BackgroundPostpartum haemorrhage complicates approximately 10% of all deliveries and contributes to at least a quarter of all maternal deaths worldwide. The competency-based Helping Mothers Survive Bleeding after Birth (HMS BAB) training was developed to support evidence-based management of postpartum haemorrhage. This one-day training includes low-cost MamaNatalie® birthing simulators and addresses both prevention and first-line treatment of haemorrhage. While evidence is accumulating that the training improves health provider’s knowledge, skills and confidence, evidence is missing as to whether this translates into improved practices and reduced maternal morbidity and mortality. This cluster-randomised trial aims to assess whether this training package — involving a one-day competency-based HMS BAB in-facility training provided by certified trainers followed by 8 weeks of in-service peer-based practice — has an effect on the occurrence of haemorrhage-related morbidity and mortality.Methods/designIn Tanzania and Uganda we randomise 20 and 18 districts (clusters) respectively, with half receiving the training intervention. We use unblinded matched-pair randomisation to balance district health system characteristics and the main outcome, which is in-facility severe morbidity due to haemorrhage defined by the World Health Organizationation-promoted disease and management-based near-miss criteria. Data are collected continuously in the intervention and comparison districts throughout the 6-month baseline and the 9-month intervention phase, which commences after the training intervention. Trained facility midwives or clinicians review severe maternal complications to identify near misses on a daily basis. They abstract the case information from case notes and enter it onto programmed tablets where it is uploaded.Intention-to-treat analysis will be used, taking the matched design into consideration using paired t test statistics to compare the outcomes between the intervention and comparison districts. We also assess the impact pathway from the effects of the training on the health provider’s skills, care and interventions and health system readiness.DiscussionThis trial aims to generate evidence on the effect and limitations of this well-designed training package supported by birthing simulations. While the lack of blinding of participants and data collectors provides an inevitable limitation of this trial, the additional evaluation along the pathway of implementation will provide solid evidence on the effects of this HMS BAB training package.Trial registrationPan African Clinical Trials Registry, PACTR201604001582128. Registered on 12 April 2016.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-017-2056-7) contains supplementary material, which is available to authorized users.
Objective To estimate the stillbirth risk associated with intrapartum adverse events, controlling for fetal and maternal factors. Methods The present study was an analysis of cross‐sectional patient‐record and facility‐file data from women with viable fetuses who experienced obstetric adverse events at 23 hospitals and 38 health centers in Tanzania (between December 2015 and October 2016), and 22 hospitals, 16 level‐4 health centers, and five level‐3 health centers in Uganda (between May 2016 and September 2017). Adverse events were categorized in three severity groups (postpartum, intrapartum non‐near‐miss, and intrapartum near‐miss) to calculate stillbirth rates and adjusted prevalence ratios. Results Data from 3816 women in Tanzania and 8305 in Uganda were included. Compared with postpartum adverse events, intrapartum near‐miss was associated with a 3.73‐ and 4.55‐fold higher prevalence of stillbirth in Uganda and Tanzania, respectively. Most women who experienced near‐miss had organ dysfunction on arrival or developed it soon after. The risk of stillbirth was higher among preterm deliveries compared with term deliveries, and was 42% and 59% lower in Tanzania and Uganda, respectively, for cesarean deliveries compared with vaginal deliveries after intrapartum non‐near‐miss adverse events. Conclusion Stillbirth risk increased with severity of complications and was higher among premature deliveries. Survival was higher for cesarean deliveries in intrapartum non‐near‐miss complications, identifying the opportunity to prevent deterioration by timely actions.
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