Editor’s Note

Results

Orientation in ESMOE on-site saturation training

Test	Total mark	Participants (n)	Before mean (std)	After mean (std)	p value
Skills	20	17	9.8 (3.2)	14.3 (2.9)	<0.0001
Knowledge (MCQs)	25	17	18.7 (1.9)	19.5 (2.8)	NS

std = standard deviation NS = not significant

There was a significant improvement in the skills of participants before and after the training, but not in their knowledge

Course evaluation:

Perception / Expectation	Score (out of 4)
	Doctors	Midwives	Total
Confidence in being able to conducts emergency drills	3.40	3.17	3.24
Feasibility of the plan of action for conducting drills	3.20	3.00	3.06
Ability to get cooperation of management	3.00	3.58	3.41
Ability to get cooperation of peers for participating in drills	2.80	3.00	2.94
Ability to apply acquired mentoring skills	3.40	3.33	3.35
Understanding of the scenarios on the emergency drill score sheets	3.40	3.55	3.50
Usefulness of flipcharts as teaching aid while running drills	3.80	3.75	3.76

• 
  The new training approach was well received – “I used to say, ‘These things will never be possible because we are short staffed’, but they are possible.”
  
• 
  Participants gained confidence and felt empowered – “Even sisters can help the doctor. She knows just as much. Now nurses are able to tell the doctors if they are doing something wrong.”
  
• 
  The approach also promoted active participation – “You take part, you participate, you don’t fall asleep.”
  

Process of implementation

	Hosp1	Hosp2	Hosp3	Hosp4	Hosp5	Hosp6	Hosp7
								Total__64%__60%__Shoulder_distocia'>Total__Mean'>Total	Mean
Modules covered (n)	10	12	10	12	12	6	12	-	10.6
Drills conducted (n)	14	24	22	17	17	9	12	115	16.4
Number of staff in relation to the number of topics they are trained in:								Total
All 12 topics	0	0	0	0	1	0	0	1
9-11 topics	0	3	5	1	0	0	0	9
6-8 topics	0	5	14	5	2	0	0	26
<6 topics	12	6	6	11	12	8	18	73
Total	25	14	12	15	15	8	18	109

Sites in Nkangala completed an average of 10.6 modules (range: 6-12), with an average of 16.4 EOST exercises conducted per site (range: 9-24). 33% of staff received training in at least 6 module topics. Duty rosters were given as the most important reason for poor coverage.

Outcomes of the unannounced emergency drills

Drill	Score breakdown	Nkangala (n=7) (on-site)	Gert Sibande (n= 9) (off-site)
Eclampsia	Interventions	58%	56%
	Team work	76%	68%
	Total	64%	60%
Shoulder distocia	Interventions	55%	49%
	Team work	67%	48%
	Total	59%	53%

Conclusion

1. 
   The orientation to on-site saturation training improved the skills of future EFMs. The on-site training approach was well received, as it provided clarity on the sequence of activities during an emergency. Participants were generally satisfied with the orientation they received for conducting on-site training.
   
2. 
   A longer time period is needed to achieve 80% staff coverage in all modules.
   
3. 
   Facility participants experienced the EOST exercises as participatory, more relaxed than formal training, empowering and improving teamwork.
   
4. 
   The outcomes for on-site and off-site saturation training were similar and it is worthwhile to continue testing the on-site ESMOE-EOST saturation training approach in more districts.
   
5. 
   A longer period of time for the intervention could have provided more information and insights on effectiveness and potential sustainability of this training method. Further follow-up is also needed to assess the long-term impact of the training.
   

References

¹ NDOH. National Department of Health Strategic Plan 2010/11-2012/13. Pretoria; NDOH; 2010.

² NDOH, CARMMA. South Africa’s National Strategic Plan for a Campaign on Accelerated Reduction of Maternal and Child Mortality in Africa (CARMMA); 2012.
DEVELOPING EOST VIDEO CLIPS AND TESTING THEM AS A METHOD FOR IMPLEMENTING FIREDRILL TRAINING IN THE LABOURWARD: A PILOT STUDY
E. Wethmar; S. Baloyi; R. C. Pattinson; J. Makin

Department Obstetrics and Gynaecology, University Of Pretoria,

MRC Unit for Maternal and Infant Health Care Strategies
Introduction

Maternal and perinatal mortality remain a major challenge to health systems worldwide. The focus on maternal and perinatal mortality was intensified when reduction in child mortality as well as reduction in maternal mortality became goals 4 and 5 of the eight goals for development in the Millennium Declaration. The target for Millennium Development Goal (MDG) 5 is to reduce the maternal mortality ratio (MMR) by three quarters during the period1990 to 2015.

South Africa is unfortunately one of only twelve countries among which perinatal mortality has increased over the Millennium Developmental Goals period. It is thus crucial that South Africa develops strategies to decrease both child and maternal mortality.
Background

Saving lives is dependent on investigating what errors are made in perinatal care and then developing strategies to rectify this.

In order to identify areas that must be improved on, most countries have various types of audit. In South Africa three national audits are used to evaluate the quality of care in child and maternal health, namely Saving Mothers, Saving Babies and Saving Children.

These reports identify major contributors to maternal deaths as well as identify the areas in which the health care system is deficient. The assessor of these reports felt that 38% of maternal deaths and over half the perinatal deaths due to asphyxia were definitely preventable. The most common health-provider avoidable factor recorded was not adhering to standard protocols. These audits have clearly identified the lack of quality of care and skills. These reports all recommended the need to improve knowledge and skill of all labour ward staff.

There are many educationally sound methods for improving knowledge. Printed educational material, lectures, internet courses, workshops, audits with feedback are but a few methods that have been used with great success. Improving skill is more difficult to achieve. Emergency events are relatively rare and when they happen it is usually at inconvenient times. When such an emergency takes place, time is of the essence and training others whilst managing the emergency is not usually feasible..

Merely improving knowledge and skill however is not the only objectives in improving quality of care in the labour ward setting; to be effective the knowledge and skill must be used in a team setting. As a consequence, there has been a shift away from striving for individual technical perfection towards better team co-ordination and training. If team work during an emergency situation is lacking, it will lead to mismanagement of the emergency and increased morbidity and mortality. Enquiries into maternal deaths have identified common errors, namely confusion in rolls and responsibilities, lack of cross monitoring, failure to prioritise and perform clinical tasks in a structured and coordinated manner, poor communication and lack of organisational support.

The answer is thus to reproduce the emergency scenario during training so that the necessary skill to manage the emergency can be conveyed in a non-threatening way, the knowledge and protocols with regards to the emergency management can be refreshed and teamwork practised. This type of training is called simulation training or fire drill training.
Rationale for creating video clips

In the Third world or developing countries the concept of fire drills and the implementation of fire drill training into maternity units are faced with many challenges, the following are a few examples:

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  Time limitations: organizing and running a fire drill in units that are already under pressure due to staff shortages in the labour ward and maternity section
  
• 
  Human resource factor: there are few trainers and these trainers might not always be available
  
• 
  Budget constraints: the cost of equipment and simulators as well as the trainers’ fees must be taken into consideration.
  

This study therefore developed and investigated an alternative method for implementing fire drills in labour wards, with the use of Emergency Obstetric Simulation Training (EOST) video clips. This method has never been used or tested before in the implementation and running of fire drills. The reason why this method is proposed is to address some of the challenges mentioned above.

Methods

Ethical approval to conduct the study was obtained from the Research Ethics Committee of the University of Pretoria. All participants involved in the study, in other words the participants involved in the filming of the video clips as well as the labour ward staff of the two hospitals participating in the study, gave informed consent to participate in the study.

A Video Training Package was developed consisting out of an introductory video clip and an explanation on the importance of fire drill training and an explanation on how to conduct a fire drill in the labour ward. The rest of the video (DVD) consists out of the following nine obstetric and neonatal emergencies: PET and eclampsia, Shoulder dystocia, Cord prolapse, Breech delivery, Post-partum haemorrhage, Vacuum delivery, Forceps delivery, Maternal and Neonatal Resuscitation. A short power point presentation explains the theory of each topic and then a clinical scenario is managed by a team of registrars from the University of Pretoria in a video clip.

A pilot study was conducted at Pretoria West Hospital and Laudium Hospital. The pilot study population consisted out of fifteen participants in total. Before the intervention, each participant was asked to complete a Multiple Choice Questionnaire on the management of pre-eclampsia and asked to manage a delivery complicated by Shoulder dystocia as a team, and scored with the STORC clinical teamwork scale on the management of Shoulder Dystocia.

The participants then viewed the power point presentation and clinical scenario video clips on aforementioned emergencies and were then re-tested in the same way. Six weeks later a second post-test or re-test was done on the participants to review retention of knowledge, skill and teamwork. Both visits were conducted without the participants having prior knowledge of the visit. Comparisons between pre-test and post-test; post-test and re-test; and pre-test and re-test were made making use of the paired T-test.
Results

Team work was scored via the STORC clinical team work scale and the data was analysed for the total group and for the separate hospitals.

• 
  There was a significant difference with regards to skills performance between the pre-test and the post-test in the total group mean 2.6 [Standard deviation 1.7] p< 0.001).
  
• 
  There was a significantly higher score for the post-test 7.0 [1.4] performance compared to the pre-test2.1 [1.7] performance.
  
• 
  However there was a significant decrease in skills performance from the post-test to the re-test 7.5 [1.4] to 4.6 [2.2] P <0.001.
  
• 
  The scores for re-test 4.6 [2.2] still are significantly better than those for the pre-test 2.1 [1.7].
  

Knowledge was assessed via a multiple choice questionnaire. This MCQ shows a significant improvement in knowledge.

• 
  The mean pre-test score of 3.7 [3.0] increased to a mean post-test score of 6.9 [2.1].
  
• 
  There was no significant decrease in knowledge between the post-test 7 [2.1] and re-test 6.6 [2.1]
  
• 
  There remains a significant difference between pre-test 4.0 [3.0] and re-test 6.0 [2.1]. P<0.001 scores
  

The mean score in terms of evaluation of the course was 46.2 [SD 2.8] (Total score 50).

Conclusion

It appears that the Video Training Package significantly improved knowledge, skill and team work immediately after exposure. In the re-test there was a decrease in knowledge, but the values remained higher than in the pre-test scores. It thus emphasises the need of continuous refreshment and re-training after the initial exposure, therefore highlighting the importance of repeated practise of the emergencies via fire drill training aided by the use of video clips.

The participants found this a satisfactory way of training.

It was noted during the pilot study that running a fire drill in the labour ward is very time effective. Performing the drill and watching the video afterwards on both occasions took less than 30 minutes.

This pilot study sets the ground work for a larger study which tests the feasibility and effectiveness of this Video Training Package.

CHILDBIRTH EDUCATION TRENDS IN THE PRIVATE SECTOR OF SOUTH AFRICA (ABSTRACT)
Barbara Hanrahan, Lynne bluff, Hettie Grove, Lynda Lilianfeld

University of the Witwatersrand: Consortium For the Advancement of Nursing Science; Childbirth Educators Professional forum

The South African Certified Perinatal Education for Health Professionals course (SACPE) is accredited by the Witwatersrand University as a short course. The consultant team set out to explore the nature and reach of childbirth education in the private sector in South Africa.
A structured questionnaire with some open ended questionnaires was used. Post-partum women were recruited to participate in the survey, when they attended a well-baby visit with a perinatal educator / midwife who is part of the Professional Forum’s national network.
Some of the topics being investigated included the location, duration and cost of childbirth education classes, the manner in which the class presentations were done, the range of services offered – antenatal classes, well baby clinic, breastfeeding support etc.
The Childbirth educators Professional; Forum together with the Wits link, strives to assist educators in building their teaching skills, professional knowledge and small business skills – by using evidence based information.
The study’s outcomes will be presented on the poster.
THE USE OF ACTION LEARNING AS A METHODOLOGY TO IMPROVE NEWBORN CARE IN KWAZULU-NATAL (ABSTRACT)
D. Nyasulu, P. Ngxekama, L. Haskins, B. Carpenter, C. Horwood

University of KwaZulu-Natal, Centre for Rural Health (CRH)

Introduction:

An essential component of scaling up newborn health services to reach the Millennium Development Goals is to strengthen leadership and management abilities. Action learning, a learning by sharing real problems with others, as opposed to theoretical classroom learning, is one approach which may be used to strengthen and support managers in neonatal nurseries in order to improve newborn care.