Global evidence suggests that improving the quality of obstetric and newborn care can directly reduce
maternal and neonatal deaths. Helping Babies Breathe (HBB) is an educational program that teaches
essential neonatal resuscitation techniques to health workers in resource-limited areas.
The Malawi Ministry of Health (MOH), Reproductive Health Division (RHD), has been working with
partners since March 2011 to scale up the HBB approach nationally. Accurate and reliable data are needed on
the quality of the Helping Babies Breathe program and the resulting services offered in health facilities in
Malawi. With support from the United States Agency for International Development (USAID), and in
collaboration with the Malawi MOH, the Maternal and Child Health Integrated Program (MCHIP) and the
Support for Service Delivery Integration Program (SSDI) conducted a performance evaluation of the Helping
Babies Breathe program in Malawi.
The primary objective of the evaluation was to assess the quality of care and coverage of the HBB newborn
resuscitation intervention at the facility level in Malawi. The results of this evaluation will help to inform and
guide the ongoing scale-up of this program in Malawi and in other countries. A similar evaluation of the HBB
initiative in Bangladesh is currently under way and will complement impact evaluations being conducted by
the United States’ National Institute of Child Health and Human Development in India and Kenya.
The evaluation consisted of data collection at two points in time: the first round was in September 2012, after
the intervention had begun in 13 districts; and the second round was in September 2013, when the
intervention had been expanded to all districts in Malawi.
The methodological strength of this evaluation is that it employs direct observation of labor and delivery and
management of newborns who are not breathing at birth, complemented by data collected through
interviews, facility audits, and qualitative key informant interviews. Seven data collection tools were used to
gather data during health facility visits: (1) health worker interviews and knowledge assessments on essential
newborn care; (2 and 3) skills assessments of health providers using clinical simulations of newborn
resuscitation; (4) a structured clinical observation checklist for labor and delivery (L&D); (5) a structured
clinical observation checklist for the management of asphyxiated newborns; (6) in-depth interviews with key
stakeholders who either made or influenced policy decisions related to newborn health in Malawi; and
(7) a health facility supply and equipment inventory checklist.
The evaluation used a quasi-experimental design for the initial analysis of round 1, whereby 13 districts were
classified as “intervention” districts if they were part of the first phase of HBB scale-up in Malawi. The
remaining districts were classified as “comparison” districts. However, by the time of the round 2 data
collection, all districts in Malawi had been exposed to the HBB intervention. Thus, the final comparative
analysis of the round 1 and round 2 data used a dose-response analysis. For this analysis, districts were
classified into three dose-response groups based on their level of exposure to the different elements of the
HBB intervention—high, medium, and low dose—based on a score created by combining responses for
16 items related to health provider training, practice with the NeoNatalie anatomic model, supervision, and
availability of equipment and supplies for newborn care at facility level.