Practical Simulation Training for Maternity Care: Where We Are and Where Next

Improving maternal and perinatal care is a goal that is being addressed world-wide. Increasing evidence suggests that simulation training may be associated with improved clinical outcomes. This review summarizes 8 years of experience in the evaluation of the effectiveness of obstetric simulation training, and presents a vision for ensuring that practical simulation training can be used to reduce global maternal and perinatal morbidity and mortality. One of the first published descriptions of obstetric simulation involved the management of a patient with eclampsia. A randomized controlled trial found that simulation led to marked improvement in all aspects of care. When caregivers were randomly allocated to local or simulation center training, significant improvements were found in the completion of basic tasks and in the administration of magnesium sulfate in simulated eclampsia. Because equal improvements in performance were obtained regardless of whether the training occurred at a local hospital or at a simulation center, they were attributed to the simulation training. Another study assessed the effectiveness of simulation training for the management of shoulder dystocia. Before training, only 43% of staff was able to appropriately manage a severe shoulder dystocia. After a 40-minute practical training session, successful management of a simulated shoulder dystocia improved to 83%. Improved performance was maintained at 6 and 12 months after training. In a retrospective review that analyzed outcomes in births complicated by shoulder dystocia before and after the establishment of a simulation program, the use of appropriate maneuvers increased and the rate of neonatal brachial plexus injury and/or bony fracture fell from 9.3% to 2.3%. Simulation training has also been used for the management of postpartum hemorrhage. One study compared simulation-based versus lecture-based training. Although knowledge base was improved in both the groups, those who participated in simulation training also showed improvement in teamwork skills. Improvements in managing vaginal breech delivery have also been observed after training on a birth simulator. Training that included a simulated cord prolapse drill significantly reduced the diagnosis-to-delivery interval from 25 to 14.5 minutes and reduced admissions to the neonatal intensive care unit from 39% to 22%. The common factors associated with effective training programs are: multiprofessional training; training of all staff; training within the unit in which staff work; integrating teamwork training with clinical teaching; using high-fidelity simulation models; providing institutionallevel incentives (such as reduced insurance costs); and using self-assessment to direct changes in infrastructure. In the future, outcome studies should be performed to assess objective improvements in clinical outcomes associated with practical simulation training. Currently, no studies have been carried out showing improvement in maternal morbidity or mortality after these training programs. Improved neonatal outcomes have been reported, however, after simulation training. Training for more complex conditions, including severe maternal sepsis, is also needed. Another concern is that despite an increase in the availability of mannequins and other practical aids for training, time and cost constraints can limit their use. Training in low-resource settings cannot necessarily follow the methods used in developed high-income countries. Two factors that are necessary to ensure a successful training program are a sufficient number of appropriately skilled instructors and the availability of easy-to-understand, locally adapted training materials. Global efforts are underway to provide training that reaches everyone in need, not just to those with sufficient financial resources. Training in whatever setting must be cost effective and sustainable. Continued research is required to assess the effect of training on outcomes in varied clinical settings to firmly establish what programs work and why. Only then can improvements in reducing maternal and neonatal morbidity and mortality be achieved by practical simulation training.