Practical simulation training for maternity care—where we are and where next
Dr JF Crofts, School of Clinical Sciences, University of Bristol, Bristol, BS10 5NB, UK. Email email@example.com
Please cite this paper as: Crofts J, Winter C, Sowter M. Practical simulation training for maternity care—where we are and where next. BJOG 2011; 118 (Suppl. 3): 11–16.
Improving maternal and perinatal care is a global priority. Practical simulation training for maternity care might prevent many of these deaths. There have been numerous evaluation studies published on the effectiveness of simulation training for obstetric emergencies, with increasing evidence that it is associated with improvement in clinical outcomes. Evidence has begun to move from subjective assessment of participants’ experiences towards objective assessment of clinical outcomes. However, the results are not entirely consistent and, at present, all of the evidence associating training with improvements in clinical outcomes relates to neonatal outcomes. This review summarises recent progress in the evaluation of the effectiveness of simulation training for maternity care in both high- and low-resource settings, and presents a vision for ensuring that practical simulation training for maternity care can become an effective tool to reduce global maternal and perinatal morbidity and mortality.
Improving maternal and perinatal care is a global priority. The World Health Organization (WHO)1 has estimated that 1000 women die every day from preventable complications of pregnancy and childbirth. Worldwide, there are approximately four million neonatal deaths each year and a similar number of stillbirths.2 Practical simulation training for maternity care might prevent many of these deaths.
Simulation training in obstetrics is not new. In 1748, Madame du Coudray, the King of France’s midwife, developed a life-size mannequin from leather and bone to teach the management of childbirth.3 She trained local doctors who, in turn, trained local women. In this way, du Coudray disseminated practical training, enabling hundreds of women in France to experience safer childbirth.3 Over 250 years later, there appeared to have been little progress; a systematic review of obstetric emergencies training published in 2003 concluded that few methods of training had been evaluated, and there was minimal evidence of their effectiveness.4
This review summarises the 8 years of progress since 2003 and presents a vision for ensuring that practical simulation training for maternity care can become an effective tool to reduce global maternal and perinatal morbidity and mortality.
Evidence for effectiveness
Numerous studies have evaluated the effectiveness of practical simulation training for obstetric emergencies, with increasing evidence that practical training is associated with improvements in clinical outcomes.5–9 The results are not entirely consistent, however. Emerging evidence for training for individual emergencies is presented below.
One of the first published descriptions of obstetric simulation was an eclampsia drill.10 The simulation of eclampsia enabled departmental staff to develop and trial an eclampsia box containing the equipment, drugs and guidelines required to manage this rare emergency. A randomised controlled trial comparing the effectiveness of multiprofessional training for eclampsia in local hospitals with training in a regional simulation centre showed marked improvement in all aspects of care after training.11 Training at local sites involved patient-actors, whereas a high-fidelity, full-body simulator was used at the simulation centre; 140 midwives and obstetricians were randomly allocated to local or simulation centre training. Following training, there were significant improvements in the completion of basic tasks (87%, 100%) and in the administration of magnesium sulphate (61%, 92%) in simulated eclampsia. The time taken to commence the administration of magnesium was, on average, nearly 2 minutes quicker following training. There were equal improvements in both settings; it was the training itself, rather than the location or the simulation equipment used, that appeared to be the key to success.11
Shoulder dystocia is an unpredictable and therefore unpreventable emergency. A large, multisite, randomised controlled trial demonstrated that the management of shoulder dystocia before training was often poor, with only 43% of staff able to successfully manage severe shoulder dystocia.12 Following a 40-minute practical training session undertaken in multiprofessional teams, there was a significant improvement in the proportion of participants who successfully achieved simulated delivery (43% pre- and 83% post-training). This improvement was largely sustained at 6 months (84%) and 12 months (85%) after training. Training on a high-fidelity mannequin (which included force-perception teaching) offered additional benefit when compared with training on standard equipment; after training, there was a higher successful delivery rate (72%, 94%) and, on average, the deliveries were completed more quickly with a lower total force applied. Deering et al.13 and Goffman et al.14separately demonstrated improved performance of advanced shoulder dystocia manoeuvres following simulation training. Deering et al.13 found that obstetric trainees who had undergone simulation training scored better for the timeliness of both completion of manoeuvres and delivery compared with those who had received conventional training.
Of greater importance is the effect of shoulder dystocia training on clinical outcomes. A retrospective review over an 8-year period compared birth outcomes for shoulder dystocia before and after the introduction of a local training programme in one UK hospital using a prototype PROMPT Birthing Trainer® (Limbs and Things Ltd, Bristol, UK).7 Following the introduction of training, there was a significant increase in the use of appropriate management manoeuvres, with at least one appropriate manoeuvre used in 90% of cases after training, compared with <50% before. Moreover, the use of excessive traction fell from 54% to 24%. In conjunction with the improvements in clinical management, there was an associated improvement in clinical outcomes. Obstetric brachial plexus injury (OBPI) and/or bony fracture in cases of shoulder dystocia fell from 9.3% before training to 2.3% afterwards.7 Similar improvements in neonatal outcomes have also been demonstrated after the introduction of annual multiprofessional simulation training for all staff in an American hospital. The OBPI rate after shoulder dystocia decreased from 30% before training to 10.7% after training.15 Not all training has been found to be effective; introduction into another UK hospital was associated with a higher rate of OBPI.16 This suggests that not all training is equal in effect.
Postpartum haemorrhage (PPH) contributes to 140 000 deaths worldwide.17 Deering et al.18 studied the simulation of PPH secondary to uterine atony with 40 obstetric trainees. Only 45% controlled the haemorrhage within 5 minutes, and 48% made medication errors. Birch et al.19 compared lecture-based training with simulated drills in the management of PPH. All participants showed increased knowledge following training, but those who had undergone simulation training also improved teamworking skills when compared with those who had only lectures.19 Maslovitz et al.20 demonstrated that simulation training for PPH enabled the identification of common errors which allowed targeted teaching and training. This training was associated with an improvement in management, which was still evident 6 months later.20 The common errors identified were a lack of knowledge of medication, delay in transfer to theatre and underestimation of blood loss.
Vaginal breech delivery
Following publication of the Term Breech Trial,21 planned vaginal breech birth has become rarer, but competence in assisted vaginal breech delivery remains an essential skill. Practical simulation provides an opportunity for staff to practise management. A significant improvement in residents’ ability to perform simulated breech deliveries following training on a birth simulator with a patient-actor has been observed.22
Maternal cardiac arrest
A recent retrospective cohort study investigated the use of peri-mortem caesarean section (PMCS) in the Netherlands between 1993 and 2008 following the introduction of Managing Obstetric Emergencies and Trauma (MOET) obstetric training in 2004. The rate of PMCS increased after the introduction of training from 12% to 35%.23 Despite this increase in the use of PMCS, maternal outcomes remained poor, most probably as a result of the delay in performing the procedure; no case of PMCS was carried out within 5 minutes of the cardiac arrest.23
A retrospective cohort study assessed the effect of training on the management of cord prolapse in a UK maternity unit.24 Staff attended in-house, multiprofessional training with a simulated cord prolapse drill. Following the introduction of training, there was a significant reduction in the diagnosis-to-delivery interval from 25 to 14.5 minutes, and a reduction in admissions to the neonatal intensive care unit (NICU) from 39% to 22%.24
The appropriate and safe use of forceps and vacuum instruments to assist vaginal birth is an essential obstetric skill.25 Dupuis et al.26 developed a high-fidelity model that allows the trajectory of the application of forceps blades to be tracked using spatial sensors. Senior obstetricians demonstrated a superior technique but, after training, the abilities of junior staff improved.26 Other models have been developed to train medical trainees in appropriate traction. After practical training, both the correct forces and successful delivery were achieved more often in simulated instrumental births.27,28
A systematic review concluded that perinatal mortality might be reduced if birth attendants received practical neonatal resuscitation training,29 but the evidence of effectiveness was not strong. More recent studies have evaluated the effect of the WHO Essential Newborn Care course, a neonatal rather than obstetric training course. One study using a before-and-after implementation design showed that training staff on the course was associated with improvements in midwives’ skills and knowledge.30 There was also a reduction in early neonatal deaths among low-risk women who delivered in first-level clinics in Zambia.31 A cluster randomised controlled trial to assess this neonatal resuscitation intervention did not concur with these initial findings, however.9 Following the introduction of the 3-day Essential Newborn Care course in six countries (Argentina, Democratic Republic of Congo, Guatemala, India, Pakistan and Zambia), there was no significant reduction in the rate of early neonatal deaths or in the rate of perinatal death. Interestingly, there was a significant reduction in the rate of stillbirth (relative risk with training, 0.69). It is plausible that the observed reduction in stillbirths might have been the result of training; before training, infants born without obvious signs of life may have been misidentified as stillbirths. After training, resuscitation was more likely to be attempted, with a consequential reduction in births classified as stillbirths. The decrease in fresh stillbirths, but not in macerated stillbirths, after the introduction of the Essential Newborn Care training programme supports this hypothesis.9
Promising preliminary observations of the effect of the Helping Babies Breathe programme have been presented recently.32 This is an educational training programme for low-resource countries that aims to improve neonatal resuscitation using basic simulation scenarios. Preliminary analysis of 13 575 births in Tanzania revealed a significant decrease in early neonatal mortality from 13.4 to 6.3 deaths per 1000 live births after the implementation of training.32
Common themes of effectiveness
A review of training programmes associated with improvements in clinical outcomes was published in 2009.33 Common features of clinically effective training programmes were as follows:
- • Multiprofessional training.
- • Training of all staff in an institution.
- • Training staff locally within the unit in which they work.
- • Integrating teamwork training with clinical teaching.
- • Use of high-fidelity simulation models.
- • Institution-level incentives for training (e.g. reduced hospital insurance premiums).
- • Use of self-assessment to direct infrastructural changes.
A vision for the future
Testing the effectiveness of training
There has been significant progress in the evaluation of simulation training for maternity care over the last 8 years. Evidence has begun to move from the subjective assessment of participants’ experiences towards the objective assessment of clinical outcomes. However, at present, all of the evidence associating training with improvements in clinical outcomes relates to neonatal outcomes. There are no studies that objectively demonstrate improvements in maternal morbidity or mortality. Clearly, more research is required to investigate the clinical effectiveness of simulation training on maternal outcome.
Quality improvement programmes, including training interventions, have been more successful in some organisations than in others.34 This variation might be a consequence of local contextual factors: differences in organisational preconditions, readiness at programme onset, interpretation of the intervention and local implementation strategies. A recent review of the Matching-Michigan central venous line project identified six key elements through which the project achieved its effects.35 These might be equally relevant to simulation training programmes.
Training for more complex conditions
There have been significant changes in the causality of direct maternal deaths in the UK.36 Sepsis is now the leading cause of direct maternal death. Severe maternal sepsis is a rare obstetric emergency and, at present, there are no published data on its simulation. With the development of novel, whole-body, computer-controlled mannequins, there is the opportunity for the simulation of more complex clinical conditions, such as severe sepsis. Simulation may be a training tool that can be used to increase the awareness of the presentation and clinical management of sepsis, as well as of other complex clinical situations.
In parallel with the increased uptake and evaluation of practical training for maternity care, there has been an increase in the number of mannequins and practical aids available for training. In their 2008 review, Gardner & Raemer37 compared 20 commercial maternity training aids manufactured by eight different companies. These training aids ranged from low-cost, simple pelvis, to expensive, whole-body simulators. At present, some aids remain research tools and are yet to be commercialised, whereas others are being brought to market by large medical mannequin companies.
Training equipment, however, is often expensive and can be difficult to transport and use. In 2009, an Evidence-for-Action call to reduce intrapartum related deaths was published.38 This article suggested that ‘significantly lower cost, durable, easy to disassemble and sanitise, high-fidelity mannequins with culturally appropriate features’ were required to reduce intrapartum related deaths in low-resource settings.38 Two recent developments in maternity care training are NeoNatalie 39 and MamaNatalie (Laerdal Medical, Stavanger, Norway).40 MamaNatalie is a birthing simulator that can be strapped onto an instructor, who manually controls the birth of the baby, uterine firmness, and volume and rate of blood loss post-delivery.40 The simulator can be used to train for normal and instrumental deliveries, and PPH. As yet, there are no published studies on the clinical effectiveness of training using MamaNatalie.
NeoNatalie, a low-cost neonatal simulator, was developed to help train birth attendants in developing countries in neonatal resuscitation courses, such as the Helping Babies Breathe programme.41 Preliminary data suggest that training using NeoNatalie within the above programme is associated with a reduction in early neonatal deaths.32 A Global Public–Private Alliance has been formed to ensure that the Helping Babies Breathe Campaign can be effectively disseminated around the world. Furthermore, Laerdal has pledged that the NeoNatalie Newborn Simulator will be available to low-resource countries on a not-for-profit basis until 2015.
Building on the success of the Helping Babies Breathe initiative, a new company, Laerdal Global Health,42 was established in 2010 to help developing countries reduce significantly infant, child and maternal mortality. The aim of this new company is to introduce 10–15 innovative products over the next 3–5 years focused on the needs of the mother and baby on the day of birth in low-resource settings. They plan to develop products that are culturally adapted, affordable, simple and durable.42
Training in low-resource settings
A recent review of training used to improve neonatal and child outcomes in low- and middle-income countries, published by WHO, concluded that:
Where in-service training can be provided at a low cost, it may be worthwhile to do so, given that some improvements in care process can be expected. However, in general, such training may be associated with high cost and therefore for most settings it is difficult to justify the conduct of routine in-service neonatal and paediatric training courses primarily based on models developed in high-income countries.43
Although this review did not evaluate the effectiveness of training programmes for maternity care per se, as obstetricians, midwives, anaesthetists and neonatologists we should heed the authors’ recommendations. The authors propose that the success of in-service training of health-care professionals depends on a number of factors, but two are especially important: appropriately skilled instructors in sufficient numbers and suitable, locally adapted training materials.
Many courses have been developed that include simulations of obstetric emergencies to train staff in low-resource settings. Examples include the Pacific Emergency Obstetric Course (http://www.psrh.org.nz), the Life Saving Skills Course (http://www.rcog.org.uk/international) and the Practical Obstetric Multi-Professional Training (PROMPT) course (http://www.prompt-course.org). Challenges, in addition to those outlined above, include the wide variation in local settings, practices and staffing, as well as under-resourced health services that are often overwhelmed. Care must be taken to ensure that areas with the highest maternal and neonatal mortality and, perhaps, with the most need for training are given appropriate support to develop and evaluate sustainable, clinically effective training programmes.
Significant progress has been made over the last 8 years in the availability, and evidence supporting the use, of practical simulation training for maternity care. New training courses have been planned, implemented and evaluated, and new training equipment has been developed. There is an increasing global effort to ensure that training reaches all those in need, not just those with sufficient financial resource. We must ensure that training, in whatever setting, is both clinically and cost-effective, and sustainable. Simply exporting maternity training courses that have been effective in one setting might not achieve the same improvements in morbidity and mortality in others. There is a need for continued research to measure the effect of training on clinical outcomes in a wide variety of clinical settings to establish what works, where and why. Future work must also study the implementation and sustainability of training programmes, evaluating the costs of, and human resources needed for, the conduct of training for maternity care in both low- and high-income settings.
Recent research has highlighted the potential of practical simulation for maternity care to improve outcomes for mothers and their babies. We must ensure that there is continued development, evaluation and dissemination of clinically effective training equipment and courses to ensure that maternity staff, in all clinical settings, have the necessary skills required to prevent unnecessary maternal and neonatal morbidity and mortality.
Disclosure of interests
JFC is a member of the PROMPT Maternity Foundation, a UK-based charity which runs obstetric emergencies training courses in many countries. She has no financial interest from this association. CW is also a member of the PROMPT Maternity Foundation and works 2 days per week for the charity. MCS is a local organiser for PROMPT courses in New Zealand. He has no financial gain from this association. None of the authors own stock, or hold stock options, in any obstetric emergency training company.
Contribution to authorship
JFC conducted a literature search. JFC, CW and MCS co-authored and revised the text.
Details of ethics approval
Not applicable for this review.
JFC’s salary is funded by the National Institute for Healthcare Research. JFC has received a research and development grant from the Laerdal Foundation. CW’s salary is partly funded by the PROMPT Maternity Foundation.
Reviewed by Robert Fox, Consultant Obstetrician, Taunton & Somerset NHS Trust, UK and Tim Draycott, Consultant Obstetrician, North Bristol Trust, UK.