• 1.
  

  a) F b) F c) T d) F e) T

The Kirkpatrick model of programme evaluation is a system for evaluating training programmes according to four levels of training achievements. The first two levels refer to the reaction of training participants (satisfaction after training) and the knowledge and skills learning of the trainee. The third level measures the implementation or application of learned skills and behaviour in clinical practice. The fourth level relates to the patient effect of training assessed by measurable clinical outcomes. Most training courses do not go beyond measuring participant satisfaction and individual learning. Levels 3c and 4 of the revised Kirkpatrick levels measure beyond individual performance or perceptions and are linked to the performance of the team. Level 4c is the ‘gold standard’ for an efficient EmONC training programme and refers to the impact of training on patient outcomes in terms of reducing in mortality, morbidity and adverse events.

• 2.
  

  a) F b) T c) F d) F e) T

All the prominent available EmONC training packages referred to in the papers covered by the review had been developed in high-income countries and were adapted for use in low- and middle-income countries. Emergency drills with scenarios for simulating emergencies have shown to be effective in enhancing teamwork and team communication. Teamwork training has been associated with a reduction in morbidity and/or mortality in some studies, but a randomised controlled trial conducted by Nielsen and colleagues in the United States in which a crew-resource management (CRM) approach had been used did not show a significant difference in the adverse outcomes index (AOI) between the intervention and control hospitals. The Simulation and Fire-drill Evaluation (SaFE) study concluded that there was no advantage training at a high-fidelity simulation centre (offsite) instead of training onsite using low-fidelity models and patient-actors. At institutional level, regular ‘in-house’ refresher training sessions that include emergency drills have been shown to be effective for maintaining quality of care over time. The SaFE study recommended annual updating for training participants proficient in the management of shoulder dystocia, with more frequent rehearsals for non-proficient performers.

• 3.
  

  a) F b) T c) F d) T e) T

Five randomised controlled trials (RCTs) were included in the review and three of them measured impact on Level 4b and/or 4c of the Kirkpatrick model. In high-income countries, where many standard obstetric-care practices are assumed to be in place, the main focus is on reducing process errors for further improving patient safety, reducing morbidity and minimising litigation. In low- and middle-income countries, the training focus is on improving capacity and providing safe clinical skills to directly reduce maternal and neonatal mortality and morbidity. Drayott and colleagues reported a 50% reduction in hypoxic-ischaemic encephalopathy (HIE) after training, whereas an abstract on an Americanised PROMPT study also reported a significant reduction in perinatal HIE. Two papers and the American abstract reported on the decrease of brachial plexus injury after training with mannequins. Training does not take place in a vacuum and are often accompanied by other clinical initiatives directly related to improving obstetric care in the form of continuous quality improvement and the introduction of clinical-governance interventions. A systematic review found that single interventions (e.g. training without improvement in services) did not really make a difference in the reduction of maternal mortality in resource-limited countries. Training on its own may therefore not always change practice or have the desired effect. Institutions and health authorities should investigate simple ways of how best to integrate other context-specific initiatives into a multifaceted training package.

• 4.
  

  a) T b) F c) F d) T e) T

Training if done properly contributes to behavioural changes in both high- and low-income countries. The Simulation and Fire-drill Evaluation (SaFE) study concluded that there was no advantage training at a high-fidelity simulation centre (offsite) instead of training onsite using low-fidelity models and patient-actors. In low- and middle-income countries EmONC training is donor funded and there is little evidence of internally initiated efforts of embedding training packages in the health system as part of normal in-service training and practice. In planning a training package quality assurance and monitoring and evaluation mechanisms should be built-in features. At institutional level measures to monitor and ensure mandatory attendance of training should also be in place. In the United Kingdom, annual obstetric skills training is required, a recommendation endorsed by the SaFE study.

• 5.
  

  a) T b) F c) F d) F e) F

Uterine displacement improves venous return by relieving aorta-caval compression. Chest compressions should be performed 2–3 cm higher than the inter-nipple line for a woman in the 3 ^rd trimester due to the anatomical changes that occur. This is a witnessed cardiac arrest. Defibrillation should occur as soon as possible. The CD should be done in the maternity unit to have any benefit. Transferring to the OT wastes time and the benefit of the 4-5 minute window is lost. Intubate early in a pregnant woman to protect and secure the airway.

• 6.
  

  a) F b) F c) F d) T e) F

The best way to improve performance is to ask staff to reflect on their performance by providing constructive feedback and encouraging interaction. The better way is to get staff to do the skills and facilitate their improvement by mentoring the skill. Emergency equipment issues need to be dealt with as a matter of urgency and this must be communicated to the managers responsible as soon as possible. Repeating the fire-drill improves confidence and develops competence.

• 7.
  

  a) F b) F c) T d) F e) F

Evidence shows that debriefing following an event is not beneficial, and can even be harmful after traumatic events. Maternity staff should explain what is happening during the emergency. SBAR is a structured handover tool which stands for Situation, Background, Assessment and Recommendation. Closed-loop communication should minimise misunderstandings, ensuring that information and allocation of tasks is appropriately interpreted and acted upon. The leader should be the member of the team with the most experience of the emergency, not necessarily the most senior. Ideally, leaders will be aware of the capabilities of each team member prior to the emergency. However, if unknown, briefly stopping to clarify what team members can and cannot do is advisable.

• 8.
  

  a) F b) T c) F d) T e) F

MBRRACE highlighted ongoing problems with communication, clinical leadership and teamwork in maternity care, citing particular problems when managing PPH. In the UK, one in six women face a potentially life threatening intrapartum emergency. Deficiencies in communication and team training have been identified as the most common root causes for infant death in developed countries. Cardiac arrest situations are uncommon, extremely stressful and prone to error.

• 9.
  

  a) F b) T c) F d) F e) T

Evidence shows that participants training as individuals, rather than in teams, were more likely to miss critical steps to relieve the shoulder dystocia. The SaFE study demonstrated a definitive improvement in knowledge and skills which was sustained for 12 months following training. A study identified inadequacies in team response to a simulated maternal cardiac arrest despite team members having attended advanced life support. Research has shown that training ‘in-house’ with patient actors is preferable to training at simulation centres with high technology mannequins. The UK NHS Litigation Authority mandates annual multi-disciplinary skills and drills training.

• 10.
  

  a) F b) F c) T d) T e) F

Some studies have shown that improvements in knowledge and confidence seen immediately following training were not sustained 6 weeks later. The SaFE study demonstrated no benefit from training with sophisticated models in a simulation centre over local training for eclampsia. Few training programmes have been formally costed, but training in local clinical units is likely to be cheaper than in simulation centres. There is little in-depth understanding yet of how and why training can be effective. Process evaluations of complex interventions (such as the THISTLE-Plus study in Scotland, evaluating PROMPT implementation at scale) are required. Clinical knowledge improvement may not always be associated with improved clinical outcomes

• 11.
  

  a) T b) F c) F d) T e) T

Reports from CMACE and MBRRACE have recommended regular teamwork training. Stating the problem clearly has been identified as a feature of an efficient team. Isolated teamwork and human factors training do not appear to be associated with improvements in clinical or process outcomes. For example, when asking for a certain drug to be administered during an emergency, another team member reports back to the leader when that drug has been given. Patients and relatives report feeling safe having overheard team members using SBAR-type techniques.

• 12.
  

  a) F b) T c) F d) F e) F

Emergency obstetric and neonatal care (EmONC) should be considered a basic quality-of-care intervention for which universal access and coverage is needed. Although EmONC programmes vary in complexity, in our experience there are three basic building blocks that have to be attended to simultaneously: developing knowledgeable and skilled clinicians (training); allocating appropriate resources (including staff) to improve emergency services; and building up a reliable referral transport system.

• 13.
  

  a) T b) F c) F d) F e) F

The various facets of an EmONC programme cannot all be addressed at the same time and it takes time to institutionalise a programme, especially at grassroots level. The six stages of change framework allows drivers of EmONC scale up to address the conditions needed to make scale up successful. The framework consists of three phases. In the pre-implementation phase two stages are distinguished: creating awareness (after getting acquainted with a programme/intervention/innovation) and committing to implement (adopting the concept). The two stages in the implementation phase are preparation for implementation (taking ownership and mobilising resources) and initial implementation. The stages in the institutionalisation phase consist of integrating the programme/intervention/innovation into routine practice and sustaining the new practice.

• 14.
  

  a) T b) F c) T d) F e) T

Once willing to deliver in a facility, women and communities must be educated about where to deliver related to a risk assessment so that no undue burden is placed on a select group of care providers. Women must then have transport to access the EmONC service, as delay in getting to a care facility impacts on the outcomes of an EmONC programme. Maternal and newborn care is high on many policy agendas and a conscious change is needed for a shift in political will and public policy to create the right environment for scale up. Leadership amongst local policy makers provides the impetus for involving government partners. Leaders initiate planning for the needs of the local health system and facilitate the dialogue between healthcare and public policy providers. Scale up of EmONC should be considered against the backdrop of a health system’s ability to undertake the scale up, inter alia by means of health-system strengthening. A new EmONC training programme and service may struggle to take flight in an already non-optimally utilised service because of other system failures. Methods of strengthening may include expanding the capacity of the organisation and staff to implement a programme – a critical factor in success of scale up. The principles of equity and equality require putting EmONC services in the right place for the right people, with a fair balance between available resources, the distribution of coverage of services and improved health workforce competencies.

• 15.
  

  a) F b) F c) T d) T e) F

Monitoring and evaluation is a key component of all scale-up programmes. Scalability includes planning prior to scale up, for an appropriate evaluation approach able to show that the programme continues to have worth and is sustainable. The evaluation of the programme therefore needs to involve audit, which has been shown to potentially reduce mortality by up to 30% in LMICs. Monitoring of scale up requires collection of data around set end points. Internally owned data may enhance sustainability; however, it is possible that this process ends up placing a burden on individuals at the centre of a programme, from national to institutional level. Mechanisms to enable the system and facilities, not just the passionate individuals and drivers, to support data collection are essential and the assessment and monitoring of a scale-up programme. Constant re-evaluation of the stages of change is necessary to ensure sustainability of scale-up and flexibility to meet changing needs within a health system.

• 16.
  

  a) F b) F c) T d) F e) T

Process measures are still valid but need to be combined with outcome measures to be balanced. A US study found that although process measures may be associated with an adverse outcome, the hospitals that performed best on those measures did not have the best risk-adjusted rates of obstetric morbidity. Population risk adjustment is necessary to allow data from units with different demographics to be fairly compared. No consensus has been reached on a core set of quality indicators, but one is urgently needed. Use of routinely collected data facilitates the measurement of quality, and removes obstacles to data collection.

• 17.
  

  a) T b) F c) T d) F e) T

The RCOG has recommended introduction of clinical dashboards since 2008. A maternity dashboard was first described in UK practice in 2005 after several preventable maternal deaths, to help measure and manage what was described as serious clinical underperformance. By informing stakeholders about areas of clinical risk or unexpectedly high numbers of specific adverse events, it may be possible to demonstrate where training needs to be targeted or changes need to be made. There is limited data on the use of dashboards, but the published literature currently available does show early promise that they can be successfully implemented. Underperformance as defined by failure to reach certain defined benchmarks of quality, can allow attention to be focused on improving particular problems in a maternity unit.

• 18.
  

  a) F b) T c) F d) F e) T

The Saving Mothers reports present data from notified maternal deaths. It is a legal requirement that all maternal deaths be notified. The numbers of maternal deaths increased with each report until the last one (2011–2013), which for the first time showed a decrease compared to previous reports. The 2011–2013 report demonstrated an overall decrease in maternal deaths, but this was mainly due to a decrease in HIV-related deaths, which could be attributed to the up-scaling of the national anti-retroviral treatment programme. Deaths due to obstetric haemorrhage increased, suggesting that management of obstetric emergencies had not improved.

• 19.
  

  a) F b) T c) T d) F e) F

ESMOE stands for Essential Steps in the Management of Obstetric Emergencies. ESMOE is a standardised programme for the whole country. The content is regularly updated by a national ESMOE board. The “fire drill” is a term used to describe emergency obstetric simulation training, where a mock scenario is enacted to practise the team management of an obstetric emergency.

• 20.
  

  a) F b) T c) F d) T e) T

Introducing ESMOE at undergraduate level was recommended in the Saving Mothers report 2008–2010. As well as increasing the knowledge and skills of the students, it would be likely to make them more willing to participate in ESMOE training once they reach the workplace. A recent study from South Africa showed that doctors were not conducting instrumental delivery despite having been trained in instrumental delivery. The skills learnt through ESMOE training are not likely to translate into practice unless clinical leaders promote them in the clinical setting.

• 21.
  

  a) T b) T c) F d) F e) F

The date for achieving MDG targets is the end of 2015. Progress is evaluated against a 1990 reference point. MDG 5 targets also include achieving universal access to reproductive health services by 2015. Whilst significant progress has been made, both MDG 4 and 5 targets are unlikely to be reached.

Stillbirths are not tracked by Countdown to 2015, therefore it is not possible to determine the relative prevalence of this important indicator of the quality of antenatal and intrapartum care in Countdown countries. The slowest progress in mortality reduction has occurred in neonates, with an increasing proportion of under-five deaths occurring in the first four weeks of life. Neonates account for approximately 39% (median) of all under-five deaths in the 75 Countdown countries.

• 22.
  

  a) F b) F c) T d) F e) T

Approximately three to six percent of newborns require basic neonatal resuscitation (airway clearing, head positioning, bag-and-mask ventilation). Bag-and-mask ventilation is effective with room air and might not be enhanced by the use of supplementary oxygen. For five to 10% of infants, simple stimulation is all that is needed to help the newborn initiate breathing. The first minute of life (the so-called ‘golden minute’) is the most critical to establish breathing and to reduce poor neonatal outcomes.

Simple stimulation techniques include rubbing and drying the infant. Smacking or other vigorous methods are inappropriate and may be harmful.

• 23.
  

  a) T b) F c) T d) F e) F

A meta-analysis of three before-and-after facility-based studies estimated that basic neonatal resuscitation training of healthcare practitioners in facilities reduced the risk of term neonatal death by 30%. Evidence suggests that the practical resuscitation skills of healthcare practitioners decline quite rapidly and that refresher courses are necessary every three to six months after initial training. In addition to improving resuscitation performance, a Kenyan study found a significant reduction in inappropriate and potentially harmful practices. More research is needed to corroborate this important finding. Evidence suggests that training and maintaining basic neonatal resuscitation skills in TBAs is feasible. In a cluster randomised controlled trial conducted in Zambia, neonatal deaths among liveborn infants delivered by trained TBAs was almost halved compared with untrained controls. Global efforts have been focused on increasing facility-based deliveries, however, frequently basic life-saving skills within facilities are lacking. Therefore it is imperative that all healthcare practitioners in facilities receive basic neonatal resuscitation skills training with regular booster sessions to ensure good coverage and to reduce attrition of skills over time. The availability of advanced resuscitation techniques does not reduce the need for widespread competence of core neonatal resuscitation skills.

• 24.
  

  a) T b) F c) F d) F e) F

The aggregate maternal case fatality rate among Caesarean section patients operated upon by non-physician mid-level providers of care (AMOs) in Tanzania is approximately 1–2%.

• 25.
  

  a) F b) F c) F d) F e) T

At district hospital level the proportion of all Caesarean sections carried out by non-physician mid-level providers of care (“técnicos de cirurgia”) is 85–90% of cases.

• 26.
  

  a) F b) F c) T d) F e) F

  
  
• 27.
  

  a) F b) T c) T d) T e) T

Maternity claims account for the highest value, and the second highest number of claims. In percentage terms, this means that obstetrics and gynaecology claims account for 20% of the number of all clinical negligence claims notified to the NHSLA and 49% of the total value. Claims involving children should have court proceedings issued within three years of the child’s 18th birthday. If the child will never have capacity, no time limit is imposed (NHSLA. Ten Years of Maternity Claims. NHS Litigation Authority; 2012).

• 28.
  

  a) F b) T c) T d) F e) T

Cerebral palsy, CTG interpretation and management of labour are the top 3 categories of claims by total value, and together constitute 70% of the value of claims to the NHSLA. Caesarean section and antenatal investigations are 4th and 5th respectively (NHSLA. Ten Years of Maternity Claims. NHS Litigation Authority; 2012).

• 29.
  

  a) F b) F c) T d) T e) T

To determine negligence, a three stage test must be satisfied.

• 1)
  

  The patient is owed a duty of care.

  
  
• 2)
  

  A breach if that duty of care is found to have taken place.

  
  
• 3)
  

  The harm was caused as a direct result of that breach in the duty of care.

The standard of evidence required is that of ‘balance of probabilities’.

• 30.
  

  a) F b) T c) F d) T e) T

Studies report incidences of shoulder dystocia of between 0.58 and 0.7%. Brachial plexus injury occurs in 2.3–16% of deliveries complicated by shoulder dystocia. However, some studies report that up to 12% of brachial plexus injuries occur after uncomplicated caesarean section. The rate of PPH is 11% following shoulder dystocia, and the rate of 3/4th degree tear is 4%. Simulation training has been shown to improve knowledge, confidence and management of shoulder dystocia. Shoulder dystocia is 10 times more likely to occur in a patient with previous shoulder dystocia, compared to the general population. (RCOG Green top guideline 42).