Multi-professional simulation training on postpartum hemorrhage in Tanzania and Norway
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- PhD theses (SV-IH) 
Original versionMulti-professional simulation training on postpartum hemorrhage in Tanzania and Norway by Signe Egenberg, Stavanger : University of Stavanger, 2017 (PhD thesis UiS, no. 343)
There is a continuous drama going on worldwide, where women are fighting for their lives on the battlefield of childbirth. Every day, 830 mothers are dying during pregnancy and childbirth, or 300 000 mothers annually (WHO, 2016). Out of these deaths, 99% occur in low-resource countries (WHO, 2015b). Of the 830 deaths daily, 250 are dying because of postpartum hemorrhage (PPH) (Afnan-Holmes et al., 2015). For every mother dying, another 20-30 women are suffering from complications causing long-lasting sequelae (UNFPA, 2016). According to WHO, most of the maternal deaths are preventable (WHO, 2015b). There is an inequity regarding access to skilled birth attendance, due to the fact that 78% of the world’s total births have access to less than 42% of the world’s midwives, nurses and doctors (UNFPA, 2014). Two thirds of the mothers who are developing PPH, have no known risk factors. Active management of third stage of labor is expected to contribute to reduced maternal mortality (POPPHI, 2007), including an intramuscular injection of oxytocin 10 international units after the birth of the newborn (Gulmezoglu et al., 2012). However, birth attendants have to be alert and able to identify and treat PPH accordingly. Most studies on clinical outcomes after PPH-training have used estimated blood loss after birth as outcome measure (Shoushtarian, Barnett, McMahon, & Ferris, 2014; Sorensen et al., 2011; Spitzer et al., 2014). Visual estimation is known to be inaccurate and an unreliable measurement, with a tendency of underestimation (Al-Kadri et al., 2014; Bose, Regan, & Paterson-Brown, 2006; Hancock, Weeks, & Lavender, 2015). Different courses have been established in low- and high-resource countries to prepare midwives, nurses and doctors for obstetric emergencies like PPH (Bergh, Baloyi, & Pattinson, 2015; Dao, 2012; Dresang et al., 2015; Evans et al., 2014; Spitzer et al., 2014; The PROMPT Maternity Foundation, 2008). Obstetrical health care is considered a complex system, and an intervention must pay attention to the constantly changing interconnections and relationships (Dekker, Bergström, Amer-Wåhlin, & Cilliers, 2013; van Schaik, Plant, & O'Brien, 2015). Simulation training on PPH was associated with increased confidence level compared to traditional lectures (Andrighetti, Knestrick, Marowitz, Martin, & Engstrom, 2012; Birch et al., 2007). The participants’ previous clinical experiences together with their acquired experiences from simulation training, are likely to influence their self-efficacy, understood as judgment of own exercise of control, and collective efficacy, being the belief in the capability to solve a problem through unified efforts. Perceived efficacy beliefs are important for future performance (Bandura, 1997). Educational interventions have resulted in improved perinatal outcomes (Draycott et al., 2006; Mduma et al., 2015; Spitzer et al., 2014). Literature searches did not identify any educational intervention that led to significant reduction in blood transfusion rates after birth, as an indirect marker for reduced blood loss (Dumont et al., 2013; Sorensen et al., 2011). No follow- up studies were identified exploring the informants’ experiences after participation in an educational intervention on PPH-management. It seemed feasible and timely to investigate whether an educational intervention emphasizing teamwork and reflective practice, could contribute to new knowledge and understanding of crucial learning features and learning outcomes for improved PPH-management and maternal health. The implementation of multi-professional training on PPH-management was carried out in Tanzania and Norway, organized by the local management, faculty and research team. All cadres were involved in the training, which included realistic and relevant PPH-scenarios. The scenarios were followed by debriefing sessions to optimize reflective learning. By combining pedagogical and obstetrical academic traditions with midwifery practice emphasizing the promotion of normal birth, the overall aim was to investigate the effects of this educational intervention. We hypothesized that simulation training would contribute to increased efficacy beliefs and reduction in blood transfusion rate after birth. The investigation included assessment of how this simulation training may influence individual and collective efficacy beliefs. Another aim was to exploreparticipants’ experiences related to learning features and learning outcomes ofthe training in multi-professional teams. An issue discussed throughout the project, was how to measure outcomes from the educational intervention related to maternal health, with valid inference of the findings. Finally, blood transfusion rate as dependent variable was chosen as an indirect measurement of blood loss after birth. Mixed methods design was chosen to investigate staff’s experiences, efficacy beliefs and patient outcomes at four study sites: Stavanger University Hospital, University Hospital of North Norway, Kilimanjaro Christian Medical Centre(KCMC) and Mawenzi Hospital, both Tanzania.
PhD thesis in Health, medicine and welfare
Has partsEgenberg S, Øian P, Bru LE, Sautter M, Kristoffersen G, Eggebø TM. Can inter-professional simulation training influence the frequency of blood transfusions after birth? Acta Obstet Gynecol Scand 2015 Mar; 94(3):316-23.
Egenberg S, Øian P, Eggebø TM, Arsenovic MG, Bru LE. Changes in self-efficacy, collective efficacy, and patient outcome following inter- professional simulation training on postpartum haemorrhage. Journal of Clinical Nursing 2016 Nov 22.
Egenberg S, Masenga G, Bru LE, Eggebø TM, Mushi C, Massay D, Øian P. Impact of multi-professional, scenario-based training on postpartum hemorrhage in Tanzania: a quasi-experimental, pre- vs. post-intervention study. Submitted BMC Pregnancy and Childbirth June 2016
Egenberg, S., Karlsen, B., Massay, D., Kimaro, H., & Bru, L. E. (2017). “No patient should die of PPH just for the lack of training!” Experiences from multi-professional simulation training on postpartum hemorrhage in northern Tanzania: a qualitative study. BMC Medical Education, 17(1), 119. doi:10.1186/s12909-017-0957-5