Background: Simulation-based Helping Babies Breathe (HBB) training is currently rolled-out in around 80 low-income countries with various results.

Method: Workflow was analyzed in 76 video-recorded newborn resuscitations performed by regularly HBB-trained nurse-midwives over 3 years in rural Tanzania.

Results: Actual newborn resuscitation practice deviated from HBB intention/guideline: most newborns underwent prolonged suction and stimulation before ventilation; ventilation was delayed and frequently interrupted. Nurse-midwives often worked together.

Conclusions:There is a gap between training intention and clinical practice. HBB trainings should focus more on urgency, ventilation skills, and team training. Combining clinical debriefing with HBB simulations could facilitate continuous learning and application