Can a simulation-based training program impact the use of evidence based routine practices at birth? Results of a hospital-based cluster randomized trial in Mexico

PLOS ONE, Dec 2019

Background In 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. Objective To perform a secondary analysis to evaluate the impact of a simulation and team-training program (PRONTO) on the performance of EBP in normal births. Methods A 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. Results Significant 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. Conclusions The 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.

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Can a simulation-based training program impact the use of evidence based routine practices at birth? Results of a hospital-based cluster randomized trial in Mexico

March Can a simulation-based training program impact the use of evidence based routine practices at birth? Results of a hospital-based cluster randomized trial in Mexico Jimena Fritz 0 1 Dilys M. Walker 0 Susanna Cohen 0 Gustavo Angeles 0 Hector Lamadrid- Figueroa 0 1 0 Editor: Jacobus P. van Wouwe, TNO , NETHERLANDS 1 Division of Reproductive Health, Research Center for Population Health, National Institute of Public Health (INSP) , Cuernavaca, Morelos , MeÀ‚ xico, 2 Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California in San Francisco , (UCSF), San Francisco , California, United States of America, 3 College of Nursing, University of Utah, Salt Lake City, Utah, United States of America, 4 Department of Maternal and Child Health, University of North Carolina at Chapel Hill (UNC) , Chapel Hill, North Carolina , United States of America - Data Availability Statement: All relevant data are included within the paper and its Supporting Information files. Funding: The main funder for this project was the Mexican National Institute for Women (INMUJERES), www.inmujeres.gob.mx, under agreement number 274, with additional funding from the Bill and Melinda Gates Foundation. DW received the funding. The funders had no role in Background Objective Methods A pair-matched cluster randomized controlled trial of the intervention was designed to mea sure 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 proba bility 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. study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: Dilys Walker and Susanna Cohen are on the Board of Directors of PRONTO International, a recently formed NGO that offers PRONTO trainings. This does not alter our adherence to PLOS ONE policies on sharing data and materials. The other authors have no disclosure of interests to report. Results Significant 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. Conclusions The 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. Introduction Reducing maternal and neonatal mortality (MM and NM) have been global priorities for over two decades.[ 1,2 ] Considerable effort has focused on enhancing infrastructure, training of birth attendants, and improving emergency obstetric care in limited-resource settings.[ 1,2 ] In Mexico, the 2013 MM ratio Global Burden of Disease estimate was 54 deaths per 100,000 live births [ 3 ] with the majority of deaths due to obstetric emergencies, namely postpartum hemorrhage, preeclampsia and sepsis.[ 4 ] Mexico, has focused on increasing the access to facility-based birth attended by skilled professionals.[ 5 ] Although, 99.6% of births in Mexico were attended by skilled providers in hospitals,[ 6 ] 80% of maternal deaths took place inside a medical facility and 87% of the women who died received facility-based attention before their death.[ 4 ] For NM, increased efforts have resulted in a decreased rate of 7.2 per 1,000 live births, a figure that is still high compared to high-income countries.[ 7 ] Global efforts have refocused towards the provision of patient-centered and evidence-based quality care, thus acknowledging that a good share of morbidity and mortality are linked to the mis-management of normal physiologic births and not only to the response to emergencies.[ 1,2,5,8 ] Renfrew and colleagues conducted a systematic review to categorize obstetric and neonatal practices by the level of evidence regarding benefit and/or harm.[1] They devised a framework for quality mater (...truncated)


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Jimena Fritz, Dilys M. Walker, Susanna Cohen, Gustavo Angeles, Hector Lamadrid-Figueroa. Can a simulation-based training program impact the use of evidence based routine practices at birth? Results of a hospital-based cluster randomized trial in Mexico, PLOS ONE, 2017, Volume 12, Issue 3, DOI: 10.1371/journal.pone.0172623