Editor’s Note

³ Overgaard C, Møller AM, Fenger-Grøn M, Knudsen LB, Sandall J. Freestanding midwifery unit versus obstetric unit: a matched cohort study of outcomes in low-risk women. BMJ Open. 2011 Jan 1;1(2):e000262

⁴ Laws PJ, Lim C, Tracy S, Sullivan EA. Characteristics and practices of birth centres in Australia. Aust N Z J Obstet Gynaecol. 2009 Jun;49(3):290-5

⁵ Eide BI, Nilsen AB, Rasmussen S. Births in two different delivery units in the same clinic--a prospective study of healthy primiparous women. BMC Pregnancy Childbirth. 2009 Jun 22;9:25

⁶ Suzuki S, Hiraizumi Y, Satomi M, Miyake H. Midwife-led care unit for 'low risk' pregnant women in a Japanese hospital. J Matern Fetal Neonatal Med. 2011 Aug;24(8):1046-50

⁷ Rowe RE, Kurinczuk JJ, Locock L, Fitzpatrick R. Women's experience of transfer from midwifery unit to hospital obstetric unit during labour: a qualitative interview study. BMC Pregnancy Childbirth. 2012 Nov 15;12:129

PRE- AND POST-TEST RESULTS AT ESMOE SATURATION TRAINING IN SIX PRIORITY DISTRICTS
E Buchmann, R Pattinson, J Makin

Department of Obstetrics and Gynaecology, University of the Witwatersrand Department of Obstetrics and Gynaecology, University of Pretoria

Introduction

To meet the need for reduction in maternal and perinatal mortality rates in South Africa, the ESMOE (Essential Steps in Managing Obstetrics Emergencies) was introduced to improve the knowledge and skills of midwives and doctors. ESMOE is a twelve-module practical training programme usually presented as a three-day workshop. Twelve South African districts were chosen as priority districts for mortality reduction, in view of their total burden of mortality as well as high mortality rates. Six of these districts completed ESMOE saturation training, where doctors and midwives from district hospitals, as well as some staff from Community Health Centres, were trained in ESMOE. The six districts are Waterberg (Limpopo), Bojanala Platinum (North-West), Gert Sibande (Mpumalanga), and Fezile Dabi, Lejwelputswa, and Thabo Mofutsanyana (Free State). This study was done to evaluate the ESMOE training in terms of immediate gains of knowledge and practical skills

Methods

Just before training at ‘island’ venues in the provinces, ESMOE participants wrote theoretical pre-tests by answering true-false questions for ten of the 12 modules, with five questions per module. The ten modules were eclampsia, obstetric haemorrhage, partogram, sepsis and the unconscious patient, assisted delivery, obstetric complications, surgical skills, abortion, adult cardiopulmonary resuscitation and neonatal resuscitation. A sample of participants also underwent practical skills pre-tests in six selected modules. The six modules were partogram completion, partogram interpretation, cardiotocographs, vacuum delivery, shoulder dystocia and neonatal resuscitation. The same true/false tests and skills tests were repeated at the venues as post-tests immediately after the training. The true/false test marks were converted to ‘knowledge marks’, because actual marks of 50% were equivalent to zero knowledge, assuming a 50% probability of answering a true/false question correctly in the absence of any knowledge. A participant’s percentage knowledge mark (M_k) was derived from the true/false mark (M_t/f) using the formula: M_k = 2(M_t/f)-100. For the skills test, the test mark was accepted as the knowledge mark. Pre-test and post-test marks were compared in each district using paired t-tests. Statistical significance was accepted as P<0.05.

Results

The results of 1138 true/false pre- and post-tests, and 376 skills pre- and post-tests were analysed. The true/false tests were written by 259 doctors, 83 advanced midwives, 712 professional nurses with midwifery, and 84 unspecified midwives. The skills tests were taken by 87 doctors, 13 advanced midwives and 276 professional nurses with midwifery. There were statistically significant improvements in knowledge marks between pre-tests and post-tests in all modules except for that of ‘Sepsis and the Unconscious Patient’ (Figure 1). These differences were seen in all three grades of staff tested (Figure 2). For the skills tests, there were statistically significant improvements in skills between pre-tests and post-tests for all modules tested (Figure 3), with both midwives and doctors showing these improvements (Figure 4).

Figure 1 Percentage knowledge marks in true/false pre- and post-tests (all districts and all staff grades combined) for ten of the ESMOE modules



Figure 2 Percentage marks in pre- and post-tests (all modules combined, all districts) for true-false tests, comparing doctors, advanced midwives and professional nurses with midwifery.





Figure 3 Percentage knowledge marks in skills pre- and post-tests (all

districts and all staff grades combined) for six of the ESMOE modules.

Figure 4 Percentage marks in pre- and post-tests (all modules combined, all districts) for skills, comparing doctors and midwives (combined advanced midwives and professional nurses).
Discussion

Knowledge and skills improved significantly in all modules tested in all districts, with the exception of the sepsis and unconscious patient module. These improvements were seen for all grades of staff. However, pre-test and post-test marks were poor for a number of modules, notably abortion, adult cardiopulmonary resuscitation, surgical skills, assisted delivery and cardiotocography. The results depend on the content of the modules, the quality of the trainers, and the test assessment methods. It was noticeable that the content validity (general applicability of the questions to the module content) of some of the true/false questions was poor. Attention needs to be given to the content of some of the modules and tests.

The results are positive about ESMOE training and its immediate effects on knowledge and skills. Further evaluation of ESMOE needs to assess longer-term retention of knowledge and skills, changes in clinical practices, and, eventually reductions in maternal and perinatal mortality rates.
Scaling up of ESMOE in South Africa: What is it going to cost and what type of training are we going to use? (ABSTRACT)
CM Bezuidenhout, JD Makin, RC Pattinson

MRC Maternal and Infant Health Care Strategies Research Unit and Obstetrics and Gynaecology Department, University of Pretoria

INTRODUCTION:

Essential Steps in Managing Emergency Obstetrics (ESMOE) in South Africa has been shown to improve the knowledge and skills of health care providers^. The different methods of scale up and the cost should be considered.

AIM:

The aim of the study was to compare the cost of on-site saturation training with the cost of off-site saturation training. Both types of training have limitations and benefits. Saturation training is defined as training of at least eighty per cent of relevant healthcare providers. One of the most import factors that will influence decision makers will be the actual cost of scale up.

On-site saturation training involves facilitator mentor training and extensive support from within and outside its institution. Off-site saturation training involves training off all health care providers in ESMOE through a 2 or 3 day workshop at a venue away from its institution.
METHOD:

Both training methods were implemented in 2 districts in Mpumalanga, one making use of the on-site saturation training method and the other making use of the off-site saturation training method. Only the actual costs to the project were taken into consideration. Cost of transport of supportive supervision visits, cost of mannequins provided to institutions and rate per hour of lecturers/master trainers, were not taken into consideration.

RESULTS:

Description of actual expenses	District 1 On-Site Saturation R	District 2 Off-Site Saturation R
Hire of training venues & accommodation of delegates/facilitators	52,955	779,737
Printing of training materials for delegates/facilitators	59,241	33,353
Travel costs of master trainers/facilitators	1,800	42,792
Meetings of management teams	26,500	0
Un-announced EOST (Firedrill) visit to each site, eg Transport/accommodation evaluators	13,850	13,850
Total	154,346	869,732

CONCLUSION:

When comparing the actual cost of the 2 different types of training, the decision makers will without doubt choose to implement on-site saturation training as there is a large difference in the costs – R715 386. Clearly other factors need to be taken into consideration when making this decision.

K Frank, H Lombaard, RC Pattinson. Does completion of the Essential Steps in Managing Obstetrics Emergencies (ESMOE) training package result in improved knowledge and skills in managing obstetric emergencies? SAJOG. 2009;15(3):94-99.

THE IMPACT OF ONSITE ESMOE TRAINING ON CAESAREAN SECTION RATE AND COMPLICATIONS IN THREE DISTRICT HOSPITALS IN NKANGALA DISTRICT, MPUMALANGA PROVINCE SOUTH AFRICA (ABSTRACT)
Dr Donald HA Amoko, Clinical Head, Department of Obstetrics and Gynaecology Witbank Hospital Senior Lecturer Department of Obstetrics and Gynaecology, University of Pretoria and acting District Specialist Obstetrician and Gynaecologist, Nkangala District Mpumalanga Province
Introduction

One of the direct causes of maternal deaths in South Africa is complication associated with caesarean sections. ESMOE has several modules such as the partogram and the CTG which have direct impact on the indications for caesarean sections which determine caesarean section rates and complications associated with them. Reduction in the number of caesarean sections to those that are absolutely necessary will reduce the number of deaths due to complications and deaths associated with caesarean sections. The aim of this study is therefore to determine whether on site ESMOE training does result in the reduction of Caesarean sections and complications associated with them.

Objective

1. 
   Determine the impact/effect of onsite ESMOE training on the rate of Caesarean sections in three district hospitals in Nkangala District, Mpumalanga Province
   
2. 
   Determine the rate and type of maternal complications in the three district hospitals in Nkangala District
   

Methodology

A retrospective comparison of caesarean section rates and maternal complications in three hospitals before and three months after completion of onsite ESMOE training.

The indications for caesarean sections and the caesarean section rates and maternal complications in three district hospitals before and three months following the introduction of onsite ESMOE training were extracted. Comparison analysis of the data is done and the results summarized.
Results

In all the three hospitals, there was a significant reduction in the number (rate) of caesarean sections after the onsite ESMOE training. Furthermore, there was a reduction in the number of maternal complications after onsite ESMOE training although this reduction did not achieve level of significant. However, there was a significant increase in the number of caesarean sections done for pathological CTG compared to the pre- introduction of ESMOE training. There was significant reduction in the number of caesarean sections done for obstructed labour.

Conclusion

There was a significant reduction in the caesarean section rates, indications and incidence of maternal complications after ESMOE training although there was increase in the number of caesarean section rates due to pathological CTG.

Recommendations

Onsite ESMOE training should be implemented in all district hospitals. Further studies must be undertaken to determine whether the increase in caesarean sections due to pathological CTG is associated with a corresponding improvement in fetal/neonatal outcomes.

A REALIST REVIEW OF PARTOGRAPH USE
Lavender T (University of Manchester), Bedwell C (University of Manchester), Levin K (Engender Health), Pett C (Engender Health)
Background: Prolonged and obstructed labour contributes significantly to maternal and newborn mortality and morbidity, particularly in low resource settings. Effective monitoring is fundamental to the management and prevention of prolonged labour, However, after decades of training and investment in labour monitoring tools, such as the partograph, there remains little evidence to suggest effectiveness of such tools. This may be due to contextual factors which prevent competent use of labour monitoring tools (e.g. partograph), rather than the tools themselves.
Aim: To produce an innovative synthesis of existing evidence on the partograph to monitor labour progress to inform, practice, research and policy development.
Method: A realist review is being conducted, drawing on the iterative approach proposed by Pawson (2005). The aim of such a review is to provide understanding of the association between context, mechanisms and outcomes through review of existing literature. The review will take into account wider literature including all types of studies, regardless of methodology, policy and guidance documents, grey literature and opinion pieces. The subsequent synthesis will lead to enhanced understanding of both how the partograph contributes to labour outcomes and what contextual, or other, influences contribute to the success or failure of labour monitoring using such a tool.
Ethical issues: The realist review does not require ethical approval.
Findings: The initial search revealed 729 papers, of which 291 papers were eligible for assessment. Analysis and synthesis is in progress. The review will be completed by February 2014 and the findings available for presentation. The review is original, being the first review aimed at understanding the context in which the labour monitoring tools are used and how this affects their success, in addition to labour outcomes.
Implications for practice and research: This review will provide information which can inform future practice, research and policy development and contribute to improving outcomes for women.
Funding: Gates’ Foundation

DELIVERY OF WOMEN WITH A PREVIOUS UNEXPLAINED INTRA-UTERINE FETAL DEATH AT TERM: A PROSPECTIVE COHORT STUDY AT TYGERBERG HOSPITAL, SOUTH AFRICA.
L Oberholzer. Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Hospital, South Africa

E-mail: [e-mail]

GS Gebhardt. Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Hospital, South Africa.
Introduction

Pregnancies in women with a previous unexplained stillbirth may be jeopardized by increased antenatal surveillance and higher rates of induction of labour and caesarean delivery without clear evidence of benefit. A policy of routine induction of labour (IOL) at 38 weeks for a previous intra-uterine death (IUD), with all the associated maternal, fetal and health-care associated costs, was in practice at Tygerberg Hospital for the past 30 years without data from randomized controlled trials that support routine delivery at 38 weeks. In the past few years several studies confirmed that elective early term delivery (before 39 weeks) puts the newborn at risk for adverse neonatal outcome and should be avoided. Based on this data, the Tygerberg Hospital departmental protocol to deliver women with a previous unexplained loss was changed in 2012 to one of elective delivery at term. This study aimed to investigate the safety of this protocol change (continuation of these pregnancies until >39 weeks).

Methodology

This was a prospective observational study on the safety of a new hospital protocol which was introduced in 2012. The protocol extended the gestation for induction after a previous IUD from 38 weeks to term. The study population included all pregnant patients with a current singleton pregnancy; and a previous unexplained or unexplored singleton fetal demise ≥24 weeks/500grams referred to Tygerberg Hospital during 2012. Patients with known or recurrent risks for intra-uterine death were managed according to their relevant clinical condition and were excluded from the study. Induction of labour was offered at term (>39 weeks); it was left to the attending clinician to use their preferred definition of term (39 completed weeks or 40 completed weeks).

Results

During the audit period, 306 patients with a previous intra-uterine fetal death were referred for further management. Of these, 161 had a clear indication for either earlier intervention or no intervention and were excluded from the index management protocol. Of the remaining 145 patients, 9 met exclusion criteria and there were 2 patients who defaulted. Forty-two of the study patients (with no known previous medical problems) developed complications during their antenatal course that necessitated a change in clinical management and earlier (<39 weeks) delivery:

Table : Complications that necessitated earlier delivery in patients with previous intra-uterine fetal deaths

Complication during antenatal course	Number	Percentage
Gestational diabetes mellitus	20	47.62
Preeclampsia	10	23.81
Placenta praevia	3	7.14
Pregnancy induced hypertension	3	7.14
Abruptio placentae	2	4.76
Severe intra-uterine growth restriction	1	2.38
Eclampsia	1	2.38
Preterm labour (PPROM)	1	2.38
Chorioangioma of the placenta	1	2.38
Total	42	100.00

The remaining ninety-two women were delivered at term. Table 2 shows the breakdown of gestational age at delivery:

Table 2: Breakdown of gestational age at delivery:

	Total group (n=92) IOL planned at term	IOL planned at 39 weeks (n=18)	IOL planned at 40 weeks (n=70)
Actual gestation at delivery	39 weeks 2 days	39 weeks 1 days	39 weeks and 2 days
Gestation at delivery when spontaneous onset of labour occurred	38 weeks 6 days	38 weeks 6 days	38 weeks 4 days
Gestation at delivery when IOL was performed	39 weeks 6 days	39 weeks 1 day	40 weeks 1 day
Birth weight at delivery: mean (and range) in grams	3167g (2220-4680)	3170g (2170-3670)	3147 g (2220-4680)

Forty-seven women (51% of the total study population) went into spontaneous labour before their planned induction of labour date. Of the women booked for induction at 40 weeks, 58% went into spontaneous labour (vs 16.6% of those (n=18) that were booked for induction at 39 weeks). There was no difference in outcome whether induction was booked at 39 or 40 weeks, most patients went into spontaneous labour by 39 weeks. There were no intra-uterine deaths in the group.

Of the 47 women planned for induction of labour but who went into spontaneous labour, only 6 were delivered via a caesarean section; 5 for fetal distress and one for prolonged spontaneous rupture of membranes with unsuccessful attempts at induction of labour. Induction of labour was performed in 45 patients. Twenty (44.44%) of these women had a Caesarean delivery. For 6 of the cases, the indication was fetal compromise (fetal distress during labour). Four were due to poor progress, 1 for a failed induction and 9 were scheduled (elective) Caesarean sections for obstetrical reasons. As expected, there was a significantly higher risk for any Caesarean section in the IOL group (RR 2.27; 95% CI 1.5-3.4; P <0.05) and also a higher risk for emergency Caesarean section in the induction group (RR 1.9; 95% CI 1.16-3.1; P <0.05).
In terms of fetal outcome, all babies from the 92 cases included in the audit were born alive, with a median 5-minute Apgar score of 9 (range 8-10). Only 4 babies needed admission; the rest were discharged with their mothers. None needed ICU admission. The reasons for admission as well as the duration of admission are shown in table 3. The mode of delivery is also shown.