Digital Health Innovations, Tools, and Resources to Support Helping Babies Survive Programs
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Digital Health Innovations, Tools, and
Resources to Support Helping Babies
Survive Programs
Sherri L. Bucher, PhD, MA,a,b Peter Cardellichio, PhD,c Naomi Muinga, Msc,d Jackie K. Patterson, MD, MPH,e
Anu Thukral, MD, DM,f Ashok K. Deorari, MD,f Santorino Data, MBChB, MMed,g Rachel Umoren, MBChB, MS,h,i
Saptarshi Purkayastha, PhDj
The Helping Babies Survive (HBS) initiative features a suite of evidence-based curricula and abstract
simulation-based training programs designed to provide health workers in low- and middle-
income countries (LMICs) with the knowledge, skills, and competencies to prevent, recognize,
and manage leading causes of newborn morbidity and mortality. Global scale-up of HBS
initiatives has been rapid. As HBS initiatives rolled out across LMIC settings, numerous
bottlenecks, gaps, and barriers to the effective, consistent dissemination and implementation
of the programs, across both the pre- and in-service continuums, emerged. Within the first
decade of expansive scale-up of HBS programs, mobile phone ownership and access to cellular
networks have also concomitantly surged in LMICs. In this article, we describe a number of
HBS digital health innovations and resources that have been developed from 2010 to 2020 to
support education and training, data collection for monitoring and evaluation, clinical decision
support, and quality improvement. Helping Babies Survive partners and stakeholders can
potentially integrate the described digital tools with HBS dissemination and implementation
efforts in a myriad of ways to support low-dose high-frequency skills practice, in-person
refresher courses, continuing medical and nursing education, on-the-job training, or peer-to-
peer learning, and strengthen data collection for key newborn care and quality improvement
indicators and outcomes. Thoughtful integration of purpose-built digital health tools,
innovations, and resources may assist HBS practitioners to more effectively disseminate and
implement newborn care programs in LMICs, and facilitate progress toward the achievement
of Sustainable Development Goal health goals, targets, and objectives.
a
Division of Neonatal-Perinatal Medicine, Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana; bEck Institute for Global Health, University of Notre Dame,
Notre Dame, Indiana; cGlobal Health Media Project, Waitsfield, Vermont; dKenya Medical Research Institute Wellcome Trust Research Programme, Nairobi, Kenya; eDepartment of Pediatrics,
School of Medicine, University of North Carolina, Chapel Hill, North Carolina; fDepartment of Pediatrics, All India Institute of Medical Sciences, New Delhi, India; gDepartment of Pediatrics and
Child Health, Mbarara University of Science and Technology, Mbarara, Uganda; hDivision of Neonatology, Department of Pediatrics, School of Medicine, Seattle, Washington; iDepartment of
Global Health, School of Medicine, University of Washington, Seattle, Washington; and jDepartment of Data Science and Health Informatics, School of Informatics and Computing, Indiana
University–Purdue University Indianapolis, Indianapolis, Indiana
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PEDIATRICS Volume 146, number s2, October 2020:e2020016915I SUPPLEMENT ARTICLE
BACKGROUND AND SIGNIFICANCE to sustained translation of knowledge 53% of global citizens (4.021 billion)
and skills into clinical practice.15 Also, with access in 2018.32 Acceptance of,
History and Context of Helping Babies even when knowledge and skills are and access to, a wide variety of digital
Survive Programs
robustly acquired initially, if not health interventions has also
The Helping Babies Survive (HBS) supported by subsequent in-person skyrocketed, among a wide range of
initiative features a suite of refresher courses,16 peer learning, or stakeholders, including HCPs.33–38
evidence-based curricula and low-dose high-frequency training,17 Implementation of mobile health and
simulation-based training programs competencies rapidly decay over digital tools in LMICs has been
designed to provide health workers time.18,19 demonstrated to have numerous
in low- and middle-income countries benefits, including improving access
Another key challenge that emerged,
(LMICs) with the knowledge, skills,
as HBS programs rapidly scaled, was to care for patients,39,40 increasing
and competencies to prevent, knowledge retention and
reliance on paper-based methods
recognize, and manage leading competencies among community
for data collection and reporting. As
causes of newborn morbidity and
compared to digitized data health workers,41,42 and improving
mortality. HBS was built on the training outcomes, confidence and
collection systems, paper-based
success of its flagship program, satisfaction, and reporting of key
efforts are often plagued by a higher
Helping Babies Breathe (HBB), indicators among health
rate of data entry errors and are
a global initiative launched in 2010
difficult to search.20 Thus, although providers.35,43–46
to educate and train LMIC health
paper-based systems can be easy to
care providers (HCPs) in knowledge, Over the past decade, a number of
use for initial data collection, this
skills, and competencies for basic digital resources and innovations
can create bottlenecks in the
neonatal resuscitation.1–4 In addition have been developed to augment
subsequent collation and extraction
to HBB, HBS includes Essential Care HBS initiatives. Below, we describe
of crucial information, which, in
for Every Baby (ECEB),5 essential some of these. This article does not
turn, can then impede integrated
newborn care from birth through serve as an exhaustive systematic
and timely documentation efforts,
24 hours postnatal,6,7 and Essential review of all digital tools or
underlie time lags in reporting, and
Care for Small Babies (ECSB),8 educational repositories that have
hamper effective monitoring,
essential care for the small well been reported during 2010–2020.
evaluation, and QI efforts.21,22
infant.9 Rather, the interventions selected
Thoughtfully designed digital health
have been designed and developed
Dissemination and Implementation interventions may help to
in collaboration with partners of
Challenges ameliorate educational and training
the former Survive and Thrive
gaps, barriers, and bottlenecks
The scale-up of HBS programs has Global Development Alliance
identified within the HBS
been explosive; during the initial (2012–2017), 47 and as such, have
dissemination and implementation
5 years after the global launch, HBB received significant input from
cascade or that are created by
was disseminated in .80 countries, reliance on paper-based data
a broad coalition of local, national,
many at a national scale.10 As HBS collection systems.23–27
and international stakeholders for
initiatives rolled out across LMIC specific alignment with evidence-
settings, numerous bottlenecks, gaps, based HBS curriculum and training
and barriers to the effective, THE PROMISE OF DIGITAL HEALTH TO content. The featured digital
consistent dissemination and SUPPORT HBS resources and innovations are
implementation of the programs Within the first decade of expansive organized according to their
emerged. These educational, data scale-up of HBS programs, mobile primary function(s). Broadly, we
collection, and quality improvement phone ownership and access to describe HBS digital innovations
(QI) challenges were detected across cellular networks has concomitantly that support (1) education and
both the pre- and in-service surged in LMICs.28–31 In 2018, there training, (2) data collection for
continuums and emerged at multiple were 5.135 billion mobile phone monitoring and evaluation, (3)
points throughout the HBS training users, and two-thirds of the world’s clinical decision support, and (4)
cascade, including before, during, and population of 7.6 billion people QI. Some of the innovations
after training.11–13 For example, owned a mobile phone; half of these described in this article have
although HBS training is successful at devices were “smart” (ie, enabled multiple, overlapping functions
initially improving knowledge, skills, with Internet access, data storage, (Table 1). Additional digital
and competencies among HCPs,14 and other computing capabilities). health tools of potential interest
HBB 1-day training courses, on their Globally, Internet penetration also to HBS practitioners are shown
own, are often insufficient in leading continues to rise, with an estimated in Table 2.
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S166 BUCHER et al
TABLE 1 Digital Tools To Support HBS Programs
Digital Tool Developer Brief Description HBS Functions Web Site
Content
GHMP Video GHMP Live-action videos of evidence- HBB, Education and https://globalhealthmedia.org/
Repository based practices with patients ECEB, training
and HCPs in clinical settings in ESCB
LMICs
AIIMS ECEB app AIIMS Digital reference for ECEB ECEB Education and https://play.google.com/store/apps/
curriculum with scenarios for training; details?id=com.eceb
role playing and evaluation of clinical
knowledge through case decision
exercises support
AIIMS ECSB app AIIMS Digital reference for ECSB ECSB Education and https://play.google.com/store/apps/
curriculum with scenarios for training; details?id=com.ecsb
role playing and evaluation of clinical
knowledge through case decision
exercises support
LIFE (VR and mobile) KEMRI Oxford University Mobile VR simulation for neonatal HBB Education and https://play.google.com/store/apps/
resuscitation training details?id=uk.ac.ox.NDM.LIFE
eHBB VR and eHBB University of Washington and Mobile VR simulation for neonatal HBB Education and https://play.google.com/store/search?
mobile apps Oxford LIFE team resuscitation training q=ehbb
Liveborn Laerdal Global Health, UNC Audit-feedback app for observer HBB Data collection https://play.google.com/store/apps/
SOM documentation of timing of for details?id=com.
resuscitation actions; gives monitoring laerdalglobalhealth.
automated feedback that is and neobeatbirthregistration.
based on the HBB algorithm evaluation; QI newborn_ventilation_tool
mHBS-DHIS272,91,92,94: Indiana University School of Digitalized curricula, such as the HBB, Education and https://github.com/iupui-soic/mHBS_
Trainer module Medicine, IUPUI School of provider’s guide; access to ECEB, training tracker
Informatics and Computing, educational and VR training ECSB
Alupe University College, videos (ie, eHBB); linkage to
and Moi Teaching and partner Web sites
Referral Hospital
mHBS- Indiana University School of Digitized knowledge checks, BMV HBB, Data collection https://github.com/iupui-soic/dhis2-
DHIS271,73–75,93,94: Medicine, IUPUI School of and OSCE skills checklists, and ECEB, for android-trackercapture
Tracker module Informatics and Computing, QI tools such as delivery ECSB monitoring
Alupe University College, observation checklist, and and
and Moi Teaching and perinatal death audit; linkage to evaluation; QI
Referral Hospital partner apps (eg, AIIMS, Safe
Delivery, eHBB)
mHBS-DHIS295–97: Indiana University School of Support tool to track multiple ECEB Clinical decision —
ECEB Digital Action Medicine, IUPUI School of infants with automated advice support
Plan app Informatics and Computing, for management
Alupe University College,
and Moi Teaching and
Referral Hospital
BMV, bag mask ventilation; IUPUI, Indiana University–Purdue University Indianapolis; KEMRI, Kenya Medical Research Institute; —, not applicable.
EDUCATION AND TRAINING and health outcomes.48 The media are The videos, which are accessible
designed to be basic, practical, and across various modalities,
Global Health Media Project reliable. The content is distilled from demonstrate kind and respectful
Educational Video Repository
current international guidelines, and behavior and are carefully crafted to
Global Health Media Project (GHMP) is scripts and videos are rigorously draw a trainee’s eyes and ears to all
a US-based nonprofit founded in 2010 reviewed by global content experts the subtleties that lead to good
that has created a large digital with extensive experience in low- knowledge acquisition. Voice-over
repository of live-action videos to help resource settings. The videos are shot makes it easy to narrate the films in
health workers and caregivers in low- with in-service frontline health multiple languages. Using real HCPs
resource settings obtain information workers, exhibiting best practices with who role model best practices for
and skills that can improve health care patients in actual LMIC clinical settings. delivery of evidence-based health
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PEDIATRICS Volume 146, number s2, October 2020 S167
TABLE 2 Additional Digital Health Innovations of
Potential Interest to HBS Practitioners
Delivery room timer
In conjunction with a large global
implementation trial of HBB in Kenya and
India,3,4,116 Somannavar et al117 developed
and tested a voice-activated mobile
phone–based timer to be used during
deliveries for capture of time elapsed
between birth and beginning of bag mask
ventilation efforts in non-crying infants.
HBB Prompt
Investigators from North America and
Uganda are currently designing,
developing, and performing feasibility
testing in Uganda for an app, HBB Prompt,
to improve retention of HBB skills and
competencies.104
NeoTree
This is an mHealth tool that integrates
educational, data collection, and neonatal
care decision support functions to
improve the quality of care provided to
newborns in LMICs. The content is aligned
with HBS curricula. Usability testing was
conducted in Malawi.118
Safe Delivery app
The Safe Delivery app is a digital health tool
used to support acquisition of knowledge
and skills for basic emergency obstetric
and neonatal care; the guidelines for
FIGURE 1
AIIMS HBS-ECEB Android app (reproduced with the permission from A.D.). Screenshots from the
neonatal resuscitation align with
AIIMS HBS-ECEB Android app demonstrating the classify-the-infant function.
recommendations found in HBB, second
edition. Recommendations for labor,
delivery, and postpartum care harmonize nearly every country in the world and are aligned with existing versions of
with those found in the Helping Mothers
Survive curricula.43–45
streamed online .430 million times. the American Academy of Pediatrics’
Telehealth Available in .40 languages, they have (AAP) ECEB and ECSB programs.
Increasingly, Telehealth is being used for been downloaded by .7500 They support acquisition of
telementoring to foster north-south and organizations. Recently, GHMP knowledge among HCPs in regard to
south-south educational and training released the Birth & Beyond app, immediate care of the newborn after
relationships and to support virtual
learning within neonatal resuscitation
available on iOS; it allows 1-click birth and during the first day (HBS-
training programs,119 including HBB.120 access to their 28 videos that have ENC) and for well small infants (HBS-
been designed specifically for ECSB).
mothers and caregivers and are
The HBS-ENC can be paired with the
available in 21 languages.
ECEB curriculum as a ready digital
care aligns with adult-learning
The All India Institute of Medical reference for the action plan, which
principles for the development of
Sciences Essential Newborn Care highlights key steps in essential care
competencies through self-directed
and ECSB Apps and classification of the newborn.
learning.49,50
(Fig 1). The app also has case
Developed by collaborators at the All
exercises for paired practice by health
GHMP has created 150 videos that are India Institute of Medical Sciences
care workers that combine several
focused on maternal, newborn, and (AIIMS), the Helping Babies
actions with an objective to harness
child health. For HBS, there are 4 Survive–Essential Newborn Care
skills for each component of the
videos with live footage to (HBS-ENC) and Helping Babies
action plan.
complement HBB and 30 videos Survive–Essential Care for Small
closely aligned with ECEB, covering Babies (HBS-ECSB) apps are available The HBS-ECSB app is structured
newborn care skills, problems, and on Google Play and iOS; the Android similar to the HBS-ENC app, but the
breastfeeding.51 To support ECSB versions of HBS-ENC and HBS-ECSB content is based on the ECSB program
content, 27 videos are available.52 have been downloaded .5000 and (Fig 2).8 In addition to offering
GHMP videos have been watched in 1000 times, respectively. Both apps opportunities for self-directed
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S168 BUCHER et al
learning to serve as memory aides courses.53,54 Although these software entertainment. Through integration of
and tips for facility-based QI, both programs require a high-speed simulations, virtual environments,
apps also link to educational videos Internet connection and a personal and mixed reality and media, they
that are offered by a variety of computer with sufficient graphics provide educational and training
newborn care partners, including capabilities, mobile virtual opportunities through storytelling,
GHMP. HCPs may use the apps as simulations, such as Life-Saving narratives, and game-play
preparation for and during an initial Instruction for Emergencies (LIFE) encounters.58 There is evidence that
training workshop, as well as after (mobile) and the electronic Helping serious-game simulations result in
the completion of the course for self- Babies Breathe (eHBB) program (see a 20% higher post-training self-
directed knowledge refresher training descriptions below), can be delivered efficacy, 11% higher declarative
and as point-of-care tools at the off-line on mobile phones as screen- knowledge, 14% higher procedural
bedside. The apps guide activities that based experiences transformed into knowledge, and 9% higher
help providers maintain and improve immersive experiences with the use retention.59 Serious games and virtual
knowledge and skills through review of a low-cost virtual reality (VR) simulations are increasingly being
and practice. In addition, both apps headset.54 Game-based learning used to augment traditional methods
also incorporate QI functions. creates interconnections between the of neonatal resuscitation training and
off-line identity, the game scenarios, have particular potential to augment
and the actual interactions with and simulation-based medical and
VIRTUAL REALITY EDUCATION AND within the virtual simulation, nursing education.53,54,60,61 Mobile
TRAINING TOOLS allowing the learner to demonstrate VR simulations can be used to
In high-income countries, computer- skills and modify behaviors that demonstrate real-world phenomena,
based training simulations such as relate to clinical practice.55–57 illustrate abstract concepts, and
HeartCode Pediatric Advanced Life motivate learners.62 In a national
Support and the Neonatal “Serious games” are electronic games survey of 161 pediatric health care
Resuscitation Program eSIM or apps that are deliberatively workers in Nigeria, nearly all
programs complement in-person designed for learning as well as respondents (98% physicians [n =
FIGURE 2
AIIMS HBS-ECEB IOS app (reproduced with the permission from A.D.). Screenshots from the AIIMS HBS-ECEB iOS app: home screen, tabs to navigate
through content, “Essential care for every baby,” and prevention of disease.
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PEDIATRICS Volume 146, number s2, October 2020 S169
LIFE has partnered with the Kenya
Pediatric Association to offer
Continuing Professional Development
points to providers using the platform.
Additional training modules are being
developed, and user design and
evaluation research is currently being
conducted.70
eHBB
FIGURE 3 eHBB VR and mobile applications
LIFE screenshots (reproduced with permission from Dr Chris Paton, Oxford University). Screenshots feature 3 simulations that are based
from the LIFE VR serious gaming platform reveal interactive learning and labor and delivery room
screens.
on the HBB curriculum (second
edition) in which a newborn may
require only routine care, some
92] and 96% of nurses [n = 52]) headsets or mobile phones. The
resuscitation, or resuscitation with
would recommend the use of online scenarios hosted in the LIFE app,
positive-pressure ventilation (Fig 4).
simulation for their center.63 available on Google Play67 and iOS,
eHBB VR is designed primarily to
are based on the Emergency Triage,
work on low-cost mobile VR viewers
LIFE Assessment and Treatment plus
such as Google Cardboard. The focus
admission care program (ETAT1).68
LIFE is a platform that was developed in of the activity is to have the user
More than 5000 African health
a partnership between researchers in “show” what they would do for the
workers have received ETAT1
Kenya and the United Kingdom.64,65 It infant by interacting with the
training. The initial steps of ETAT1
hosts mobile and VR training scenarios three-dimensional objects in the
basic neonatal resuscitation training
that help health workers to learn the simulation and making selections by
are closely aligned with those of HBB;
steps they need to manage medical pressing a button-lever mechanism
also similar to HBB, ETAT1 training
emergencies. The LIFE platform on the outside of the headset or
among health workers is associated
employs the concept of serious games to by touching the screen. eHBB is
with reduced child mortality at
deliver training in a virtual environment designed to complement in-person
facilities where it is implemented.69
that follows highly structured care classes, promote individualized
pathways (or algorithms; Fig 3). learning, and provide standardized
LIFE (mobile) is a highly interactive
feedback that is based on the HBB
The LIFE platform is intended to three-dimensional mobile game,
Action Plan.
serve as a tool for neonatal currently being rolled out nationwide
resuscitation refresher training to in Kenya, in collaboration with the To develop eHBB, the eHBB research
prevent the documented decay in Kenya Pediatric Association. Using team, led by the University of
knowledge and skills that occur after LIFE (mobile), health workers can Washington, worked with the Oxford
initial skills acquisition.66 When access neonatal resuscitation training LIFE team to codesign scenarios with
subsequent face-to-face training modules off-line via their smartphones stakeholders representing a range of
courses are not accessible, LIFE offers whenever desired. To incentivize technical and clinical experience in
realistic simulation training via VR health workers to keep using the app, Nigeria and Kenya. The working
group used an agile, iterative
codesign and testing approach to
create VR scenario storyboards,
identify game actions and animations,
specify user prompts, and create
individualized feedback. Internal
testing during development was
performed by the project team at
several international sites: University
of Washington, Seattle, Washington;
Indiana University, Indianapolis,
FIGURE 4 Indiana; National Hospital Abuja,
eHBB screenshots (reproduced with permission from R.U.). A, eHBB mobile screen-based simulation. Abuja, Nigeria; and the Kenya Medical
B, eHBB mobile VR simulation. Research Institute, Nairobi, Kenya.
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S170 BUCHER et al
User feedback was also obtained
during demonstrations at several
national and international meetings.
Collaborating institutions for pilot
testing were the University of Lagos
(Nigeria) and Alupe University
College (Busia, Kenya). Mobile
eHBB VR training for retention of
neonatal resuscitation knowledge
and skills is being field tested in
a randomized controlled trial among
nurses and midwives in Nigeria and
Kenya.
EDUCATION, TRAINING, AND DATA
COLLECTION FOR MONITORING AND
EVALUATION: MOBILE HELPING BABIES
SURVIVE POWERED BY DISTRICT
HEALTH INFORMATION SYSTEM 2
The mobile Helping Babies Survive
powered by District Health
Information System 2 app (mHBS-
DHIS2) is an integrated suite of open-
source digital health tools to equip
HCPs with one-stop access to, and
linkage of, key resources and
functions that are of particular
importance to them in their
educational, training, and clinical
service trajectories.71–75 mHBS-
DHIS2 supports off-line mobile
phone- and tablet-based data
collection, education and training,
reporting, and QI functions, as well as
Web-based data visualization and
dashboards via individually owned or
shared (facility-based) Android
devices. Built within the District
Health Information System 2
platform,76 which is currently used in
.60 countries, including by many
ministries of health that have also
integrated HBB at the national
level,77–81 mHBS-DHIS2 is extremely
flexible and customizable; it is
purpose designed for rapid scale-up
and sustainability within the global
regions where neonatal mortality is
the highest,82,83 where HBS programs
FIGURE 5 have scaled, and where partners are
Screenshots of the mHBS-DHIS2 tracker (version 1.0.1, build 653). A, Enrollment of new participants
can be customized by geographic location, facility, and type of HBS program. B, Digitized data focused on achieving Sustainable
collection forms enable mobile devices to be used for monitoring, evaluating, and reporting of HBS Development Goals.19,79,84–89
educational and training outcomes; OSCE B is shown. C, Providers can self-report information that
may be useful for QI initiatives; the delivery observation checklist is shown. Screenshots were The methods used to develop the
reproduced with permission from S.L.B. BMV, bag mask ventilation. mHBS-DHIS2 app included a human-
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PEDIATRICS Volume 146, number s2, October 2020 S171
FIGURE 6
Screenshots from the mHBS-DHIS2 trainer app. A, The mHBS-DHIS2 trainer app, in addition to other Android-based educational, training, and data
collection apps, is accessed from links integrated in the mHBS-DHIS2 tracker app. B, From the mHBS-DHIS2 trainer home screen (left) users can navigate
to partner Web sites, educational videos, and digitized HBS materials, including action plans and provider’s guides (right). C, Users can navigate as
desired through the digitized HBB second edition provider’s guide. D, Web-based resources can be accessed from the mHBS-DHIS2 trainer app.
Screenshots were reproduced with permission from S.L.B.
centered design approach in compliant with the General Data credential. After logging on, users
conjunction with agile, iterative Protection Regulation (2016/679). toggle seamlessly between self-
development processes, heuristic directed learning (mHBS-DHIS2
evaluation,90 and extensive usability The mHBS-DHIS2 app is composed of trainer module) and data collection
testing, in conjunction with a suite of integrated digital modules and reporting or QI functions (mHBS-
international partners.91 All mHBS- (trainer and tracker). It is accessed DHSIS2 tracker module). Customized,
DHIS2 innovations are open source, via a single, customizable log-on permission-based access allows
and code is available on GitHub.92,93 screen using an assigned or self- various types and levels of users (eg,
The mHBS-DHIS2 privacy policy is selected username, pin code, or other country champions, district
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S172 BUCHER et alFIGURE 7
A, Screenshots from the ECEB Digital Action Plan; clinical decision support to guide essential newborn care. A, Customized log-on (left) and then register
and track multiple infants (right). B, Births are time stamped, and automated care reminders are generated. C, Requests for consultation are embedded
in the app (left); HCPs can track changes in infants’ health status over time (right). Screenshots were reproduced with permission from S.L.B.
managers, HBS master trainers or facility, and the HBS program in based educational, training, and
providers) to enroll and track which a health worker is participating implementation partner resources
participating health facilities and HBS (Fig 5A).93 (eg, AAP HBS site), educational
trainees or providers according to videos, and easily navigable digitized
geographic location (country, The mHBS-DHIS2 trainer module91 HBB second edition materials,
province, district), level of health provides linkage to digital and Web- including the action plan and
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PEDIATRICS Volume 146, number s2, October 2020 S173FIGURE 8
Screenshots from the Liveborn app. The Liveborn event registration screen allows an observer to document the timing of resuscitation actions and
breathing status of the newborn. The feedback screen depicts a time line of the resuscitation, highlights a gap in quality, provides an HBB recom-
mendation about how to improve care, and suggests a question for discussion. Screenshots were reproduced with permission from Laerdal Global Health
(https://laerdalglobalhealth.com/).
provider’s guide. Android-based the progression of learning, skills, and delivery and practice log to self-report
partner apps (eg, AIIMS apps, eHBB, competencies among trainees.94 (1) the number of deliveries and
Safe Delivery43) and online toolkits resuscitations they perform each shift
(eg, PATH) are seamlessly integrated In addition to digitized versions of the and (2) stillbirths, as well as (3) if they
with and accessible via the trainer HBB second edition multiple choice had an opportunity to engage in peer
module (Fig 6 A–D). In addition to questionnaire, bag-and-mask skills learning or skills practice. QI champions
using the mHBS-DHIS2 app for assessment (bag mask ventilation), can use the mHBS-DHIS2 app to follow-
educational and training functions, and Objective Structured Clinical up on reported resuscitations and
end users can easily and effectively Examinations (OSCEs) (Fig 5B), the perinatal deaths through use of the
capture a wide variety of key mHBS-DHIS2 tracker module includes resuscitation debriefing form and
monitoring and evaluation metrics, QI tools, such as the health facility site perinatal death audit.
indicators, and outcomes. Currently, visit, delivery observation checklist
a total of 12 HBB educational (Fig 5C), and HBB delivery and HBS program implementers and
evaluation, data collection, and practice log. The former is participants can use mHBS-DHIS2 in
reporting tools are available. Scoring a standardized tool used to rapidly various ways to support acquisition,
is automated, and “pass” or “fail” assess a facility’s readiness to provide retention, and evaluation of key
messages as well as guided debriefing basic neonatal resuscitation services. knowledge, skills, and competencies
sequences are fully customizable. The delivery observation checklist is at different time points throughout
After submission to the mHBS-DHIS2 used to assess HBB competencies the dissemination and
server, evaluation forms are no longer among HCPs during actual, observed implementation cascade. For example,
editable, providing a digital record of deliveries. HBB providers use the HBB facilitators or champions can use mHBS-
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S174 BUCHER et alDHIS2 to administer educational user (eg, birth weight, vital signs), the Liveborn is an audit-feedback mobile
evaluations and skills assessments to ECEB app automatically classifies health application for newborn
trainees before and after a course or each infant into green (normal), resuscitation designed by Laerdal
during QI exercises. HBS providers can yellow (problem), or red (high-risk) Global Health in partnership with the
use the app to evaluate one another zones and generates advice for University of North Carolina School of
during peer learning at a course or management. The app then Medicine (UNC SOM). Initially
subsequently as part of low-dose high- automatically tracks the infants’ developed as a data collection tool,
frequency training sessions after an in- health status over time, including the application has been adapted for
person workshop. their movement between ECEB zones. clinical use with the additions of
Requests for consultation or help a simplified documentation screen
Currently used as a research tool in
from on-call providers can be sent and automated feedback after
conjunction with partners from Alupe
directly from the app. a resuscitation. To date, Liveborn has
University College, Lagos University,
been used in the Democratic Republic
University of Washington, and Kenya The ECEB Digital Action Plan was of the Congo (DRC), Nepal, Norway,
Medical Research Institute/Oxford designed by an international team of and Tanzania to document .26 564
University (United Kingdom), mHBS- faculty, students, and clinicians, newborn resuscitations.98
DHIS2 is undergoing field testing including content experts and mobile
among HBB providers at 20 health app developers from Indiana Using Liveborn, an observer can
facilities in Kenya and Nigeria. After University School of Medicine, document the timing of resuscitation
completion of the study, mHBS-DHIS2 Indiana University–Purdue University actions using push buttons with HBB
will be available for free download School of Informatics and Computing, icons for dry or stimulate, skin-to-
from Google Play. Alupe University College, and Moi skin, clamp cord, suction, and
Teaching and Referral Hospital ventilate (Fig 8). The observer can
(Eldoret, Kenya). The also document when the infant begins
CLINICAL DECISION SUPPORT breathing and crying. Using Bluetooth
multidisciplinary team collaborated
The ECEB Digital Action Plan (Fig 7 over 10 months to design, develop, technology, Liveborn includes the
A–C) is a mobile phone–based clinical evaluate, and build a user interface option to stream heart rate from
decision support tool built to support prototype.95 Heuristic evaluation and NeoBeat, Laerdal’s battery-operated
nurses, midwives, and physicians in person-centered design assessments newborn heart rate meter. After the
LMICs to more effectively deliver key were conducted in Kenya among 40 resuscitation, providers can review
newborn care interventions from birth nurses and midwives from 3 a feedback screen that visually
through 24 hours postnatal and to equip facilities.96 The app, which works off- displays a time line of resuscitation
HCPs to prevent, recognize, and manage line, was awarded first prize in the events and the newborn’s breathing
common newborn complications as American Medical Informatics status and heart rate (if NeoBeat is
outlined in the AAP’s ECEB educational Association 2019 Student Design used). This screen includes an
and training curriculum. Challenge.97 It is anticipated to be observation about a gap in quality
available on Google Play in 2021. derived from an automatic
The ECEB app, which can be used as
comparison of recorded actions to the
a standalone app or as a module with
HBB algorithm. The observation is
mHBS-DHIS2, has numerous
QUALITY IMPROVEMENT accompanied by an HBB
functions, including allowing health
recommendation for how to improve
workers to simultaneously track Evaluation of resuscitation care in
care and a discussion question for
multiple infants across nursing shifts LMICs is challenged by poor
reflection. Data from multiple
and to quickly ascertain, in real time, documentation of delivery room
resuscitations can also be aggregated
the overall patient acuity in a facility’s practices. As such, these evaluations
through a Microsoft Power BI
newborn population (eg, number of are frequently limited to an
dashboard system to support facility-
“normal” versus “problem” versus assessment of delivery room
based QI activities. Liveborn is free of
“high-risk”). Births are time stamped, preparedness (availability of an HBB-
charge and publicly available on both
and automated, time-specific trained birth attendant and essential
Android and iOS platforms with
reminders for ECEB interventions are resuscitation equipment) rather than
English and French versions.
generated for each infant according to actions taken during a resuscitation.
the infant’s time of birth. There are Digital tools to document resuscitation Although publicly available, there is still
checklists that providers can use to actions in real time provide a unique uncertainty regarding how best to use
track the delivery of ECEB opportunity to enhance understanding Liveborn in the clinical setting. A team
interventions for each infant. On the of delivery room practices in LMICs of investigators from UNC SOM, the
basis of information entered by the and ultimately support QI. Kinshasa School of Public Health, and
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PEDIATRICS Volume 146, number s2, October 2020 S175Laerdal are evaluating usability, platforms may have the potential to Anushri S. Rajapuri, Radhika
feasibility, and acceptability of Liveborn address some of the gaps and barriers Ravindran, Kevin Horan, Kevin
in a pilot study in one health center in that have been identified in the Otieno, Janet Rukunga, Sammy
Kinshasa, DRC (University of North dissemination and implementation Barasa, Bonnie Munyalo, Geoffrey
Carolina Institutional Review Board cascade for HBS. Overcoming these Mwai, Mary Concepta Nafula, Annet
19–3479; DRC Institutional Review challenges might, in turn, augment Musale, Professor Fabian Esamai, and
Board 166/CNES/BN/PMMF/2020). global progress toward better the many nurses and nurse-midwives
Future directions for Liveborn include policies, outcomes, and clinical care who have graciously provided
audiovisual real-time feedback during for newborns in LMICs.106–108 invaluable feedback over the years.
a resuscitation when paired with
NeoBeat, as well as automation of data Stakeholders can potentially integrate
capture to eliminate the need for an digital innovations with HBS ABBREVIATIONS
observer. dissemination and implementation AAP: American Academy of
efforts in a myriad of ways. For example, Pediatrics
all of the digital tools described in this AIIMS: All India Institute for
CONCLUSIONS article could be potentially used in Medical Science
creative ways to support acquisition, DRC: Democratic Republic of the
The global community has 10 years to consolidation, and retention of
achieve Sustainable Development Congo
knowledge, skills, and performance ECEB: Essential Care for
Goals, including health target 3.2, to competencies for neonatal
reduce the overall global neonatal Every Baby
resuscitation,2,4,109 both during pre- ECSB: Essential Care for Small
mortality rate to 12 per 1000 live service and through integration into low-
births.99 HBS partners and related Babies
dose high-frequency skills practice, in- eHBB: electronic Helping Babies
collaboratives, such as the World person refresher courses, continuing
Health Organization’s Every Newborn Breathe
medical and/or nursing education, on- ETAT1: Emergency Triage,
Action Plan and Quality, Equity, the-job training, or peer-to-peer learning
Dignity Network, are striving to Assessment and Treatment
among in-service providers.2,4,109,110 The plus admission care
achieve this ambitious goal. To be quality of newborn care is also often
successful, there is a critical need to program
impacted by high rates of staff turnover GHMP: Global Health Media
substantially improve the quality of and chronic shortages of skilled nursing
health worker education and training Project
and physician cadres, as well as lack of HBB: Helping Babies Breathe
and delivery of newborn care for high-quality data regarding key
effective, high-impact interventions HBS: Helping Babies Survive
indicators and outcomes.111 Thus, any HBS-ECSB: Helping Babies
such as neonatal resuscitation, training and data collection efficiencies
essential newborn care, and care for Survive–Essential Care
that can be leveraged, via digital health for Small Babies
premature and small infants.19,84,85,100 interventions, to ameliorate these
Better tracking of high-quality HBS-ENC: Helping Babies Survive–
challenges and strengthen health Essential Newborn Care
neonatal data and key indicators is systems112 are potentially of high
also urgently needed.79,101 HCP: health care providers
value.113–115 LIFE: Life-Saving Instruction for
Over the past decade, a number of Emergencies
mobile phone app and digital health LMIC: low- and middle-income
innovations have been developed to ACKNOWLEDGMENTS
country
support education and training, data We thank the many student and mHBS-DHIS2: mobile Helping
collection for monitoring and Kenyan collaborators who have Babies Survive
evaluation, clinical decision support, contributed to the mHBS-DHIS2 and powered by District
and QI for HBS programs. Additional ECEB Digital Action Plan design, Health Information
data are needed regarding the development, usability testing, and System 2
efficacy, cost, and impact of each of evaluation from 2012 to 2020, OSCE: Objective Structured Clinical
these apps as standalone tools and as including M.T. Imran Chowdhury, Examination
bundled innovations, where Bhavani Singh Agnikula Kshatriya, QI: quality improvement
applicable.102,103 A number of trials Prem Chand Avanigadda, Siva UNC SOM: University of North
are currently underway.98,104 If Addepally, Elisabeth Meyers (in Carolina School of
shown to be effective, and if adopted memoriam), Taylor Childers, Medicine
and scaled, particularly as integrated Olakunle Olardiran, Siddhartha VR: virtual reality
interventions,105 digital tools and Nuthakki, Chinazom Chukwuemeka,
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S176 BUCHER et alDr Bucher conceptualized and designed the review, drafted the initial manuscript, coauthored the sections on mobile Helping Babies Survive powered by the
District Health Information System 2 (mHBS-DHIS2), was the primary author for the section regarding the Essential Care for Every Baby Digital Action Plan, and
created the mHBS-DHIS2 and mobile Helping Babies Survive–Essential Care for Every Baby figures; Dr Cardellichio was the primary author for the section regarding
Global Health Media Project; Ms Muinga was the primary author for the section regarding the Life-Saving Instruction for Emergencies platform and created the Life-
Saving Instruction for Emergencies figure; Dr Patterson was the primary author for the section regarding Liveborn, created the Liveborn figure, and developed
Table 1; Drs Thukral and Deorari were the primary authors for the section regarding the All India Institute for Medical Science apps and created the All India
Institute for Medical Science app figures; Dr Umoren was the primary author for the section regarding electronic Helping Babies Breathe and created the electronic
Helping Babies Breathe figure; Dr Purkayastha coauthored the sections on mHBS-DHIS2 and cocreated the mHBS-DHIS2 figures; and all authors reviewed and
revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.
DOI: https://doi.org/10.1542/peds.2020-016915I
Accepted for publication Aug 4, 2020
Address correspondence to Sherri L. Bucher, PhD, MA, Division of Neonatal-Perinatal Medicine, Department of Pediatrics, School of Medicine, Indiana University,
1030 W Michigan St, Suite C4600, Indianapolis, IN 46202-5119. E-mail: shbucher@iu.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2020 by the American Academy of Pediatrics
FINANCIAL DISCLOSURES: Support for the development of Global Health Media Project videos related to Helping Babies Survive programs was provided by the
Laerdal Foundation, Latter-day Saint Charities, Vitol Foundation, and Save the Children Federation. Life-Saving Instruction for Emergencies design and development
funding was provided through a crowdfunding initiative by the University of Oxford and the Saving Lives at Birth seed funds (round 6). Support for the development
of electronic Helping Babies Breathe and electronic Helping Babies Breathe 1 mobile Helping Babies Survive powered by the District Health Information System 2
(mHBS-DHIS2) field testing activities was provided by Bill and Melinda Gates Foundation to the University of Washington (Dr Umoren; OPP1169873). Development and
proof-of-concept funding for mHBS-DHIS2 was provided, in part, to Dr Bucher by the Laerdal Foundation for Acute Medicine (2012–2014); contextual analysis
(2015–2016) by Johnson & Johnson corporate giving (4581903); and Indiana University–Purdue University Indianapolis Center for Teaching and Learning,
Multidisciplinary Undergraduate Research Institute (summer 2017; academic year 2017–2018). Essential Care for Every Baby Digital Action Plan app development
and additional mHBS-DHIS2 server hosting were supported by Indiana University School of Medicine (Bucher) and Indiana University–Purdue University Indianapolis
School of Informatics and Computing (Dr Purkayastha). Dr Santorino Data received funding from Grand Challenges Canada for the development and testing of the
Helping Babies Breathe Prompt application; support for development and b-testing of Liveborn was provided, in part, by a University of North Carolina Junior
Faculty Development Award to Dr Patterson; the authors have indicated they have no other financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: Dr Bucher is principal investigator (PI) of mobile Helping Babies Survive (HBS) powered by the District Health Information
System 2 and Essential Care for Every Baby Digital Action Plan initiatives. She was the co-PI for the electronic Helping Babies Breathe (HBB) project, in collaboration
with Dr Umoren. She serves as an international mentor, on behalf of the American Academy of Pediatrics, for HBS programs, and as the HBS country mentor for
Kenya and Liberia. Dr Cardellichio is the associate director of Global Health Media Project. Ms Muinga is a health informatics researcher based at Kenya Medical
Research Institute Wellcome Trust Programme for the Life-Saving Instruction for Emergencies initiative. Dr Patterson is the PI for the feedback and debriefing
portions of Liveborn and the ongoing b-testing of Liveborn. Dr Thukral and Prof Deorari serve as associate professor in the department of pediatrics and professor
and head of the department of pediatrics at All India Institute for Medical Science, New Delhi; Prof Deorari serves on the HBS Planning Group. Dr Santorino Data is
the PI and colead designer for the HBB Prompt app. Dr Umoren was lead PI for the electronic HBB project. Dr Saptarshi Purkayastha is co-PI of the HBS powered by
the District Health Information System 2 and Essential Care for Every Baby app projects. The authors have indicated they have no other potential conflicts of interest
to disclose
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