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
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.

 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
Digital Health Innovations, Tools, and Resources to Support Helping Babies Survive Programs
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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TABLE 1 Digital Tools To Support HBS Programs
 Digital Tool                          Developer                         Brief Description                HBS           Functions                      Web Site
 GHMP Video                 GHMP                       Live-action videos of evidence-                  HBB,        Education and
   Repository                                             based practices with patients                   ECEB,       training
                                                          and HCPs in clinical settings in                ESCB
 AIIMS ECEB app          AIIMS                         Digital reference for ECEB                       ECEB        Education and
                                                          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
                                                          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
                                                          resuscitation                                               training              details?
 eHBB VR and eHBB        University of Washington and Mobile VR simulation for neonatal                 HBB         Education and
    mobile apps             Oxford LIFE team              resuscitation                                               training                           q=ehbb
 Liveborn                Laerdal Global Health, UNC    Audit-feedback app for observer                  HBB         Data collection
                            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
    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
    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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Digital Health Innovations, Tools, and Resources to Support Helping Babies Survive Programs
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
    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.
                                                                                                       (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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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 =

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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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

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
                                                                                                    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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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

                                                                                                      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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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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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                                                                                                       S173
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

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 al
DHIS2 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                                                                                           S175
Laerdal 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
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 al
Dr 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.
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:
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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