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Addressing High Infant Mortality in the Developing

World: A Glimmer of Hope

Extraordinary progress has been made in reducing infant mortality in the developed world over the past 7 decades, with death rates during thefirst year of life falling by more than 90% since my own birth in 1941. However, infant mortality rates in the developing world are still nearly 10 times higher than in the United States (Fig 1). Two articles in this month’sPediatricssuggest that help is on the way to narrow this unacceptable gap.1,2

It has been estimated that early birth asphyxia is responsible for nearly one-third of the neonatal mortality rate (NMR), as well as contribut-ing substantially to neurodevelopmental disability.3 To address this problem in the United States, the American Academy of Pediatrics (AAP) and American Heart Association developed the Neonatal Re-suscitation Program (NRP), which has been highly successful, with .3 million health care providers completing the course in the United States alone. This success has led.130 other countries, from both the developed and developing world, to express interest in adopting the NRP curriculum. But is NRP really an appropriate model for the developing world? At least 1 intervention attempting to do just that produced disappointing results,4,5 perhaps because of differences in the environment, personnel, and equipment associated with child-birth in the United States. In most of the world, most child-births take place in the mother’s home or in regional clinics rather than in hospitals. Physicians or highly trained midwives attend nearly all births in the United States, whereas traditional midwives, doulas, or all too fre-quently no trained attendants at all are present during births in the developing world. Optimum equipment for resuscitating newborns is available in every licensed hospital in the United States, whereas such equipment is not available for the vast majority of births in the de-veloping world, even if an attendant were to be available and knew how to use it.

Recognizing these differences, the AAP moved quickly to develop a new resuscitation program, Helping Babies Breathe (HBB), by using the same evidence-based, breathing-first principles on which NRP was based. Because evidence has shown that resuscitation steps beyond assisted ventilation are unnecessary for.99% of compromised new-borns,6it stops short of activities that are impractical and generally unachievable in developing areas.

The reports published this month describing implementation of the HBB strategy in 2 developing countries suggest that this new program may well be an effective tool to bring infant mortality in the developing world more in line with that achieved in the rest of the world.

Goudar et al1implemented HBB in southern India, with AAP instruc-tors conducting 2-day workshops for regional trainers, who sub-sequently educated 599 birth attendants from rural primary health AUTHOR:John Kattwinkel, MD

Department of Pediatrics, University of Virginia, Charlottesville, Virginia

KEY WORDS

asphyxia, infant mortality, Helping Babies Breathe, neonatal mortality, neonatal resuscitation

ABBREVIATIONS

AAP—American Academy of Pediatrics FSB—fresh stillbirth

HBB—Helping Babies Breathe NMR—neonatal mortality rate NRP—Neonatal Resuscitation Program

Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.

www.pediatrics.org/cgi/doi/10.1542/peds.2012-3171

doi:10.1542/peds.2012-3171

Accepted for publication Oct 24, 2012

Address correspondence to John Kattwinkel, MD, University of Virginia, Department of Pediatrics, PO Box 800386, Charlottesville, VA 22908. E-mail: jk3f@virginia.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2013 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE:Dr Kattwinkel received a stipend from the American Academy of Pediatrics and American Heart Association to serve as editor of the Neonatal Resuscitation Program Textbook.

FUNDING:No external funding.

COMPANION PAPERS:Companions to this article can be found on pages e353 and e344, online at www.pediatrics.org/cgi/doi/ 10.1542/peds.2012-1795 and www.pediatrics.org/cgi/doi/10. 1542/peds.2012-2112.

PEDIATRICS Volume 131, Number 2, February 2013 e579

COMMENTARY

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centers and district and urban hos-pitals. During the relatively brief pe-riod of 6 months after the program, there was a 48% reduction in “fresh stillbirths” (FSBs), which have been speculated to include a substantial number of potentially viable infants who would not have previously been offered resuscitation.7 It should be noted, however, that .90% of the attendants who administered bag-and-mask ventilation in both the pre- and post-training periods were physicians, not the nurses and other providers who are generally the workers in the field.

In the second study, by Msemo et al,2 a similar HBB strategy was used to train 40 “master instructors” from 8 study site hospitals in Tanzania, who then delivered the program to regional instructors who in turn trained health providers in the smaller facilities within each of the 8 districts. During the 2 years after intervention, there was a 24% reduction in FSBs and a 47% reduction in early neonatal mor-tality, defined as death within thefirst 24 hours. This program was focused on the grass-roots birth attendants, many of whom practice in rural facilities,

rather than on hospital-based physi-cians, and included strategies such as conducting refresher courses and re-quiring all attendants to demonstrate resuscitation skills with a manikin at the start of each shift in the delivery area, including practicing bag-and-mask ventilation.

Although both studies used the HBB program as their primary intervention, the study designs were sufficiently different to prohibit direct comparisons. Nevertheless, several conclusions ap-pear justified. First, a reduction in FSB rates in both studies without a simulta-neous increase in NMR indicates that lives were indeed saved, particularly with the observation in India that nearly 3 times as many infants re-ceived positive pressure ventilation during the post-training period. Sec-ond, the observed decrease in early neonatal mortality in the Tanzanian study, where education was focused on the traditional birth attendants rather than physicians, with repeated expo-sure to the intervention over a 2-year period, and where over 78 000 births were evaluated, suggests that the HBB program may well result in a sub-stantial improvement in NMR when

implemented in large populations and aimed at primary birth attendants. The Tanzanian study does not report the more conventional 28-day NMR, perhaps because of the difficulties in-volved with obtaining reliable follow-up in these populations, where the moth-ers and infants are often available to the investigators for only a few hours after birth. UNICEF has estimated that a child is “about 500 times” more likely to die in thefirst day after birth than at 1 month of age,8so the“early NMR”reported in the Tanzanian study likely provides a reasonable reflection of trends in a country’s 28-day NMR and even its 1-year infant mortality rate. Third, both studies were con-ducted in the environment of hos-pitals, presumably because of the controlled environment and inability to collect reliable data in the more common birthing environment of the home or rural clinic. However, if the Tanzanian study design of focusing repeated exposure of HBB to primary birth attendants can be replicated in rural traditional birthing settings, where training is currently often non-existent, the impact on FSB and NMR would likely be even greater than ob-served in these hospital-based studies.

With the identification of a promising intervention, those in a position to provide the resources have recognized the need, including private and in-ternational organizations, such as the US Agency for International Develop-ment, Save the Children, the Laerdal Foundation, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The United Nations Millennium Summit of 2000 had recently defined targets for suc-cess: the Millennium Development Goals.

Now that we have a tool that seems to work, the next step is to get the job done.

FIGURE 1

Infant mortality. From: United Nations. Department of Economic and Scientific Affairs, Populations Division. 2011. World Population Prospects: The 2010 Revision. CD-ROM Edition.

e580 KATTWINKEL

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REFERENCES

1. Goudar SS, Somannavar MS, Clark R, et al. Stillbirth and newborn mortality in India after Helping Babies Breathe training. Pedi-atrics. 2013;131(2)

2. Msemo G, Massawe A, Mmbando D, et al. Newborn mortality and fresh stillbirth rates in Tanzania after Helping Babies Breathe training.Pediatrics. 2013;131(2)

3. Mwaniki MK, Atieno M, Lawn JE, Newton CR. Long-term neurodevelopmental outcomes

after intrauterine and neonatal insults: a sys-tematic review. Lancet. 2012;379(9814):445– 452

4. Carlo WA, Goudar SS, Jehan I, et al; First Breath Study Group. Newborn-care training and perinatal mortality in developing coun-tries.N Engl J Med. 2010;362(7):614–623 5. Olson KR, Caldwell A, Nelson BD.

Newborn-care training in developing countries.N Engl J Med. 2010;362(25):2427–2428

6. Perlman JM, Risser R. Cardiopulmonary re-suscitation in the delivery room. Associated clinical events.Arch Pediatr Adolesc Med. 1995;149(1):20–25

7. Spector JM, Daga S. Preventing those so-called stillbirths. Bull World Health Organ. 2008;86(4):315–316

8. UNICEF. Maternal and newborn health. Available at: www.unicef.org/health/index_ maternalhealth.html. Accessed October 15, 2012

COMMENTARY

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DOI: 10.1542/peds.2012-3171 originally published online January 21, 2013;

2013;131;e579

Pediatrics

John Kattwinkel

Addressing High Infant Mortality in the Developing World: A Glimmer of Hope

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DOI: 10.1542/peds.2012-3171 originally published online January 21, 2013;

2013;131;e579

Pediatrics

John Kattwinkel

Addressing High Infant Mortality in the Developing World: A Glimmer of Hope

http://pediatrics.aappublications.org/content/131/2/e579

located on the World Wide Web at:

The online version of this article, along with updated information and services, is

by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2013 has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

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Figure

FIGURE 1

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