Frequency of team-simulation and reduction in maternal deaths following Safer Births Bundle of Care implementation – a prospective observational study

Abstract Background: Safer Births Bundle of Care (SBBC) is a continuous quality improvement (CQI) program, implemented in 30 facilities in Tanzania, resulting in a 75% reduction in maternal deaths. Simulation training was introduced as a component of the CQI efforts, targeting individual and team skills, focusing on identified clinical needs. Objective: The aim of this study was to describe the frequency of documented simulation sessions and number of recurrent participants and associations to changes in maternal death. Methods: SBBC was a stepped wedge cluster randomised implementation trial in 30 facilities in 5 regions of Tanzania from 2020 and through 2023. The SimBegin® facilitator training program was introduced to train facilitators and support implementation of a training cascade. Fifteen selected healthcare workers were trained in three levels of SimBegin® to become facilitators (level 1) and mentors (level 2). Eight were trained to become instructors (Level 3). In total, 90 local facilitators were trained to review local clinical data, run simulation sessions, and document in logbooks. Clinical data were collected from patient files by independent data collectors and looped back to the facilities on a weekly basis. Training interventions were planned, conducted, and evaluated based on identified gaps. Output measures were the frequency of simulation sessions, the number of recurring participants, and maternal death within 7 days postpartum the following month. Results: Overall, 281,165 parturient women were included in this study. The SBBC implementation period was 24-32 months, and 1280 simulation sessions were documented. Maternal deaths declined from 240/100,000 births in baseline to 60/100,000 after start of SBBC. There was an association between the frequency of simulation sessions and reduction in maternal deaths (23% reduction per each unit increase on log scale, P=0.0018), and between the number of recurring participants and reduction in maternal deaths (16% reduction per each unit increase on log scale, P=0.0006). Conclusion: This study documents a significant and clinically relevant association between the frequency of and participation in simulation sessions and reduction of maternal deaths the following month. SBBC main protocol ISRCTN Registry: ISRCTN30541755. Prospectively Registered 12.10.2020.