriculum
emphasizing the initial steps, a care-
fully crafted educational design, and
NeoReviews Vol.15 No.9 September 2014 e373
international perspectives

purpose-built clinical and training

equipment. The HBB Learner Work-
book opens by defining the focus of
the curriculum, “A skilled birth at-
tendant can help a baby who does
not breathe and promotes warmth,
cleanliness, and breastfeeding for all
babies.”(19) Content stresses the im-
portance of routine care at birth (eg,
thorough drying, thermal protection
with skin-to-skin care, early breastfeed-
ing) for all infants and basic interven-
tions that, when applied in a timely
way, can help save lives (eg, thorough
drying and specific stimulation to
breathe, clearing the airway as neces-
sary, bag and mask ventilation, steps
to improve ventilation). The curriculum
does not address the entire spectrum of
neonatal resuscitation care but instead
focuses on the steps that are effective
and sufficient for establishing and sup-
porting breathing in 95% of infants.
(13) The program does not distract
from the central focus by including
interventions such as use of supple-
mental oxygen, ventilation through
endotracheal intubation, and chest com-
pressions that are available in more
resource-intensive environments.
The Action Plan (Fig 1), a pictorial
equivalent to a resuscitation algorithm
such as that of NRP, drives the timing
and sequence of steps through a series
of evaluation/decision/action cycles.
The Action Plan begins with prepara-
tion, a concept that previously had
been underemphasized in resource-
limited settings. All infants are dried
thoroughly and then evaluated with
the question “Is the baby crying?”
Those who are crying receive routine
care in the green zone. Those who
are not crying enter into the yellow
zone, or The Golden Minute. Infants
who improve move back to the green
zone for ongoing care with the
mother. The small proportion of in-
Figure 4. Algorithm from 5th Edition of Neonatal Resuscitation Program (NRP) Textbook.
(c) 2006, American Academy of Pediatrics, American Heart Association. fants who do not improve despite
HR[heart rate (given in beats per minute). a Endotracheal intubation may be considered at several bag and mask ventilation ideally con-
steps. tinue to advanced care where resources

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 international perspectives

correlates with decreased survival. (20)

Timeline of HBB Developmental
Table 2. The Golden Minute also emphasizes
that initial efforts to stimulate breathing
Milestones should occur before clamping the um-
August 2006 GITF: Curriculum visioning
bilical cord. When the infant requires
• De novo development of an educational program that would be an effective bag and mask ventilation, cutting the
educational and medical intervention, not a revision or condensation of NRP; cord is necessary to move the infant
empowerment of first-level health providers to a separate area for ventilation. How-
February 2007 GITF: Working meeting (Elk Grove Village) ever, if only one skilled attendant is
• Outline of curriculum content and educational principles, representatives from available, the reality may be that ven-
precursors of HBB
tilation is provided adjacent to the
July 2007: Women Deliver (London)
• Advocacy with midwifery and obstetric groups and WHO Safe Motherhood
mother, often with umbilical cord in-
Program tact. Emerging experimental evidence
August 2007: AAP Forum at International Pediatric Association Meeting suggests that establishing lung expan-
(Athens) sion before cutting the cord promotes
• Strong cautionary advice from global clinical and academic leaders against placental transfusion and cardiovascu-
complexity; GITF commitment to a draft curriculum within 1 year lar stability. (21) During routine care,
January 2008 GITF: Expanded stakeholders meeting when the infant is breathing and cry-
• Broadening the inclusivity (WHO, USAID, SNL) and honing the focus of the
content
ing, umbilical cord clamping is delayed
March 2008: HBB is born!
at least ‡1 minute at the discretion of
• Naming of the new educational program the birth attendant. For both term
July 2008: WHO presentation (Geneva) and preterm infants, the transferred iron
• Presentation of program content, harmonization with global guidelines, and stores associated with appropriate delay
mechanism for review in cord clamping are vital to alleviate
July 2008: Laerdal Foundation (Stavanger) anemia of infancy in the resource-limited
• Collaboration on graphics/educational design and simulator setting. (22)(23)
August 2008: Delphi review (electronic) of draft educational materials Development of HBB educational
September 2008 GITF: Educational materials review (Elk Grove Village) design and equipment was concurrent
• Formative review and transformation from curriculum into educational
program; development of field testing protocol
and synergistic with development of
October–November 2008: RFA for field testing
medical curriculum content from early
January 2009: WHO technical working group review of curriculum materials
in the process. The commitment to
(Geneva) resource-limited areas served to con-
March 2009: USAID presentation of curriculum materials stantly reinforce sustainability, durabil-
May–July 2009: Educational field testing (Kenya, Pakistan, India) ity, and cost as primary considerations,
September 2009: Implementation trial launch (Tanzania) but aesthetic and design qualities were
January–June 2010: Implementation trials (Kenya, Pakistan) also priorities. HBB’s planned global dis-
June 2010: global launch of HBB GDA and Master Trainer Workshop semination into widely varied environ-
(Washington, DC) ments and populations served to guide
development of a standardized and flex-
AAP¼American Academy of Pediatrics; HBB¼Helping Babies Breathe; GITF¼Global
Implementation Task Force; RFA¼request for applications; SNL¼Saving Newborn Lives; ible educational design. The curriculum
USAID¼US Agency for International Development; WHO¼World Health Organization. is intended for environments from hos-
pitals and birthing facilities to the poorest
are available. In the red zone, the Ac- when a infant does not breathe, even sites. All providers of care at delivery,
tion Plan can merge seamlessly into the when there is only one birth attendant including those who due to circum-
advanced resuscitation algorithm of caring for two patients (ie, mother and stances have limited formal education,
NRP or other programs. infant). The Golden Minute empha- are considered to be appropriate learners.
The Golden Minute is an integral sizes that the infant is the priority Figure 6 displays the training ma-
HBB concept prominently depicted in the first minute. Observational re- terials and equipment. Printed mate-
in the Action Plan to call attention search affirms that further delay in rial includes the Learner Workbook
to the importance of prompt interven- time to first breath, either spontane- and Facilitator Flip Chart. The neo-
tion in achieving a successful result ous or assisted with positive pressure, natal simulator is purpose-designed

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international perspectives
Figure 5. Transitional 2008 action plan from minutes of the Global Implementation
Task Force (GITF). Compare with the Neonatal Resuscitation Program (NRP) 2006
algorithm (Fig 4) and the final Action Plan (Fig 1).
to display the cardinal evaluation
points of crying, breathing, and heart
rate. Pneumatic bulbs controlled by
the facilitator or a learner produce
spontaneous chest movement and pal-
pable umbilical cord pulse; a separate
squeeze bulb mimics a cry. When filled
with 2 L of warm water, the simulator
has the weight (2 kg), warmth, and hy-
potonic tone of a newly born infant
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who requires resuscitation. Learning
materials that double as clinical tools
include a bag and mask ventilation ap-
paratus designed to meet requirements
for cleaning and durability and a reus-
able suction device that can be opened
for cleaning and boiled for disinfection.
(24)
The Learner Workbook follows
a format of knowledge presentation,
skill practice, and group discussion,
with exercises that bring together
a series of skills and decision-making.
Use of illustrations and universally
recognizable icons as well as limited,
precise vocabulary simplify transla-
tion into languages other than En-
glish. Color zones (green, yellow,
and red) link the learner’s materials
to the Action Plan. “Check yourself”
questions and small group discussion
questions aim at revealing cultural
and system-related issues that may
pose barriers to new practices and im-
plementing solutions to these.
The Facilitator Flip Chart provides
a manual for facilitation of learning on
the back of each page that presents il-
lustrations of skills to the learners. The
illustrations are designed to “make the
invisible become visible” for resuscita-
tion interventions. All educational
materials are easily portable and re-
quire no electricity. Participants in
an HBB workshop practice together
in pairs or dyads, which promotes
cooperative learning, self-reflection,
and performance of scenarios used
for simulation-based learning (Fig 7).
Evaluation includes a written or ver-
bal assessment of knowledge, bag
and mask ventilation skill assessment,
and Objective Standardized Clinical
Evaluations, which integrate multiple
skills with decision-making.
Development of the clinical and
educational equipment in large part
emanated from a continuing dynamic
partnership that included expertise
and resources from the health equip-
ment industry. Transparent recogni-
tion of a partnership with Laerdal
Global Health has been maintained.
Educational materials and equipment
for clinical care are available to MDG
4 and 5 countries at cost through Laer-
dal Global Health, a not-for-profit
corporation. Although not essential
or required, equipment designed for
use with the program offers advan-
tages over conventional mannequins
 international perspectives

Figure 6. Educational materials for Helping Babies Breathe. The bag and mask ventilator and aspirator at the lower right are also
tested clinically effective apparatus.

and previously available ventilation and support the value of access to the activities. As other options emerge
suction devices. Equipment testing and neonatal simulator for ongoing low- with time, they should be evaluated
experience during development, as dose, high-frequency practice as part with the same performance and cost
well as HBB outcome studies to date, of deliberate quality improvement standards.

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international perspectives
Figure 7. District-based Helping Babies
Breathe training in Malawi. Note dyad of
two trainees to the right who are paired
to alternate as trainer and trainee. To the
left is a master trainer initially trained at
the national rollout training who is pro-
viding bag and mask ventilation skill set
education. Note also the flip chart dis-
playing the Improve Ventilation page and
the Action Plan posted on the wall.
Implementation of the
Intervention: Dissemination
and Sustainability of HBB
The AAP as a professional associa-
tion has guided and supported HBB
development, and it remains com-
mitted as a partner in program im-
plementation and sustainability to
achieve an impact on population-
level indicators of neonatal health.
The original commitment was for
development of a curriculum to be
freely available for global use. As HBB
matured within a strong collabora-
tive environment, the AAP accepted
a major role in a broad community
of global implementers through the
Figure 8. Members of the Helping Babies Breathe Global Development Alliance.
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HBB Global Development Alliance
(GDA).
The GDA is a public–private part-
nership founded at the time of the
global rollout of HBB in 2010 to ac-
celerate implementation in support
of the efforts to meet MDG 4. The
organizations included in the GDA
partnership (Fig 8) function in a collab-
orative fashion with host governments
to combine strengths and resources.
(25) The GDA has gained additional
partners and is extending its collabora-
tion to other GDAs with closely allied
missions. Collaboration with the
mPowering Frontline Health Workers
GDA explores ways to increase access
to educational content by use of mo-
bile platforms, and collaboration with
the Survive and Thrive GDA adds a fo-
cus on prematurity prevention and
management as well as professional as-
sociation strengthening.
Initial implementation efforts fo-
cused on promoting an understanding
of the unique educational approach of
HBB and how the program could be
used as a catalyst for improvement of
systems for perinatal health. HBB is in-
tended for implementation within pri-
mary macrosystems and microsystems
of care as a center of excellence. It is
not meant to be freestanding, iso-
lated, or compartmentalized. It is in-
tended for integration with the World
Health Organization Essential New-
born Care program (http://www.who.
int/maternal_child_adolescent/docu-
ments/newborncare_course/en/) and
other comprehensive maternal/neo-
natal/child health efforts.
An online implementation guide
directed to policy makers, program
managers, and HBB master trainers
and facilitators includes suggestions
for convening stakeholders and plan-
ning at the national level as well as
training, monitoring and evaluation,
and hyperlinks to specific tools. Trans-
lation into local languages is funda-
mental to extending the reach of
education and eliminating disparities.
The AAP enters into agreements for
translation and maintains a process of
no-cost review and approval as part
of the ongoing commitment to qual-
ity assurance and improvement. Pe-
riodic revisions on a 5-year cycle
will update the program with the lat-
est consensus on resuscitation and
implementation science. The HBB
website (www.helpingbabiesbreathe.
org) also features a facilitator video,
stories from the field, frequently asked
questions, and a matrix of contacts in
sites where the program has been
implemented.
By June 2014, HBB had been
introduced in 73 countries, and 18
countries have national programs
coordinated by their governments
(Fig 2). More than 220,000 atten-
dants have been trained and equipped
with educational and clinical resources.

Although the HBB GDA was directly
involved in much of the introduction
and support of HBB, there are also
national efforts that are not directly
supported by the GDA as well as re-
gional and local initiatives by many
private and faith-based nongovern-
mental organizations.
Implementation trials from coun-
tries involved in early field testing have
documented the effectiveness of the
HBB intervention. Results from a pre-
paratory baseline study in sub-Saharan
Africa (Tanzania) showed that as-
phyxia accounts for 60% of deaths in
the first 24 hours, a far greater propor-
tion than later in the first month. (9)
Application of HBB resulted in an ini-
tial 47% reduction in 24-hour mortal-
ity among infants not breathing at
birth and a 24% reduction in fresh still-
births. (1) In India, a 24% reduction in
all stillbirths (odds ratio June 2013:
0.76, 95% CI 0.59¼0.98) and a 46%
reduction in fresh stillbirths (odds ra-
tio: 0.54, 95% CI 0.37–0.78) occurred
after introduction of HBB. There
was no change in neonatal deaths,
suggesting that survivors went on to
be healthy newborns. (2) A multisite
implementation trial to examine
population-level impact on indicators
of neonatal mortality and stillbirth is
concluding at three sites of the Na-
tional Institute of Child Health and
Human Development Global Network
(www.clinicaltrials.gov/ct2/show/
NCT01681017).
Achieving sustained impact re-
quires much more than a training in-
tervention. Each successful program
has developed local leadership to en-
sure high-quality training and to pro-
mote behavior and systems change
through quality improvement ac-
tivities. Sustainable change requires
close collaboration with Ministries
of Health to revise and update poli-
cies and includes financing for resusci-
tation and neonatal care in national
and regional budgets. Ongoing quality
Downloaded from http://neoreviews.aappublications.org/ at Health Internetwork on September 3, 2014
improvement is needed to demon-
strate and document reductions in
population-based indicators such as
early neonatal mortality and fresh still-
birth rates. Through collaboration with
professional organizations in countries,
the AAP has fostered local ownership
and interprofessional cooperation that
are necessary to achieve sustained im-
provement in neonatal and maternal
health.
Present and Future Directions
HBB continues to serve as a catalyst for
change, improvement, and expansion
of comprehensive care for all infants.
The model of targeted curriculum de-
velopment, innovation in educational
design, and implementation through
broad partnerships is now being ex-
tended to a suite of three programs un-
der an umbrella heading of Helping
Babies Survive. This suite of coordi-
nated educational programs aims to
address all three major causes of global
neonatal death: intrapartum-related
events, infection, and prematurity/
small size at birth. HBB is the first
and enduring model program and is
planned to have a revised curriculum
in 2015–2016.
Essential Care for Every Baby, the
second module, continues care
through the first day, emphasizing
early and exclusive breastfeeding,
thermal protection, good hygiene
and protection from infection, and
recognition of danger signs. Field
testing has been completed in Kenya
and India, and implementation testing
occurred in Uganda in collaboration
with the World Health Organiza-
tion. Program launch will take place
in 2014.
A third program for care of the
well, premature, and/or small in-
fant is under active development,
spurred in large part from by publi-
cation of Born Too Soon, the Global
Action Report on Preterm Birth. (26)
international perspectives
The three programs align closely
with the strategic approaches and
survival solutions proposed by the
Every Newborn Action Plan (www.
everynewborn.org). Helping Mothers
Survive (HMS) is an education pro-
gram that has adapted the HBB model
to teach the prevention of postpartum
hemorrhage with a unique hybrid
maternal simulator. (27) Additional
modules emphasizing obstetric/
midwifery content (eg, antenatal
corticosteroids and management of
preterm labor) are in preparation
and planning.
HBB and the rest of the Helping
Babies Survive suite are poised to ef-
fect widespread change in the outlook
for mothers and infants in resource-
limited regions of the world. As
Gawande pointed out in a recent dis-
cussion of “Slow Ideas,” technology
and incentive programs are not enough
to achieve change in behavior and prac-
tice. Successful innovation appears to
depend upon a dynamic interpersonal
diffusion process that is self-generating
(28). HBB shows promise of being
such an innovation.
American Board of Pediatrics
Neonatal–Perinatal Content
Specification
• Know the issues in
the organization
of perinatal
care (eg,
regionalization,
transport quality
control, practice
guidelines).
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 International Perspectives: Helping Babies Breathe: Evolution of a Global
Neonatal Resuscitation Program for Resource-Limited Areas
George A. Little, William J. Keenan, Nalini Singhal and Susan Niermeyer
Neoreviews 2014;15;e369
DOI: 10.1542/neo.15-9-e369

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