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Background: 2.6 million neonates die annually; the vast majorityof deaths occur in low- and middle-income countries (LMICs). TheHelping Babies Survive (HBS) programs are commonly used inLMICs to reduce neonatal mortality through education. They aretypically disseminated using a train-the-trainer cascade. However,there is little published literature on the extent and cost ofdissemination. In 2015, the Ethiopian Ministry of Health andpartner organizations implemented a countrywide HBS trainingcascade for midwives in 169 hospitals.Methods: We quantified the extent of HBS dissemination, andcharacterized barriers that impeded successful hospital-basedtraining by surveying a representative from each of the 169participant hospitals. This occurred from September 2017 to April2018. We also assessed the cost of the training cascade. To assessacquisition of knowledge and skill in the training cascade,multiple-choice question examinations (MCQE) and objectivestructured clinical evaluations (OSCE) were conducted.Results: Hospital-based training occurred in 132 participanthospitals (78%). 1,146 midwives, 69% of those employed byparticipant hospitals, received hospital-based training. Barriersincluded lack of preparation of hospital-based educators andlimited logistical support. The cascade cost an average of 2,105USD per facility or 197 USD per trainee. Knowledge improved andskills were adequate for regional workshop attendees based onMCQE and OSCE performance.Conclusion: The train-the-trainer strategy is an effective andaffordable strategy for widespread dissemination of the HBSprograms in LMICs. Future studies should assess knowledge andskill acquisition following the variety of pragmatic trainingapproaches that may be employed at the facility-level.