title: Evaluation of Helping Babies Breathe Quality Improvement Cycle (HBB-QIC) on retention of neonatal resuscitation skills six months after training in Nepal.
abstract: Each year 700,000 infants die due to intrapartum-related complications. Implementation of Helping Babies Breathe (HBB)-a simplified neonatal resuscitation protocol in low-resource clinical settings has shown to reduce intrapartum stillbirths and first-day neonatal mortality. However, there is a lack of evidence on the effect of different HBB implementation strategies to improve and sustain the clinical competency of health workers on bag-and-mask ventilation. This study was conducted to evaluate the impact of multi-faceted implementation strategy for HBB, as a quality improvement cycle (HBB-QIC), on the retention of neonatal resuscitation skills in a tertiary hospital of Nepal.
  
  
  
  A time-series design was applied. The multi-faceted intervention for HBB-QIC included training, daily bag-and-mask skill checks, preparation for resuscitation before every birth, self-evaluation and peer review on neonatal resuscitation skills, and weekly review meetings. Knowledge and skills were assessed through questionnaires, skill checklists, and Objective Structured Clinical Examinations (OSCE) before implementation of the HBB-QIC, immediately after HBB training, and again at 6 months. Means were compared using paired t-tests, and associations between skill retention and HBB-QIC components were analyzed using logistic regression analysis.
  
  
  
  One hundred thirty seven health workers were enrolled in the study. Knowledge scores were higher immediately following the HBB training, 16.4 ± 1.4 compared to 12.8 ± 1.6 before (out of 17), and the knowledge was retained 6 months after the training (16.5 ± 1.1). Bag-and-mask skills improved immediately after the training and were retained 6 months after the training. The retention of bag-and-mask skills was associated with daily bag-and-mask skill checks, preparation for resuscitation before every birth, use of a self-evaluation checklist, and attendance at weekly review meetings. The implementation strategies with the highest association to skill retention were daily bag-and-mask skill checks (RR-5.1, 95% CI 1.9-13.5) and use of self-evaluation checklists after every delivery (RR-3.8, 95% CI 1.4-9.7).
  
  
  
  Health workers who practiced bag-and-mask skills, prepared for resuscitation before every birth, used self-evaluation checklists, and attended weekly review meetings were more likely to retain their neonatal resuscitation skills. Further studies are required to evaluate HBB-QIC in primary care settings, where the number of deliveries is gradually increasing.
  
  
  
  ISRCTN97846009 . Date of Registration- 15 August 2012.
authors.affiliation: International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden. aaashis7@yahoo.com.|United Nation's Children's Fund (UNICEF), Nepal Country Officer, UN House, Lalitpur, Nepal. aaashis7@yahoo.com.
authors.forename: Ashish
authors.initials: A
authors.lastname: Kc
authors.affiliation: International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
authors.forename: Johan
authors.initials: J
authors.lastname: Wrammert
authors.affiliation: International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
authors.forename: Viktoria
authors.initials: V
authors.lastname: Nelin
authors.affiliation: Latter-day Saint Charities, Salt Lake City, UT, USA.
authors.forename: Robert B
authors.initials: RB
authors.lastname: Clark
authors.affiliation: International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
authors.forename: Uwe
authors.initials: U
authors.lastname: Ewald
authors.affiliation: International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.|Global Health, Public Health Services, Karolinska Institute, Stockholm, Sweden.|School of Public Health, Makerere University, Kamala, Uganda.|Health Section, Programme Division, United Nations Children Fund (UNICEF), United Nations Plaza, New York, NY, 10017, USA.
authors.forename: Stefan
authors.initials: S
authors.lastname: Peterson
authors.affiliation: International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
authors.forename: Mats
authors.initials: M
authors.lastname: Målqvist
mesh_terms: D000328:Adult; D001238:Asphyxia Neonatorum / Q000628:therapy*; D002983:Clinical Competence; D004509:Education, Nursing, Continuing / Q000379:methods*; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D016015:Logistic Models; D017283:Neonatal Nursing / Q000193:education / Q000379:methods / Q000592:standards; D009390:Nepal; D009721:Nurse Midwives / Q000193:education / Q000592:standards; D018743:Perinatal Care / Q000379:methods / Q000592:standards*; D015397:Program Evaluation; D058996:Quality Improvement; D012151:Resuscitation / Q000193:education* / Q000295:instrumentation / Q000379:methods / Q000592:standards; D012153:Retention, Psychology; D012647:Self-Assessment
keywords: Helping babies breathe; Multi-faceted implementation strategy; Neonatal resuscitation; Nepal; Quality improvement cycle; Retention of skills