Health Service Quality Improvement after Normal Delivery Competency-Based Training Package
Research Project Proposal
The aim of the study: To compare the impact on health provider's clinical skills after competency-based training on active management versus expectant management of normal delivery in basic maternal health care service. The influence of the training on the evidence of postpartum hemorrhage and the influence of the normal delivery competency-based training with active management of third-stage of labor at the incidence of delivery complications, maternal and perinatal morbidity and mortality.
Methodology: "Randomized controlled clinical trial".
The benefit of the research: To understand and have the experience on the advantage and disadvantage of active management of third-stage of labor in the effort to decrease the evidence of postpartum hemorrhage and maternal and perinatal morbidity and mortality. To provide a national standard clinical procedure in management of normal delivery with active management of third-stage of labor.
Location of research: Multi-center study in Indonesia, involving specific areas that has been conducted normal delivery basic maternal health care training for health service providers.
Sample criteria: Every woman at the first-stage of delivery with a life intrauterine singleton pregnancy, at-term pregnancy, head presentation and predicted for a normal delivery.
Intervention Pregnant women who intended to deliver their babies normally, received randomly an examination to determine the boundaries of the risk of pregnancy and delivery. In the low-risk group, both standardized management of normal delivery with expectant and active management of third-stage of labor was executed by a competent health care provider who has received the competency-based normal delivery basic maternal health care training. Normal delivery competency-based training package consists of high-risk pregnancy screening, management of first stage pregnancy using partogram, management of second stage delivery, third-stage active management and newborn care.
Outcome measurement: Evaluation on the outcome of the delivery was based on the amount of third-stage hemorrhage, the incidence of postpartum hemorrhage, delivery complications, and the evidence of maternal and neonatal / perinatal morbidity and mortality in comparison with the control group who has served expectant (physiological) third-stage management and baseline data before the training has been done.
Postpartum hemorrhage is one of the most common causes of 585,000 annual worldwide maternal deaths during pregnancy and delivery. Of these, 99% were found in developing countries, including Indonesia. Postpartum hemorrhage has become the most important complication during the third stage of labor (the stage between newborn delivery and placental delivery). Any effort to decrease maternal morbidity and mortality can not be separated from active management of labor which includes to minimize the risk of postpartum hemorrhage.
Pathologic delivery and its complications usually begin with predicted normal delivery. Based on this experience, it is reasonable to closely observe and evaluate every normal delivery by early detection of significant abnormal deviation in order to prevent complications.
Normal delivery competency-based training package consists of: high-risk pregnancy screening, management of first-stage pregnancy using partogram, management of second-stage delivery, third-stage active management and newborn care.
The aim of the clinical skills training package is to train health service providers to become competent in providing the service, preventing and managing delivery complications and other health problems associated with normal delivery.
The training course is designed for clinicians (physicians, nurses and midwives). The course builds on each participant's past knowledge and takes advantage of his/her high motivation to accomplish the learning tasks in the minimum time. The training emphasizes on practical aspects, not just knowing, and uses competency based evaluation of performance. As a result, the training will also generate standard guidelines and clinical procedure.
Every effort has been made to prepare these guidelines and standard clinical procedures to ensure that they are of practical value and can be continuously evaluated.
Third-stage active management in this training consists of oxytocin injection shortly after newborn delivery, early umbilical cord clamping and controlled cord traction (CCT) for delivery of the placenta.
STATEMENT OF PROBLEMS
In Indonesia, there has been an increasing demand for health services at all levels of the health system. The major problems have been related to the lack of good information regarding human resources and the need to develop clear concepts and strategies to resolve some major problems and imply changes in the workforce in health.The directions of health development in Indonesia have been guided by the following principles:
The government of Indonesia with their Safe Motherhood programs is committed to reduce maternal mortality rate (MMR) by 50% by the year 2000. By acceleration of different initiatives, e.g. revision of training programs for midwives and medical doctors, changes in the health service structure, policy and legislative changes and innovate interventions for reduction of maternal mortality. An initiative to update the curriculum of medical students and midwives and the method of competency-based training have been introduced to improve clinical skills of emergency, obstetric and neonatal health workers.A comprehensive package of services for Safe Motherhood should include:
In order to prevent third-stage and postpartum hemorrhage, much research has been done and most of it reported that prophylactic administration of oxytocin 10IU in the third-stage of labor, as part of active management, prevents postpartum hemorrhage without increasing the incidence of retained placenta.
Texas obstetricians use oxytocin routinely in the management of third-stage of labor, but few are converted to active management. Oxytocin was the chosen oxytocic drug for routine third-stage management (95%) as well as for postpartum hemorrhage (73.3%)
Any oxytocic drug administered in the third-stage of labor reduces the blood loss of approximately 40% and hence the incidence of postpartum hemorrhage from 10 to 6%. Therefore, routine active management of third-stage of labor with an oxytocic drug is strongly recommended. Because of the few side-effects oxytocin is regarded as the best drug available at the moment.
Prophylactic administration of oxytocin or sulprostone directly after delivery followed by expectant management of third-stage will reduce postpartum blood loss and will shorten the duration of third-stage.
Incidence of postpartum hemorrhage was 5.9% in the active management group and 17.9% in the physiological group (odds ratio 3.13; 95% CI 2.3 to 4.2), a contrast reflected in other indices of blood loss. Apgar scores at one and five minutes and incidence of neonatal respiratory problems were not significantly different between the groups. When women allocated to active management (840) were compared with those who actually received physiological management (403), active management still produced lower rate of postpartum hemorrhage (odds ratio 2.4; 95% CI 1.6 to 3.7). As a conclusion of the study, policy of active management practiced in the trial leads to reduced incidence of postpartum hemorrhage, shortening of third-stage and reduced neonatal packed cell volume.
PURPOSE OF STUDY
BENEFIT OF THE RESEARCHThe benefit of the research is:
DESCRIPTION OF TERMS
Competency-based clinical skills training builds on each participant's past knowledge and takes advantage of his/her high motivation to accomplish the learning tasks in minimum time. Training emphasizes on practical aspects not just knowing, and uses competency-based evaluation of performance.This training course differs from traditional courses in several ways :
Successful completion of the course is based on passing both contents (knowledge and attitudes) and skills component (i.e. satisfactory performance on mid-course questionnaire and competency-based performance evaluation by the trainer).
There are opportunities for practicing in normal delivery services, as well as training in taking patient's history techniques, infection prevention, record keeping and postpartum follow-up of clients.Training in communication
This consists in the skills necessary to undertake effective history. It would cover the characteristics of high-risk pregnancy and delivery, including the management of complication through health referral system and ways of maintaining good relations with the community.Training in clinical management
This comprises high-risk pregnancy and delivery screening, the techniques for providing normal delivery management and management of complications and referral system.Training in logistics and service delivery management
This covers procurement, storage of supplies, care of the equipment, maintenance of aseptic conditions, organization of services, medical-record keeping and postpartum follow-up.
Approach to competency-based contraception method training
Because trainees may vary widely in experience and/or previous training, the length and content of normal delivery course and the clinical training activities involved in them will vary accordingly.Courses should be based on:
Effective training will use these four essential elements to facilitate the learning process and foster competence in the task or activity.
Training in clinical skills should make as much use of teaching techniques that minimize risk to clients. For example, the use of well-designed visual aids and anatomical model rather than women for training at the skill acquisition and skill competency levels should be encouraged. Effective training with models facilitates learning and shorten training time, and is therefore an important factor in improving the quality of clinical skills training and minimizing risk to the client.
Table 1. Definition of the terms used to describe the different levels of clinical skills
As an example, before a new trainee attempts to help deliver the placenta using third-stage active management, the required skill and appropriate interactions with the woman should be demonstrated several times using pelvic model and/or appropriate training slide sets and video tapes. These should then be practiced repeatedly, using pelvic models and actual instruments and equipment under supervision in a setting that simulates reality as closely as possible.Only after skill competency and some degree of skill proficiency have been demonstrated on models the trainee should have his/her first contact with a patient
The number of procedures that trainees observe, assist with and perform will vary depending on their background and skills and on the method of training.
In a recent study conducted for IUD insertion in Thailand, the traditional training method was compared with one in which models were used. Of trainees who used models, 70% were judged to be competent after only two insertion and 100% after six. By contrast, of the 150 trainees taught without the use of models, 50% achieved competency after 6 or 7 insertion and 10% did not do so even after 15.
Use of realistic anatomical models for training, not only for demonstration purposes, can reduce training time to 2 weeks or less, which represents a considerable saving in both time and cost.
In the Duke University, Durham NC USA, family practice residency programs have been designed on a rotation-based format. It has been assumed that by having residents rotating through a series of educational experiences, they would assimilate the skills necessary to effectively serve as a family physician. An alternative approach is based on the attainment of competency, rather than on the completion of a set of experiences. This method of education is known as competency-based education, mastery learning, or, more recently, outcomes-based assessment. Within family medicine there is a strong interest in the application of competency-based education to family practice residency training.
A study in Indonesia aimed to determine the learning curves and rapidity with which clinicians became competent to remove implants. Two Norplant removal techniques were used. Twenty-four physicians, none of whom were experienced in the use of Norplant implants were randomly assigned to learn either the new "U" removal or the standard technique. As a result, using competency-based training methods, the "U" removal technique was learned easily by inexperienced clinicians. It appears to offer significant improvements in speed and achievement of proficiency over the standard technique recommended by the manufacturer.
This is a randomized controlled trial including pregnant women with expected normal vaginal delivery by a competent health care provider who has received the competency-based normal delivery basic maternal health care training.Selection of subjects
Women who fulfill the inclusion criteria will be selected randomly using a random table. Every woman who intends to deliver her baby at the birthing hut will be examined to assess the risk of pregnancy and delivery. If after thorough explanation of the advantages and disadvantages (if any) of the procedure and of possible alternatives the women agrees to participate, she will be asked to sign a written consent form. An open discussion of the research procedure will be performed with each woman.
Every woman at the first-stage of delivery with a live intrauterine singleton pregnancy, at-term pregnancy, head presentation and predicted for a normal delivery.
Predicted to be abnormal or high-risk pregnancies and deliveries caused by maternal with or without fetal anomaly.Not intended to continue the research criteria
The woman has the right to withdraw her consent at any time . In this case, she will be fully informed of any examination and management that has been done and other possible medical advice or alternatives for further delivery process.Collection of data
Evaluation of the outcome of the basic maternal health care normal delivery training intervention will be based on:
will be compared with the control group who has received expectant (physiological) third-stage management and baseline data before the training has been done.Data analysis
Statistical analysis will be used for analyzing the data:
Every woman who intended to deliver her baby at the birthing health facilities will be examined to assess of the risk of pregnancy and delivery. An informed consent will be obtained and disadvantages (if any) and other possible delivery alternatives will be explained by the health service. An open discussion of the research procedure will be performed with each woman. After giving information on the aim and benefit of the research, the woman will be asked to sign a consent form.
In the low risk group, both standardized management of normal delivery with expectant and active management of third-stage of labor was executed by a competent health care provider who has received the competency-based normal delivery basic maternal health care training. Normal delivery competency-based training package consists of high-risk pregnancy screening, management of first-stage pregnancy using a partogram, management of second-stage, third-stage active management and newborn care.
BASIC MATERNAL HEALTH CARE CLINICAL PROCEDURE - THIRD-STAGE ACTIVE MANAGEMENT
Edited by Aldo Campana,