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Partner Q&A: Dr Susan Niermeyer, International Pediatrics Association

The journey from Helping Babies Breathe and beyond 

Dr. Susan Niermeyer is a Professor Emerita of Pediatrics at the University of Colorado School of Medicine and a faculty member of the Colorado School of Public Health. She is a neonatologist with a special interest in newborn resuscitation and maternal and child health in resource-limited settings.   
Dr Niermeyer has been involved in the development and implementation of educational programs, such as Helping Babies Breathe (HBB), Helping Mothers Survive (HMS), and Essential Care for Every Baby (ECEB) and Essential Care for Small Babies (ECSB) that aim to improve the quality of care and outcomes for mothers and babies around the world.   
Here she shares her unique perspectives based on her extensive experience developing and implementing global programs.   
Can you describe why and how the Helping Babies Breathe program was first developed?  
Helping Babies Breathe was developed by the Global Implementation Task Force of the American Academy of Pediatrics. In the early 2000s it became evident that meeting the 2015 Millenium Development Goals would require new initiatives.  The AAP had experienced tremendous demand for its Neonatal Resuscitation Program outside the US, but there still was a gap in having basic resuscitation education reach outside major hospitals to every facility where births took place. HBB was designed to fill that gap, and it overturned the idea that neonatal resuscitation equated with intensive care.  Instead, HBB emphasized the fundamentals of thermal protection, help to breathe, delayed cord clamping, and early initiation of breastfeeding that are all truly lifesaving.  It made education accessible to all cadres of health workers who attend births and emphasized development of their skills (with the NeoNatalie simulator), not just knowledge.  A Global Development Alliance (GDA), a public-private partnership, powered the initial implementation of the program, but a key to its success was the immediate impact on skills and patient outcomes. It’s been implemented in more than 80 countries and used to train millions of health workers.  
Can you share your most memorable personal story about the impact of HBB? 
A moment that is etched in my memory took place in Rukunjiri, Uganda.  We had just done a facilitator course in HBB with midwives who previously completed Helping Mothers Survive Bleeding at Birth.  The new facilitators then returned to their regions to teach HBB with the mentorship of a faculty member. Monicah, a midwife in the Rukunjiri Health Center, was presenting the skills of The Golden Minute when one of her colleagues slipped out to attend the delivery of a woman who had been laboring overnight.  We heard her shout from the next room “Come quick, the baby is not breathing!”  The health center had no neonatal bags before, so Monicah took a bag from the workshop, I cleaned off the mask, and she began to ventilate the baby.  It was 15, then 30, then 45 seconds – and the baby cried and began to breathe!  All her midwife colleagues were watching, and in that instant they were transformed.  They understood the power of what they were learning.  
How did the introduction of simulation-based training change the way trainings were practiced and perceived?  
Simulation is key because many interventions in essential newborn care involve psychomotor skills and communication skills.  For resuscitation, timely action and teamwork also come into play. Active learning with the neonatal simulator, peer-to-peer learning (practice in pairs with feedback), and small group simulation were game-changers for participants accustomed to an hour lecture on neonatal resuscitation.  Participants actually commented that they came to a course expecting to sleep after a night shift but found themselves engaged and invigorated.  The affordable simulator also made it possible to continue practice after the formal course, an essential step to prevent skills decay. 
How has what you learned from HBB influenced the development of the suite of programs that has become Helping Mothers and Babies Survive?   
Some aspects of the educational design stand out as being especially important. The Action Plans were designed to be graphic and easy to understand and related all skills and knowledge to an evaluation/decision/action algorithm designed with robust logic. Visual learning was key. It used consistent color coding and layout across programs, icons to represent concepts, illustrations to make the invisible become visible, and videos to show physical signs and human interaction. The language and program structure were designed to be “as simple as possible but no simpler” to make learning accessible and efficient and to facilitate translation. The materials use active learning – doing, not just thinking or saying, for every skill or concept and stress the importance of contextualization – asking participants to relate learning to their own setting. 
What are some of the most important learnings from developing courses using the HMBS methodology, specifically?  
There has been a continual process of learning, which is not yet complete, but a few lessons stand out to me. First is that the workshop or course is only a first step – the real work continues after the educational session with continued practice and quality improvement activities to translate knowledge and skills into clinical care. Also, local ownership of educational programming allows for adaptation in some cases, but in almost all cases a sense of self-determination, control and empowerment that adds sustainability. We also learned that interprofessional education – including all cadres involved in care of the newborn/mother and all ranks from pre-service learner to most senior clinician (or even administrator) – is vital to putting education into practice. Facility-based education is not only cost-efficient, but essential to identifying gaps in care and designing quality improvement activities. And finally, I’d say that quality improvement is the true mechanism for creating and institutionalizing positive change.  This involves many aspects in addition to PDSA cycles – routine data collection of important indicators, debriefing after clinical events to identify systems issues, team simulation and debriefing to promote team function across the perinatal continuum.   

In your experience, how do we ensure skills transfer from training to clinical practice?  
A large number of users of Helping Babies Survive and Helping Mothers Survive programs employed the Utstein consensus process to distill 10 steps for successful implementation of perinatal education programs (Ersdal H, PLoS ONE 2017; 12(6):e0178073) 
Skills transfer from education to clinical practice depends on high coverage of all involved health workers, in-facility champions for education and improvement, administrative and budgetary support, ongoing active learning (practice), debriefing, case reviews and audits, and simulation.  It is essential that equipment and supplies be available to deliver the care learned in educational sessions. Data recording and use underpin not only daily clinical care, but also demonstrating the gaps and positive changes with quality improvement. 
What is the importance of building capacity of facilitators and mentors in simulation to achieve improved health outcomes?  
Simulation is one of the most powerful methods of preparing health workers, but it is also a relatively new skill for facilitators and mentors – both in pre-service and in-service education.  The HBS and HMS programs have introduced the concept of simulation, focusing on individual skills and decision-making, but tackling the issues in quality improvement that span across maternal (intrapartum) and neonatal care requires more sophisticated team simulation.  There is also an opportunity to use simulation in preparation for advanced care and to employ debriefing routinely after clinical events, not just in the educational setting. 
How important is collaboration with partners?  
As the proverb says, “If you want to go fast, go alone; if you want to go far, go together.”  Collaboration has value in itself; everyone feels better being a part of an initiative. Partners in the Global Development Alliance for HBB expressed many reasons why collaboration is a powerful strategy to accelerate dissemination and implementation of perinatal educational programs.  There is also supportive research:  Keenan WJ, Niermeyer S, af Ugglas A, et al. Helping Babies Breathe Global Development Alliance and the power of partnerships. Pediatrics 2020; 146(s2):e2020016915G.   
What are the most important elements of a good partnership?  
Shared vision and mission – cohesive, but not too broad. Complementary contributions, inlcuding time, talent and financial resources. Trust and frequent, open communication.

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