Peer-assisted learning after onsite, low-dose, high-frequency training and practice on simulators to prevent and treat postpartum hemorrhage and neonatal asphyxia: A pragmatic trial in 12 districts in Uganda

Abstract

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.

Simulation-based low-dose, high-frequency plus mobile mentoring versus traditional group-based trainings among health workers in Nigeria; a cluster randomized controlled trial

“…Similar studies done in Ghana and Uganda (7,8) showed promising results with the onsite simulationbased low-dose, high-frequency (LDHF) plus mobile (m)-mentoring training approach. In these studies health workers competencies were better with the LDHF+mMentoring approach compared with the TRAD approach although limited skills were assessed such as newborn resuscitation and postpartum haemorrhage (PPH).…”

“…The acquisition and retention of BEmONC skills was different at 12 months with the LDHF/m-mentoring arm demonstrating better performance than the TRAD arm. This study contributes to the much needed evidence base for LDHF/m-mentoring training approach in LMICs, adding on the finding of related studies done in Uganda [7] and Ghana [8]. As part of the intervention package, LDHF/m-mentoring study arm participants received weekly SMS reminders and quizzes along with continuous skills practice on anatomical models, which helped, reinforce knowledge on specific clinical areas over time.…”

“…Studies on BEmONC in-service training have demonstrated the value of simulation and continuous practice in improving knowledge and skills competency [2,7,8]. This has led to adaptation of various approaches to determine which ones led to the greatest returns on investment [3--10].…”

“…Health workers in Nigeria are usually trained using traditional lecture-based, offsite approach in which a limited number of persons from any health facility can be trained at one time. This approach to training is known to be expensive [7][8][9][10]. Maternal and newborn health outcomes have remained suboptimal despite continuous training of health workers [8].…”

Factors Related to the Practice of Vacuum-Assisted Birth: Findings from Provider Interviews in Kigoma, Tanzania

“…One training modality that has been reported to signi cantly in uence the uptake and performance of other maternal and neonatal life-saving procedures is the use of low-dose high-frequency skills-building sessions. Studies in Ghana, Tanzania and Uganda reported improved knowledge and skills of providers and better maternal and perinatal outcomes when providers were trained through simulation, case-based learning and small content packages spread over short time intervals (25)(26)(27)(28).…”