source are credited. Open Access ISSN: 2469-5769 Naresh et al. Int J Pediatr Res 2022, 8:087 • Page 1 of 9 • Newborn Resuscitation Scale Up and Retention Program Associated with Improved Neonatal Outcomes in Western Nepal Naresh Pratap KC1 , Ranjan Dhungana1 , Emily Gamboa2 , Siena F Davis2 , Michael K Visick3 and Robert B Clark, MD, MPH4* iD 1 Safa Sanaulo Nepal, Kathmandu, Nepal 2 Children’s Medical Mission, Salem, USA 3 University of Utah School of Medicine, Salt Lake City, USA 4 Brigham Young University, Provo, USA *Corresponding author: Robert B Clark, MD, MPH, Brigham Young University, Provo, Utah, USA Abstract Background: The adoption of the Helping Babies Breath (HBB) tool has improved the outcomes of neonatal resuscitation following intrapartum events. Perinatal asphyxia however remains a leading cause of neonatal morbidity and mortality in Nepal. HBB training has proven effective, but a major challenge is maintaining resuscitation skills over time. Safa Sanaulo Nepal (SSN) designed an evidence-based strategy for scaling up training and sustaining long-term retention. This paper describes the implementation of SSN’s model, and changes in newborn outcomes that occurred during the program. Methods and findings: The skills retention strategy relied on facility-based trainers to scale up and maintain resuscitation skills in 18 facilities in the area of Nepalgunj, Nepal. A single external mentor coached and assisted the facilitybased trainers, provided general support, and monitored progress. Prospective outcome monitoring tracked changes in health metrics for a period of 24 months (March 2018 to March 2020). During this time, 46 facility-based trainers taught resuscitation skills to 1,785 midwives, nurses, and physicians, and supported skill retention with limited data gathered on neonatal health outcomes of 49,809 vaginal deliveries and 12,823 Caesarean sections. To analyze changes over the time SSN’s program was implemented, a comparison of beginning (first three months of assessment) and follow-up (last three months) rates of neonatal mortality, morbidity, and stillbirths was conducted. The total number of births assessed in this comparison was 15,947. Results indicate mortality dropped 60% (p = 0.01), morbidity dropped 77% (p = 0.01), and intrapartum stillbirths dropped 73% (p = 0.001) from beginning to follow-up. Conclusions: SSN’s model provides a valuable example of how an evidence-based program focusing on facilitybased trainers, who are mentored and supported to scaleup and sustain resuscitation skills over time, may have a substantial influence on critical neonatal outcomes. This program demonstrated that capacity building required minimal external support and expense, with a single mentor mentoring, supporting, and monitoring 18 facilities. Future programs working to reduce neonatal mortality, morbidity, and intrapartum stillbirths may incorporate program elements to further improve neonatal outcomes. Original Article Check for updates Introduction The Millennium Development Goals (MDG) brought focus and resources to child and newborn outcomes worldwide. In Nepal, the three goals of MDG Target # 4 (Reducing Child Mortality) were met. However, while the under-5 mortality rate (U5MR) did decline, major inequalities persist in parts of Nepal [1]. The neonatal mortality rate (NMR) reduction did not decline as rapidly as the U5MR, causing the NMR to rise to 61% of the U5MR [2]. Intrapartum events leading to asphyxia around the time of birth continue to be a leading cause of neonatal DOI: 10.23937/2469-5769/1510087 ISSN: 2469-5769 Naresh et al. Int J Pediatr Res 2022, 8:087 • Page 2 of 9 • regarding low-cost approaches to skill retention appropriate for low-to-middle-income countries (LMIC) [24]. In contrast, collection and analysis of minimal, easily obtainable indicators may enhance sustainability by decreasing the necessary resource input. SSN designed a package centered on building and maintaining the capacity of facility-based trainers to sustain the skills required to manage newborn emergencies. The package had three fundamental goals: 1. Utilize evidence-based strategies for scaling up and supporting HBB 2. Implement a cost-effective program 3. Monitor the process with minimal indicators The purpose of this paper is to describe the two-year implementation of SSN’s package in western Nepal and report changes in newborn outcomes that occurred during the time of program implementation. Methods Setting Nepalgunj is the third largest city in Province 5 of Nepal. Provinces 5, 6, and 7 comprise much of the former Mid-Western and Far-Western regions of Nepal, regions where child mortality and morbidity have traditionally been the highest [25]. As a sub-metropolitan city in the Terai region, Nepalgunj is a medical referral center for the surrounding districts and home to regional, subregional, and private healthcare facilities. The Mid-Western and Far-Western Regions had been designated by NHTC as underserved by health services, with neonatal mortality above the national average. NHTC recommended specific facilities in these regions for support in training staff and increasing staff performance. Accordingly, a cross-section of both public and private facilities, including those with large delivery services, were invited to participate in a combined