Helping Mothers Survive Bleeding After Birth: Retention of knowledge, skills, and confidence nine months after obstetric simulation-based training

BMC Pregnancy and Childbirth, Volume 15, No. 1, Year 2015

Interpretation

Background: It is important to know the decay of knowledge, skills, and confidence over time to provide evidence-based guidance on timing of follow-up training. Studies addressing retention of simulation-based education reveal mixed results. The aim of this study was to measure the level of knowledge, skills, and confidence before, immediately after, and nine months after simulation-based training in obstetric care in order to understand the impact of training on these components. Methods: An educational intervention study was carried out in 2012 in a rural referral hospital in Northern Tanzania. Eighty-nine healthcare workers of different cadres were trained in “Helping Mothers Survive Bleeding After Birth”, which addresses basic delivery skills including active management of third stage of labour and management of postpartum haemorrhage (PPH). Knowledge, skills, and confidence were tested before, immediately after, and nine months after training amongst 38 healthcare workers. Knowledge was tested by completing a written 26-item multiple-choice questionnaire. Skills were tested in two simulated scenarios “basic delivery” and “management of PPH”. Confidence in active management of third stage of labour, management of PPH, determination of completeness of the placenta, bimanual uterine compression, and accessing advanced care was self-assessed using a written 5-item questionnaire. Results: Mean knowledge scores increased immediately after training from 70 % to 77 %, but decreased close to pre-training levels (72 %) at nine-month follow-up (p = 0.386) (all p-levels are compared to pre-training). The mean score in basic delivery skills increased after training from 43 % to 51 %, and was 49 % after nine months (p = 0.165). Mean scores of management of PPH increased from 39 % to 51 % and were sustained at 50 % at nine months (p = 0.003). Bimanual uterine compression skills increased from 19 % before, to 43 % immediately after, to 48 % nine months after training (p = 0.000). Confidence increased immediately after training, and was largely retained at nine-month follow-up. Conclusions: Training resulted in an immediate increase in knowledge, skills, and confidence. While knowledge and simulated basic delivery skills decayed after nine months, confidence and simulated obstetric emergency skills were largely retained. These findings indicate a need for continuation of training. Future research should focus on the frequency and dosage of follow-up training. An educational intervention study with pre-, post-, and nine-month follow-up assessments was performed from March to December 2012. The Helping Mothers Survive Bleeding After Birth simulation-based training programme was introduced in a rural referral hospital in Northern Tanzania in March 2012. A cross-sectional study that took place in this hospital from November 2009 until November 2011 showed that the maternal mortality ratio was 350 maternal deaths per 100,000 live births (95 % confidence interval: 243–488) [12]. PPH accounted for 27 % of all maternal morbidity and mortality, and the case fatality rate of PPH was as high as 9 % [12]. During the time of this study, the hospital had 420 beds and provided free reproductive services and comprehensive emergency obstetric care. The annual number of births in this period was approximately 4,700 [13]. Helping Mothers Survive Bleeding After Birth uses a train-the-trainer model in which training is cascaded down from master trainers to local facilitators to learners [14]. In two sessions, four master trainers trained eight local facilitators in a one-to-one ratio. Training of local facilitators lasted a full day and consisted of a half-day theory and a half-day skills and scenario teaching regarding basic delivery skills including active management of third stage of labour and management of PPH. Subsequently, these eight facilitators trained 89 local learners in half-day sessions under supervision of master trainers. The number of learners per facilitator ranged from three to six. Clinicians, nurse-midwives, medical attendants (nurse aides without formal medical education), ambulance drivers (without formal medical education), and other staff involved in maternity care (including nurse-midwives from the intensive care unit and operating theatre), were selected by the hospital management to attend training. Due to logistical reasons, only participants working on labour ward, ambulance drivers, and facilitators were enrolled for testing, thus rendering 38 out of the original 89 learners eligible for analysis. Checking competency (or validation) of local facilitators by means of knowledge and skills testing was done after teaching learners. Further details of the training are described elsewhere [3]. The study design was based on the four levels of Kirkpatrick’s model for evaluation of training programmes [15]. In this paper, we report on Kirkpatrick level 2 (learning), for which we have measured changes in knowledge, skills, and confidence due to training. The assessment tools and their validation have been described in detail previously [3]. In brief, knowledge, skills, and confidence were tested on three occasions; immediately before training, immediately after training, and nine months after training. Knowledge about basic delivery skills, active management of third stage of labour, and management of PPH was tested using a written 26-item multiple-choice questionnaire. The criterion-referenced pass score was ≥ 70 % correct answers. The test was developed and assessed for face, content, and construct validity by Jhpiego, of which the details are described elsewhere [3]. Skills performance was assessed in two simulated scenarios using a low-cost, low-tech birthing simulator (MamaNatalie, Laerdal Global Health): “basic delivery” and “management of PPH”. A checklist for the assessment of skills performance was developed and validated by the authors [3]. To pass the test, five essential items for basic delivery, and eight essential items for management of PPH were identified that needed to be performed. Each participant’s skills test was videotaped and subsequently assessed by two independent assessors, who were blinded for the time of testing. Confidence of participants to perform active management of third stage of labour, manage PPH, determine completeness of the placenta, perform bimanual uterine compression, and access advanced care was self-assessed using a questionnaire. Five answers were possible, ranging from 1 = I cannot perform this skill to 5 = extremely confident. At the nine-month assessment all facilitators and learners were interviewed about the number of deliveries performed since initial training, as well as the number of bimanual uterine compressions performed, the number of times MamaNatalie was used for practise, and the participation in any other practise or training regarding basic delivery and management of PPH. All assessment materials were available in two languages, English and Kiswahili (local language). Data was double entered in EpiData (The EpiData Association, Odense, Denmark), and analysed using IBM SPSS Statistics, version 20 (IBM, Armonk, NY, USA). Descriptive statistics were calculated for participant characteristics, exposure to clinical work and training during the follow-up time, knowledge, skills, and confidence. Results are reported as number (n), percentage (%), mean, standard deviation (SD), and range. Statistical analyses of the changes from pre-training assessment to nine-month follow-up and from post-training to nine-month follow-up included McNemar’s test for categorical values, and paired samples t-test for continuous values. Ethical approval was obtained from the Tanzanian National Institute for Medical Research (reference NIMR/HQ/R.8a/Vol.IX/1247), the Tanzania Commission for Science and Technology (reference 2013-41-ER-2011-201), and from the VU University Medical Centre, the Netherlands (reference 2011/389). Permission to conduct the study was obtained from the hospital management. Written informed consent was obtained from each participant before entering the study.

AI Digest

Study Justification:

This study aimed to measure the retention of knowledge, skills, and confidence among healthcare workers after simulation-based training in obstetric care. The decay of these components over time is important to understand in order to determine the timing of follow-up training. The study addresses the need for evidence-based guidance on the frequency and dosage of training to ensure healthcare workers maintain their proficiency in providing obstetric care.

Highlights:

– The study found that training resulted in an immediate increase in knowledge, skills, and confidence among healthcare workers.
– While knowledge and simulated basic delivery skills decreased after nine months, confidence and simulated obstetric emergency skills were largely retained.
– These findings indicate a need for continuation of training and suggest that future research should focus on the frequency and dosage of follow-up training.

Recommendations:

Based on the study findings, the following recommendations can be made:

1. Healthcare workers should receive regular follow-up training to maintain their knowledge, skills, and confidence in obstetric care.
2. Future research should investigate the optimal frequency and dosage of follow-up training to ensure sustained proficiency among healthcare workers.

Key Role Players:

1. Master trainers: These individuals are responsible for cascading the training down to local facilitators and learners.
2. Local facilitators: They are trained by the master trainers and are responsible for training the local learners.
3. Local learners: These are the healthcare workers who receive the training and are responsible for providing obstetric care.
4. Hospital management: They play a crucial role in selecting participants for training and providing support for the implementation of the training program.

Cost Items for Planning Recommendations:

1. Training materials: This includes the cost of simulation-based training equipment, such as birthing simulators.
2. Trainer fees: The cost of hiring master trainers and local facilitators.
3. Travel and accommodation: If the training is conducted in different locations, the cost of travel and accommodation for trainers and participants may need to be considered.
4. Evaluation and monitoring: The cost of assessing the knowledge, skills, and confidence of healthcare workers before, immediately after, and nine months after training.
5. Follow-up training sessions: The cost of organizing and conducting regular follow-up training sessions for healthcare workers.
Please note that the above cost items are general categories and the actual cost will depend on various factors such as the location, number of participants, and specific training requirements.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on an educational intervention study with pre-, post-, and nine-month follow-up assessments. The study measured the level of knowledge, skills, and confidence before, immediately after, and nine months after simulation-based training in obstetric care. The study included 38 healthcare workers and used written questionnaires and simulated scenarios to assess knowledge and skills. The results showed an immediate increase in knowledge, skills, and confidence after training, but knowledge and simulated basic delivery skills decayed after nine months. Confidence and simulated obstetric emergency skills were largely retained. The study suggests a need for continuation of training and further research on the frequency and dosage of follow-up training. To improve the strength of the evidence, future studies could include a larger sample size and a longer follow-up period to assess the long-term impact of training on knowledge, skills, and confidence.

Abstract

An educational intervention study with pre-, post-, and nine-month follow-up assessments was performed from March to December 2012. The Helping Mothers Survive Bleeding After Birth simulation-based training programme was introduced in a rural referral hospital in Northern Tanzania in March 2012. A cross-sectional study that took place in this hospital from November 2009 until November 2011 showed that the maternal mortality ratio was 350 maternal deaths per 100,000 live births (95 % confidence interval: 243–488) [12]. PPH accounted for 27 % of all maternal morbidity and mortality, and the case fatality rate of PPH was as high as 9 % [12]. During the time of this study, the hospital had 420 beds and provided free reproductive services and comprehensive emergency obstetric care. The annual number of births in this period was approximately 4,700 [13]. Helping Mothers Survive Bleeding After Birth uses a train-the-trainer model in which training is cascaded down from master trainers to local facilitators to learners [14]. In two sessions, four master trainers trained eight local facilitators in a one-to-one ratio. Training of local facilitators lasted a full day and consisted of a half-day theory and a half-day skills and scenario teaching regarding basic delivery skills including active management of third stage of labour and management of PPH. Subsequently, these eight facilitators trained 89 local learners in half-day sessions under supervision of master trainers. The number of learners per facilitator ranged from three to six. Clinicians, nurse-midwives, medical attendants (nurse aides without formal medical education), ambulance drivers (without formal medical education), and other staff involved in maternity care (including nurse-midwives from the intensive care unit and operating theatre), were selected by the hospital management to attend training. Due to logistical reasons, only participants working on labour ward, ambulance drivers, and facilitators were enrolled for testing, thus rendering 38 out of the original 89 learners eligible for analysis. Checking competency (or validation) of local facilitators by means of knowledge and skills testing was done after teaching learners. Further details of the training are described elsewhere [3]. The study design was based on the four levels of Kirkpatrick’s model for evaluation of training programmes [15]. In this paper, we report on Kirkpatrick level 2 (learning), for which we have measured changes in knowledge, skills, and confidence due to training. The assessment tools and their validation have been described in detail previously [3]. In brief, knowledge, skills, and confidence were tested on three occasions; immediately before training, immediately after training, and nine months after training. Knowledge about basic delivery skills, active management of third stage of labour, and management of PPH was tested using a written 26-item multiple-choice questionnaire. The criterion-referenced pass score was ≥ 70 % correct answers. The test was developed and assessed for face, content, and construct validity by Jhpiego, of which the details are described elsewhere [3]. Skills performance was assessed in two simulated scenarios using a low-cost, low-tech birthing simulator (MamaNatalie, Laerdal Global Health): “basic delivery” and “management of PPH”. A checklist for the assessment of skills performance was developed and validated by the authors [3]. To pass the test, five essential items for basic delivery, and eight essential items for management of PPH were identified that needed to be performed. Each participant’s skills test was videotaped and subsequently assessed by two independent assessors, who were blinded for the time of testing. Confidence of participants to perform active management of third stage of labour, manage PPH, determine completeness of the placenta, perform bimanual uterine compression, and access advanced care was self-assessed using a questionnaire. Five answers were possible, ranging from 1 = I cannot perform this skill to 5 = extremely confident. At the nine-month assessment all facilitators and learners were interviewed about the number of deliveries performed since initial training, as well as the number of bimanual uterine compressions performed, the number of times MamaNatalie was used for practise, and the participation in any other practise or training regarding basic delivery and management of PPH. All assessment materials were available in two languages, English and Kiswahili (local language). Data was double entered in EpiData (The EpiData Association, Odense, Denmark), and analysed using IBM SPSS Statistics, version 20 (IBM, Armonk, NY, USA). Descriptive statistics were calculated for participant characteristics, exposure to clinical work and training during the follow-up time, knowledge, skills, and confidence. Results are reported as number (n), percentage (%), mean, standard deviation (SD), and range. Statistical analyses of the changes from pre-training assessment to nine-month follow-up and from post-training to nine-month follow-up included McNemar’s test for categorical values, and paired samples t-test for continuous values. Ethical approval was obtained from the Tanzanian National Institute for Medical Research (reference NIMR/HQ/R.8a/Vol.IX/1247), the Tanzania Commission for Science and Technology (reference 2013-41-ER-2011-201), and from the VU University Medical Centre, the Netherlands (reference 2011/389). Permission to conduct the study was obtained from the hospital management. Written informed consent was obtained from each participant before entering the study.

Materials

N/A

Innovations

Based on the information provided, here are some potential recommendations for innovations to improve access to maternal health:

1. Mobile-based Training: Develop a mobile application or platform that delivers simulation-based training on maternal health to healthcare workers in remote areas. This would allow for continuous learning and reinforcement of knowledge and skills.

2. Virtual Reality Training: Utilize virtual reality technology to create immersive training experiences for healthcare workers. This would provide a realistic simulation of obstetric emergencies and allow for hands-on practice in a safe environment.

3. Telemedicine Consultations: Implement telemedicine consultations for healthcare workers in remote areas to connect them with obstetric specialists. This would enable real-time guidance and support during complicated deliveries or postpartum hemorrhage cases.

4. Peer-to-Peer Learning Networks: Establish peer-to-peer learning networks among healthcare workers to facilitate knowledge sharing and continuous professional development. This could be done through online platforms or regular meetings and workshops.

5. Community Health Worker Training: Develop targeted training programs for community health workers to enhance their knowledge and skills in maternal health. This would empower them to provide basic obstetric care and identify high-risk cases in their communities.

6. Task Shifting and Delegation: Explore opportunities for task shifting and delegation of certain maternal health responsibilities to lower-level healthcare workers, under appropriate supervision. This would help alleviate the burden on skilled healthcare providers and improve access to timely care.

7. Quality Improvement Initiatives: Implement quality improvement initiatives in healthcare facilities to ensure adherence to evidence-based practices for maternal health. This could involve regular audits, feedback mechanisms, and performance monitoring.

8. Public Awareness Campaigns: Launch public awareness campaigns to educate communities about the importance of maternal health and encourage early antenatal care, skilled birth attendance, and postpartum care. This would help increase demand for maternal health services.

9. Strengthening Referral Systems: Improve the referral systems between primary healthcare facilities and higher-level hospitals to ensure timely access to emergency obstetric care. This could involve training healthcare workers on referral protocols and improving communication channels.

10. Sustainable Funding Models: Develop sustainable funding models to support maternal health programs and initiatives. This could involve partnerships with government agencies, NGOs, and private sector organizations to secure long-term funding and resources.

It is important to note that these recommendations are based on the information provided and may need to be tailored to the specific context and resources available in each setting.

AI Innovations Description

The recommendation to improve access to maternal health based on the study is to provide continuation of training. The study found that while knowledge and simulated basic delivery skills decayed after nine months, confidence and simulated obstetric emergency skills were largely retained. Therefore, it is important to provide follow-up training to healthcare workers to ensure that their knowledge and skills remain up-to-date and to improve their confidence in managing obstetric emergencies. Future research should focus on determining the frequency and dosage of follow-up training needed.

AI Innovations Methodology

Based on the provided description, the study “Helping Mothers Survive Bleeding After Birth: Retention of knowledge, skills, and confidence nine months after obstetric simulation-based training” aimed to measure the level of knowledge, skills, and confidence before, immediately after, and nine months after simulation-based training in obstetric care. The study used the Helping Mothers Survive Bleeding After Birth simulation-based training program, which focuses on basic delivery skills and management of postpartum hemorrhage (PPH).

To improve access to maternal health, the following recommendations can be considered:

1. Expand the reach of simulation-based training: Implement the Helping Mothers Survive Bleeding After Birth training program in more healthcare facilities, especially in rural areas where access to maternal health services may be limited. This can be done by training more master trainers and local facilitators who can then cascade the training to healthcare workers in their respective regions.

2. Incorporate technology: Utilize technology to enhance the training experience and reach a larger audience. This can include the development of online modules or virtual simulations that can be accessed remotely. Technology can also be used for ongoing monitoring and evaluation of training effectiveness.

3. Strengthen referral systems: Improve the coordination and communication between healthcare facilities to ensure timely and appropriate referrals for obstetric emergencies. This can involve establishing clear protocols and guidelines for transferring patients, as well as providing training on emergency transportation and communication systems.

4. Community engagement and education: Increase community awareness and knowledge about maternal health through targeted education campaigns. This can involve conducting community workshops, distributing informational materials, and engaging local leaders and influencers to promote the importance of maternal health.

To simulate the impact of these recommendations on improving access to maternal health, a methodology can be developed as follows:

1. Define the indicators: Identify specific indicators that will be used to measure the impact of the recommendations. This can include metrics such as the number of healthcare facilities implementing the training program, the percentage increase in healthcare workers trained, the number of successful referrals, and the level of community awareness.

2. Collect baseline data: Gather data on the current state of access to maternal health in the target area. This can include information on the number of healthcare facilities, the availability of trained healthcare workers, the referral systems in place, and the level of community knowledge and awareness.

3. Implement the recommendations: Roll out the recommended interventions, such as expanding the training program, incorporating technology, strengthening referral systems, and conducting community engagement activities.

4. Monitor and evaluate: Continuously monitor the implementation of the recommendations and collect data on the identified indicators. This can involve regular data collection through surveys, interviews, and observations. Use this data to assess the progress and impact of the interventions.

5. Analyze the data: Analyze the collected data to determine the effectiveness of the recommendations in improving access to maternal health. This can involve comparing the baseline data with the post-intervention data to identify any changes or improvements.

6. Adjust and refine: Based on the findings from the data analysis, make any necessary adjustments or refinements to the interventions. This can include scaling up successful interventions, addressing any challenges or barriers identified, and incorporating lessons learned into future implementation.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health and make evidence-based decisions for further interventions.

Author

Dima Health

Statistics:

Citations: 37

Identifiers:

DOI: 10.1186/s12884-015-0612-2

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations, Workforce

Study Countries:

Tanzania

Study Design:

Cohort Study, Cross Sectional Study, randomised-control-trial

Study Approach:

Quantitative