What is the impact of multi-professional emergency obstetric and neonatal care training?

Synthesis of evidence for managing hypertensive disorders of pregnancy in low middle-income countries: a scoping review

BACKGROUND AND OBJECTIVES

Hypertensive disorders of pregnancy (HDPs) remain one of the leading causes of maternal mortality globally, especially in Low- and middle-income countries (LMICs). To reduce the burden of associated morbidity and mortality, standardized prompt recognition, evaluation, and treatment have been proposed. Health disparities, barriers to access to healthcare, and shortage of resources influence these conditions. We aimed to synthesize the literature evidence for the management of HDPs in LMICs.

METHODS

A scoping review was conducted in five databases (PubMed, Web of Science, Epistemonikos, Clinical Key and, Scielo) using MeSh terms, keywords, and Boolean connectors. We summarized the included studies according to the following categories: study design, objectives, settings, participant characteristics, eligibility criteria, interventions, assessed outcomes, and general findings.

RESULTS

Six hundred fifty-one articles were retrieved from the literature search in five databases. Following the selection process, 65 articles met the predefined eligibility criteria. After performing a full-text analysis, 27 articles were included. Three themes were identified from the articles reviewed: prevention of HDPs, management of HDPs (antihypertensive and non-hypertensive management) and pregnancy monitoring and follow-up. The topics were approached from the perspective of LMICs.

CONCLUSIONS

LMICs face substantial limitations and obstacles in the comprehensive management of HDPs. While management recommendations in most LMICs align with international guidelines, several factors, including limited access to crucial medications, unavailability of diagnostic tests, deficiencies in high-quality healthcare infrastructure, restrictions on continuing professional development, a shortage of trained personnel, community perceptions of preeclampsia, and outdated local clinical practice guidelines, impede the comprehensive management of patients. The development and implementation of protocols, standardized guides and intervention packages are a priority.

Virtual simulation training for postpartum hemorrhage in low-to-moderate-volume hospitals in the US

Background

Maternal mortality in the United States is rising and many deaths are preventable. Emergencies, such as postpartum hemorrhage, occur less frequently in non-teaching, rural, and urban low-birth volume hospitals. There is an urgent need for accessible, evidence-based, and sustainable inter-professional education that creates the opportunity for clinical teams to practice their response to rare, but potentially devastating events.

Objective

To assess the feasibility of virtual simulation training for the management of postpartum hemorrhage in low-to-moderate-volume delivery hospitals.

Study design

The study occurred between December 2021 and March 2022 within 8 non-academic hospitals in the United States with low-to-moderate-delivery volumes, randomized to one of two models: direct simulation training and train-the-trainer. In the direct simulation training model, simulation faculty conducted a virtual simulation training program with participants. In the train-the-trainer model, simulation faculty conducted virtual lessons with new simulation instructors on how to prepare and conduct a simulation course. Following this training, the instructors led their own simulation training program at their respective hospitals. The direct simulation training participants and students trained by new instructors from the train-the-trainer program were evaluated with a multiple-choice questionnaire on postpartum hemorrhage knowledge and a confidence and attitude survey at 3 timepoints: prior to, immediately after, and at 3 months post-training. Paired t-tests were performed to assess for changes in knowledge and confidence within teaching models across time points. ANOVA was performed to test cross-sectionally for differences in knowledge and confidence between teaching models at each time point.

Results

Direct simulation training participants (n=22) and students of the train-the-trainer instructors (n=18) included nurses, certified nurse midwives and attending physicians in obstetrics, family practice or anesthesiology. Mean pre-course knowledge and confidence scores were not statistically different between direct simulation participants and the students of the instructors from the train-the-trainer course (79%+/-13 versus 75%+/-14, respectively, P-value=.45). Within the direct simulation group, knowledge and confidence scores significantly improved from pre- to immediately post-training (knowledge score mean difference 9.81 [95% CI 3.23-16.40], P-value<.01; confidence score mean difference 13.64 [95% CI 6.79-20.48], P-value<.01), which were maintained 3-months post-training. Within the train-the-trainer group, knowledge and confidence scores immediate post-intervention were not significantly different compared with pre-course or 3-month post-course scores. Mean knowledge scores were significantly greater for the direct simulation group compared to the train-the-trainer group immediately post-training (89%+/-7 versus 74%+/-8, P-value<.01) and at 3-months (88%+/-7 versus 76%+/-12, P-value<.01). Comparisons between groups showed no difference in confidence and attitude scores at these timepoints. Both direct simulation participants and train-the-trainer instructors preferred virtual education, or a hybrid structure, over in-person education.

Conclusion

Virtual education for obstetric simulation training is feasible, acceptable, and effective. Utilizing a direct simulation model for postpartum hemorrhage management resulted in enhanced knowledge acquisition and retention compared to a train-the-trainer model.

Impact of a regional simulation-based training course in the implementation of external cephalic version: Intervention study

OBJECTIVE

The aims of this study were to assess whether a regional simulation-based training course in external cephalic version (ECV) would lead to the adoption of this technique in hospitals where it was not previously practiced, and to improve success rates in those already performing it.

METHODS

This was an intervention study where two specialists in obstetrics and gynecology from 10 Portuguese public maternity hospitals attended a structured simulation-based training in ECV. Hospitals were categorized based on whether ECV was conducted prior to the training program, and on their annual number of deliveries. Main outcomes were the number of ECVs performed in the 2 years before and after the course, and their success rates.

RESULTS

Implementation of ECV was achieved in four additional hospitals during the 2 years following the course. Among the three hospitals already performing ECV and able to report their data, no significant differences in success rates were observed in the 2 years following the course (45.6% vs. 47.9%, P = 0.797). After a successful ECV, 77.7% of women had a vaginal delivery.

CONCLUSION

A regional simulation-based training course in ECV led to an increase in the number of hospitals implementing the technique in the subsequent 2 years, but it did not impact the success rates in centers where it was already performed. This study highlights the potential of simulation-based courses in ECV, as well as the need to improve patients´ access to the technique and to centralize ECV services at a regional level.

National survey regarding obstetricians' perspective of obstetric emergencies in Brazil

INTRODUCTION

The maternal mortality rate in developing countries, such as Brazil, has significantly increased since 2020. Obstetric Emergencies (OE) account for 72.5% of these deaths. A national survey was conducted in Brazil to evaluate how gynecologists and obstetricians deal with OE and identify the main difficulties regarding theoretical/practical knowledge and structural resources.

METHODS

An electronic questionnaire assessing resource availability, health teams, institutional protocols, and provision of OE training courses was completed by Brazilian obstetricians.

RESULTS

More than 90 % of the questionnaire respondents reported treating a pregnant and/or puerperal patient with severe morbidity and that their health network has human resources, trained professionals, and structural resources required for this type of care. However, few respondents participate in continuing education programs (36 %) or specific training for the medical team (61.41 %). The implementation rates of obstetric risk identification protocols (33.09 %), a rapid response team (46.54 %), and boxes and emergency cart assembly teams (71.68 %) were determined.

CONCLUSION

A high Maternal Mortality Ratio (MMR) may be related to disorganized healthcare systems, low implementation of risk classification protocols for the care of severe maternal and fetal conditions, and lack of access to continued/specific training programs. The Brazilian MMR is multifactorial. According to obstetricians, Brazilian health services include care teams, essential medications, obstetric centers, and clinical analysis laboratories, though they lack systematized processes and permanent professional training for qualified care of OE.

Quantification of blood loss for the diagnosis of postpartum hemorrhage: a systematic review and meta-analysis

OBJECTIVE

to compare the effectiveness of different diagnostic methods to estimate postpartum blood volume loss.

METHODS

a systematic review of effectiveness according to PRISMA and JBI Protocol. Searches in PubMed/MEDLINE, LILACS, Scopus, Embase, Web of Science and CINAHL, with descriptor "Postpartum Hemorrhage" associated with keyword "Quantification of Blood Loss". Tabulated extracted data, presented in metasynthesis and meta-analysis was applied to quantitative data. To assess risk of bias, JBI Appraisal Tools were applied.

RESULTS

fourteen studies were included, published between 2006 and 2021. Quantification of loss by any method was superior to visual estimation and is highly recommended, however the studies' high heterogeneity did not allow estimating this association.

CONCLUSION

the studies' high heterogeneity, with a probable margin of error given the uncontrolled factors, indicates the need for further studies, however quantification proved to be effective in relation to visual estimate. PROSPERO registration CRD 42021234486.

Simulation-Based Training in Emergency Obstetric Care in Sub-Saharan and Central Africa: A Scoping Review

Background

Every day approximately 810 women die from complications related to pregnancy and childbirth worldwide. Around two thirds of these deaths happen in sub-Saharan Africa. One of the strategies to decrease these numbers is improving the quality of care by emergency obstetric simulation-based training. The effectiveness of such training programs depends on the program's instructional design.

Objective

This review gives an overview of studies about emergency obstetric simulation-based training and examines the applied instructional design of the training programs in sub-Saharan and Central Africa.

Methods

We searched Medline, Embase and Cochrane Library from inception to May 2021. Peer-reviewed articles on emergency obstetric, postgraduate, simulation-based training in sub-Saharan and Central Africa were included. Outcome measures were categorized based on Kirkpatrick's levels of training evaluation. The instructional design was evaluated by using the ID-SIM questionnaire.

Findings

In total, 47 studies met the inclusion criteria. Evaluation on Kirkpatrick level 1 showed positive reactions in 18 studies. Challenges and recommendations were considered. Results on knowledge, skills, and predictors for these results (Kirkpatrick level 2) were described in 29 studies. Retention as well as decay of knowledge and skills over time were presented. Results at Kirkpatrick level 3 were measured in 12 studies of which seven studies demonstrated improvements of skills on-the-job. Improvements of maternal and neonatal outcomes were described in fifteen studies and three studies reported on cost-estimations for training rollout (Kirkpatrick level 4). Instructional design items were heterogeneously applied and described.

Conclusions

Results of 47 studies indicate evidence that simulation-based training in sub-Saharan and Central Africa can have a positive impact across all four levels of Kirkpatrick's training evaluation model. However, results were not consistent across all studies and the effects vary over time. A detailed description of instructional design features in future publications on simulation-based training will contribute to a deeper understanding of the underlying mechanisms that determine why certain training programs are more effective in improving maternal and neonatal healthcare outcomes than other.

Definition, management, and training in impacted fetal head at cesarean birth: a national survey of maternity professionals

INTRODUCTION

This study assessed views, understanding and current practices of maternity professionals in relation to impacted fetal head at cesarean birth, with the aim of informing a standardized definition, clinical management approaches and training.

MATERIAL AND METHODS

We conducted a survey consultation including the range of maternity professionals who attend emergency cesarean births in the UK. Thiscovery, an online research and development platform, was used to ask closed-ended and free-text questions. Simple descriptive analysis was undertaken for closed-ended responses, and content analysis for categorization and counting of free-text responses. Main outcome measures included the count and percentage of participants selecting predefined options on clinical definition, multi-professional team approach, communication, clinical management and training.

RESULTS

In total, 419 professionals took part, including 144 midwives, 216 obstetricians and 59 other clinicians (eg anesthetists). We found high levels of agreement on the components of an impacted fetal head definition (79% of obstetricians) and the need for use of a multi-professional approach to management (95% of all participants). Over 70% of obstetricians deemed nine techniques acceptable for management of impacted fetal head, but some obstetricians also considered potentially unsafe practices appropriate. Access to professional training in management of impacted fetal head was highly variable, with over 80% of midwives reporting no training in vaginal disimpaction.

CONCLUSIONS

These findings demonstrate agreement on the components of a standardized definition for impacted fetal head, and a need and appetite for multi-professional training. These findings can inform a program of work to improve care, including use of structured management algorithms and simulation-based multi-professional training.

Catalyzing Collaboration Among Interprofessional Birth Transfer Teams Through Simulation

INTRODUCTION

Planned home or birth center births sometimes require emergency transfers to a hospital. Poor communication among members of the birth care team during a transfer can lead to unfavorable outcomes for the birthing person and newborn. To improve the quality of birth transfers in Utah, the Utah Women and Newborns Quality Collaborative partnered with the LIFT Simulation Design Lab to develop and pilot an interprofessional birth transfer simulation training.

METHODS

We engaged community stakeholders to identify learning objectives and co-design the simulation trainings using principles of participatory design. We conducted 5 simulation trainings featuring birth transfers during a postpartum hemorrhage. The LIFT Lab evaluated the trainings to determine if they were feasible, acceptable, and effective. Measures included a post-training form asking participants to evaluate the quality of the training and a 9-question pre- and post-training survey measuring changes in participants' self-efficacy regarding components of birth transfer. The changes were assessed for significance using a paired t test.

RESULTS

A total of 102 participants attended the 5 trainings; all health care provider groups were well represented. Most participants felt the simulations were similar to real situations and would benefit others in their professions. All participants said the trainings were a good use of their time. Following the training, participants had significantly higher levels of self-efficacy regarding their ability to manage birth transfers.

DISCUSSION

Birth transfer simulation trainings are an acceptable, feasible, and effective method for training interprofessional birth care teams.

Training for managing impacted fetal head at caesarean birth: multimethod evaluation of a pilot

BACKGROUND

Implementation of national multiprofessional training for managing the obstetric emergency of impacted fetal head (IFH) at caesarean birth has potential to improve quality and safety in maternity care, but is currently lacking in the UK.

OBJECTIVES

To evaluate a training package for managing IFH at caesarean birth with multiprofessional maternity teams.

METHODS

The training included an evidence-based lecture supported by an animated video showing management of IFH, followed by hands-on workshops and real-time simulations with use of a birth simulation trainer, augmented reality and management algorithms. Guided by the Kirkpatrick framework, we conducted a multimethod evaluation of the training with multiprofessional maternity teams. Participants rated post-training statements about relevance and helpfulness of the training and pre-training and post-training confidence in their knowledge and skills relating to IFH (7-point Likert scales, strongly disagree to strongly agree). An ethnographer recorded sociotechnical observations during the training. Participants provided feedback in post-training focus groups.

RESULTS

Participants (N=57) included 21 midwives, 25 obstetricians, 7 anaesthetists and 4 other professionals from five maternity units. Over 95% of participants agreed that the training was relevant and helpful for their clinical practice and improving outcomes following IFH. Confidence in technical and non-technical skills relating to managing IFH was variable before the training (5%-92% agreement with the pre-training statements), but improved in nearly all participants after the training (71%-100% agreement with the post-training statements). Participants and ethnographers reported that the training helped to: (i) better understand the complexity of IFH, (ii) recognise the need for multiprofessional training and management and (iii) optimise communication with those in labour and their birth partners.

CONCLUSIONS

The evaluated training package can improve self-reported knowledge, skills and confidence of multiprofessional teams involved in management of IFH at caesarean birth. A larger-scale evaluation is required to validate these findings and establish how best to scale and implement the training.

Evidence-informed framework for gender transformative continuing education interventions for midwives and midwifery associations

INTRODUCTION

Continuing education for midwives is an important investment area to improve the quality of sexual and reproductive health services. Interventions must take into account and provide solutions for the systemic barriers and gender inequities faced by midwives. Our objective was to generate concepts and a theoretical framework of the range of factors and gender transformative considerations for the development of continuing education interventions for midwives.

METHODS

A critical interpretive synthesis complemented by key informant interviews, focus groups, observations and document review was applied. Three electronic bibliographic databases (CINAHL, EMBASE and MEDLINE) were searched from July 2019 to September 2020 and were again updated in June 2021. A coding structure was created to guide the synthesis across the five sources of evidence.

RESULTS

A total of 4519 records were retrieved through electronic searches and 103 documents were included in the critical interpretive synthesis. Additional evidence totalled 31 key informant interviews, 5 focus groups (Democratic Republic of Congo and Tanzania), 24 programme documents and field observations in the form of notes. The resulting theoretical framework outlines the key considerations including gender, the role of the midwifery association, political and health systems and external forces along with key enabling elements for the design, implementation and evaluation of gender transformative continuing education interventions.

CONCLUSION

Investments in gender transformative continuing education for midwives, led by midwifery associations, can lead to the improvement of midwifery across all United Nations' target areas including governance, health workforce, health system arrangements and education.

Evaluation of an immersive simulation programme for mental health clinicians to address aggression, violence, and clinical deterioration

This study investigated the effectiveness of high-fidelity immersive simulation education to support inter-professional hospital clinical staff in recognizing and responding to aggression, violence, and clinical deterioration of patients admitted with mental health issues. Increased incidents of aggression and violence have been reported in many clinical hospital settings, especially in mental health wards. Patients experiencing severe psychological distress/agitation can result in the escalation of physiological symptoms such as chest pain, difficulty breathing, traumatic injury, etc. Mental health staff do receive aggression prevention training and medical emergency team training. However, there is added complexity when dealing with a mental health patient who is exhibiting aggressive, violent behaviour while also experiencing a medical or psychological emergency. Therefore, mental health staff needed a combined training programme that enhanced their delivery of recovery focussed care, de-escalation, and medical emergency crisis resource management skills. This study used a prospective quasi experimental research design with repeated measures. Hospital clinical staff were immersed in two mental health emergency response and clinical deterioration scenarios and debriefing sessions. Self-efficacy was evaluated using a 10-item validated tool which addressed non-technical skills of Leadership, Management, Communication, and Teamwork. The sample consisted of 122 clinical staff, with the majority from mental health wards (52%; n = 63) who were nurses (68%; n = 83). Mean self-efficacy scores increased significantly across the three time points (F = 11.555; df = 2; P = 0.000). Post hoc pairwise comparisons showed that self-efficacy scores increased between pretest (mean 62.9; n = 122) and posttest 1 (mean 83.2; n = 122) and follow up, 3 months later (posttest 2; mean 81.9; n = 24). Between pre- and posttest 1, significant improvements in self-efficacy were observed for both the Leadership/Management domain (t = 8.2; df 119; P < 0.000; 95% CI 13.3-21.7) and the Communication/Teamwork domain (t = 8.0; df 119; P < 0.000; 95% CI 11.1-18.4). Immersive simulation with high fidelity education was found to be effective in improving hospital nursing and medical staffs' confidence, when responding to incidents of aggression/violence and clinical deterioration of a mental health patient.

Mixed methods evaluation of simulation-based training for postpartum hemorrhage management in Guatemala

BACKGROUND

To assess if simulation-based training (SBT) of B-Lynch suture and uterine balloon tamponade (UBT) for the management of postpartum hemorrhage (PPH) impacted provider attitudes, practice patterns, and patient management in Guatemala, using a mixed-methods approach.

METHODS

We conducted an in-country SBT course on the management of PPH in a governmental teaching hospital in Guatemala City, Guatemala. Participants were OB/GYN providers (n = 39) who had or had not received SBT before. Surveys and qualitative interviews evaluated provider knowledge and experiences with B-Lynch and UBT to treat PPH.

RESULTS

Multiple-choice surveys indicated that providers who received SBT were more comfortable performing and teaching B-Lynch compared to those who did not (p = 0.003 and 0.005). Qualitative interviews revealed increased provider comfort with B-Lynch compared to UBT and identified multiple barriers to uterine balloon tamponade implementation.

CONCLUSIONS

Simulation-based training had a stronger impact on provider comfort with B-Lynch compared to uterine balloon tamponade. Qualitative interviews provided insight into the challenges that hinder uptake of uterine balloon tamponade, namely resource limitations and decision-making hierarchies. Capturing data through a mixed-methods approach allowed for more comprehensive program evaluation.

Evaluating the impact of a maternity and neonatal emergencies education programme in Australian regional and rural health services on clinician knowledge and confidence: a pre-test post-test study

INTRODUCTION

Almost 78 000 women gave birth in the state of Victoria, Australia, in 2019. While most births occurred in metropolitan Melbourne and large regional centres, a significant proportion of women birthed in rural services. In late 2016, to support clinicians to recognise and respond to clinical deterioration, the Victorian government mandated provision of an emergency training programme, called Maternity and Newborn Emergencies (MANE), to rural and regional maternity services across the state. This paper describes the evaluation of MANE.

DESIGN AND SETTING

A quasi-experimental study design was used; the Kirkpatrick Evaluation Model provided the framework.

PARTICIPANTS

Participants came from the 17 rural and regional Victorian maternity services who received MANE in 2018 and/or 2019.

OUTCOME MEASURES

Baseline data were collected from MANE attendees before MANE delivery, and at four time points up to 12 months post-delivery. Clinicians' knowledge of the MANE learning objectives, and confidence ratings regarding the emergencies covered in MANE were evaluated. The Safety Attitudes Questionnaire (SAQ) assessed safety climate pre-MANE and 6 months post-MANE among all maternity providers at the sites.

RESULTS

Immediately post-MANE, most attendees reported increased confidence to escalate clinical concerns (n=251/259). Knowledge in the non-technical and practical aspects of the programme increased. Management of perinatal emergencies was viewed as equally stressful pre-MANE and post-MANE, but confidence to manage these emergencies increased post-delivery. Pre-MANE SAQ scores showed consistently strong and poor performing services. Six months post-MANE, some services showed improvements in SAQ scores indicative of improved safety climate.

CONCLUSION

MANE delivery resulted in both short-term and sustained improvements in knowledge of, and confidence in, maternity emergencies. Further investigation of the SAQ across Victoria may facilitate identification of services with a poor safety climate who could benefit from frequent targeted interventions (such as the MANE programme) at these sites.

Neonatal Resuscitation Skill-Training Using a New Neonatal Simulator, Facilitated by Local Motivators: Two-Year Prospective Observational Study of 9000 Trainings

Globally, intrapartum-related complications account for approximately 2 million perinatal deaths annually. Adequate skills in neonatal resuscitation are required to reduce perinatal mortality. NeoNatalie Live is a newborn simulator providing immediate feedback, originally designed to accomplish Helping Babies Breathe training in low-resource settings. The objectives of this study were to describe changes in staff participation, skill-training frequency, and simulated ventilation quality before and after the introduction of “local motivators” in a rural Tanzanian hospital with 4000–5000 deliveries annually. Midwives (n = 15–27) were encouraged to perform in situ low-dose high-frequency simulation skill-training using NeoNatalie Live from September 2016 through to August 2018. Frequency and quality of trainings were automatically recorded in the simulator. The number of skill-trainings increased from 688 (12 months) to 8451 (11 months) after the introduction of local motivators in October 2017. Staff participation increased from 43% to 74% of the midwives. The quality of training performance, measured as “well done” feedback, increased from 75% to 91%. We conclude that training frequency, participation, and performance increased after introduction of dedicated motivators. In addition, the immediate constructive feedback features of the simulator may have influenced motivation and training quality performance.

Evaluation in health professions education-Is measuring outcomes enough?

INTRODUCTION

In an effort to increase the rigour of evaluation in health professions education (HPE), a range of evaluation approaches are used. These largely focus on outcome evaluation as opposed to programme evaluation. We aim to review and critique the use of outcome evaluation models, using the Kirkpatrick Model as an example given its wide acceptance and use, and advocate for the use of programme evaluation models that help us understand how and why outcomes are occurring.

METHODS

We systematically searched OVID medline, Scopus, CINAHL and Pubmed, and hand searched six leading HPE journals to provide an overview of the use of the Kirkpatrick Model as well as a range of programme evaluation models in HPE. In addition to this, we synthesised the existing critiques of the Kirkpatrick Model as an example of outcome evaluation, to highlight the limitations of such models.

RESULTS

The use of the Kirkpatrick Model in HPE is widespread and increasing; however, studies focus on categorising outcomes, rather than explaining how and why they occur. The main criticisms of the model are as follows: it is outcomes focused and fails to consider factors that can impact training outcomes; it assumes positive casual linkages between the levels; there is an assumption that the higher-level outcomes are more important; and unintended impacts are not considered. The use of the Kirkpatrick Model by the MERSQI, BEME and WHO contribute to the myth that the Kirkpatrick Model is the gold standard for programme evaluation.

DISCUSSION

Moving forward, evaluations of HPE interventions must shift from focusing largely on measuring outcomes of interventions with little consideration for how and why these outcomes are occurring to programme evaluation that investigates what contributes to these outcomes. Other models that facilitate the evaluation of the complex processes that occur in HPE should be used instead of Kirkpatrick's.

Staying alive-training with anaesthetists

An effective working relationship between obstetricians and anaesthetists is crucial for patient safety in maternity care. Anaesthetists' skills and scope of clinical practice complement those of obstetricians, particularly during obstetric emergencies. Anaesthetists also bring expertise in resuscitation, critical care, and a training programme that is underpinned by non-technical as well as technical skills. Through training together, obstetricians and anaesthetists can help plug one another's knowledge gaps, identify each other's blind spots, aid mutual decision-making, and share relevant national guidance between specialties. Training also aids the development of a shared mental model, which contributes to improved teamwork. To be effective, this training should involve the whole team, be conducted in-house, be used to tackle local as well as national priorities, and be repeated regularly.

How often will midwives and obstetricians experience obstetric emergencies or high-risk deliveries: a national cross-sectional study

OBJECTIVE

To estimate how often midwives, specialty trainees and doctors specialised in obstetrics and gynaecology are attending to specific obstetric emergencies or high-risk deliveries (obstetric events).

DESIGN

A national cross-sectional study.

SETTING

All hospital labour wards in Denmark.

PARTICIPANTS

Midwives (n=1303), specialty trainees (n=179) and doctors specialised in obstetrics and gynaecology (n=343) working in hospital labour wards (n=21) in Denmark in 2018.

METHODS

Categories of obstetric events comprised of Apgar score <7/5 min, eclampsia, emergency caesarean sections, severe postpartum haemorrhage, shoulder dystocia, umbilical cord prolapse, vaginal breech deliveries, vaginal twin deliveries and vacuum extraction. Data on number of healthcare professionals were obtained through the Danish maternity wards, the Danish Health Authority and the Danish Society of Obstetricians and Gynaecologists. We calculated the time interval between attending each obstetric event by dividing the number of events occurred with the number of healthcare professionals.

OUTCOME MEASURES

The time interval between attending a specific obstetric event.

RESULTS

The average time between experiencing obstetric events ranged from days to years. Emergency caesarean sections, which occur relatively frequent, were attended on average every other month by midwives, every 9 days for specialty trainees and every 17 days by specialist doctors. On average, rare events like eclampsia were experienced by midwives only every 42 years, every 6 years by specialty trainees and every 11 years by specialist doctors.

CONCLUSIONS

Some obstetric events occur extremely rarely, hindering the ability to obtain and maintain the clinical skills to manage them through clinical practice alone. By assessing the frequency of a healthcare professionals attending an obstetric emergency, our study contributes to assessing the need for supplementary educational initiatives and interventions to learn and maintain clinical skills.

The effects of obstetric emergency team training on patient outcome: A systematic review and meta-analysis

INTRODUCTION

Little is known about the optimal simulation-based team training in obstetric emergencies. We aimed to review how simulation-based team training affects patient outcomes in obstetric emergencies.

MATERIAL AND METHODS

Search Strategy: MEDLINE, Embase, Cochrane Library, and Cochrane Central Register of Controlled Trials were searched up to and including May 15, 2021.

SELECTION CRITERIA

randomized controlled trials (RCTs) and cohort studies on obstetric teams in high-resource settings comparing the effect of simulation-based obstetric emergency team training with no training on the risk of Apgar scores less than 7 at 5 min, neonatal hypoxic ischemic encephalopathy, severe postpartum hemorrhage, blood transfusion of four or more units, and delay of emergency cesarean section by more than 30 min.

DATA COLLECTION AND ANALYSIS

The included studies were assessed using PRISMA, EPCO, and GRADE.

RESULTS

We found 21 studies, four RCTs and 17 cohort studies, evaluating patient outcomes after obstetric team training compared with no training. Annual obstetric emergency team training may reduce brachial plexus injury (six cohort studies: odds ratio [OR] 0.47, 95% CI 0.33-0.68; one RCT: OR 1.30, 95 CI% 0.39-4.33, low certainty evidence) and suggest a positive effect; but it was not significant on Apgar score below 7 at 5 min (three cohort studies: OR 0.77, 95% CI 0.51-1.19; two RCT: OR 0.87, 95% CI 0.72-1.05, moderate certainty evidence). The effect was unclear for hypoxic ischemic encephalopathy, umbilical prolapse, decision to birth interval in emergency cesarean section, and for severe postpartum hemorrhage. Studies with in situ multi-professional simulation-based training demonstrated the best effect.

CONCLUSIONS

Emerging evidence suggests an effect of obstetric team training on obstetric outcomes, but conflicting results call for controlled trials targeted to identify the optimal methodology for effective team training.

Does simulation improve clinical performance in management of postpartum hemorrhage?

BACKGROUND

Although simulation is now widely used to improve teamwork and communication, data demonstrating improvement in clinical outcomes are limited.

OBJECTIVE

This study aimed to examine the clinical performance and outcomes associated with postpartum hemorrhage because of uterine atony following the implementation of a multidisciplinary simulation program.

STUDY DESIGN

This was a prospective observational study of response to postpartum hemorrhage because of uterine atony in an academic medical center before (epoch 1: July 2017-June 2018) and after (epoch 2: July 2019-June 2020) implementing a multidisciplinary simulation program. A total of 22 postpartum hemorrhage simulations were performed from July 2018 to June 2019 involving more than 300 nursing, obstetrical, and anesthesia providers. The simulation program focused on managing postpartum hemorrhage events and improving teamwork and communication of the multidisciplinary teams. To evaluate the clinical effectiveness of the simulation program, the primary outcome was response to postpartum hemorrhage defined as the time from the administration of uterotonic medications to transfusion of the first unit of blood in the first 12 hours following delivery, comparing epoch 2 to epoch 1 following the implementation of a simulation program. Statistical analysis included the use of the Pearson chi-square test, Wilcoxon rank-sum test, Hodges-Lehmann statistic for differences, and bootstrap methods with a P value of <.05 considered significant.

RESULTS

Between July 1, 2017, and June 30, 2018, there were 12,305 patients who delivered, of which 495 patients (4%) required transfusion. Between July 1, 2019, and June 30, 2020, there were 12,414 patients who delivered, of which 480 patients (4%) required transfusion. When isolating cases of postpartum hemorrhage because of uterine atony in both transfused groups, there were 157 women in the presimulation group (epoch 1) and 165 women in the postsimulation group (epoch 2), respectively. There was no difference in age, race, parity, or perinatal outcomes between the 2 epochs. Women in epoch 2 began receiving blood products significantly earlier in the first 12 hours following delivery compared with women in epoch 1 (51 [range, 28-125] minutes vs 102 [range, 32-320] minutes; P=.005). In addition, there was a significantly decreased variation in the time from the administration of uterotonic medications to transfusion of blood in epoch 2 (P=.035). Furthermore, women in epoch 2 had significantly lower estimated blood loss than women in epoch 1 (1250 [range, 1000-1750] mL vs 1500 [range, 1000-2000] mL; P=.032).

CONCLUSION

The implementation of a multidisciplinary simulation program at a large academic center focusing on the management of postpartum hemorrhage was associated with an improved clinical response. Specifically, there were significantly faster times from the administration of uterotonic medications to transfusion of blood, decreased variance in the time from the administration of uterotonic medications to transfusion of blood, and lower estimated blood loss following the implementation of a simulation program. Because delay in treatment is a major cause of preventable maternal death in obstetrical hemorrhage, the results in our study provided clinical evidence that a simulation program may improve patient outcomes in such emergencies.

Single-center task analysis and user-centered assessment of physical space impacts on emergency Cesarean delivery

Cesarean delivery is the most common surgery performed in the United States, accounting for approximately 32% of all births. Emergency Cesarean deliveries are performed in the event of critical maternal or fetal distress and require effective collaboration and coordination of care by a multidisciplinary team with a high level of technical expertise. It is not well understood how the physical environment of the operating room (OR) impacts performance and how specialties work together in the space.

Key components influencing the sustainability of a multi-professional obstetric emergencies training programme in a middle-income setting: a qualitative study

BACKGROUND

Multi-professional obstetric emergencies training is one promising strategy to improve maternity care. Sustaining training programmes following successful implementation remains a challenge. Understanding, and incorporating, key components within the implementation process can embed interventions within healthcare systems, thereby enhancing sustainability. This study aimed to identify key components influencing sustainability of PRactical Obstetric Multi-Professional Training (PROMPT) in the Philippines, a middle-income setting.

METHODS

Three hospitals were purposively sampled to represent private, public and teaching hospital settings. Two focus groups, one comprising local trainers and one comprising training participants, were conducted in each hospital using a semi-structured topic guide. Focus groups were audio recorded. Data were analysed using thematic analysis. Three researchers independently coded transcripts to ensure interpretation consistency.

RESULTS

Three themes influencing sustainability were identified; attributes of local champions, multi-level organisational involvement and addressing organisational challenges.

CONCLUSIONS

These themes, including potential barriers to sustainability, should be considered when designing and implementing training programmes in middle-income settings. When 'scaling-up', local clinicians should be actively involved in selecting influential implementation champions to identify challenges and strategies specific to their organisation. Network meetings could enable shared learning and sustain enthusiasm amongst local training teams. Policy makers should be engaged early, to support funding and align training with national priorities.

A model-based cost-utility analysis of multi-professional simulation training in obstetric emergencies

OBJECTIVE

To determine the cost-utility of a multi-professional simulation training programme for obstetric emergencies-Practical Obstetric Multi-Professional Training (PROMPT)-with a particular focus on its impact on permanent obstetric brachial plexus injuries (OBPIs).

DESIGN

A model-based cost-utility analysis.

SETTING

Maternity units in England.

POPULATION

Simulated cohorts of individuals affected by permanent OBPIs.

METHODS

A decision tree model was developed to estimate the cost-utility of adopting annual, PROMPT training (scenario 1a) or standalone shoulder dystocia training (scenario 1b) in all maternity units in England compared to current practice, where only a proportion of English units use the training programme (scenario 2). The time horizon was 30 years and the analysis was conducted from an English National Health Service (NHS) and Personal Social Services perspective. A probabilistic sensitivity analysis was performed to account for uncertainties in the model parameters.

MAIN OUTCOME MEASURES

Outcomes for the entire simulated period included the following: total costs for PROMPT or shoulder dystocia training (including costs of OBPIs), number of OBPIs averted, number of affected adult/parental/dyadic quality adjusted life years (QALYs) gained and the incremental cost per QALY gained.

RESULTS

Nationwide PROMPT or shoulder dystocia training conferred significant savings (in excess of £1 billion ($1.5 billion)) compared to current practice, resulting in cost-savings of at least £1 million ($1.5 million) per any type of QALY gained. The probabilistic sensitivity analysis demonstrated similar findings.

CONCLUSION

In this model, national implementation of multi-professional simulation training for obstetric emergencies (or standalone shoulder dystocia training) in England appeared to both be cost-saving when evaluating their impact on permanent OBPIs.

Increases in diagnosis and management of obstetric and neonatal complications in district hospitals during a high intensity nurse-mentoring program in Bihar, India

Maternal and neonatal mortality in Bihar, India was far higher than the aspirational levels set out by the Sustainable Development Goals. Provider training programs have been implemented in many low-resource settings to improve obstetric and neonatal outcomes. This longitudinal investigation assessed diagnoses and management of postpartum hemorrhage (PPH), hypertensive disorders of pregnancy, birth asphyxia (BA), and low birth weight (LBW), as part of the CARE’s AMANAT program in 22 District Hospitals in Bihar, between 2015 and 2017. Physicians and nurse mentors conducted clinical instruction, simulations and teamwork and communication activities, infrastructure and management support, and data collection for 6 consecutive months. Analysis of diagnosis included 11,259 non-referred and management included 11,800 total (non-referred and referred) admissions that were observed. Data were analyzed using the chi-square test for trend. PPH was diagnosed in 3.7% with no significant trend but diagnosis of hypertensive disorders increased from 1.0% to 1.7%, (p_trend = 0.04), over the 6 months. BA was diagnosed in 5.8% with no significant trend but LBW diagnoses increased from 11% to 16% (p_trend<0.01). Among PPH patients, 96% received fluids, 85% received uterotonics and 11% received Tranexamic Acid (TXA). There was a significant positive trend in the number of patients receiving TXA for PPH (6% to 13.8%, p_trend = 0.03). Of all neonates with BA, there were statistically significant increases in the proportion who were initially warmed, dried, and stimulated (78% to 94%, p_trend = 0.02), received airway suction (80% to 93%, p_trend = 0.03), and supplemental oxygen without positive pressure ventilation (73% to 86%, p_trend = 0.05). Diagnoses of hypertensive disorders and LBW as well as initial management of BA increased during the AMANAT program. However, underdiagnoses of PPH and hypertensive disorders relative to population levels remain critical barriers to improving maternal morbidity and mortality.

Evaluating the Instructional Design and Effect on Knowledge, Teamwork, and Skills of Technology-Enhanced Simulation-Based Training in Obstetrics in Uganda: Stepped-Wedge Cluster Randomized Trial

BACKGROUND

Simulation-based training is a common strategy for improving the quality of facility-based maternity services and is often evaluated using Kirkpatrick's theoretical model. The results on the Kirkpatrick levels are closely related to the quality of the instructional design of a training program. The instructional design is generally defined as the "set of prescriptions for teaching methods to improve the quality of instruction with a goal of optimizing learning outcomes."

OBJECTIVE

The aim of this study is to evaluate the instructional design of a technology-enhanced simulation-based training in obstetrics, the reaction of participants, and the effect on knowledge, teamwork, and skills in a low-income country.

METHODS

A stepped-wedge cluster randomized trial was performed in a university hospital in Kampala, Uganda, with an annual delivery volume of over 31,000. In November 2014, a medical simulation center was installed with a full-body birthing simulator (Noelle S550, Gaumard Scientific), an interactive neonate (Simon S102 Newborn CPR Simulator, Gaumard Scientific), and an audio and video recording system. Twelve local obstetricians were trained and certified as medical simulation trainers. From 2014 to 2016, training was provided to 57 residents in groups of 6 to 9 students. Descriptive statistics were calculated for ten instructional design features of the training course measured by the 42-item ID-SIM (Instructional Design of a Simulation Improved by Monitoring). The Wilcoxon signed rank test was conducted to investigate the differences in scores on knowledge, the Clinical Teamwork Scale, and medical technical skills.

RESULTS

The mean scores on the ten instructional design features ranged from 54.9 (95% CI 48.5-61.3) to 84.3 (95% CI 80.9-87.6) out of 100. The highest mean score was given on the feature feedback and the lowest scores on repetitive practice and controlled environment. The overall score for the training day was 92.8 out of 100 (95% CI 89.5-96.1). Knowledge improved significantly, with a test score of 63.4% (95% CI 60.7-66.1) before and 78.9% (95% CI 76.8-81.1) after the training (P<.001). The overall score on the 10-point Clinical Teamwork Scale was 6.0 (95% CI 4.4-7.6) before and 5.9 (95% CI 4.5-7.2) after the training (P=.78). Medical technical skills were scored at 55.5% (95% CI 47.2-63.8) before and 65.6% (95% CI 56.5-74.7) after training (P=.08).

CONCLUSIONS

Most instructional design features of a technology-enhanced simulation-based training in obstetrics in a low-income country were scored high, although intervals were large. The overall score for the training day was high, and knowledge did improve after the training program, but no changes in teamwork and (most) medical technical skills were found. The lowest-scored instructional design features may be improved to achieve further learning aims.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN98617255; http://www.isrctn.com/ISRCTN98617255.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12884-020-03050-3.

Multi-professional simulation-based team training in obstetric emergencies for improving patient outcomes and trainees' performance

BACKGROUND

Simulation-based obstetric team training focuses on building a system that will anticipate errors, improve patient outcomes and the performance of clinical care teams. Simulation-based obstetric team training has been proposed as a tool to improve the overall outcome of obstetric health care.

OBJECTIVES

To assess the effects of simulation-based obstetric team training on patient outcomes, performance of obstetric care teams in practice and educational settings, and trainees' experience.

SEARCH METHODS

The Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) were searched (14 April 2020), together with references checking and hand searching the available proceedings of 2 international conferences.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) (including cluster-randomised trials) comparing simulation-based obstetric team training with no, or other type of training.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, to identify articles, assess methodological quality and extract data. Data from three cluster-randomised trials could be used to perform generic inverse variance meta-analyses. The meta-analyses were based on risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). We used the GRADE approach to rate the certainty of the evidence. We used Kirkpatrick's model of training evaluation to categorise the outcomes of interest; we chose Level 3 (behavioural change) and Level 4 (patient outcome) to categorise the primary outcomes.

MAIN RESULTS

We included eight RCTs, six of which were cluster-randomised trials, involving more than 1000 training participants and more than 200,000 pregnancies/births. Four studies reported on outcome measures on Kirkpatrick level 4 (patient outcome), three studies on Kirkpatrick level 3 (performance in practice), two studies on Kitkpatrick level 2 (performance in educational settings), and none on Kirkpatrick level 1 (trainees' experience). The included studies were from Mexico, the Netherlands, the UK and the USA, all middle- and high-income countries. Kirkpatrick level 4 (patient outcome) Simulation-based obstetric team training may make little or no difference for composite outcomes of maternal and/or perinatal adverse events compared with no training (3 studies; n = 28,731, low-certainty evidence, data not pooled due to different composite outcome definitions). We are uncertain whether simulation-based obstetric team training affects maternal mortality compared with no training (2 studies; 79,246 women; very low-certainty evidence). However, it may reduce neonatal mortality (RR 0.70, 95% CI 0.48 to 1.01; 2 studies, 79,246 pregnancies/births, low-certainty evidence). Simulation-based obstetric team training may have little to no effect on low Apgar score compared with no training (RR 0.99, 95% 0.85 to 1.15; 2 studies; 115,171 infants; low-certainty evidence), but it probably reduces trauma after shoulder dystocia (RR 0.50, 95% CI 0.25 to 0.99; 1 study; moderate-certainty evidence) and probably slightly reduces the number of caesarean deliveries (RR 0.79, 95% CI 0.67 to 0.93; 1 study; n = 50,589; moderate-certainty evidence) Kirkpatrick level 3 (performance in practice) We found that simulation-based obstetric team training probably improves the performance of the obstetric teams in practice, compared with no training (3 studies; 2398 obstetric staff members, moderate-certainty evidence, data not pooled due to different outcome definitions).

AUTHORS' CONCLUSIONS

Simulation-based obstetric team training may help to improve team performance of obstetric teams, and it might contribute to improvement of specific maternal and perinatal outcomes, compared with no training. However, high-certainty evidence is lacking due to serious risk of bias and imprecision, and the effect cannot be generalised for all outcomes. Future studies investigating simulation-based obstetric team training compared to training courses with a different instructional design should carefully consider how and when to measure outcomes. Particular attention should be paid to effect measurement at the level of patient outcome, taking into consideration the low incidence of adverse maternal and perinatal events.

Simulation for intrapartum care: from training to novel device innovation

Improving maternal and perinatal care is a global priority. Simulation training and novel applications of simulation for intrapartum care may help to reduce preventable deaths worldwide. Evaluation studies have published details of the effectiveness of simulation training for obstetric emergencies, exploring clinical and non-clinical factors as well as the impact on patient outcomes (both maternal and neonatal). This review summarized the many uses of simulation in obstetric emergencies from training to assessment. It also described the adaption of training in low-resource settings and the evidence behind the equipment recommended to support simulation training. The review also discussed novel applications for simulation such as its use in the development of a new device for assisted vaginal birth and its potential role in Cesarean section training. This study analyzed the financial implications of simulation training and how this may impact the delivery of such training packages, considering that simulation should be developed and utilized as a key tool in the development of safe intrapartum care in both emergency and non-emergency settings, in innovation and product development.

Implementing E-Learning to Enhance the Management of Postpartum Hemorrhage

OBJECTIVE

To determine if perinatal outcomes related to postpartum hemorrhage could be improved by blending existing strategies with the use of an online, assessment-driven electronic learning (e-learning) platform.

DESIGN

The Institute for Healthcare Improvement's Model for Improvement provided a structure for this performance improvement project. Outcome evaluation was further supported by the Kirkpatrick model.

SETTING/LOCAL PROBLEM

Reports of rising maternal morbidity and mortality in the United States prompted action within a multisite health system. Maternity care teams were determined to proactively support excellence in practice through enhancements to continuing education.

PARTICIPANTS

Maternity providers and nurses practicing within the organization completed the training.

INTERVENTION/MEASUREMENTS

Online, assessment-driven learning modules for maternity emergencies were blended with existing instructor-led courses, simulation, and Team Strategies to Enhance Performance and Patient Safety (TeamSTEPPS) training in early 2017. In addition, a postpartum hemorrhage safety bundle was implemented. Outcome measures included rates of hemorrhage, massive transfusion, and intensive care unit admission for women admitted for childbirth. Outcome measures were tracked using retrospective chart review with baseline period October 1, 2016, through March 31, 2017, and performance period April 1, 2017, through March 31, 2018.

RESULTS

Improvements in perinatal outcomes were observed. The average rate of hemorrhage decreased by 3% (from 56.4/1,000 to 54.7/1,000). Median massive transfusion rates decreased by 35% (from 2.3/1,000 to 1.5/1,000). Similarly, the median rate of maternal intensive care unit admissions decreased by 77% (from 3.1/1,000 to 0.7/1,000). A downward shift was supported with zero intensive care unit admissions for 6 of the last 7 months (n = 4,422 pregnant women or women who experienced birth during the current admission).

CONCLUSION

Excellence in the management of postpartum hemorrhage was supported through a multipronged approach that included the use of an online e-learning platform for maternity emergencies.

Developing and implementing a novel mentorship model (4+ 1) for maternal, newborn and child health in Rwanda

BACKGROUND

There are a number of factors that may contribute to high mortality and morbidity of women and newborns in low-income countries. These include a shortage of competent health care providers (HCP) and a lack of sufficient continuous professional development (CPD) opportunities. Strengthening the skills and building the capacity of HCP involved in the provision of maternal, newborn and child health (MNCH) is essential to ensure quality care for mothers, newborns and children. To address this challenge in Rwanda, mentorship of HCPs was identified as an approach that could help build capacity, improve the provision of care and accelerate the reduction in maternal and neonatal mortality and morbidity. In this paper, we describe the development and implementation of a novel mentorship model named Four plus One (4^+ 1) for MNCH in Rwanda.

METHODS

The mentorship model built on the basis of inter-professional collaboration (IPC) was developed in early 2017 through consultations with different key actors. The design phase included refresher courses in specific skills and training course on mentoring. Field visits were conducted in 10 hospitals from June 2017 to February 2020. Hospital management teams (MT) were involved in the development and implementation of this mentorship model to ensure ownership of the program.

RESULTS

Upon completion of planned visits to each hospital, a total of 218 HCPs were involved in the process. Reports prepared by mentors upon each mentorship visit and compiled by Training Support and Access Model (TSAM) for MNCH'CPD team, highlighted the mothers and newborns who were saved by both mentors and mentees. Also, different logbooks of mentees showed how the capacity of staff was strengthened, thereby suggesting effectiveness of the model. Through different mentorship coordination meetings, the model was much appreciated by the MTs of hospitals, especially the IPC component of the model and confirmed the program 'effectiveness.

CONCLUSION

The initiation of a mentorship model built on IPC together with the involvement of the leadership of the hospital may be the cause effect of reduction of specific mortality and improve MNCH in low resource settings even when there are a limited number of specialists in the health facilities.

Study protocol training for life: a stepped wedge cluster randomized trial about emergency obstetric simulation-based training in a low-income country

BACKGROUND

Globally perinatal and maternal mortality rates remain unacceptably high. There is increasing evidence that simulation-based training in obstetric emergencies is associated with improvement in clinical outcomes. However, the results are not entirely consistent. The need for continued research in a wide variety of clinical settings to establish what works, where and why was recommended. The aim of this study is to investigate the effectiveness of an emergency obstetric simulation-based training program with medical technical and teamwork skills on maternal and perinatal mortality in a low-income country.

METHODS

A stepped wedge cluster randomized trial will be conducted at the medium to high-risk labour ward at Mulago Hospital, Kampala, Uganda, with an annual delivery rate of over 23,000. The training will be performed using a train-the-trainers model in which training is cascaded down from master trainers to local facilitators (gynaecologists) to learners (senior house officers). Local facilitators will be trained during a four-day train-the-trainers course with an annual repetition. The senior house officers will be naturally divided in seven clusters and randomized for the moment of training. The training consists of a one-day, monodisciplinary, simulation-based training followed by repetition training sessions. Scenarios are based on the main local causes of maternal and neonatal mortality and focus on both medical technical and crew resource management skills. Kirkpatrick's classification will be used to evaluate the training program. Primary outcome will be the composite of maternal and neonatal mortality ratios. Secondary outcome will comprise course perception, evaluation of the instructional design of the training, knowledge, technical skills, team performance, percentage of ventouse deliveries, percentage of caesarean sections, and a Weighted Adverse Outcome Score.

DISCUSSION

This stepped wedge cluster randomized trial will investigate the effect of a monodisciplinary simulation-based obstetric training in a low-income country, focusing on both medical technical skills and crew resource management skills, on patient outcome at one of the largest labour wards worldwide. We will use a robust study design which will allow us to better understand the training effects, and difficulties in evaluating training programs in low-income countries.

TRIAL REGISTRATION

ISRCTN98617255 , retrospectively registered July 23, 2018.

A Nationwide Needs Assessment to Identify and Prioritize Technical Procedures for Simulation in Obstetrics and Gynaecology: A Delphi Study

OBJECTIVE

The aims of the study were to identify and prioritize technical procedures that should be developed and integrated in a simulation-based curriculum for obstetrics and gynaecology residents.

METHODS

The Delphi method was used, consisting of three rounds of survey questionnaires. Key leaders across Denmark were invited to participate. In Delphi round 1, the participants individually identified technical procedures that newly authorized specialists should be able to perform. These procedures were sent to round 2 to be explored for need for simulation-based training by estimating frequency of procedures, number of doctors, potential patient risk and/or discomfort, and feasibility of simulation. Round 3 consisted of elimination and prioritization of remaining procedures (Canadian Task Force Classification III).

RESULTS

A total of 165 key leaders were invited. Response rates were 61%, 50%, and 53%, respectively. Identified procedures in Round 1 were as follows: gynaecology (n = 51), obstetrics (n = 40), and general procedures (n = 10). A needs assessment formula was used to calculate needs for training on the basis of the answers in round 2 and produce a preliminary prioritized list that was sent to round 3 for final exploration. Round 3 consisted of elimination and final prioritization, where gynaecology (n = 17) prioritized basic laparoscopy, vaginal ultrasound, and laparoscopy with salpingostomy and salpingectomy; obstetrics procedures (n = 16) prioritized basic resuscitation of newborn, vacuum extraction, and management of shoulder dystocia; and one general procedure (basic adult resuscitation) was included.

CONCLUSION

A needs assessment using the Delphi method produced a prioritized list of technical procedures suitable for simulation. This can guide the development of simulation-based training programs.

Using the Kirkpatrick Model to evaluate the Maternity and Neonatal Emergencies (MANE) programme: Background and study protocol

INTRODUCTION

Over 310 000 women gave birth in Australia in 2016, with approximately 80 000 births in the state of Victoria. While most of these births occur in metropolitan Melbourne and other large regional centres, a significant proportion of Victorian women birth in local rural health services. The Victorian state government recently mandated the provision of a maternal and neonatal emergency training programme, called Maternal and Newborn Emergencies (MANE), to rural and regional maternity service providers across the state. MANE aims to educate maternity and newborn care clinicians about recognising and responding to clinical deterioration in an effort to improve clinical outcomes. This paper describes the protocol for an evaluation of the MANE programme.

METHODS AND ANALYSIS

This study will evaluate the effectiveness of MANE in relation to: clinician confidence, skills and knowledge; changes in teamwork and collaboration; and consumer experience and satisfaction, and will explore and describe any governance changes within the organisations after MANE implementation. The Kirkpatrick Evaluation Model will provide a framework for the evaluation. The participants of MANE, 27 rural and regional Victorian health services ranging in size from approximately 20 to 1000 births per year, will be invited to participate. Baseline data will be collected from maternity service staff and consumers at each health service before MANE delivery, and at four time-points post-MANE delivery. There will be four components to data collection: a survey of maternity services staff; follow-up interviews with Maternity Managers at health services 4 months after MANE delivery; consumer feedback from all health services collected through the Victorian Healthcare Experience Survey; case studies with five regional or rural health service providers.

ETHICS AND DISSEMINATION

This evaluation has been approved by the La Trobe University Science, Health and Engineering College Human Ethics Sub-Committee. Findings will be presented to project stakeholders in a deidentified report, and disseminated through peer-reviewed publications and conference presentations.

Perspectives of stakeholders on emergency obstetric care training in Kenya: a qualitative study

Background

This study explores stakeholders’ perceptions of emergency obstetric care (EmOC) ‘skills-and-drills’-type training including the outcomes, strengths, weaknesses, opportunities and threats of the intervention in Kenya.

Methods

Stakeholders who either benefited from or contributed to EmOC training were purposively sampled. Semi-structured topic guides were used for key informant interviews and focus group discussions. Following verbatim transcriptions of recordings, the thematic approach was used for data analysis.

Results

Sixty-nine trained healthcare providers (HCPs), 114 women who received EmOC and their relatives, 30 master trainers and training organizers, and six EmOC facility/Ministry of Health staff were recruited. Following training, deemed valuable for its ‘hands-on’ approach and content by HCPs, women reported that they experienced improvements in the quality of care provided. HCPs reported that training led to improved knowledge, skills and attitudes, with improved care outcomes. However, they also reported an increased workload. Implementing stakeholders stressed the need to explore strategies that help to maximize and sustain training outcomes.

Conclusions

The value of EmOC training in improving the capacity of HCPs and outcomes for mothers and newborns is not just ascribed but felt by beneficiaries. However, unintended outcomes such as increased workload may occur and need to be systematically addressed to maximize training gains.

How do supply- and demand-side interventions influence equity in healthcare utilisation? Evidence from maternal healthcare in Senegal

The launch of the Millennium Development Goals in 2000, followed by the Sustainable Development Goals in 2015, and the increasing focus on achieving universal health coverage has led to numerous interventions on both supply- and demand-sides of health systems in low- and middle-income countries. While tremendous progress has been achieved, inequities in access to healthcare persist, leading to calls for a closer examination of the equity implications of these interventions. This paper examines the equity implications of two such interventions in the context of maternal healthcare in Senegal. The first intervention on the supply-side focuses on improving the availability of maternal health services while the second intervention, on the demand-side, abolished user fees for facility deliveries. Using three rounds of Demographic Health Surveys covering the period 1992 to 2010 and employing three measures of socioeconomic status (SES) based on household wealth, mothers' education and rural/urban residence - we find that although both interventions increase utilisation of maternal health services, the rich benefit more from the supply-side intervention, thereby increasing inequity, while those living in poverty benefit more from the demand-side intervention i.e. reducing inequity. Both interventions positively influence facility deliveries in rural areas although the increase in facility deliveries after the demand-side intervention is more than the increase after the supply-side intervention. There is no significant difference in utilisation based on mothers' education. Since people from different SES categories are likely to respond differently to interventions on the supply- and demand-side of the health system, policymakers involved in the design of health programmes should pay closer attention to concerns of inequity and elite capture that may unintentionally result from these interventions.

The effects of interactive training of healthcare providers on the management of life-threatening emergencies in hospital

BACKGROUND

Preparing healthcare providers to manage relatively rare life-threatening emergency situations effectively is a challenge. Training sessions enable staff to rehearse for these events and are recommended by several reports and guidelines. In this review we have focused on interactive training, this includes any element where the training is not solely didactic but provides opportunity for discussions, rehearsals, or interaction with faculty or technology. It is important to understand the effective methods and essential elements for successful emergency training so that resources can be appropriately targeted to improve outcomes.

OBJECTIVES

To assess the effects of interactive training of healthcare providers on the management of life-threatening emergencies in hospital on patient outcomes, clinical care practices, or organisational practices, and to identify essential components of effective interactive emergency training programmes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and ERIC and two trials registers up to 11 March 2019. We searched references of included studies, conference proceedings, and contacted study authors.

SELECTION CRITERIA

We included randomised trials and cluster-randomised trials comparing interactive training for emergency situations with standard/no training. We defined emergency situations as those in which immediate lifesaving action is required, for example cardiac arrests and major haemorrhage. We included all studies where healthcare workers involved in providing direct clinical care were participants. We excluded studies outside of a hospital setting or where the intervention was not targeted at practicing healthcare workers. We included trials irrespective of publication status, date, and language.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane and Cochrane Effective Practice and Organisation of Care (EPOC) Group. Two review authors independently extracted data and assessed the risk of bias of each included trial. Due to the small number of studies and the heterogeneity in outcome measures, we were unable to perform the planned meta-analysis. We provide a structured synthesis for the following outcomes: survival to hospital discharge, morbidity rate, protocol or guideline adherence, patient outcomes, clinical practice outcomes, and organisation-of-care outcomes. We used the GRADE approach to rate the certainty of the evidence and the strength of recommendations for each outcome.

MAIN RESULTS

We included 11 studies that reported on 2000 healthcare providers and over 300,000 patients; one study did not report the number of participants. Seven were cluster randomised trials and four were single centre studies. Four studies focused on obstetric training, three on obstetric and neonatal care, two on neonatal training, one on trauma and one on general resuscitations. The studies were spread across high-, middle- and low-income settings.Interactive training may make little or no difference in survival to hospital discharge for patients requiring resuscitation (1 study; 30 participants; 98 events; low-certainty evidence). We are uncertain if emergency training changes morbidity rate, as the certainty of the evidence is very low (3 studies; 1778 participants; 57,193 patients, when reported). We are uncertain if training alters healthcare providers' adherence to clinical protocols or guidelines, as the certainty of the evidence is very low (3 studies; 156 participants; 558 patients). We are uncertain if there were improvements in patient outcomes following interactive training for emergency situations, as we assessed the evidence as very low-certainty (5 studies, 951 participants; 314,055 patients). We are uncertain if training for emergency situations improves clinical practice outcomes as the certainty of the evidence is very low (4 studies; 1417 participants; 28,676 patients, when reported). Two studies reported organisation-of-care outcomes, we are uncertain if interactive emergency training has any effect on this outcome as the certainty of the evidence is very low (634 participants; 179,400 patient population).We examined prespecified subgroups and found no clear commonalities in effect of multidisciplinary training, location of training, duration of the course, or duration of follow-up. We also examined areas arising from the studies including focus of training, proportion of staff trained, leadership of intervention, and incentive/trigger to participate, and again identified no clear mediating factors. The sources of funding for the studies were governmental, local organisations, or philanthropic donors.

AUTHORS' CONCLUSIONS

We are uncertain if there are any benefits of interactive training of healthcare providers on the management of life-threatening emergencies in hospital as the certainty of the evidence is very low. We were unable to identify any factors that may have allowed us to identify an essential element of these interactive training courses.We found a lack of consistent reporting, which contributed to the inability to meta-analyse across specialities. More trials are required to build the evidence base for the optimum way to prepare healthcare providers for rare life-threatening emergency events. These trials need to be conducted with attention to outcomes important to patients, healthcare providers, and policymakers. It is vitally important to develop high-quality studies adequately powered and with attention to minimising the risk of bias.

Knowledge of intrapartum care among obstetric care providers in rural Kenya

BACKGROUND

Kenya did not meet its maternal mortality ratio (MMR) target under the Millennium Development Goals. The aim of this study was to examine the gaps in knowledge of intrapartum care among obstetric care providers (OCPs) in rural Nandi County, Kenya.

METHODS

This cross-sectional study in 2015 surveyed 326 nurses, midwives, clinical officers and physicians about their knowledge, attitudes and practices related to normal labor and childbirth, immediate newborn care and management of obstetric complications.

RESULTS

Self-reported intrapartum knowledge among OCPs was insufficient according to accepted international standards. The mean total knowledge score for all OCPs based on a validated 30-question inventory was 62% (range 23-90%). Only 14 providers (4%) scored as 'competent' (a score ≥80%). Scores were higher for OCPs who had received pre- and postemployment emergency obstetric care training and those with higher levels of confidence in their skills. Survey respondents identified a lack of knowledge as one of the greatest barriers to high-quality patient care.

CONCLUSIONS

Increasing training opportunities for OCPs may improve the quality of obstetric care provided to women in Kenya and other high-MMR locations in sub-Saharan Africa and enable progress toward achieving the ambitious Sustainable Development Goals target for maternal survival.

Effect of a cluster randomised team training intervention on adverse perinatal and maternal outcomes: a stepped wedge study

OBJECTIVE

To study the effect of an intervention based on Crew Resource Management team training, including a tool for structured communication, on adverse perinatal and maternal outcomes.

DESIGN

Stepped wedge.

SETTING

The Netherlands.

POPULATION OR SAMPLE

Registry data of 8123 women referred from primary care to a hospital during childbirth, at ≥ 32.0 weeks of singleton gestation and with no congenital abnormalities, in the period 2012-15.

METHODS

Obstetric teams of five hospitals and their surrounding primary-care midwifery practices participated in the intervention. In total, 49 team training sessions were organised for 465 care professionals (75.5% participated). Adverse perinatal and maternal outcomes before, during and after the intervention were analysed using multivariate logistic regression analyses.

MAIN OUTCOME MEASURES

Adverse Outcome Index (AOI-5), a composite measure involving; intrapartum or neonatal death, admission to neonatal intensive care unit, Apgar < 7 at 5 minutes, postpartum haemorrhage and/or perineal tear.

RESULTS

In total, an AOI-5 score was reported in 11.3% of the study population. No significant difference was found in the incidence of the AOI-5 score after the intervention compared with before the intervention (OR 1.07: 95% CI 0.92-1.24).

CONCLUSIONS

We found no effect of the intervention on adverse perinatal and maternal outcomes for women who were referred during childbirth. Team training is appreciated in practice, but evidence on the long-term impact is still limited. Upcoming studies should build on previous research and consider more sensitive outcome measures.

TWEETABLE ABSTRACT

A cluster randomised team training intervention showed no effect on adverse perinatal and maternal outcomes for women referred during childbirth.

Obstetric emergency simulation training course: experience of a private-public partnership in Brazil

Background

Lack of skills on how to diagnose and manage obstetric emergencies contribute to substandard institutional care and preventable maternal deaths in Brazil. Simulation-based obstetric emergency team training can reduce adverse maternal outcomes. However, this type of training is expensive and not widely available, especially in low resource settings. We present the experience of a private-public partnership that offered a two-day obstetric emergency simulation-training course to hundreds of Brazilian professionals working in the public sector. We also present participants´ short-term learning outcomes (Kirkpatrick’s level 2) and satisfaction (Kirkpatrick’s level 1).

Methods

This was a non-experimental before-and-after study. The free 16-h course was held over a 14 months period in a large private hospital’s simulation center using multidisciplinary scenario and model-based training. The training sessions consisted of four (4-h) modules on pre-eclampsia/eclampsia, hemorrhage, sepsis and resuscitation. An anonymous questionnaire collected participants´ satisfaction at the end of each module. Learning outcomes were assessed by comparing differences in participants´ pre- versus immediate post-course test scores. Wilcoxon, Kruskal-Wallis and Friedman tests were used for statistical analyses. P < 0.05 was considered significant.

Results

340 professionals (117 doctors, 179 registered nurses-RN and 44 licensed practical nurses-LPN) working in 33 public Brazilian hospitals were trained. There was a significant increase in post-course test scores in all four modules. On average, scores increased 55% in the hypertension and 65–69% in the hemorrhage, sepsis and resuscitation modules (p = 0.019). Knowledge acquisition of RN and LPN was similar in the hypertension, hemorrhage and sepsis modules and significantly higher than doctors´ (p < 0.05). On a 0 to 10 scale, mean overall satisfaction ranged from 9.6 (for the hypertension module) to 9.8 (for the resuscitation module).

Conclusions

This successful experience of a private-public partnership to offer obstetric emergency simulation training required strategic organization and a strong commitment from both sides. This promising private-public partnership model could be replicated in similar settings. The training course obtained high satisfaction scores and significantly improved the knowledge of public-sector health professionals on how to manage the main causes of maternal mortality.

Social return on investment of emergency obstetric care training in Kenya

Introduction

Emergency obstetric care (EmOC) training is considered a key strategy for reducing maternal and perinatal morbidity and mortality. Although generally considered effective, there is minimal evidence on the broader social impact and/or value-for-money (VfM). This study assessed the social impact and VfM of EmOC training in Kenya using social return on investment (SROI) methodology.

Methods

Mixed-methods approach was used, including interviews (n=21), focus group discussions (n=18) incorporating a value game, secondary data analysis and literature review, to obtain all relevant data for the SROI analysis. Findings were incorporated into the impact map and used to estimate the SROI ratio. Sensitivity analyses were done to test assumptions.

Results

Trained healthcare providers, women and their babies who received care from those providers were identified as primary beneficiaries. EmOC training led to improved knowledge and skills and improved attitudes towards patients. However, increased workload was reported as a negative outcome by some healthcare providers. Women who received care expected and experienced positive outcomes including reduced maternal and newborn morbidity and mortality. After accounting for external influences, the total social impact for 93 5-day EmOC training workshops over a 1-year period was valued at I$9.5 million, with women benefitting the most from the intervention (73%). Total direct implementation cost was I$745 000 for 2965 healthcare providers trained. The cost per trained healthcare provider per day was I$50.23 and SROI ratio was 12.74:1. Based on multiple one-way sensitivity analyses, EmOC training guaranteed VfM in all scenarios except when trainers were paid consultancy fees and the least amount of training outcomes occurred.

Conclusion

EmOC training workshops are a worthwhile investment. The implementation approach influences how much VfM is achieved. The use of volunteer facilitators, particularly those based locally, to deliver EmOC training is a critical driver in increasing social impact and achieving VfM for investments made.

Peer-assisted learning after onsite, low-dose, high-frequency training and practice on simulators to prevent and treat postpartum hemorrhage and neonatal asphyxia: A pragmatic trial in 12 districts in Uganda

An urgent need exists to improve and maintain intrapartum skills of providers in sub-Saharan Africa. Peer-assisted learning may address this need, but few rigorous evaluations have been conducted in real-world settings. A pragmatic, cluster-randomized trial in 12 Ugandan districts provided facility-based, team training for prevention and management of postpartum hemorrhage and birth asphyxia at 125 facilities. Three approaches to facilitating simulation-based, peer assisted learning were compared. The primary outcome was the proportion of births with uterotonic given within one minute of birth. Outcomes were evaluated using observation of birth and supplemented by skills assessments and service delivery data. Individual and composite variables were compared across groups, using generalized linear models. Overall, 107, 195, and 199 providers were observed at three time points during 1,716 births across 44 facilities. Uterotonic coverage within one minute increased from: full group: 8% (CI 4%‒12%) to 50% (CI 42%‒59%); partial group: 19% (CI 9%‒30%) to 42% (CI 31%‒53%); and control group: 11% (5%‒7%) to 51% (40%‒61%). Observed care of mother and newborn improved in all groups. Simulated skills maintenance for postpartum hemorrhage prophylaxis remained high across groups 7 to 8 months after the intervention. Simulated skills for newborn bag-and-mask ventilation remained high only in the full group. For all groups combined, incidence of postpartum hemorrhage and retained placenta declined 17% and 47%, respectively, from during the intervention period compared to the 6‒9 month period after the intervention. Fresh stillbirths and newborn deaths before discharge decreased by 34% and 62%, respectively, from baseline to after completion, and remained reduced 6‒9 months post-implementation. Significant improvements in uterotonic coverage remained across groups 6 months after the intervention. Findings suggest that while short, simulation-based training at the facility improves care and is feasible, more complex clinical skills used infrequently such as newborn resuscitation may require more practice to maintain skills. Trial Registration: ClinicalTrials.gov NCT03254628.

Effect of an in-situ simulation workshop on home birth practice in Australia

PROBLEM

Interprofessional training programs for obstetric emergencies have been introduced for up-skilling birth unit staff in hospitals but not frequently used in training midwives and paramedicine staff for home birth emergency.

BACKGROUND

Practical Obstetric Multiprofessional Training (PROMPT) has previously been described in the home birth setting using in-situ simulation training of home births for midwifery and paramedicine staff.

AIM

The aim of this study was to evaluate the benefit of the home birth simulation in clinical practice and to explore how the simulation program prepared the midwives for a birth-related emergency in a publicly funded home birth program.

METHODS

Midwives conducting home births, the midwifery educator and the simulated woman in labour (n=9) attended an interview that explored how the midwives' learning through simulation affected their home birth clinical practice. The simulated woman and the facilitator who conducted the simulation for more than six years were also interviewed to comment on the observed change in performance in simulation. The interview transcripts were thematically analysed.

FINDINGS

The themes that were identified and agreed upon, were applying learning to clinical practice, learning in teams, valuing realism, facilitating simulation based education and managing variation.

DISCUSSION

In-situ nature of simulation with home birth midwives and paramedical staff facilitated learning transfer and team-based approach to practice. The careful simulation design provided a breadth of experience in emergencies.

CONCLUSION

Applying learning to prepare for clinical emergency situations changed the midwives' approach in managing home births. This provided evidence for a change in behaviour (Level 3 Kirkpatrick's framework) and transfer of learning, leading to changed protocols (Level 4a Kirkpatrick's framework).

A rapid cycle method for local adaptation of an obstetric emergencies training program

OBJECTIVE

To describe the adaptation of an obstetric emergencies training program to align with local clinical practice.

METHODS

A feasibility study was conducted to investigate the potential implementation of the PRactical Obstetric Multi-Professional Training (PROMPT) program at eight urban tertiary hospitals in the Philippines. Multi-professional teams attended a 2-day course on September 23 and 24, 2015, that comprised a demonstration PROMPT course (day 1) and a Train-the-Trainers session (day 2). During a facilitated adaptation session, each team reviewed the PROMPT algorithms for eclampsia, severe pre-eclampsia, postpartum hemorrhage and sepsis. The teams marked steps concordant with local practice and identified differences with local practice. Suggested amendments were reviewed by the PROMPT project team, using clinical guidelines to support any adaptations.

RESULTS

The PROMPT algorithm for initial management of eclampsia was used as an exemplar. Five of the nine management steps were concordant with local practice: support; airway; breathing; circulation; and control seizures. Amendments were successfully implemented for the following steps: call for help; magnesium sulfate loading dose; and magnesium sulfate maintenance dose.

CONCLUSION

Rapid and efficient adaptation of PROMPT training materials for use in the Philippines was possible using a facilitated and focused approach, utilizing the expertise of a representative mix of local healthcare professionals and evidence-based guidelines.

Measuring movement towards improved emergency obstetric care in rural Kenya with implementation of the PRONTO simulation and team training program

As the proportion of facility-based births increases, so does the need to ensure that mothers and their newborns receive quality care. Developing facility-oriented obstetric and neonatal training programs grounded in principles of teamwork utilizing simulation-based training for emergency response is an important strategy for improving the quality care. This study uses 3 dimensions of the Kirkpatrick Model to measure the impact of PRONTO International (PRONTO) simulation-based training as part of the Linda Afya ya Mama na Mtoto (LAMMP, Protect the Health of mother and child) in Kenya. Changes in knowledge of obstetric and neonatal emergency response, self-efficacy, and teamwork were analyzed using longitudinal, fixed-effects, linear regression models. Participants from 26 facilities participated in the training between 2013 and 2014. The results demonstrate improvements in knowledge, self-efficacy, and teamwork self-assessment. When comparing pre-Module I scores with post-training scores, improvements range from 9 to 24 percentage points (p values < .0001 to .026). Compared to baseline, post-Module I and post-Module II (3 months later) scores in these domains were similar. The intervention not only improved participant teamwork skills, obstetric and neonatal knowledge, and self-efficacy but also fostered sustained changes at 3 months. The proportion of facilities achieving self-defined strategic goals was high: 95.8% of the 192 strategic goals. Participants rated the PRONTO intervention as extremely useful, with an overall score of 1.4 out of 5 (1, extremely useful; 5, not at all useful). Evaluation of how these improvements affect maternal and perinatal clinical outcomes is forthcoming.

Evaluation of learning from Practical Obstetric Multi-Professional Training and its impact on patient outcomes in Australia using Kirkpatrick's framework: a mixed methods study

OBJECTIVES

The aim of this study was to evaluate the implementation of the Practical Obstetric Multi-Professional Training (PROMPT) simulation using the Kirkpatrick's framework. We explored participants' acquisition of knowledge and skills, its impact on clinical outcomes and organisational change to integrate the PROMPT programme as a credentialing tool. We also aimed to assess participants' perception of usefulness of PROMPT in their clinical practice.

STUDY DESIGN

Mixed methods approach with a pre-test/post-test design.

SETTING

Healthcare network providing obstetric care in Victoria, Australia.

PARTICIPANTS

Medical and midwifery staff attending PROMPT between 2013 and 2015 (n=508); clinical outcomes were evaluated in two cohorts: 2011-2012 (n=15 361 births) and 2014-2015 (n=12 388 births).

INTERVENTION

Attendance of the PROMPT programme, a simulation programme taught in multidisciplinary teams to facilitate teaching emergency obstetric skills.

MAIN OUTCOME MEASURE

Clinical outcomes compared before and after embedding PROMPT in educational practice.

SECONDARY OUTCOME MEASURE

Assessment of knowledge gained by participants through a qualitative analysis and description of process of embedding PROMPT in educational practice.

RESULTS

There was a change in the management of postpartum haemorrhage by early recognition and intervention. The key learning themes described by participants were being prepared with a prior understanding of procedures and equipment, communication, leadership and learning in a safe, supportive environment. Participants reported a positive learning experience and increase in confidence in managing emergency obstetric situations through the PROMPT programme, which was perceived as a realistic demonstration of the emergencies.

CONCLUSION

Participants reported an improvement of both clinical and non-technical skills highlighting principles of teamwork, communication, leadership and prioritisation in an emergency situation. An improvement was observed in management of postpartum haemorrhage, but no significant change was noted in clinical outcomes over a 2-year period after PROMPT. However, the skills acquired by medical and midwifery staff justify embedding PROMPT in educational programmes.

Economic evaluation of emergency obstetric care training: a systematic review

Background

Training healthcare providers in Emergency Obstetric Care (EmOC) has been shown to be effective in improving their capacity to provide this critical care package for mothers and babies. However, little is known about the costs and cost-effectiveness of such training. Understanding costs and cost-effectiveness is essential in guaranteeing value-for-money in healthcare spending. This study systematically reviewed the available literature on cost and cost-effectiveness of EmOC trainings.

Methods

Peer-reviewed and grey literature was searched for relevant papers published after 1990. Studies were included if they described an economic evaluation of EmOC training and the training cost data were available. Two reviewers independently searched, screened, and selected studies that met the inclusion criteria, with disagreements resolved by a third reviewer. Quality of studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards statement. For comparability, all costs in local currency were converted to International dollar (I$) equivalents using purchasing power parity conversion factors. The cost per training per participant was calculated. Narrative synthesis was used to summarise the available evidence on cost effectiveness.

Results

Fourteen studies (five full and nine partial economic evaluations) met the inclusion criteria. All five and two of the nine partial economic evaluations were of high quality. The majority of studies (13/14) were from low- and middle-income countries. Training equipment, per diems and resource person allowance were the most expensive components. Cost of training per person per day ranged from I$33 to I$90 when accommodation was required and from I$5 to I$21 when training was facility-based. Cost-effectiveness of training was assessed in 5 studies with differing measures of effectiveness (knowledge, skills, procedure cost and lives saved) making comparison difficult.

Conclusions

Economic evaluations of EmOC training are limited. There is a need to scale-up and standardise processes that capture both cost and effectiveness of training and to agree on suitable economic evaluation models that allow for comparability across settings.

Trial registration

PROSPERO_CRD42016041911.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1586-z) contains supplementary material, which is available to authorized users.

Clinical performance and patient outcome after simulation-based training in prevention and management of postpartum haemorrhage: an educational intervention study in a low-resource setting

Background

Postpartum haemorrhage (PPH) is a major cause of maternal mortality. Prevention and adequate treatment are therefore important. However, most births in low-resource settings are not attended by skilled providers, and knowledge and skills of healthcare workers that are available are low. Simulation-based training effectively improves knowledge and simulated skills, but the effectiveness of training on clinical behaviour and patient outcome is not yet fully understood. The aim of this study was to assess the effect of obstetric simulation-based training on the incidence of PPH and clinical performance of basic delivery skills and management of PPH.

Methods

A prospective educational intervention study was performed in a rural referral hospital in Tanzania. Sixteen research assistants observed all births with a gestational age of more than 28 weeks from May 2011 to June 2013. In March 2012 a half-day obstetric simulation-based training in management of PPH was introduced. Observations before and after training were compared. The main outcome measures were incidence of PPH (500–1000 ml and >1000 ml), use and timing of administration of uterotonic drugs, removal of placenta by controlled cord traction, uterine massage, examination of the placenta, management of PPH (>500 ml), and maternal and neonatal mortality at 24 h.

Results

Three thousand six hundred twenty two births before and 5824 births after intervention were included. The incidence of PPH (500–1000 ml) significantly reduced from 2.1% to 1.3% after training (effect size Cohen’s d = 0.07). The proportion of women that received oxytocin (87.8%), removal of placenta by controlled cord traction (96.5%), and uterine massage after birth (93.0%) significantly increased after training (to 91.7%, 98.8%, 99.0% respectively). The proportion of women who received oxytocin as part of management of PPH increased significantly (before training 43.0%, after training 61.2%). Other skills in management of PPH improved (uterine massage, examination of birth canal, bimanual uterine compression), but these were not statistically significant.

Conclusions

The introduction of obstetric simulation-based training was associated with a 38% reduction in incidence of PPH and improved clinical performance of basic delivery skills and management of PPH.

Impact of multi-professional, scenario-based training on postpartum hemorrhage in Tanzania: a quasi-experimental, pre- vs. post-intervention study

BACKGROUND

Tanzania has a relatively high maternal mortality ratio of 410 per 100,000 live births. Severe postpartum hemorrhage (PPH) is a major cause of maternal deaths, but in most cases, it is preventable. However, most pregnant women that develop PPH, have no known risk factors. Therefore, preventive measures must be offered to all pregnant women. This study investigated the effects of multi-professional, scenario-based training on the prevention and management of PPH at a Tanzanian zonal consultant hospital. We hypothesized that scenario-based training could contribute to improved competence on PPH-management, which would result in improved team efficiency and patient outcome.

METHODS

This quasi-experimental, pre-vs. post-interventional study involved on-site multi-professional, scenario-based PPH training, conducted in a two-week period in October 2013 and another 2 weeks in November 2014. Training teams included nurses, midwives, doctors, and medical attendants in the Department of Obstetrics and Gynecology. After technical skill training on the birthing simulator MamaNatalie®, the teams practiced in realistic scenarios on PPH. Each scenario was followed by debriefing and repeated scenario. Afterwards, the group swapped roles and the observers became the participants. To evaluate the effects of training, we measured patient outcomes by determining blood transfusion rates. Patient data were collected by randomly sampling Medical birth registry files from the pre-training and post-training study periods (n = 1667 and 1641 files, respectively). Data were analyzed with the Chi-square test, Mann-Whitney U-test, and binary logistic regression.

RESULTS

The random patient samples (n = 3308) showed that, compared to pre-training, post-training patients had a 47% drop in whole blood transfusion rates and significant increases in cesarean section rates, birth weights, and vacuum deliveries. The logistic regression analysis showed that transfusion rates were significantly associated with the time period (pre- vs. post-training), cesarean section, patients tranferred from other hospitals, maternal age, and female genital mutilation and cutting.

CONCLUSIONS

We found that multi-professional, scenario-based training was associated with a significant, 47% reduction in whole blood transfusion rates. These results suggested that training that included all levels of maternity staff, repeated sessions with realistic scenarios, and debriefing may have contributed to reduced blood transfusion rates in this high-risk maternity setting.

Does the effect of one-day simulation team training in obstetric emergencies decline within one year? A post-hoc analysis of a multicentre cluster randomised controlled trial

Does the effect of one-day simulation team training in obstetric emergencies decline within one year? A post-hoc analysis of a multicentre cluster randomised controlled trial. J van de Ven, AF Fransen, E Schuit, PJ van Runnard Heimel, BW Mol, SG Oei OBJECTIVE: To investigate whether the effect of a one-day simulation-based obstetric team training on patient outcome changes over time.

STUDY DESIGN

Post-hoc analysis of a multicentre, open, randomised controlled trial that evaluated team training in obstetrics (TOSTI study).We studied women with a singleton pregnancy beyond 24 weeks of gestation in 24 obstetric units. Included obstetric units were randomised to either a one-day, multi-professional simulation-based team training focusing on crew resource management in a medical simulation centre (12 units) or to no team training (12 units). We assessed whether outcomes differed between both groups in each of the first four quarters following the team training and compared the effect of team training over quarters. Primary outcome was a composite outcome of low Apgar score, severe postpartum haemorrhage, trauma due to shoulder dystocia, eclampsia and hypoxic-ischemic encephalopathy.

RESULTS

During a one year period after the team training the rate of obstetric complications, both on the composite level and the individual component level, did not differ between any of the quarters. For trauma due to shoulder dystocia team training led to a significant decrease in the first quarter (0.06% versus 0.26%, OR 0.19, 95% CI 0.03 to 0.98) but in the subsequent quarters no significant reductions were observed. Similar results were found for invasive treatment for severe postpartum haemorrhage where a significant increase was only seen in the first quarter (0.4% versus 0.03%, OR 19, 95% CI 2.5-147), and not thereafter.

CONCLUSION

The beneficial effect of a one-day, simulation-based, multiprofessional, obstetric team training seems to decline after three months. If team training is further evaluated or implemented, repetitive training sessions every three months seem therefore recommended.