Katherine Horan, MD

The group of new midwives yells out in perfect unison, “Ventiler! Ventiler! Ventiler!” That’s French for “Breathe! Breathe! Breathe!” and it is music to my ears. We have just completed a training session in newborn resuscitation at the Médecins Sans Frontières (MSF; Doctors Without Borders) clinic in Katiola, Côte d’Ivoire, Africa. Everyone is laughing and smiling and it looks like the core message has made an impact.

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	At the beginning of the course, I asked these midwives what the greatest danger was for a baby at the time of birth. “An infection.” “He could get too cold.” “If his mother dies, he can’t eat” were some of the responses. Although certainly valid concerns, particularly in rural Africa, the greatest threat to any baby is the same in South Sudan as it is in New York: a delay in effective breathing.

	The first breath is the single most important moment in anyone’s life. It is when life outside the womb truly begins, the moment that makes all other moments possible.

	I remember my first delivery room experience in medical school and the sense of awe that I felt at the sound of the baby’s first cry. Years of practice have done little to diminish the wonder and relief of witnessing a safe transition. Even the most experienced practitioner can appreciate the cascade of miraculous changes that occur in every part of the body.

	The oxygen from a baby’s first breath decreases pulmonary vascular resistance, allowing the lungs to open and expel amniotic fluid. Appropriate oxygenation in the first minutes of life stimulates brain, kidney, endocrine, and digestive function. The oxygen is even powerful enough to change the structure of the heart, closing the foramen ovale and ductus arteriosus. How amazing to think that so many complicated events are dependent on such a simple act. Conversely, how devastating to think that so many infants die needlessly because of the lack of proper ventilation.

	The past decade has seen a notable increase in interest and efforts to improve newborn resuscitation. The Helping Babies Breathe initiative, developed by the American Academy of Pediatrics (AAP) with an international team of collaborators, has played a major role in resuscitation training. The program is designed to train health providers in the critical concept of the “Golden Minute,” which involves helping a baby to start breathing within the first 60 seconds of life. The teaching mannequins, training modules, and resuscitation equipment are in use in dozens of countries around the world and have been adapted by numerous medical nongovernmental organizations (NGOs) including MSF. The equipment can be ordered at low cost and all education materials can be downloaded free of charge in multiple languages. It’s a great example of how simple, cost-effective initiatives are often the most successful.

	Despite this notable achievement, access to safe delivery globally remains a dismal reality. The World Health Organization estimates that of the 130 million babies born annually, roughly 20% (over 50% in certain regions) arrive without the presence of an appropriately skilled birth attendant. Nearly one-quarter of the 3 million annual neonatal deaths are caused by birth asphyxia, defined simply as the failure to initiate and sustain breathing at birth. Asphyxia along with prematurity and infection are the 3 main causes of global newborn mortality, and are all highly preventable and treatable.

	Neonatology has historically been seen as too difficult, high-tech, and costly to be delivered in conflict zones and low-resource settings, but things are finally changing. I believe, as does MSF, that healthy newborns are not a luxury. Active in over 70 countries, we have built dozens of neonatal intensive care units (NICUs) around the world and trained thousands of health workers in safe delivery and neonatal management practices. In 2015 we developed a highly effective neonatology field protocol, and we continue to make progress every day in caring for the world’s most vulnerable patients. Our actions align well with the United Nations-led Every Newborn coalition with a goal of significantly reducing preventable maternal and neonatal deaths.

	Our interventions are simple but highly effective. In addition to safe delivery room management and the early detection of danger signs, we focus on appropriate antibiotic and oxygen use, seizure control, thermoregulation, and proper feeding and fluid management. The foundation of our work is cultivating a well-trained, dedicated medical staff. The MSF Paediatric Working Group recently completed an intensive training course in neonatology for nurses and doctors that will be delivered in all the countries where we work to ensure high-level, evidence-based practices.

	The fundamental reason behind our efforts is simple and one that we shouldn’t have to defend: The babies deserve it. They deserve to be here. At the very least, they deserve to take their first breath.

	I can’t wait to see what we can accomplish in 2017 and beyond-one baby step at a time.

Articles

The first breath is the single most important moment in anyone’s life. It is when life outside the womb truly begins, the moment that makes all other moments possible.

Author | Katherine Horan, MD

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