Journal of Clinical Neonatology

: 2018  |  Volume : 7  |  Issue : 2  |  Page : 89--95

Retention of knowledge and skill of birth attendants in newborn care and resuscitation after 1 Year in clinical practice: An experience from India

Manoja Kumar Das1, Chetna Chaudhary1, Surender Singh Bisht2, Arti Maria3, Ashish Jain4, Santosh Kumar Kaushal5, Rajesh Khanna6, Surojit Chatterji5,  
1 The INCLEN Trust International, New Delhi, India
2 Department of Pediatrics, Swami Dayanand Hospital, New Delhi, India
3 Department of Neonatology, Post Graduate Institute and RML Hospital, New Delhi, India
4 Department of Neonatology, Maulana Azad Medical College, New Delhi, India
5 Save the Children, Lucknow, Uttar Pradesh, India
6 Save the Children, Gurgaon, Haryana, India

Correspondence Address:
Dr. Manoja Kumar Das
The INCLEN Trust International, F1/5, Okhla Industrial Area, Phase 1, New Delhi -110 020


Background: In India, 18%–20% of newborn deaths are attributed to perinatal asphyxia. Effective resuscitation at birth can prevent neonatal mortality and improve the chances of intact survival. The information about sustainability and retention of gained resuscitation knowledge and skill in India is limited. Objective: The objective of this study is to evaluate the retention of newborn care and resuscitation knowledge and skill of birth attendants at public health facilities after 1 year of clinical practice at the health facilities within Public Health System in India. Methods: In three districts of Uttar Pradesh, knowledge and skill status of 168 birth attendants (54 doctors and 114 nurses) were documented at pre- and posttraining and after 1 year. Results: There was a marked improvement in knowledge scores (doctors: 42%–85% and nurses: 35%–86%) and skill scores (doctors: 15%–89% and nurses: 15%–90%) after training. There was significant retention of knowledge (doctors 58% and nurses 52%) and skill (doctors 82% and nurses 79%) after 1 year, although there was knowledge–skill gap observed after 1 year. Conclusion: The improvement and retention of skill and knowledge among the birth attendants were encouraging. The differential retention of skill and knowledge may be due to the training methodology and opportunity for skill refresher through the skill laboratories.

How to cite this article:
Das MK, Chaudhary C, Bisht SS, Maria A, Jain A, Kaushal SK, Khanna R, Chatterji S. Retention of knowledge and skill of birth attendants in newborn care and resuscitation after 1 Year in clinical practice: An experience from India.J Clin Neonatol 2018;7:89-95

How to cite this URL:
Das MK, Chaudhary C, Bisht SS, Maria A, Jain A, Kaushal SK, Khanna R, Chatterji S. Retention of knowledge and skill of birth attendants in newborn care and resuscitation after 1 Year in clinical practice: An experience from India. J Clin Neonatol [serial online] 2018 [cited 2022 Oct 1 ];7:89-95
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Of the 25 million children born annually in India, almost 900,000 die within the 1st month of birth.[1] Newborn deaths contribute to 55% of all under-five deaths in India.[1],[2] Decline in neonatal mortality rate (NMR) in India and globally is relatively slower than the infant mortality rate over the last three decades.[2] The first day of life is associated with the highest risk of death accounting for almost 50% of newborn deaths.[1],[2] Globally, the main direct causes of neonatal death are estimated to be preterm birth (28%), severe infections (26%), and asphyxia (23%).[3],[4] In India, an estimated 18%–20% of newborn deaths are due to birth asphyxia.[4],[5],[6] For newborns, initiation of breathing is the critical physiologic transition from intrauterine to extrauterine life. It is reported that approximately 85% of term babies initiate spontaneous breathing within 30 s of birth and an additional 10% initiate breathing with drying and tactile stimulation. Of the remaining, about 3% of the newborns require positive-pressure ventilation (PPV), 2% need intubation and ventilator support to initiate breathing function, and few (0.1%) require chest compressions and/or medications like epinephrine for the transition.[7] Effective resuscitation could prevent some of these asphyxia deaths as well as improve the outcomes of surviving asphyxiated babies. Studies on the effectiveness of neonatal resuscitation program (NRP) training and adoption of different methodologies indicate an increase in knowledge and skill scores after training. Several of the studies have documented the immediate outcomes in terms of knowledge and skills of the participants after training in low-resource settings.[8],[9],[10],[11],[12],[13],[14],[15],[16] However, there is limited information on the sustainability and retention in clinical practice in low-resource settings.

All these assessments vary in the methodology and scoring pattern, which makes the comparison challenging. However, the overall impact and trend can be considered to be positive. Ultimately, the effect of NRP on patient outcomes depends on retention of the knowledge and skills learned and their correct application. The problem of poor retention of the skills could be due to several factors including opportunity for practice in clinical setting, supportive supervision, availability of supplies and equipment, opportunity for practice, and refresher orientation. There is an assumption that provision of appropriate training coupled with an enabling environment and facility for skill practice and refresher may help in longer retention of skills among the skilled birth attendants.

An implementation project supported by USAID under the FY12 Child Survival and Health Grant Program: “Saving Newborn Lives in Uttar Pradesh through Improved Management of Birth Asphyxia (CS-28)” focused on the impact of training of the birth attendants at the public health facilities on essential newborn care and newborn resuscitation. Three districts of Uttar Pradesh: Gonda, Aligarh, and Raebareli were selected owing to higher NMR in consultation with the state government for implementation of the program. Under the program, all the health functionaries engaged in delivery and newborn care including doctors, nurses, and auxiliary nurse midwives (ANMs) at all the public health facilities in these three districts were trained on NRP and essential newborn care. The primary health centers (PHCs) are the first-level health facilities with in-patient and delivery facilities with the availability of doctor and nurses/ANMs. The community health centers (CHCs) and subdistrict hospitals are the second-level health facilities with specialists and function as first referral units (FRUs) with some having facilities for cesarean section. The district hospitals are the referral facilities with specialists and sick newborn care units providing comprehensive obstetric and newborn care. Training was provided by the technical experts from the state using a modified 3-day NRP training module with more emphasis on skill building and hands-on practice. A total of 779 birth attendants including 69 doctors, 281 nurses, and 429 ANMs at all level of facilities in the district including district hospital, CHCs, PHCs, and subcenters were trained. Twelve skill laboratories (4 in each district, including one at the district hospital and three at FRUs) were also established to provide opportunity for practice and peer-learning for retention of the skills. The skill laboratories were equipped with necessary kits including radiant warmer, self-inflating resuscitation bags and masks, mannequin, guidelines, charts, and job aids. The project was implemented through the public health system in the three districts of Uttar Pradesh, India with facilitation and supervision from Save the Children. Following the training, supportive supervision for clinical practice and neonatal resuscitation refresher training and regular standard practice drills using mannequin in skill laboratories was facilitated. Baseline and endline assessment were undertaken by INCLEN after an interval of 12–18 months to document the impact. This article reports on the retention of knowledge and skill by the birth attendants after at least 1 year of implementation of the interventions.


Study design

Impact evaluation of the implementation was done following a before-after study design was conducted in three districts of Uttar Pradesh: Gonda, Aligarh and Raebareli. A pretraining assessment was undertaken in the districts of Gonda and Aligarh in August 2014 and Raebareli in May 2015. The training of health functionaries was done during August to December 2014 in Gonda and Aligarh districts and during May–June 2015 in Raebareli district in batches of 21–28 participants. Following the training, a posttraining assessment of knowledge and skill was done. To assess the impact of the intervention, an assessment was undertaken in May 2016 in all three districts, about 12–18 months after the training. Knowledge and skill scores of health-care providers obtained during three time points, pre- and posttraining and after 12–18 months of training were compared to assess the retention. It was part of the impact evaluation of the program.

Data collection

Knowledge and skill assessment of the health providers were done on the following five domains: (a) Thermoregulation; (b) routine care; (c) resuscitation-initial steps; (d) PPV; and (e) chest compression. The assessment was done with the help of structured tools which were developed in reference to the modules and national guidelines for essential newborn care and newborn resuscitation. The tools were translated into local language (Hindi) and available in bilingual version. Knowledge assessment tools were self-administered by the participants. Once the participants completed knowledge assessment tool, skill assessment was done by a pediatrician trained in NSSK/NRP using newborn mannequins and standard NRP skill assessment modules. All the pediatricians were oriented on the skill assessment protocol and methodology to ensure uniformity. Knowledge and skill assessment were done using case scenario-based question and demonstration approach, respectively. Following the training of the participants, the knowledge and skill assessment were also done in similar manner on the last day after completion of the training sessions. The posttraining data related to the knowledge and skill were used in analysis. From each district hospital, two doctors and six nurses; from each CHC, at least one doctor (two doctors if available on the day of visit) and two nurses and from each PHC, one doctor and two nurses engaged in delivery and newborn care were included randomly. We also included ANMs from top five subcenters from each district conducting deliveries. Knowledge and skill scores were derived for five domains. For each correct response, score of one was awarded. Domain scores were calculated as percentage of correct responses under each domain. Multilevel quality assurance measures were put in place including field-level monitoring and supervision. The collected data and filled forms were checked for completeness and quality by the team leaders and INCLEN team.

Data management and analysis

Double data entry was done using customized data entry and quality check software (in-house developed at INCLEN using PHP and MySQL platform). The entered data were matched by the software and the mismatches were flagged for attention. The matched and clean data was passed to the final database. Descriptive statistics were used to summarize the proportions and means. The proportions were compared using Chi-square test. Data were analyzed using STATA (StataCorp LLC, Texas, USA) software. Sample size was estimated to detect a minimum of 25% difference in knowledge and skill scores from pretraining level (minimum score of 15%) with 80% power at 95% confidence level was 152.

Research ethics

This study was reviewed and approved by INCLEN institute ethics committee. Approval from the National Rural Health Mission, Uttar Pradesh and permission from the district health authorities were obtained.


Characteristics of health-care providers participated in the assessment

In the three districts 42 public health facilities including district hospital (n = 3), subdistrict hospital (n = 1), CHCs (n = 29), PHCs (n = 9), and 15 subcenters were included in the study. A total of 168 health functionaries participated in the study including 54 doctors and 114 nurses/ANMs. The distribution and characteristics of the doctors and nurses/ANMs are shown in [Table 1]. As few nurses were available at these facilities, we have pooled the nurses and ANMs for analysis and interpretation. The median number of years of service for doctors and nurses was found to be 8 and 9 years, respectively.{Table 1}

The status of knowledge scores among the doctors and nurses in the five domains at three time points of assessment, pre- and posttraining, and retention after 1 year are reflected in [Table 2].{Table 2}

Status of knowledge retention

As reflected in [Table 2], the pretraining scores for knowledge were low for both doctors and nurses and comparable for all the domains. The knowledge scores for both doctors and nurses markedly increased after training [Table 3]. The knowledge scores declined across all the domains after 1 year of training. The knowledge scores were better for doctors than the nurses in most of the domains. There was a larger decline in scores in the domains of PPV and PPV corrective measures. The changes in scores across all domains were statistically significant [Table 3].{Table 3}

Status of skill retention

As reflected in [Table 2], the pretraining scores for skill in all domains were very low for both doctors and nurses. Following the training, the scores across all skill domains improved markedly. After 1 year, there was significant retention in the skill status across all the domains for both doctors and nurses [Table 3]. The skill scores were highest for thermoregulation and lowest for PPV corrective measures for both doctors and nurses. There was no statistically significant difference among the performance of nurses compared to the doctors.

Knowledge–skill gap

The knowledge–skill score gap for doctors and nurses according to the domains is shown in [Figure 1] and [Figure 2]. Both doctors and nurses had considerably higher skill scores compared to their knowledge scores in all the domains of newborn care and resuscitation. The gap was wider in the domains of PPV and corrective measures during ventilation.{Figure 1}{Figure 2}


This study attempted to document the impact of the modified 3-day training on neonatal resuscitation and essential newborn care for the doctors and nurses at Public Health Facilities in three districts of Uttar Pradesh. The pretraining status of knowledge (15%–53%) and skill (9%–21%) among the doctors and nurses was poor for most of the domains. The project used a modified training package with more emphasis on the skill building through hands-on practice followed by creating opportunity for continued peer-stimulated refresher opportunity through the skill laboratories. The assessment after 1 year of training showed significant retention of the knowledge (21%–77%) and skill (69%–96%) among the doctors and nurses. However, there was considerable gap in the knowledge and skill scores for all the areas of assessment. The gaps were consistent for both the doctors (13%–39%) and nurses (9%–48%). The reason for the knowledge–skill gap was not clear. We assume the knowledge–skill gap phenomenon may be due to the modified training module and pro-skill methodology coupled with the skill laboratories with opportunity for skill practice. We reviewed the function and activities at the 12 skill laboratories. On average, these skill laboratories conducted about 19 (range: 7–60) peer-training sessions. As per the available attendance records at these skill laboratories, 157 doctors and 449 nurses attended the training sessions. The batch sizes ranged from 4 to 12 participants, and usually, the sessions lasted for 2–4 h. Based on the interaction with the health functionaries, it was understood that the skill laboratories provided opportunity for repeated skill practice using the mannequin, bag and mask, but not the knowledge. Probably, the participants have retained how to do the things better than the rationale and concepts for the actions.

The reports from India, Zambia, Ghana, and Malawi have reported improvement of knowledge and skill scores following the neonatal resuscitation trainings.[8],[9],[10],[11],[12],[15] The study in Delhi documented improvement in NRP knowledge scores among nurses from 19.1 to 30.7 and skill scores from 12.8 to 20.6 after training.[8] The study from Zambia reported an increase in the knowledge and skill scores among nurses from 56% to 71% and 58% to 81%, respectively, after training. These scores declined after 6 months of training.[9] In the study among health-care providers in Malawi, there was increase in knowledge and skill scores from 30.4% to 58.7%, and 57.5% to 75.5%, respectively.[10] Among multi-cadre health professionals in Ghana, there was improvement in knowledge scores from 38% to 71% for midwives, 43% to 81% for nurses, and 62% to 98% for physicians.[11] There are few reports on retention of knowledge and skill after longer time. A report from Tanzania reported significant improvement in the knowledge scores among health-care providers, but the retention of skill was poorer compared to the knowledge.[17] The knowledge scores changed from 23% in 2010 to 41% in 2012 (P< 0.0001). The knowledge of equipment required for essential newborn and resuscitation care rose by 34% (P< 0.0001). The skill retention was poorer, as 32% of the health-care providers were able to correctly perform tactile stimulation and bag-mask ventilation in 2012 compared to 28% in 2010.[17] Among Canadian health-care providers (doctors and nurses), there was better retention of knowledge scores at 12 months after training, but the skill scores dropped after 6 months.[18] The magnitude of improvement has been variable, perhaps due to variation in the training and assessment methodology. Lack of uniformity in the methodology challenges the comparability between the studies.

Globally, especially in developing countries with high neonatal mortality, appropriate and timely resuscitation remains a challenge. The low performance and poor retention of newborn resuscitation skill and knowledge continue to question what needs to be done and how to improve and retain providers' skills in newborn resuscitation, especially at peripheral health facilities with low delivery load, with limited opportunity to perform resuscitation. The current study documented the experience of the skill and knowledge retention by the health-care providers with training and opportunity of skill practice at the skill laboratories at the local health facilities. The study has several limitations. There was no interim documentation of the knowledge and skill of the health-care providers at before end of the year. The participants at pre- and posttraining and follow-up after 1 year were not same and the participants were selected randomly from the health-care providers available on the day of visit to the facility.


To the best of our knowledge, this was the first implementation research using the modified training methodology focusing on skill building in neonatal resuscitation coupled with an opportunity for skill retention through the skill laboratories at local nodal health facilities. There was encouraging level of skill scores observed among the health providers, nurses, and doctors after 1 year of training. The retention in knowledge scores was lower than the skill score level. The knowledge–skill gap among the doctors and nurses was consistent. The reason for the observed knowledge–skill gap is not clear. However, we feel that the gap may be due to the methodology of training, which focused on hands-on practice and refresher skill practice through the skill laboratories. Implementation of the activities across all levels of health facilities in these districts within public health system assures about generalizability. Further exploration is needed to understand the factors affecting how health-care providers gain and retain knowledge and skills related to neonatal resuscitation.


We acknowledge the support of National Health Mission, Government of Uttar Pradesh and District Health Administration of the districts for their continued facilitation and support. We highly appreciate the participation of the doctors, nurses, and ANMs in these districts. We also acknowledge the contribution of the pediatricians and other research team members for accomplishing the study.

Financial support and sponsorship

This manuscript is the result of a research study supported by the United States Agency for International Development through the Save the Children, India.

Conflicts of interest

There are no conflicts of interest.


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