Evaluation of simulation-based training on the ability of birth attendants to correctly perform bimanual compression as obstetric first aid

Background: Maternal mortality from postpartum hemorrhage remains high globally, in large part because women give birth in rural communities where unskilled (traditional birth attendants) provide care for delivering mothers. Traditional attendants are neither trained nor equipped to recognize or manage postpartum hemorrhage as a life-threatening emergent condition. Recommended treatment includes using uterotonic agents and physical manipulation to aid uterine contraction. In resource-limited areas where Obstetric first aid may be the only care option, physical methods such as bimanual uterine compression are easily taught, highly practical and if performed correctly, highly effective. A simulator with objective performance feedback was designed to teach skilled and unskilled birth attendants to perform the technique. Objectives: To evaluate the impact of simulation-based training on the ability of birth attendants to correctly perform bimanual compression in response to postpartum hemorrhage from uterine atony. Methods: Simulation-based training was conducted for skilled (N=111) and unskilled birth attendants (N=14) at two regional (Kumasi, Tamale) and two district (Savelugu, Sene) medical centers in Ghana. Training was evaluated using Kirkpatrick's 4-level model. Results: All participants significantly increased their bimanual uterine compression skills after training (p=0.000). There were no significant differences between 2-week delayed post-test performances indicating retention (p=0.52). Applied behavioral and clinical outcomes were reported for 9 months from a subset of birth attendants in Sene District: 425 births, 13 postpartum hemorrhages were reported without concomitant maternal mortality. Conclusions: The results of this study suggest that simulation-based training for skilled and unskilled birth attendants to perform bi-manual uterine compression as postpartum hemorrhage Obstetric first aid leads to improved applied procedural skills. Results from a smaller subset of the sample suggest that these skills could potentially lead to improved clinical outcomes and additional study is merited.