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There are limited data and no current World Health Organization (WHO) standards for staff-to-baby ratios in neonatal units in low- and middle-income countries (LMICs) to inform policy, planning, and investment.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>In 65 neonatal units (36 in Malawi, 13 in Kenya, 7 in Tanzania, and 9 in Nigeria), a health facility assessment (HFA) for SSNC and government-led quality improvement (QI) processes were implemented. Staffing data were collated from baseline HFA (Sept 2019\u2013March 2021) and mid-2023 HFAs, and quarterly QI processes. The unit of analysis was the neonatal unit with day and night staff-to-baby ratios calculated. Ratios were aggregated overall, by country, by hospital level, and by neonatal unit occupancy rates. Staff coverage and skill-mix were also analysed for nurses, doctors, clinical officers, laboratory technicians, data clerks, biomedical technicians, and engineers.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      For 65 neonatal units, the median time between baseline and 2023 HFAs was 31\u00a0months (Interquartile Range (IQR) 29\u201334\u00a0months). In 2023, only 3 (5%) neonatal units had zero neonatal ward-specific nurses compared to 8 (12%) at baseline during the day. Between baseline and 2023 HFAs, median nurse-to-baby ratios were 1:6 (IQR 1:3\u20131:11) during the day and 1:10 (IQR 1:6\u20131:17) at night, with consistency over time. At baseline, only one third of neonatal units had a doctor providing care, or on-call coverage, at all times of day and night (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200920, 31%), and half of hospitals lacked 24\u00a0h laboratory coverage (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200925, 45%) with no change over time. There were improvements in neonatal data clerk (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200932, 49% to\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200958, 89%) and biomedical technician (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200945, 69% to\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200956, 86%) coverage between baseline and 2023 HFAs.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>Evaluation revealed variability by country and hospital level, and important shortfalls remain in the number of staff providing care. Neonatal survival in hospitals requires better staff-to-baby ratios and more skilled staff. To meet the projected shortfall in the health workforce, governments must invest in training more health workers for neonatal care.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12960-025-01031-1","type":"journal-article","created":{"date-parts":[[2025,11,12]],"date-time":"2025-11-12T14:21:20Z","timestamp":1762957280000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":9,"title":["Neonatal unit human resources: coverage for six cadres and trends for staff-to-baby ratios in 65 neonatal units implementing with NEST360 in Kenya, Malawi, Nigeria, and Tanzania"],"prefix":"10.1186","volume":"23","author":[{"given":"Rebecca E.","family":"Penzias","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric 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