This study, accomplished with the use of a variety of data sources from health care facilities in a number of developing countries, demonstrates quite clearly the overall relatively low use of assisted vaginal delivery (AVD, obstetrical forceps and the vacuum extractor) in most of the facilities. The information available to the investigators did not allow an assessment of the comparative risks and benefits of AVD in these settings. Not surprising was that factors responsible for the low use of AVD were low availability of equipment and scarcity of adequately trained personnel, which varied in degree among the facilities studied. Also not unexpected was that the use of forceps delivery was much less common than assisted delivery with a vacuum extractor. Even in facilities in developed countries the rate of forceps deliveries has declined over the past three decades, with a concomitant increase in the use of the vacuum extractor (Patel et al. BMJ 2004;328:1302-5). This has occurred despite the fact that forceps deliveries are associated with fewer failures than vacuum extraction and that in cases of fetal distress, delivery can be accomplished more rapidly with forceps than with vacuum extraction. Of course, part, if not all, of the explanation for the declining use of forceps for AVD is that teaching and learning the skillful and safe use of forceps is far more difficult than learning the safe use of the vacuum extractor. This difficulty is augmented by the rise of caesarean delivery as an alternative for an attempted AVD and the decline in the number of practitioners who have sufficient experience using obstetrics forceps to be efficient teachers of the necessary skills using these instruments. Also, safe forceps delivery relies on an adequate knowledge of pelvic anatomy and a familiarity with the pros and cons of several types of forceps, neither of which is a requisite with the vacuum extractor. Evidence of this conundrum is a recent study of 5 years of deliveries (n = 5375) in an obstetric service in Mexico City in which there were only 146 forceps deliveries (i.e. approximately 29 per year) (Ayala-Y a~ nez et al. J Pregnancy 2015:489 267). Although this institution was not described as a training centre for physicians or nurse midwives, it nevertheless shows how few opportunities are available to train young practitioners in the use of forceps. Although the vacuum extractor is a reliable choice for AVD in most cases, it is of no use in a vaginal breech delivery. If spontaneous delivery of the after-coming head does not occur, the only safe alternative is the use of forceps (in most cases the Piper forceps). One of the most important conclusions of the authors of this study is the need for more comprehensive and reliable data collection in obstet-ric facilities in underdeveloped countries. This would allow an assessment of benefits and risks of AVD in these settings and a better estimate of where resources could most efficiently be directed to meet the need for more and better equipment and more trained pers...

An urgent need exists to improve and maintain intrapartum skills of providers in sub-Saharan Africa. Peer-assisted learning may address this need, but few rigorous evaluations have been conducted in real-world settings. A pragmatic, cluster-randomized trial in 12 Ugandan districts provided facility-based, team training for prevention and management of postpartum hemorrhage and birth asphyxia at 125 facilities. Three approaches to facilitating simulation-based, peer assisted learning were compared. The primary outcome was the proportion of births with uterotonic given within one minute of birth. Outcomes were evaluated using observation of birth and supplemented by skills assessments and service delivery data. Individual and composite variables were compared across groups, using generalized linear models. Overall, 107, 195, and 199 providers were observed at three time points during 1,716 births across 44 facilities. Uterotonic coverage within one minute increased from: full group: 8% (CI 4%‒12%) to 50% (CI 42%‒59%); partial group: 19% (CI 9%‒30%) to 42% (CI 31%‒53%); and control group: 11% (5%‒7%) to 51% (40%‒61%). Observed care of mother and newborn improved in all groups. Simulated skills maintenance for postpartum hemorrhage prophylaxis remained high across groups 7 to 8 months after the intervention. Simulated skills for newborn bag-and-mask ventilation remained high only in the full group. For all groups combined, incidence of postpartum hemorrhage and retained placenta declined 17% and 47%, respectively, from during the intervention period compared to the 6‒9 month period after the intervention. Fresh stillbirths and newborn deaths before discharge decreased by 34% and 62%, respectively, from baseline to after completion, and remained reduced 6‒9 months post-implementation. Significant improvements in uterotonic coverage remained across groups 6 months after the intervention. Findings suggest that while short, simulation-based training at the facility improves care and is feasible, more complex clinical skills used infrequently such as newborn resuscitation may require more practice to maintain skills.Trial Registration: ClinicalTrials.gov NCT03254628.

BAB training in prevention and management of postpartum hemorrhage increased knowledge and confidence among skilled and semiskilled birth attendants. Further studies are needed to determine the impact of this training on skills retention and clinical outcomes following postpartum hemorrhage, after broader implementation of the training program.

To implement a successful nationwide scale-up, several steps should be taken. These include, selecting motivated trainees, implementing the training as it was designed, improving support for trainees, and ensuring appropriate staff and infrastructure for trainees at their facilities before they return from training.