Effectiveness of Simulation-based Training Delivered to Special Newborn Care Providers on Resuscitation Management and Kangaroo Mother Care: Simulation-based Training for Asyphxia in Babies Trial (STAR-Baby Trial)

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Summary Background Neonatal mortality remains a major global public health challenge, with about 2.4 million newborn deaths occurring within the first month of life in 2020. Central and Southern Asia account for 36% of these deaths, with a neonatal mortality rate (NMR) of 23 per 1,000 live births. Birth asphyxia is a leading cause, responsible for nearly 900,000 deaths annually. In Nepal, neonatal mortality has remained stagnant over the past decade, with an NMR of 21 per 1,000 live births in both 2016 and 2022. This is far above the national Sustainable Development Goal target of 12 per 1,000 by 2030. Despite initiatives such as the Every Newborn Action Plan, more than 80% of neonatal deaths are still due to preventable causes such as prematurity, birth asphyxia, and infections. Although Nepal has expanded services through 61 Special Newborn Care Units (SNCUs), improvements in neonatal outcomes have been limited due to persistent gaps in quality of care and health worker skills. Studies highlight shortages of essential equipment, including neonatal resuscitation devices, and inadequate competency among providers, especially in managing non-breathing newborns. Provincial disparities further worsen outcomes and Lumbini provinces showing the highest NMRs. Poor facility readiness, lack of training, and limited availability of drugs and equipment contribute to suboptimal care. Hypothermia and inadequate Kangaroo Mother Care (KMC) practices also increase risks, particularly among low-birth-weight infants. Simulation-based training has emerged as an effective strategy to strengthen healthcare providers' skills in neonatal resuscitation. Evidence from countries like Tanzania shows improved clinical performance and reduced neonatal complications. The NeoNatalie™ simulator, a low-cost and portable training tool, has been effective in enhancing providers' competence and confidence. In Nepal's context of limited resources and skill gaps, such training offers a practical and scalable solution to improve neonatal outcomes and accelerate progress toward SDG targets. This study aims to evaluate the effectiveness of simulation-based training in improving the knowledge, skills, and performance of newborn care providers and reducing neonatal mortality in Nepal. Methods The study is designed as a two-arm, parallel cluster randomized controlled trial conducted in SNCUs across Lumbini province of Nepal. Hospitals will serve as clusters, with equal allocation into intervention and control groups. Participants will include medical officers, nurses, and paramedics working in SNCUs for at least six months. A total of 240 providers (120 per arm) will be enrolled, accounting for clustering and potential attrition. Randomization will be conducted by an independent statistician, with allocation concealment ensured. Intervention The intervention includes a three-day simulation-based training using the Helping Babies Breathe (HBB) program and NeoNatalie™ simulator. It covers essential newborn care, neonatal resuscitation within the "Golden Minute," breastfeeding, hypothermia prevention, KMC, and infection management. This will be followed by twelve months of mentoring and coaching by trained health workers. The control group will continue routine care. Data collection and analysis Data will be collected using standardized tools and electronic systems, ensuring quality monitoring. Data analysis will use appropriate statistical methods, including Analysis of Covariance (ANCOVA), to compare outcomes between groups. Ethical approval will be obtained from Nepal Health Research Council, and informed consent will be ensured. Data confidentiality and trial registration will also be maintained. Study Management This study will be conducted in coordination with the Provincial Health Training Center, Provincial Health Directorate and provincial hospitals of Lumbini province and led by a team of experts in newborn health, research and epidemiology. Overall, this study addresses critical gaps in newborn care in Nepal by testing a context-specific, skill-based intervention. The study has the potential to improve provider performance, enhance quality of care, and significantly reduce preventable neonatal deaths in resource limited settings in Nepal and elsewhere globally. Expected outcome and measures Key outcomes include provider knowledge, confidence, and clinical skills assessed through structured questionnaires and Objective Structured Clinical Examinations (OSCEs). These will measure both routine newborn care and management of non-breathing infants, along with KMC implementation.

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