Dhungana, the field coordinator, are summarized in a letter dated 9/16/2020. Funding Safa Sanaulo received funding from Latter-day Saints Charities. LDSC had no role in data collection and analysis, decision to publish, or preparation of the manuscript. Volunteers for LDSC assisted SSN in the design of the scale-up/retention initiative. Conflict of Interests All authors report no outside financial relationships or conflicts of interest. RD and NP were full-time employees of SSN during the time of this initiative. References 1. Commission NP (2016) Nepal and the millennium development goals. Final status report, 2000-2015. Kathmandu, Nepal: Government of Nepal, National Planning Commission. 2. Knoema (2020) Nepal neonatal mortality rate, 1960-2018. 3. UNICEF (2016) Maternal and newborn health disparities country profiles - UNICEF data. 4. Kc A, Wrammert J, Ewald U, Clark RB, Gautam J, et al. (2016) Incidence of intrapartum stillbirth and associated risk factors in tertiary care setting of Nepal: A case-control study. Reprod Health 13: 103. 5. WHO (2019) Children: improving survival and well-being. 6. UNICEF (2021) Neonatal mortality - UNICEF Data. 7. Zulliger R (2018) Nepal’s frontline health workers. CHW Central. 8. Kc A, Wrammert J, Clark RB, Ewald U, Vitrakoti R, et al. mentored in the SSN program. UNICEF clinical trials, which included HBB refreshers, did include two of the regional facilities in the Nepalgunj area [14]. Individual hospitals, such as regional facilities, may have had other resources focusing on immediate newborn care. While the exact contribution of this HBB scale-up and support program to the marked improvements in neonatal outcomes is unknown, it may be significant. The continued scale-up of training, combined with persistent support focused on utilizing new skills coincided with steadily improving outcome measures. It is noteworthy that all three run charts showed worsening trends in Ashad 2076, consistent with the challenges of the major reassignments in healthcare personnel mentioned above (Personal communication, Ranjan Dhungana). Strengths of the program report include the number of deliveries assessed, the range of facilities included, generally HBB-naïve facility staff, the association between shifts in the run charts and external influences, the strong support to the program from facility administrators and NHTC, and the consistency of the mentoring and supportive activities. Newborn resuscitation training in general, and HBB training specifically, is not novel in Nepal. Of note is the finding that 93% of the trainers had previously used a bag and mask. The improvements associated with this program, despite prior training and experience, suggest that this approach may be appropriate for adaptation in other areas of Nepal. However, the degree of improvement may not be generalizable due to a variety of influences in other areas. This evidence-based model, which focused on building in-facility capacity, centered on supporting infacility trainers. External resources were minimal but dedicated to this effort. Data collected were consistent with governmental standards. The program thus leveraged available evidence, current systems, and MOHP goals into a lower-cost, longer-term sustainability program than prior models. Conclusion The implementation and retention of neonatal life-saving skills requires support and reinforcement over time. SSN organized and supervised a two-year evidence-based, low-cost program, centered on facilitybased trainer’s implementation of on-site HBB training, practice, and subsequent mentorship. This provides a valuable example of how facility-based trainers can have a substantial influence on critical neonatal outcomes. Furthermore, this program demonstrated that capacity building required minimal external support, with a single mentor supervising and monitoring quality enhancement in 18 facilities. Future research is needed to better define the sustainability of training by similar programs, strengthen the data capture of newborn parameters, DOI: 10.23937/2469-5769/1510087 ISSN: 2469-5769 Naresh et al. Int J Pediatr Res 2022, 8:087 • Page 9 of 9 • 20. Evans CL, Bazant E, Atukunda I, Williams E, Niermeyer S, et al. (2018) Peer-assisted learning after onsite, lowdose, high-frequency training and practice on simulators to prevent and treat postpartum hemorrhage and neonatal asphyxia: A pragmatic trial in 12 districts in Uganda. PLoS One 13: e0207909. 21. Mduma E, Kvaløy JT, Soreide E, Svensen E, Mdoe P, et al. (2019) Frequent refresher training on newborn resuscitation and potential impact on perinatal outcome over time in a rural Tanzanian hospital: An observational study. BMJ Open 9: e030572. 22. Reisman J, Arlington L, Jensen L, Louis H, Suarez-Rebling D, et al. (2016) Newborn resuscitation training in resourcelimited settings: A systematic literature review. Pediatrics 138: e20154490. 23. Thacker N, Clark R, Keenan W, et al. (2019) Nursing skill assessment for essential newborn care in one of the districts under helping babies survive pilot programme in India. Pediatric Academic Societies. 24. Wilson GM, Ame AM, Khatib MM, Khalfan BS, Thompson J, et al. (2020) Helping Babies Breathe (2nd edition) implementation on a shoestring budget in Zanzibar, Tanzania. Maternal Health Neonatol Perinatol 6: 3. 25. Singh S, Shrestha G, Joshi D, Gebreselassie T (2019)