Background

A significant proportion of newborn and maternal deaths can be prevented through simple and cost-effective strategies. The main aim of this study was to evaluate the impact of the PRONTO obstetric-emergency management training for improving evidence-based birth attendance practices among providers attending the training at 12 hospitals in three states of Mexico from 2010 to 2012, and to estimate dissemination of the training within the hospitals.

Methods

The average treatment on the treated effect of the PRONTO intervention for the probability of performing certain practices during birth attendance was estimated in a sample of 310 health providers. Impact estimates were obtained by performing provider-level matching using a mixed Mahalanobis distance one-to-one nearest-neighbor and exact matching approach. A secondary analysis estimated the positive externalities caused by the intervention in the treated hospitals using the same analytical approach. Provider-level fixed effects regression models were used to estimate the rate of decay of the probability of performing the examined practices.

Results

Providers attending the PRONTO training showed significant increases in the probability of performing the complete active management of the third stage of labor, especially the first and third steps, and skin-to-skin-contact. There was a negative and significant effect on the probability of performing uterine sweeping. Providers who did not attend the training in treated hospitals also showed marked significant changes in the same practices, except for uterine sweeping. There was no evidence of a significant decay of the probability of performing the routine practices over time among the treated providers.

Conclusions

PRONTO is efficacious in changing trained providers' behavior, but not on all practices, suggesting that some practices are deeply ingrained. The results also suggest that information on practices is effectively transmitted to peers within treated hospitals. Previous findings of the dilution of the effect of PRONTO on some practices seem to be more related to the rotation of personnel (mainly interns) rather than providers returning to their former habits.

Trial registration

NCT01477554 . Registered on November 18, 2011; retrospectively registered.

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.

Background

Continuing education is essential for healthcare workers. Education interventions can help to maintain and improve competency and confidence in the technical skills necessary to address adverse events. However, characteristics of the health provider such as age (related to more critical and reflexive attitude); sex (relationship with gender socialization), profession and work conditions might have an influence on the effect of continuing education efforts.

Methods

A training in the management of obstetric and neonatal emergencies (PRONTO, Spanish acronym for Neonatal and Obstetric Rescue Program: Optimal and Timely treatment) was implemented in 14 hospitals in six Mexican states between 2013 and 2014, with a before-after evaluation design. A total of 351 health providers including physicians, interns, nurses and midwives completed the training and were included in the analytic sample. Mixed-effects regression models were fitted to model changes in knowledge and self-efficacy scores after the training for each training topic. Interaction terms of training with age, gender, profession, and shift were included to evaluate possible heterogeneities of effect. All models considered the within-hospital clustering of participants.

Results

After training, all participants showed a significant knowledge gain by an average of 19 percentage points for hemorrhage, 23 for neonatal resuscitation, 19 for shoulder dystocia, and 15 for preeclampsia/eclampsia (p < 0.001). Participants who worked night shifts showed lower scores for overall knowledge, compared with morning shift workers. Interns perceived the lowest self-efficacy while they scored very high in knowledge. Self-efficacy in managing obstetric and neonatal emergencies increased significantly by 16 percentage points in average.

Conclusions

Our results show that PRONTO is generally successful in increasing knowledge and self-efficacy on all topics but knowledge and self efficacy levels vary greatly by factors such as work shift. Training should be particularly aimed at personnel working during weekends and night shifts, as well as interns and nurses.