Field Validation of Helping Mothers Survive

Bleeding after Birth

An Innovative Approach to Training Frontline Health Workers

Cherrie Lynn Evans, DrPH, CNM

Senior MNH Advisor

International Federation of Gynecology

and Obstetrics (FIGO)
October 2012
Bleeding after Birth Training – Concept

Train ALL
authorized
providers
Shared Highly
facilitation graphic
of practice materials

Change in
practice
Low-dose/
high- One day
frequency onsite
practice
Simulation-
based
 Builds Essential
Clinical Decision-
Making Skills

Tri-Colored Action Plan

using the HBB style
Flipbook Facilitates Facility-Based Training
Facilitation
Guide:
Demystifies
Training
 Bleeding after Birth
Emphasizes Simulation
Practice in Multidisciplinary Small Groups
 Field Validation Study Objectives
• Validate BAB training
methods, materials,
curriculum and
integration with
simulator
– Time allotment
– English
– 6:1 learner/facilitator
• Validate learner
assessment tools for
use during scale-up
Kirkpatrick Framework
for Training Evaluation

Source: Kirkpatrick, 1994

 Field Validation – Methods
• Grant from Lærdal Foundation
• India, Malawi and Zanzibar – February–July 2012
• Pre-Post Training Knowledge Assessment
• Post-Training Skill Assessment
• Trainer and Participant Focus Group Discussions
• Field Guide – Feedback from trainers and external
observers

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Providers Trained (N=139)
Cadre N
Nurses and Nurse Midwives 74

Health Orderlies 22

Auxiliary Nurse Midwives 20

Doctors (general and specialist) 9

Clinical Officers/Medical Assistants 7

 Provider Characteristics
Average years conducting births 11 years
Average number of births in last 30 days 21

% of providers actively delivering 81%

% of providers with ANY training in 73%

AMTSL
% of providers with pre-service training in 57%
AMTSL
% of providers with oxytocin as first or 76%
second choice
Findings – Knowledge Assessment
26-item oral MCQ – Validated by 37 global SME
BAB Knowledge Assessment: By Country
Average Scores Pass Rate

Pretest Post- p-valuea Pre-test Post- p-value

test test
Total 76% 89% *** 71% 94% ***
India 70% 87% *** 45% 89% ***
(n=47)
Malawi 83% 93% *** 100% 100% n/a
(n=44)
Zanzibar 75% 87% *** 70% 92% *
(n=26)
a *p<.05 and ***p<.001
BAB Knowledge Assessment: By Cadre
Pre-Test Post-Test p-Value
MD (n=9)
avg 85% 97% **
pass rate (100%) (100%) n/a
CO/MA (n=7)
avg 89% 96% *
pass rate (100%) (100%) n/a
Nurses/Mw (n=74)
avg 78% 91% ***
pass rate (84%) (99%) **
ANMs (n=20)
avg 62% 81% ***
pass rate (15%) (80%) ***
Orderlies (n=22)
avg 69% 77% ***
pass rate (41%) (68%) .08
*p<.05, **p<.01, ***p<.001
 Findings – Skills Assessments
• 3 skills stations – validated by 60 SME
Pass Rate
Retained Placenta Bimanual Uterine
AMTSL Compression
(11 items) (7 items) (12 items)
Total 83 89 85

India 82 88 90

Malawi 83 90 79
Self-Reported Confidence in Skills*
Before After p-Value
Training Training
Providing AMTSL 3.3 4.1 p<.001
Managing PPH 3.1 3.9 p<.001
Performing bimanual 2.9 4.0 p<.001
uterine compression
*Likert scale: 1 = “I cannot perform this skill”
5 = “I am extremely confident”
Learner Reaction*
Training Characteristic Likert Rating
(avg)
6:1 ratio is good 4.7
Time for training enough 4.0
Time for practice enough 4.3
Acceptability of English 3.1 - ANMs 4.1 5.0 - MDs
Facilitation Guide easy to understand 4.4
*Likert scale: 1 = “Strongly disagree”
5 = “Strongly agree”
 Conclusions
• Good knowledge
transfer
• Highly acceptable
package
– Ratio, 1 day training,
simulator
• English acceptable in some contexts and with
some cadres, local language preferred in others
• Materials have been adjusted based on specific
feedback from the validation
Further Research

Source: Kirkpatrick, 1994

Next Steps
• Low-dose, high-frequency
Simulator left on site
Peer training
Study SMS support for practice
• 2-year study in Uganda –
BAB + HBB
• New modules for Helping
Mothers Survive
 Acknowledgments
 Peter Johnson, Eva Bazant, Sheena Currie,
Bonnie Dowling
 Lærdal Global Health
 ICM
 FIGO
 AAP
 India, Malawi and Tanzanian country teams

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