The effectiveness of training in emergency obstetric care: a systematic literature review

2 August, 2019

Dear HIFA colleagues,

One of the challenges of systematic reviews on training is the variability of what is studied. In this review, 'Duration of training ranged from 2 minutes covering one component of EmOC (newborn resuscitation) (Mazza et al., 2017) to 24 weeks for the additional training of medical doctors to provide comprehensive EmOC (Gill and Ahmed, 2004).' Furthermore, the term 'training' typically does not include experiential learning or learning by observation or direct clinical teaching (eg ward rounds, journal clubs).

Only one of the studies attempted to look at knowledge retention. Common sense would suggest that the most enabling environment for retentive learning is one where there is everyday active sharing of expertise and experience, underpinned by access to the best available evidence. Where is the research that demonstrates the impact of this approach as compared with

conventional 'training'?

Citation, abstract and selected extracts below.

CITATION: The effectiveness of training in emergency obstetric care: a systematic literature review

Charles A Ameh, Mselenge Mdegela, Sarah White, Nynke van den Broek

Health Policy and Planning, Volume 34, Issue 4, May 2019, Pages 257–270,


Providing quality emergency obstetric care (EmOC) reduces the risk of maternal and newborn mortality and morbidity. There is evidence that over 50% of maternal health programmes that result in improving access to EmOC and reduce maternal mortality have an EmOC training component. The objective was to review the evidence for the effectiveness of training in EmOC. Eleven databases and websites were searched for publications describing EmOC training evaluations between 1997 and 2017. Effectiveness was assessed at four levels: (1) participant reaction, (2) knowledge and skills, (3) change in behaviour and clinical practice and (4) availability of EmOC and health outcomes. Weighted means for change in knowledge and skills obtained, narrative synthesis of results for other levels. One hundred and one studies including before–after studies (n = 44) and randomized controlled trials (RCTs) (n = 15). Level 1 and/or 2 was assessed in 68 studies; Level 3 in 51, Level 4 in 21 studies. Only three studies assessed effectiveness at all four levels. Weighted mean scores pre-training, and change after training were 67.0% and 10.6% for knowledge (7750 participants) and 53.1% and 29.8% for skills (6054 participants; 13 studies). There is strong evidence for improved clinical practice (adherence to protocols, resuscitation technique, communication and team work) and improved neonatal outcomes (reduced trauma after shoulder dystocia, reduced number of babies with hypothermia and hypoxia). Evidence for a reduction in the number of cases of post-partum haemorrhage, case fatality rates, stillbirths and institutional maternal mortality is less strong. Short competency-based training in EmOC results in significant improvements in healthcare provider knowledge/skills and change in clinical practice. There is emerging evidence that this results in improved health outcomes.


Specific issues addressed included requests from participants for longer periods of training and translation of training materials into the local language. The largest multi-country study in sub-Saharan Africa included 600 participants and reported that healthcare providers gave high scores for acceptability and enjoyment of training and considered the content useful in their setting to improve quality of care.

Forty-two (48%) studies included evaluation of knowledge and skills of participants, usually comparing scores before the training with those obtained immediately after.

Only one study (before–after study in one institution) from a LMIC evaluated knowledge and skills retention after training which included all the EmOC signal functions, at 3 and 6 months (Tang et al., 2016). The immediate post-training improvement in knowledge was not retained by 6 months (n = 111, difference 3.1%, P < 0.001) but was retained for skills (n = 111, difference 1.7% P < 0.054) (Cooper et al., 2011). Tang et al. (2016) reported that lack of opportunities to put into practice what was learned and associated with a significant reduction in knowledge and skills at 6 months post-training.

An evaluation of the Helping Babies Breathe programme using a before–after study design (n = 53) reported that improved knowledge and skills after training in newborn resuscitation training did not result in a change in clinical practice.


Best wishes, Neil

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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - ), a global community with more than 19,000 members in 177 countries, interacting on six global forums in four languages. Twitter: @hifa_org FB: