Limited Effectiveness of a Skills and Drills Intervention to Improve Emergency Obstetric and Newborn Care in Karnataka, India: A Proof-of-Concept Study

We read with interest the paper by Varghese et al 1 regarding the limited effectiveness of a skills and drills intervention to improve Emergency Obstetric and Newborn Care and the editorial by Ricca2.

Ricca has discussed some possible reasons as to why the intervention had limited effect when it came to improved diagnosis and management of maternal and newborn complications, including systems weaknesses, provider motivation and behaviour and barriers to teamwork in the workplace.

We would like to draw attention to a further possible reason for the limited effectiveness in translating the training into demonstrable improvements in clinical care. Whilst there were statistically significant improvements in both knowledge and skills, as assessed by pre and post intervention knowledge and skills assessments, it may be that these improvements, albeit of significance, still did not cross a threshold of improvement necessary to make a real difference in clinical practice. It could be argued, for example, that a score of 56% in understanding how to recognise and act in an obstetric emergency, is simply still not enough.

We would, therefore, suggest that prior to implementing any further such intervention, both the content and mode of delivery of the training intervention be re-explored with a view to gaining an understanding as to why it was that participants' scores did not reach a higher level, and implementing appropriate changes in the training in order to achieve a greater demonstrable level of knowledge and skills improvement such as may be more likely to impact on clinical practice.

In our experience in the multi country Making it Happen programme3, setting up of skills training rooms4,5, training of healthcare facility- based mentors and supervisors were successful approaches in bringing about change in behaviour and practice after training.

Finally, evaluating the effectiveness of training programmes is the final step of an effective training programme design but in order to improve the strength of the results, attention must be paid to more robust designs beyond pre and post training assessments. Having a matched comparison group with outcome indictors linked to the training intervention will minimise bias associated with the results. The stepped wedge research design6 will allow all clusters to receive the intervention at various times but being part of the control group at some point. This design is better suited for when it is known that an intervention has benefits, and it is therefore unethical to withhold the intervention from other groups.

Helen Allott, Helen Smith, Terry Kana, Mselenge Mdegela, Sarah Bar- Zeev and Charles Ameh Centre for Maternal and Newborn Health Liverpool School of Tropical Medicine

1. Varghese B, Krishnamurthy J, Correia B, Panigrahi R, Washington M, Ponnuswary V, et al. Limited effectiveness of a Skills and Drills intervention to improve Emergency Obstetric and Newborn Care in Karnataka, India: A proof-of-concept study. Glob Health Sci Pract. December 19, 2016, doi:10.9745/GHSP-D-16-00272

2. Ricca J. Limits of "Skills and Drills" Intervetions to Improving Obstetric and Newborn Emergency Response: What More DO We Need to Learn? Glob Health Sci Pract. Dec 19, 2016, doi:10.9745/GHSP-D-16-00272

3. Ameh CA and van den Broek N. Making it Happen:Training health-care providers in emergency obstetric and newborn care. Best Practice & Research Clinical Obstetrics and Gynaecology. 2015; 29:1077-1091

4. Utz B, Kana T and van den Broek N. Practical aspects of setting up obstetrics skills laboratories -A literature review and proposed model. Midwifery. 2015; 31: 400-408

5. Raven J, Utz B, Roberts D and van den Broek N. The @Making it Happen@ programme in India and Bangladesh. BJOG. 2011.Sept:118 Suppl 2:100 -103

6. Hemming K, Haines TP, Chilton PJ, Girling AJ and Lilford RJ. The stepped wedge cluster randomised trial: rationale, design, analysis and reporting. BMJ. 2015; 350: h391

Conflict of Interest:

None declared