Introduction A disproportionate share of global neonatal deaths occurs in armed-conflict settings, where progress in reducing neonatal mortality remains slow. This systematic review aims to synthesise the literature on implementing essential newborn care (ENC) interventions in high-intensity armed conflict settings.Methods We searched PubMed, CINAHL, Embase and the grey literature from January 2014 to March 2024. Eligible original studies in English implemented at least one component of ENC in settings experiencing high-intensity armed conflict. Data were extracted on study characteristics, ENC implementation and outcomes. Certainty of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) for quantitative studies and GRADE-Confidence in the Evidence from Reviews of Qualitative Research for qualitative and mixed-method studies.Results 32 studies were included, primarily from hospital settings (n=15, 47%) in Pakistan (n=6, 19%) and South Sudan (n=5, 16%). Interventions focused on health workforce (n=19, 59%) and service delivery (n=8, 25%), predominantly through community health worker training (n=27, 84%). Positive effects were observed for ENC coverage (8/10 studies) and health outcomes (7/12 studies), particularly for interventions promoting breastfeeding, skin-to-skin contact, chlorhexidine applications to the umbilical cord and quality improvement approaches. Neonatal resuscitation training showed variable effects. Key facilitators included local healthcare workers providing emergency supervision and the use of audio-visual or mobile technologies, while barriers included insecurity, conflict-imposed movement restrictions, violence against health facilities and workers, the inability of supervisors to access facilities and the community, population displacement and degradation of ENC quality.Conclusion Implementation of ENC interventions, particularly breastfeeding promotion, Kangaroo Mother Care and cord care, that do not depend on functional health facilities can improve coverage and neonatal health outcomes in high-intensity armed conflicts, but requires adaptations to context-specific challenges. Strategies to strengthen the health workforce, leverage community health workers and integrate technology may enhance the delivery of lifesaving newborn care amidst armed conflict. Our review was limited by a lack of grey and non-English literature and studies on caring for small and/or sick newborns, implementation of comprehensive care packages and effectiveness evaluations. Further research is needed on comprehensive ENC packages and innovative approaches to overcome systemic barriers.PROSPERO registration number CRD42023388617.

Importance:Human milk is beneficial for preterm newborns, and pasteurized donor human milk (PDHM) is increasingly used when mother's own milk (MM) is insufficient. However, PDHM has been associated with suboptimal growth outcomes. Objective:To quantify the comparative clinical effectiveness of PDHM, MM, and formula in supporting daily weight gain and growth outcomes during the birth hospitalization. Design:Retrospective cohort study of infants born before 34 weeks' gestation between 2016 and 2024. Setting:Five newborn nurseries across the Mass General Brigham healthcare system (Boston, MA), including one Level IV, one Level III, and three Level II newborn units. Participants:A total of 2,635 preterm infants born before 34 weeks' gestation between 2016 and late 2024 were included in the daily weight gain analysis, contributing 40,007 days of eligible enteral intake data for evaluation of in-hospital growth outcomes. For the analysis examining the association between PDHM use and discharge weight, 2,719 infants met eligibility criteria. Exposures:PDHM, MM, formula. Main Outcomes and Measures:The primary outcome was daily weight gain (g/kg/day). The secondary outcome was the change in weight Z-score from birth to discharge. Results:In adjusted analyses, an equal volume of PDHM was associated with 74% of the daily weight gain achieved with MM (p < 0.0001, 95% CI 70%-77%), and formula with 115% of MM (p < 0.0001, 95% CI 111%-119%). During the birth hospitalization, infants in the highest quartile of PDHM exposure had a significantly greater decline in weight-for-age Z-score compared with those with no exposure (-0.09, p = 0.005), while no differences were observed in the lower quartiles. Conclusions and Relevance:Growth outcomes varied by PDHM exposure, with a significant decline observed only in the highest quartile, while lower exposure levels showed no significant effect. Formula-fed infants were observed to have greater weight gain than either PDHM or MM. These results highlight the need for close growth monitoring and timely nutritional adjustments in preterm infants, particularly when PDHM is the primary source of enteral nutrition. Question:How does pasteurized donor human milk (PDHM) compare with mother's own milk (MM) and formula in supporting in-hospital growth among preterm infants born at or before 34 weeks' gestation? Findings:In this multicenter retrospective cohort study involving > 2500 preterm infants contributing over 40,000 infant-days of enteral data, PDHM correlated with significantly reduced daily weight gain compared with MM, whereas formula supported greater weight gain than either human milk source. At discharge, infants with the highest quartile of PDHM exposure showed a greater reduction in weight-for-age Z-score than infants with no PDHM exposure. No association was observed in the lower quartiles. Meaning:Our findings underscore the need for close growth monitoring and potentially greater nutritional supplementation in relation to PDHM exposure.

The Ethiopian Newborn Quality Improvement (EN-QI) Extension for Community Healthcare Outcomes (ECHO) promoted the implementation of Helping Babies Survive training in eight Ethiopian health facilities. The initiative incorporated U.S based Neonatal-Perinatal Medicine (NPM) fellows into the ECHO Expert Hub. This study evaluates the experiences of the NPM fellows. This mixed-methods study incorporated objective data, survey responses, and qualitative focus group analysis from the eight participating fellows. Fellows described benefits including mentoring, networking, career development, and quality improvement experience. Their experience would have been improved with more thorough onboarding and clarification of the fellow role at the start of the project. This study demonstrates a model for inclusion of fellows in a virtual partnership as a low-cost and high value approach to global health work. This project was well-received and highly valued by fellows as a meaningful training opportunity.

BACKGROUND:Gender equity is essential for improving health outcomes globally. Despite comprising 75% of the global health workforce and dominating academic global health programs, women remain underrepresented in leadership positions in global health organizations. Our study aimed to identify potential gender differences in the beliefs and attitudes regarding barriers that women anesthesiologists encounter in pursuing careers and leadership roles in global health and to identify recommendations for improving gender equity in global health. METHODS:We conducted a cross-sectional online survey focusing on career leadership opportunities and challenges uniquely faced by women clinicians in global health. We obtained permission from the World Federation of Societies of Anaesthesiologists to distribute our questionnaire to their leadership committee members during 2 months (May-July 2022). RESULTS:The questionnaire was distributed to 164 study participants with 67 individuals (44.8% female) based in 38 different countries completing the survey (response rate 40.9%). Overall, 47.8% of the participants aspired to a leadership position in global health and 58.2% agreed women face unique barriers to global health leadership (70.0% of women compared to 48.6% of men; P = .081). Female gender (odds ratio [OR], 19.22, P = .004) and divorced marital status (OR, 746.26, P = .004) were positively associated and African ethnicity (OR, 0.002, P = .017) was negatively associated with the perception of gender bias in their career growth. The main challenges included balancing work and family responsibilities, lack of female mentors or role models, gender-based discrimination, and limited opportunities for career advancement. Men acknowledged these challenges but reported personally experiencing them to a lesser extent, particularly concerning lack of opportunities ( P = .005), inadequate pay ( P = .000), and lack of training ( P = .000). CONCLUSIONS:Gender disparities exist in the pursuit of global health careers. This study underscored that more women than men perceive barriers in pursuing leadership roles in global health and that men generally encounter these obstacles to a lesser extent. Female representation in leadership positions could be supported through evidence-informed policies that promote work-life balance, improve mentorship, offer equal opportunities for career advancement and adequate pay, and combat gender-based discrimination.

OBJECTIVES Effective bag-valve-mask ventilation is critical for reducing perinatal asphyxia-related neonatal deaths; however, providers often fail to achieve and maintain effective ventilation. The Augmented Infant Resuscitator (AIR) attaches to bag-valve-masks and provides visual feedback on air leaks, blocked airways, harsh breaths, and improper ventilatory rates. We evaluated the effect of this real-time-digital feedback on ventilation quality and the effective determination of airway integrity in a randomized controlled study in Uganda and the United States. METHODS Birth attendants trained in newborn resuscitation were randomized to receive either real-time AIR device feedback (intervention) or no feedback (control) during ventilation exercises. Intervention-arm participants received a 2-minute orientation on interpreting AIR feedback using a single-page iconography chart. All participants were randomly assigned to 3 blinded ventilation scenarios on identical-appearing manikins with airways that were either normal, significantly leaking air, or obstructed. RESULTS We enrolled 270 birth attendants: 77.8% from Uganda and 22.2% from the United States. Birth attendants receiving AIR feedback achieved effective ventilation 2.0 times faster: intervention mean 13.8s (95% confidence interval 10.6-17.1) versus 27.9s (21.6-34.3) for controls (P < .001). The duration of effective ventilation was 1.5 times longer: intervention mean 72.1s (66.7-77.5) versus 47.9s (41.6-54.2) for controls (P < .001). AIR feedback was associated with significantly more accurate and faster airway condition assessment (intervention mean 43.7s [40.5-47.0] versus 55.6s [51.6-59.6]). CONCLUSIONS Providers receiving real-time-digital AIR device feedback achieved effective ventilation significantly faster, maintained it longer, and determined airway condition faster and more accurately than providers in the control group.

Conflict-related sexual and gender-based violence is common in the eastern Democratic Republic of Congo, but there are few evaluations of multisectoral training interventions in conflict settings. We conducted high-quality, trauma-informed medicolegal trainings amongst multisectoral professionals and sought to describe changes in knowledge after training and perceived training acceptability. Participants were health, law enforcement, and legal professionals who completed training at one of four sites from January 2012 to December 2018. Twelve trainings were randomly selected for evaluation. We conducted pre-and post-training assessments and semi-structured interviews of participants within 12 months of index training. Forty-six trainings of 1,060 individuals were conducted during the study period. Of the randomly selected trainings, 368 questionnaires were included in the analysis (36% health, 31% legal, 12% law enforcement, 21% other). The mean knowledge scores (standard deviation) significantly improved after training: 77.9 (22.9) vs. 70.4 (20.8) (p <0.001). Four key benefits were identified: 1) improved cross-sector coordination; 2) enhanced survivor-centered care; 3) increased standardization of forensic practices; and 4) higher quality evidence collection. Participants completing the training had improved knowledge scores and perceived several key benefits, suggesting the multi-sectoral training was acceptable in this under-resourced, conflict region.

Sexual and gender-based violence (SGBV) leads to severe sequelae for individuals and communities. Lack of cross-sector coordination inhibits effective medical–legal support and justice for survivors. Multisectoral trainings for health, legal, and law enforcement professionals on survivor-centered SGBV care were conducted in Kenya during 2012–2018. Evaluation utilized objective structured clinical examinations, standardized patients, knowledge assessments, and interviews. A total of 446 professionals participated in 18 trainings. Mean knowledge scores increased from 75.6% to 84.7% ( p < .001). Thirty interviews revealed improved survivor confidentiality, increased specialized hospital care, more comprehensive forensic care, and greater cross-sector collaboration. Participants reported survivors feeling more comfortable pursuing legal action and increased perpetrator convictions.

OBJECTIVES Necrotizing enterocolitis (NEC) is a severe intestinal inflammatory disease and a leading cause of morbidity and mortality in NICUs. Management of NEC is variable because of the lack of evidence-based recommendations. It is widely accepted that standardization of patient care leads to improved outcomes. This quality improvement project aimed to decrease variation in the evaluation and management of NEC in a Level IV NICU. METHODS A multidisciplinary team investigated institutional variation in NEC management and developed a standardized guideline and electronic medical record tools to assist in evaluation and management. Retrospective baseline data were collected for 2 years previously and prospectively for 3.5 years after interventions. Outcomes included the ratio of observed-to-expected days of antibiotics and nil per os (NPO) on the basis of the novel guidelines and the percentage of cases treated with piperacillin/tazobactam. Balancing measures were death, surgery, and antifungal use. RESULTS Over 5.5 years, there were 124 evaluations for NEC. Special cause variation was noted in the observed-to-expected antibiotic and NPO days ratios, decreasing from 1.94 to 1.18 and 1.69 to 1.14, respectively. Piperacillin/tazobactam utilization increased from 30% to 91%. There were no increases in antifungal use, surgery, or death. CONCLUSIONS Variation in evaluation and management of NEC decreased after initiation of a guideline and supporting electronic medical record tools, with fewer antibiotic and NPO days without an increase in morbidity or mortality. A quality improvement approach can benefit patients and decrease variability, even in diseases with limited evidence-based standards.

Background: A maternal diagnosis of chorioamnionitis, based on maternal peripartum fever of 100.4 degrees F alone, is commonly used as an indication for blood work and antibiotic treatment in newborns. New strategies such as the Kaiser Permanente early-onset sepsis (EOS) calculator have proven effective in identifying high-risk newborns and reducing unnecessary antibiotic administration. Purpose: Retrospective data from October 2017 to September 2018 from 297 well-appearing newborns >= 35 weeks' gestational age (GA) with maternal chorioamnionitis showed that 93.6% had blood work and 90.2% were treated with antibiotics. This was despite no culture-positive cases of sepsis. Our aim was to reduce by 50% blood work evaluation and antibiotic treatment within a 6-month period. Methods: Using plan-do-study-act (PDSA) cycles, we adopted the Kaiser Permanente EOS calculator. We collected longitudinal data to track the outcomes after its implementation. Results: In 423 newborns with maternal chorioamnionitis triaged with the EOS calculator from October 2018 to July 2020, the rates of blood culture and antibiotic treatment decreased from 93.6% to 26.7% and 90.2% to 12.3% (P < .0001). In the larger population of 6426 newborns >= 35 weeks' GA, the rate of blood culture and antibiotic treatment decreased from 12.8% to 5.8% and 9.9% to 2.5% (P < .0001). Implications for Practice: The EOS calculator substantially and safely decreases blood work and antibiotic administration in asymptomatic newborns with maternal chorioamnionitis. Implications for Research: Our findings provide further evidence for the effectiveness and safety of the EOS calculator.

Background Due to the COVID-19 pandemic, the 2021 Harvard Medical School course Clinical Topics in Global Health was offered for the first time as a remote class. We sought to understand student and faculty perceptions of the elective and evaluate the perceived effectiveness of teaching global health using an online education platform. Methods Following the course, students and faculty were invited to complete a combined total of three online surveys, which consisted of closed- and open-response questions assessing the strengths and challenges of online learning. Data analyses included traditional descriptive statistics, Net Promoter Score calculation, and inductive thematic analysis of qualitative data. Results Thirty-two students and eighteen guest faculty (including four international faculty) participated in the course. Highly-rated course components included guest lecturers, practical skill sessions, polls, and case studies. The Net Promoter Score for the course was excellent at 92, and students reported a greater likelihood of pursuing a career in global health because of the course. While students and faculty highlighted limitations of the remote learning platform (lack of community and interactivity), they also commented on increased accessibility and faculty diversity. Most faculty and students recommended a hybrid model for future versions of the course and suggested strategies to address current limitations. Conclusions A remote learning platform can effectively deliver global health education, both in the pandemic setting and beyond.

Mediratta, R. P.1; Moutwakil, A.2; Nelson, B. D.3; Amsalu, R.4; Li, A. T.2; Kumar, A.2; Huang, C.2; Balter, L. E.2; Woodward, A.1; Darmstadt, G. L.1 Author Information

Background Survivors of sexual violence deserve timely and high-quality forensic examination, evidence collection, and documentation as part of comprehensive care. However, in many countries, the quality of medical-legal documentation is severely limited. MediCapt is an innovative digital application that enables clinicians to document forensic medical evidence as well as capture and securely store forensic photographs of injuries. This study evaluated the effectiveness and usability of MediCapt to document forensic medical evidence of sexual violence. Methods This mixed-methods evaluation involved key-informant interviews, usability questionnaires, and forensic record reviews. Participants included clinicians, medical records personnel, information technology personnel, and health facility administrators, as well as law enforcement and legal professionals in Kenya. Results The Physicians for Human Rights (PHR) data quality checklist found that using MediCapt led to significantly higher data-quality scores compared to paper-based forms. MediCapt forms scored higher on 23 of 26 checklist items. While a wide difference in quality was seen among paper-based forms, MediCapt appeared to both standardize and improve quality of documentation across sites. MediCapt strengths included data security and confidentiality, accuracy and efficiency, and supplemental documentation with photography. Weaknesses included infrastructure challenges, required technological proficiencies, and time to learn the new system. Although it is early to assess the impact of MediCapt on prosecutions, providers and law and justice sector professionals were optimistic about its usefulness. They identified MediCapt as appropriate for use with survivors of sexual violence and reported MediCapt’s legibility and photography features had already been commended by the court. Conclusion MediCapt was well-received across all sectors, its use was perceived as feasible and sustainable, and it significantly improved the quality of collected forensic data. It is anticipated this improvement in forensic documentation will increase successful prosecutions, strengthen accountability for perpetrators, and improve justice for survivors.

Introduction High-quality forensic documentation can improve justice outcomes for survivors of sexual and gender-based violence, but there are limited tools to assess documentation data quality. This study aimed to develop and validate a data quality assessment index to objectively assess clinician documentation across the 26 key elements of the standardized forensic evidence forms used in Kenya. Methods Informed by prior quality assessment tools, an initial draft of the index was developed. Feedback from Kenya- and U.S.-based clinicians and human rights experts was solicited and incorporated into the draft index in an iterative fashion. Two raters independently employed the finalized Physicians for Human Rights Data Quality Index to assess and score the quality of documentation across 31 clinician-completed forms. Inter-rater reliability was determined using Cohen kappa (к) coefficients. Results The Index was found to have substantial overall reliability. Of the 26 documentation items, the Index had a perfect (к = 1.0) and almost perfect (к = 0.81–0.99) level of inter-rater agreement across 17 (65.4%) and 5 (19.2%) items, respectively. On a low-to-high documentation quality scale of 0 to 2, the majority of items (n = 19, 73.1%) had a mean documentation quality score >1.5–2. Conclusion Quality assurance of forensic documentation is an essential component of post-sexual assault care. To our knowledge, this is the first validated quality-assessment tool in the peer-reviewed literature for sexual assault documentation and may be a promising strategy to enhance the quality of sexual assault documentation in other settings, locally, regionally, and internationally.

Background: A maternal diagnosis of chorioamnionitis, based on maternal peripartum fever of 100.4°F alone, is commonly used as an indication for blood work and antibiotic treatment in newborns. New strategies such as the Kaiser Permanente early-onset sepsis (EOS) calculator have proven effective in identifying high-risk newborns and reducing unnecessary antibiotic administration. Purpose: Retrospective data from October 2017 to September 2018 from 297 well-appearing newborns ≥35 weeks' gestational age (GA) with maternal chorioamnionitis showed that 93.6% had blood work and 90.2% were treated with antibiotics. This was despite no culture-positive cases of sepsis. Our aim was to reduce by 50% blood work evaluation and antibiotic treatment within a 6-month period. Methods: Using plan-do-study-act (PDSA) cycles, we adopted the Kaiser Permanente EOS calculator. We collected longitudinal data to track the outcomes after its implementation. Results: In 423 newborns with maternal chorioamnionitis triaged with the EOS calculator from October 2018 to July 2020, the rates of blood culture and antibiotic treatment decreased from 93.6% to 26.7% and 90.2% to 12.3% (P < .0001). In the larger population of 6426 newborns ≥35 weeks' GA, the rate of blood culture and antibiotic treatment decreased from 12.8% to 5.8% and 9.9% to 2.5% (P < .0001). Implications for Practice: The EOS calculator substantially and safely decreases blood work and antibiotic administration in asymptomatic newborns with maternal chorioamnionitis. Implications for Research: Our findings provide further evidence for the effectiveness and safety of the EOS calculator. Video abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.

Human trafficking is associated with a profound burden of physical and psychological trauma. Survivors of trafficking interact with the health care system during and after their experiences of trafficking. Socioeconomic isolation, stigma, shame, guilt, fear of judgment, fear of retribution by traffickers, fear of law enforcement authorities, and other factors known to inhibit disclosure can exert a formative influence on survivors' health care experiences, health care access, and health services engagement. Using a mixed qualitative-quantitative social science research method, known as by-person factor analysis (or Q-methodology), the current analysis systematically examines the scope of trafficking survivors' health care experiences and perceptions of medical care, health care access behaviors, and degree of engagement with health services. Among 33 survivors of human trafficking surveyed, 21 met inclusion criteria for this analysis. Three distinct profiles of survivor health care experiences and health services engagement-Avoidant, Distrustful, and Constrained-are identified from the aggregate of survivors' perceptions of medical care. Although there are salient differences across the three survivor profiles, a feeling of disenfranchisement is a common thread and directly related to health care access behaviors and health services engagement. Understanding that the feeling of disenfranchisement functions as a filter through which trafficking survivors perceive and experience medical care can help health care professionals take appropriate countermeasures. Implications for improving health care access and engagement include the implementation of trauma-responsive, culturally sensitive, and survivor-centered care practices.

Introduction: Developed and introduced in 2010, Helping Babies Breathe (HBB) has found great success globally as an easily-implementable neonatal resuscitation training program for healthcare providers working in resource-limited settings. As HBB approaches a decade of in-field use in over 80 countries, this systematic literature review aimed to identify challenges, knowledge gaps, and successes associated with each stage of HBB programming. Methods: A systematic …

Postgraduate clinical global health (GH) training is a rapidly evolving field. To understand and improve training opportunities, we sought the perspectives of current and former trainees related to their advanced clinical training or global health fellowships and the anticipated impact on their careers. Clinical GH fellowships across North America were identified through websites and previous studies. An e-mail was sent to program directors to invite all current and former GH fellows to complete a web-based questionnaire. We contacted 100 GH fellowship programs. Fifty-two fellows from 10 different specialties completed the survey. The median fellowship length was 23.3 months, with an annual median of 4.8 months spent in low-income and middle-income countries, which was less than their reported ideal of 6 months. The majority reported satisfaction, the anticipation of career benefits, and that they would recommend fellowship training to others. Challenges included insufficient funding, mentorship, and formal curricula. Conducting research in high-income countries was a significant negative predictor of fellowship satisfaction. Most fellows (73.1%) were not at all or only a little concerned about the absence of fellowship accreditation, with only 17.3% desiring accreditation. Survey respondents were largely satisfied with their training and valued program flexibility and educational opportunities, including advanced tropical medicine certificates or diplomas. However, to improve fellowship training, improvements are needed in mentorship, standardized curricula, institutional support, and funding. For GH fellowship training to be effective and sustainable, institutions will need to balance the needs of fellows, training programs, and the communities (low-, middle-, and high-income countries) where the fellows serve.

BACKGROUND:The phenomenon of moral distress is prevalent in the literature, but little is known about the experiences of nurses working in the neonatal intensive care unit (NICU). In addition, a paucity of literature exists exploring the relationship between moral distress and intent to leave a position in NICU nurses.PURPOSE:To explore the phenomenon of moral distress in NICU nurses using the Measure of Moral Distress for Health Care Professionals (MMD-HP) survey.METHODS:A cross-sectional, descriptive, correlational study was conducted nationally via an electronic survey distributed to NICU nurses who are members of National Association of Neonatal Nurses (NANN). Participants were asked to electronically complete the MMD-HP survey between March 27 and April 8, 2020.FINDINGS:A total of 75 NICU nurses completed the survey, and 65 surveys were included for data analysis. Five situations from the survey had a composite MMD-HP score of more than 400. Results indicated that 41.5% of the NICU nurses surveyed considered leaving a clinical position due to moral distress, and 23.1% of the nurses surveyed left a position due to moral distress.IMPLICATIONS:for Practice: NICU nurses experiencing high MMD-HP scores are more likely to leave a position. Further research is needed to develop strategies useful in mitigating moral distress in and prevent attrition of NICU nurses.IMPLICATIONS FOR RESEARCH:Many NICU nurses experiencing high levels of moral distress have left positions or are considering leaving a clinical position. Longitudinal interventional studies are vital to understand, prevent, and address the root causes of moral distress experienced by NICU nurses.

Introduction With 70.8 million people displaced worldwide, there is an increasing need for medical professionals to provide medical care to refugees. Insufficient training on refugee health poses a barrier to effective care delivery. Methods This workshop addressed common challenges in providing family-centered pediatric refugee care in community settings as well as barriers related to policy changes. Presentations covered prearrival experiences, medical screening, and trauma-based care. In small groups, participants discussed cases that featured medical, behavioral health, social, and cultural factors impacting the provision of family-centered pediatric care that was culturally respectful and included shared decision-making. After the breakout session, each small group informed the larger group of topics discussed. Facilitators identified themes and reinforced key learning points. At the workshop's conclusion, participants were guided to create their own personalized action plan. Results This workshop was presented at two international conferences to more than 47 participants, including clinicians, nurse practitioners, pediatric residents, and medical students. Evaluations were completed by 34 individuals. Participants' overall comfort level with taking care of refugee patients increased from 3.3 to 4.0 (on a 5-point scale, p = .24) during the 3-hour version of the workshop and from 3.8 to 4.0 (p = .43) in the 1-hour version of the workshop. Mean overall ratings of the 3- and 1-hour workshop versions on conference-administered evaluations were 4.8 and 4.2, respectively, on a 5-point scale. Discussions This workshop was well received and equipped participants with knowledge, tools, and strategies regarding pediatric refugee health in a community setting.

CONTEXT: Helping Babies Breathe (HBB) is a well-established neonatal resuscitation program designed to reduce newborn mortality in low-resource settings. OBJECTIVES: In this literature review, we aim to identify challenges, knowledge gaps, and successes associated with each stage of HBB programming. DATA SOURCES: Databases used in the systematic search included Medline, POPLINE, Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Health Sciences Literature, African Index Medicus, Cochrane, and Index Medicus. STUDY SELECTION: All articles related to HBB, in any language, were included. Article quality was assessed by using the Grading of Recommendations Assessment, Development, and Evaluation framework. DATA EXTRACTION: Data were extracted if related to HBB, including its implementation, acquisition and retention of HBB knowledge and skills, changes in provider behavior and clinical care, or the impact on newborn outcomes. RESULTS: Ninety-four articles met inclusion criteria. Barriers to HBB implementation include staff turnover and limited time or focus on training and practice. Researchers of several studies found HBB cost-effective. Posttraining decline in knowledge and skills can be prevented with low-dose high-frequency refresher trainings, on-the-job practice, or similar interventions. Impact of HBB training on provider clinical practices varies. Although not universal, researchers in multiple studies have shown a significant association of decreased perinatal mortality with HBB implementation. LIMITATIONS: In addition to not conducting a gray literature search, articles relating only to Essential Care for Every Baby or Essential Care for Small Babies were not included in this review. CONCLUSIONS: Key challenges and requirements for success associated with each stage of HBB programming were identified. Despite challenges in obtaining neonatal mortality data, the program is widely believed to improve neonatal outcomes in resource-limited settings.