The newborn mortality rate decreased by 47% worldwide between 1990 and 2015, from 36 to 19 deaths per 1000 live births, but the rate has declined more slowly in most low-resource settings, and is still far from the Sustainable Development Goal of less than 12 newborn deaths per 1000 live births by 2030.¹ Nearly half of newborn deaths take place during the first day of life [1]. Intrapartum-related events are now the third leading cause of all deaths among children under age 5 (U5 mortality) [2]. Rates of intrapartum stillbirths are a measure of the quality of care during labor, and newborn mortality in the 24 h following birth can reflect the quality of care during labor as well as immediate postnatal care [3].

Ghana’s U5 mortality rate is 60/1000 live births and the newborn mortality rate is 29/1000 live births. Thus, newborn mortality represents 48% of U5 mortality despite the fact that 68% of births occur with a skilled birth attendant (SBA)² present [4]. The country’s stillbirth rate is estimated at 22/1000 total births, although this estimate is not disaggregated by fetal deaths prior to labor or intrapartum stillbirths, and accurate information about the incidence of intrapartum stillbirth is lacking [5]. Two major causes of newborn deaths in Ghana, asphyxia (23%) and sepsis (32%), [6] could be prevented by increasing the use of evidence-based interventions during labor, birth, and the immediate postnatal period. The Ghana National Newborn Health Strategy and Action Plan 2014–2018 describes the country’s goal to reduce institutional newborn mortality by at least 35% by 2018 through training of least 90% of SBAs in essential newborn care and basic resuscitation [6].

In-service training for SBAs is one of the most common interventions to address lack of knowledge and skills. However, these training interventions are seldom evaluated for effectiveness in improving learning or performance [7]. A literature review of effective in-service training described techniques that may improve learning outcomes and result in changes in performance [8]. The review found that didactic instruction often results in improved knowledge but no improvement in clinical practice. In contrast, the use of interactive techniques, including clinical simulation, case-based learning, hands-on practice with anatomic models, and immediate feedback on performance, results in greater improvement in knowledge and/or clinical practice than do passive techniques such as lecture or reading. Targeted, repeated training opportunities are preferable to one-time training and lead to the use of new skills in the clinical setting. Workplace learning may be superior for skill acquisition, and using multiple types of media can deliver training more efficiently. Thus, learning at the job site coupled with ongoing, repeated exposure to content is associated with greater improvement in clinical performance and health outcomes.

We hypothesized that the LDHF approach to improving clinical skills would lead to a reduction in institutional intrapartum stillbirths and newborn mortality within 24 h of birth during the year of the intervention. We also hypothesized that the approach would result in improved and retained skills and knowledge among SBAs in maternity wards in study sites after a year.

In the 40 facilities, 403 SBAs consented and were enrolled in the study. Two hundred and one SBAs (50%) were available for OSCE and knowledge assessment at 1 year after the intervention due to SBA rotation to other facilities, further education, and annual leave (Fig. 3).

Implementation of the LDHF package resulted in a 55% reduction in risk of newborn mortality within 24 h of birth in the 6 months after LD1 (unadjusted RR 0·45, 95% CI 0·35–0·58; p < 0·001) and a 65% reduction in risk in the next 6-month follow-up period (unadjusted RR 0·35, 95% CI 0·24–0·50; p < 0·001). After adjusting for region and facility level, the reduction in risk increased to 59% and 70%, respectively (adjusted RRs 0·41, 95% CI 0·32–0·51 and 0·30, 95% CI 0.21–0.43, in months 1–6 and months 7–12, respectively). Regional-level facilities had a significantly greater risk of 24-h newborn mortality compared to district-level facilities and polyclinics (RR 5·11, 95% CI 3·55–7·36; p < 0·001).

There was no evidence of a temporal trend in intrapartum stillbirth or 24-h newborn mortality rates in study sites before the intervention. Therefore, the model did not adjust for calendar time. Once the intervention began, newborn mortality declined significantly from 1 month to the next over the one-year intervention period. Intrapartum stillbirth rates did not change significantly on a monthly basis; from this, we infer that the reduction in stillbirth rate was more drastic and immediate following the start of the intervention, and remained low for the remainder of the one-year follow-up period. Wave 3 facilities showed a greater reduction in risk of 24-h newborn mortality during months 7–12 post-intervention compared to facilities in the other three waves. Risk of intrapartum stillbirth decreased more dramatically in wave 2 facilities compared to other facilities (Additional files 1 and 2: Tables S1 and S2). We found no significant difference in the mortality rates as a result of a master mentor being present at a study site.

We tested to see if there is a difference in the mortality rates between cohorts of facilities in the intervention phase and the baseline phase during the same calendar period. In all three time periods analyzed, newborn mortality rates were significantly lower in facilities in the intervention phase compared to those in the baseline phase; intrapartum stillbirth rates were also lower but only statistically significant in two of the three analyzed calendar periods. This analysis was conducted for a subset of the total study time and outcome observations, as the study was not designed or resourced to conduct a full randomization with comparison sites throughout the study duration.

The primary aim of the study was to assess newborn outcomes. Results showed significant reduction in intrapartum stillbirth and newborn death within 24 h. This could indicate that the quality of care during labor was sufficient to maintain maternal and fetal well-being. In addition, since resuscitation was attempted for all non-macerated newborns not breathing at birth, many babies who would otherwise have been declared intrapartum stillbirths but actually had intrapartum-related asphyxia, were successfully resuscitated [11] corroborating the assertion by Wall et al. that training SBAs in newborn resuscitation could prevent up to 30% of mortality in full-term babies due to intrapartum-related events [12]. Reduction in newborn deaths within 24 h may be attributed to the use of newborn care interventions for every baby (immediate drying and warming, skin-to-skin-contact, and immediate and exclusive breastfeeding) as well as rapid recognition and appropriate management of intrapartum-related asphyxia.

A second aim of the study was to assess the effect of the LDHF package on retention of key knowledge and skills after 1 year. We found that SBAs retained most knowledge and skills gained during low-dose sessions, which contributed to their ability to apply appropriate clinical interventions for improved newborn outcomes. The expectation after the low-dose sessions was that SBAs’ skills should not be lost after training, but maintained or even improved. The lowest 1-year OSCE score occurred in relation to LD1, which dealt with care during normal labor and birth and newborn resuscitation. This implies that although SBAs attended many births, their practices did not reflect the evidence-based approaches presented during the first low-dose session. Thus, they might have needed more practice in simulated and clinical settings in the updated skills and/or reinforcement by PPCs or master mentors. Similarly, the skills for newborn resuscitation were new for most SBAs, and since resuscitation is a comparatively rare event, there may have been a need for reinforcement over time to maintain them. This is consistent with evaluations of maintenance of newborn resuscitation skills during which SBAs had the opportunity to review and practice skills on a regular basis after training [13].

In addition, our results demonstrate the impact and importance of an integrated package of evidence-based, clinical interventions that considers the continuum of care for the mother and baby on the day of birth. The components of the LDHF approach were chosen to target the major global causes of intrapartum-related events that are associated with up to 42% of maternal mortality, 32% of stillbirths, and 23% of newborn mortality [14]. They included cross-cutting elements of care that can improve maternal and newborn outcomes, such as respectful maternity care, which includes encouragement of continuous support during labor, ambulation, and positions of choice for labor and birth. These have been shown to decrease the duration of labor and the use of cesarean or assisted delivery [15, 16]. Key evidence-based infection prevention practices were introduced during LD1 to decrease the risk of maternal and newborn sepsis. Hand hygiene, [17] instrument processing, [18] reduction of vaginal exams during labor, [19] avoiding routine rupture of membranes, [20] and prompt management of maternal fever and newborn sepsis were emphasized [21]. Severe pre-eclampsia and eclampsia are implicated globally in up to 4·7% of stillbirths, with the highest burden in south Asia and sub-Saharan Africa. Improved management of these disorders during labor could avert these deaths [22, 23]. Respectful maternity care and infection prevention were part of all OSCEs and skills checklists used by providers during training and high-frequency practice sessions.

The study emphasized correct use of the partograph to monitor labor and support clinical decision-making, which has been shown to improve identification of prolonged labor, a major contributor to perinatal mortality [24]. Best practices for immediate newborn care included immediate drying and skin-to-skin contact, [25, 26] delayed cord clamping, [27] and breastfeeding in the hour following birth [25].

Leading causes of maternal mortality in sub-Saharan Africa include hemorrhage (25%), hypertension (16%), and sepsis (10%) [5]. Data for Ghana indicate that hemorrhage causes 24·3% of maternal mortality, hypertension accounts for 8·5%, and sepsis is the cause of 6·7% of deaths [28]. Thus, the LDHF approach targeted management of severe pre-eclampsia/eclampsia, using magnesium sulfate and antihypertensive medications, [29] and prevention and treatment of postpartum hemorrhage [30].

One of the factors contributing to effective implementation of the LDHF approach was close collaboration with all levels of the Ghana Health Service. National-level support was obtained at the outset, and regional health directors agreed to implementation in their regions. They also selected the MMs who carried out study activities as part of their normal duties; no MMs or SBAs were hired for the study. The investment in the development of a cadre of ten MMs in each region enabled close local follow-up of PPCs and SBAs in study facilities, both face-to-face and via mMentoring.

This study provides evidence that can guide strategies for health worker capacity-building at scale. Our results show a plausible causative association between use of an LDHF approach for facility-based in-service training and significant reductions in intrapartum stillbirths and newborn deaths in health facilities in low-resource settings. Health facilities did not undergo structural changes or receive additional equipment beyond delivery sets and resuscitation equipment. The LDHF approach built SBAs’ competency in essential maternal and newborn health care practices. In each facility, all SBAs providing intrapartum and immediate postpartum care participated in this approach, resulting in facility-wide improvement in service quality, while minimizing the amount of time the SBAs spent outside of their facilities. It also enabled nearly all SBAs in each facility to receive the same training and follow-up support, which may have enhanced consistency of knowledge and skill transfer to the clinical setting. The critical mass of trained SBAs at each facility reinforces learning and builds a system of checks and balances throughout the health facility, likely rendering the change more sustainable. Coupled with ongoing practice and mentorship, improved practices are sustained and health outcomes continue to improve over time, even with staff attrition and turnover, as new SBAs are taught the skills by existing staff and can practice them on the simulators. Moreover, a pool of highly competent MMs enables continued application of the package after the study ends.

There are methodological limitations to consider in assessing the study implications. Because the study was embedded in program implementation, facility staff were aware of the outcome of interest, which could have affected their actions and performance. The presence of MMs at some facilities before intervention start-up could also have affected baseline outcome measurement rates. However, our analysis shows that mortality rates in all waves were comparable at baseline, and therefore we do not believe this has an effect on the results achieved. In addition, our study was not designed to be able to conduct a full time-series or randomized control trial analysis, due to resource limitations on baseline and control site data collection. Multiple analyses conducted using available data demonstrate qualitatively the same result. Other sources of potential bias include lack of concealment in group (i.e., wave) assignment and information bias such that data quality may have improved after the intervention started. In all likelihood, improved data quality following the intervention would result in more deaths being reported, rather than fewer, resulting in a smaller observed effect.

Although the regions for study implementation were chosen specifically to avoid overlap with other interventions conducted by the GHS and nongovernmental organizations, some SBAs from study facilities were invited to attend training on content related to BEmONC and/or newborn resuscitation, but none of the training was similar to the LDHF approach. However, the influence of these activities on our outcomes cannot be ruled out.

Finally, while the technical approach demonstrates results, other factors such as cost and human resource availability (for trainers and mentors) must be considered. A nested costing study showed that the LDHF package was less expensive per participant compared to the traditional approach [31].

Implementation of an LDHF approach to train SBAs in key evidence-based intrapartum and immediate newborn care practices is associated with a significant reduction in the risks of intrapartum stillbirth and newborn mortality within 24 h of birth. The components of the approach were chosen specifically to address the most common causes of intrapartum stillbirth and early newborn death in Ghana and were reinforced in multiple ways: classroom learning and practice with simulators during and between low-dose sessions; peer-led practice and feedback between and after low-dose sessions; follow-up via targeted SMS messaging and support by a master mentor; and robust data collection and reporting. In addition, all training was done onsite and involved nearly all maternity ward SBAs at each site. These elements contributed to transfer of knowledge and skills to the clinical setting and thus to improved outcomes. The adoption of the LDHF approach in Ghana and other low-resource countries has the potential to contribute to the acceleration of newborn survival and the achievement of Sustainable Development Goal 3 (reduction of neonatal mortality to at least as low as 12 per 1000 by 2030).

Policymakers and health partners should review current approaches to improving service delivery in maternal and newborn health, and consider investing in and adopting this approach as an innovative and effective method of training health care workers. While further research is necessary, we believe this approach should be considered for the improvement of clinical services in other technical areas that mandate acquisition and retention of skills to improve health outcomes.