Impact of a low-technology simulation-based obstetric and newborn care training scheme on non-emergency delivery practices in Guatemala

Enhancing the competencies of obstetrical nurses and midwives in high-risk pregnancy management through simulation-based training in Lao people's democratic republic: A pilot study

BACKGROUND

Simulation-based training has been widely used as a valuable strategy for learning and evaluating clinical skills at different levels of nursing and midwifery education. The impact of simulation training on intensive management for high-risk pregnancy in a low-resource setting has been limited.

AIM

To examine the effect of simulation-based training with low-fidelity mannequins on obstetrical nurses and midwives' knowledge, attitude, and skills for high-risk pregnancy management in a low-resource setting.

METHOD

During September 2023, twenty-five obstetrical nurses or midwives who worked in five tertiary public hospitals in Vientiane Prefecture participated in the three-day training workshops for intensive management in high-risk pregnant women and newborns that used a simulation-based training approach integrating problem-based learning. The evaluated criteria of knowledge, attitudes, and skills pre- and post-test scores were statistically compared.

FINDINGS

Workshop trainees demonstrated an increase significantly in knowledge for high-risk pregnancy management (p = 0.012), attitude toward high-risk pregnancy management (p = 0.000), and attitude toward simulation-based training design (p = 0.002). The clinical skills were used on the simulation performance checklist, and the pre-posttest gain in overall performance scores had a statistically significant difference (p = 0.000). The mean score of postpartum hemorrhage management skills was 11.48±2.23, which increased the highest score among all skills.

CONCLUSIONS

The simulation-based training in high-risk pregnancy management improves the knowledge, attitude, and skills of nurses and midwives in low-resource settings. Next steps include direct observation of trainees in the clinical setting to assess their competence in ensuring patient safety, achieving positive pregnancy outcomes, and enhancing satisfaction.

Systematic Review of Procedural Skill Simulation in Health Care in Low- and Middle-Income Countries

ABSTRACT

Low- and middle-income countries (LMICs) have adopted procedural skill simulation, with researchers increasingly investigating simulation efforts in resource-strained settings. We aim to summarize the current state of procedural skill simulation research in LMICs focusing on methodology, clinical area, types of outcomes and cost, cost-effectiveness, and overall sustainability. We performed a comprehensive literature review of original articles that assessed procedural skill simulation from database inception until April 2022.From 5371 screened articles, 262 were included in this review. All included studies were in English. Most studies were observational cohort studies (72.9%) and focused on obstetrics and neonatal medicine (32.4%). Most measured outcome was the process of task performance (56.5%). Several studies mentioned cost (38.9%) or sustainability (29.8%). However, few articles included actual monetary cost information (11.1%); only 1 article assessed cost-effectiveness. Based on our review, future research of procedural skill simulation in LMICS should focus on more rigorous research, cost assessments, and on less studied areas.

Effect of a quality improvement intervention for management of preterm births on outcomes of all births in Kenya and Uganda: A secondary analysis from a facility-based cluster randomized trial

Background

A large proportion of early neonatal deaths occur at the time or on the first day of birth. The Preterm Birth Initiative East Africa (PTBi EA) set out to decrease mortality among preterm births through improving quality of facility-based intrapartum care. The PTBi EA cluster randomized trial's primary analysis showed the package reduced intrapartum stillbirth and neonatal death among preterm infants. This secondary analysis examines the impact of the PTBi intervention package on stillbirth and predischarge newborn deaths combined, among all births in 20 participating facilities in Kenya and Uganda.

Methods

Eligible facilities were pair-matched and randomly assigned (1:1) into either the intervention or the control group. All facilities received support for data strengthening and a modified World Health Organization (WHO) Safe Childbirth Checklist; facilities in the intervention group additionally received provider mentoring using PRONTO simulation and team training as well as quality improvement collaboratives. We abstracted data from maternity registers.

Results

Of the total 29 442 births that were included, Kenya had 8468 and 6465 births and Uganda had 8719 and 5790 births, in the control and intervention arms, respectively. There were 935 stillbirths and predischarge newborn deaths in the control arm and 439 in the intervention arm. The adjusted odds ratio (aOR) for the effect of the intervention on the combined outcome, among all births, was 0.96 (95% confidence interval (CI) = 0.69-1.32), which was different by country: Kenya - 1.12 (95% CI = 0.72-1.73); Uganda - 0.65 (95% CI = 0.44-0.98); P_interaction  = 0.025. These trends were similar after excluding the PTBi primary cohort.

Conclusions

The intervention package improved survival among all births in Uganda but not in Kenya. These results suggest the importance of context and facility differences that were observed between the two countries.

Registration

This trial is registered with ClinicalTrials.gov, NCT03112018.

Training nurse simulation educators at scale to improve maternal and newborn health: a case study from Bihar, India

BACKGROUND

Simulation has been shown to improve clinical and behavioral skills of birth attendants in low-resource settings at a low scale. Populous, low-resource settings such as Bihar, India, require large cadres of simulation educators to improve maternal and newborn health. It's unknown if simulation facilitation skills can be adopted through a train of trainers' cascade. To fill this gap, we designed a study to evaluate the simulation and debrief knowledge, attitudes and skills of a third generation of 701 simulation educators in Bihar, India. In addition, we assessed the physical infrastructure where simulation takes place in 40 primary healthcare facilities in Bihar, India.

METHODS

We performed a 1 year before-after intervention study to assess the simulation facilitation strengths and weaknesses of a cadre of 701 nurses in Bihar, India. The data included 701 pre-post knowledge and attitudes self-assessments; videos of simulations and associated debriefs conducted by 701 providers at 40 primary healthcare centers.

RESULTS

We observed a statistically significant difference in knowledge and attitude scores before and after the 4-day PRONTO simulation educator training. The average number of participants in a simulation video was 5 participants (range 3-8). The average length of simulation videos was 10:21 minutes. The simulation educators under study, covered behavioral in 90% of debriefs and cognitive objectives were discussed in all debriefs.

CONCLUSION

This is the first study assessing the simulation and debrief facilitation knowledge and skills of a cadre of 701 nurses in a low-resource setting. Simulation was implemented by local nurses at 353 primary healthcare centers in Bihar, India. Primary healthcare centers have the physical infrastructure to conduct simulation training. Some simulation skills such as communication via whiteboard were widely adopted. Advanced skills such as eliciting constructive feedback without judgment require practice.

Off-site simulation-based training on management of postpartum hemorrhage amongst final-year medical students

Background

Postpartum hemorrhage (PPH) is an obstetric emergency, and training of health-care providers for early diagnosis and intervention improves morbidity and mortality. Regular simulation-based training modules are conducted in our institute for health-care providers. The objective of this study was to assess the final-year medical students on their subjective improvement in the management of PPH after an off-site simulation-based training which was conducted after a conventional lecture.

Methods

A survey was administered on medical students and their subjective retrospective analysis of both pre and post off-site simulation was collected. The survey was analyzed, and results were formulated.

Results

Forty-six students completed the survey. Although students felt their confidence level in enumerating the steps in management of PPH less than 50% before the drill, it increased to 70% after the drill. The confidence of the students in carrying out the procedures of PPH also increased. The results showed a considerable subjective improvement in skill and cognitive enhancement after an off-site simulation-based training. There was a significant improvement in the pre and postsimulation training scores in the test. The faculty felt that there was an enhancement in learning after the simulation training.

Conclusion

Off-site simulation of an emergency condition improves both knowledge and skill in students.

Simulation training for obstetric emergencies in low- and lower-middle income countries: A systematic review

BACKGROUND

This review aims to systematically evaluate the currently available evidence investigating the effectiveness of simulation-based training (SBT) in emergency obstetrics care (EmOC) in Low- and Lower-Middle Income Countries (LMIC). Furthermore, based on the challenges identified we aim to provide a series of recommendations and a knowledge base for future research in the field.

METHODS

A systematic database search was conducted of original articles that explored the use of simulation-based training for EmOC in LMIC in EMBASE, MEDLINE, Cochrane database and Google Scholar, from inception to January 2022.

RESULTS

The literature search identified 1,957 articles of which a total of 15 studies were included in this review, featuring 8,900 healthcare professionals from 18 countries. The SBT programmes varied in the reviewed studies. The most common training programme consisted of the PRONTO programme implemented by four studies, comprising of 970 participants across four different countries. In general, programmes consisted of lectures, workshops and simulations of emergency obstetric scenarios followed by a debrief of participants. There were thirteen studies, comprising of 8,332 participants, which tested for improvements in clinical knowledge in post-partum haemorrhage, neonatal resuscitation, pre-eclampsia, shoulder dystocia and sepsis. All the included studies reported improvements in clinical knowledge following the simulation of scenarios. Changes in teamwork, improvement in leadership and in communication skills were also widely reported.

CONCLUSION

The use of SBT programmes is not only sustainable, feasible and acceptable in LMIC, but could also improve clinical knowledge, communication, and teamwork among healthcare providers, thus directly addressing the UN Sustainable Development Goals.

Simulation and nurse-mentoring in a statewide nurse mentoring program in Bihar, India: diagnosis of postpartum hemorrhage and intrapartum asphyxia

Background: Mentoring programs that include simulation, bedside mentoring, and didactic components are becoming increasingly popular to improve quality. These programs are designed with little evidence to inform the optimal composition of mentoring activities that would yield the greatest impact on provider skills and patient outcomes. We examined the association of number of maternal and neonatal emergency simulations performed with the diagnosis of postpartum hemorrhage (PPH) and intrapartum asphyxia in real patients. Methods: We used a prospective cohort and births were compared between- and within-facility over time. Setting included 320 public facilities in the state of Bihar, India May 2015 - 2017. The participants were deliveries and livebirths. The interventions carried out were mobile nurse-mentoring program with simulations, teamwork and communication activities, didactic teaching, demonstrations of clinical procedures and bedside mentoring including conducting deliveries. Nurse mentor pairs visited each facility for one week, covering four facilities over a four-week period, for seven to nine consecutive months. The outcome measures were diagnosis of PPH and intrapartum asphyxia. Results:Relative to the bottom one-third facilities that performed the fewest maternal simulations, facilities in the middle one-third group diagnosed 26% (incidence rate ratio [IRR] = 1.26, 95% confidence interval [CI]: 1.00, 1.59) more cases of PPH in real patients. Similarly, facilities in the middle one-third group, diagnosed 25% (IRR = 1.25, 95% CI: 1.04, 1.50) more cases of intrapartum asphyxia relative to the bottom third group that did the fewest neonatal simulations. Facilities in the top one-third group (i.e., performed the most simulations) did not have a significant difference in diagnosis of both outcomes, relative to the bottom one-third group. Results:Relative to the bottom one-third facilities that performed the fewest maternal simulations, facilities in the middle one-third group diagnosed 26% (incidence rate ratio [IRR] = 1.26, 95% confidence interval [CI]: 1.00, 1.59) more cases of PPH in real patients. Similarly, facilities in the middle one-third group, diagnosed 25% (IRR = 1.25, 95% CI: 1.04, 1.50) more cases of intrapartum asphyxia relative to the bottom third group that did the fewest neonatal simulations. Facilities in the top one-third group (i.e., performed the most simulations) did not have a significant difference in diagnosis of both outcomes, relative to the bottom one-third group. Conclusions: Findings suggest a complex relationship between performing simulations and opportunities for direct practice with patients, and there may be an optimal balance in performing the two that would maximize diagnosis of PPH and intrapartum asphyxia.

A summative content analysis of how programmes to improve the right to sexual and reproductive health address power

INTRODUCTION

Power shapes all aspects of global health. The concept of power is not only useful in understanding the current situation, but it is also regularly mobilised in programmatic efforts that seek to change power relations. This paper uses summative content analysis to describe how sexual and reproductive health (SRH) programmes in low-income and middle-income countries explicitly and implicitly aim to alter relations of power.

METHODS

Content analysis is a qualitative approach to analysing textual data; in our analysis, peer-reviewed articles that describe programmes aiming to alter power relations to improve SRH constituted the data. We searched three databases, ultimately including 108 articles. We extracted the articles into a spreadsheet that included basic details about the paper and the programme, including what level of the social ecological model programme activities addressed.

RESULTS

The programmes reviewed reflect a diversity of priorities and approaches to addressing power, though most papers were largely based in a biomedical framework. Most programmes intervened at multiple levels simultaneously; some of these were 'structural' programmes that explicitly aimed to shift power relations, others addressed multiple levels using a more typical programme theory that sought to change individual behaviours and proximate drivers. This prevailing focus on proximate behaviours is somewhat mismatched with the broader literature on the power-related drivers of SRH health inequities, which explores the role of embedded norms and structures.

CONCLUSION

This paper adds value by summarising what the academic public health community has chosen to test and research in terms of power relations and SRH, and by raising questions about how this corresponds to the significant task of effecting change in power relations to improve the right to SRH.

Effectiveness of Communication Interventions in Obstetrics-A Systematic Review

(1) Background: Obstetric work requires good communication, which can be trained through interventions targeting healthcare providers and pregnant women/patients. This systematic review aims to aggregate the current state of research on communication interventions in obstetrics. (2) Methods: Using the PICOS scheme, we searched for studies published in peer-reviewed journals in English or German between 2000 and 2020. Out of 7018 results, 71 studies were included and evaluated in this synthesis using the Oxford Level of Evidence Scale. (3) Results: The 63 studies that included a communication component revealed a positive effect on different proximal outcomes (i.e., communication skills). Three studies revealed a beneficial effect of communication trainings on distal performance indicators (i.e., patient safety), but only to a limited extent. Most studies simultaneously examined different groups, however, those addressing healthcare providers were more common than those with students (61 vs. 12). Only nine studies targeted expectant mothers. Overall, the evidence level of studies was low (only 11 RCTs), with 24 studies with an evidence level I-II, 35 with level III, and 10 with level IV. (4) Conclusions: Communication trainings should be more frequently applied to improve communication of staff, students, and pregnant women and their partners, thereby improving patient safety.

Changing the landscape of obstetric resident education in low- and middle-income countries using simulation-based training

OBJECTIVE

To evaluate simulation-based training (SBT) in low- and-middle-income countries (LMIC) and the long-term retention of knowledge and self-efficacy.

METHODS

We conducted an SBT course on the management of postpartum hemorrhage (PPH), shoulder dystocia (SD), and maternal cardiac arrest (MCA) in three government teaching hospitals in Guatemala. We evaluated changes in knowledge and self-efficacy using a multiple-choice questionnaire for 46 obstetrics/gynecology residents. A paired Student's t test was used to analyze changes at 1 week and 6 months after the SBT.

RESULTS

There was an increase in scores in clinical knowledge of MCA (p < 0. 001, 95% confidence interval [CI] 0.81-1.49) and SD (p < 0.001, 95% CI 0.41-1.02) 1 week after SBT, and a statistically insignificant increase in PPH scores (p = 0.617, 95% CI -0.96 to 0.60). This increase in scores was maintained after 6 months for MCA (p < 0.001, 95% CI 0.69-1.53), SD (p = 0.02 95% CI 0.07-0.85), and PPH (p = 0.04, 95% CI 0.01-1.26). For MCA and SD, the levels of self-efficacy were increased 1 week following training (p < 0.001, 95% CI 0.83-2.30 and p = 0.008, 95% CI 0.60-3.92, respectively), and at 6 months (p < 0.001, 95% CI 0.79-2.42 and p = 0.006, 95% CI 0.66-3.81, respectively). There was a slight increase in PPH self-efficacy scores 1 week after SBT (p = 0.73, 95% CI -6.05 to 4.41), maintained after 6 months (p = 0.38, 95% CI -6.85 to 2.85).

CONCLUSION

SBT was found to be an effective and feasible method to increase short- and long-term clinical knowledge and self-efficacy of obstetric emergencies in LMIC.

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.

An integrated approach to improve maternal and perinatal outcomes in rural Guatemala: A stepped-wedge cluster randomized trial

OBJECTIVE

To evaluate the impact of an intervention package on maternal and newborn health indicators.

METHODS

A randomized stepped-wedge non-blind trial was conducted across six subdistricts within two districts in Guatemala from January 2014 to January 2017. Data on outcomes were collected on all deliveries in all 33 health centers. The intervention package included distribution of promotional materials encouraging health center delivery; education for traditional birth attendants about the importance of health center delivery; and provider capacity building using simulation training. Main outcomes were number of health center deliveries, maternal morbidity, and perinatal morbidity and mortality.

RESULTS

Overall, there were 24 412 deliveries. Health center deliveries per 1000 live births showed an overall increase, although after adjustment for secular trends and clustering, the relative risk for the treatment effect was not statistically significant (aRR, 1.04; 95% confidence interval [CI], 0.97-1.11, P=0.242). Although not statistically significant, maternal morbidity (aRR, 0.78; 95% CI, 0.60-1.02; P=0.068) and perinatal morbidity (aRR, 0.84; 95% CI, 0.68-1.05; P=0.133) showed a tendency toward a decrease.

CONCLUSION

The present study represents one of the few randomized evaluations of an integrated approach to improve birth outcomes in a low-income setting. ClinicalTrials.gov: NCT0315107.

Interdisciplinary simulation scenario in nursing education: Humanized childbirth and birth

Objective:

to develop and validate with a panel of experts a scenario of maternal-child clinical simulation, related to humanized childbirth and birth.

Method:

methodological study based on the Jeffries framework and standardized guides of the International Nursing Association for Clinical Simulation in Learning, which used analysis with descriptive statistics for general aspects of adherence to the aforementioned guide and inferential statistics for validating the checklist of actions through the Intraclass Correlation Coefficient (ICC).

Results:

the scenario contains learning objectives, necessary resources, prebriefing and debriefing of guidelines, description of the simulated situation, participants and roles, and checklist of expected actions. The validation obtained an agreement level above 80% in all aspects evaluated by 31 experts, highlighting realism of the environment and setting, vital sign parameters, alignment with scientific literature and encouragement of critical thinking and problem solving. In addition, the checklist of actions was validated with 0.899 agreement among experts, statistically analyzed by the ICC and Cronbach’s alpha 0.908 (95% confidence interval).

Conclusion:

the simulated scenario on humanized childbirth and birth can strengthen the articulation between women’s and children’s health disciplines, and was validated by experts.

Access and use of oxytocin for postpartum haemorrhage prevention: a pre-post study targeting the poorest in six Mesoamerican countries

OBJECTIVES

Haemorrhage remains the leading cause of maternal mortality in Central America. The Salud Mesoamérica Initiative aims to reduce such mortality via performance indicators. Our objective was to assess the availability and administration of oxytocin, before and after applying Salud Mesoamérica Initiative interventions in the poorest health facilities across Central America.

DESIGN

Pre-post study.

SETTING

166 basic-level and comprehensive-level health facilities in Belize, Guatemala, Honduras, Mexico, Nicaragua and Panama.

PARTICIPANTS

A random sample of medical records for uncomplicated full-term deliveries (n=2470) per International Classification of Diseases coding at baseline (July 2011 to August 2013) and at first-phase follow-up (January 2014 to October 2014).

INTERVENTIONS

A year of intervention implementation prior to first-phase follow-up data collection focused on improving access to oxytocin by strengthening supply chains, procurement, storage practices and pharmacy inventory monitoring, using a results-based financing model.

PRIMARY AND SECONDARY OUTCOME MEASURES

Oxytocin availability (primary outcome) and administration (secondary outcome) for postpartum haemorrhage prevention.

RESULTS

Availability of oxytocin increased from 82.9% to 97.6%. Oxytocin administration increased from 83.6% to 88.4%. Significant improvements were seen for availability of oxytocin (adjusted OR (aOR)=8.41, 95% CI 1.50 to 47.30). Administration of oxytocin was found to be significantly higher in Honduras (aOR=2.96; 95% CI 1.00 to 8.76) in reference to Guatemala at follow-up.

CONCLUSION

After interventions to increase health facility supplies, the study showed a significant improvement in availability but not administration of oxytocin in poor communities within Mesoamerica. Efforts are needed to improve the use of oxytocin.

Training and evaluating simulation debriefers in low-resource settings: lessons learned from Bihar, India

BACKGROUND

To develop effective and sustainable simulation training programs in low-resource settings, it is critical that facilitators are thoroughly trained in debriefing, a critical component of simulation learning. However, large knowledge gaps exist regarding the best way to train and evaluate debrief facilitators in low-resource settings.

METHODS

Using a mixed methods approach, this study explored the feasibility of evaluating the debriefing skills of nurse mentors in Bihar, India. Videos of obstetric and neonatal post-simulation debriefs were assessed using two known tools: the Center for Advanced Pediatric and Perinatal Education (CAPE) tool and Debriefing Assessment for Simulation in Healthcare (DASH). Video data was used to evaluate interrater reliability and changes in debriefing performance over time. Additionally, twenty semi-structured interviews with nurse mentors explored perceived barriers and enablers of debriefing in Bihar.

RESULTS

A total of 73 debriefing videos, averaging 18 min each, were analyzed by two raters. The CAPE tool demonstrated higher interrater reliability than the DASH; 13 of 16 CAPE indicators and two of six DASH indicators were judged reliable (ICC > 0.6 or kappa > 0.40). All indicators remained stable or improved over time. The number of 'instructors questions,' the amount of 'trainee responses,' and the ability to 'organize the debrief' improved significantly over time (p < 0.01, p < 0.01, p = 0.04). Barriers included fear of making mistakes, time constraints, and technical challenges. Enablers included creating a safe learning environment, using contextually appropriate debriefing strategies, and team building. Overall, nurse mentors believed that debriefing was a vital aspect of simulation-based training.

CONCLUSION

Simulation debriefing and evaluation was feasible among nurse mentors in Bihar. Results demonstrated that the CAPE demonstrated higher interrater reliability than the DASH and that nurse mentors were able to maintain or improve their debriefing skills overtime. Further, debriefing was considered to be critical to the success of the simulation training. However, fear of making mistakes and logistical challenges must be addressed to maximize learning. Teamwork, adaptability, and building a safe learning environment enhanced the quality enhanced the quality of simulation-based training, which could ultimately help to improve maternal and neonatal health outcomes in Bihar.

Working with lay midwives to improve the detection of neonatal complications in rural Guatemala

Background

Globally most neonatal deaths occur within the first week of life and in low-income and middle-income countries. Strengthening health system linkages for frontline providers—such as lay midwives providing home-based obstetrical care—may improve neonatal outcomes in these settings. Here, we conducted a quality improvement study to increase the detection of neonatal complications by lay midwives in rural Guatemala, thereby increasing referrals to a higher level of care.

Methods

A quality improvement team in Guatemala reviewed drivers of neonatal health services provided by lay midwives. Improvement interventions included training on neonatal warning signs, optimised mobile health technology to standardise assessments and financial incentives for providers. The primary quality outcome was the rate of neonatal referral to a higher level of care.

Results

From September 2017 to September 2018, participating midwives attended 869 home deliveries and referred 80 neonates to a higher level of care. A proportion control chart, using the preintervention period from January to September 2017 as the baseline, showed an increase in the referral rate of all births from 1.5% to 9.9%. Special cause was obtained in January 2018 and sustained except for May 2018. The proportion of neonates receiving assessments by midwives in the first week of life increased to >90%. A trend toward an increasing number of days between neonatal deaths did not attain special cause.

Conclusions

Structured improvement interventions, including mobile health decision support and financial incentives, significantly increased the detection of neonatal complications and referral of neonates to higher levels of care by lay midwives operating in rural home-based settings in Guatemala. The results show the value of improving the integration of lay midwives and other first responders into neonatal systems of care in low-resource settings.

Ethical issues in the design and conduct of stepped-wedge cluster randomized trials in low-resource settings

Background

Stepped-wedge cluster randomized trials (SW-CRTs) are increasingly popular in health-related research in both high- and low-resource settings. There may be specific ethical issues that researchers face when designing and conducting SW-CRTs in low-resource settings. Knowledge of these issues can help to improve the ethical conduct of SW-CRTs in a global health context.

Methods

We performed an ethical analysis of two studies using SW-CRT designs in low-resource settings: the Que Vivan Las Madres study conducted from 2014 to 2017 in Guatemala and the Atmiyata study conducted from 2017 to 2018 in rural parts of India. For both case studies, we identified and evaluated the classification of the study as research or nonresearch and the ethical issues regarding the justification of the design, including the delayed rollout of an intervention that had a promising effect.

Results

In our case studies, some minor ethical issues surfaced about the registration and stakeholder pressure on the order of randomization, but both included good justification for the design and delayed rollout. Our analysis did, however, demonstrate that careful consideration of the role of randomization and registration of the trials is important.

Discussion

SW-CRTs can provide an opportunity for rigorous evaluation of interventions destined to be rolled out on the basis of limited evidence. Furthermore, in SW-CRTs, the underlying objective is often to provide a robust evaluation of the effectiveness for generalized dissemination, and this makes the SW-CRT no less a research study than any other form of cluster randomized trial.

Conclusion

The design and conduct of stepped-wedge cluster randomized trials raises at least two ethical issues that need special consideration in both high- and low-resource settings: the justification for using the design, specifically the delayed rollout of the intervention to the control group, and the classification of the study as research or nonresearch. In our case studies, these issues did not seem to raise special ethical scrutiny in low-resource settings. Further ethical evaluation will hopefully result in specific ethical guidelines for the use of SW-CRTs in both high- and low-resource settings to contribute to responsible functioning of these trials and adequate protection of participants.

Perinatal and newborn care in a two years retrospective study in a first level peripheral hospital in Sicily (Italy)

BACKGROUND

Two hundred seventy-five thousand maternal deaths, 2.7 million neonatal deaths, and 2.6 million stillbirths have been estimated in 2015 worldwide, almost all in low-income countries (LICs). Moreover, more than 20 million severe disabilities result from the complications of pregnancy, childbirth or its management each year. A significant decrease of mortality/morbidity rates could be achieved by providing effective perinatal and newborn care also in high-income countries (HICs), especially in peripheral hospitals and/or rural areas, where the number of childbirths per year is often under the minimal threshold recognized by the reference legislation. We report on a 2 years retrospective cohort study, conducted in a first level peripheral hospital in Cefalù, a small city in Sicily (Italy), to evaluate care provided and mortality/morbidity rates. The proposed goal is to improve the quality of care, and the services that peripheral centers can offer.

METHODS

We collected data from maternity and neonatal records, over a 2-year period from January 2017 to December 2018. The informations analyzed were related to demographic features (age, ethnicity/origin area, residence, educational level, marital status), diagnosis at admission (attendance of birth training courses, parity, type of pregnancy, gestational age, fetal presentation), mode of delivery, obstetric complications, the weight of the newborns, their feeding and eventual transfer to II level hospitals, also through the Neonatal Emergency Transport Service, if the established criteria were present.

RESULTS

Eight hundred sixteen women were included (age 18-48 years). 179 (22%) attended birth training courses. 763 (93%) were Italian, 53 foreign (7%). 175 (21%) came from outside the province of Palermo. Eight hundred ten were single pregnancies, 6 bigeminal; 783 were at term (96%), 33 preterm (4%, GA 30-41 WG); 434 vaginal deliveries (53%), 382 caesarean sections (47%). One maternal death and 28 (3%) obstetric complications occurred during the study period. The total number of children born to these women was 822, 3 of which stillbirths (3.6‰). 787 (96%) were born at term (>37WG), 35 preterm (4%), 31 of which late preterm. Twenty-one newborns (2.5%) were transferred to II level hospitals. Among them, 3 for moderate/severe prematurity, 18 for mild prematurity/other pathology. The outcome was favorable for all women (except 1 hysterectomy) and the newborns transferred, and no neonatal deaths occurred in the biennium under investigation. Of the remaining 798 newborns, 440 were breastfed at discharge (55%), 337 had a mixed feeding (breastfed/formula fed, 42%) and 21 were formula fed (3%).

CONCLUSIONS

Although the minimal standard of adequate perinatal care in Italy is >500 childbirths/year, the aims of the Italian legislation concern the rationalization of birth centers as well as the structural, technological and organizational improvement of health facilities. Therefore, specific contexts and critical areas need to be identified and managed. Adequate resources and intervention strategies should be addressed not only to perinatal emergencies, but also to the management of mild prematurity/pathology, especially in vulnerable populations for social or orographic reasons. The increasing availability and spread of health care offers, even in HICs, cannot be separated from the goal of quality of care, which is an ethic and public health imperative.

The effectiveness of training in emergency obstetric care: a systematic literature review

Providing quality emergency obstetric care (EmOC) reduces the risk of maternal and newborn mortality and morbidity. There is evidence that over 50% of maternal health programmes that result in improving access to EmOC and reduce maternal mortality have an EmOC training component. The objective was to review the evidence for the effectiveness of training in EmOC. Eleven databases and websites were searched for publications describing EmOC training evaluations between 1997 and 2017. Effectiveness was assessed at four levels: (1) participant reaction, (2) knowledge and skills, (3) change in behaviour and clinical practice and (4) availability of EmOC and health outcomes. Weighted means for change in knowledge and skills obtained, narrative synthesis of results for other levels. One hundred and one studies including before-after studies (n = 44) and randomized controlled trials (RCTs) (n = 15). Level 1 and/or 2 was assessed in 68 studies; Level 3 in 51, Level 4 in 21 studies. Only three studies assessed effectiveness at all four levels. Weighted mean scores pre-training, and change after training were 67.0% and 10.6% for knowledge (7750 participants) and 53.1% and 29.8% for skills (6054 participants; 13 studies). There is strong evidence for improved clinical practice (adherence to protocols, resuscitation technique, communication and team work) and improved neonatal outcomes (reduced trauma after shoulder dystocia, reduced number of babies with hypothermia and hypoxia). Evidence for a reduction in the number of cases of post-partum haemorrhage, case fatality rates, stillbirths and institutional maternal mortality is less strong. Short competency-based training in EmOC results in significant improvements in healthcare provider knowledge/skills and change in clinical practice. There is emerging evidence that this results in improved health outcomes.

Simulation-enhanced nurse mentoring to improve preeclampsia and eclampsia care: an education intervention study in Bihar, India

BACKGROUND

Inadequately treated, preeclampsia and eclampsia (PE/E) may rapidly lead to severe complications in both mothers and neonates, and are estimated to cause 60,000 global maternal deaths annually. Simulation-based training on obstetric and neonatal emergency management has demonstrated promising results in low- and middle-income countries. However, the impact of simulation training on use of evidence-based practices for PE/E diagnosis and management in low-resource settings remains unknown.

METHODS

This study was based on a statewide, high fidelity in-situ simulation training program developed by PRONTO International and implemented in collaboration with CARE India on PE/E management in Bihar, India. Using a mixed methods approach, we evaluated changes over time in nurse mentees' use of evidence-based practices during simulated births at primary health clinics. We compared the proportion and efficiency of evidence-based practices completed during nurse mentees' first and last participation in simulated PE/E cases. Twelve semi-structured interviews with nurse mentors explored barriers and enablers to high quality PE/E care in Bihar.

RESULTS

A total of 39 matched first and last simulation videos, paired by facility, were analyzed. Videos occurred a median of 62 days apart and included 94 nurses from 33 primary health centers. Results showed significant increases in the median number of 'key history questions asked,' (1.0 to 2.0, p = 0.03) and 'key management steps completed,' (2.0 to 3.0, p = 0.03). The time from BP measured to magnesium sulfate given trended downwards by 3.2 min, though not significantly (p = 0.06). Key barriers to high quality PE/E care included knowledge gaps, resource shortages, staff hierarchy between physicians and nurses, and poor relationships with patients. Enablers included case-based and simulation learning, promotion of teamwork and communication, and effective leadership.

CONCLUSION

Simulation training improved the use of evidence-based practices in PE/E simulated cases and has the potential to increase nurse competency in diagnosing and managing complex maternal complications such as PE/E. However, knowledge gaps, resource limitations, and interpersonal barriers must be addressed in order to improve care. Teamwork, communication, and leadership are key mechanisms to facilitate high quality PE/E care in Bihar.

Impact of Standardized Prenatal Clinical Training for Traditional Birth Attendants in Rural Guatemala

In low-and-middle-income countries (LMICs), traditional birth attendant (TBA) training programs are increasing, yet reports are limited on how those programs affect the prenatal clinical abilities of trained TBAs. This study aims to assess the impact of clinical training on TBAs before and after a maternal health-training program. A prospective observational study was conducted in rural Guatemala from March to December 2017. Thirteen participants conducted 116 prenatal home visits. Data acquisition occurred before any prenatal clinical training had occurred, at the completion of the 14-week training program, and at six months post program completion. The paired t-test and McNemar’s test was used and statistical analyses were performed with R Version 3.3.1. There was a statistically significant improvement in prenatal clinical skills before and after the completion of the training program. The mean percentage of prenatal skills done correctly before any training occurred was 25.8%, 62.3% at the completion of the training program (p-value = 0.0001), and 71.0% after six months of continued training (p-value = 0.034). This study highlights the feasibility of prenatal skill improvement through a standardized and continuous clinical training program for TBAs. The improvement of TBA prenatal clinical skills could benefit indigenous women in rural Guatemala and other LMICs.

Strengthening intrapartum and immediate newborn care to reduce morbidity and mortality of preterm infants born in health facilities in Migori County, Kenya and Busoga Region, Uganda: a study protocol for a randomized controlled trial

BACKGROUND

Preterm birth (birth before 37 weeks of gestation) and its complications are the leading contributors to neonatal and under-5 mortality. The majority of neonatal deaths in Kenya and Uganda occur during the intrapartum and immediate postnatal period. This paper describes our study protocol for implementing and evaluating a package of facility-based interventions to improve care during this critical window.

METHODS/DESIGN

This is a pair-matched, cluster randomized controlled trial across 20 facilities in Eastern Uganda and Western Kenya. The intervention facilities receive four components: (1) strengthening of routine data collection and data use activities; (2) implementation of the WHO Safe Childbirth Checklist modified for preterm birth; (3) PRONTO simulation training and mentoring to strengthen intrapartum and immediate newborn care; and (4) support of quality improvement teams. The control facilities receive both data strengthening and introduction of the modified checklist. The primary outcome for this study is 28-day mortality rate among preterm infants. The denominator will include all live births and fresh stillbirths weighing greater than 1000 g and less than 2500 g; all live births and fresh stillbirths weighing between 2501 and 3000 g with a documented gestational age less than 37 weeks.

DISCUSSION

The results of this study will inform interventions to improve personnel and facility capacity to respond to preterm labor and delivery, as well as care for the preterm infant.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03112018 . Registered on 13 April 2017.

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.

Evaluating the effect of the Helping Mothers Survive Bleeding after Birth (HMS BAB) training in Tanzania and Uganda: study protocol for a randomised controlled trial

Background

Postpartum haemorrhage complicates approximately 10% of all deliveries and contributes to at least a quarter of all maternal deaths worldwide. The competency-based Helping Mothers Survive Bleeding after Birth (HMS BAB) training was developed to support evidence-based management of postpartum haemorrhage. This one-day training includes low-cost MamaNatalie® birthing simulators and addresses both prevention and first-line treatment of haemorrhage. While evidence is accumulating that the training improves health provider’s knowledge, skills and confidence, evidence is missing as to whether this translates into improved practices and reduced maternal morbidity and mortality. This cluster-randomised trial aims to assess whether this training package — involving a one-day competency-based HMS BAB in-facility training provided by certified trainers followed by 8 weeks of in-service peer-based practice — has an effect on the occurrence of haemorrhage-related morbidity and mortality.

Methods/design

In Tanzania and Uganda we randomise 20 and 18 districts (clusters) respectively, with half receiving the training intervention. We use unblinded matched-pair randomisation to balance district health system characteristics and the main outcome, which is in-facility severe morbidity due to haemorrhage defined by the World Health Organizationation-promoted disease and management-based near-miss criteria. Data are collected continuously in the intervention and comparison districts throughout the 6-month baseline and the 9-month intervention phase, which commences after the training intervention. Trained facility midwives or clinicians review severe maternal complications to identify near misses on a daily basis. They abstract the case information from case notes and enter it onto programmed tablets where it is uploaded.

Intention-to-treat analysis will be used, taking the matched design into consideration using paired t test statistics to compare the outcomes between the intervention and comparison districts. We also assess the impact pathway from the effects of the training on the health provider’s skills, care and interventions and health system readiness.

Discussion

This trial aims to generate evidence on the effect and limitations of this well-designed training package supported by birthing simulations. While the lack of blinding of participants and data collectors provides an inevitable limitation of this trial, the additional evaluation along the pathway of implementation will provide solid evidence on the effects of this HMS BAB training package.

Trial registration

Pan African Clinical Trials Registry, PACTR201604001582128. Registered on 12 April 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2056-7) contains supplementary material, which is available to authorized users.