program of newborn resuscitation skills training, mentored scale-up, and on-going facility support. Program design In April 2018, the two-day HBBTOT course was attended by 46 trainers representing the 18 facilities in the study cohort. The training was held under NHTC direction and supervision. The 46 trainers included 35 (76%) nurses, 28 (61%) who had worked in their facility for more than 5 years, and 19 (42%) who worked in large urban hospitals. Twenty-four (53%) indicated they personally attended up to 25 deliveries in an average month. Forty-two (93%) trainers indicated they resuscitated babies with a bag and mask as part of their current job. The HBB TOT was facilitated by eight experienced Nepali trainers and two U.S. trainers. SSN and LDSC provided the 46 new trainers with instructional morbidity and mortality in Nepal [3-6]. The Nepalese Ministry of Health and Population (MOHP) was an early adopter of programs to improve neonatal resuscitation in response to perinatal asphyxia, including the training of Female Community Health Volunteers (FCHV) in 2004 [7]. At that time the FCHV were supplied with bag and masks to support ventilation in order to address the burden of asphyxia. However, this intervention was not sustained. In 2015, the Helping Babies Breathe (HBB) training curriculum, produced by the American Academy of Pediatrics, was incorporated into in-service training packages launched by the Child Health Division of the Ministry of Health and Population. An abbreviated form of HBB was specifically included in the Skill Birth Attendant in-service training package, and HBB training was encouraged in other settings. This decision was based upon, in part, the very successful pilot of HBB in Nepal in 2013 [8]. Multiple studies, including two systematic reviews, have documented HBB as an effective tool for reducing newborn morbidity and mortality, and reducing stillbirths [8-12]. The dissemination of improved resuscitation techniques using HBB has been supported by multiple child health partners in Nepal. UNICEF upgraded the resuscitation capacity in a portfolio of large hospitals during two clinical trials [13,14]. Safa Sanaulo Nepal (SSN), founded by the late Rakesh Hamal and supported by Latter-day Saint Charities (LDSC), has sponsored multiple HBB training-of-trainer (TOT) courses in all seven Nepal provinces since 2014. The National Health Training Center (NHTC), a branch of the MOHP, is responsible for disseminating approved in-service provider training at its centers throughout the country. NHTC has orchestrated HBB training in collaboration with LDSC and others [15]. HBB follow-up studies have shown a decline in knowledge and skills over time [16-19]. Thus, a major challenge in both clinical trials and implementation/ dissemination efforts around newborn resuscitation has been maintaining resuscitation skills over time. This dilemma has affected western Nepal as well as other regions and countries. The eight largest facilities in this program had previously received training in HBB but had failed to scale up and/or perpetuate the knowledge and skills of newborn resuscitation. There is now a robust evidence base for effective tools to sustain the skills of resuscitation, including clinical trials conducted in Nepal [6,13,17,19,20-23]. These have provided guidance regarding the elements needed to both improve and retain resuscitation skills. Sustainable change is further augmented by cost-effective strategies that include minimal data gathering and analysis. While well-funded, short-term clinical studies have produced important evidence for sustainable change, relatively little has been published DOI: 10.23937/2469-5769/1510087 ISSN: 2469-5769 Naresh et al. Int J Pediatr Res 2022, 8:087 • Page 3 of 9 • In the tertiary level facilities, monthly facilitylevel data were derived from the health information department, which tabulated and reported MOHPmandated metrics. In smaller facilities, the program coordinator gathered data from registers or logs maintained in the labor room and in the maternity ward. Patient’s personal data, such as demographic data, were not collected. In all facilities, data was customarily curated and reported by the month and year of the Nepali calendar. Data was collected from the Nepali month and year of Chaitra 2074 to Chaitra 2076, for a total of 25 Nepali months. Trends were assessed over the entire 25-month period. To better understand improvements in care, the initial three months of data were compared with the final three months of data. The initial three months of Ashad, Shrawan, and Bhadra 2075 included one month before training began and the first two months after the training of trainers, during which time scale-up was beginning. The final three months of Poush, Magh, and Falgun 2076 comprised the time in which the training had previously been scaled up, with mentoring and supportive mechanisms well established. Data analysis The monthly scale-up and supportive supervision parameters were generally qualitative in nature, with a descriptive summary provided below. Facility-level metrics were analyzed, including the total number of deliveries, Caesarian sections, neonatal deaths less than 24 hours, intrapartum still births, and sick newborns transferred or discharged. The beginning measurements were the sum of these data for the initial