Saving lives at birth

in low-resource settings

Helping save 500,000 more newborns a year by 2030 and preventing 50,000 more maternal deaths, account for more than half of the One Million Lives goal. Worldwide, nearly 3 million newborn deaths and 1.3 million fresh stillbirths occur each year, 99% of them in low- and middle-income countries (LMICs). This chapter relates to the needs and initiatives in LMICs, but the initiatives can also feed into making births in high-income countries safer.

Birth-related complications cost about 200,000 maternal lives each year. In most of these cases simple procedures will suffice to save both mother and baby – if the birth attendant is well trained and confident. Early detection and treatment of complications greatly improve the chances of a good outcome.

SDG3 on health and well-being for all is more holistic than the previous health MDGs. With every life saved there is a significant amount of life years saved. Estimating that each saved baby will live for 70 years and each mother for 50, achieving the goal of saving 550,000 mothers and newborns means nearly 40 million life years gained – that is not counting the cases of prevented disablement.

As the shift progresses from donorship to ownership – the means of providing aid to enable governments and people to help themselves – partnerships are becoming increasingly important and are the bedrock of Laerdal’s approach to helping improve global health.

Regina’s Story

Regina’s baby did not breathe when it was born, but Monica Tippe, one of the most experienced midwives in Haydom Lutheran hospital in rural Tanzania, immediately started resuscitation, helping the baby survive. When the baby was brought to the Neonatal Unit, Mama Regina started bleeding heavily because the placenta was not complete when it emerged. Midwife Monica manually removed the remains and stopped the haemorrhage.

Regina and her baby

Regina and her baby

LGH Annual Update 2022:

Laerdal Global Health is Born

The story behind the One Million Lives goal starts in 2010, when Laerdal established the not-for-profit sister company, Laerdal Global Health (LGH), and became a dedicated member of the Helping Babies Breathe Global Development Alliance established by USAID.

Some years before, in 2007, the American Academy of Pediatrics (AAP) invited Laerdal to collaborate on developing a much-simplified and culturally-adapted course in newborn resuscitation to meet the needs in low-resource settings. Laerdal responded by providing educational design for the course that was to become widely known as Helping Babies Breathe (HBB) and the low-cost simulator, NeoNatalie, to make the training more engaging and effective. Lifesaving equipment, the Penguin Suction and the Upright Resuscitator, also became available as part of the program. When presented in 2008, the project elicited much enthusiasm. Testing in India, Kenya and Tanzania yielded ground-breaking knowledge: the HBB program was born.

Since then, large-scale studies that evaluated HBB programs in Tanzania and Nepal showed a 47% reduction in early 24-hour neonatal mortality and a 24% reduction in fresh stillbirths. This spurred further motivation to bring these innovations to scale.

Helping Babies and Mothers Survive

The tremendous interest that HBB raised triggered the obvious question: if hundreds of thousands of birth attendants could be reached by this course, would this be opportunity to also train them to prevent the number one killer of mothers, uncontrolled bleeding after birth?

Laerdal teamed up with Jhpiego, an affiliate of Johns Hopkins University, the leading NGO for maternal care. This inspired the development of the birthing simulator MamaNatalie as well as the Helping Mothers Survive (HMS) program.

With inclusion of the HMS program, the HBB alliance developed into the Survive & Thrive public-private partnership, including professional associations, the private sector, NGOs and others. Although the formal partnership ended in 2017, its educational programs are reaching more than 100,000 new birth attendants every year by being embedded in national programs and through initiatives such as 50,000 Happy Birthdays.

Together with its partners, LGH has developed 25 products and programs over the company’s first ten years. These products are provided on a not-for-profit basis to the countries with the highest maternal and newborn mortality, and have reached more than 750,000 birth attendants.

Lily Kak, Sr Advisor for Global Partnerships and Newborn Health at USAID
“The HBB GDA has demonstrated that public-private partnerships, driven by a shared goal and vision, can be a highly effective strategy for health development.”

Lily Kak
Senior Advisor for Global Partnerships and Newborn Health at USAID

Cherrie Evans, Senior Technical Advisor, Jhpiego
“The Helping Mothers Survive program is already in use in over 50 low-resource countries.”

Cherrie Evans
Senior Technical Advisor, Jhpiego

Antenatal Care

Labour Management

Birth

Postpartum Care

Newborn Care

Doctor helping patient
Nurse and parents greeting newborn baby
Parents helping pregnant person
Three persons greeting newborn baby
a lady stands by another lady in bed
Three persons greeting newborn baby

Pre-eclampsia & Eclampsia

addresses the second leading cause of maternal mortality.

Threatened Preterm Birth

focusses on identifying women likely to deliver a preterm baby and the actions that can be taken prior to birth.

Essential Care for Labour & Birth and Complicated Labour & Birth

focusses on how to ensure what starts out as a normal birth remains normal.

Helping Babies Breathe

teaches the initial steps of neonatal resuscitation to save lives and how to give a much better start to many babies who struggle to breathe at birth.

Bleeding after Birth

teaches active management of the third stage of labour, and early detection and basic management in order to reduce maternal deaths caused by postpartum haemorrhage.

Essential Care for Every Baby and Essential Care for Small Babies

teach essential newborn care practices to keep all babies healthy from the time of birth to discharge from the healthcare facility.

More and More Happy Birthdays

Tanzania, Ethiopia and Rwanda have achieved wide-scale implementation of the Helping Mothers and Babies Survive programs through the 50,000 Happy Birthdays program. This 2018 – 2020 project was implemented by the national midwifery associations and the International Confederation of Midwives (ICM). It used a cascade model for facility-based training with ongoing continuous refresher training both in-service and pre-service.

The idea was launched in 2014 when, together with Laerdal and ICM, the midwifery associations in Malawi and Zambia set off the pilot 10,000 Happy Birthdays program in their countries, where maternal mortality was amongst the highest in the world. The project educated close to 10,000 birth attendants – the idea being that each trained attendant would help save at least one extra life every year.

Mom kissing baby

Guiding the Way Forward

In 2017, an evaluation of the Survive & Thrive alliance (see below) concluded that the following key achievements had been made:

Key Achievements

  • Developed an evidence-based transformative training methodology for maternal and newborn care.
  • Demonstrated that quality improvement approaches are essential to sustain quality care.
  • Transformed the global landscape for basic newborn resuscitation.
  • Increased access to lifesaving resuscitation and training equipment.
  • Integrated Helping Babies Survive and Helping Mothers Survive into 30 national programs.
  • Demonstrated that strong professional associations are a pathway to sustainability.
  • Mobilized $120m in contributions from all partners, 45% of which was in cash.

Best Practices Implementation of Helping Mothers and Babies Survive Programs

  • Secure Ministry of Health buy-in.
  • Form a working group for planning, training, and monitoring.
  • Develop national roll-out plan for pre-service and in-service training in both public and private sector.
  • Provide learning materials and equipment at time of training.
  • Identify and support local leaders and champions.
  • Establish low-dose, high-frequency refresher training.
  • Establish facility-level Quality Improvement teams.
  • Collect and report local data on standardised indicators.
  • Establish a system for reporting and feedback.
  • Engage healthcare providers, families, and the broader community.

An Utstein meeting in June 2015 established best practice principles for implementation of the Helping Mothers and Babies Survive programs.

Strengthening Midwifery Education

The Helping Mothers and Babies Survive programs have been shown to be very effective, providing an introduction to simulation for in-service training. Through the 10,000 and 50,000 Happy Birthdays programs they have also been successfully introduced to pre-service education. Laerdal, together with SAFER, the Stavanger Acute medicine Foundation for Education and Research, has worked with local partners in Nepal and India to strengthen midwifery education by integrating simulation into the curricula, educating faculty and setting up simulation labs. As many students leave school with very little practical and hands-on experience, this becomes a critical part of building the capacity of the health workers from day one.

Sally Pairman, CEO, International Confederation of Midwives
“A happy birthday is a live and happy mother, a live and healthy baby, and a happy and excited family with a positive experience.”

Sally Pairman
CEO, International Confederation of Midwives

Scaling up Kangaroo Mother Care to Help Small Babies

Every year, 1 million preterm babies die, accounting for 35% of all neonatal mortality. Kangaroo Mother Care (KMC) includes skin-to-skin contact, breastfeeding and infection control, and remains a low-hanging fruit to improve survival of small newborns. Although the intervention is considered simple, the world has yet to implement it to scale and reap the benefits.

The Essential Care for Small Babies Program, together with the PreemieNatalie and MamaBreast simulators, was developed with the AAP to provide training on how to effectively implement and support KMC. The Nifty Feeding Cup and the Care Plus preterm wrap were designed to support mothers caring for small babies.

While the training programs focus on the initiation of care at the healthcare facilities, survival and growth of small babies depend on continuing KMC in the community by family members. “Saving Little Lives at Birth”, a winning proposal in the Innovation-to-Scale initiative of the Global Finance Facility, aims to increase the coverage from 5 to 80 per cent within a three-year time frame in four regions of Ethiopia.

Increasing the Reach

Complementing the mother and baby programs, the Laerdal Foundation has supported the Global Health Media Project, which has developed 90 videos that cover small baby care, newborn care, breastfeeding and childbirth. Available in 30 languages, they have over 90 million online views. A future focus for Laerdal is to develop digital solutions that support quality scale up and low-dose, high-frequency training tailored for the needs of the providers and the facility.

Together with AAP and WHO, the Helping Babies Survive program has been integrated with the WHO Essential Newborn Care program, with all materials and support tools available in a digital format.

27,000 Safer Births Studied

Haydom Lutheran Hospital in rural Tanzania was one of the Helping Babies Breathe research sites, leading up to the the ground-breaking “Safer Births” project. Led by Hege Ersdal of Stavanger and Estomih Mduma of Tanzania, by end 2019 the continuously growing team for research, innovation, and implementation had sparked twenty PhDs, completed or in progress – seven from Tanzania.

More than 100 people have been involved in the project, forming the basis for developing research and knowledge that were transformed into lifesaving medical devices in the hands of Tanzanian midwives. Observations and collected data from over 27,000 consecutive deliveries and 1,700 resuscitation cases make this the largest study on newborn resuscitation.

“We have very good knowledge about what is best to do, but this is useless if people don’t know what to do. Most research projects concentrate on just one of the elements in the Utstein formula of survival: medical science, educational efficiency, or local implementation. We now have 10 years’ experience in looking at all the elements, and we are confident that we can propose a Safer Births package that makes a difference in knowledge, innovation, educational efficiency, and local implementation,” says Hege Ersdal, Principal Investigator, Safer Births.

Over a 5-year study period the Safer Births project has saved 250 newborn lives at the Haydom Lutheran Hospital in Tanzania.

Jeffrey Perlman, Professor of Paediatrics, Weill Cornell Medicine, New York
“The patient data gathered in Haydom represent an unparalleled source for research.”

Jeffrey Perlman
Professor of Paediatrics, Weill Cornell Medicine, New York

The Safer Births Bundle

The implementation of HBB in Tanzania and the collaborative Safer Births research stimulated the development of the Safer Births Bundle. This consists of groundbreaking fetal and newborn heart rate monitors, an improved bag and mask, and a “smart” training manikin with varying lung and heart rate functions that provide feedback to the learner and facility.

The researchers and healthcare workers in Haydom and Muhimbili hospitals were instrumental in developing these innovations. All innovations have proved effective, efficient, and lifesaving. Almost 70 papers have been published in high-impact peer-reviewed international journals, evaluating and describing the bundle.

Safer Births in Nepal and DR Congo

In Nepal, Grand Challenges Canada supported Golden Community to implement a scaleup project of the Safer Births bundle coupled with HBB and a quality improvement system in eight high-delivery hospitals covering 100,000 deliveries a year. The goal is to reduce perinatal mortality by 25%.

In DR Congo, the AAP received a Saving Lives at Birth Grand Challenges award to pilot in three hospitals the NeoBeat Newborn Heart Rate Monitor with an adapted HBB algorithm.

Safer Births Scale Up

The Safer Births research team will play an integral role in supporting the scale up of the Safer Births Bundle throughout Tanzania. This scale up is made possible by a grant from the Global Financing Facility (GFF), a sub-division of the World Bank, in an Innovation-to-Scale initiative. Learn more

Data-Driven Quality Improvement

Digital technologies are playing a major role in Safer Births: affordable solutions developed on a basis of research are rapidly replacing conventional technologies as they help improve systems and programs and accelerate implementation.

“The collecting and analysing of data from products and services open a whole new world, bringing the use and the outcome of the product and program much closer,” says Helge Myklebust, Laerdal’s Director of Strategic Research. “With NeoNatalie Live, we see every day where the product is used, how it is used, and the competency it created. With our LIVEBORN system we can see every day how babies are resuscitated and what the outcome is.”

Over the coming years, the development of digital platforms will promote easy data collection and utilisation, with data analytics and artificial intelligence used to create value.

Hege Ersdal, Principal Investigator, Safer Births
“Based on the encouraging results at the Haydom hospital, the Safer Births Bundle will now be implemented at 30 district hospitals in Tanzania.”

Hege Ersdal
Principal Investigator, Safer Births

Keeping Normal Births Normal

With partners prioritising the prevention and early management of complications, the Helping Mothers Survive programs were expanded to include Essential Care for Labour and Birth and Prolonged and Complicated Labour and Birth for respectful care and support of a well-progressing birth. These programs focus on teamwork and decision-making at the time of birth and are supported by the MamaBirthie birthing simulator and skills trainer which can be used both for simulation and demonstration of birth. A new baby, BabyBirthie, allows training on normal as well as vacuum-assisted delivery.

The LIVEBORN App

LIVEBORN is a bundle of user-oriented, ”smart” products and services to support healthcare workers and health systems globally to deliver better quality care at birth, with increased efficiency and accountability.

The Liveborn app is now being used at 12 hospitals in 4 countries. From April 2019 to March 2020, about 18 000 births were observed. Among these over 500 babies were resuscitated with ventilation. The data collected with the Liveborn app show an improvement in quality of care/improved management of birth asphyxia.

A baby with a heartmonitor showing the pulse and a tablet with The Liveborn app

Training in post-partum intrauterine device insertion in India.

Caesarean-section simulator in use in Cambodia.

Safer Caesarean Sections and Anaesthesia

Devising low-cost and effective training programs for preventing unnecessary Caesarean(C)-sections is gaining priority. Too little too late, too much too soon, is often used to describe the dual challenge around C-section. Whilst a C-section is a lifesaving intervention when needed, a problem that is coming into focus is the wide-spread use of unnecessary C-sections as well as unsafe C-sections. Building on the MamaBirthie training solution, LGH has developed a new C-section trainer, to help ensure that when the procedure is needed it is carried out safely.

A parallel need relates to better anaesthesia training, and equipment more affordable for LMICs. The Utstein meeting on Safer Surgery and Anaesthesia in 2019 looked at indicators and charted the reality. Building local knowledge – including technical knowledge – is essential. Low-cost anaesthesia machines that supply their own oxygen are a perfect case for collaboration. One of the successful projects in the GFF Innovation-to-Scale initiative is providing simulation-based, on-site training to teams in Tanzania and Sierra Leone who will be users of these new anaesthesia machines.

Family Planning

More active family planning through access to sexual and reproductive health care is essential for ensuring healthy lives. A two-year spacing between births may also help reduce birth-related deaths by 10%. India’s Family Planning 2020 program entails providing contraceptive services to 48 million new users, aiming to prevent 1 million infant deaths and over 42,000 maternal deaths by 2020. At the request of, and in close collaboration with, the Indian Ministry of Health and Family Welfare, LGH has designed an affordable, portable, modular training solution for wide-scale intrauterine contraceptive device insertion.

Coming Full-Circle

Laerdal has been involved in helping save the lives of infants and babies in HICs for more than half a century. It is only relatively recently that significant efforts have been directed to LMICs and included the health of the mother as well. The lessons learned from this, with the imperative to develop solutions that were highly cost effective and improved the efficiency of the limited pool of nurses and midwives, can also be translated to HICs where both human and financial resources are being increasingly stretched.

It was in the mid-1960s that Laerdal introduced its first baby, Resusci Baby. The AHA guidelines for neonatal resuscitation were published in 1980 with support from the company. SimBaby, a high-fidelity simulator first introduced in 2003 and recently updated, continues to serve the needs of the AHA Pediatric Advanced Life Support course.

In addition, an alliance with the UK Bristol-based company, Limbs & Things, over many years has supported skills training and higher-fidelity birthing simulation.

Laerdal’s involvement in neonatal well-being has accelerated over the last three decades in its close partnership with the American Academy of Pediatrics and its Neonatal Resuscitation Program (NRP) which was launched in 1987. The program is now used in 130 countries with over 200,000 instructors and over 4 million providers trained. SimNewB, first introduced in 2008 with the second generation following in 2019, and Premature Anne were designed especially for this program. And it was this involvement with the NRP that stimulated the formation of LGH.

A prime example of how solutions originally designed for low resource settings can serve the needs of HICs is the NeoBeat newborn heart rate monitor. This innovation was developed to support the Helping Babies Breathe (HBB) program. Supported by the WHO and the Gates Foundation, researchers have validated the NeoBeat at a network of hospitals in Europe and Australia, comparing its efficiency during real resuscitation with traditional tools. It has generated such great interest in those validation sites that they want to use it themselves. They find that this simple, low-cost pulse monitor provides heart rate data much quicker than their pulse oximeters and is much easier to apply to a newborn than traditional ECG electrodes, enabling lifesaving ventilation to be started sooner.