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Effects of emergency obstetric care training on maternal and perinatal outcomes: a stepped wedge cluster randomised trial in South Africa.
BMJ Glob Health 2019; 4(6):e001670BG

Abstract

Introduction

Two-thirds of maternal deaths and 40% of intrapartum-related neonatal deaths are thought to be preventable through emergency obstetric and newborn care (EmOC&NC). The effectiveness of 'skills and drills' training of maternity staff in EmOC&NC was evaluated.

Methods

Implementation research using a stepped wedge cluster randomised trial including 127 of 129 healthcare facilities (HCFs) across the 11 districts in South Africa with the highest maternal mortality. The sequence in which all districts received EmOC&NC training was randomised but could not be blinded. The timing of training resulted in 10 districts providing data before and 10 providing data after EmOC&NC training. Primary outcome measures derived for HCFs are as follows: stillbirth rate (SBR), early neonatal death (ENND) rate, institutional maternal mortality ratio (iMMR) and direct obstetric case fatality rate (CFR), number of complications recognised and managed and CFR by complication.

Results

At baseline, median SBR (per 1000 births) and ENND rate (per 1000 live births) were 9 (IQR 0-28) and 0 (IQR 0-9). No significant changes following training in EmOC&NC were detected for any of the stated outcomes: SBR (adjusted incidence rate ratio (aIRR) 0.97, 95% CI 0.91 to 1.05), iMMR (aIRR 1.23, 95% CI 0.80 to 1.90), ENND rate (aIRR 1.04, 95% CI 0.92 to 1.17) and direct obstetric CFR (aIRR 1.15, 95% CI 0.66 to 2.02). The number of women who were recognised to need and received EmOC was significantly increased overall (aIRR 1.14, 95% CI 1.02 to 1.27), for haemorrhage (aIRR 1.31, 95% CI 1.13 to 1.52) and for postpartum sepsis (aIRR 1.86, 95% CI 1.17 to 2.95).

Conclusion

Following EmOC&NC training, healthcare providers are more able to recognise and manage complications at time of birth. This trial did not provide evidence that the intervention was effective in reducing adverse clinical outcomes, but demonstrates randomised evaluations are feasible in implementation research.

Trial registration number

ISRCTN11224105.

Authors+Show Affiliations

Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK.Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK.Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK.Department of Obstetrics & Gynaecology, University of Pretoria, Pretoria, South Africa.Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK.Institute of Applied Health Research, University of Birmingham, Birmingham, UK.Womens Health and HIV Reaserch unit, University of KwaZulu Natal, Durban, South Africa.MRC Maternal and Infant Health Care Strategies Unit, University of Pretoria, Pretoria, South Africa.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

31798985

Citation

van den Broek, Nynke, et al. "Effects of Emergency Obstetric Care Training On Maternal and Perinatal Outcomes: a Stepped Wedge Cluster Randomised Trial in South Africa." BMJ Global Health, vol. 4, no. 6, 2019, pp. e001670.
van den Broek N, Ameh C, Madaj B, et al. Effects of emergency obstetric care training on maternal and perinatal outcomes: a stepped wedge cluster randomised trial in South Africa. BMJ Glob Health. 2019;4(6):e001670.
van den Broek, N., Ameh, C., Madaj, B., Makin, J., White, S., Hemming, K., ... Pattinson, R. (2019). Effects of emergency obstetric care training on maternal and perinatal outcomes: a stepped wedge cluster randomised trial in South Africa. BMJ Global Health, 4(6), pp. e001670. doi:10.1136/bmjgh-2019-001670.
van den Broek N, et al. Effects of Emergency Obstetric Care Training On Maternal and Perinatal Outcomes: a Stepped Wedge Cluster Randomised Trial in South Africa. BMJ Glob Health. 2019;4(6):e001670. PubMed PMID: 31798985.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Effects of emergency obstetric care training on maternal and perinatal outcomes: a stepped wedge cluster randomised trial in South Africa. AU - van den Broek,Nynke, AU - Ameh,Charles, AU - Madaj,Barbara, AU - Makin,Jennifer, AU - White,Sarah, AU - Hemming,Karla, AU - Moodley,J, AU - Pattinson,Robert, Y1 - 2019/11/10/ PY - 2019/04/26/received PY - 2019/08/02/revised PY - 2019/08/10/accepted PY - 2019/12/5/entrez PY - 2019/12/5/pubmed PY - 2019/12/5/medline KW - health services research KW - health systems evaluation KW - maternal health KW - obstetrics SP - e001670 EP - e001670 JF - BMJ global health JO - BMJ Glob Health VL - 4 IS - 6 N2 - Introduction: Two-thirds of maternal deaths and 40% of intrapartum-related neonatal deaths are thought to be preventable through emergency obstetric and newborn care (EmOC&NC). The effectiveness of 'skills and drills' training of maternity staff in EmOC&NC was evaluated. Methods: Implementation research using a stepped wedge cluster randomised trial including 127 of 129 healthcare facilities (HCFs) across the 11 districts in South Africa with the highest maternal mortality. The sequence in which all districts received EmOC&NC training was randomised but could not be blinded. The timing of training resulted in 10 districts providing data before and 10 providing data after EmOC&NC training. Primary outcome measures derived for HCFs are as follows: stillbirth rate (SBR), early neonatal death (ENND) rate, institutional maternal mortality ratio (iMMR) and direct obstetric case fatality rate (CFR), number of complications recognised and managed and CFR by complication. Results: At baseline, median SBR (per 1000 births) and ENND rate (per 1000 live births) were 9 (IQR 0-28) and 0 (IQR 0-9). No significant changes following training in EmOC&NC were detected for any of the stated outcomes: SBR (adjusted incidence rate ratio (aIRR) 0.97, 95% CI 0.91 to 1.05), iMMR (aIRR 1.23, 95% CI 0.80 to 1.90), ENND rate (aIRR 1.04, 95% CI 0.92 to 1.17) and direct obstetric CFR (aIRR 1.15, 95% CI 0.66 to 2.02). The number of women who were recognised to need and received EmOC was significantly increased overall (aIRR 1.14, 95% CI 1.02 to 1.27), for haemorrhage (aIRR 1.31, 95% CI 1.13 to 1.52) and for postpartum sepsis (aIRR 1.86, 95% CI 1.17 to 2.95). Conclusion: Following EmOC&NC training, healthcare providers are more able to recognise and manage complications at time of birth. This trial did not provide evidence that the intervention was effective in reducing adverse clinical outcomes, but demonstrates randomised evaluations are feasible in implementation research. Trial registration number: ISRCTN11224105. SN - 2059-7908 UR - https://www.unboundmedicine.com/medline/citation/31798985/Effects_of_emergency_obstetric_care_training_on_maternal_and_perinatal_outcomes:_a_stepped_wedge_cluster_randomised_trial_in_South_Africa L2 - https://dx.doi.org/10.1136/bmjgh-2019-001670 DB - PRIME DP - Unbound Medicine ER -