Effects of emergency obstetric care training on maternal and perinatal outcomes: a stepped wedge cluster randomised trial in South Africa
Open accessAbstract
INTRODUCTION: Two-thirds of maternal deaths and 40% of intrapartum-related neonatal deaths are thought to be preventable through emergency obstetric and newborn care (EmOC&NC). The effectiveness of 'skills and drills' training of maternity staff in EmOC&NC was evaluated. METHODS: Implementation research using a stepped wedge cluster randomised trial including 127 of 129 healthcare facilities (HCFs) across the 11 districts in South Africa with the highest maternal mortality. The sequence in which all districts received EmOC&NC training was randomised but could not be blinded. The timing of training resulted in 10 districts providing data before and 10 providing data after EmOC&NC training. Primary outcome measures derived for HCFs are as follows: stillbirth rate (SBR), early neonatal death (ENND) rate, institutional maternal mortality ratio (iMMR) and direct obstetric case fatality rate (CFR), number of complications recognised and managed and CFR by complication. RESULTS: At baseline, median SBR (per 1000 births) and ENND rate (per 1000 live births) were 9 (IQR 0-28) and 0 (IQR 0-9). No significant changes following training in EmOC&NC were detected for any of the stated outcomes: SBR (adjusted incidence rate ratio (aIRR) 0.97, 95% CI 0.91 to 1.05), iMMR (aIRR 1.23, 95% CI 0.80 to 1.90), ENND rate (aIRR 1.04, 95% CI 0.92 to 1.17) and direct obstetric CFR (aIRR 1.15, 95% CI 0.66 to 2.02). The number of women who were recognised to need and received EmOC was significantly increased overall (aIRR 1.14, 95% CI 1.02 to 1.27), for haemorrhage (aIRR 1.31, 95% CI 1.13 to 1.52) and for postpartum sepsis (aIRR 1.86, 95% CI 1.17 to 2.95). CONCLUSION: Following EmOC&NC training, healthcare providers are more able to recognise and manage complications at time of birth. This trial did not provide evidence that the intervention was effective in reducing adverse clinical outcomes, but demonstrates randomised evaluations are feasible in implementation research. TRIAL REGISTRATION NUMBER: ISRCTN11224105.
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The study with the most clusters included 142 clusters, as seen in Pren Naidoo (2017) and Nynke van den Broek (2019).
“The study with the most clusters included 142 clusters, as seen in Pren Naidoo (2017) and Nynke van den Broek (2019) (86, 90).”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [86]
The Results section reports 127 healthcare facilities from 11 districts, not 142 clusters. The Statistical methods section treats each facility as a cluster, so this paper contradicts the cluster count attributed to it. The copy provides no basis to judge the separate citation to Naidoo (2017). (LLM, conf=0.88)
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Experimental — accuracy not yet measuredThe stepped-wedge design in van den Broek et al. 2019 was chosen to accommodate logistical constraints, allowing for phased implementation of the intervention while ensuring that each district received the training.
“The stepped-wedge design was chosen to accommodate logistical constraints, allowing for phased implementation of the intervention while ensuring that each district received the training.”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [86]
The Methods section (Study sites and implementation schedule; page unavailable) says the 11 study districts were assigned a randomised roll-out order and training was delivered one district at a time. This supports phased implementation and training across the participating districts. The paper does not say that logistical constraints were the reason for choosing the stepped-wedge design. (LLM, conf=0.83)
Experimental — accuracy not yet measuredThe sequence of implementing the intervention in van den Broek et al. 2019 was determined using simple random sampling by an independent person drawing district names from a hat.
“The sequence of implementing the intervention was determined using simple random sampling by an independent person drawing district names from a hat.”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [86]
The sample size in van den Broek et al. 2019 was determined by the number of clusters available for inclusion and the number of observations within each cluster, dictated by the number of births over the 26-month study period. No post hoc power calculation was performed.
“The sample size was determined by the number of clusters available for inclusion and the number of observations within each cluster, dictated by the number of births over the 26-month study period. No post hoc power calculation was performed.”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [86]
One district in van den Broek et al. 2019 was randomly selected to be a pilot site and was excluded from the main study.
“One district was randomly selected to be a pilot site and was excluded from the main study.”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [86]
The sequence in which all districts in van den Broek et al. 2019 received the EmOC&NC training was randomized.
“The sequence in which all districts received the EmOC&NC training was randomized.”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [86]
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Cites
The stepped wedge cluster randomised trial: rationale, design, analysis, and reporting
Hemming, K., Haines, T. P., Chilton, P. J., Girling, A. J., & Lilford, R. J. (2015) · BMJ · doi:10.1136/bmj.h391 · Cited by 1,410 · see citing works
Self-citationBhutta, Z. A., Das, J. K., Bahl, R., Lawn, J. E., Salam, R. A., Paul, V. K., Sankar, M. J., Blencowe, H., Rizvi, A., Chou, V. B., et al. (2014) · The Lancet · doi:10.1016/s0140-6736(14)60792-3 · Cited by 1,367 · see citing works
The stepped wedge trial design: a systematic review
Brown, C. A., & Lilford, R. J. (2006) · BMC Medical Research Methodology · doi:10.1186/1471-2288-6-54 · Cited by 907 · see citing works
Guide to Effective Care in Pregnancy and Childbirth
Enkin, M. W., Keirse, M. J. N. C., Neilson, J., Crowther, C. A., Duley, L., HODNETT, E. D., & Hofmeyr, J. (2000) · Oxford University Press eBooks · doi:10.1093/med/9780192631732.001.0001 · Cited by 906 · see citing works
Monitoring emergency obstetric care : a handbook
Disability (2009) · Cited by 710 · see citing works
Hemming, K., Taljaard, M., McKenzie, J. E., Hooper, R., Copas, A., Thompson, J. A., Dixon-Woods, M., Aldcroft, A., Doussau, A., Grayling, M., et al. (2018) · BMJ · doi:10.1136/bmj.k1614 · Cited by 475 · see citing works
Self-citationMdege, N. D., Man, M.-S., Taylor (nee Brown), C. A., & Torgerson, D. J. (2011) · Journal of Clinical Epidemiology · doi:10.1016/j.jclinepi.2010.12.003 · Cited by 425 · see citing works
Recurrent Obstetric Management Mistakes Identified by Simulation
Maslovitz, S., Barkai, G., Lessing, J. B., Ziv, A., & Many, A. (2007) · Obstetrics and Gynecology · doi:10.1097/01.aog.0000265208.16659.c9 · Cited by 164 · see citing works
Stepped wedge cluster randomised trials: a review of the statistical methodology used and available
Barker, D., McElduff, P., D’Este, C. A., & Campbell, M. J. (2016) · BMC Medical Research Methodology · doi:10.1186/s12874-016-0176-5 · Cited by 160 · see citing works
The effectiveness of training in emergency obstetric care: a systematic literature review.
Ameh, C. A., Mdegela, M., White, S., & van den Broek, N. (2019) · Health Policy and Planning · doi:10.1093/heapol/czz028 · Cited by 147 · see citing works
Self-citationEffects of shoulder dystocia training on the incidence of brachial plexus injury
Inglis, S. R., Feier, N., Chetiyaar, J. B., et al. (2011) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2011.01.027 · Cited by 135 · see citing works
The confidential enquiry into maternal deaths in S outh A frica: a case study
Moodley, J., Pattinson, R. C., Fawcus, S., Schoon, M. G., Moran, N. F., & Shweni, P. M. (2014) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/1471-0528.12869 · Cited by 122 · see citing works
Self-citationMaking It Happen: Training health-care providers in emergency obstetric and newborn care
Ameh, C., & van den Broek, N. R. (2015) · Best Practice & Research Clinical Obstetrics & Gynaecology · doi:10.1016/j.bpobgyn.2015.03.019 · Cited by 120 · see citing works
Self-citationAmeh, C. A., Kerr, R., Madaj, B., Mdegela, M., Kana, T., Jones, S., Lambert, J., Dickinson, F., White, S., & van den Broek, N. (2016) · PLOS ONE · doi:10.1371/journal.pone.0167270 · Cited by 109 · see citing works
Self-citationSubstantial risks associated with few clusters in cluster randomized and stepped wedge designs
Taljaard, M., Teerenstra, S., Ivers, N. M., & Fergusson, D. A. (2016) · Clinical Trials · doi:10.1177/1740774516634316 · Cited by 96 · see citing works
Outcomes associated with introduction of a shoulder dystocia protocol
Grobman, W. A., Miller, D., Burke, C. A., et al. (2011) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2011.05.002 · Cited by 95 · see citing works
The quality of antenatal care in rural Tanzania: what is behind the number of visits?
Nyamtema, A., Jong, A. B.-D., Urassa, D. P., Hagen, J. P., & van Roosmalen, J. (2012) · BMC Pregnancy and Childbirth · doi:10.1186/1471-2393-12-70 · Cited by 85 · see citing works
Rahman, A. E., Iqbal, A., Hoque, D. M. E., Moinuddin, M., Zaman, S. B., Rahman, Q. S.-U., Begum, T., Chowdhury, A. I., Haider, R., Arifeen, S. E., et al. (2017) · PLoS ONE · doi:10.1371/journal.pone.0170267 · Cited by 72 · see citing works
Improving essential obstetric and newborn care in resource-poor countries
Grady, K. M., Ameh, C., Adegoke, A. A., Kongnyuy, E. J., Dornan, J. C., Falconer, T., Islam, M. S., & van den Broek, N. R. (2011) · Journal of Obstetrics and Gynaecology · doi:10.3109/01443615.2010.533218 · Cited by 60 · see citing works
Self-citationOpiyo, N., & English, M. (2015) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd007071.pub3 · Cited by 42 · see citing works
Basic and comprehensive emergency obstetric and neonatal care in 12 South African health districts
Pattinson, R., Makin, J. D., Pillay, Y. G., van den Broek, N. R., & Moodley, J. (2015) · South African Medical Journal · doi:10.7196/samj.9181 · Cited by 42 · see citing works
Self-citationTaljaard, M., Hemming, K., Shah, L., Giraudeau, B., Grimshaw, J. M., & Weijer, C. (2017) · Clinical Trials · doi:10.1177/1740774517703057 · Cited by 41 · see citing works
Self-citationVarghese, B., Jayanna, K., Correia, B., et al. (2016) · Global Health Science and Practice · doi:10.9745/ghsp-d-16-00143 · Cited by 19 · see citing works
Effectiveness of team training in managing shoulder dystocia: a retrospective study
van de Ven, J., van Deursen, F., Heimel, P. J. V. R., et al. (2015) · The Journal of Maternal-Fetal & Neonatal Medicine · doi:10.3109/14767058.2015.1118037 · Cited by 18 · see citing works
Burstein, P. D., Zalenski, D., Edwards, J. L., Rafi, I. Z., Darden, J., Firneno, C., & Santos, P. (2016) · Health Services Research · doi:10.1111/1475-6773.12589 · Cited by 5 · see citing works
Flagged first, then by citations
Research works printed but not linked: 2
- [4]Lancet Stillbirths 2016: ending preventable stillbirths executive summary, 2016 Available: https://www.thelancet.com/series/ending-preventable-stillbirths?code=lancet-site
- [17]van den Broek N Life saving skills manual: essential obstetric and newborn care. London: RCOG Press, 2007.
Cited by
Sorted by citations
Fransen, A. F., van de Ven, J., Banga, F. R., Mol, B. W. J., & Oei, S. G. (2020) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd011545.pub2 · Cited by 89 · see citing works
McGready, R., Rijken, M. J., Turner, C., Than, H. H., Tun, N. W., Min, A. M., Hla, S., Wai, N. S., Proux, K., Min, T. H., et al. (2021) · Wellcome Open Research · doi:10.12688/wellcomeopenres.16599.2 · Cited by 22 · see citing works
Musa, Z. A., Akinsolu, F. T., Salako, A. O., Abodunrin, O. R., Ola, O. M., & Ezechi, O. C. (2026) · Frontiers in Epidemiology · doi:10.3389/fepid.2026.1529289
- Authors
- van den Broek, N., Ameh, C., Madaj, B., Makin, J., White, S., Hemming, K., Moodley, J., & Pattinson, R.
- Affiliations
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Liverpool School of Tropical Medicine (GB)
- University of Pretoria (ZA)
- University of Birmingham (GB)
- University of KwaZulu-Natal (ZA)
- ORCID
- Venue
- BMJ Global Health
- Publisher
- BMJ
- Published
- 2019-11
- Volume
- 4
- Issue
- 6
- Pages
- e001670
- ISSN
- 2059-7908 (ISSN-L)
- PMC
- PMC6861119
- OpenAlex
- W2988250481
- Cited by
- 21
- References
- 25
- Citations by year
- 2026: 2 · 2025: 2 · 2024: 6 · 2023: 3 · 2022: 1 · 2021: 3 · 2020: 4
- FWCI
- 2.07
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- BMJ Global Health (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- LSTM Online Archive (Liverpool School of Tropical Medicine) (acceptedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- UpSpace Institutional Repository (University of Pretoria) (submittedVersion, other-oa)
- PubMed
- Funders
- Department for International Development (200245-101, 200295-102)
- Topics
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and fetal healthcare
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Keywords
- emergency obstetric and newborn care, maternal mortality, perinatal outcomes, stillbirth, early neonatal death, case fatality rate, puerperal fever, South Africa, maternal mortality reduction, implementation research
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