A process evaluation of PRONTO simulation training for obstetric and neonatal emergency response teams in Guatemala.

BACKGROUND: Despite expanding access to institutional birth in Guatemala, maternal mortality remains largely unchanged over the last ten years. Enhancing the quality of emergency obstetric and neonatal care is one important strategy to decrease mortality. An innovative, low-tech, simulation-based team training program (PRONTO) aims to optimize care provided during obstetric and neonatal emergencies in low-resource settings. METHODS: We conducted PRONTO simulation training between July 2012 and December 2012 in 15 clinics in Alta Verapaz, Huehuetenango, San Marcos, and Quiche, Guatemala. These clinics received PRONTO as part of a larger pair-matched cluster randomized trial of a comprehensive intervention package. Training participants were obstetric and neonatal care providers that completed pre- and post- training assessments for the two PRONTO training modules, which evaluated knowledge of evidence-based practice and self-efficacy in obstetric and neonatal topics. Part of the training included a session for trained teams to establish strategic goals to improve clinical practice. We utilized a pre/post-test design to evaluate the impact of the course on both knowledge and self-efficacy with longitudinal fixed effects linear regression with robust standard errors. Pearson correlation coefficients were used to assess the correlation between knowledge and self-efficacy. Poisson regression was used to assess the association between the number of goals achieved and knowledge, self-efficacy, and identified facility-level factors. RESULTS: Knowledge and self-efficacy scores improved significantly in all areas of teaching. Scores were correlated for all topics overall at training completion. More than 60 % of goals set to improve clinic functioning and emergency care were achieved. No predictors of goal achievement were identified. CONCLUSIONS: PRONTO training is effective at improving provider knowledge and self-efficacy in training areas. Further research is needed to evaluate the impact of the training on provider use of evidence-based practices and on maternal and neonatal health outcomes. TRIAL REGISTRATION: NCT01653626.

Interpregnancy body mass index change and success of term vaginal birth after cesarean delivery.

OBJECTIVE: We investigated the effect of interpregnancy body mass index (BMI) change on success of term vaginal birth after cesarean (VBAC) among normal, overweight and obese women. STUDY DESIGN: Using 1992-2009 Washington State birth certificate data linked with hospitalization records, we conducted a population-based retrospective cohort study of nulliparous women (BMI ≥18.5 kg/m(2)) with a primary cesarean in their first birth and a term trial of labor in their second. Interpregnancy weight change (difference between first and second prepregnancy BMIs) was categorized as maintenance (<1 BMI unit change), loss (≥1 unit), moderate gain (≥1 and <2 units), high gain (≥2 units). We estimated relative risks of VBAC success using generalized linear models with a log-link function, adjusting for maternal age, race/ethnicity, nativity, marital status, education, smoking, primary cesarean indication, interpregnancy interval, birth year for second birth, and prenatal care adequacy. RESULTS: Among 8302 women who attempted a term trial of labor, 65% had a successful VBAC. Women with normal BMI before their first pregnancy experienced an 8% decrease in VBAC success with moderate gain (relative risk [RR], 0.92; 95% confidence interval [CI], 0.87-0.98) and a 12% decrease in success with high gain (RR, 0.88; 95% CI, 0.83-0.93), compared with normal weight women who maintained weight. Weight loss increased VBAC success in women who were overweight (RR, 1.12; 95% CI, 1.01-1.25) or obese before their first delivery (RR, 1.24; 95% CI, 1.04-1.49), compared with overweight and obese women, respectively, who maintained weight. CONCLUSION: Women can improve their chance of successful VBAC through interpregnancy weight management.

Impact Evaluation of PRONTO Mexico: A Simulation-Based Program in Obstetric and Neonatal Emergencies and Team Training.

INTRODUCTION: Most maternal deaths in Mexico occur within health facilities, often attributable to suboptimal care and lack of access to emergency services. Improving obstetric and neonatal emergency care can improve health outcomes. We evaluated the impact of PRONTO, a simulation-based low-cost obstetric and neonatal emergency and team training program on patient outcomes. METHODS: We conducted a pair-matched hospital-based trial in Mexico from 2010 to 2013 with 24 public hospitals. Obstetric and neonatal care providers participated in PRONTO trainings at intervention hospitals. Control hospitals received no intervention. Outcome measures included hospital-based neonatal mortality, maternal complications, and cesarean delivery. We fitted mixed-effects negative binomial regression models to estimate incidence rate ratios and 95% confidence intervals using a difference-in-differences approach, cumulatively, and at follow-up intervals measured at 4, 8, and 12 months. RESULTS: There was a significant estimated impact of PRONTO on the incidence of cesarean sections in intervention hospitals relative to controls adjusting for baseline differences during all 12 months cumulative of follow-up (21% decrease, P = 0.005) and in intervals measured at 4 (16% decrease, P = 0.02), 8 (20% decrease, P = 0.004), and 12 months' (20% decrease, P = 0.003) follow-up. We found no statistically significant impact of the intervention on the incidence of maternal complications. A significant impact of a 40% reduction in neonatal mortality adjusting for baseline differences was apparent at 8 months postintervention but not at 4 or 12 months. CONCLUSIONS: PRONTO reduced the incidence of cesarean delivery and may improve neonatal mortality, although the effect on the latter might not be sustainable. Further study is warranted to confirm whether obstetric and neonatal emergency simulation and team training can have lasting results on patient outcomes.

Interventions to increase the duration of breastfeeding in obese mothers: the Bassett Improving Breastfeeding Study.

OBJECTIVE: Maternal obesity is associated with poor breastfeeding outcomes, yet no intervention has been developed to improve them. To ascertain whether increased breastfeeding support or provision of a breast pump is a feasible, effective intervention to improve breastfeeding, we enrolled obese women who intended to breastfeed in two randomized trials. METHODS: In Bassett Improving Breastfeeding Study (BIBS) 1, 40 women received targeted breastfeeding support in the hospital and via telephone or usual care. Information regarding breastfeeding was collected via telephone for 7 days after delivery and at 30 and 90 days postpartum. In BIBS 2, 34 obese mothers received a manual or electric breast pump to use for 10-14 days or no pump; data collection was similar. RESULTS: In both experiments, randomization failed to distribute women of differing postpartum body mass index adequately among the treatment groups. When analyses were adjusted for this, there was no difference in BIBS 1 between targeted and usual care groups and in BIBS 2 among the treatment groups in the proportion of women still breastfeeding at the times studied. CONCLUSIONS: In future studies of obese women, stratified randomization may be necessary. Further development of interventions to help obese women achieve optimal breastfeeding outcomes is required.