International Journal of Pediatrics that the clinical impact was not suﬃcient to reduce overall in-hospital mortality. There are four possible explanations for the discordant results between our pre-/postintervention evaluation data and our mortality data. First, the modiﬁcation of NRP required for the program’s eﬀectiveness within this time- and resource-deprived setting may have resulted in the unchanged rates of neonatal mortality. The modiﬁcations may have rendered the curriculum too short. What may be eﬃcacious in a controlled setting might not be feasible or eﬀective in developing communities. Second, factors external to the curriculum may have overwhelmed any statistically signiﬁcant impact. For example, there was staﬀ turnover with seven of the 14 health workers who received the LPCH neonatal resuscitation training continuing to work at St. Gabriel’s. This likely had a negative impact on the level of neonatal resuscitation at deliveries. This creates a compelling case for the necessity of longitudinal train-the-trainer pro- grams for St. Gabriel’s staﬀ. Third, our curriculum may not have addressed crucial aspects in the care of neonates. For example, the WHO Essential Newborn Care program addressed topics like cleanliness, temperature management, infection prevention, skin-to-skin care, breastfeeding, care of the small infant, and care of common illnesses. A recent study shows this program’s relative eﬀectiveness in reducing neonatal mortality rates [30]. Fourth, the LPCH neonatal resuscitation curriculum may not incorporate enough adult learning theory. Simulation-based training can be an eﬀec- tive educational methodology to promote skill acquisition and performance enhancement in neonatal resuscitation providers [31]. The LPCH neonatal resuscitation curriculum may be overwhelmed by didactical instruction (representing three of the six total hours) compared to hands-on activity. We hope that a qualitative assessment of the LPCH neonatal resuscitation training at St. Gabriel’s Hospital will allow our community partner to make recommendations for further curriculum modiﬁcations. Our ﬁndings are consistent with a study in Zambia that reports signiﬁcant improvement in healthcare providers’ knowledge and skills following curriculum intervention despite a limited application of curriculum guidelines due to local conditions [16]. Although NRP training reduces neonatal mortality in controlled, nonrandomized studies in China, India, and Africa [10, 15, 32, 33], the literature surrounding NRP curriculums’ impact is not consistent. Our results contribute to that literature. These ﬁndings may have important implications for the children of the developing world born without adequate neonatal resuscitation services because of the complexity and high program cost [13, 34]. However, if 90% of asphyxiated newborns require only drying, warming, and stimulation for survival, then an abbreviated NRP-based curriculum could improve outcomes in an aﬀordable way [10]. There has been a general progression in the evidence behind neonatal resuscitation. The WHO published its abbreviated NRP called Basic Newborn Resuscitation (BNR) in 1997 [35], a potential outline for future programs aimed at reducing developing world neonatal mortality. The assessment of BNR’s eﬀect on outcomes has been limited. 5 It is possible that, like the LPCH neonatal resuscitation curriculum, such abbreviated education programs may not improve outcomes and be too costly in time. Health care workers’ time away from patient care while in workshops can be a diﬃcult obstacle to overcome, particularly in the developing world. However, Helping Babies Breath (HBB) [36], an evidence-based educational program released in June 2010 by the American Academy of Pediatrics, was devel- oped to improve and be compatible with existing neonatal resuscitation programs experiencing the common obstacles of low-resource settings. HBB trains birth attendants in only the essential skills of newborn resuscitation (assessment, temperature support, stimulation to breathe, and assisted ventilation as needed) with particular emphasis on the ﬁrst minute after birth. Studies to assess HBB’s impact on outcomes are underway. Our study has ﬁve important limitations to consider. First, its retrospective analysis of large aggregate data brings inherent restrictions. Data at the individual patient level could have revealed a statistically signiﬁcant impact of the LPCH neonatal resuscitation curriculum on neonatal mortality for certain subpopulations of neonates born at St. Gabriel’s such as stillbirths. A prospective study, for example, in India found that while neonatal mortality did not decrease following the implementation of neonatal resuscitation programs, asphyxia-related deaths did signiﬁcantly decline [33]. We were limited in our ability to individually track cases because such data is not collected at St. Gabriel’s Hospital; thus, we were unable to compare the two cohorts on variables such as maternal age, prenatal health, and maternal health. Eﬀorts to collect this individual patient data pose a signiﬁcant administrative burden to our community partner. Second, the nature of the busy labor wards at St. Gabriel’s Hospital poses a signiﬁcant challenge to collecting data on how many deliveries are covered by individuals who received LPCH neonatal resuscitation training and if the skills learned during training are applied in postintervention months by trainees. Third, our results may be limited in generality. This was a unique NRP-based curriculum in a speciﬁc developing community. However, curricula must be tailored to meet the needs and realities of their settings. Fourth, we may have experienced a glass-ceiling eﬀect. The Malawian neonatal mortality rate is low as compared to much of the developing world as it falls below the 30 deaths per 1000 live births target of Millennium Development Goal number 4 [6]. Finally, we were unable to compare the pre- and postintervention maternal complications given that the data were collected in aggregate. It was impossible to determine whether the observations were independent of one another as one female might have given birth during both the pre- and postintervention periods. Analytical approaches were limited due to the two samples violating the assumption of independence. 5. Conclusion Global health interventions require robust evaluation. Short- term pre- versus postintervention assessments frequently show positive results, as ours did. These results are only