"Practice so that the skill does not disappear": mixed methods evaluation of simulator-based learning for midwives in Uganda

Perceptions and experiences of the prevention, detection, and management of postpartum haemorrhage: a qualitative evidence synthesis

BACKGROUND

Postpartum haemorrhage (PPH), defined as blood loss of 500 mL or more after childbirth, is the leading cause of maternal mortality worldwide. It is possible to prevent complications of PPH with timely and appropriate detection and management. However, implementing the best methods of PPH prevention, detection and management can be challenging, particularly in low- and middle-income countries.

OBJECTIVES

Our overall objective was to explore the perceptions and experiences of women, community members, lay health workers, and skilled healthcare providers who have experience with PPH or with preventing, detecting, and managing PPH, in community or health facility settings.

SEARCH METHODS

We searched MEDLINE, CINAHL, Scopus, and grey literature on 13 November 2022 with no language restrictions. We then performed reference checking and forward citation searching of the included studies.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that explored perceptions and experiences of PPH prevention, detection, and management among women, community members, traditional birth attendants, healthcare providers, and managers.

DATA COLLECTION AND ANALYSIS

We used three-stage maximum variation sampling to ensure diversity in terms of relevance of the study to the review objectives, richness of data, and coverage of critical contextual elements: setting (region, country income level), perspective (type of participant), and topic (prevention, detection, management). We extracted data using a data extraction form designed for this review. We used thematic synthesis to analyse and synthesise the evidence, and we used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. To identify factors that may influence intervention implementation, we mapped each review finding to the Theoretical Domains Framework (TDF) and the Capability, Motivation, and Opportunity model of Behaviour change (COM-B). We used the Behaviour Change Wheel to explore implications for practice.

MAIN RESULTS

We included 67 studies and sampled 43 studies for our analysis. Most were from low- or middle-income countries (33 studies), and most included the perspectives of women and health workers. We downgraded our confidence in several findings from high confidence to moderate, low, or very-low confidence, mainly due to concerns about how the studies were conducted (methodological limitations) or concerns about missing important perspectives from some types of participants or in some settings (relevance). In many communities, bleeding during and after childbirth is considered "normal" and necessary to expel "impurities" and restore and cleanse the woman's body after pregnancy and birth (moderate confidence). In some communities, people have misconceptions about causes of PPH or believe that PPH is caused by supernatural powers or evil spirits that punish women for ignoring or disobeying social rules or for past mistakes (high confidence). For women who give birth at home or in the community, female family members or traditional birth attendants are the first to recognise excess bleeding after birth (high confidence). Family members typically take the decision of whether and when to seek care if PPH is suspected, and these family members are often influenced by trusted traditional birth attendants or community midwives (high confidence). If PPH is identified for women birthing at home or in the community, decision-making about the subsequent referral and care pathway can be multifaceted and complex (high confidence). First responders to PPH are not always skilled or trained healthcare providers (high confidence). In health facilities, midwives may consider it easy to implement visual estimation of blood loss with a kidney dish or under-pad, but difficult to accurately interpret the amount of blood loss (very low confidence). Quantifying (rather than estimating) blood loss may be a complex and contentious change of practice for health workers (low confidence). Women who gave birth in health facilities and experienced PPH described it as painful, embarrassing, and traumatic. Partners or other family members also found the experience stressful. While some women were dissatisfied with their level of involvement in decision-making for PPH management, others felt health workers were best placed to make decisions (moderate confidence). Inconsistent availability of resources (drugs, medical supplies, blood) causes delays in the timely management of PPH (high confidence). There is limited availability of misoprostol in the community owing to stockouts, poor supply systems, and the difficulty of navigating misoprostol procurement for community health workers (moderate confidence). Health workers described working on the maternity ward as stressful and intense due to short staffing, long shifts, and the unpredictability of emergencies. Exhausted and overwhelmed staff may be unable to appropriately monitor all women, particularly when multiple women are giving birth simultaneously or on the floor of the health facility; this could lead to delays in detecting PPH (moderate confidence). Inadequate staffing, high turnover of skilled health workers, and appointment of lower-level cadres of health workers are key challenges to the provision of quality PPH care (high confidence). Through team-based simulation training, health workers of different cadres (doctors, midwives, lay health workers) can develop a shared mental model to help them work quickly, efficiently, and amicably as a team when managing women with PPH (moderate confidence).

AUTHORS' CONCLUSIONS

Our findings highlight how improving PPH prevention, detection, and management is underpinned by a complex system of interacting roles and behaviours (community, women, health workers of different types and with different experiences). Multiple individual, sociocultural, and environmental factors influence the decisions and behaviours of women, families, communities, health workers, and managers. It is crucial to consider the broader health and social systems when designing and implementing PPH interventions to change or influence these behaviours. We have developed a set of prompts that may help programme managers, policymakers, researchers, and other key stakeholders to identify and address factors that affect implementation and scale-up of interventions to improve PPH prevention, detection, and management.

Implementation of a three-pillar training intervention to improve maternal and neonatal healthcare in the Democratic Republic Of Congo: a process evaluation study in an urban health zone

Background

Numerous quality-improvement projects including healthcare professional training are conducted globally every year, but there is a gap between the knowledge obtained in the training and its implementation in practice and policy. A quality-improvement programme was conducted in eastern Democratic Republic of Congo (DRC) to reduce maternal and neonatal mortality and morbidity.

Objective

This study explores the implementation process, mechanisms of impact, and outcomes of a training intervention addressing labour and birth management and involving healthcare providers in an urban health zone in eastern part of DRC.

Methods

In 2019, master trainers were educated and in turn trained facilitators from seven participating healthcare facilities, which received the necessary equipment. Data comprised statistics on maternal and neonatal birth outcomes for the years before and after the training intervention, and focus group discussions (n = 18); and interviews (n = 2) with healthcare professionals, at the end of (n = 52) and after the training intervention (n = 59), respectively. The analysis was guided by a process evaluation framework, using descriptive statistics and content analysis.

Results

The three-pillar training intervention using a low-dose, high-frequency approach was successfully implemented in terms of fidelity, dose, adaptation, and reach. Several improved care routines were established, including improved planning, teamwork, and self-reflection skills, as well as improved awareness of the influence of the care environment, of having a respectful encounter, and of allowing a companion to be present with the birthing woman. The proportions of emergency caesareans decreased and of vaginal births increased without an increase in maternal and neonatal complications.

Conclusion

The findings of this study are encouraging and provide learnings for other healthcare facilities in DRC as well as other low-income countries. When designing similar training interventions, it is crucial to consider contextual factors such as incentives and to measure more salutogenic outcomes.

Do in-service training materials for midwifery care providers in sub-Saharan Africa meet international competency standards? A scoping review 2000-2020

BACKGROUND

Levels of maternal and neonatal mortality remain high in sub-Saharan Africa, with an estimated 66% of global maternal deaths occurring in this region. Many deaths are linked to poor quality of care, which in turn has been linked to gaps in pre-service training programmes for midwifery care providers. In-service training packages have been developed and implemented across sub-Saharan Africa in an attempt to overcome the shortfalls in pre-service training. This scoping review has aimed to summarize in-service training materials used in sub-Saharan Africa for midwifery care providers between 2000 and 2020 and mapped their content to the International Confederation of Midwives (ICM) Essential Competencies for Midwifery Practice.

METHODS

Searches were conducted for the years 2000-2020 in Cumulative Index of Nursing and Allied Health Literature, PubMed/MEDLINE, Social Science Citation Index, African Index Medicus and Google Scholar. A manual search of reference lists from identified studies and a search of grey literature from international organizations was also performed. Identified in-service training materials that were accessible freely on-line were mapped to the ICM Essential Competencies for midwifery practice.

RESULTS

The database searches identified 1884 articles after removing duplicates. After applying exclusion criteria, 87 articles were identified for data extraction. During data extraction, a further 66 articles were excluded, leaving 21 articles to be included in the review. From these 21 articles, six different training materials were identified. The grey literature yielded 35 training materials, bringing the total number of in-service training materials that were reviewed to 41. Identified in-service training materials mainly focused on emergency obstetric care in a limited number of sub-Saharan Africa countries. Results also indicate that a significant number of in-service training materials are not readily and/or freely accessible. However, the content of in-service training materials largely met the ICM Essential Competencies, with gaps noted in the aspect of woman-centred care and shared decision making.

CONCLUSION

To reduce maternal and newborn morbidity and mortality midwifery care providers should have access to evidence-based in-service training materials that include antenatal care and routine intrapartum care, and places women at the centre of their care as shared decision makers.

Peer Learning and Mentorship for Neonatal Management Skills: A Cluster-Randomized Trial

BACKGROUND

Clinical knowledge and skills acquired during training programs like Helping Babies Breathe (HBB) and Essential Care for Every Baby (ECEB) decay within weeks or months. We assessed the effect of a peer learning intervention paired with mentorship on retention of HBB and ECEB skills, knowledge, and teamwork in 5 districts of Uganda.

METHODS

We randomized participants from 36 Ugandan health centers to control and intervention arms. Intervention participants received HBB and ECEB training, a 1 day peer learning course, peer practice scenarios for facility-based practice, and mentorship visits at 2 to 3 and 6 to 7 months. Control arm participants received HBB and ECEB training alone. We assessed clinical skills, knowledge, and teamwork immediately before and after HBB/ECEB training and at 12 months.

RESULTS

Peer learning (intervention) participants demonstrated higher HBB and ECEB skills scores at 12 months compared with control (HBB: intervention, 57.9%, control, 48.5%, P = .007; ECEB: intervention, 61.7%, control, 49.9%, P = .004). Knowledge scores decayed in both arms (intervention after course 91.1%, at 12 months 84%, P = .0001; control after course 90.9%, at 12 months 82.9%, P = .0001). This decay at 12 months was not significantly different (intervention 84%, control 82.9%, P = .24). Teamwork skills were similar in both arms immediately after training and at 12 months (intervention after course 72.9%, control after course 67.2%, P = .02; intervention at 12 months 70.7%, control at 12 months 67.9%, P = .19).

CONCLUSIONS

A peer learning intervention resulted in improved HBB and ECEB skills retention after 12 months compared with HBB and ECEB training alone.

The Effect of Obstetric Drills Training - Jamaica Core Obstetric Teaching and Training in Emergencies (JOTTIE) on Postpartum Haemorrhage at a Jamaican Teaching Hospital

OBJECTIVE

To evaluate whether the initiation of JOTTIE, a one day simulation training course focussed on the management of common obstetric emergencies, was associated with a reduction in the morbidity and mortality associated with postpartum haemorrhage (PPH) at the University Hospital of the West Indies (UHWI).

STUDY DESIGN

We conducted a retrospective comparative study that evaluated the incidence of multiple outcomes related to maternal morbidity secondary to PPH, during the two year period immediately prior to the introduction of JOTTIE (pre course arm, N = 88) or the two year period, one year post introduction (post course arm, N = 103) for all women who had vaginal deliveries complicated by PPH at UHWI. A relationship was said to be statistically significant if p < 0.05. Additionally, the study examined risk factors in relation to severity of haemorrhage.

RESULTS

Genital tract trauma represented the highest recorded cause of PPH (approximately 71%). The data revealed that patients in the pre training arm were similarly likely to have no adverse outcome in comparison to patients in the post training arm (p = 0.962). There was also no statistically significant relationship between the time period of patient exposure in relation to the JOTTIE course and severity of PPH (p > 0.05). Uterine fibroids and Crohn's disease were the only co-morbidities found to increase the likelihood of severe PPH, at 5.154 times (p = 0.019,OR = 5.154, CI = 1.314-20.212) and 17.848 times (p = 0.085,OR = 17.848,CI = 0.672-474.365), respectively.

CONCLUSIONS

This study suggests that prior to the introduction of the JOTTIE the rate of maternal morbidity associated with PPH was relatively low at UHWI and there was no significant effect on its management or a significant reduction in maternal morbidity since introduction of the course. Future research on the morbidity related to the other obstetric emergencies addressed at JOTTIE is needed in order to assess the effect of the course as a whole.

Impact of the Helping Mothers Survive Bleeding After Birth learning programme on care provider skills and maternal health outcomes in low-income countries - An integrative review

BACKGROUND

To improve maternal health outcomes, highly competent healthcare providers are needed. One strategy used to improve performance among healthcare providers is simulation-based learning. An integrative review was designed with the aim of synthesising available research on Helping Mothers Survive (HMS), a learning programme used in low-income countries, and its impact on care provider skills and maternal health outcomes.

METHOD

A systematic search was conducted in June 2020 in CINAHL, PubMed, Scopus, and Web of Science. All stages of inclusion, quality assessment, and data extraction were done independently by four reviewers. A narrative synthesis was used for the outcomes of care provider skills and knowledge, as well as maternal health outcomes.

FINDINGS

The search identified 50 articles, 22 of which were excluded due to being duplicates, 16 based on their title and abstract, and two based on their full text. Eleven papers were included in the synthesis: eight quantitative, two qualitative, and one mixed-method study, originating from India, Malawi, Tanzania, Uganda, and Zanzibar. The Helping Mothers Survive-Bleeding After Birth (HMS-BAB) learning programme was found to have a positive impact on care providers' competencies and maternal health outcomes, with a reduced number of postpartum haemorrhages and a reduction in maternal mortality.

CONCLUSION

The HMS-BAB learning programme has the potential to increase competence among care providers and improve maternal health outcomes in low-income settings. A successful use of the programme to maintain improved care routines for mothers requires multi-professional teams, facility readiness, a low-dose high-frequency approach, a local coordinator, and accountability and ownership.

Predictors of change of health workers' knowledge and skills after the Helping Mothers Survive Bleeding after Birth (HMS BAB) in-facility training in Tanzania

BACKGROUND

Our study aimed to assess the effect of Helping Mothers Survive Bleeding after Birth on knowledge and skills of health workers and whether such effect varies by health workers characteristics.

METHODS

Nested in a cluster-randomised trial to assess the effect of the training on health outcomes, we assessed changes in knowledge and simulated skills in 61 facilities. The assessments were done i) before, ii) immediately-after training session and iii) at 10-month follow-up for subset of health-workers of implementation facilities as defined by the trial. We used a self-administered questionnaire and Objective Structures Clinical Examinations to assess three skill sets: Active Management of Third Stage of Labour, removal of retained placenta and management of severe postpartum haemorrhage. We computed summary statistics and used the paired t-test to assess change of knowledge and skills immediately post-training and at 10-month follow-up. Linear regression was done to assess association of scores and health worker characteristics.

RESULTS

Of the 636 health workers included, 606 (96.7%) and 591 (91.4%) completed the knowledge and skills assessments, respectively. Majority of the participants (68%) were nurse-midwives. Knowledge scores increased by 15 percentage-points from 77.5% to 93% (95% CI 14.3, 16.3, p-value <0.000), and skills scores by 47 percentage-points (95% CI 46.5, 49.2, p-value <0.000) from 37.5% to 83%. There was a 4.0% decline of skills at 10-month follow-up. The decline was higher in auxiliary staff (-11.8%) and least in nurse-midwives (-2.1%) p-value <0.001. Health workers who assisted less than 5 deliveries in the last month, those who never attended postpartum haemorrhage in-service training and profession experience >8 years were associated with lower mean skill change immediately post-training.

CONCLUSION

Our study supports the potential of the Helping Mothers Survive Bleeding after Birth training to increase knowledge and skills of postpartum haemorrhage among all professional groups. Auxiliary staff benefited most from the training but also showed higher skill decline at 10-month. Our study highlights the importance to disaggregate knowledge and skills by health workers characteristics.

Dealing with neonatal emergencies in low-resource settings

We describe the development and delivery of neonatal care including trends and impacts of major interventions on neonatal mortality particularly in low-resource settings. Low- and middle-income countries continue to be major contributors to neonatal mortality. Although there has been progress in reducing neonatal mortality, neonatal deaths are contributing an increasing percentage of childhood mortality. Several interventions targeting neonatal care such as neonatal resuscitation and essential newborn care have contributed to improved outcomes. However, there are still many neonatal deaths that are preventable with known effective interventions. This review addresses interventions proven effective in reducing neonatal mortality, challenges to implement them, and future directions of implementing these interventions in low- and middle-income countries.

"It builds your confidence… you've done well": Healthcare workers' experiences of participating in a low-dose, high-frequency training to improve newborn survival on the day of birth in Ghana

Background: The majority of newborn deaths occur during the first week of life, and 25‒45% occur within the first 24 hours. A low-dose, high-frequency (LDHF) training approach was introduced in 40 hospitals in Ghana to improve newborn survival. The aim of this qualitative study was to explore healthcare workers' experiences with the LDHF approach to in-service training. Methods: A total of 20 in-depth interviews and nine focus group discussions were conducted in 2016 in three regions of Ghana with healthcare workers who participated in implementation of the LDHF training approach. In-depth interviews were conducted with 20 master mentors and peer practice coordinators; 51 practicing doctors, midwives and nurses participated in focus group discussions. Data were analyzed using a thematic analysis approach. Results: Healthcare workers reflected on the differences between the LDHF approach and past learning experiences, highlighting how the skills-based team training approach, coupled with high-frequency practice and mobile mentoring, built their competency and confidence. As participants shared their experiences, they highlighted relationships established between Master Mentors and healthcare workers, and motivation stemming from pride in contributing to reductions in maternal and newborn deaths as critical factors in improving quality of care at participating health facilities. Conclusion: This nested qualitative study documents experiences of healthcare workers and mentors involved in implementation of a multi-faceted intervention that effectively improved maternal and newborn care at health facilities in Ghana. The way the intervention was implemented created an environment conducive to learning within the hospital setting, thus providing an opportunity for professional growth and quality improvement for all staff working in the maternity ward.

"It builds your confidence… you've done well": Healthcare workers' experiences of participating in a low-dose, high-frequency training to improve newborn survival on the day of birth in Ghana

Background: The majority of newborn deaths occur during the first week of life, and 25‒45% occur within the first 24 hours. A low-dose, high-frequency (LDHF) training approach was introduced in 40 hospitals in Ghana to improve newborn survival. The aim of this qualitative study was to explore healthcare workers’ experiences with the LDHF approach to in-service training.

Methods: A total of 20 in-depth interviews and nine focus group discussions were conducted in 2016 in three regions of Ghana with healthcare workers who participated in implementation of the LDHF training approach. In-depth interviews were conducted with 20 master mentors and peer practice coordinators; 51 practicing doctors, midwives and nurses participated in focus group discussions. Data were analyzed using a thematic analysis approach.

Results: Healthcare workers reflected on the differences between the LDHF approach and past learning experiences, highlighting how the skills-based team training approach, coupled with high-frequency practice and mobile mentoring, built their competency and confidence. As participants shared their experiences, they highlighted relationships established between Master Mentors and healthcare workers, and motivation stemming from pride in contributing to reductions in maternal and newborn deaths as critical factors in improving quality of care at participating health facilities.

Conclusion: This nested qualitative study documents experiences of healthcare workers and mentors involved in implementation of a multi-faceted intervention that effectively improved maternal and newborn care at health facilities in Ghana. The way the intervention was implemented created an environment conducive to learning within the hospital setting, thus providing an opportunity for professional growth and quality improvement for all staff working in the maternity ward.