> For the complete documentation index, see [llms.txt](https://research.ambitiousimpact.com/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://research.ambitiousimpact.com/bemonc/simulation-based-training-for-emergency-obstetric-and-newborn-care/4-expert-views.md). # 4 Expert views *We spoke with six experts across research, implementation, and philanthropic evaluation to pressure-test the BEmONC training concept. Interviewees included academic researchers who have led or evaluated (LDHF) training trials; practitioners running simulation-based programs in SSA and South Asia; a digital training charity founder; a global health funding analyst; and a human resources specialist. We summarize interviews from our original 2023 report, and new interviews carried out in April 2026.* The experts we spoke with were largely supportive of the model for this charity, confirming need and the issue of low quality of care in facilities they had visited or supported. They listed a range of reasons (beyond the lack of training) for high maternal and neonatal mortality in LMIC settings, shared suggestions and concerns about implementation and scaling, and discussed their views on the need for a new charity—issues that are covered in the following sections. ## Barriers to better outcomes **Experts consistently identified multiple, layered barriers—and differed on the relative weight of training versus other constraints.** Diwakar Mohan (Johns Hopkins Bloomberg School of Public Health) described arriving at facilities and finding that providers had received poor in-service training and "really don't know what to do," sometimes requiring trainers to cover foundational skills before delivering planned LDHF content. He listed training and supportive supervision as one of several components of what he calls "implementation strength" and placed "extreme importance" on this component, calling capacity building "probably the single most important factor for any program." Heidi Breeze-Harris (PRONTO International) similarly confirmed that baseline knowledge can be "catastrophically low"—her trainers in Côte d'Ivoire found providers who could not achieve basic neonatal resuscitation techniques. However, **she argued that "a lot of the gap in the marketplace has nothing to do with training—it has to do with supplies, supply chain, human resources, people getting paid on time.”** Other barriers PRONTO International has encountered include teamwork and communication failures, driven by hierarchy between doctors and midwives. She also described cultural and fear barriers: providers in India refused to resuscitate non-breathing babies after families had threatened them following failed attempts. **Expert A** (from an implementing organization) **named human resources (HR) as the number one bottleneck for better care.** He noted that vacancy analysis suggests HR gaps can be as high as 82% in essential healthcare workers such as skilled birth attendants, with most facilities relying on ad hoc staff or volunteers. He identified three main barriers to adequate HR: funding and resources; the availability of healthcare workers in the workforce; and socioeconomic factors such as the reluctance of nurses—predominantly female—to work and raise families in rural areas, compounded by foreign emigration. **Meika Ball** (GiveWell, 2023) **had a sense that commodities are not the key bottleneck, and said training and staffing are the larger constraints.** She described health workers as very overworked and noted that health worker knowledge is a key barrier to quality care. **Mohan added that supply chains have improved substantially over the past decade.** He identified neonatal resuscitation as the skill with the most remaining need, because it is performed rarely and providers lose competency without ongoing practice. **In summary, there are a range of other barriers to achieving high-quality obstetric and neonatal care, and training alone can only close part of the mortality gap.** ## Training methodology **Breeze-Harris distinguished between what she called simulation "zones 1–2"—covering skills, drills, and didactics, where programs like Helping Mothers Survive (HMS) and Helping Babies Breathe (HBB) operate—and zones 3–4, which involve high-fidelity, team-based simulation with structured debrief, where PRONTO operates.** She noted that providers who have been through foundational zone 1–2 training tend to perform better in PRONTO's simulation, suggesting the approaches are complementary rather than competing. **Expert A cautioned against training traditional birth attendants (TBAs)**, noting that they are mostly uneducated and illiterate, making them difficult to train, and that government policy aims to encourage facility births rather than support TBA practice. Marshall Thomas (HealthLearn) similarly flagged that regulations require nurses or midwives to hold professional licenses to work in a facility, which could complicate any model relying on less formally qualified staff. ## Scaling and sustainability **Experts raised consistent concerns about whether high-quality training can be delivered at scale without significant cost or fidelity tradeoffs.** **Thomas raised concerns about measurement and staffing.** He flagged that any new charity should consider avoiding recruiting health workers from other facilities, which would exacerbate existing capacity constraints. He also identified monitoring and evaluation (M\&E) as a distinct concern: demonstrating impact statistically is difficult because newborn death is a relatively rare event at the facility level. He also drew a clear distinction between HealthLearn's approach—simple, universal practices delivered digitally at massive scale—and BEmONC hands-on training, which requires complex procedural skills and in-person delivery. He described BEmONC as requiring a much larger team, limiting geographic scope, and creating a replication problem: maintaining fidelity as an organization moves beyond its founding team is, in his framing, "more of an HR problem." **Mohan raised the cost of paying on-site coaches as unsustainable across many facilities and endorsed virtual practice sessions as a feasible lower-cost alternative.** He warned of what he described as "voltage drop and program shift"—effects diminishing as programs move from trial to real-world conditions—and advised monitoring both fidelity and context continuously. **Breeze-Harris described sustainability as taking years to build.** In Mozambique, after six years, PRONTO built a cadre of master trainers and is now working with the government to embed simulation into the continuing professional development system. She acknowledged that in most countries, programming ends when the grant cycle does and governments rarely continue funding. She also pushed back on virtual or digital training as a substitute for in-person simulation. ## Room for a new organization **Expert views on whether there is room for a new organization were mixed.** Thomas named Laerdal and Jhpiego as major actors already in the space and questioned whether a new charity could compete or do better. Breeze-Harris, whose organization has trained over 11,000 providers in 17 countries, agreed, describing the space as "extremely well covered" and arguing that existing organizations need funding rather than new competition. Mohan, who has led or evaluated LDHF training interventions across SSA and India, offered a contrasting view, saying that there is "definitely" space for a new charity—particularly one that can deliver training more efficiently and cheaply than existing actors. --- # Agent Instructions This documentation is published with GitBook. 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