Table 2 Comparison of total mean practice session per provider and themes by level of practice achieved, facility type, and study arm

 Hospitals, arms 2 and 3

Facilitators: Appreciation for training opportunity. Changes in clinical behavior described. Practice coordinators described as motivated and supportive.

Barriers: Broken equipment for resuscitation, harder to realize success on NeoNatalie compared to real baby.

“We always appreciate them, we say you are doing well. …Let us continue but we need to first again, practice so that that skill does not disappear because we are getting fewer asphyxiated babies these days.”—Practice coordinator

 Health centers, arms 2 and 3

Facilitators: Practice coordinators give feedback, able to describe practice in detail. Perceived reductions in intrapartum stillbirth and PPH, Desire for “skills and confidence”. Scheduling practice in advance.

Barriers: Some colleagues more willing to practice than others, some practice coordinators are not midwives and are uncomfortable instructing midwives, scheduling conflicts, staff transfers (including practice coordinator).

“What really motivated me I was faced with it one time. …In fact the baby came out well but after some, time the condition changed but I realized it was asphyxia. …. we had to refer the child to [referral hospital] and we ended up even losing that child. …So that thing motivated me to continue practicing.”—Focus group discussion participant

  Health centers, arm 1

Facilitators: In-charge motivated staff to practice. Changes in clinical behavior following training sessions. Practice during less busy times.

Barriers: Short staffing.

“Our in charge gives us courage that… [we] are supposed to do this and this, so we have to keep on practicing.”—Focus group discussion participant

 Hospitals, arms 2 and 3

Barriers: Staffing less willing to practice. Lots of turnover, including practice coordinators. Continuing professional development requirements and grand rounds compete for practice time. Need for regular feedback to stay motivated. Providers enjoy offsite training sessions. Practice randomly, when time available, not after adverse events.

“Most of the people who were trained have gone. So when we are doing mentorship we are even like teaching. … And even those who trained, they are like less interested, they think they know.”—Practice coordinator

 Hospitals, arm 1

Barriers: Change in clinical practice described, but skeptical of new information. Short staffing. High patient loads. Staff transfers within facility. Patients must pay for misoprostol. Simulator not realistic enough.

“We have sat with our boss and she knows what is taking place in maternity… we have complained, talked to her, had meetings, nothing has changed. So about the shortage of staff, I do not think you can do much.”—Focus group discussion participant

 Health centers, arms 2 and 3

Barriers: Change in clinical practice following training sessions. CM not a midwife and cannot mentor midwives. Lots of staff did not complete training session. Many interruptions to practice schedule (sickness, etc.) Need more support from district trainers. Broken equipment. Staff not motivated to practice, expect compensation (“motivation”) for participation.

“They were used to being motivated. They feel as if when they sit they can get something from the training. Something, at least little either a soda.”—Practice coordinator

 Health centers, arm 1

Barriers: Need more support and feedback. Lack of time to practice. Shortage of equipment and supplies. Stockouts.

“Monday, basically we have no clinic but patients are just many… Tuesday we have postnatal, we have antenatal, we have immunization. Wednesday we have antenatal, on Thursday we have ART clinic and outreach, on Friday, we have nutrition clinics. … So to practice, you need to find your own time outside the working hours.”—Focus group discussion participant