No abstract

BackgroundInadequately treated, preeclampsia and eclampsia (PE/E) may rapidly lead to severe complications in both mothers and neonates, and are estimated to cause 60,000 global maternal deaths annually. Simulation-based training on obstetric and neonatal emergency management has demonstrated promising results in low- and middle-income countries. However, the impact of simulation training on use of evidence-based practices for PE/E diagnosis and management in low-resource settings remains unknown.MethodsThis study was based on a statewide, high fidelity in-situ simulation training program developed by PRONTO International and implemented in collaboration with CARE India on PE/E management in Bihar, India. Using a mixed methods approach, we evaluated changes over time in nurse mentees’ use of evidence-based practices during simulated births at primary health clinics. We compared the proportion and efficiency of evidence-based practices completed during nurse mentees’ first and last participation in simulated PE/E cases. Twelve semi-structured interviews with nurse mentors explored barriers and enablers to high quality PE/E care in Bihar.ResultsA total of 39 matched first and last simulation videos, paired by facility, were analyzed. Videos occurred a median of 62 days apart and included 94 nurses from 33 primary health centers. Results showed significant increases in the median number of ‘key history questions asked,’ (1.0 to 2.0, p = 0.03) and ‘key management steps completed,’ (2.0 to 3.0, p = 0.03). The time from BP measured to magnesium sulfate given trended downwards by 3.2 min, though not significantly (p = 0.06). Key barriers to high quality PE/E care included knowledge gaps, resource shortages, staff hierarchy between physicians and nurses, and poor relationships with patients. Enablers included case-based and simulation learning, promotion of teamwork and communication, and effective leadership.ConclusionSimulation training improved the use of evidence-based practices in PE/E simulated cases and has the potential to increase nurse competency in diagnosing and managing complex maternal complications such as PE/E. However, knowledge gaps, resource limitations, and interpersonal barriers must be addressed in order to improve care. Teamwork, communication, and leadership are key mechanisms to facilitate high quality PE/E care in Bihar.

BackgroundIn India, the neonatal mortality rate is nearly double the Sustainable Development Goal target with more than half of neonatal deaths occurring in only four states, one of which is Bihar. Evaluations of immediate neonatal care and neonatal resuscitation skills in Bihar have demonstrated a need for significant improvement. However, barriers to evidence based practices in clinical care remain incompletely characterized.MethodsTo better understand such barriers, semi-structured interviews were conducted with 18 nurses who participated as mentors in the AMANAT maternal and child health quality improvement project, implemented by CARE India and the Government of Bihar. Nurse-mentors worked in primary health centers throughout Bihar facilitating PRONTO International emergency obstetric and neonatal simulations for nurse-mentees in addition to providing direct supervision of clinical care. Interviews focused on mentors’ perceptions of barriers to evidence based practices in immediate neonatal care and neonatal resuscitation faced by mentees employed at Bihar’s rural primary health centers. Data was analyzed using the thematic content approach.ResultsMentors identified numerous interacting logistical, cultural, and structural barriers to care. Logistical barriers included poor facility layout, supply issues, human resource shortages, and problems with the local referral system. Cultural barriers included norms such as male infant preference, traditional clinical practices, hierarchy in the labor room, and interpersonal relations amongst staff as well as with patients’ relatives. Poverty was described as an overarching structural barrier.ConclusionInteracting logistical, cultural and structural barriers affect all aspects of immediate neonatal care and resuscitation in Bihar. These barriers must be addressed in any intervention focused on improving providers’ clinical skills. Strategic local partnerships are vital to addressing such barriers and to contextualizing skills-based trainings developed in Western contexts to achieve the desired impact of reducing neonatal mortality.

BackgroundGlobally, an estimated 275,000 maternal deaths, 2.7 million neonatal deaths, and 2.6 million third trimester stillbirths occurred in 2015. Major improvements could be achieved by providing effective care in low- and middle-income countries, where the majority of these deaths occur. Mentoring programs have become a popular modality to improve knowledge and skills among providers in low-resource settings. Thus, a detailed understanding of interrelated factors affecting care provision and mentorship is necessary both to improve the quality of care and to maximize the impact of mentoring programs.MethodsIn partnership with the Government of Bihar, CARE India and PRONTO International implemented simulation-enhanced mentoring in 320 primary health clinics (PHC) across the state of Bihar, India from 2015 to 2017, within the context of the AMANAT mobile nurse mentoring program. Between June and August 2016, we conducted semi-structured interviews with 20 AMANAT nurse mentors to explore barriers and facilitators to optimal care provision and to implementation of simulation-enhanced mentorship in PHCs in Bihar. Data were analyzed using the thematic content approach.ResultsMentors identified numerous factors affecting care provision and mentorship, many of which were interdependent. Such barriers included human resource shortages, nurse-nurse hierarchy, distance between labor and training rooms, cultural norms, and low skill level and resistance to change among mentees. In contrast, physical resource shortages, doctor-nurse hierarchy, corruption, and violence against providers posed barriers to care provision alone. Facilitators included improved skills and confidence among providers, inclusion of doctors in training, increased training frequency, establishment of strong mentor-mentee relationships, administrative support, and nursing supervision and feedback.ConclusionsThis study has identified many interrelated factors affecting care provision and mentorship in Bihar. The mentoring program was not designed to address several barriers, including resource shortages, facility infrastructure, corruption, and cultural norms. These require government support, community awareness, and other systemic changes. Programs may be adapted to address some barriers beyond knowledge and skill deficiencies, notably hierarchy, violence against providers, and certain cultural taboos. An in-depth understanding of barriers and facilitators is essential to enable the design of targeted interventions to improve maternal and neonatal survival in Bihar and related contexts.Electronic supplementary materialThe online version of this article (10.1186/s12884-018-2059-8) contains supplementary material, which is available to authorized users.

BackgroundGlobally, neonatal mortality accounts for nearly half of under-five mortality, and intrapartum related events are a leading cause. Despite the rise in neonatal resuscitation (NR) training programs in low- and middle-income countries, their impact on the quality of NR skills amongst providers with limited formal medical education, particularly those working in rural primary health centers (PHCs), remains incompletely understood.MethodsThis study evaluates the impact of PRONTO International simulation training on the quality of NR skills in simulated resuscitations and live deliveries in rural PHCs throughout Bihar, India. Further, it explores barriers to performance of key NR skills. PRONTO training was conducted within CARE India’s AMANAT intervention, a maternal and child health quality improvement project. Performance in simulations was evaluated using video-recorded assessment simulations at weeks 4 and 8 of training. Performance in live deliveries was evaluated in real time using a mobile-phone application. Barriers were explored through semi-structured interviews with simulation facilitators.ResultsIn total, 1342 nurses participated in PRONTO training and 226 NR assessment simulations were matched by PHC and evaluated. From week 4 to 8 of training, proper neck extension, positive pressure ventilation (PPV) with chest rise, and assessment of heart rate increased by 14%, 19%, and 12% respectively (all p ≤ 0.01). No difference was noted in stimulation, suction, proper PPV rate, or time to completion of key steps. In 252 live deliveries, identification of non-vigorous neonates, use of suction, and use of PPV increased by 21%, 25%, and 23% respectively (all p < 0.01) between weeks 1–3 and 4–8. Eighteen interviews revealed individual, logistical, and cultural barriers to key NR skills.ConclusionPRONTO simulation training had a positive impact on the quality of key skills in simulated and live resuscitations throughout Bihar. Nevertheless, there is need for ongoing improvement that will likely require both further clinical training and addressing barriers that go beyond the scope of such training. In settings where clinical outcome data is unreliable, data triangulation, the process of synthesizing multiple data sources to generate a better-informed evaluation, offers a powerful tool for guiding this process.

BackgroundAs the global under-five mortality rate declines, an increasing percentage is attributable to early neonatal mortality. A quarter of early neonatal deaths are due to perinatal asphyxia. However, neonatal resuscitation (NR) simulation training in low-resource settings, where the majority of neonatal deaths occur, has achieved variable success. In Bihar, India, the poorest region in South Asia, there is tremendous need for a new approach to reducing neonatal morality.MethodsThis analysis aims to assess the impact of a novel in-situ simulation training program, developed by PRONTO International and implemented in collaboration with CARE India, on NR skills of nurses in Bihar. Skills were evaluated by clinical complexity of the simulated scenario, which ranged from level 1, requiring NR without a maternal complication, to level 3, requiring simultaneous management of neonatal and maternal complications. A total of 658 nurses at 80 facilities received training 1 week per month for 8 months. Simulations were video-recorded and coded for pre-defined clinical skills using Studiocode™.ResultsA total of 298 NR simulations were analyzed. As simulation complexity increased, the percentage of simulations in which nurses completed key steps of NR did not change, even with only 1–2 providers in the simulation. This suggests that with PRONTO training, nurses were able to maintain key skills despite higher clinical demands. As simulation complexity increased from level 1 to 3, time to completion of key NR steps decreased non-significantly. Median time to infant drying decreased by 7.5 s (p = 0.12), time to placing the infant on the warmer decreased by 21.7 s (p = 0.27), and time to the initiation of positive pressure ventilation decreased by 20.8 s (p = 0.12). Nevertheless, there remains a need for improvement in absolute time elapsed between delivery and completion of key NR tasks.ConclusionsPRONTO simulation training enabled nurses in Bihar to maintain core NR skills in simulation despite demands for higher-level triage and management. Although further evaluation of the PRONTO methodology is necessary to understand the full scope of its impact, this analysis highlights the importance of conducting and evaluating simulation training in low-resource settings based on simultaneous care of the mother-infant dyad.

AimKangaroo mother care (KMC) is a safe and effective method of reducing neonatal mortality in resource‐limited settings, but there has been a lack of data on the duration of skin‐to‐skin contact (SSC) in busy, low‐resource newborn units. Previous studies of intermittent KMC suggest the duration of SSC ranged from 10 minutes to 17 hours per day.MethodsThis was an observational study of newborn infants born weighing less than 2000 g, which collected quantitative data on SSC over the first week after birth. The study took place in July 2016 in the newborn unit of a low‐resource facility in Uganda.ResultsThe mean daily duration of SSC over the first week after birth was three hours. This differed significantly from the World Health Organization recommendation of at least 20 hours of SSC per day. SSC was provided by mothers most of the time (73.5%), but other family members also took part, especially on the day of birth.ConclusionOur study found a disappointingly low daily duration of SSC in this Ugandan newborn unit. However, advocacy and community education of SSC may help to decrease the stigma of KMC, improve overall acceptance and reduce the age at SSC initiation.

Background In the state of Bihar, India a multi-faceted quality improvement nurse-mentoring program was implemented to improve provider skills in normal and complicated deliveries. The objective of this analysis was to examine changes in diagnosis and management of postpartum hemorrhage (PPH) of the mother and intrapartum asphyxia of the infant in primary care facilities in Bihar, during the program. Methods During the program, mentor pairs visited each facility for one week, covering four facilities over a four-week period and returned for subsequent week-long visits once every month for seven to nine consecutive months. Between- and within-facility comparisons were made using a quasi-experimental and a longitudinal design over time, respectively, to measure change due to the intervention. The proportions of PPH and intrapartum asphyxia among all births as well as the proportions of PPH and intrapartum asphyxia cases that were effectively managed were examined. Zero-inflated negative binomial models and marginal structural methodology were used to assess change in diagnosis and management of complications after accounting for clustering of deliveries within facilities as well as time varying confounding. Results This analysis included 55,938 deliveries from 320 facilities. About 2% of all deliveries, were complicated with PPH and 3% with intrapartum asphyxia. Between-facility comparisons across phases demonstrated diagnosis was always higher in the final week of intervention (PPH: 2.5–5.4%, intrapartum asphyxia: 4.2–5.6%) relative to the first week (PPH: 1.2–2.1%, intrapartum asphyxia: 0.7–3.3%). Within-facility comparisons showed PPH diagnosis increased from week 1 through 5 (from 1.6% to 4.4%), after which it decreased through week 7 (3.1%). A similar trend was observed for intrapartum asphyxia. For both outcomes, the proportion of diagnosed cases where selected evidence-based practices were used for management either remained stable or increased over time. Conclusions The nurse-mentoring program appears to have built providers’ capacity to identify PPH and intrapartum asphyxia cases but diagnosis levels are still not on par with levels observed in Southeast Asia and globally.