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