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A Population Based Study: Changing the Landscape of Obstetric Care and Resident Education in LMIC using Simulation Based Training

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Maternal mortality continues to be one of the largest health
burdens in reproductive-aged women in low- and middleincome
countries (LMIC).1 In an effort to address the high rates
of maternal mortality the United Nations set a goal to increase
the quality of medical training systems to meet the needs of
women.2 Simulation-based training (SBT) program have been
previously successfully piloted demonstrating that SBT and
increased team-based training was an accepted method of
teaching skills for managing high-risk labor in LMIC.3 This
gave support for use of the GO MOMS (Global Outreach
Mobile Obstetrics Medical Simulation) program, developed at
Stanford University, across various hospitals in Guatemala City,
Guatemala in order to improve medical resident’s management
of obstetric emergencies during labor.

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A Population Based Study: Changing the Landscape of Obstetric Care and Resident Education in LMIC using Simulation Based Training

  1. 1. A Population Based Study: Changing the Landscape of Obstetric Care and Resident Education in LMIC using Simulation Based Training Pamela K. Meza, Katherine Bianco, MD1., Edgar Herrarte, MD.2, Kay Daniels, MD1 1. Stanford University School of Medicine Department of Obstetrics and Gynecology- Maternal Fetal Medicine 2. Hospital de Gineco Obstetricia, Instituto Guatemalteco de Seguridad Social - Universidad de San Carlos de Guatemala Introduction Maternal mortality continues to be one of the largest health burdens in reproductive-aged women in low- and middle- income countries (LMIC).1 In an effort to address the high rates of maternal mortality the United Nations set a goal to increase the quality of medical training systems to meet the needs of women.2 Simulation-based training (SBT) program have been previously successfully piloted demonstrating that SBT and increased team-based training was an accepted method of teaching skills for managing high-risk labor in LMIC.3 This gave support for use of the GO MOMS (Global Outreach Mobile Obstetrics Medical Simulation) program, developed at Stanford University, across various hospitals in Guatemala City, Guatemala in order to improve medical resident’s management of obstetric emergencies during labor. Objectives • Develop a version of GOMOMS simulation-based training that is culturally appropriate and relevant to resources in Guatemala City • Evaluate the impact of simulation based training on the management of obstetric emergencies in various residency training programs in Guatemala City, Guatemala. • Assess the changes in residents’ confidence levels following hands on practice with simulation mannequins and technology. • Assess retention of clinical knowledge following training at two time points one week post and six-months post. • Evaluate changes in clinical practice and patient management based on skills learned Methods • An in-country simulation based education course on the management of pre-eclampsia, post partum hemorrhage, shoulder dystocia, and maternal cardiac arrest were provided to three major governmental teaching hospitals in Guatemala City, Guatemala. • The participants were OB/GYN residents encompassing all 4 levels of training • Participants’ baseline confidence in identifying, performing, and teaching procedures for shoulder dystocia (SD) and post- partum hemorrhage (PPH) was reported using an online 5- point Likert scale questionnaire prior to the courses (maximum score = 55, most confident). Clinical knowledge regarding SD and maternal cardiac arrest (MCA) management was assessed using a peer-validated multiple- choice questionnaire prior to the course (maximum score = 9 points). Preliminary Results 1. World Health Organization. World Health Statistics Data Visualizations Dashboard. World Health Organization. Accessed January 4, 2018, http://apps.who.int/gho/data/node.sdg.3-1-viz?lang=en. 2. World Health Organization. WHO Estimates cost of Reaching Global Health Targets by 2030. World Health Organization Media Centre. Last Modified July 17, 2017. http://www.who.int/mediacentre/news/releases/2017/cost-health-targets/en/ 3. Walton, A., Kestler, E., Dettinger, J. C., Zelek, S., Holme, F. and Walker, D. Impact of a low-technology simulation-based obstetric and newborn care training scheme on non-emergency delivery practices in Guatemala. International Journal of Gynecology & Obstetrics 2016; 132: 359–364. doi:10.1016/j.ijgo.2015.08.009 Funding provided by the Stanford Medical Scholars Fellowship Program. Conclusion References • There was an even higher significant increase in confidence scores in in identifying, performing, and teaching procedures for the management of SD, PPH, and MCA six months following SBT (M= 49.96, SD=7.17) compared to baseline (M =43.49, SD = 7.60); t(45)= 4.84, p < 0.01. • Contrarily, there was not a statistically significant difference in scores for confidence in identifying, performing, and teaching procedures for the management of SD, PPH, and MCA one week following SBT (M = 47.28, SD = 13.44) compared to baseline (M =43.49, SD = 7.60); t (45) =1.86, p =0.07. • There was significant difference in scores in clinical knowledge of SD and MCA one week following SBT (M = 7.83, SD = 1.1) compared to baseline (M =5.96, SD = 1.75); t (45) =7.43, p< 0.01. • Additionally, there was a maintained significant difference in scores in clinical knowledge of SD and MCA six- months following SBT (M= 7.52, SD = 1.09) compared to baseline (M =5.96, SD = 1.75); t (45) = 5.15, p < 0.01. • Participants’ levels of confidence and knowledge were reassessed using the same peer-validated questionnaires one week and six- months following the training. • A paired samples T-test was conducted to compare overall confidence and clinical knowledge regarding obstetric emergencies by residents before and after the simulation based training. • 65 OB/GYN residents were initially enrolled in the study, due to loss of follow-up or inability to participate in the training a total of 46 participants were included in the analysis. • Hands on low-fidelity simulation-based training was found to be an effective method to teach life saving procedures to physicians in LMIC. • Cognitive clinical knowledge as measured by the pre- and post-training MCQ testing increased significantly immediately and was maintained six-months after participation in the training. • Overall confidence in managing, and teaching, the procedures taught during the simulation-based training was improved following the training, and was effective in maintaining physicians level of comfort in managing life- threatening complications in the labor and delivery ward. • Further investigation regarding change in patient management based on the educational intervention presented by the SBT course will be conducted to assess the impact of simulation based training on patient care. 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