Effects of helping mothers survive bleeding after birth in-service training of maternity staff : a cluster-randomized trial and mixed-method evaluation

Sammanfattning: Background: Postpartum Haemorrhage (PPH) causes a significant amount of morbidity and mortality among mothers giving birth in sub-Saharan Africa, Tanzania included. One root cause is the insufficient health worker skills to address postpartum haemorrhage. To combat this in-service training using competency-based simulation is proposed. Aim: To assess the effectiveness of the Helping Mothers Survive Bleeding After Birth (HMS BAB) in-service training of maternity staff on PPH related health outcomes, and health workers’ skills. The thesis also assessed health workers’ perceptions of the training and facility preparedness to support care of women with PPH in Tanzania. Methods: Study I was conceptualised as a cluster-randomized trial. Interrupted time-series analysis was used to compare the following PPH related health outcomes i) PPH near miss and ii) PPH case fatality between 10 intervention and 10 comparison clusters. Study II was a before-after study of health workers (n=636), and assessed skills change immediately and ten months after the training, as well as the association between health workers’ characteristics and skill change. Study III was a qualitative study using seven Focus Group Discussions (FGD) of health workers to explore their perceptions of the training implementation. A deductive theory-driven analysis informed by integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework was used. Study IV explored health workers (FGDs, n=7) and health managers (In-depth interviews, n=12) perceptions of health facility preparedness to support care given to women with PPH. The data was analysed using thematic analysis. Results: There was a significant decline of severe PPH cases in intervention clusters compared to the comparison clusters observed immediately after the intervention. This was sustained in the post-intervention period (Study I). A small reduction in PPH case fatality was observed in intervention clusters during the post-intervention period. Health workers’ skills were significantly improved immediately after the training with a small decline at ten-months follow up (Study II). In Study III health workers reported positive perceptions of the training: the content, the training technique, use of simulated scenarios and peer practice facilitators enhanced learning. Challenges to successful training were related to organization of the training and allocating time for weekly skill practices. In Study IV health workers reported poor facility preparedness with inconsistencies and insufficiencies of resources, including few and overwhelmed maternity staff. This constrained their ability to use the new skills and to provide quality PPH-care. Additional challenges on human interactions such as communication, collaborations and leadership were highlighted. Conclusion: The HMS BAB one-day training followed by eight weekly drills was effective in reducing PPH morbidities and mortality and improved health workers skills. Implementational challenges included i) organizational aspects of in-facility training, and ii) protected time for health workers to engage in weekly drills. Health providers voiced their struggle to put their new knowledge into practice highlighting insufficiencies in health facility readiness, such as lack of drugs and blood products.