To determine the effect of simulation-based obstetric team training on patient outcomes, performance of the obstetric care team in practice and educational settings, and trainees' experience, when compared to no training or another type of training.
What is the issue?
Obstetric emergencies are pregnancy-related conditions that can threaten the well-being of mother and baby in pregnancy or around birth. These emergencies can happen at any time, result in high-level pressure with high-stakes decisions, and technical and ethical challenges of caring for both the mother and her child. Organisational and human factors are considered to be major sources of preventable, substandard care. Simulation-based team training focuses on building a system that will anticipate errors, improve patient outcomes and the performance of obstetric care teams.
Why is this important?
Adequate performance of the obstetric care team is essential for safe management of obstetric emergencies. Inadequate performance of care teams can lead to substandard care resulting in poor outcomes for mothers and their children. Simulation-based obstetric team training has been recommended to improve the overall outcome and quality of obstetric health care. Its effectiveness needs to be evaluated.
What evidence did we find?
The search was performed in April 2020. We identified eight randomised studies. Six cluster-randomised studies compared simulation-based obstetric team training with no training.
Kirkpatrick level 4 (patient outcome): simulation-based obstetric team training may make little or no difference for a combination of adverse events in the mother or the infant. We are uncertain whether simulation-based obstetric team training affects the risk of death for the mother. However, it may reduce the risk of death for the newborn baby. Simulation-based obstetric team training may have little to no effect on low Apgar score but it probably reduces trauma after shoulder dystocia and probably slightly reduces the number of caesarean deliveries.
Kirkpatrick level 3 (performance in practice): we found that simulation-based obstetric team training probably improves the performance of the obstetric teams in practice.
What does this mean?
Simulation-based obstetric team training might be helpful for the improvement of team performance and specific maternal and perinatal outcomes. High-certainty evidence was lacking due to limitations in the way the studies were designed and conducted. Six studies were performed in high-income countries (the Netherlands, the UK, and the USA), and two studies were performed in a middle-income country (Mexico).This meant that we could not combine all the data to reach robust conclusions. Future studies investigating simulation-based obstetric team training compared to different designs of training courses should carefully consider how and when to measure the effects of the interventions.
Simulation-based obstetric team training may help to improve team performance of obstetric teams, and it might contribute to improvement of specific maternal and perinatal outcomes, compared with no training. However, high-certainty evidence is lacking due to serious risk of bias and imprecision, and the effect cannot be generalised for all outcomes. Future studies investigating simulation-based obstetric team training compared to training courses with a different instructional design should carefully consider how and when to measure outcomes. Particular attention should be paid to effect measurement at the level of patient outcome, taking into consideration the low incidence of adverse maternal and perinatal events.
Simulation-based obstetric team training focuses on building a system that will anticipate errors, improve patient outcomes and the performance of clinical care teams. Simulation-based obstetric team training has been proposed as a tool to improve the overall outcome of obstetric health care.
To assess the effects of simulation-based obstetric team training on patient outcomes, performance of obstetric care teams in practice and educational settings, and trainees' experience.
The Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) were searched (14 April 2020), together with references checking and hand searching the available proceedings of 2 international conferences.
We included randomised controlled trials (RCTs) (including cluster-randomised trials) comparing simulation-based obstetric team training with no, or other type of training.
We used standard methodological procedures expected by Cochrane, to identify articles, assess methodological quality and extract data. Data from three cluster-randomised trials could be used to perform generic inverse variance meta-analyses. The meta-analyses were based on risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). We used the GRADE approach to rate the certainty of the evidence. We used Kirkpatrick's model of training evaluation to categorise the outcomes of interest; we chose Level 3 (behavioural change) and Level 4 (patient outcome) to categorise the primary outcomes.
We included eight RCTs, six of which were cluster-randomised trials, involving more than 1000 training participants and more than 200,000 pregnancies/births. Four studies reported on outcome measures on Kirkpatrick level 4 (patient outcome), three studies on Kirkpatrick level 3 (performance in practice), two studies on Kitkpatrick level 2 (performance in educational settings), and none on Kirkpatrick level 1 (trainees' experience). The included studies were from Mexico, the Netherlands, the UK and the USA, all middle- and high-income countries.
Kirkpatrick level 4 (patient outcome)
Simulation-based obstetric team training may make little or no difference for composite outcomes of maternal and/or perinatal adverse events compared with no training (3 studies; n = 28,731, low-certainty evidence, data not pooled due to different composite outcome definitions). We are uncertain whether simulation-based obstetric team training affects maternal mortality compared with no training (2 studies; 79,246 women; very low-certainty evidence). However, it may reduce neonatal mortality (RR 0.70, 95% CI 0.48 to 1.01; 2 studies, 79,246 pregnancies/births, low-certainty evidence). Simulation-based obstetric team training may have little to no effect on low Apgar score compared with no training (RR 0.99, 95% 0.85 to 1.15; 2 studies; 115,171 infants; low-certainty evidence), but it probably reduces trauma after shoulder dystocia (RR 0.50, 95% CI 0.25 to 0.99; 1 study; moderate-certainty evidence) and probably slightly reduces the number of caesarean deliveries (RR 0.79, 95% CI 0.67 to 0.93; 1 study; n = 50,589; moderate-certainty evidence)
Kirkpatrick level 3 (performance in practice)
We found that simulation-based obstetric team training probably improves the performance of the obstetric teams in practice, compared with no training (3 studies; 2398 obstetric staff members, moderate-certainty evidence, data not pooled due to different outcome definitions).