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Improving Neonatal Outcomes Through Global Professional Development

Riley, Cheryl, DNP, APRN, NNP-BC; Spies, Lori A., PhD, RN, NP-C; Prater, Lyn, PhD, RN, CNE; Garner, Shelby L., PhD, RN, CNE

Section Editor(s): Samra, Haifa A.

doi: 10.1097/ANC.0000000000000550
Professional Growth and Development

Background: Globally, stillbirths account for 2.7 million infant deaths each year, with the vast majority occurring in sub-Saharan Africa and South Asia. Approximately 900,000 infants die due to birth asphyxia. The focus of the Helping Babies Breathe (HBB) program is to help the nonbreathing infant to breathe within the first minute of life, termed the “Golden Minute.”

Purpose: To present a multinational interprofessional development program utilizing the train-the-trainer methodology for HBB to address neonatal morbidity and mortality. Involving nursing students in collaboration with established global partners provided an innovative method of professional development. Lessons learned and challenges will be shared to enhance success of future efforts.

Project Implementation: HBB train-the-trainer workshops were held to provide professional development for nurses and nursing students in 5 locations in 4 countries including Ethiopia, India, Vietnam, and Zambia. Workshop participants and the trainers participated in discussions and informal conversation to assess impact on professional development.

Results: HBB training and train-the-trainer workshops were implemented in 4 counties. Equipment and supplies were provided in these countries through several internal university grants. All 145 participants demonstrated increased knowledge and skills at the end of the workshops through the HBB check off. Collaborative teaching and cross-cultural professional skills were enhanced in student and faculty trainers.

Implications for Practice: Nurses, midwives, and advance practice nurses can engage globally and contribute to closing this gap in knowledge and skills by providing train-the-trainer workshops.

Implications for Research: Developing systems to integrate the HBB program within each country's existing healthcare infrastructure promotes in-country ownership. Joining the global effort to save the lives of neonates can be a meaningful opportunity for innovative professional development projects. While HBB education has been shown to save lives, a 1-time training is insufficient. Determining how often HBB updates or refreshers are required to maintain skills is an important next step. Another direction for research is to implement this project within prelicensure nursing programs.

Louise Herrington School of Nursing, Baylor University, Dallas, Texas.

Correspondence: Cheryl Riley, DNP, APRN, NNP-BC, Baylor University, Louise Herrington School of Nursing, 3700 Worth St, Dallas, TX 75246 (

This project was supported in part by two internal Baylor University Mission Research Grants.

The authors declare no conflicts of interest.

The goal of decreasing neonatal morbidity and mortality is shared by nurses globally. Developing and sharing our expertise can add a new dimension and value to our professional practice. Many neonatal deaths in low- and middle-income countries (LMICs) are due to the scarcity of nurses and trained healthcare workers. The authors share a commitment to improving population health by building capacity globally through education and clinical partnerships. The Helping Babies Breathe (HBB) program is a systematic intervention for neonatal asphyxia.1 Engaging in a proven and effective educational intervention in international settings helps develop and enhance the professional skills of both students and global healthcare workers. The HBB algorithm focuses on placing the infant skin to skin right after birth, rapid identification of the nonbreathing infant, stimulation if nonbreathing, and detailed instruction on how to ventilate with a bag and mask, if required, all within the first minute of life. In this article we present how a train-the-trainer model of HBB was initiated in 4 countries and used to foster professional growth and development.

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Globally, stillbirths account for approximately 2.7 million infant deaths each year, with the vast majority occurring in sub-Saharan Africa and South Asia.2 Of these deaths, 900,000 are due to birth asphyxia, which is defined as “failure to establish breathing at birth.”3–6 Neonatal mortality also accounts for an increased proportion of under-5 child mortality. The Neonatal Resuscitation Program (NRP) provides evidence-based training for both the normal newborn and the depressed or asphyxiated infant after delivery all within a specified time frame. The NRP is required for healthcare providers who take care of infants in hospital settings in the United States and in many other countries. There is clear evidence that improving neonatal resuscitation skills can decrease the rate of neonatal deaths from birth asphyxia.7 Both HBB and the NRP are based on the International Liaison Committee on Resuscitation guidelines.1 When compared with the HBB algorithm, the NRP algorithm has many steps that can be difficult for traditional birth attendants to follow such as frequent heart rate assessment, oxygen saturation monitoring, and intravenous medications. The NRP is difficult to implement in areas where there are limited resources and familiarity with the equipment. To help address this, the HBB program was developed for LMICs.1 The effectiveness of HBB in decreasing neonatal morbidity and mortality is supported in emerging research. Niermeyer3 conducted a review to explicate how HBB contributed to improvements in neonatal care at various levels in limited resource settings in rural Tanzania and Karnataka, India. Both neonatal death rates and fresh stillbirths were impacted in these 2 settings “by applying the action steps at all births, some infants previously misclassified as stillbirths (those who were literally ‘still at birth’ but had a heart rate) shifted into the category of live births and survivors.”3 (p306).

The HBB Global Development Alliance was created in response to the overwhelming infant mortality rate, especially in low-resource countries.8 The American Academy of Pediatrics, the United States Agency for International Development, Global Health, Save the Children, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development formed this alliance in 2010. Their goal was to improve: (1) the availability of high-quality, appropriate, and affordable resuscitation devices and training materials; (2) the resuscitation capabilities of birth attendants with emphasis on skilled birth attendants; (3) the supply chain logistics system for resuscitation devices; and (4) to evaluate the impact of resuscitation programs in populations.8

The focus of the program is to help the nonbreathing infant breathe within the “Golden Minute,” the first minute of life.8 This is accomplished by following the HBB algorithm. The first question after birth is, “Is the baby breathing or crying”? The answer to this question will guide the care from normal newborn care to resuscitation with a bag and mask. While HBB is easily taught, the adaptation in low-resource countries has been challenged by differences in language, infrastructure, and culture.9 Training healthcare providers is not successful unless they are able to translate the content into clinical practice and have the needed equipment. The Utstein formula of survival states that patient outcomes are a product of medical science, educational efficiency, and implementation.10 HBB is designed to translate knowledge into practice, improve the ability to implement knowledge, and evaluate the outcomes. Implementing these processes will begin to address the gap in care provided to infants in LMICs.10 Since the launch of HBB, over 400,000 healthcare providers in 77 countries have been trained and equipped to provide resuscitation. The implementation of the HBB program in Tanzania has resulted in a 47% reduction in early neonatal mortality and a 24% reduction in stillbirths.11 HBB uses low-fidelity simulation equipment as an efficient and affordable teaching and learning strategy.11 To provide equipment for each of the partner sites, a Baylor University Mission Grant was obtained. The HBB project was reviewed and determined to be exempt by the Baylor University Institutional Review Board.

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While the effectiveness of HBB is supported in the literature, there is an identified need for expanded community-level implementation.1 , 2 , 8 The project undertaken met this need while developing globally relevant lifesaving professional skills.

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Mezirow's Transformative Learning Theory

The conceptual framework used for the professional development of faculty and students was Mezirow's transformative learning theory.12 Facets of cultural humility theory were incorporated to focus on the inherent cultural aspects in global endeavors. Transformative learning theory was selected because it provides a way to consider the changes in cognitive and emotional learning relevant to both professional and student participants. The theory focuses on the frame of reference; that is, how faculty, students, and others understand experiences. The process, according to Mezirow, is to move a learner toward a more inclusive and self-reflective frame of reference.12 (p5) This translates well to those engaged in developing, implementing, and evaluating programs to improve population outcomes. Transformative theory can be encouraged through task-oriented or instrumental learning and in communicative learning that incorporates reflective practice.12 One participant stated, “This trip has taught me how similar we are as humans all over the world.”

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Cultural Humility

Cultural humility is a theory developed by Tervalon and Murray-Garcia13 that encourages the participant to be aware of one's own perspective. The emphasis is not on gaining expertise in a new culture; rather, it is accepting the parity of diverse ways of doing things and deep respect for the culture of the people with whom one interacts.13–15 Project participants were encouraged to cultivate an attitude of cultural humility to increase self-awareness and professional effectiveness. “It's amazing how many lessons God can teach you when you are thrown outside of your comfort zone,” stated a Baylor University student. Cultural humility and transformative learning theory were incorporated because they are consistent with the goal of acquiring and teaching new skills using a train-the-trainer model. “The nursing theory is a connector for nurses everywhere,” concluded another Baylor student.

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Evaluation Plan

The innovation approach provided Baylor University students and faculty opportunities for professional growth, as they learned the HBB program, how to teach cross-culturally, and applying several teaching strategies and simulation modalities. Four teams with 2 faculty and 6 to 10 students per team were trained using the HBB guidelines. The collaborative work in-country required close cross-cultural interaction. The transformational learning theory focuses on recognizing and critically considering one's own assumptions, an important component of cultural humility. Transformational learning theory is consistent with cultural humility, recognizing that knowledge alone without action has little value. The growth and development of students, faculty, and in-country partners was explored and evaluated through reflective practice that included journaling and student and faculty group debriefing and discussion.

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Simulation is an evidence-based teaching and learning pedagogy used to improve critical thinking and skill performance.16 The International Nursing Association for Clinical Simulation defines simulation as “An educational strategy in which a particular set of conditions are created or replicated to resemble authentic situations that are possible in real life.”17 The National League for Nursing Simulation Innovation Resource Center includes experiences “using partial task trainers or static mannequins to immerse students or professionals in a clinical situation or the practice of a specific skill” in its definition of low-fidelity simulation.18 HBB exemplifies a low-fidelity simulation program because it uses realistic low-fidelity neonatal simulators and neonatal simulation-based scenarios to practice skills and to deliver objective structured clinical examinations.1

In an age of increased use of high-fidelity simulation, low-fidelity simulation remains a popular and effective modality for health education.19–21 In a systematic review on simulation-based education in midwifery, Cooper et al19 reported that low-fidelity approaches to simulation were used in 10 of the 24 studies included in the review. Low-fidelity simulation, such as HBB, has also been shown to be a cost-effective method for improving health and health education outcomes in LMICs.20 , 21 In a study to increase the use of delayed cord clamping among midwives in Hyderabad, India, researchers found that nurses had a significant increase in both knowledge and positive perceptions of delayed cord clamping when using a low-fidelity birthing simulator.20 Vosslus et al21 compared neonatal mortality 1 year before and after low-fidelity simulation training in Tanzania. The findings suggested that a low-fidelity program was highly cost-effective and could be affordably implemented in LMICs.

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Effective professional collaboration often involves a team. An important aspect of team building is for the group to understand, believe in, and work toward a common goal.22 , 23 Building cohesive teams takes time: to know each other, trust each other, and learn from each other. Team meetings were held with Baylor University students and faculty monthly not only to learn how to teach HBB but to learn about the culture, appropriate dress, and topics such as food and water safety. Each team progressed through several stages of development achieving their best when there were openness, good communication, and trust.22 , 23 Didactic education, simulation, and role-play were all used during the train-the-trainer sessions. In addition, refreshers were done periodically prior to the trip and each team member chose a portion of the HBB program that they were responsible for teaching. A Baylor University Mission grant provided each team with equipment to use and to leave in each country so that the train-the-trainer model could continue to be taught and have supplies on-site when a nonbreathing infant needed to be resuscitated.

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The Baylor University Louise Herrington School of Nursing has a commitment to care for the underserved populations. Global partnerships have been established in multiple locations where Baylor University faculty and students have worked with professionals and students at hospitals, clinics, and universities. These relationships serve to build nurse capacity by fostering collaborative research efforts, strengthening faculty, and providing clinical updates.24 To help address the global concern of neonatal mortality, 3 faculty members from Baylor have obtained the Master Trainer designation in Helping Babies Survive that includes HBB, Essential Care for Every Baby, and Essential Care for Small Babies. The structured teaching uses a large flip chart with information for the instructor on one side and a corresponding culturally appropriate picture facing the workshop participants. An observed skills competency evaluation is part of the training. The participants receiving the training are divided into groups of 2 to 5 with an assigned facilitator (a team member). Active learning is encouraged by the use of role-play where each learner takes on the role of both the mother and the provider. As new concepts and skills are introduced, they are demonstrated by the trainer from the beginning and the learner return demonstrates each step from the beginning as well. This repetition increases learning and skill retention. There is a final skill checkoff for each participant with a timed resuscitation scenario with the goal of providing bag-and-mask ventilation within the first minute of life to the nonbreathing infant.

The training and education alone is insufficient, providing the tools needed for neonatal resuscitations are also critical for sustainability. The NeoNatalie is a low-cost, low-fidelity simulator that is effective for teaching newborn care and resuscitation skills. The heart rate and respiratory rate can be controlled for role-playing in relevant scenarios from normal newborn care to resuscitating an infant who is not breathing. This simulator is portable, inexpensive, and can be utilized in a variety of clinical/educational settings. Neonatal nurses interested in conducting an HBB workshop can get additional information from the AAP or Web sites. Globally, the Louise Herrington School of Nursing faculty and students have had a significant impact by employing low-fidelity simulation. While teaching HBB was the vehicle for professional development, the overarching purpose was to increase global connectedness, enhance student and colleague skills, and develop cultural humility. The following 4 countries were chosen to exemplify the implementation of HBB and are discussed here in detail.

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Ethiopia and Zambia

Low-fidelity simulation has been used to good effect during an international month-long clinical immersion course that was developed for graduate students in 2005. Since 2008, the primary destination for this course has been a rural clinic in Ethiopia. A mutually beneficial practice with our Ethiopian partners has been the implementation of community and clinical education led by Baylor graduate students. The topics are selected in consultation with our in-country hosts and have included a wide array of projects from community trachoma prevention initiatives to continuing education about breast cancer screening. In the spring of 2016, 2 Baylor faculty and 3 nurse practitioner students conducted HBB workshops in Ethiopia and Zambia.

In Ethiopia the neonatal mortality rate is 28/1000.25 Ethiopian providers made the students aware of the local resource constraints and the typical practice of tending to the mother before assessing the infant. The Baylor students agreed to provide HBB training workshops for all clinic staff including nonclinicians and the community health extension workers. See Figure 1.



The initial student-led workshops were in the Langano region of Ethiopia. They were provided twice with local nurses translating in both Amarharic and Oromo to facilitate full participation and understanding. Participation was robust with male and female, clinic and community, professional, and ancillary staff all fully engaged.

The second location that HBB was taught was in a remote clinic that provides healthcare for people in the Mursi tribe. The smaller cohort was strategically selected to provide outreach in the underserved and underresourced area. In attendance at the workshop was the very first Mursi to become a nurse and midwife. The impact of her participation in the HBB training has the potential to decrease infant mortality within her community. Forty-two participants from both locations were trained. A closing dinner was held at the Langano clinic and provided an opportunity for Ethiopian providers and US students to reflect on their time together and offer thanks for the work accomplished. The profound importance of the HBB workshops was brought to life by the thanks offered by the lead Ethiopian clinician. He stood and formally thanked the Baylor Team for their commitment to the clinic and the people in the community. He then shared a story of a birth that happened days before. A woman with placenta previa and pregnant with twins had gone into premature labor. One twin was born and the woman began to hemorrhage. Transport to the closest hospital was quickly arranged. While the driver began the 2-hour journey over bumpy roads, the clinician and an interpreter/assistant were in the back of the repurposed Land Cruiser. After being turned away from one hospital and heading to the second hospital, the woman gave birth to the twin and her hemorrhaging increased. While the clinician was furiously working to save the life of the mother, he handed the infant, who was not breathing, to the assistant for care. “It is because of the education you provided that he knew what to do with the newborn that was not breathing. It is because of your work the mother and both twins are now alive.”

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Hyderabad, India

India had a neonatal mortality rate of 25/1000 live births in 2012.26 While there has been a reduction in maternal and child mortality, neonatal deaths have increased. This may be due to the complexity of India with its demographic and cultural diversity. There also exist disparities between rural and urban areas, economic and educational status, and male preference. Infants born in rural India are twice as likely to die as those born in urban settings.9 , 27 In addition, India ranked last among all Southeast Asia Region countries in the categories for reproductive, maternal, newborn, and child health intervention coverage—showing a significant gap between the poorest and the national average.28

Teams from Baylor have been going to Hyderabad, India, for the last 6 years to provide education to increase nurse capacity. For the last 4 years, HBB has been a part of the education provided to the nurses and midwives at the Neonatal Intensive Care Emergencies Hospital (NICE) in Hyderabad and in the rural area located in the state of Telangana, the Nagarkurnool district. Mduma et al29 reported that frequent brief on-site training improved skills and confidence in maternity care providers in the delivery room. Based on this research, our education in early 2016 focused on implementing monthly mock codes in addition to annual HBB refresher training.

In the summer of 2016, a team of 2 faculty, 2 undergraduate students, 2 graduate students, and a physician originally from Hyderabad provided a train-the-trainer workshop to approximately 35 nurses and midwives at the NICE hospital. See Figure 2. For many nurses this was a refresher course, but due to the high turnover rate of nurses in India this provided an opportunity to train new nurses. The NICE Foundation has 4 birth centers in the Nagarkurnool district. Three of these clinics are midwifery-led and provide care to approximately 100 rural villages per clinic. The team conducted education on the management and transport of asphyxiated infants using HBB and the World Health Organization safe birth checklist. A midwife at the training commented “the heart rate and breathing look so real.” The physician who was also a master trainer acted as an interpreter. Having HBB trainers available in both the hospital and the rural area is extremely important to ensure that all infant care providers are trained in resuscitation. Subsequent to this project a Laerdal Grant was funded to collect outcome data after implementation of HBB in the rural area with village healthcare workers associated with the midwifery-run clinics in 2017. While institutional births are on the rise, 10% to 30% of deliveries still occur in the homes and it is essential for the village healthcare workers to be proficient with resuscitation to support this population.



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Bengaluru, India

A longstanding relationship exists between Baylor and the Bangalore Baptist Hospital Institute of Nursing in Bengaluru, India.24 This relationship was developed through multiple faculty and student collaborations with a focus on missions, teaching, and research. In 2015, Baylor was awarded a grant by the United States Agency for International Development American Schools and Hospitals abroad to build a Simulation Education and Research Centre at Bangalore Baptist Hospital.30 HBB was identified as a sustainable program to be delivered through this center.

In 2016, 3 HBB kits including NeoNatalie simulators were purchased through an internal Baylor University Research Missions Grant for the simulation center. A demonstration of HBB was performed at a nursing workshop and ground breaking ceremony for the Simulation Education and Research Centre in January 2016. A total of 140 nurses from all over Bengaluru, representing 13 nursing schools, attended the ceremony and workshop. Evaluations from the workshop were favorable and nurses expressed interest in learning more about the initiative. The first cohort of nurses was fully trained in July 2016 and included 8 community health nurses employed by Bangalore Baptist Hospital. This cohort of nurses was identified as a priority because Bangalore Baptist Hospital's outreach work extends to the urban slums of Bengaluru and to 1700 surrounding villages where healthcare access is limited. The second cohort to participate in the training was 30 undergraduate nursing students enrolled in the General Nurse Midwifery program at the Bangalore Baptist Hospital Institute of Nursing and 2-community health faculty. Each program consisted of a half-day training workshop. See Figure 3. Upon project completion, 100% of the participants demonstrated HBB skills competency using low-fidelity simulation.



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Nam Dinh, Vietnam

The Ministry of Health in Vietnam published its National Plan of Action for Child Survival in 2009, stating “Limited access and/or low quality of obstetric and newborn care, particularly at remote, minority communities has resulted in the high rates of neonatal mortality which represents about 70 percent of infant mortality and more than 50 percent of under-five mortality.”31 Factors associated with increased neonatal mortality in Vietnam include the distance to the nearest health facility,32 the level of healthcare at the institution where delivery took place,33 and adequate supplies and the ability of personnel to provide resuscitation at birth.34 , 35 Wallin et al36 have suggested utilizing a community-based training program with local health workers to initiate steps to improve maternal–newborn health, especially at the time of delivery. Baylor University has developed a strong relationship over the past 8 years with Nam Dinh Nursing University in North Vietnam. By participating and leading faculty development workshops, using low-fidelity simulation for teaching skills, as well as teaching courses in their Master of Science in Nursing program, Baylor faculty have been a collaborative partner in facilitating change at Nam Dinh Nursing University. In the summer of 2016, 2 Baylor faculty along with 4 students taught an HBB workshop at Nam Dinh Nursing University. See Figure 4. Participants at this workshop included 30 undergraduate nursing students and their faculty. Before the workshop, the Baylor team toured the pediatric hospital, pairing Baylor students with Nam Dinh students for a shadowing experience. During the hospital visit, several infants were observed who had not been resuscitated in a timely manner at birth. The next day when the HBB training sessions were held, the Baylor students felt great enthusiasm at the impact this education could have on newborns in Vietnam. Training materials were left at the university so that their faculty could hold further training sessions. Plans to incorporate this training into the undergraduate curriculum were discussed with the Nam Dinh Nursing University faculty and will be further addressed when the Baylor teaching teams return in the summer of 2018.



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The primary purpose of this project was to increase awareness of neonatal care and enhance the professional growth of students and global colleagues. This professional developmental effort was deemed successful by all. The HBB skills checkoff demonstrated that learners in all countries had improved knowledge and skills. Upon project completion, 100% of the 145 participants demonstrated HBB skills competency using low-fidelity simulation and the HBB skills checklist.

Reflecting on the HBB workshops and the resulting interactions provided an opportunity to review and refine technical procedures. Tips for implementation and lessons learned with application examples are delineated in Table 1. Baylor University student responses were captured through reflective journaling and posttrip group conversations and were incorporated into the project evaluation. An example of this would be the identification of a need, when planning future trips, to schedule additional workshop time to allow for translation. Reflections after the initial day of the workshops in Hyderabad led to the identification of the need for extra time practicing with the resuscitation equipment. Reflection helps create ideas of how best to offer professional development internationally in a contextually relevant way to meet the goals of all. This was made clear by seeking input from our partners in Ethiopia on who to invite to the workshops. Our initial plan was to only invite healthcare workers at the clinic, but on the recommendations of the Clinic Director we included all clinic staff and community workers. If we had not included the additional participants, the twin in Ethiopia may not have survived. Participants and trainers considered each of the workshops to be worthwhile endeavors that enhanced their ability to help the nonbreathing infant.



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While HBB uses a standard curriculum, we learned the implementation could be adapted to the individual setting. For example, in Ethiopia learning is best facilitated when a tea and coffee break is provided initially; in India the teaching may be best accomplished with the facilitator sitting on the floor with the learners. As part of the introduction and to engage learners' hierarchal titles are not used, the participants existing experience and expertise is acknowledged, and emphasis is placed on teaching methods. HBB is a teaching strategy to facilitate the sharing of information. A statement by one student illustrates transformation-learning application of self-reflection, “There is so much to learn from other cultures and we are missing out on so much if we are just limited to the American way.”12 To be fully effective in providing professional development in diverse populations, cultural humility is required. Humility is manifest in the attitude of understanding that difference does not necessitate ranking or equate with merit and cultivating humility leads to a teaching approach that seeks opportunities for mutual learning and goal achievement.13–24 A simple but significant example experienced by a Baylor student was the importance of allowing adequate implementation time when using interpretation and incorporation of cultural perspectives of start and stop times. “It was supposed to start at 10:00 and no one came until 11:00.” Being aware of the cultural norms and power differences inherent in cross-culture teaching motivates those conducting workshops to be careful to create a cooperative and collaborative experience.37

This Louise Herrington School of Nursing service project was a success. Eight faculty and 30 Baylor students were trained and provide HBB training in 4 countries to 145 healthcare providers, community workers, and students. To help ensure the sustainability of the HBB program equipment for each site was provided to resuscitate infants and to continue HBB training. All participants gained knowledge and skills that were demonstrated by a skill checkoff at the end of the workshop, which required providing bag-and-mask ventilation within the first minute of life. A 1-time training may not be sufficient to maintain skills, and research is needed to determine how often updates are needed to maintain proficiency.

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Challenges and Rewards

The project implementation and professional development were rewarding. The feedback from the US students was overwhelmingly positive with enthusiasm for their chosen profession of nursing and for global work. The increase in knowledge surrounding neonatal morbidity and mortality in the US students, faculty, and our international colleagues was gratifying. Our observation of enhanced skills and the successful completion of the structured HBB checkoff was extremely satisfying. The antidotal stories of success and lives saved coupled with the enthusiasm of global colleagues encouraged our efforts and motivated our students. Consistent with all rewarding endeavors the successes were coupled by challenges.

Acclimating to the difference in time after traveling for 24 hours can be difficult for even the experienced traveler. Language barriers presented challenges related to assuring content was accurately conveyed and also in the length of time each workshop segment required. Our workshops were held for working nurses and at times nurses would attend our daylong workshop after having worked all night. As is typical of education endeavors, we had the occasional comical misunderstandings such as when teaching about the mucous sucker (bulb syringe). The tendency was to blow air out rather than using it for suction. This challenge was incorporated into the training and became an icebreaker activity, as we elected to demonstrate suction-versus-blowing bubbles using cups of water.

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Implications for Professional Development

Around the world the HBB program provides a platform to teach neonatal resuscitation and essential care for every newborn to healthcare providers in low-resource countries. It provides opportunity for professional development in the trainer and the recipient. A current initiative is to save 100,000 lives with HBB.8 In order to meet this goal, community-based healthcare workers and village healthcare workers will need to be trained. While there has been an increase in facility births globally, 30% of births occur at home without a skilled attendant.8 Nurses, midwives, and advance practice nurses can engage globally and contribute to closing this gap by providing train-the-trainer workshops. Targeted mutual professional development can be sustainably and collaboratively implemented to build capacity and compassion.

Baylor University has provided HBB training for approximately 300 nurses, midwives, village healthcare workers, and students around the world. The education was provided through train-the-trainer workshops that included the provision of supplies in 4 counties to both providers and prelicensure nurses, at urban and rural hospitals, at community clinics, and remote rural areas.

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Limited human resource for healthcare is profound in sub-Saharan Africa and Southeast Asia. The lack of healthcare providers is particularly severe in rural settings in all countries.28 The healthcare needs across the lifespan exceed what can be met by the current numbers of providers.28 Collaboratively developing professionals and upscaling capacity is needed.

According to the American Academy of Pediatrics, in-country leadership and ownership is essential to making HBB a sustainable program.1 Developing systems to integrate the program with each country's existing healthcare infrastructure promotes in-country ownership. One future direction of this project is to implement it in prelicensure programs, ensuring a continuous population of healthcare professionals trained to deliver essential newborn care and who are also prepared to teach other healthcare workers. We recommend Ministries of Education and/or Health work in tandem with Nursing Councils to implement HBB in prelicensure programs.

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Africa; community-based health education; Ethiopia; evidence-based practice; health disparities; India; nursing capacity building; population health; professional development; resuscitation; simulation; Vietnam; Zambia

© 2019 by The National Association of Neonatal Nurses