The power of practice: simulation training improving the quality of neonatal resuscitation skills in Bihar, India.

BACKGROUND: Globally, neonatal mortality accounts for nearly half of under-five mortality, and intrapartum related events are a leading cause. Despite the rise in neonatal resuscitation (NR) training programs in low- and middle-income countries, their impact on the quality of NR skills amongst providers with limited formal medical education, particularly those working in rural primary health centers (PHCs), remains incompletely understood. METHODS: This study evaluates the impact of PRONTO International simulation training on the quality of NR skills in simulated resuscitations and live deliveries in rural PHCs throughout Bihar, India. Further, it explores barriers to performance of key NR skills. PRONTO training was conducted within CARE India's AMANAT intervention, a maternal and child health quality improvement project. Performance in simulations was evaluated using video-recorded assessment simulations at weeks 4 and 8 of training. Performance in live deliveries was evaluated in real time using a mobile-phone application. Barriers were explored through semi-structured interviews with simulation facilitators. RESULTS: In total, 1342 nurses participated in PRONTO training and 226 NR assessment simulations were matched by PHC and evaluated. From week 4 to 8 of training, proper neck extension, positive pressure ventilation (PPV) with chest rise, and assessment of heart rate increased by 14%, 19%, and 12% respectively (all p ≤ 0.01). No difference was noted in stimulation, suction, proper PPV rate, or time to completion of key steps. In 252 live deliveries, identification of non-vigorous neonates, use of suction, and use of PPV increased by 21%, 25%, and 23% respectively (all p < 0.01) between weeks 1-3 and 4-8. Eighteen interviews revealed individual, logistical, and cultural barriers to key NR skills. CONCLUSION: PRONTO simulation training had a positive impact on the quality of key skills in simulated and live resuscitations throughout Bihar. Nevertheless, there is need for ongoing improvement that will likely require both further clinical training and addressing barriers that go beyond the scope of such training. In settings where clinical outcome data is unreliable, data triangulation, the process of synthesizing multiple data sources to generate a better-informed evaluation, offers a powerful tool for guiding this process

Aflatoxin B1 Contamination in Porridge Formulations for Children and Ingredients Sourced From Selected Markets in Rwanda

Providing safe and nutritious food for children globally is a challenge. In Rwanda, an initiative was introduced in 2018 to tackle chronic malnutrition by offering fortified porridge flour to economically disadvantaged families during critical periods. However, flour-based products in the sub-region have caused public health concerns following aflatoxin B1 (AFB1) contamination. This study analyzed the levels of AFB1 in 197 porridge formulations from health centers, and 248 samples of porridge ingredients from open markets in three districts of Rwanda. Samples were collected between June 2021 and December 2022 and analyzed using ultra-high-performance liquid chromatography. Of the 197 samples from health centers, 97.9 and 89.8% exceeded the European Union maximum limits for baby foods and foods for special medical purposes (0.1 μg/kg), and cereals and nuts (2 μg/kg), respectively with an average contamination level of 2.77 μg/kg (±0.98). Only four samples exceeded the East African Community maximum limits of 5 μg/kg for AFB1. Samples from open markets that exceeded the European Union and East African community limits of 0.1 μg/kg, 2 μg/kg, and 5 μg/kg ranged from 17 to 100%, 0 to 100%, and 0 to 100%, respectively. Site and processing significantly influenced levels of AFB1 contamination in open-market samples. The mean AFB1 levels were 17.85 μg/kg (±70.25) in Burera District, 36.04 μg/kg (±85.59) in Huye District, and 9.01 μg/kg (±18.49) in Nyarugenge District. The average AFB1 levels significantly varied between different products. Peanut samples showed higher contamination levels of 56.79 and 99.08 μg/kg for grain and flour, respectively. Flour samples in general had a higher mean of 51.65 μg/kg (±105.75), compared to grain samples, 16.5 μg/kg (±44). Thus, there are potential health risks associated with chronic exposure to AFB1 in children consuming flourbased foods from health centers and open markets. Interventions to mitigate AFB1 contamination and protect children should focus on food processing practices, implementing strict quality control measures, and raising awareness among stakeholders about the risks of AFB1 in flour-based products provided to children in Rwanda and similar settings