CONTEXT: Birth asphyxia contributes substantially to neonatal mortality in low-and middleincome countries (LMICs). The effects of training birth attendants in neonatal resuscitation (NR) on mortality are limited by falloff of skills and knowledge over time and transference of learned skills into clinical practice.OBJECTIVE: This review examined acquisition and retention of NR knowledge and skills by birth attendants in LMICs and the effectiveness of interventions to improve them.DATA SOURCES: Medline, Cochrane, Embase, CINAHL, Bireme, and African Index Medicus databases were searched. We reviewed Web pages and reports from non-peer-reviewed (or "gray") literature sources addressing NR training in LMICs. STUDY SELECTION:Articles on acquisition and retention of NR knowledge and skills, and interventions to improve them, were limited to LMICs. RESULTS:The initial search identified 767 articles, of which 45 met all inclusion criteria. Of these, 31 articles analyzed acquisition of knowledge and skills, and 19 analyzed retention. Most studies found high acquisition rates, although birth attendants struggled to learn bag-mask ventilation. Although significant falloff of knowledge and skills occurred after training, refresher training seemed to improve retention. Results of the gray literature analysis suggest that formal, structured practice sessions improve retention. LIMITATIONS: This review did not analyze training's direct impact on mortality.CONCLUSIONS: Knowledge and skills falloff is a significant barrier to the success of NR training programs and possibly to reducing newborn mortality in LMICs. Refresher training and structured practice show significant promise. Additional research is needed to implement and assess retention improvement strategies in classroom and clinical settings.a Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; b Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts; c Harvard Medical School, Boston, Massachusetts; and d Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah Dr Reisman oversaw the literature reviews, interpreted the results, and drafted the initial manuscript; Ms Arlington assisted with the gray literature search and reviewed and revised the manuscript; Dr Jensen performed the initial gray literature analysis and reviewed and revised the manuscript; Mr Louis and Ms SuarezRebling conducted the initial literature review; and Dr Nelson conceptualized and designed the literature review and reviewed and revised the manuscript. All authors approved the fi nal manuscript as submitted.

Objective To validate a simplified objective structured clinical examination (OSCE) tool for evaluating the competency of birth attendants in low‐resource countries who have been trained in neonatal resuscitation by the Helping Babies Breathe (HBB) program. Methods A prospective cross‐sectional study of the OSCE tool was conducted among trained birth attendants working at dispensaries, health centers, or hospitals in five regions of Tanzania between October 1, 2013, and May 1, 2014. A 13‐item checklist was used to assess clinical competency in a simulated newborn resuscitation scenario. The OSCE tool was simultaneously administered by HBB trainers and experienced external evaluators. Paired results were compared using the Cohen κ value to measure inter‐rater reliability. Participant performance was rated by health cadre, region, and facility type. Results Inter‐rater reliability was moderate (κ = 0.41–0.60) or substantial (κ = 0.61–0.80) for eight of the OSCE items; agreement was fair (κ = 0.21–0.41) for the remaining five items. The best OSCE performances were recorded among nurses and providers from facilities with high annual birth volumes. Conclusion The simplified OSCE tool could facilitate efficient implementation of national‐level HBB programs. Limitations in inter‐rater reliability might be improved through additional training.

Higher colonization prevalence may partially explain increased IPD rates seen in those lacking in-home water services. Improving availability of sanitation services and reducing household crowding may reduce the burden of IPD in this population.