National Health Research Council, both of whom had oversight responsibilities for the program. The Nepal implementation staff was composed of the program coordinator in Nepalgunj and the SSN supervisor in Kathmandu. Only the program coordinator was engaged full-time. Results Scale-up and support The scale-up of training resulted in 1,785 providers receiving HBB training during the program. Approximately 29% of the healthcare personnel received HBB training in the first three months following the TOT while 3% received HBB training in the last three months. The new facility-based trainers, with the assistance of the program coordinator, cascaded the training in their facilities, trained new staff during the course of the program, and held refresher training sessions. At the conclusion of the program, all facilities reported practice corners that were equipped and utilized, held periodic review meetings, conducted selfevaluation surveys, and maintained both delivery and newborn logs. The 18 facilities in the program represented 6 different facility types: zonal hospital (2), regional hospital (3), district hospital (5), medical college (2), health posts (3), and primary health center (3) (Table 1). The urban zonal hospitals, regional hospitals, and medical colleges each accounted for about 25% of all deliveries, with the rural district hospitals, primary Table 1: Overview of metrics at beginning and follow-up. Metric Beginninga Follow-upb P-Value Sum (%) Sum (%) Total deliveries 8019 (100%) 7928 (100%) - Vaginal deliveries * a : Beginning was measured in Ashad, Shrawan & Bhadra 2075; b :Follow up measurements were collected Magh, Falgun, Chaitra 2076; * : Paired t-test results with significant p value. DOI: 10.23937/2469-5769/1510087 ISSN: 2469-5769 Naresh et al. Int J Pediatr Res 2022, 8:087 • Page 5 of 9 • Trends over time Neonatal deaths decreased from the beginning of the program. The average number of deaths in the first three months was 21, compared to 8 in the last three months. This equates to a reduction of approximately 60% (p = 0.01). In addition to the beginning-to-followup comparison, the trend over time in neonatal deaths is shown in Figure 1. The number of intrapartum stillbirths generally decreased over time, as shown in Figure 2. The average number of intrapartum stillbirths decreased by approximately 73% (p = 0.001), going from an average of 47 in the first 3 months to 13 in the last 3 months. Sick newborns transferred or discharged from the maternity unit was a proxy for all-cause newborn morbidity during the first days of life. Overall, morbidity decreased over time, as shown in Figure 3. The average number of sick newborns discharged in the first 3 months was reduced by 77% (p = 0.01), causing the mean average to drop from 402 in the first three months to 93 in the last three months. Discussion The implementation of the Millennium Development Goals, combined with numerous influential voices (including contributors to Lancet’s Newborn/Stillbirth series) appropriately refocused global attention on newborn outcomes in LMIC [26]. This newborn focus hastened the development of improved neonatal resuscitation training curricula, such as HBB, and accelerated their deployment. The Sustainable Development Goals continue to fuel this focus, with a neonatal mortality goal of 12 by 2030 [27]. HBB has been introduced, with variable scale-up, in over 90 countries. Over the last 11 years, the body of literature on the relationship between HBB and neonatal outcomes has grown considerably. HBB has been validated as effective in reducing both neonatal mortality at 24 hours and the burden of stillbirths. Mortality reductions result from the timely and competent resuscitation of severely depressed neonates. Stillbirth reductions result from the resuscitation of all nonmacerated “stillbirths,” of whom portions are actually severely depressed live births. Research has also demonstrated deterioration over time in the application and retention of new lifesaving skills [28-30]. To combat skill deterioration, the literature has provided evidence-based steps to retain skills and sustain improved newborn outcomes that are simple and effective. Scaling-up interventions at the population level is difficult, complex, and as in many disciplines, there is a significant gap between research and implementation [31,32]. Despite numerous research protocols utilizing Table 2: Key indicators by facility type. Facility Type Zonal Hospital Regional Hospital District Hospital Medical College Health Post Primary Health Center Total Count Percentage Count Percentage Count Percentage Count Percentage Count Percentage Count Percentage # of deliveries (except C/ • training to all newborn providers in a portfolio of 18 facilities and supported the application of improved resuscitation techniques for a period of two years. By the end of the program, all facilities were engaged in high-frequency, low-dose practice, held review meetings, conducted self-evaluation surveys, trained new staff, and held refresher training sessions. Both the scale-up and retention efforts confronted a variety of challenges during the program that varied significantly by facility, including differences in staffing HBB, only very few countries have scaled up HBB nationwide. This report describes one potential