model to obtain longer-term sustainability that is evidencebased, relatively low cost, and assesses limited indicators of progress. It is a model that contemplates population-level scale-up of HBB, to be modified or adjusted according to need, strengths, and challenges. Facilities in and around Nepalgunj, Nepal, were selected due to existing disparities in newborn health outcomes. This program successfully scaled up HBB Figure 1: Number of neonatal deaths less than 24 hours from birth. Figure 2: Number of intrapartum stillbirths. DOI: 10.23937/2469-5769/1510087 ISSN: 2469-5769 Naresh et al. Int J Pediatr Res 2022, 8:087 • Page 7 of 9 • As a scale-up and retention program, rather than a clinical study, there were several inherent limitations. First, demographic data of doctors, nurses, and patients were not collected. Second, there was no control group. Third, the introduction of metrics that were not routinely measured. Fourth, this program was neither intended nor designed to measure causality. This two-year program suggests that initiatives focused on applying and maintaining HBB skills were associated with sustained improvements in newborn outcomes. 24-hour mortality decreased 60%, morbidity fell 77%, and intrapartum stillbirths dropped 73%. While these results are encouraging, several factors may influence both the interpretation of results and the extrapolation of the results to other settings. The improved neonatal health outcomes reported here cannot be fully attributed to the HBB scale-up program as other concurrent training programs may have contributed to the improved outcomes. HBB training had been conducted at some of the facilities by NHTC and LDSC three years previously. However, the training coordinator reported that staff at all facilities was generally HBB-naïve, illustrating the need for better retention initiatives. The midwives, nurses, and physicians at the target hospitals may have received reinforcement of resuscitation training from other sources. Two inservice curricula, the Community-Based Integrated Management of Neonatal and Childhood Illness (CBIMNCI) and the Skilled Birth Attendant programs have been taught intermittently in the Nepalgunj area and contain components of HBB. However, these two curricula give minimal attention to resuscitation skill development and involved only a few, if any, of the staff ratios and turnover, staff acceptance of change, and facility readiness. The COVID-19 pandemic substantially disrupted all quality improvement efforts during the final months of the study [33]. The significant shifting of trained personnel to other hospital units resulted in the cessation of training, mentoring activities, and practice. Data collection was remote, delayed, with decreased validation of accuracy (Personal communication, Ranjan Dhungana). Prior to the pandemic, the human resource adjustments in Ashad to Shrawan 2076 due to MOHP reorganization resulted in similar disruptions and the influx of untrained, inexperienced staff as the trained staff was transferred to other hospitals and units. This affected the overall quality of newborn care and was associated with data collection challenges (Personal communication, Ranjan Dhungana). Throughout the program, the data collection process was not as straight forward as anticipated. Since all facilities report deaths to the MOHP, this metric was standard, tracked by the facilities, and less prone to error. Stillbirths were also tracked by most facilities prior to this program, but not always characterized by intrapartum vs. pre-admission. Accordingly, delivery logs were reviewed to obtain this information, which were influenced by intra-observer variability and bias in providers’ observations and documentation. Sick newborn transfer or discharge is a proxy indicator for significant all-cause morbidity, an underreported metric in the literature. This was not a standard metric tracked by facilities and necessitated a review of newborn logs to determine the number of sick infants transferred or discharged. Figure 3: Number of sick newborns transferred or discharged from the maternity unit. DOI: 10.23937/2469-5769/1510087 ISSN: 2469-5769 Naresh et al. Int J Pediatr Res 2022, 8:087 • Page 8 of 9 • measure quality gaps, and assess alternative low-cost, long-term mentoring approaches to sustainable change. Future programs working to reduce neonatal mortality, morbidity, and intrapartum stillbirths could build on the program strengths documented here to further improve neonatal outcomes. Acknowledgements We thank the late Rakesh Hamal, founder and director of Safa Sanaulo Nepal during this initiative, whose vision and leadership made this program possible. We are extremely grateful to the facility directors, administrators, matrons, nursing staff, and trainers for their front-line efforts to improve newborn care. The National Health Training Centers of Nepal deserve special recognition for their leadership in providing in-service education for providers across Nepal. The Nepal National Health Research Council provided an invaluable partnership with the facilities. Supporting Information All data underlying the findings reported herein will be available and on deposit with the Nepal National Health Research Council. Personal Communications from Ranjan