Background
The world has made remarkable progress over the past two decades in reducing child mortality, however, the pace was insufficient to universally achieve Millennium Development Goal 4, or the reduction of under-five mortality by two-thirds. Only about a third of countries, including Tanzania, was able to achieve this target [
1]. The decline in neonatal mortality has been slower than that of post-neonatal under-five mortality and has only dropped from 21 per 1000 to 20 per 1000 [
2]. To achieve the Sustainable Development Goal of reducing neonatal mortality to 12 per 1000 live births or lower, we must end preventable deaths. Birth asphyxia remains the leading cause of newborn mortality and accounts for nearly 900,000 neonatal deaths annually [
3].
Strengthening the capacity of health workers to provide newborn resuscitation is critical to reducing newborn deaths. In response to this challenge, the American Academy of Paediatrics and other partners developed the Helping Babies Breathe (HBB) curriculum [
4] to teach providers how to respond to asphyxiated newborns with life-saving measures. The HBB course utilizes simulation like many other life-saving skills courses [
5].
In addition to acquiring initial competency, retention of skills over time is extremely important. Retention of knowledge and clinical skills following training, however, has been reported as a challenge in most settings. In a systematic review of literature on newborn resuscitation trainings, up to 50% of studies analysed demonstrated significant performance decline over time [
6]. To improve birth asphyxia outcomes, studies of health care worker knowledge and skills following newborn resuscitation training indicate increased emphasis should be placed on health care workers’ self-efficacy and mastery of newborn resuscitation skills [
7]. It has been shown in similar studies that skills drops could happen as early as 12 weeks following training, suggesting that stand-alone training, without follow-up activities for trainees to practice learned skills, may not be adequate in resource-limited settings [
8,
9]. Some training programmes with no drop in skills were characterized by having structured follow-up activities to reinforce materials learned at primary training such as refresher trainings and mentoring [
6].
Tanzania has substantially reduced child mortality in the past 10 years, but most of the decline has come after the first month of life with neonatal mortality remaining largely unchanged. Each year, at least 51,000 Tanzanian newborns die, and an additional 43,000 babies are stillborn [
10]. The neonatal mortality rate in Tanzania remains high at 21 deaths per 1000 live births, with birth asphyxia being one of the leading causes, contributing to 31% of deaths [
11]. A 2009–2011 pilot study of HBB within eight healthcare facilities in Tanzania produced a 47% reduction in facility-based early neonatal mortality rate within 24 h of life [
12]. These results prompted the Tanzania Ministry of Health (MoH) to prioritize implementing HBB nationwide with support from the Children’s Investment Fund Foundation (London, UK).
The MoH and Jhpiego worked to rapidly implement a 3-year, capacity-building programme in newborn resuscitation. Programme data to measure providers’ retention of HBB skills was analysed to assess whether modifications to the training approach could enhance retention of newborn resuscitation skills in Tanzania.
Discussion
Participants trained in the initial and modified training approaches displayed similar acquisition of HBB skills, as shown by statistically equivalent scores immediately after training. Nurses/midwives and the cadre of other clinicians obtained higher scores compared to those of medical attendants. Skills were also generally higher for bulb suctioning and bag-mask ventilation and lower for tactile stimulation of the non-vigorous newborn.
In assessments conducted 4–6 weeks after training, skills drops were observed among participants in both training approaches, and this drop occurred in all three critical skills: bulb suctioning, stimulation, and bag-mask ventilation. Similar findings of fall off in skills over time have been seen in other studies [
6,
15]. Some studies have indicated that skills drops could happen as early as within 3 months following structured resuscitation trainings [
5,
7,
16]. Findings from this study add to evidence specifically from low- and middle-income countries that a significant fall off in skills can be identified even earlier after initial training -- within 4–6 weeks in both training approaches. A study from India and Kenya by Bang et al. [
17] reported on factors associated with loss of skills post-initial training to include providers from higher-level health facilities, having no prior resuscitation training, and timing of training. Of these factors, lack of prior training in newborn resuscitation could apply to our study since this was the first time HBB was being rolled out in intervention health facilities.
However, this natural fall off in provider-level skills can be effectively addressed. Follow-up OSCE scores in the modified training approach show improved skills retention among every healthcare cadre, with the most dramatic attenuation in skills drop occurring among medical attendants who were expected to have had less exposure to newborn resuscitation skills based on their regular roles compared to clinicians and midwives. This kind of improved performance across cadres after HBB training was reported in another study in Honduras [
18].
A systematic review showed that simulation and refresher training improve skills retention [
6]. This reveals that there are ways of making skills last longer with modification in training approaches. We hypothesize that the reduced skills drop in the modified training group was mainly due to the introduction of a modified training approach which included structured OJT tools and supervision. Another study in Honduras showed similar improved retention of skills from monthly practice [
19]. A study from India and Kenya demonstrated that providers could retain almost universal knowledge but not skills following an initial HBB training [
17], whereas providers could retain bag-and-mask skills 6 months after training by instituting follow on activities in Nepal [
20]. Accordingly, the structured guide was designed to reinforce self-directed, repetitive practice of HBB skills at the workplace. The OJT included clearly defined learning outcomes and directed providers to have regular practice of skills through simulation, which are other attributes that have been reported to facilitate learning [
5]. These factors were absent from the design of the initial training approach, which despite providing instructions for participants to continue practicing with simulation, lacked any structured tool to reinforce that behaviour. Our findings also support the importance of workplace-based practice, consistent with other published work [
6,
21] as well as repeated exposure to learning interventions to improve knowledge and skills retention [
22].
Previous studies have noted the challenges of linking skills demonstration with improved practice and clinical outcomes [
6,
9,
23]. Promisingly, some recent studies in Ghana show linkages between modified training approaches such as low-dose high frequency (LDH) and workplace-based simulation for improved skills retention and improved clinical outcomes including newborn death within 24 h and intrapartum stillbirth [
15,
20,
24,
25]. Such interventions are appropriate to low-resource settings being reported to be cost effective and presenting value for money [
26,
27]. The modified training approach that we studied has similar characteristics to those studies including the repetitive exposure to training, use of simulation, and being conducted at the workplace. Similar characteristics are emphasized in the second edition of HBB that reinforces learning through practice, fosters facilitator mentoring, and promotes quality improvement [
28]. Some elements that differ may represent missing pieces of the puzzle to ensure training programs that lead to better outcomes, such as training in a package of care rather than a single condition, and utilizing SMS for mentoring and making sustainability a core feature of the training approach [
29]. Additionally, strengthening timeliness, completeness and accuracy of data through training, supervision and mentorship is a critical element to better study the link between clinical training, application of practices and clinical outcomes.
Limitations
Inclusion of many participants from different regions is a major strength of this study but also may be a limitation. This is because the current study is based on the country-level implementation of HBB in Tanzania where health service organization and challenges may be different from other countries even within a similar income group. Therefore, the results should be considered in the context of a low-resource setting where large-scale training on newborn resuscitation had not previously been established. Since the initial and modified training approaches were implemented sequentially, the results may have been impacted by any interim events, however, we are not aware of any interim trainings or other potential confounders. Additionally, this study did not look at clinical outcomes due to data limitations (availability of timely, complete and accurate data). Lastly, data on skills retention are limited in this study to the follow-up period of 4–6 weeks.
Conclusion
This study demonstrates that retention of HBB skills can be significantly improved by including the contextually structured OJT tools in HBB program. This was particularly evident among medical attendants, who in many low- and middle-income countries are the only healthcare cadre present in lower-level health facilities. It will be useful to have study on further mastery of skills as well as retention beyond 4–6 weeks after training. Furthermore, additional studies to identify the optimal package of OJT such as which competencies to practice, for what duration, at what frequency, timing during the work day, mix of provider types to do OJT together, user-friendly tracking and reporting tools, as well as feasibility of implementing OJT as a routine approach can contribute to further increasing skills retention of providers performing this life-saving intervention.
Acknowledgements
We appreciate the collaboration with and hard work of the Reproductive and Child Health section of the MoH in rolling out HBB in Tanzania, the regional and district health officials, as well as all the health providers in the 16 regions where HBB has been scaled up in Tanzania at the time of this study. We would like to thank the Tanzania Jhpiego Newborn Resuscitation staff who participated in the HBB programme roll out, and the Harvard external evaluation team for their contributions.