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.
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.
Division of Reproductive Health, Research Center for Population Health, National Institute of Public Health (INSP), Cuernavaca, Morelos, México.
Jimena
J
Fritz
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.
Dilys M
DM
Walker
College of Nursing, University of Utah, Salt Lake City, Utah, United States of America.
Susanna
S
Cohen
Department of Maternal and Child Health, University of North Carolina at Chapel Hill (UNC), Chapel Hill, North Carolina, United States of America.
Gustavo
G
Angeles
Division of Reproductive Health, Research Center for Population Health, National Institute of Public Health (INSP), Cuernavaca, Morelos, México.
Hector
H
Lamadrid-Figueroa
D001339:Autonomic Fibers, Preganglionic; D036861:Delivery, Obstetric / Q000193:education*; D004632:Emergency Medical Services; D055317:Evidence-Based Practice; D006282:Health Personnel / Q000193:education; D006761:Hospitals; D006801:Humans; D015931:Intensive Care, Neonatal; D008800:Mexico; D010348:Patient Care Team; D058996:Quality Improvement