Not all training for obstetric emergencies is equal, or effective.

Abstract

More and better training for obstetric emergencies has been an almost ubiquitous recommendation for two decades. Robust evaluation using scientifically rigorous study designs is essential because training for obstetric emergencies, however well intentioned, is not cheap (Yau et al. Acta Obstet Gynecol Scand 2016: in press), nor is it always associated with improvements in clinical outcomes (Draycott et al. Best Practice Res Clin Obstet Gynaecol 2015: epub). The team behind this excellent study should be commended for their use of a robust study design at scale, the use of clinical outcomes to measure effect and the candid discussion of their findings. Fransen et al. (Fransen et al. BJOG 2017;124:641–650) investigated the clinical effect of a simulation based training programme for multi-professional teams using a robust multi-centre cluster randomised trial design and demonstrated that a 1-day, off-site, simulation-based team training, focusing on teamwork skills, did not reduce a composite of adverse maternal and perinatal outcome. The study authors propose several factors that may explain the lack of effect on patient outcomes: the study was single-dose and off-site in a simulation centre, the foundation course (MOET) has not previously been associated with improved clinical outcomes; and the focus on non-clinical elements, particularly Crew Resource Management (CRM), may not have been helpful. These findings resonate with other negative studies of isolated teamwork, human factors and/or CRM training (Kemper et al. BMJ Qual Saf 2016;25:577–87). These results beg the question: what training is likely to be effective? A recent review of 23 published studies of obstetric emergency training concluded that multi-professional training conducted locally at unit level was the most effective model (Bergh et al. Best Pract Res Clin Obstet Gynaecol 2015;29:1028–43). This may be because effective training is likely to be more about training teams to use local practice-based tools, i.e. boxes and checklists, and learning in local communities of practice, than transferring new knowledge (Draycott et al. Best Pract Res Clin Obstet Gynaecol 2015;29:1067–76). This study also raises a number of other relevant issues for the evaluation of educational and simulation-based interventions. The inconsistent quality of reporting in health profession education research hinders reproducibility. We could usefully adopt the SQUIRE 2 guidelines that recommend an accurate description of the intervention in sufficient detail that others could reproduce it. This should also include the mannequins used, where appropriate. Standardisation of outcomes reporting would also improve generalisability, i.e. expressing Low Apgar scores as a proportion of term births to eliminate the effect of gestational age and to express brachial plexus injuries as a proportion of vaginal births to reduce subjectivity. Finally, further studies should be conducted using similar robust study designs, including cluster RCTs and stepped wedge designs; but with an additional parallel process evaluation. This would allow us to better understand what training works, but possibly even more importantly: how, why and where training works. Training for obstetric emergencies is not always effective. Currently, the evidence supports local, multi-professional training, with integrated clinical and teamwork/human factors elements, for all staff annually. Other models of training should be required to provide robust evidence of a positive effect before they are adopted or funded by national bodies. Full disclosure of interests available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.