Retention of knowledge and skills among midwives one year after completing helping babies breathe pre-service training in Ethiopia: a non-randomized quasi-experimental study

Abstract

Background

Neonatal mortality remains a significant public health challenge in Ethiopia, often attributed to asphyxia at birth. Helping Babies Breathe (HBB), an evidence-based neonatal resuscitation program aims to address this issue. However, the sustainability of knowledge and skills acquired during pre-service training is less understood.

Objective

This study assessed the retention of knowledge and skills among midwives one year after completing the HBB pre-service training in Ethiopia.

Methods

A non-randomized quasi-experimental study was conducted involving a cohort of midwifery graduates who completed HBB training during their final year. Knowledge was assessed using a multiple-choice questionnaire, while skills were evaluated using Objective Structured Clinical Examinations (OSCEs). Data were collected immediately post-training, six months later, and one year later. Paired t-tests and Wilcoxon signed-rank tests were used to analyze changes over time.

Results

Of the 60 midwives initially trained, 50 (83.3%) participated in the follow-up assessment. The median knowledge score decreased significantly from 98% immediately post-training to 74% one year later (p < 0.01). Similarly, OSCE performance declined, with 36% of participants demonstrating proficiency compared to 62% at baseline (p < 0.05). A paired t-test was performed to evaluate whether students’ psychomotor skills significantly declined 12 months after initial training. The results of the analysis showed a highly significant decline in psychomotor skills during this time, with a mean difference of -2.29 (SE = 0.29; p < 0.001). This negative mean difference, with pre-test scores averaging 27.59 (SD = 2.78) and post-test scores after 12 months averaging 25.31 (SD = 2.11), indicates a noticeable drop in skill levels following training.

Conclusion

While midwives retained moderate knowledge and skills one year after completing HBB training, significant attrition highlights the need for periodic refresher training and improved access to resuscitation tools. Strengthening these aspects may enhance the long-term impact of HBB in reducing neonatal mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40748-025-00201-2.

Background

Many neonatal deaths that occur within the first 28 days could be prevented with quality care at birth, or skilled care and treatment offered immediately after birth. In 2022, almost half (47%) of all deaths in children under five occurred during the neonatal period, which is one of the most vulnerable periods of life. Birth asphyxia or the inability to initiate or sustain spontaneous breathing at birth, accounts for between 27 and 30% of newborn deaths in low-resource countries like Ethiopia [1]. Improved quality newborn and intrapartum care is required [2]. Sub-Saharan Africa (SSA) has the highest rate of neonatal death at 28 per 1,000 live births, which is 10 times higher than that of high-income regions [3]. Ethiopia has one of the highest rates of newborn mortality in the world with 29 deaths for every 1,000 live births [4]. This is almost nine times higher than the average of 3 deaths for every 1,000 live births in wealthy countries. The Sustainable Development Goal (SDG) 3.2 aims to end preventable deaths of newborns and children under 5 years of age by 2030. Its goals are to reduce neonatal mortality to at least 12 per 1000 live births and under-5 mortality to at least 25 per 1000 live births [5].

The American Academy of Pediatrics (AAP), in partnership with the World Health Organization (WHO), launched and developed the life-saving training program Helping Babies Breathe (HBB) in 2010 [6]. HBB is a 1-to-2-day simulation-based program to teach healthcare professionals (HCPs) the initial steps of neonatal resuscitation. One of the most important tasks for HCPs is to perform neonatal resuscitation within the first minute following delivery, also referred to as “The Golden Minute.” The newborn’s shift from fetus to newborn breathing in extra uterine life occurs at this crucial period when survival and possibly even growth are at stake. The initial steps include assessing a baby, drying a baby thoroughly, and keeping the baby warm on the mother’s chest while removing secretions if needed; basic interventions in that 90% of newborns who are not breathing will start breathing on their own [6, 7]. HBB is a vital educational program designed to enhance neonatal resuscitation skills among healthcare providers, significantly impacting newborn survival rates. The program emphasizes immediate care practices, such as stimulating breathing, initiating bag-mask ventilation (BMV), and delayed cord clamping (DCC). Research indicates that HBB training leads to improved clinical performance and reduced neonatal mortality, particularly in low-resource settings [8, 9].

HBB knowledge and skills can be boosted over time and retained using easy, low-cost interventions. Regular practice is necessary to develop the skills needed for life-saving clinical procedures such as bag-and-mask resuscitation [10]. Normal deliveries are mainly handled by nurses and midwives in Ethiopia. HBB, which was designed specifically for midwives and birth attendants in low-resource nations like Ethiopia, enhances neonatal resuscitation abilities through practical instruction and practice on a newborn mannequin simulator [11]. Research has addressed variations in the retention of HBB knowledge and skills. For example, a study in Kenya and India found that skills declined more quickly than knowledge over time, and it was suggested that continuous practice and monitoring, more recurrent retesting, and refresher training are essential to maintain neonatal resuscitation skills [12]. This study aimed to assess midwives’ retention of knowledge and skills after completing HBB pre-service training.

The study design, population and sampling

This study used a quasi-experimental study. The study population consisted of BSc-licensed midwives who completed the HBB pre-service training in 2023. Sixty fourth-year midwifery students completed the HBB courses for two days during the first phase at baseline and immediately after two days, held between May and July 2023. Participants for the current study were selected using a purposive sampling method, based on their prior training in HBB protocols in 2023. They were invited to participate in the follow-up study, conducted between May and June 2024, through email or mobile phone contact. Fifty of those invited agreed to take part, and they were reassessed for two days at six and twelve months.

Evaluation of knowledge and practical skills

Four-time points for testing were used to obtain scores: before training, two days after training, at 6 months, and one -year after training. This article extends the “HBB Project,” which assessed participants’ knowledge and skills at baseline and two days post-training at Addis Ababa University (AAU) and Menelik II Medical & Health Science College in Addis Ababa, Ethiopia, in 2023. The findings will be published in a separate journal. In the current article, the authors aimed to examine the changes in knowledge and skills at 6 months and one year post-training.

The HBB training materials used in the study were developed by the AAP and WHO and were (Second edition). A multiple-choice (MCQ) questionnaire was used to determine the level of HBB knowledge among participants. To gauge their knowledge, participants completed a 30-minute written test before and after the training sessions after six and twelve months. The test consisted of 18 MCQs based on the HBB flip chart (Appendix S1).

An assessment of post-course practical skills was conducted using the NeoNatalie mannequin, an inflatable simulator designed to teach basic neonatal resuscitation, and the Objective Structured Clinical Examination B (OSCE B) after six and twelve months (Appendix S2). As the participants practiced on a mannequin, a designated instructor gave them instructions and gave them feedback on their skills. The OSCE B includes 18 items reflecting the key components of the course. Each item was scored a 1 if carried out correctly. Any partially correct or incorrect action was scored as 0. A passing score required 14 items to be completed (78%) of a total of 18 tasks. The 14 items correctly performed must include the following main procedures: recognize baby is not breathing, ventilate at 40 breaths per minute, look for chest movement, and improve ventilation.

The HBB training was led by the principal investigator (PI), a midwifery educator, and one tutor who is a Master HBB-certified midwife. The training session was divided into smaller groups to ensure a ratio of one trainer to five trainees (1:5) and to provide them feedback on their skills.

Data analysis

Data from answer sheets and evaluation checklists were collected and entered in EPi Data version 4.0.2.49 and then exported to SPSS version 25 for data further cleaning and analysis. The descriptive results were obtained to describe the study participants concerning their sex and age composition, and mean score test results at each evaluation point. Since the knowledge level of the educators was obtained at different times (repeated measure), the score of the students at different points is expected to be correlated. For such measurements, Freidman test is appropriate to compare the mean differences at each point where the number of mean to be compared is more than two given that the assumptions of parametric test is failed. Hence, Freidman test was used to test whether the training rain improved the knowledge of the educators, and that knowledge is retained through comparisons of their mean knowledge score at pre-training, immediately after training, six months, and one year. A chi-square test with a p-value of 0.05 was used to declare the existence of the mean knowledge differences. Following the significance of the omnibus test, the Wilcoxon sign rank test was followed to identify the point of the differences. These differences were decided based on the values of the Z-test with its corresponding p-values. Similarly, the psychomotor skill was measured at two points i.e. immediately after training and one year. The difference was evaluated with a paired t-test and its significance was declared at p-value 0.05. Finally, the result was presented through tables and graphs.

Clinical trial number

not applicable.

Ethical clearance

The study was granted ethical approval [Protocol Number 008/23/Midwife] by the Institutional Review Board for the College of Health Sciences [IRB- CHS] at Addis Ababa University. The purpose of the study was explained to the study participants, and they gave informed voluntary, written consent. Their involvement in the study was completely voluntary, and they were free to stop at any time or refuse to answer any questions that made them uncomfortable. The data-gathering process was anonymous to protect the confidentiality of any information supplied by study participants.

Results

Background characteristics of study participants

Participants in this study included 60 fourth-year midwifery students from two public health science colleges that provide undergraduate midwifery education. Of them, 54 successfully finished the pre-test and immediate post-test evaluations after completing a two-day HBB training course. Six students withdrew from the study during the immediate post-test phase due to personal reasons. Finally, 50 students completed the entire follow-up and recorded test scores. Of these participants, 44 were female, and 6 were male. The participants’ ages ranged from 21 to 24 years, with an average age of 22.18 years and a standard deviation of 0.94. (Table 1)

Table 1.

Age and sex distribution of study participants, September, 2024

Variable	Category	Frequency (%) N = 50
Sex	Male	6(12.00)
	Female	44(88.00)
Age	Mean(SD)	22.18(0.981)

Knowledge and psychomotor skill distribution of study participants

To assess the effectiveness of the HBB intervention, participants completed a 30-minute written test consisting of 18 multiple-choice questions before the course, immediately after, six months, and twelve months post-intervention. This test evaluated their knowledge of neonatal resuscitation. The findings showed that prior to the intervention, more than one-third of the participants (19; 38%) had inadequate knowledge about managing birth asphyxia. Following the intervention, nearly all participants (98%) achieved adequate knowledge of newborn resuscitation immediately after the HBB training. However, this level of knowledge gradually declined over time, with 37 participants (74%) maintaining adequate knowledge. The post-intervention assessment indicates a substantial decrease in the proportion of individuals with adequate skills, dropping from 62 to 36%. Conversely, the percentage of individuals with inadequate skills increased from 38 to 64% (Table 2).

Table 2.

Knowledge and psychomotor skill distribution of study participants, September, 2024

Variable	Adequate knowledge	Inadequate knowledge	Mean score rank for knowledge /mean score for skills
Knowledge level before intervention	31(62.00)	19(38.00)		1.91
Knowledge level immediately after intervention	49(98.00)	1(2.00)		3.45
Knowledge level at six months of intervention	44(88.00)	6(12.00)		2.66
Knowledge level at twelve months of intervention	37(74.00)	13(26.00)		1.98
Psychomotor skill at baseline intervention	31(62.00)	19(38.00)		27.59
Psychomotor skill after 12 months of intervention	18(36.00)	64(64.00)		25.31

Test for the difference in knowledge pre and post-HBB training intervention

The line graph demonstrates how the intervention initially increased the students’ knowledge levels over a brief period. However, following the immediate post-intervention phase, the curve’s slope turns negative, indicating a gradual decline in knowledge retention over time. (Fig. 1)

Fig. 1.

Line curve representing the mean score of the study participant at different time points

The descriptive analysis revealed a variation in knowledge levels across the pre-intervention, immediate post-intervention, six-month, and twelve-month assessments regarding newborn resuscitation [Table 3]. A Friedman test was used to determine the points at which the differences are statistically significant. The findings showed that the mean ranks of the knowledge level scores varied significantly. (χ² = 59.03, p-value = 0.00).

Table 3.

Pairwise comparison of the mean score levels at different points in time

Possible Pairwise differences	Z-value	P-value
Immediate post-training test result - Pre-test result	-5.002b	0.00
Post-test result after six months - Pre-test result	-3.141b	0.002
Post-test result after twelve months - Pre-test result	-1.098b	0.272
Post-test result after six months - Immediate post-training test result	-3.338c	0.001
Post-test result after six months - Immediate post-training test result	-5.182c	0.00
Post-test result after twelve months - Post-test result after six months	-3.570c	0.00

a. Wilcoxon Signed Ranks Test

b. Based on negative ranks

c. Based on positive ranks

The omnibus test results indicated a significant difference in the mean knowledge level scores. As a result, a Wilcoxon Signed Rank post hoc test was conducted to identify the specific points of difference among the means. The results revealed significant differences in all possible pairwise comparisons, except between the pre-test and twelve-month post-test, where no significant difference was observed. (Table 4)

Table 4.

Paired t-test result for psychomotor skill among participants, September 2024

	Mean(SD)	Mean difference(SE)	p-value
Pre-test	27.59(2.78)	-2.29(0.29)	0.00
Post-test after 12 months	25.31(2.11)

Test for the difference in psychomotor skill pre and post-HBB training intervention after twelve months

The paired t-test was conducted to assess whether the psychomotor skills of students declined significantly 12 months after initial training. Assumptions of the paired t-test, including the normality of the difference scores, were verified before the analysis. The results indicated a significant decrease in psychomotor skills among the students after 12 months, with a mean difference of (-2.29, SE = 0.29; p-value = 0.00), which is highly significant. This negative mean difference demonstrates a measurable drop in skill level post-training, with pre-test scores averaging 27.59 (SD = 2.78) and post-test scores 12 months later averaging 25.31 (SD = 2.11). (See Table 4)

Discussion

This study assessed the retention of knowledge and skills among midwives one year after completing the Helping Babies Breathe (HBB) pre-service training in Ethiopia. Studies show that Continuous training and practice are crucial for maintaining the skills necessary for neonatal resuscitation, as skills tend to decline over time without reinforcement [13, 14]. The findings from the current study provide insight into the feasibility of neonatal resuscitation training in resource-constrained settings in Ethiopia. The study found that midwives’ knowledge scores decreased statistically significantly a year after the intervention, despite having a solid foundation immediately following the intervention. This decline is in line with findings from other studies that demonstrated that early gains in neonatal resuscitation knowledge gradually faded in the absence of ongoing reinforcement [1, 15]. The reduction emphasizes the necessity of regular refresher courses to ensure midwives retain their knowledge and apply it effectively in neonatal emergencies.

Skills retention presented a more concerning trend, with notable deterioration observed in key competencies such as effective bag-mask ventilation. This decrease is consistent with past studies that show that, in contrast to theoretical knowledge, skill retention is more susceptible to deterioration over time [16]. The results imply that regular simulation-based retraining is necessary for skill-based practices to strengthen competency. Furthermore, the loss of skills might have been caused by environmental factors like insufficient simulation tools in the workplace and little exposure to real-life neonatal resuscitation scenarios. The variability in retention among participants designates the influence of factors such as workload, practice opportunities, and institutional support. Midwives in facilities with functional equipment and supportive supervisors demonstrated better retention, echoing evidence from studies that emphasize the importance of system-level readiness in sustaining skills [17, 18]. Furthermore, the lack of structured mentoring programs may have limited the ability to translate knowledge into practice over time [19].

Implications for practice and policy

The results highlight the necessity of including regular refresher courses in the national curriculum in order to guarantee long-term proficiency in neonatal resuscitation. Incorporating low-dose, high-frequency training sessions, as recommended by studies [20, 21], could address gaps in retention and enhance HBB performance. Enhancing the accessibility of resuscitation tools and simulation models in health facilities is also essential for promoting ongoing practice.

Study strengths and limitations

This study contributes valuable evidence on the long-term outcomes of HBB training in Ethiopia. However, its quasi-experimental design and the lack of a control group limit the ability to draw causal inferences. Future research could use randomized controlled designs and examine how supportive supervision and mentoring can improve the retention of skills.

Conclusion

In conclusion, while HBB training effectively builds initial knowledge and skills in neonatal resuscitation, maintaining these competencies over time remains a challenge. Our study highlights the importance of continuous training and practice in maintaining neonatal resuscitation skills, as these skills tend to deteriorate over time without regular reinforcement.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

EGS conceptualized and designed the study, served as the principal applicant for funding, and took the lead in writing the manuscript. FA and LAG conducted the quantitative data analysis and interpretations. All authors reviewed and approved the final manuscript.

Funding

This research was funded by the Laerdal Foundation under grant number 2022 − 0192. However, the opinions expressed in this publication are solely those of the authors and do not represent the views of the funding agency.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

The study was granted ethical approval [Protocol Number 008/23/Midwife] by the Institutional Review Board of the College of Health Sciences [IRB-CHS] at Addis Ababa University.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.