Knowledge, skills and competency retention among health workers one year after completing helping babies breathe training in South Sudan

Of the 200,000 children born annually in South Sudan, an estimated 40% die in the first month of life [1]. Newborn mortality accounts for 39% of all under-five deaths in South Sudan. Over the last decade, the decline in the newborn mortality rate in South Sudan has been slower than the global average [2]. An estimated 136 million infants are born each year and this figure is expected to rise in the coming years. The highest risk of newborn mortality is present during the first day of life. Death during this period accounts for almost 5% of newborn deaths worldwide [3, 4]. Globally and in South Sudan, the main direct causes of newborn deaths are usually infection-related complications (26%); intrapartum complications (24%), including birth asphyxia; preterm delivery (34%) and congenital abnormalities (9%). In South Sudan, 20% of newborn deaths are associated with birth asphyxia [5, 6]. The transition from intrauterine to extra uterine life requires the initiation of breathing, which is a critical physiological change required for newborn survival. Research has indicated that most newborns initiate breathing within 30 minutes, and an estimated 10% breathe when they receive drying and stimulation from health workers. Three percent of newborns require positive pressure (PPV) while another 2% need ventilation and intubation [7, 8]. Training health workers on effective and timely newborn resuscitation could reduce newborn asphyxia and improve survival rates. To address inadequate resuscitation training in health facilities in low-resource areas and improve neonatal outcomes, in 2010 the American Academy of Pediatrics developed a newborn-care training program for healthcare professionals called Helping Babies Breathe (HBB) [9]. The HBB curriculum is designed to train birth attendants in low-resource countries in neonatal resuscitation. It is evidence based and specifically geared toward reducing global neonatal mortality. HBB focuses on the essential steps of resuscitation, including the birth evaluation of the infant, breathing stimulation, and ventilation during the critical “golden minute” after birth [10]. The HBB curriculum promotes active learning and hands-on practice using newborn simulators, self-reflection, and group discussion and feedback after completing a task. It also focuses on paired learning, which is tested based on four formative assessments. Competence and performance can also be determined based on multiple-choice questionnaires, bag-mask ventilation (BMV) tests, and objective structural clinical examination consisting of sections A and B (OSCEA&B). Before its global launch, HBB curriculum assessment was modified based on the study of Singhal et al. on the educational evaluation of HBB assessment in Kenya and Pakistan. Further studies of HBB curriculum assessment in Africa and Asia using pre- and posttest scores showed significant gains in resuscitation knowledge and skills immediately after training [11, 12]. However, those studies did not conduct detailed examinations of learners' qualifications and the characteristics of their performance. Understanding learners' performance and competence could help refine the HBB curriculum to promote the retention of neonatal resuscitation knowledge and skills tailored to specific learners. Studies on the effectiveness of newborn resuscitation training programs have shown increased knowledge, skills, and competency after training, which was sometimes retained for one year. The evaluation of newborn resuscitation training has shown immediate increases in knowledge, practical skills, and competency, with improved newborn outcomes [13]. Nevertheless, there has been limited rigorous evaluation of the retention of knowledge, skills, and competency, and of subsequent newborn outcomes, in low-resource and post conflict settings, such as South Sudan. Training outcomes depend not only on the extent to which such knowledge and skills are retained but also on the ability to apply them at appropriate times. This depends on several factors, including conditions in the clinical environment, regular supervision, settings, practice opportunities, and the availability of supplies and appropriate equipment [14]. Providing appropriate training, offering refresher training and support, and ensuring good training environments facilitate long-term knowledge, skills, and competency retention among health workers in low-resource settings [14]. In South Sudan, nurses and midwives typically manage normal deliveries, and birth asphyxia is usually not recognized early enough. Due to critical shortages, medical doctors are usually not involved until the late stages of managing birth asphyxia, even in major hospital settings. The present study aimed to evaluate the retention of knowledge, skills, and competency among health workers and the effects on newborn mortality one year after implementation.