Effectiveness of Obstetric Emergency Workshop in Medical Students in Newcastle University Malaysia

 

Mon Mon Yee¹, Myat San Yi², Myat Kalayar Nyunt¹, Bhavani Veasuvalingam¹, Sein Yee Sint¹, Hassan Karali¹, Alice Kurein¹

1Newcastle University Medicine Malaysia, Johor, Malaysia.

2Faculty of Medicine and Health Science, University Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia.

*Corresponding Author E-mail ID: mon-mon.yee@newcastle.edu.my

 

ABSTRACT:

Global practices in health sectors envisioned maternal mortality as an indicator of the health standard of the nation. World Health Organization rests its goal on ‘Eight Millennium Development’ over the globe by means of MDG 5 is to improve the maternal health. The aim of the study is to upgrade teaching and learning method to optimise acquisition of knowledge in undergraduate students to meet the effectiveness of obstetric emergencies. We evaluated changes in knowledge using a single best answers questionnaire. The study 115 stage-5 students from 2019-2020 academic years were selected, and they were divided into 5 small groups with monthly rotation to attend the workshop. There are 23-24 students in each rotation. The assessment of knowledge of obstetrics emergencies carried out by using the SBA test before and after the workshop conducted by means of teaching and learning method.

 

KEYWORDS: Emergency obstetric care workshop, Maternal mortality, Evaluation, lifesaving skills.

 

 


INTRODUCTION:

Globally, maternal mortality is an important indicator of the health standard of its nation. The World Health Organization laid out the eight Millennium Development Goals globally among them, MDG 5 is to improve maternal health. There is a set Target 5 A, which aimed at reducing the maternal mortality rate by three quarters between 1990 and 2015.1

 

The set target 5 A by WHO paved the way to a significant reduction in the number of maternal deaths from an estimated 523 000 in 1990 to 289 000 in 2013, though the rate of decline was found to be less than half of what is needed to achieve.2 In Malaysia, the Ministry of health implements the pregnancy-related mortality surveillances and compiles annually of the mortality data to identify the risk factors, to strengthen the health care services, and to improve the health standards of the country. The estimated population of Malaysia is 32.7 million in 2020 by Department of Statistics Malaysia.3,4  The maternal mortality ratio of Malaysia is 21.1, the maternal deaths per one hundred thousand live births in 2019, which is the lowest in this decade (Department of Statistics Malaysia, 2019). It is very encouraging for all policymakers, stakeholders, and others who work very enthusiastically to keep the outcome at the utmost for a longer period.4 Complications can arise any time during delivery. One study indicated that at least 8% of all labors are associated with an adverse outcome.5 The main contribution to the country that brings the slow progress towards achieving Millennium Development Goal 5 is that policy choices have often been in response to emergencies. This is exemplified in Ghana, people have benefited greatly from long-term protective measures such as advancing human resources, infrastructure, and community health education.6

 

As clinicians, we need to try our best to avoid these complications; there are many studies that focus on measures to avoid these adverse outcomes. These studies made us understand that unclear roles and responsibilities in team members, Lack of recognition of warning signs, failure to prioritize the appropriate measures, and poor communication among the team favor these untoward outcomes. One Brazilian study stated that a Lack of skills on how to diagnose and manage obstetric emergencies, which contributes to substandard institutional care and preventable maternal deaths.7

 

It was very important to avoid human errors and organizational errors in the management of obstetric emergencies, to improve the safety of the patient. It is undeniable that the training course for obstetric emergencies plays an important role in producing well-qualified and competent doctors to deal with these emergencies. Obstetric emergencies are dilemmas for those involved, and their contribution to significant adverse outcomes in maternal morbidity and mortality should be significantly focused in each level of the health system. There are many measures with a tactful road map for reducing maternal mortality and morbidity, the training of competent human resources is one of the measures. Medical educators are responsible for this important task. During Stage 5 training, students get the learning opportunities to participate in the on-call service. In modern education, Obstetric Emergency Workshops are incorporated into the teaching-learning model of most universities. Newcastle University Medicine Malaysia is practicing an outcome-based program and train a fresh graduated, competent medical doctor who acquires emergency and life-saving skills for gynecology emergencies and obstetric care.8

 

Several studies stated that improving students’ confidence through provision of pre-learning material, small group intensive teaching, observe and participate in the labour ward and eventually giving the opportunity of hands-on training could improve the students’ experiences, enhance their knowledge and skills on obstetrics and gynaecology.9 The significance of obstetric educative workshop in medical students at Newcastle University Malaysia they also included the themes such as learning by simulation and stated clinical time constraints, retaining the ability to make mistakes, linking theory to practice, appreciating the interprofessional experience, and ensuring equal learning opportunities for all participating professional groups.10 Specific adjustment and modification on Obstetric Emergencies training are applied to the necessary demands of the medical education curriculum, which will apparently narrow the gap in the students’ learning curve.11

 

The evidence shows that simulation-based training was found to be an effective and feasible method to increase short- and long-term clinical knowledge and self-efficacy of obstetric emergencies. It’s analyzed from the previous literature, that the changing the elegance of obstetric resident education in under developing countries using simulation-based training improve self-efficacy in meeting obstetric emergencies.12 Learn, Practice, and Reflect in their pre-graduate learning period in the context of stressful emergency obstetric simulations have the potential to improve their knowledge and skills. By doing so, it will definitely empower our students to develop the knowledge and skills to respond more effectively on obstetrics and gynaecology emergencies.

 

OBJECTIVES:

1.       To explore the effectiveness of obstetric emergency training course in undergraduate teaching

2.       To improve the teaching and learning method through the feedback from workshop in the acquisition of knowledge in undergraduate students.

 

METHOD AND METERIALS:

The study design was a cross-sectional descriptive study.

 

Materials and Method:         

The researchers of this study evaluated changes in knowledge using one best answer in the given questions. The subjects were 115 stage-5 students in the 2019-2020 academic year who are divided into 5 small groups with monthly rotation to attend the workshop. There are 23-24 students in each rotation.

 

The assessment of knowledge of Obstetrics emergencies was carried out by using the SBA test before and after the workshop, which was led as a part of the teaching plan. The questionnaires were administered before and immediately after the workshop to determine the level of knowledge improvement.

 

Feedback on scores or answers of subjects was given to participants after the training. the study had applied 10 simple best answers SBAs over Multiple Choice Questions because it was better suited to the assessment of the higher levels of knowledge essential for clinical practice, such as data interpretation, problem-solving and decision making, than traditional true/false MCQ.13

 

The questions were made on the 4 workstations to determine their knowledge level. The questions focused on the ability to recognize the situation, steps and measures in the prevention and management of the conditions. Each mark was awarded for each question, and a total score out of 10 was calculated for each student. As a part of the learning method, four workstations were level conducted to determine participant's level of knowledge. The single best answer to the questions is created in accordance with 5 stage learning outcomes, and one best answer to these questions was collected in all four workstations of the learning methods. The questions focused on the ability to recognize the situation, steps, and measures in the prevention and management of the conditions. Each mark was awarded for each question, and a total score out of 10 was calculated for each student.

 

The working station was conducted using “demonstrate, perform, the re-perform pattern” in the clinical skill lab of Newcastle Medical University Malaysia. Once the workshop commenced, the team leader explained the overview of the workshop. Formerly, the students worked on 10 pre-test SBA questions. The facilitators addressed the mini lectures for about 15 minutes for each topic. Immediately after lectures, the students rotated among the 4 skill workstations. At that time, students learned their skill training on how to manage postpartum hemorrhage, sepsis, maternal collapse and eclampsia in each station. The simulated team-based learning approach was applied. In each station, the students were assigned their task as house officer, medical officer, obstetric consultant, anesthetist consultant, registrars, midwife, and student nurse. After that the students practiced the necessary skills under supervision. The facilitators guided the performance in the correct manners to achieve the expected competency.

 

All volunteers were made to sign written consent before participation in the study. To assure anonymity each participant, they were assigned a special code that was securely maintained by the primary investigator. Data entry was made using a Microsoft Excel sheet. Students who achieved SBA scores 8 and above were regarded as good, scores 5-7 were the average, and 0-4 were assumed as poor knowledge. The data were extracted onto an Excel spreadsheet and analyzed in SPSS version 21. The scores were generated using percentages. A paired t-test was used to analyze the difference between knowledge scores.

 

The feedback survey on the workshop was carried out with well-structured, validated feedback, questionnaires after confirming its validity by 0.85. (Cronbach α). Open- comments from participant's feedback were collected to identify the areas for future improvement. The response of the survey was compiled, and open comments were categorized according to respective themes.

 

RESULTS:

Characteristics of Year-5 medical students at Newcastle medical university Malaysia (n= 115) shown in Table-1.

 

 

Table-1 Students’ characteristics

Characteristics       

No. (%)

Gender

 

Male

45 (39.13%)

Female

70 (60.87%)

International students

10 (8.7%)

Male

3

Female

7

Malaysian students

105 (91.3%)

Male

38

Female

67

 

The mean score and standard deviation for pre-test and post-test were 5.71±1.33 and 8.94±0.8. Improvement in knowledge was defined as an increase in assessment score and we found out that 36.12% higher score from pre- to post-training tests. The results of pre-test and post-test confirmed the satisfactory improvement after attending the workshop. P-value <0.01 was considered statistically significance. Hence, the planned teaching programme was recognised as effective in improving the knowledge regarding management of obstetric emergency. In comparison to other studies, the knowledge score in our study was noted to be improved by 36.12% at the end of workshop which was slightly lesser while compared to the study conducted at National University of Rwanda. The findings of the study were supported by a similar study conducted by

 

Shazia S, et al., Impact of emergency obstetric care skill training workshops for medical students at Ziauddin University, Karachi, Pakistan14

 

Table-2: Mean difference, standard deviation, and test of knowledge scores of the fifth-year medical students, n=11

Paired Sample

Pre and post score test

 

P-value

 

Mean ± SD

Mean Difference

 

Pre-Score Test

5.71 ± 1.33

- 3.23

p < 0.01

Post Score Test

8.94 ± 0.8

t = - 28.89

 

                                                                                                                                      

About 61.7% of the students had average knowledge in pre-test score, however, the post-test knowledge score has shown that 63.2% of students attained the good score.

 

Table-3 Frequency and percentage distribution of knowledge scores of fifth year medical students regarding management of Obstetric emergencies during the pre-test and post-test.

Knowledge Score

Pre-test Frequency %

Post-test Frequency %

Good

13.4%

63.2%

Average

61.7%

28.7%

Poor

24.9%

10.1%


Second part of our study is by using the validated questionnaire and checking the effectiveness of the workshop. Feedback form questionnaires showed a range of 66-77 percent of the students are strongly agreed that the workshop was effective for them. It was surprising that not 100% of the participants did not agree on that.

 

The students’ feedback on the workshop showed that 76% agreed that the objective was stated clearly, 77% agreed that workshop was enjoyable, 75% agreed that it was well organized, 74% confirmed that it helped them to learn how to work effectively with the peers and the other team members, 71% said that it is comfortable to carry out the interactive sessions. About 77% of the students like the venues conducting the workshop. More than 76% of students admit that pre and post SBA tests were relevant and useful for them. (Figure-1).

 

DISCUSSION:

The obstetric emergency workshop was an evidence-based intervention for the reduction of maternal and fetal morbidity and mortality. the current study supported its hypothetical views by demonstrating a significant increase in knowledge of obstetric emergency management results of provided workshop and training; the mean score increased by 36.12%. and it was statistically significant. That confirmed the efficacy of the workshop resulted in satisfactory knowledge improvement in the participants. Literature studies likewise reveal that Simulation for obstetric emergencies has advanced knowing from the theory to the level of an evidence-based intervention that improves the outcomes. 15 The expected learning outcome of the workshop was to develop the self-efficacy and confidence by experiencing the simulated obstetric emergencies and familiarizing the scenarios. It aims to achieve the necessary knowledge, team spirits and leadership skill.16 In comparison to other studies, the knowledge score in our study was noted to be improved by 36.12% at the end of workshop which was slightly lesser while compared to the study conducted at National University of Rwanda which was 38%. in 2011.17

 

There were so many studies which proved that the Obstetric training courses helped to improve the subject’s knowledge and performance in dealing with emergency situations of life or death. Multimedia presentations were used in the lecture sessions and their usage helped tremendously in transmission of knowledge to the participants. The simulated scenarios were applied for the students to get exposed to the similar situations in real world. Students learned how to tackle the situations ahead of their career.18

 

It will assist them to prepare in advance so they will not be caught off-guard once they started their career. It was the high time for the students to enhance their theoretical knowledge and equipped themselves with necessary skills once they graduated. As an experts say a wider array of education and skills-building programs will be created to meet new demands of career.19 Our findings revealed that the learning outcomes are fulfilled according to the elaboration comments from their feedback session. They expressed their satisfaction about the workshop as they not only gained the knowledge of the Obstetrics and Gynaecological emergency conditions but also practiced the management skills by the approach of interactive hands-on working station. Furthermore, Stage 5 students had a great opportunity to learn how to communicate with team members and group leaders and how to cooperate each other’s in teamwork.


 

 

Figure -1. Depicts the graphic representation on students’ feedback on workshop


It contributed to achieve other benefits such as building up the confidence, dealing with stressful situations, team communication and prioritization of measures. These benefits were well-recognized by the participants beyond their expectations.  Most feedback were positive on the workshop. These positive feedbacks included it was easily practice able as there was provision of teaching aids like video clips especially demonstration videos, provision of equipment with mannequins in simulated sessions. It enhanced self-efficacy and self-esteem of the participants by improving their confidence level. They enjoyed the workshop very much and tried to accommodate to the challenges of simulated          scenarios.20

 

It was a valuable experience for them as they were geared up to the next level of competency-based learning by a continuous transformation of evidenced-based knowledge into real practice.  They claimed their confidence level after the workshop was remarkably higher than before and they learned how to be a good team player. The role of multidisciplinary involvement with communication between the departments was recognized by the students too. The interesting thing was although they described the positive comments in their feedback, 66- 77 % of the participants were strongly agreed on the effectiveness of workshop while a study from Ghana had 95% agreement from the participants.21

 

It is evidenced by the multi-disciplinary course for preparing maternity caregivers to manage obstetric emergencies. Hong Kong provides a model for emergency physicians and is instrumental in promoting the ALSO program for educational and health outcomes. 22 Developed countries of the globe have been implements advanced life support in obstetrics courses is designed to help maternity care providers prepare for obstetrical emergencies.23

 

Negative feedback showed time restraints and they wanted more duration for each lecture and each working station. They complained of too much information during the short period and it was too much to digest to retain the information. They would like to be more focused on the management and would like to get more clinical exposure by creating more case scenarios. It will assist in their expansion of the knowledge in the management according to case-by-case basis.

 

It was our limitations as we could not assess the level of self-efficacy or skills among the participants after completing the workshop as the workshop has not designed to evaluate the skills by objective structured clinical examination. It was partly due to the time constraint of the workshop. Besides, it does not involve the OSCE type of assessment in year 5. There were some potential areas where we would like to conduct the research in the future like retain ability of knowledge in the participants after completing the workshop for a certain period. The main theme of learning from this study was it was acceptable, feasible, and beneficial in terms of confidence, increased knowledge level, reinforced team spirit, and cost-effective. Widespread research has produced plentiful models of effective teamwork observed in previous literature.24

 

CONCLUSION:

The researchers of the current study derived with the conclusion, recognizing, and conceptualizing resultant derivation of their study, that the workshop had a remarkable impact on the participants for strengthening their learning curve. This workshop was considered to improve the skill and competency level of the participants in terms of knowledge, self-confidence, and team communication. An emergency obstetrics training course contributed the necessary knowledge and competency in year 5 medical students to manage emergency situations. We expect that reinforcing Obstetrics Emergency training in the medical curriculum will help to improve clinical outcomes and it will indirectly help to drop the maternal mortality rate of Malaysia in the future.

 

The student's and facilitators’ perspectives are that the interactive OSCE skill assessment should be added to the workshop. This would ingrain students with the adequate knowledge and necessary skill to be equipped to confront the exposure to emergency situations in the future.

 

CONFLICT OF INTEREST:

The authors report no conflict of interest.

 

ACKNOWLEDGEMENT:

Authors, hereby, would like to express our gratitude to Professor Daw Khin Saw Naing for her valuable advice and guidance. Our special thanks to clinical dean Professor Jade Chow who gave the wonderful opportunity to do this study and presentation. We also wish to thank those who took the time to participate in the study.

 

REFERENCES:                                                                                 

1.      World Health Organization. Trends in maternal mortality: 1990-2015: estimates from WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. World Health Organization; 2015.

2.      Gulland A. Worldwide Maternal Mortality Rate Falls by 45% in 13 years.

3.      Malaysia MM. Department of Statistics, Malaysia. Change. 2014 Aug; 2015,

4.      Dato'Onn J. Department of Statistics Malaysia.

5.      Siassakos D, Crofts JF, Winter C, Weiner CP, Draycott TJ. The active components of effective training in obstetric emergencies. BJOG: An International Journal of Obstetrics and Gynecology. 2009 July; 116(8): 1028-32.

6.      Kyei-Nimakoh M, Carolan-Olah M, McCann TV. Millennium development Goal 5: progress and challenges in reducing maternal deaths in Ghana. BMC Pregnancy and Childbirth. 2016 Dec; 16(1): 1-9.

7.      Siaulys MM, da Cunha LB, Torloni MR, Kondo MM. Obstetric emergency simulation training course: experience of a private-public partnership in Brazil. Reproductive Health. 2019 Dec; 16(1): 1-8.

8.      Banerjee Y, Tuffnell C, Alkhadragy R. Mento’s change model in teaching competency-based medical education. BMC Medical Education. 2019 Dec; 19(1): 1-8.

9.      Amorosa JM, Graham MJ, Ratan RB. Medical students as learners: transforming the resident-level microskills of teaching into a parallel curriculum for medical students to aid the transition from classroom to OB/GYN clerkship. Education for Health. 2012 Sep 1; 25(3): 135.

10.   Gorantla S, Bansal U, Singh JV, Dwivedi AD, Malhotra A, Kumar A. Introduction of an undergraduate interprofessional simulation-based skills training program in obstetrics and Gynaecology in India. Advances in Simulation. 2019 Dec; 4(1): 1-9.

11.   Ker J, Bradley P. Simulation in medical education. Understanding medical education: Evidence, Theory, and Practice. 2010 Jun 28; 1: 164-80.

12.   Meza PK, Bianco K, Herrarte E, Daniels K. Changing the landscape of obstetric resident education in low‐and middle‐income countries using simulation‐based training. International Journal of Gynecology and Obstetrics. 2021 Jul; 154(1): 72-8.

13.   Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R, Murray CJ. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. The Lancet. 2010 May 8; 375(9726): 1609-23.

14.   Sultana S, Ishtiaq S, Hussain R, Lateef N. Impact of Emergency Obstetric Care Skill Training Workshops For Medical Students At Ziauddin University. Karachi. Pakistan. The Pakistan Journal of Medicine and Dentistry. 2017; 6(4): 26-32.

15.   Deering S, Rowland J. Obstetric emergency simulation. In Seminars in Perinatology 2013 Jun 1 (Vol. 37, No. 3, pp. 179-188).

16.   Baker DP, Gustafson S, Beaubien J, Salas E, Barach P. Medical teamwork, and patient safety: the evidence-based relation. AHRQ Publication. 2005 Apr; 5(53): 1-64.

17.   Logie DE, Rowson M, Ndagije F. Innovations in Rwanda's health system: looking to the future. The Lancet. 2008 Jul 19; 372(9634): 256-61.

18.   Berger T, Frey CB. Structural transformation in the OECD: Digitalization, deindustrialization, and the future of work.

19.   Rainie L, Anderson J. The Future of Jobs and Jobs Training. Pew Research Center. 2017 May 3.

20.   Cline MK, Taylor H, Baxley EG. Advanced life support in obstetrics instructor manual. Shawnee Mission (KS): American Academy of Family Physicians. 2002: 1-75.

21.   Afulani PA, Dyer J, Calkins K, Aborigo RA, Mcnally B, Cohen SR. Provider knowledge and perceptions following an integrated simulation training on emergency obstetric and neonatal care and respectful maternity care: A mixed-methods study in Ghana. Midwifery. 2020 Jun 1; 85: 102667.

22.   Beasley JW, Dresang LT, Winslow DB, Damos JR. The Advanced Life Support in Obstetrics (ALSO®) Program: Fourteen Years of Progress. Prehospital and Disaster Medicine. 2005 Aug; 20(4): 271-5.

23.   Dresang LT, Rodney WM, Leeman L, Dees J, Koch P, Palencia M. Advanced life support in obstetrics in Ecuador: Teaching the teachers. The Journal of the American Board of Family Practice. 2004 Jul 1; 17(4): 276-82.

24.   Stevens MJ, Campion MA. The knowledge, skill, and ability requirements for teamwork: Implications for human resource management. Journal of Management 1994; 20(2): 503-530

 

 

 

 

 

Received on 23.07.2021           Modified on 05.08.2021

Accepted on 21.08.2021         © RJPT All right reserved

Research J. Pharm. and Tech. 2021; 14(9):4749-4754.

DOI: 10.52711/0974-360X.2021.00826