The WHO Millennium Goals 4 and 5 aim to reduce infant mor-tality rates by two-thirds and maternal mormor-tality rates by 75%
by year 2015. Simulation will have a role in reaching these tar-gets if it is not solely confined to the developed world. Training should be universal. Many candidates reading this book, par-ticularly overseas candidates, will question the role of simula-tion training in obstetric emergencies. Even in busy units where emergencies such as eclampsia and shoulder dystocia are rel-atively more frequent, there is still an important role for sim-ulation-based training. A recent WHO review of intrapartum training in low- and middle-income countries 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 the 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 primar-ily based on models developed in high-income countries.93 Care must be taken to avoid inappropriate ‘square peg in a round hole’ introduction of non-localised courses from high-income settings.
Once again the published data are conflicting: the intro-duction of training with the Essential Newborn Care course based in six countries (Argentina, Democratic Republic of Congo, Guatemala, India, Pakistan and Zambia) showed significant reduction in rate of stillbirths following training (23 per 1000 pre vs 15.9 per 1000 post),94 whereas another study assessing the effect of training in improving outcomes done in a regional hospital in Tanzania showed that the intro-duction of ALSO training from the United States did not improve outcomes.62
Success of training programmes in low-resource set-tings depends on many factors such as appropriately skilled instructors, locally adapted training materials and time for training. More work is required to understand the specific requirements for, and local adaptation of training in, devel-oping world settings.
CONCLUSION
Reducing avoidable harm is a priority for midwives, women and families across the world. Simulation-based training for obstetric emergencies appears to offer a direct route to
improvement, but the effect of intrapartum training pro-grammes has been inconsistent, if not conflicting.
Significant progress has been made at establishing an evi-dence base for training in obstetric emergencies since the pub-lication of Black and Brocklehurst’s paper in 2003.28 However, those studies that demonstrate improvement in clinical out-comes are retrospective and only report neonatal outcome data, and there remains very little evidence for maternal out-comes. The next stage should be a well-designed RCT studying the effect of training on both maternal and neonatal outcomes across several hospitals while adjusting for baseline changes and temporal changes.
There is currently evidence of a positive impact of training on confidence, knowledge and skills, with emerg-ing evidence of improvements for at least some perinatal outcomes. Therefore, based on the current available evi-dence, training for obstetric emergencies should be local, multiprofessional, mandatory for all staff and ideally sup-ported by institutional incentives (most often insurance based) to train.
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KEY POINTS
● Poor team working, suboptimal communication and lack of proper training can lead to preventable maternal and perinatal harm.
● Simulation-based training is one of the most promising strategies and can potentially reduce these avoidable complications by 50–70%.6
● Simulation-based training for maternity staff should be both effective and sustainable.
● Training programmes associated with improvements in perinatal outcome were all conducted ‘in-house’, trained 100% of staff, reported the introduction of system changes suggested by their staff after participating in the training, and trained all staff together, incorporating teamwork principles into clinical training scenarios.76
● Training in low-resource settings may be different and local adaptation of training courses is crucial for locally sustainable training programmes.
Conclusion 45
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