Making It Happen: Training health-care providers in emergency obstetric and newborn care

Keywords: pregnancy complications newborn emergency care in-service training health-care providers An estimated 289,000 maternal deaths, 2.6 million stillbirths and 2.4 million newborn deaths occur globally each year, with the majority occurring around the time of childbirth. The medical and surgical interventions to prevent this loss of life are known, and most maternal and newborn deaths are in principle preventable. There is a need to build the capacity of health-care providers to recognize and manage complications during pregnancy, childbirth and the post-partum period. Skills-and-drills competency-based training in skilled birth attendance, emergency obstetric care and early newborn care (EmONC) is an approach that is successful in improving knowledge and skills. There is emerging evidence of this resulting in improved availability and quality of care. To evaluate the effectiveness of EmONC training, operational research using an adapted Kirkpatrick framework and a theory of change approach is needed. The Making It Happen programme is an example of this. © 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). Introduction An estimated 289,000 maternal deaths occurred worldwide in 2013, most of which were in subSaharan Africa (SSA) (62%) and southern Asia (24%) An estimated 75% of neonatal deaths occur in the first week of life, and the greatest risk of death is in the first day of life World leaders gathered at the United Nations (UN) headquarters in New York in September 2000 to make major commitments by agreeing upon goals and to set targets to reduce world poverty, eliminate hunger and improve health. The key Millennium Development Goals (MDGs) and their respective targets, related to women and children, are the improvement of maternal health by reducing the maternal mortality ratio (MMR) by 75% (MDG 5) and the improvement of child mortality through under-five mortality reduction by two-thirds between 1990 and 2015 (MDG 4) Under-five mortality reduced by 35% from 97 to 63 deaths per 1000 live births between 1990 and 2013. The MMR decreased globally by 45% from 380/100,000 to 220/100,000 live births, and in SSA MMR decreased by 49% from 990/100,000 to 510/100,000 live births. However, the MMR in developing regions (230/100,000) remains 14 times higher than in developed regions (16/100,000) making this the health indicator with the greatest discrepancy across income and development levels Obstetric complications require prompt action by skilled health-care providers/birth attendants; any delay e including at the health facility level e can result in loss of life and/or poor maternal health outcomes Key intervention packages or 'bundles of care' that need to be in place to reduce maternal and newborn mortality and morbidity are as follows: skilled birth attendance (SBA), provision of emergency obstetric care (EmOC) and early NC and these need to be provided within a continuum of care that includes antenatal and postnatal care and family planning Skilled birth attendance A skilled birth attendant 'is an accredited health professional-such as a midwife, doctor or nurse-who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborn babies' [13]. Skilled birth attendants need to be trained to have the required competencies and should be provided with an 'enabling environment' that includes drugs, supplies, appropriate policies and a functional referral system Globally, 72% of births are now attended by a skilled birth attendant. This, however, varies according to income group (46% in low-income groups and 99% in high-income groups) and by geographical area (48% in the African region, 67% in Southeast Asia and 99% in Europe) There is a critical shortage of health-care providers in Africa; the World Health Organization (WHO) reported that 36 of the 57 countries facing chronic human resource shortages in the health sector are in SSA Approaches used to improve coverage of SBA include increasing the number of SBAs trained (preservice) and increasing the skills and knowledge of existing cadres of staff to be able to provide SBA and . In addition, research has shown that a large variety of cadres of health-care providers are expected to provide SBA in SSA and Asia. However, not all are trained to the required standard and/or supported and legislated to carry out all tasks required of a SBA according to the international definition Emergency obstetric care An estimated 15% of pregnant women will develop a complication during pregnancy, childbirth or the puerperium, which will require EmOC [24] These were first described and internationally agreed upon in 1997, and they consist of key interventions (or signal functions) that must be available at health-care facilities designated to provide either comprehensive (nine signal functions) or basic (seven signal functions) EmOC More recently, new signal functions to measure the ability of health facilities to provide routine care and emergency obstetric and newborn care have been described, one general and three for obstetric and newborn care. These are as follows: (a) general requirements for health-care facilities such as 24/7 service availability, sufficient numbers of SBAs, functional referral systems and infrastructure; (b) routine care for all mothers and babies; (c) basic EmONC for mothers and babies with complications; and (d) comprehensive EmONC to include blood transfusion and caesarean section at the secondary level The availability of EmONC with a minimum acceptable level of five health-care facilities per 500,000 people (one of which should be a comprehensive EmONC health-care facility) providing all EmONC signal functions in the 3 months preceding the assessment is one of the eight indicators for monitoring the availability and utilization of EmOC A number of surveys have shown that the majority of health-care facilities in low-and middleincome settings, although designated to provide either basic or comprehensive EmONC, may be unable to do so Training health-care providers in emergency obstetric and early newborn care Health-care providers are expected to provide a quality of care that minimizes the risk of adverse maternal and newborn outcomes by providing prompt evidence-based actions at the point of contact with pregnant or recently pregnant women. Maternal and perinatal death audits or review show that in many cases health-care providers failed to recognize and manage complications in a timely and effective manner, and this is one of the contributors to poor-quality or substandard care However, in-service EmONC training has been criticized as delivery has often been fragmented, a variety of training packages and teaching methodology is used and the content of available training packages is often not described in much detail [27e29]. How is in-service EmONC training best delivered? In-service EmONC training programmes should utilize evidence-based learning methods including a 'skills-and-drills' approach; have sufficient content to improve the health-care providers' competency in evidence-based, effective and woman-and baby-friendly care; and be of short duration and as close to the working environment as possible Simulation-based medical education (SBME) with deliberate practice has been shown to be superior to traditional clinical and didactic education. Deliberate practice embodies strong and consistent educational interventions grounded in information processing and behavioural theories of skill acquisition and maintenance There is some evidence that short competency-based EmONC training programmes based on adult learning methodology are more effective in improving professional practice than longer didactic-based training. Several short in-service training programmes with 'skills-and-drills' components have been There are at least five emergency obstetric care facilities (including at least one comprehensive facility) for every 500,000 people 2. Geographical distribution of facilities providing EmONC All subnational areas have at least five facilities providing EmONC (including at least one providing Comprehensive EmONC) for every 500,000 people 3. Proportion of all births in facilities providing EmONC (Minimum acceptable level to be set locally) 4. Met need for EmONC: proportion of women with major direct obstetric complications who are treated in health-care facilities able to provide EmONC 100% of women estimated to have major direct obstetric complications are treated in health-care facilities providing EmONC 5. Caesarean sections as a proportion of all births The estimated proportion of births by caesarean section in the population is not less than 5% or more than 15% 6. Direct obstetric case fatality rate The case fatality rate among women with direct obstetric complications in health-care facilities providing EmONC is <1% 7. Intra-partum and very early neonatal death rate Standard to be determined 8. Proportion of maternal deaths due to indirect causes in emergency obstetric care facilities developed for well-resourced settings, and they have in some cases been modified for implementation in lower-resource settings One of the earliest EmONC in-service training packages was developed by the American College of Nurse-Midwives (ACNM), and it was designed to be primarily competency based (emphasis on acquiring skills through repetition in hands-on practice) EmONC training courses designed specifically for a low-resource country setting include the CMNH-LSTM EmONC training course Evaluation of the effectiveness of EmONC training It is important to determine the effectiveness of in-service EmONC training so as to make continuous improvements to the training programme, provide evidence to sustain the intervention and ensure limited resources are well spent. In-service training programmes are often delivered as one component of a larger maternal health intervention programme. Therefore, it may be difficult to specifically attribute a change in outcomes to EmONC training per se even if comprehensive monitoring and evaluation of the whole programme is carried out. Where EmONC training programmes have been evaluated, this has been mainly to assess health-care provider competency before and/or after training. Very few studies have evaluated the effect on change in practice and/or health outcomes Although it can be argued that regular in-service training is required to ensure that maternity care providers remain confident and competent in providing EmONC and that therefore demonstrating a change in knowledge and skills is important, evidence is also required to convince policymakers regarding what the best EmONC training approach is. Policymakers are likely to be influenced by evaluation conducted within 'real-life' settings using information generated within the health system. Key evidence required to facilitate change in policy includes information regarding the acceptance of the training by health-care providers and affirmation that they consider the training as useful; demonstrable improvement in knowledge, skills, confidence and practice; and finally improvement in maternal and newborn health outcomes. New approaches to the evaluation of effectiveness of implementation programmes in real-life settings include operational research (or implementation research) [50e53]

Recommendations for the design of therapeutic trials for neonatal seizures

Although seizures have a higher incidence in neonates than any other age group and are associated with significant mortality and neurodevelopmental disability, treatment is largely guided by physician preference and tradition, due to a lack of data from welldesigned clinical trials. There is increasing interest in conducting trials of novel drugs to treat neonatal seizures, but the unique characteristics of this disorder and patient population require special consideration with regard to trial design. The Critical Path Institute formed a global working group of experts and key stakeholders from academia, the pharmaceutical industry, regulatory agencies, neonatal nurse associations, and patient advocacy groups to develop consensus recommendations for design of clinical trials to treat neonatal seizures. The broad expertise and perspectives of this group were invaluable in developing recommendations addressing: (1) use of neonate-specific adaptive trial designs, (2) inclusion/exclusion criteria, (3) stratification and randomization, (4) statistical analysis, (5) safety monitoring, and (6) definitions of important outcomes. The guidelines are based on available literature and expert consensus, pharmacokinetic analyses, ethical considerations, and parental concerns. These recommendations will ultimately facilitate development of a Master Protocol and design of efficient and successful drug trials to improve the treatment and outcome for this highly vulnerable population

Perinatal asphyxia: current status and approaches towards neuroprotective strategies, with focus on sentinel proteins

Delivery is a stressful and risky event menacing the newborn. The mother-dependent respiration has to be replaced by autonomous pulmonary breathing immediately after delivery. If delayed, it may lead to deficient oxygen supply compromising survival and development of the central nervous system. Lack of oxygen availability gives rise to depletion of NAD+ tissue stores, decrease of ATP formation, weakening of the electron transport pump and anaerobic metabolism and acidosis, leading necessarily to death if oxygenation is not promptly re-established. Re-oxygenation triggers a cascade of compensatory biochemical events to restore function, which may be accompanied by improper homeostasis and oxidative stress. Consequences may be incomplete recovery, or excess reactions that worsen the biological outcome by disturbed metabolism and/or imbalance produced by over-expression of alternative metabolic pathways. Perinatal asphyxia has been associated with severe neurological and psychiatric sequelae with delayed clinical onset. No specific treatments have yet been established. In the clinical setting, after resuscitation of an infant with birth asphyxia, the emphasis is on supportive therapy. Several interventions have been proposed to attenuate secondary neuronal injuries elicited by asphyxia, including hypothermia. Although promising, the clinical efficacy of hypothermia has not been fully demonstrated. It is evident that new approaches are warranted. The purpose of this review is to discuss the concept of sentinel proteins as targets for neuroprotection. Several sentinel proteins have been described to protect the integrity of the genome (e.g. PARP-1; XRCC1; DNA ligase IIIα; DNA polymerase β, ERCC2, DNA-dependent protein kinases). They act by eliciting metabolic cascades leading to (i) activation of cell survival and neurotrophic pathways; (ii) early and delayed programmed cell death, and (iii) promotion of cell proliferation, differentiation, neuritogenesis and synaptogenesis. It is proposed that sentinel proteins can be used as markers for characterising long-term effects of perinatal asphyxia, and as targets for novel therapeutic development and innovative strategies for neonatal care

Anticonvulsant Effectiveness and Hemodynamic Safety of Midazolam in Full-Term Infants Treated with Hypothermia

Background: Midazolam is used as an anticonvulsant in neonatology, including newborns with perinatal asphyxia treated with hypothermia. Hypothermia may affect the safety and effectiveness of midazolam in these patients. Objectives: The objective was to evaluate the anticonvulsant effectiveness and hemodynamic safety of midazolam in hypothermic newborns and to provide dosing guidance. Methods: Hypothermic newborns with perinatal asphyxia and treated with midazolam were included. Effectiveness was studied using continuous amplitude-integrated electroencephalography. Hemodynamic safety was assessed using pharmacokinetic-pharmacodynamic modeling with plasma samples and blood pressure recordings (mean arterial blood pressure) under hypothermia. Results: No effect of therapeutic hypothermia on pharmacokinetics could be identified. Add-on seizure control with midazolam was limited (23% seizure control). An inverse relationship between the midazolam plasma concentration and mean arterial blood pressure could be identified. At least one hypotensive episode was experienced in 64%. The concomitant use of inotropes decreased midazolam clearance by 33%. Conclusions: Under therapeutic hypothermia, midazolam has limited add-on clinical anticonvulsant effectiveness after phenobarbital administration. Due to occurrence of hypotension requiring inotropic support, midazolam is less suitable as a second-line anticonvulsant drug under hypothermia. (C) 2015 S. Karger AG, Base

Using Collaborative Simulation Modeling to Develop a Web-Based Tool to Support Policy-Level Decision Making About Breast Cancer Screening Initiation Age

Background: There are no publicly available tools designed specifically to assist policy makers to make informed decisions about the optimal ages of breast cancer screening initiation for different populations of US women. Objective: To use three established simulation models to develop a web-based tool called Mammo OUTPuT. Methods: The simulation models use the 1970 US birth cohort and common parameters for incidence, digital screening performance, and treatment effects. Outcomes include breast cancers diagnosed, breast cancer deaths averted, breast cancer mortality reduction, false-positive mammograms, benign biopsies, and overdiagnosis. The Mammo OUTPuT tool displays these outcomes for combinations of age at screening initiation (every year from 40 to 49), annual versus biennial interval, lifetime versus 10-year horizon, and breast density, compared to waiting to start biennial screening at age 50 and continuing to 74. The tool was piloted by decision makers (n = 16) who completed surveys. Results: The tool demonstrates that benefits in the 40s increase linearly with earlier initiation age, without a specific threshold age. Likewise, the harms of screening increase monotonically with earlier ages of initiation in the 40s. The tool also shows users how the balance of benefits and harms varies with breast density. Surveys revealed that 100% of users (16/16) liked the appearance of the site; 94% (15/16) found the tool helpful; and 94% (15/16) would recommend the tool to a colleague. Conclusions: This tool synthesizes a representative subset of the most current CISNET (Cancer Intervention and Surveillance Modeling Network) simulation model outcomes to provide policy makers with quantitative data on the benefits and harms of screening women in the 40s. Ultimate decisions will depend on program goals, the population served, and informed judgments about the weight of benefits and harms