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.

Background Postpartum hemorrhage and neonatal asphyxia are leading causes of maternal and neonatal mortality, respectively, that occur relatively rarely in low-volume health facilities in sub-Saharan Africa. Rare occurrence of cases may limit the readiness and skills that individual birth attendants have to address complications. Evidence suggests that simulator-based training and practice sessions can help birth attendants maintain these life-saving skills; one approach is called “low-dose, high-frequency” (LDHF). The objective of this evaluation is to determine the facilitating factors and barriers to participation in LDHF practice, using qualitative and quantitative information. Methods A trial in 125 facilities in Uganda compared three strategies of support for LDHF practice to improve retention of skills in prevention and treatment of postpartum hemorrhage and neonatal asphyxia. Birth attendants kept written logs of their simulator-based practice sessions, which were entered into a database, then analyzed using Stata to compare frequency of practice by the study arm. The evaluation also included 29 in-depth interviews and 19 focus group discussions with birth attendants and district trainers. Transcripts were entered in Atlas.ti software for coding, then analyzed using content analysis to identify factors that motivated or discouraged simulator-based practice. Results Practice log data indicated that simulator-based practice sessions occurred more frequently in facilities where one or two practice coordinators helped schedule and lead the practice sessions and in health centers compared to hospitals. The qualitative data suggest that birth attendants who practiced more were motivated by a desire to maintain skills and be prepared for emergencies, external recognition, and establishing a set schedule. Barriers to consistent practice included low staffing levels, heavy workloads, and a sense that competency can be maintained through routine clinical care alone. Some facilities described norms around continuing education and some did not. Conclusions Designating practice coordinators to lead their peers in simulator-based practice led to more consistent skills practice within frontline health facilities. Ongoing support, scheduling of practice sessions, and assessment and communication of motivation factors may help sustain LDHF practice and similar forms of continuing professional development. Trial registration Registered with clinicaltrials.gov #NCT03254628 on August 18, 2018 (registered retrospectively). Electronic supplementary material The online version of this article (10.1186/s12960-019-0350-z) contains supplementary material, which is available to authorized users.

Background Post-partum haemorrhage and neonatal asphyxia are the leading causes of maternal and newborn deaths, respectively, in Uganda. However, proven interventions that can save the lives of women and children are not being widely practised. Here, we assess the effects of two onsite training programmes for interventions to reduce deaths from post-partum haemorrhage and neonatal asphyxia, plus three different levels of performance support after the training in health-care facilities in 12 districts of Uganda. Methods We invited all public and some private non-profit health facilities that deliver babies in western and eastern regions of Uganda to participate. At all study sites, training in the Helping Mothers Survive and Helping Babies Breathe interventions was given to all health-care providers who attend births-medical doctors, clinical officers, midwives, nurses, and nurse assistants. The training consisted of low-dose, high-frequency onsite training followed by 20 weeks of provider-led practise with low-cost simulators. At all intervention sites, a midwife was designated as a clinical mentor or peer leader of simulation-based practice. We used a cluster randomised design to match districts for volume of births and presence of an operating theatre, and then randomly allocated districts to one of three training follow-up groups. A full-support group had onsite training supported with a peer practice coordinator and weekly practice sessions, supplemented with mobile messages to remind providers to practise. A partial-support group had an onsite training programme supported with a peer practice coordinator; and a control group received onsite training only. We collected routine monthly service-delivery statistics from the government Integrated Maternity Register (IMR) and introduced a supplemental maternity register to capture indicators not present in the IMR. Outcomes of interest were fresh stillbirths and neonatal deaths within 24 h at baseline and 6 months after the intervention. We had also aimed to study post-partum haemorrhage retained placenta, but no baseline data were available. Findings Between May, 2013, and May, 2016, training was delivered at 125 participating health facilities: 11 hospitals, 21 level IV health centres, 79 level III health centres, and 14 level II health centres. The control and partial-support groups had three hospitals each, but the full group had five hospitals, including the only regional referral hospital. The partial-support group had more level III and II (n=35) hospitals than did the full-support and control groups (n=29 each). The proportion of adverse birth outcomes (combined fresh stillbirths and neonatal deaths within 24 h), appeared to decrease significantly in all the study groups from baseline to 6 months post intervention: from 26•5 to 9•6 per 1000 livebirths (p<0•001) in the full support group, from 24•2 to 7•8 per 1000 livebirths (p<0•001) in the partial-support group, and from 17•2 to 9•5 per 1000 livebirths in the control group (p=0•008). We also noted a 47% r...