This paper reviews evidence regarding change in health-care provider behaviour and maternal and neonatal outcomes as a result of emergency obstetric and neonatal care (EmONC) training. A refined version of the Kirkpatrick classification for programme evaluation was used to focus on change in efficiency and impact of training (levels 3 and 4). Twenty-three studies were reviewed – five randomised controlled trials, two quasi-experimental studies and 16 before-and-after observational studies. Training programmes had all been developed in high-income countries and adapted for use in low- and middle-income countries. Nine studies reported on behaviour change and 13 on process and patient outcomes. Most showed positive results. Every maternity unit should provide EmONC teamwork training, mandatory for all health-care providers. The challenges are as follows: scaling up such training to all institutions, sustaining regular in-service training, integrating training into institutional and health-system patient safety initiatives and ‘thinking out of the box’ in evaluation research.
Highlights
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There has been a shift in focus from individual skills training to team training.
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A refinement of Kirkpatrick’s model for evaluating training evidence is proposed.
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Emergency obstetric and neonatal training can save lives and improve quality of life.
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Regular mandatory in-service training is essential.
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Quality of training should be assessed for complying with minimum standards.
Introduction
Maternal and perinatal mortality remain major challenges to health systems globally, especially in low- and middle-income countries (LMICs) . The Millennium Development Goals 4 and 5 called for the reduction of under-five mortality rates (which include neonatal deaths) and maternal mortality ratios by three-quarters by the year 2015. Many Countdown countries have been unable to make sufficient progress , with the sub-Saharan region faring the worst with maternal morbidities and mortalities . Where under-five mortality has been reduced, the rate of decrease in neonatal mortality is much slower .
In high-income countries (HICs), reports such as the United Kingdom’s (UK’s) Confidential Enquiry into Maternal and Child Health and the Joint Commission on Accreditation of Healthcare Organizations in the United States (US) identified substandard care and a high incidence of medical errors as the cause of a significant proportion of preventable patient morbidity and mortality . The uniqueness of challenges in obstetric emergencies demands ‘excellent teamwork and superior communication skills between multiple medical teams’ (p. 40) . One of the root causes cited for substandard care is a threatening organisational culture that undermines teamwork and communication, leading to the following: confusion in roles and responsibilities, lack of cross-monitoring, failure to prioritise and perform clinical tasks in a structured coordinated manner and lack of support for health-care providers . These failures necessitated a shift in training away from individual technical perfection only to better team coordination for patient safety through error management and improved processes . Numerous health authorities, labour wards and institutions involved in maternal, neonatal and child health have developed or are developing emergency obstetric and neonatal care (EmONC) training packages to address the changed training needs.
Studies on EmONC training have proliferated in the past decade, and the challenge of evaluating the impact of these programmes is the large variation in the descriptions of training with regard to content, design, delivery style and duration . The aim of this paper is to map the landscape regarding training in EmONC skills and to give an overview of the different training programmes, packages and approaches discussed in peer-reviewed research reports. Of particular importance are the kinds of training results available on post-training change in (a) provider disposition or behaviour or (b) organisational impact and patient outcomes with respect to morbidity and/or mortality.
Methods
A search of peer-reviewed articles written in English and pertaining to systematic multi-professional training was conducted for the period between 1994 and October 2014. The rationale for the choice of the starting date was as follows: an initial PubMed search did not yield any publication before 1994; the publication on the Advanced Life Support in Obstetrics (ALSO ® ) course by Beasley et al. appeared in 1994 ; and the first publications included in the systematic review of the effectiveness of training in emergency obstetric care in low-resource environments by Van Lonkhuijzen et al. appeared in 1995 . The databases consulted included PubMed/MEDLINE, CINAHL, Web of Science, Science Direct, Cochrane Controlled Trials Register, Popline, African Journals Online, Directory of Open Access Journals, Google Scholar, TOC Premier and Health Source: Nursing/Academic Edition. Various Boolean combinations of the following search terms were used according to the combination possibilities allowed in each database: ‘obstetric*’, ‘emergenc*’, ‘basic emergency obstetric*’, ‘comprehensive emergency obstetric*’, ‘obstetric care training’, ‘train*’, ‘team’, ‘fire drill*’, ‘emergency drill*’, ‘simulation’, ‘simulator’, ‘mannequin*’/‘manikin*’, ‘shoulder dystocia’, ‘eclampsia’, ‘postpartum haemorrhage’, ‘breech’, ‘vacuum’ and ‘forceps’. Reference lists from relevant publications were also consulted with a view to identifying possible additional studies to include in the review. A supplementary online file provides details of the search flow.
Owing to the heterogeneity of studies, the complexity of some training interventions, and variations in assumptions, understandings and descriptions of these interventions, inclusion and exclusion criteria were further refined during the review process for facilitating a manageable set of publications. These criteria are summarised in Table 1 .
| Inclusion criteria | Exclusion criteria |
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| Level of training: | |
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| Target audience: | |
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| Nature of training: | |
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| Duration of initial training course: | |
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| Kirkpatrick’s four levels of programme evaluation: | |
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| Types of studies: | |
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a The number in the SaFe study to investigate benefits of different training methods was used as a guideline .
Fig. 1 presents a graphic depiction of the search flow and selection of publications. The initial search yielded 4235 potentially useful articles. After excluding non-English publications and duplicates, the remaining titles and abstracts were screened. Sixty-nine papers were retrieved for further examination, and a further three papers were included from the bibliographies of the identified papers. After further analysis, 35 peer-reviewed articles representing a total of 23 studies or trials remained for final review.
For two of the articles, the full papers could not be accessed and their abstracts were included in the analysis . The results for each paper were tabulated in detail (supplementary online file 2), and tables were created with extracted data for investigating particular aspects of training (supplementary online file 3). As the purpose of the review was to map the terrain of EmONC training reports, the evidence was not graded.
Methods
A search of peer-reviewed articles written in English and pertaining to systematic multi-professional training was conducted for the period between 1994 and October 2014. The rationale for the choice of the starting date was as follows: an initial PubMed search did not yield any publication before 1994; the publication on the Advanced Life Support in Obstetrics (ALSO ® ) course by Beasley et al. appeared in 1994 ; and the first publications included in the systematic review of the effectiveness of training in emergency obstetric care in low-resource environments by Van Lonkhuijzen et al. appeared in 1995 . The databases consulted included PubMed/MEDLINE, CINAHL, Web of Science, Science Direct, Cochrane Controlled Trials Register, Popline, African Journals Online, Directory of Open Access Journals, Google Scholar, TOC Premier and Health Source: Nursing/Academic Edition. Various Boolean combinations of the following search terms were used according to the combination possibilities allowed in each database: ‘obstetric*’, ‘emergenc*’, ‘basic emergency obstetric*’, ‘comprehensive emergency obstetric*’, ‘obstetric care training’, ‘train*’, ‘team’, ‘fire drill*’, ‘emergency drill*’, ‘simulation’, ‘simulator’, ‘mannequin*’/‘manikin*’, ‘shoulder dystocia’, ‘eclampsia’, ‘postpartum haemorrhage’, ‘breech’, ‘vacuum’ and ‘forceps’. Reference lists from relevant publications were also consulted with a view to identifying possible additional studies to include in the review. A supplementary online file provides details of the search flow.
Owing to the heterogeneity of studies, the complexity of some training interventions, and variations in assumptions, understandings and descriptions of these interventions, inclusion and exclusion criteria were further refined during the review process for facilitating a manageable set of publications. These criteria are summarised in Table 1 .
| Inclusion criteria | Exclusion criteria |
|---|---|
| Level of training: | |
|
|
| Target audience: | |
|
|
| Nature of training: | |
|
|
| Duration of initial training course: | |
|
|
| Kirkpatrick’s four levels of programme evaluation: | |
|
|
| Types of studies: | |
|
|
a The number in the SaFe study to investigate benefits of different training methods was used as a guideline .
Fig. 1 presents a graphic depiction of the search flow and selection of publications. The initial search yielded 4235 potentially useful articles. After excluding non-English publications and duplicates, the remaining titles and abstracts were screened. Sixty-nine papers were retrieved for further examination, and a further three papers were included from the bibliographies of the identified papers. After further analysis, 35 peer-reviewed articles representing a total of 23 studies or trials remained for final review.
For two of the articles, the full papers could not be accessed and their abstracts were included in the analysis . The results for each paper were tabulated in detail (supplementary online file 2), and tables were created with extracted data for investigating particular aspects of training (supplementary online file 3). As the purpose of the review was to map the terrain of EmONC training reports, the evidence was not graded.
Synopsis of peer-reviewed articles included in the review
The 35 identified peer-reviewed articles represented 23 studies or trials. Ten of the papers were related to the Simulation and Fire-drill Evaluation (SaFE) study and were treated as one intervention . Two articles reporting on the Programa de Rescate Obstétrico y Neonatal: Tratamiento Óptimo y Oportuno (PRONTO) trial were included (the pilot study and some of the first results pertaining to changes after the second training module) . Abstracts that demonstrate the real impact of the intervention were noted , but they were not formally included. Three papers with results from the ‘in-house’ training in Bristol in the UK were also grouped together . A synopsis of the 23 studies analysed is given in Table 2 .
| Training package | Study (name and/or location) | No. and level hospitals/health facilities in study | LMIC/HIC | No. of articles in review | Study design | Kirkpatrick levels | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| Hospitals | Health centres | 1 | 2 | 3 | 4 | |||||
| PROMPT | Bristol, UK | 1 TTH/RH | – | HIC | 3 | Before–after | 3c | 4c | ||
| SaFE trial, Southwest England | 6 DH (L2&L3) | – | HIC | 10 | RCT | 2a,b,c | 3b | |||
| NHS Foundation Trust, Liverpool, UK | – | – | HIC | 1 | Before–after | 4b,c | ||||
| Victoria, Australia | 7 | – | HIC | 1 | Before–after | 1 | 2a | 4c | ||
| PRONTO | Mexico trial a | 24 | – | LMIC | 2 | RCT | 1 | 2b,c | −−− | −−− |
| AIP | QUARITE, Senegal & Mali | 46 RH (L1&L2) | – | LMIC | 1 | RCT | 4b,c | |||
| Moi Teaching and Referral Hospital, Kenya | 1 TTH/RH | – | LMIC | 1 | Before–after | 3c | 4b,c | |||
| ALSO | Kagera Regional Hospital, Tanzania | 1 RH (L2) | – | LMIC | 1 | Before–after | 4b,c | |||
| LSTM-RCOG LSS-EOC and NC | AGOTA-NVOG, Tanzania | – | – | LMIC | 1 | Before–after | 1 | 2b | −−− | −−− |
| Sub-Saharan Africa (7 countries) | – | – | LMIC | 1 | Before–after | 1 | 2b,c | −−− | −−− | |
| Somaliland, Somalia | 3 | 8 | LMIC | 1 | Before–after | 1 | 2b,c | 3a | 4b | |
| Making it Happen, Bangladesh & India | 4 DH (Bangl.) | 21 (Bangl.) | LMIC | 1 | Before–after | 1 | 2a,b,c | −−− | −−− | |
| LSS-ACNM | Vietnam | 3 DH; 3 FH | 40 | LMIC | 1 | Quasi-experimental | 3c | |||
| CRM based | National study, US | 15 | – | HIC | 1 | RCT | 4c | |||
| Beth Israel Deaconess Medical Center, US | 1 TTH | – | HIC | 1 | Before–after | 2a | 4b,c | |||
| Perinatal Safety Initiative, US | 1 TH | – | HIC | 1 | Before–after | 3a | 4b,c | |||
| Rhode Island Hospital, US | 1 | – | HIC | 1 | Before-after | 4b,c | ||||
| Geneva University Hospital, Switzerland | 1 TTH | – | HIC | 1 | Before–after | 1 | 2a | 3a | ||
| TeamSTEPPS, US | 3 CH | – | HIC | 1 | RCT | 2a | 4c | |||
| OBCTT, Southeast US | 1 TTH | – | HIC | 1 | Quasi-experimental before-after | 1 | 2a,b,c | −−− | −−− | |
| OTHER | CEmONC, Tanzania | 1 DH | LMIC | 1 | Before-after | 3c | ||||
| Copenhagen University Hospital, Denmark | 1 TTH | – | HIC | 1 | Before-after | 1 | 2a,b | 3a | 4b | |
| University of Oporto, Portugal | 1 TTH | – | HIC | 1 | Before-after | 1 | 2b | 3a | ||
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