Background: Few evidence-based interventions exist on how to improve respectful maternity care (RMC) in low-resource settings. We sought to evaluate the effect of an integrated simulation-based training on provision of RMC. Methods: The pilot project was in East Mamprusi District in northern Ghana. We integrated specific components of RMC, emphasizing dignity and respect, communication and autonomy, and supportive care, into a simulation training to improve identification and management of obstetric and neonatal emergencies. Forty-three providers were trained. For evaluation, we conducted surveys at baseline (N = 215) and endline (N = 318) 6 months later, with recently delivered women to assess their experiences of care using the person-centered maternity care scale. Higher scores on the scale represent more respectful care. Results: Compared to the baseline, women in the endline reported more respectful care. The average person-centered maternity care score increased from 50 at baseline to 72 at endline, a relative increase of 43%. Scores on the subscales also increased between baseline and endline: 15% increase for dignity and respect, 87% increase for communication and autonomy, and 55% increase for supportive care. These differences remained significant in multivariate analysis controlling for several potential confounders. Conclusions:The findings suggest that integrated provider trainings that give providers the opportunity to learn, practice, and reflect on their provision of RMC in the context of stressful emergency obstetric simulations have the potential to improve women's childbirth experiences in low-resource settings. Incorporating such trainings into preservice and in-service training of providers will help advance global efforts to promote RMC. K E Y W O R D SGhana, mistreatment, person-centered maternity care, quality of care, respectful maternity care, simulation training 524 | AFULANI et AL.

BackgroundIneffective management of obstetric emergencies contributes significantly to maternal and neonatal morbidity and mortality in Mexico. PRONTO (Programa de Rescate Obstétrico y Neonatal: Tratamiento Óptimo y Oportuno) is a highly-realistic, low-tech simulation-based obstetric and neonatal emergency training program. A pair-matched hospital-based controlled implementation trial was undertaken in three states in Mexico, with pre/post measurement of process indicators at intervention hospitals. This report assesses the impact of PRONTO simulation training on process indicators from the pre/post study design for process indicators.MethodsData was collected in twelve intervention facilities on process indicators, including pre/post changes in knowledge and self-efficacy of obstetric emergencies and neonatal resuscitation, achievement of strategic planning goals established during training and changes in teamwork scores. Authors performed a longitudinal fixed-effects linear regression model to estimate changes in knowledge and self-efficacy and logistic regression to assess goal achievement.ResultsA total of 450 professionals in interprofessional teams were trained. Significant increases in knowledge and self-efficacy were noted for both physicians and nurses (p <0.001- 0.009) in all domains. Teamwork scores improved and were maintained over a three month period. A mean of 58.8% strategic planning goals per team in each hospital were achieved. There was no association between high goal achievement and knowledge, self-efficacy, proportion of doctors or nurses in training, state, or teamwork score.ConclusionsThese results suggest that PRONTO’s highly realistic, locally appropriate simulation and team training in maternal and neonatal emergency care may be a promising avenue for optimizing emergency response and improving quality of facility-based obstetric and neonatal care in resource-limited settings.Trial registrationNCT01477554

PRONTO brings simulation training to low-resource settings and can empower interprofessional teams to respond more effectively within their institutional limitations to emergencies involving women and newborns. Further study is warranted to evaluate the potential impact of the program on obstetric and neonatal outcome.

BackgroundDespite expanding access to institutional birth in Guatemala, maternal mortality remains largely unchanged over the last ten years. Enhancing the quality of emergency obstetric and neonatal care is one important strategy to decrease mortality. An innovative, low-tech, simulation-based team training program (PRONTO) aims to optimize care provided during obstetric and neonatal emergencies in low-resource settings.MethodsWe conducted PRONTO simulation training between July 2012 and December 2012 in 15 clinics in Alta Verapaz, Huehuetenango, San Marcos, and Quiche, Guatemala. These clinics received PRONTO as part of a larger pair-matched cluster randomized trial of a comprehensive intervention package. Training participants were obstetric and neonatal care providers that completed pre- and post- training assessments for the two PRONTO training modules, which evaluated knowledge of evidence-based practice and self-efficacy in obstetric and neonatal topics. Part of the training included a session for trained teams to establish strategic goals to improve clinical practice. We utilized a pre/post-test design to evaluate the impact of the course on both knowledge and self-efficacy with longitudinal fixed effects linear regression with robust standard errors. Pearson correlation coefficients were used to assess the correlation between knowledge and self-efficacy. Poisson regression was used to assess the association between the number of goals achieved and knowledge, self-efficacy, and identified facility-level factors.ResultsKnowledge and self-efficacy scores improved significantly in all areas of teaching. Scores were correlated for all topics overall at training completion. More than 60 % of goals set to improve clinic functioning and emergency care were achieved. No predictors of goal achievement were identified.ConclusionsPRONTO training is effective at improving provider knowledge and self-efficacy in training areas. Further research is needed to evaluate the impact of the training on provider use of evidence-based practices and on maternal and neonatal health outcomes.Trial registrationNCT01653626

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.

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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.

BackgroundIn Mexico, although the majority of births are attended in hospitals, reports have emerged of obstetric violence, use of unsafe practices, and failure to employ evidence-based practices (EBP). Recent attention has refocused global efforts towards provision of quality care that is both patient-centered and evidence-based. Scaling up of local interventions should rely on strong evidence of effectiveness.ObjectiveTo perform a secondary analysis to evaluate the impact of a simulation and team-training program (PRONTO) on the performance of EBP in normal births.MethodsA pair-matched cluster randomized controlled trial of the intervention was designed to measure the impact of the program (PRONTO intervention) on a sample of 24 hospitals (12 hospitals received the PRONTO training and 12 served as controls) in the states of Chiapas, Guerrero, and Mexico. We estimated the impact of receiving the intervention on the probability of birth practices performance in a sample of 641 observed births of which 318 occurred in the treated hospitals and 323 occurred in control hospitals. Data was collected at 4 time points (baseline, 4th, 8th and 12th months after the training). Women were blinded to treatment allocation but observers and providers were not. Estimates were obtained by fitting difference-in-differences logistic regression models considering confounding variables. The trial is registered at clinicaltrials.gov: # NCT01477554.ResultsSignificant changes were found following the intervention. At 4 months post-intervention an increase of 20 percentage points (p.p.) for complete Active Management of Third Stage of Labor (AMTSL) (p = 0.044), and 16 p.p. increase for Skin-to-Skin Contact (p = 0.067); at 12 months a 25 p.p. increase of the 1st step of AMTSL (p = 0.026) and a 42 p.p. increase of Delayed Cord Clamping (p = 0.004); at 4 months a 30 (p = 0.001) and at 8 months a 22 (p = 0.010) p.p. decrease for Uterine Sweeping.ConclusionsThe intervention has an impact on adopting EBP at birth, contributing to an increased quality of care. Long lasting impacts on these practices are possible if there were to be a widespread adoption of the training techniques including simulation, team-training and facilitated discussions regarding routine care.