BaRT–Baby Resuscitation Training System

In Southeast Asia, around 7,400 newborn deaths occur every day (UN), 25% are caused by birth asphyxia or lack of breathing. In low-resource settings like Cambodia, infrequent resuscitation practice and follow up training mean that valuable life-saving skills are not being maintained by health workers, resulting in unnecessary newborn deaths.

In Cambodia, Angkor Hospital for Children (AHC) has developed an innovative low-cost solution to this problem. By utilizing available technology, the organization has designed an intuitive Baby Resuscitation Training (BaRT) system to support health workers to keep their resuscitation skills up to date, so when an emergency situation occurs they are able to save a newborn’s life.

In a global context, the BaRT system has the ability to transform how frontline health workers’ perceive and approach neonatal resuscitation, building both their confidence and skills to effectively resuscitate newborns and reduce unnecessary neonatal mortality.

It is estimated that up to 10 million babies born each year do not cry after birth and 30% of these need bag and mask ventilation to live. Several trials have shown that a correctly administered bag and mask ventilation given to babies who are born not breathing, could reduce intrapartum-related deaths by 20%. In developing countries, it is estimated that 79% of births take place in health centers. Yet research undertaken by AHC with health workers in Cambodia has indicated a high knowledge related to neonatal resuscitation with comparatively low attitudes towards enacting such care. A lack of follow up training and infrequent practice has led to health workers not feeling confident about safely applying resuscitation. Consequently, in the ASEAN region, birth asphyxia makes up 25% of all neonatal mortality, meaning that skills such as neonatal resuscitation are vital for reducing neonatal mortality. 

BaRT is a reliable, intuitive neonatal resuscitation training system that uses existing, low-cost equipment to allow frontline health workers to refine and maintain their resuscitation technique. The system consists of two main components:

• A resuscitation simulator allows users to gain hands-on experience with the proper ventilation technique in a no-risk setting. The simulator consists of a BVM and a neonatal mannequin, which provides users with useful physiological features such as accurate size and weight, chest movement and simulated lung response.
• A feedback system allows users to quantify their technique with the intent on improving their overall efficacy. This includes a pressure detection unit (PDU) and a processing/display application (PDA). The PDU measures of the BMV generated pressure before transferring data to the PDA. The PDA consists of the hardware and software responsible for reading incoming data, processing and storing this data, and running the training system interface. The system is capable of both reading and processing data as well as running a graphical user interface for teachers and students to create user accounts, utilize real time displays of their technique and save/view their results. Progress can be tracked and analyzed to provide valuable feedback both locally and remotely.  

AHC has delivered high quality, responsive clinical education and training to healthcare professionals from across the country for over twenty years. As one of only three pediatric teaching hospitals in Cambodia, we have developed a comprehensive understanding of the training needs of healthcare professionals and developed effective blended teaching methodologies to enable health workers to apply their knowledge to the patient in front of them.

AHC has designed the BaRT system specifically for health workers who provide neonatal healthcare services in low-resource settings. We have found that after initial neonatal resuscitation training is provided infrequent follow-up training sessions is affecting proper skill maintenance. BaRT will be and piloted with frontline health workers engaged in AHC’s Saving Babies Lives (SBL), neonatal training programme network of 14 health centers in Preah Vihear Province, Cambodia. Typically, rural health centers serve between 10,000 – 20,000 people, staffed by nurses and midwives. Our SBL programme is replicating simple evidence-based interventions from our Neonatal Unit, into government health facilities across the province. By piloting BaRT in a real life setting will enable AHC to collect important data and feedback to inform further modifications to improve the usability and accuracy of BaRT and achieve proof of concept. 

In low resource setting where the majority of births take place in rural settings, neonates born with asphyxia or breathing difficulties are at risk of not receiving the vital neonatal resuscitation needed to save their life.

By supporting healthcare workers to maintain their life-saving resuscitation skills; the BaRT system has the potential to improve on the quality and availability of neonatal healthcare services provided for mothers and their newborns in health centers and prevent unnecessary newborn deaths from occurring. 

Until now, an affordable neonatal resuscitation training system appropriate for use in a low resource setting has not been available. To address this gap in training, the BaRT system has been developed utilizing standardized technology, repurposed and designed into a reliable, affordable resuscitation training system. Unique to its design is the ability to measure, collect, and display pressure delivered and the rate of delivery, on a tablet or personal cell phone in real-time.

BaRT then uses the data collected to provide immediate feedback and recommendations to the user whilst they are administering the bag-valve-mask ventilation. It will be one of the only affordable devices of its kind globally, designed specifically to improve neonatal resuscitation training in low resource settings.

Our preliminary product research on the competitive landscape shows that there are four products in different stages of development and market readiness that offer comparable services to BaRT. These include 1. Smart Resuscitation Mask Leak Trainer, 2. Monivent NEO100, 3. Air Device, 4. Little Baby QCPR. The Smart Resuscitation Mask Leak Trainer costing between $4500- $5,500, greatly exceeds our entry-level target price of $100 and therefore is a not affordable option for the same user base. The remaining three products are currently under development and not yet available on the market, in addition, they have not been designed specifically for use in low resource settings.  

The incorporation of manikins for use in medical simulation training is a widely used method for educating and training medical professionals to improve on performing various medical techniques. The BaRT system itself is centered around a manikin that allows users to gain hands-on experience of simulating resuscitation. The system combines standardized global products and applies them together to create a new innovative product. The resuscitation simulator selected for use in the system is the NeoNatalie Resuscitation Simulator by Laerdal Medical. The NeoNatalie is a stand alone inflatable simulator developed for use in low-resource settings. It has been used in over 80 countries and is part of a global neonatal programme Helping Babies Breath. The NeoNatalie has shown to reduce neonatal mortality by up to 47% and fresh stillbirths by 24%.

The pressure detection unit (PDU) used in the feedback system is the Honeywell Pressure Gage Sensor (0-1 PSI), manufactured by the multinational organization Honeywell. It has been selected for its ability to accurately measure the airway pressure applied to the manikin by the user whilst using the BMV, before transferring data to the PDU. The Arduino Nano Microcontroller used in the system is a widely used hardware utilized for professional and hobbyist applications. It reads data from the pressure sensor and sends it in a proper format to the android phone or tablet. After initial testing by AHC during the proof of concept stage, the microcontroller has achieved proof of functionality for use in the system. 

The BaRT system theory of change

The intended impact

• To reduce the number of newborn babies dying unnecessarily from asphyxia and breathing difficulties in low resource settings.

Long term outcome

• Health workers have the skills to confidently and safely enact neonatal resuscitation, improving the quality and availability of neonatal healthcare services in rural areas.

Short term outcome

• Health workers regularly practice neonatal resuscitation by utilizing the BaRT system to enhance and maintain their ability to provide neonatal resuscitation.

Activities

• Training of healthcare workers in routine neonatal resuscitation training using the BaRT system.
• Training of healthcare workers on how to independently set up and use the BaRT system.
• Data collection analysis of user registration and user results.

Intermediate outputs

• An affordable neonatal resuscitation training system and implementation package, appropriate for use in a low resource setting, which can record pressure and frequency of bag valve mask ventilation and which gives user real-time feedback on technique. 
• An implementation manual which underpins the future steps in the development of BaRT including plans for developing technology, business development, quality control and assurance, legislation, marketing, manufacturing and data storage strategies.
• User data collected for research, support and overall system improvement.

Assumptions

• Healthcare workers will be self-motivated and have the confidence to practice neonatal resuscitation using the BaRT system.
• The Cambodian MoH will approve the BaRT system to be implemented nationally.
• The BaRT system can be manufactured at an affordable cost, to meet the target starting price of $100.
• A licensed third party organization is identified who can manufacture and distribute BaRT to national and international customers.

Supporting evidence 

• Several trials have been shown that correctly administered bag and mask ventilation given to babies who are born not breathing, could reduce intrapartum-related deaths by 20>#/span###1.
• A review paper published in 2006 concluded that in low resource settings it is possible to improve neonatal outcomes with the use of a bag valve mask, without access to more sophisticated equipment and drugs2.

During the initial field testing and piloting phase (2020 – 2021), the BaRT system is expected to serve the following people:

• 42 AHC neonatal nurses who participate in field testing the BaRT system.
• 40 health workers at four health centers in Preah Vihear Province who participate in field testing the BaRT system.
• 150 health workers at ten health centers in Preah Vihear Province who participate in the piloting phase of the BaRT system.

The final product has the potential to serve the following people in five years:

• An estimated 17,000 healthcare professionals in Cambodia who utilize AHC’s BaRT system to enhance and maintain their ability to provide neonatal resuscitation.
• An estimated 400,000 babies born annually in Cambodia, who benefit from the availability of improved neonatal services.
• Global frontline health workers in low-resource settings who benefit from using AHC’s BaRT system.
• Global stakeholders in the advancement of neonatal health will benefit from access to evidence and of an effective intervention that reduces neonatal mortality in low-resource settings. 

2020: Development of a BaRT working prototype.

With input from AHC’s health professionals, a working prototype will be developed that is suitable for use in field testing.

2020: Assess the system’s applicability for use in low-resource contexts and make modifications. 

Field testing will be conducted with AHC’s Executive Committee, senior Neonatal Unit staff and resuscitation trainers. After initial modifications have been made further field testing will be carried out in Preah Vihear Province with frontline health workers from four health centers for a period of at least one month.

2021/2021: Conduct extensive testing of the system.

A final version will be piloted in 14 health centers in Preah Vihear Province for a period of at least 12 months. The pilot will test the long-term efficacy and applicability of the system, to help build an understanding of the potential the BaRT system has to improve health worker ability in neonatal resuscitation.

2021: Proof of concept achieved.

Evidence will be analyzed from the pilot to assess the effectiveness of the BaRT.

2021: Develop an implementation manual.

Follow completion of the final model of the system, an implementation manual will be developed that will detail plans for ongoing technological and business development of the system.

2022: Production of the BaRT system for external use.

Co-ordination with manufacturers to modify designs for manufacturing.

2023/25: Packaging and scaling of the system to other low-resource settings in Cambodian and internationally.

Co-ordination with product distributors and navigation of local regulations to achieve scaling nationally and internationally. 

The Covid-19 pandemic. The pandemic may affect the testing schedule for the BaRT system with health workers in Health Centres in Preah Vihear Province.

Personnel turnover. A turnover of key personnel from the development group or advisory group.

Political context. To implement the BaRT system into mainstream use within Cambodia’s health system, requires approval from the Cambodian Ministry of Health (MoH).

Manufacturing and distribution. Challenges may arise in sourcing a manufacturer to produce BaRT to the target cost. In addition, AHC is not experienced in manufacturing or distributing products to national and international markets.

Adoption of usage.  Health workers may not easily adapt to regularly practicing resuscitation using the BaRT system. 

The BaRT Development Group is formed of three principle developers including:

• Dr Claudia Turner, AHC Chief Executive and Cambodia-Oxford Medical Research Unit Pediatric Researcher (part time).
• Mr Peter Boyer, AHC Biomedical Engineer, International Volunteer (full time).
• Mr Gregor McKellar, AHC Chief Commercial Officers (part time).

The BaRT Advisory Group is made up of seven of AHC’s senior staff who have specialist knowledge in neonatal healthcare and education. The group provides expertise in development areas relating to 1. Concept, 2. Target product profile, 3. Design, 4. User testing and 5. Implementation planning for field testing of the BaRT system. 

The BaRT Development Group is formed of three principle developers including:

• Dr Claudia Turner, AHC Chief Executive and Cambodia-Oxford Medical Research Unit Pediatric Researcher (part time).
• Mr Peter Boyer, AHC Biomedical Engineer, International Volunteer (full time).
• Mr Gregor McKellar, AHC Chief Commercial Officers (part time).

The BaRT Advisory Group is made up of seven of AHC’s senior staff who have specialist knowledge in neonatal healthcare and education. The group provides expertise in development areas relating to 1. Concept, 2. Target product profile, 3. Design, 4. User testing and 5. Implementation planning for field testing of the BaRT system. 

The BaRT Development Group has a strong set of combined skills, capabilities and experiences needed to lead the development of BaRT from the concept stage, right through to the testing and scaling of the system to international low-resource settings. Specific competencies of the team include:

• Dr Claudia Turner, Chief Executive and Cambodia-Oxford Medical Research Unit Pediatric Researcher. Claudia has worked for the Oxford Medical Research Unit (MORU) as a pediatric researcher for the last 14 years. Her principle areas of expertise is in neonatal care and implementation of health systems. Claudia is responsible for the overall running of the programme and development of the implementation framework.
• Mr Peter Boyer, Biomedical Engineer, International Volunteer. Peter is an electrical engineer with over five years professional experience in electrical project design. Peter graduated from Ohio State University in Electrical and computer science in 2011, completed a Masters Degree in biomedical engineering in 2014, and obtained his professional engineer license with the state of Ohio in December 2017. Peter is responsible for the technical development of BaRT.  
• Mr Gregor McKellar, Chief Commercial Officers. Gregor is a chartered accountant and the Chief Commercial Officer of AHC. Gregor oversees the financial management of AHC and prior to joining AHC worked with Deloitte’s corporate finance and external audit business in the UK. Gregor has recently completed a Masters degree in Social Innovation from the University of Cambridge Judge Business School. Gregor is responsible for the business development aspects of BaRT. 

AHC currently has two partners who are supporting AHC in the initial development stages:

• The Mahidol Oxford Medical Research Unit Network (MORU) is a formal development partner of the BaRT system providing advice on intellectual property, legal and business development advice and access to their extensive tropical health network.
• The Oxford University Innovations and Translation Office is providing technical product development support. 

The business model is based on a social enterprise model in which income generated will be reinvested to support the development and operations of BaRT, with surplus income financially supporting AHC’s healthcare services. The target markets include governments and private healthcare organizations in low-income countries, particularly to begin with the focus will be on the Southeast Asian market with potential later on to find ways in which to adapt BaRT to be of value to western markets. The plan would be to generate a higher income from western markets, which can then subsidize access to BaRT for lower-income countries.

Because BaRT is about providing an affordable resuscitation training option, to improve health center neonatal services and reduce neonatal mortality, BaRT will be price packaged to include a range of affordable product and service options including:

• BaRT Lite: Costing $100, this core package will include the BaRT system resuscitation training product with digital application maintenance service.
• BaRT Full: Costing $500, this package will include the core package and a training service package for users.
• BaRT Plus: Costing $500, this package will provide additional options as per customer needs including further training, data services, consultancy and extended support. 

The BaRT system is an initiative led and developed by the healthcare non-profit organization AHC. The long-term goal is for profits generated through the sale of BaRT products and services to financially contribute to the costs of AHC’s operational activities.

Proof of concept of the BaRT system is expected to be achieved by the end of 2021. Whilst maintaining and protecting the intellectual property of BaRT, AHC will identify a suitable third party organization to license the manufacturing and distribution of BaRT.  The finished product will be available at price packages starting $100 to $500, depending on the level of services required by the customer. AHC will take a percentage commission of all income generated through product sales.

From 2023 when target revenue is expected, the licensed organization will initially generate sales through the Cambodian markets, focusing on the Cambodian Government and private health sector. Within the first year, $232,000 (96%) of income generation is forecasted from the Cambodian Government with a further $10,000 (4%) income forecasted from the private health sector. This is calculated on the total addressable market in Cambodia which is $1,000,000. By 2024, the plan is to expand into regional markets such as Thailand, which has an addressable market of $6,600,000. 

AHC is applying to Solve for support to advance BaRT from the proof of concept stage right through to scaling the final product to national and regional markets. Specifically at this stage, AHC requires guidance to support the development of a product licensing strategy to enable us to protect the intellectual property of BaRT and form a strategic licensing partnership. The licensed partner will play a vital role in leading on the manufacturing and distribution of BaRT nationally and regionally. This is the first time that AHC has developed a marketable product, therefore expertise is required to inform our understanding of the manufacturing and distribution processes including regulations and legislation.

Joining Solve will provide access to a pool of experts at Solve as well as exposure to MIT’s network of experts, whose expertise we can draw on to gain vital advice and support to take our product to market and scale it. In addition, we will gain support from engaging with a community of like-minded peers developing innovative solutions to important challenges around the world. As well as gaining access to expertise and support, we hope to connect with funders who want to be a part of developing an innovative solution to reduce neonatal deaths. 

Solution technology

As the system continues to be tested and iterated to develop the final product, AHC will need leaner hardware and software solutions that will promote affordability, reliability and scalability. Ideally, this will be accomplished by modifying designs for manufacturing and working with professionals in regional medical device development. A partnership in this area would support us to have a clearer understanding of the options available given the specific product and region. 

Product/service distribution

Once a final product has been developed, the next step is to scale the BaRT system within Cambodia and to regional low and middle income countries, making it accessible to wider audiences. In order to take these steps, we are seeking to coordinate with experienced product distributors to take responsibility for leading on the manufacturing and distribution of BaRT. 

To further support the development of the BaRT system, AHC would like partner with the following:

• AHC would benefit from receiving advice and support on solution technology and product distribution from Laerdal Medical, the suppliers of the resuscitation simulator selected for use in the BaRT system.
• AHC would like to partner with the Professor Mike English, a pediatrician at Oxford University and the Life Team, who focus on utilizing mobile and virtual reality technology to deliver high-quality, low-cost simulation type training. AHC would like to draw on the Life Team’s experience of developing an application for resuscitation training in an advisory capacity.
• AHC would like to receive advice on the technological development of the BaRT system and testing on the final product from D-Rev who design and deliver medical technologies for underserved populations. 

Neonatal care gaps in Cambodia and the developing world

Despite a 40% reduction in under-five mortality since 1990, the proportion of global deaths that occur in the neonatal period (0-28 days of age) is increasing. Globally, neonatal mortality comprises of 47% of all deaths in children under five years; in Cambodia, this figure is 51%. The reasons why the fall in neonatal mortality has not mirrored child mortality are complex with interrelated issues of access to care, availability of quality specialist care, knowledge and practices of parents/caregivers, and access to necessary resources.

As a result, many newborns in Cambodia are extremely vulnerable to preventable, yet life-threatening conditions such as premature birth, intrapartum events (birth asphyxia) and neonatal sepsis. Despite an estimated 79% of women giving birth in rural government run health centers, many newborns are still unable to access comprehensive neonatal facilities or trained staff with the resources or confidence to enact lifesaving care. AHC has found for example, that while most rural health workers have had previous training/knowledge of neonatal resuscitation, the majority have low confidence in enacting resuscitation due to a lack of follow-up support or ability to practice their technique. This is important as research has concluded that correctly administered resuscitation could reduce intrapartum-related mortality by up to 30% in low-middle income countries. As a result, current interventions designed to reduce neonatal mortality in low-resource settings are unlikely to achieve sustained progress without structured platforms that enable and encourage frontline health workers to utilize and refine their skills so they can enact lifesaving care when it really matters.

In response to this, AHC has worked over the last eight years to build the capacity of neonatal care not only within our hospital, but also, in collaboration with the Cambodian health authorities, to enhance the depth and breadth of neonatal care available throughout Cambodia.

Step 1: Responding to deficiencies in neonatal care: AHC’s neonatal care model

AHC has worked tirelessly over the past 21 years to improve healthcare for all Cambodian children. Working closely with the Cambodian Ministry of Health (MoH) and other prominent health stakeholders in the country and internationally, we have designed and implemented a range of interventions that directly impact child health needs. At the heart of this is AHC’s neonatal care model. Through recognition of the widening gap in availability and quality of neonatal care and our experience as a specialist pediatric care provider, 2013 saw AHC pioneer a new low-cost model for neonatal care, challenging preconceptions of complexity and reducing unnecessary mortality. The model consists of a set of simple, bottom-up interventions designed and implemented with the goal of increasing the efficiency and effectiveness of neonatal care throughout the organization. They include:

1. Dedicated environment. A fully equipped Neonatal Unit was set up for the treatment of neonates, separate from other wards within the hospital. The unit has the capacity to provide specialized care to 12 neonates at any one time and allowed neonates to be in a separate location from other patients, reducing the risk of Healthcare Acquired Infections (HCAIs).
2. Neonatal education and training. Ongoing education and training on neonatal-related topics has ensured knowledge and practice of quality care remains high. Initially AHC focused on simple, essential interventions that ensure basic care is provided at all times, but has since incorporated a range of specialized, scenario-based training. Caregivers also receive daily education designed to support long-term child health and reduce re-admission rates.
3. Infection, Prevention and Control (IPC). To reduce the risk of HCAIs, WHO guidelines for IPC were incorporated and strictly enforced throughout AHC, reducing the chance of HCAIs amongst patients.

These relatively simple interventions have transformed neonatal care in AHC, dramatically reducing mortality while demonstrating how quality neonatal care can be provided in a low-resource setting. Despite there being an increase in the number of neonatal admissions since the Neonatal Unit opened (78% increase from 2011 to 2016), neonatal mortality in AHC between 2011 and 2016 decreased by 81%, while HCAIs decreased by 68%. Subsequent research has also determined that the inclusion of ongoing training and capacity building throughout AHC has been crucial for developing the skills and confidence of AHC staff related neonatal care.

Step 2: Strengthening systems and scaling neonatal care for all

Based upon the impact of AHC’s neonatal care model at our hospital in Siem Reap, AHC is now working with the Cambodian MoH and Provincial Health Departments to replicate and scale aspects of the model, strengthening grass-root health systems throughout. One of our flagship and more ambitious programs is the Saving Babies Lives (SBL) program, which is being implemented in Preah Vihear province, one of the remote provinces in Cambodia with a disproportionately high neonatal mortality rate. The five-year research program, launched in 2017, uses implementation science and appropriate monitoring and evaluation in an applied form to demonstrate how interventions taken from AHC’s neonatal care model, including training, mentorship and the establishment of basic neonatal care facilities can have a sustained impact on neonatal mortality. Working closely with the Provincial Health Department, AHC is operational throughout Preah Vihear’s health system with community health workers, health centers and referral hospitals to understand how interventions are influencing care for neonates and neonatal mortality.

Step 3: Developing tangible solutions for sustained improvements in neonatal care

Through an ongoing analysis of SBL interventions, discussions with health authorities and ongoing research, AHC has gained a thorough understanding of the limitations experienced by frontline health workers in Cambodia. One such limitation is related to frontline health workers capacity to sustainably reduce intrapartum related mortality, typically mitigated through effective neonatal resuscitation. Surveys completed with health center workers have demonstrated that many are aware of the correct techniques required to complete neonatal resuscitation, but do not have the confidence to effectively apply them in a real-life scenarios, especially due to infrequent follow-up and support post-training. This is reinforced by data collected through verbal autopsies completed by AHC throughout Preah Vihear; despite training in neonatal resuscitation 24% of deaths in the province were due to intrapartum related events (2019/20). In response to this, and similar conclusions in other global research related to skill attrition and intrapartum mortality, AHC has developed the BaRT system. The BaRT system is a low-cost, durable solution that has been specifically designed to ensure frontline health workers in low-resource contexts can simulate resuscitation in a no-risk setting and refine their technique until they are able to confidently resuscitate newborns.

BaRT: Strengthening frontline care in low-resource settings

With support from the Bill and Melinda Gates Foundation, AHC will further strengthen the BaRT system’s capacity to enable and empower frontline health workers in enhancing neonatal resuscitation capacity. Over the next two to three years, AHC will work closely with the Cambodian MoH, technical partners and relevant health authorities to test, iterate and finalize a workable system through the SBL program platform.

Over the next year, AHC will complete training of trainers’ course with health workers who have demonstrated excellence in previous neonatal resuscitation training, before facilitating training to frontline health workers in their locality. BaRT systems will then be left within health centers for extended periods to understand how they are utilized as a tool for resuscitation simulation and how they impact the skill and confidence of frontline health workers. This includes ongoing analysis of device data (including frequency of login, user’s ability to achieve the desired technique and resuscitations completed), periodical assessments and feedback collection from end-users and health officials.

Device data, feedback and observations from testing with health workers will support the production of an implementation manual that will provide structured guidelines and a tangible strategy for an effective, reproducible and cost-effective system for use by frontline health workers. The manual will be used with social enterprise modelling to approach a range of health/technology stakeholders who will enable the further refinement and manufacture of the BaRT system. With technical and ongoing government support, AHC will distribute BaRT nationally with the goal of sustainably reducing unnecessary neonatal mortality/morbidity.

Specific outputs over the next two years include:

• Comprehensive three-day neonatal residential training provided to 127 health workers from 14 health centers across Preah Vihear province.
• 318 frontline health workers in Preah Vihear trained in how to use the BaRT system, before BaRT systems being distributed to 29 health centers throughout Preah Vihear province.
• Comprehensive data collected surrounding the use and effectiveness of the BaRT system for improving neonatal resuscitation technique.
• At least one publication published in a peer-reviewed journal evaluating the impact of the BaRT system on neonatal resuscitation technique.
• An implementation manual developed that includes plans for ongoing technology and business development.
• Agreements made with the Cambodian MoH and health-technology developers regarding the manufacture and distribution of the BaRT system for national use.

 As a result of these outputs, the BaRT system has the potential to dramatically reduce the incidence of intrapartum deaths within Cambodia, saving an estimated 3,049 neonatal deaths each year (based on current Cambodia’s neonatal mortality, with 30% of mortality being intrapartum-related), as well as reducing long-term morbidities caused by such trauma every year. As this solution gains traction within Cambodia, the BaRT system has the potential to be transferrable to other low-resource contexts both throughout Southeast Asia and the developing world. For example, if distributed throughout the ASEAN region, BaRT has the potential to save up to 60,000 lives every year.