Introduction

Reducing maternal mortality is one of the Millennium Development Goals , and it will remain high on the post-2015 development agenda, as a component of the Sustainable Development Goals . Inadequate knowledge and skills of the midwives and doctors providing maternity care, especially emergency obstetric care, is one of the problems contributing to maternal deaths. Therefore, training programmes to improve health worker skills in managing obstetric emergencies have been introduced in various countries with the hope of reducing maternal mortality . Other articles in this edition discuss the content of such programmes and recommend multidisciplinary team training using emergency obstetric simulation training (EOST), also known as ‘fire drills’ . The effectiveness of such training in improving knowledge and skills has been established , as well as improvement in some clinical outcomes at individual sites . However, can such training be successfully introduced across a whole country resulting in reduced maternal mortality? The QUARITE study in Senegal found reduced maternal mortality across a range of hospitals randomised to an intervention that included not only emergency skills training but also training at conducting mortality reviews and regular visits from an external facilitator . This article focusses specifically on the South African experience, where national recommendations on reducing maternal mortality, based on a national confidential enquiry into maternal deaths, have been regularly published and disseminated since 1999. To date, recommendations on training to improve skills have had limited impact on reducing the national maternal mortality burden. What more needs to be done? Experiences and examples from South Africa are used to discuss strategies for scaling up emergency obstetric care training and ensuring a health system environment in which such training can be effective in reducing maternal mortality.

The South African (Saving Mothers) recommendations regarding health-care worker training (from 1998 to 2008–2010)

Since 1997, all maternal deaths in South Africa have been notifiable by law. Since 1998, all reported maternal deaths have been analysed in detail in the form of confidential enquiries, as conducted by the South African National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD). The committee is tasked to ‘make recommendations, based on the confidential study of maternal deaths, to the Minister of the Department of Health, such that the implementation of the recommendations will result in a decrease in maternal mortality’ . The recommendations are published in regular ‘Saving Mothers’ reports, which are disseminated countrywide to health administrators and health-care workers. The first Saving Mothers report reported on deaths that occurred in 1998, and there have been five triennial Saving Mothers reports published subsequently, the last of which has recently been released and covers the years 2011–2013 . In total, since 1998, the NCCEMD has analysed and reported on >20,000 maternal deaths. The confidential enquiry process includes an expert assessment for each death of the presence of avoidable factors associated with the death, including health-worker-related avoidable factors. This refers to mistakes or omissions in the management of the patient by the health workers, which might have contributed to the death.

From the first Saving Mothers report (1998), it was clear, especially for the direct causes of maternal death, such as death due to obstetric haemorrhage, hypertensive disorders of pregnancy and pregnancy-related sepsis, that substandard management by the health workers during the emergency event leading to death occurred in a large proportion of cases . The substandard care included inadequate initial assessment of the patient, not recognising the problem, misdiagnosis, failure to follow standard protocols of management and substandard resuscitation.

Accordingly, for several causes, the 1998 report recommended continuing professional development courses, in-service training or perinatal education programmes for health workers specific to each cause of death, without being more specific about the type of training recommended. The overall ‘Key Recommendations’ of the report emphasised the need for guidelines on managing conditions that commonly result in maternal death, but did not refer to training of health workers .

The findings in the next Saving Mothers report (1999–2001) were similar to those of the first report in that substandard care by health workers was associated with more than half of the notified maternal deaths . The Key Recommendations of the report were also similar to those of the first report, with training as an intervention not specifically mentioned except with regard to anaesthesia, where improvement of skills in anaesthesia was recommended at all levels of care. Again, the type of training method was not specified.

The 2002–2004 Saving Mothers report showed that maternal death numbers were increasing compared with the previous triennium . The substandard care by health workers noted in the previous reports remained a prominent feature. The Key Recommendations placed more emphasis on the need for health worker training than the previous reports. The first recommendation was that ‘protocols on the management of important conditions causing maternal deaths must be available, and utilised appropriately in all institutions where women deliver’. In addition, ‘all midwives and doctors must be trained on the use of these protocols’. The recommendation also proposed a target that ‘all districts must have a written functioning training programme in all institutions’, although the type of programme was not specified. Further reference to the need for training programmes was included in several of the other key recommendations relating to intrapartum care, contraceptive services and skills in anaesthesia. The recommendations regarding improving anaesthetic skills specified that ‘current anaesthesia curricula for medical students and medical interns must include “hands-on” experience’.

The 2005–2007 Saving Mothers report showed a continuing increase in the numbers of maternal deaths in South Africa . The largest increase was observed in deaths due to non-pregnancy-related infections, which were mainly AIDS-related infections. However, it was also notable that there was no decrease in the numbers of direct maternal deaths from causes such as obstetric haemorrhage, hypertensive disorders of pregnancy and abortion, with 58.5% of the direct maternal deaths being assessed as clearly avoidable had better care been rendered by the health system. The most common health-worker-related avoidable factor was substandard management despite the diagnosis being correct, indicating failure to manage patients according to protocols. This suggested that the previous recommendations regarding training on the use of protocols had either not been implemented or not been effective.

These findings led to a new key recommendation in the 2005–2007 report, placing more emphasis on the need for practical skills training : ‘Training should be provided for all health professionals working in maternity units in practical obstetrical and surgical skills. Skills should be provided in anaesthesia, especially in level 1 institutions.’ By the time the 2005–2007 report was released in 2009, a training programme had been developed in South Africa for improving skills in managing obstetric emergencies. This programme, called ‘Essential Steps in the Management of Obstetric Emergencies’ or ESMOE , is based on the ‘Making It Happen’ programme from the Liverpool School of Tropical Medicine and the Royal College of Obstetricians and Gynaecologists’ Life Saving Skills Programme , but it has been adapted to fit the needs of the South African setting. The ESMOE programme had already been shown to be effective in improving the skills of medical interns .

The ESMOE programme initially consisted of 12 modules, each designed for a small group of participants, with a short lecture followed by skills demonstration and skills practice. Examples of the modules included use of the partogram, management of obstetric haemorrhage and surgical skills. The content of the ESMOE programme would be regularly reviewed by a national ESMOE board. Further, one of the ongoing developments when the 2005–2007 Saving Mothers report was released was the addition to the ESMOE of an EOST component for each module. The EOST component is also referred to as the obstetric ‘fire drills’ . Taking this into account, the following targets were set in the 2005–2007 Saving Mothers report with regard to skills training:

• 1.

  All hospitals must have implemented ESMOE fire-drills and skills training

• 2.

  All sub-districts must have access to the ESMOE skills training programme for all institutions in the sub-district

The time set for achieving these targets was not stated.

The next (fifth) Saving Mothers report (2008–2010) presented the maternal death status in South Africa a full 10 years from the first Saving Mothers report . Disappointingly, the numbers of deaths reported were higher than ever before. Deaths due to all causes, direct and indirect, had increased compared with the previous triennium. Overall, 53% of deaths were assessed as being possibly or probably avoidable had better care been rendered by the health service. In particular, deaths due to obstetric haemorrhage had increased in number by 40% since the previous triennium, and 80% of the haemorrhage deaths were assessed as being possibly or probably avoidable. Once more, the data from the Saving Mothers report strongly suggested a need for better competence and skills amongst maternity care health workers, particularly with regard to emergency care skills.

The key recommendations of the 2008−10 report were presented in the form of five key focus areas for intervention, referred to as the 5 Hs. The first three areas were as follows:

• •

  HIV

• •

  Haemorrhage

• •

  Hypertension

These three causes of maternal death were highlighted, as they were responsible for the majority of all avoidable maternal deaths. The other two key focus areas were as follows:

• •

  Health worker training

• •

  Health system strengthening

With regard to health worker training, the specific recommendations were as follows:

• •

  Train all health-care workers involved in maternity care in the ESMOE–EOST programme and obstetric anaesthetic module

• •

  Train all health-care workers who deal with pregnant women in HIV advice, counselling, testing and support; initiation of highly active antiretroviral therapy (HAART); monitoring of HAART; and the recognition, assessment, diagnosis and treatment of severe respiratory infections

To help implement these recommendations, the 2008–2010 report listed suggested actions that should be undertaken by people at various levels of the health service . In relation to health worker training, the following actions were suggested:

The following actions were requested from the National and Provincial Directors General for Health:

• •

  Provide support for the training of doctors and midwives in ESMOE, by instructing the chief executive officers (CEOs) of health facilities to give time for doctors and midwives to undergo training and insist on EOST exercises taking place at least monthly in their institutions

• •

  Ensure EOST exercises are performed routinely at every institution conducting births

• •

  Ensure key activities become part of the key performance areas of the appropriate managers

The following actions requested from provincial maternal health managers and district managers were similar but added more detail:

• •

  Ensure health-care institutions handling deliveries perform and score EOST exercises at least monthly and involve all their maternity staff (A roster of those attending and the score must be passed on to the CEO of the institution)

The following actions were requested from all doctors and nurses involved in the care of pregnant women:

• •

  Ensure they undergo ESMOE training

• •

  Ensure they participate in EOST exercises

The following actions were requested from nurse training institutions and medical schools:

• •

  Ensure the contents of the ESMOE course are included in their curriculum

The actions requested from the Health Professions Council of South Africa were as follows:

• •

  Make successful completion of the ESMOE course a requirement for full registration as a doctor (i.e., must be completed during medical internship)

It should be noted that the Saving Mothers reports are first presented to the National Minister of Health, and they are only released to the public after the Minister has approved the report . Therefore, the recommendations in the Saving Mothers reports can be regarded as the official policy of the Department of Health on reducing maternal mortality. By the time the recommendations from the 2008–2010 report were released in 2012, the ESMOE programme was well known throughout the country. Thus, South Africa now had a standardised emergency obstetric skills training programme with obvious political support for its widespread implementation. Furthermore, recommendations about how the programme should be ‘scaled up’ to reach all relevant health workers were now published.

The South African (Saving Mothers) recommendations regarding health-care worker training (from 1998 to 2008–2010)

Since 1997, all maternal deaths in South Africa have been notifiable by law. Since 1998, all reported maternal deaths have been analysed in detail in the form of confidential enquiries, as conducted by the South African National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD). The committee is tasked to ‘make recommendations, based on the confidential study of maternal deaths, to the Minister of the Department of Health, such that the implementation of the recommendations will result in a decrease in maternal mortality’ . The recommendations are published in regular ‘Saving Mothers’ reports, which are disseminated countrywide to health administrators and health-care workers. The first Saving Mothers report reported on deaths that occurred in 1998, and there have been five triennial Saving Mothers reports published subsequently, the last of which has recently been released and covers the years 2011–2013 . In total, since 1998, the NCCEMD has analysed and reported on >20,000 maternal deaths. The confidential enquiry process includes an expert assessment for each death of the presence of avoidable factors associated with the death, including health-worker-related avoidable factors. This refers to mistakes or omissions in the management of the patient by the health workers, which might have contributed to the death.

From the first Saving Mothers report (1998), it was clear, especially for the direct causes of maternal death, such as death due to obstetric haemorrhage, hypertensive disorders of pregnancy and pregnancy-related sepsis, that substandard management by the health workers during the emergency event leading to death occurred in a large proportion of cases . The substandard care included inadequate initial assessment of the patient, not recognising the problem, misdiagnosis, failure to follow standard protocols of management and substandard resuscitation.

Accordingly, for several causes, the 1998 report recommended continuing professional development courses, in-service training or perinatal education programmes for health workers specific to each cause of death, without being more specific about the type of training recommended. The overall ‘Key Recommendations’ of the report emphasised the need for guidelines on managing conditions that commonly result in maternal death, but did not refer to training of health workers .

The findings in the next Saving Mothers report (1999–2001) were similar to those of the first report in that substandard care by health workers was associated with more than half of the notified maternal deaths . The Key Recommendations of the report were also similar to those of the first report, with training as an intervention not specifically mentioned except with regard to anaesthesia, where improvement of skills in anaesthesia was recommended at all levels of care. Again, the type of training method was not specified.

The 2002–2004 Saving Mothers report showed that maternal death numbers were increasing compared with the previous triennium . The substandard care by health workers noted in the previous reports remained a prominent feature. The Key Recommendations placed more emphasis on the need for health worker training than the previous reports. The first recommendation was that ‘protocols on the management of important conditions causing maternal deaths must be available, and utilised appropriately in all institutions where women deliver’. In addition, ‘all midwives and doctors must be trained on the use of these protocols’. The recommendation also proposed a target that ‘all districts must have a written functioning training programme in all institutions’, although the type of programme was not specified. Further reference to the need for training programmes was included in several of the other key recommendations relating to intrapartum care, contraceptive services and skills in anaesthesia. The recommendations regarding improving anaesthetic skills specified that ‘current anaesthesia curricula for medical students and medical interns must include “hands-on” experience’.

The 2005–2007 Saving Mothers report showed a continuing increase in the numbers of maternal deaths in South Africa . The largest increase was observed in deaths due to non-pregnancy-related infections, which were mainly AIDS-related infections. However, it was also notable that there was no decrease in the numbers of direct maternal deaths from causes such as obstetric haemorrhage, hypertensive disorders of pregnancy and abortion, with 58.5% of the direct maternal deaths being assessed as clearly avoidable had better care been rendered by the health system. The most common health-worker-related avoidable factor was substandard management despite the diagnosis being correct, indicating failure to manage patients according to protocols. This suggested that the previous recommendations regarding training on the use of protocols had either not been implemented or not been effective.

These findings led to a new key recommendation in the 2005–2007 report, placing more emphasis on the need for practical skills training : ‘Training should be provided for all health professionals working in maternity units in practical obstetrical and surgical skills. Skills should be provided in anaesthesia, especially in level 1 institutions.’ By the time the 2005–2007 report was released in 2009, a training programme had been developed in South Africa for improving skills in managing obstetric emergencies. This programme, called ‘Essential Steps in the Management of Obstetric Emergencies’ or ESMOE , is based on the ‘Making It Happen’ programme from the Liverpool School of Tropical Medicine and the Royal College of Obstetricians and Gynaecologists’ Life Saving Skills Programme , but it has been adapted to fit the needs of the South African setting. The ESMOE programme had already been shown to be effective in improving the skills of medical interns .

The ESMOE programme initially consisted of 12 modules, each designed for a small group of participants, with a short lecture followed by skills demonstration and skills practice. Examples of the modules included use of the partogram, management of obstetric haemorrhage and surgical skills. The content of the ESMOE programme would be regularly reviewed by a national ESMOE board. Further, one of the ongoing developments when the 2005–2007 Saving Mothers report was released was the addition to the ESMOE of an EOST component for each module. The EOST component is also referred to as the obstetric ‘fire drills’ . Taking this into account, the following targets were set in the 2005–2007 Saving Mothers report with regard to skills training:

• 1.

  All hospitals must have implemented ESMOE fire-drills and skills training

• 2.

  All sub-districts must have access to the ESMOE skills training programme for all institutions in the sub-district

The time set for achieving these targets was not stated.

The next (fifth) Saving Mothers report (2008–2010) presented the maternal death status in South Africa a full 10 years from the first Saving Mothers report . Disappointingly, the numbers of deaths reported were higher than ever before. Deaths due to all causes, direct and indirect, had increased compared with the previous triennium. Overall, 53% of deaths were assessed as being possibly or probably avoidable had better care been rendered by the health service. In particular, deaths due to obstetric haemorrhage had increased in number by 40% since the previous triennium, and 80% of the haemorrhage deaths were assessed as being possibly or probably avoidable. Once more, the data from the Saving Mothers report strongly suggested a need for better competence and skills amongst maternity care health workers, particularly with regard to emergency care skills.

The key recommendations of the 2008−10 report were presented in the form of five key focus areas for intervention, referred to as the 5 Hs. The first three areas were as follows:

• •

  HIV

• •

  Haemorrhage

• •

  Hypertension

These three causes of maternal death were highlighted, as they were responsible for the majority of all avoidable maternal deaths. The other two key focus areas were as follows:

• •

  Health worker training

• •

  Health system strengthening

With regard to health worker training, the specific recommendations were as follows:

• •

  Train all health-care workers involved in maternity care in the ESMOE–EOST programme and obstetric anaesthetic module

• •

  Train all health-care workers who deal with pregnant women in HIV advice, counselling, testing and support; initiation of highly active antiretroviral therapy (HAART); monitoring of HAART; and the recognition, assessment, diagnosis and treatment of severe respiratory infections

To help implement these recommendations, the 2008–2010 report listed suggested actions that should be undertaken by people at various levels of the health service . In relation to health worker training, the following actions were suggested:

The following actions were requested from the National and Provincial Directors General for Health:

• •

  Provide support for the training of doctors and midwives in ESMOE, by instructing the chief executive officers (CEOs) of health facilities to give time for doctors and midwives to undergo training and insist on EOST exercises taking place at least monthly in their institutions

• •

  Ensure EOST exercises are performed routinely at every institution conducting births

• •

  Ensure key activities become part of the key performance areas of the appropriate managers

The following actions requested from provincial maternal health managers and district managers were similar but added more detail:

• •

  Ensure health-care institutions handling deliveries perform and score EOST exercises at least monthly and involve all their maternity staff (A roster of those attending and the score must be passed on to the CEO of the institution)

The following actions were requested from all doctors and nurses involved in the care of pregnant women:

• •

  Ensure they undergo ESMOE training

• •

  Ensure they participate in EOST exercises

The following actions were requested from nurse training institutions and medical schools:

• •

  Ensure the contents of the ESMOE course are included in their curriculum

The actions requested from the Health Professions Council of South Africa were as follows:

• •

  Make successful completion of the ESMOE course a requirement for full registration as a doctor (i.e., must be completed during medical internship)

It should be noted that the Saving Mothers reports are first presented to the National Minister of Health, and they are only released to the public after the Minister has approved the report . Therefore, the recommendations in the Saving Mothers reports can be regarded as the official policy of the Department of Health on reducing maternal mortality. By the time the recommendations from the 2008–2010 report were released in 2012, the ESMOE programme was well known throughout the country. Thus, South Africa now had a standardised emergency obstetric skills training programme with obvious political support for its widespread implementation. Furthermore, recommendations about how the programme should be ‘scaled up’ to reach all relevant health workers were now published.

Scaling up ESMOE training in South Africa

Based on the 2005–2007 Saving Mothers report, where the ESMOE programme was first recommended , efforts to introduce ESMOE training into hospitals across South Africa started in 2009. The first step was that selected representatives (mainly specialist obstetricians based at teaching hospitals) from across the country were trained to be ESMOE ‘master trainers’ at a 4-day course, held at a central venue, and overseen by the national ESMOE board. The participants were taken through the 12 ESMOE modules and given instructions about how the modules should be run. All participants were also given training material such as a course facilitator manual, a DVD containing all the ESMOE lectures and videos, and a set of fire-drill scenarios that could be presented to the course participants to enact. Each of these scenarios included a checklist of steps that should ideally be performed by attending health workers in response to the scenario presented.

The new master trainers were advised to return to their own provinces and start ESMOE training at the facilities where they were based. They were also requested to share the training material with other suitable potential trainers in their provinces, so that these others could in turn also use the material to teach at their respective facilities with the aim of reaching a wider audience. At the inception of this programme, the national ESMOE board advised the master trainers that the priority group to target for ESMOE training was medical interns. Before they qualify as independent doctors, all medical interns in South Africa have to rotate through a 4-month obstetrics and gynaecology (O + G) attachment at a teaching hospital under the supervision of specialists. After completing their internship, the newly qualified doctors are assigned a 1-year community service medical officer placement. These placements are usually at district hospitals, often in rural areas, where there is no specialist supervision, and sometimes very little supervision of any kind. ESMOE training for the interns during their O + G attachment was considered to be essential in saving lives, by enabling them to cope better with obstetric emergencies during their subsequent community service year.

Using this as a starting point, all provinces in South Africa embarked on a programme of scaling up ESMOE training, as recommended in the 2005–2007 Saving Mothers report. The experience of the KwaZulu-Natal (KZN) province, one of the nine provinces in South Africa, will be used to illustrate the efforts made to scale up ESMOE training and achieve the target set in the 2005–2007 Saving Mothers report that ‘all hospitals must have implemented ESMOE fire-drills and skills training’ . Although KZN is the third smallest province in South Africa, it is the country’s second most highly populated province with an estimated population (in 2013) of 10.5 million, making up about 20% of the country’s population . In all the Saving Mothers reports, the highest number of maternal deaths has been recorded in this province. In the state health sector, KZN has three tertiary hospitals, 10 regional hospitals, 38 district hospitals, and 19 community health centres providing obstetric (delivery) services, as well as about 580 primary health clinics providing antenatal and postnatal care. These facilities are spread over 11 districts, with some districts having only district hospitals and having to refer to another district for regional or tertiary care. Making ESMOE training available to all maternity care workers at all these health facilities would clearly be a huge task.

By the end of 2010 in KZN, a core of ESMOE master trainers, mainly obstetricians based at regional teaching hospitals, were conducting regular ESMOE training modules at their own hospitals, usually on a weekly basis. The main target group was medical interns, although medical officers from the same hospital might join in depending on the site. The aim was to run through the 12 ESMOE modules for each intern group rotating through the O + G department on a four-monthly basis. This represented a more structured training in obstetric emergencies than had previously been available to the interns, and it was appreciated both by the interns themselves and by their supervisors (the trainers). At most of these teaching sites, the training sessions focussed predominantly on a lecture format, with some time allocated for skills demonstration (e.g., by video) and skills practice, rather than on the ‘fire-drill’ format of training. The provincial department of health were able to purchase several sets of training mannequins required for the skills training component of some of the ESMOE modules, so that most of the intern training sites in KZN were allocated a set of these mannequins.

Several of the training sites in KZN found that attendance of the interns at the ESMOE training sessions was inconsistent, with scheduled training sessions being missed for reasons such as the intern being on leave, being ‘post-call’ or just being very busy with clinical duties. Therefore, few interns completed the full ESMOE 12-module course during their O + G block. ESMOE training of interns on a national scale was not yet be formalised as a requirement for interns to pass their O + G block. One of the regional hospitals had already extended the ESMOE training beyond intern training, conducting several ESMOE training courses for medical officers and midwives not just from that regional hospital but also from the many district hospitals and clinics within its catchment area.

An opportunity for KZN Province to further scale up ESMOE training came in 2011 through a partnership between the provincial department of health and the University of KwaZulu-Natal (UKZN), which incorporates the only medical school in the province. Part of a university grant, awarded for a 5-year period, was used to set up regular ESMOE master trainer courses for the province. ^∗ These courses, held approximately three times a year, were run jointly by the provincial department of health and by UKZN, at a central university venue, accommodating about 30 participants each time. The course was run using a train-the-trainer format, with those completing the course then formally certified by the National ESMOE board as ESMOE master trainers. Experts, both from the KZN Department of Health and from UKZN, acted as the facilitators for the various modules. These experts included obstetricians, neonatologists, family physicians, anaesthetists and emergency medicine practitioners (paramedics), many of whom were themselves ESMOE master trainers. A quality assurance observer from the national ESMOE board attended the second of these KZN ESMOE master trainer courses in 2011, recommending methods of improving the course. In particular, the organisers were advised to ensure that facilitators spent less time on going through the ESMOE lectures and more on training the participants in how to run skills demonstrations and fire drills.

This opportunity meant that the province no longer had to rely on national master trainer courses to increase its numbers of ESMOE trainers; therefore, ESMOE training could be extended more rapidly to new sites in the province. The target groups for ESMOE master training included all specialist obstetricians working in the department of health, family physicians, experienced medical officers heading or overseeing maternity units at district hospitals, advanced midwives, midwife educators and emergency medicine practitioner (paramedic) trainers. One of the key principles of the course is that these various categories of health worker should be trained together, so as to instil in them the value of team training, as different categories need to be able to function as a team when confronting real emergencies .

The provincial department of health took on the role of identifying suitable participants for the course by liaising with the district health management teams and with the facilities themselves. It was important for any prospective participant from a facility to understand that attending the course came with a responsibility to conduct regular ESMOE training at that facility after completing the course. Thus, it was important that enthusiasts with a passion for teaching others be chosen. It was also important for the managers of the facilities who sent participants for the course to understand that they should support ESMOE training at their facility by ensuring a conducive environment that would allow the master trainer to conduct training at the facility after returning from the course.

KZN set a target of ESMOE master trainers being present at every hospital in the province, at least one midwife and one doctor. This would mean that every hospital would be self-sufficient, in that regular ESMOE training could be conducted without the need for external trainers. This target was achieved by the end of 2013, by which time 10 3-day KZN ESMOE master trainer workshops had been held, and >250 master trainers trained. ESMOE master trainers had also been trained from several of the community health centres in the province. From 2013 to present day (June 2015), a further four KZN master trainer workshops have been held, increasing the number of master trainers trained to >350. Although master trainers were trained from all hospitals in the province, it has become clear that that there will be an ongoing need for master trainer courses, although perhaps less frequent with time, because there is an inevitable attrition rate of trainers due to factors such as retirement, emigration and transfer to other facilities or to other departments within the same facility. Thus, the last few courses have predominantly aimed to fill the gaps where previously trained master trainers are no longer training.

A further development in the KZN programme is that a half-day obstetric anaesthesia module, specifically for doctors, has been added to the ESMOE master trainer course. The last 10 courses have included this extra half-day training. The module has been developed for the national ESMOE board, and it is available for training across the country. In KZN, this module was initially run as an anaesthetic master trainer course targeting specialist or experienced anaesthetists involved in anaesthetic training at their facilities. However, with the last few courses, the participants have mainly been medical officers doing the ESMOE master trainer course who are often expected to administer anaesthesia for caesarean section at district hospitals. As with the other ESMOE modules, the anaesthetic module includes a lecture, skills demonstration, skills practice and fire drills.