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

Frequency of team-simulation and reduction in maternal deaths following Safer Births Bundle of Care implementation – a prospective observational study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Frequency of team-simulation and reduction in maternal deaths following Safer Births Bundle of Care implementation – a prospective observational study Kjetil Torgeirsen, Benjamin Kamala, Estomih Mduma, Florence Salvatory Kalabamu, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6990205/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Nov, 2025 Read the published version in Advances in Simulation → Version 1 posted 10 You are reading this latest preprint version 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. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction In 2020, an estimated 287 000 women died due to pregnancy and childbirth ( 1 ). The burden of maternal deaths is high in Sub-Saharan African countries, where 70% of maternal deaths occur ( 2 , 3 ). For Tanzania, the reported numbers of maternal deaths were 104 per 100,000 live births in 2022 ( 4 ) . Bleeding after birth is the leading cause of maternal deaths . Globally, about 14 million women suffer from postpartum haemorrhage (PPH) each year, primarily caused by uterine atony ( 1 , 5 ). The majority of PPH related deaths are preventable by timely and appropriate management following the WHO recommendations ( 1 ). WHO has described poor quality healthcare as a global concern. Several human factors contribute to reduced patient safety, like communication breakdown, ineffective teamwork, and cognitive bias ( 6 , 7 ). Simulation is recognized as an efficient training method to improve patient safety and as a component of continuous quality improvement (QI), targeting individual medical expertise skills -individual skills as well as social (communication, collaboration and leadership) and cognitive (situation awareness and decision making) -team skills ( 8 – 13 ). In this study, the term simulation is used to describe facilitator led, in-situ team simulation training. Common barriers for implementation of simulation-based training in healthcare are financial constraints, high burden of work, lack of simulation resources, and a need of more patient outcome oriented evidence supporting simulation training ( 14 – 17 ). Previous Safer Births studies in Tanzania have indicated that frequent individual and team-simulation training are feasible in a low resource context and can impact clinical behaviour and patient outcomes ( 18 – 20 ). Nelissen et al found a 38% reduction of PPH and improved clinical outcomes after a half-day obstetric simulation training ( 21 ). Another study found a limited clinical impact of low dose high frequency newborn resuscitation skill-training and demonstrated the need for frequent simulation sessions to improve outcomes ( 18 ). In 2021, the SBBC program was introduced in five resource challenged regions in Tanzania, including 30 healthcare facilities. The bundle is a result of over a decade of multidisciplinary collaboration between institutions inside and outside Tanzania and consists of several components: Clinical innovations and a strategy for sustainable and scalable team-simulations and data-driven QI, aiming to improve quality of care around birth and reduce perinatal and maternal mortality ( 22 ). SBBC included almost 300,000 births over a three-year period, and the recently published report documents a 75% reduction in maternal death within seven days postpartum (from 240/100,000 to 60/100,000 births) after full implementation of the program ( 23 ). Materials and methods The aim of this study was to describe the frequency of team-simulations and number of recurrent participants in the 30 facilities during SBBC implementation and investigate association to maternal death. Study design and participants This study is part of the SBBC stepped-wedge cluster randomised controlled implementation trial, which ran from March 1, 2021, to December 31, 2023 ( 22 ). The study population included all healthcare workers and parturient women in the 30 healthcare facilities in five regions of Tanzania with a high burden of newborn and maternal deaths ( 23 ). The training component of the SBBC program aims to strengthen competencies in day-of-birth emergency care through frequent individual skill-training and in-situ facilitator led team-simulation training sessions. Study interventions The SBBC program encompasses four main components: simulation training interventions, continuous QI efforts, innovative clinical tools, and systems for sustainability and scalability. Training of facilitators and healthcare workers Through the SimBegin® program, facilitators were trained to conduct simulation sessions for the team with reflection-based and structured debriefings, to identify learning needs and plan proper training interventions, and to train new facilitators. The SimBegin® program is designed to be highly scalable to increase accessibility and efficiency of simulation training. The goal is to establish a sustainable system for simulation training by training selected individuals to a level where they can train new facilitators. The SimBegin® program has a three steps design: Level 1 (becoming a facilitator), Level 2 (becoming a mentor) and Level 3 (becoming SimBegin® course faculty) training, with practicing of facilitator skills between each level ( 23 , 24 ). The implementation of SimBegin® in SBBC followed an implementation strategy and a training cascade model, aiming to stimulate frequent interprofessional simulation sessions at the facilities. The flexibility of the SimBegin® program enabled us to conduct the initial training of the national facilitators online. Travelling restrictions due to the ongoing COVID 19 pandemic, prohibited simulation experts from Norway to travel abroad. Initially, 15 members from the Tanzanian Midwifery Association (TAMA), Pediatric Associations of Tanzania (PAT), and Association of Obstetricians and Gynaecology (AGOTA) were selected to become national facilitators (completed SimBegin® Level 2 and 3), responsible for cascading the SBBC trainings and to mentor local facility champions at the SBBC facilities (Fig. 1). The training of national facilitators and facility champions also included Helping Babies Breathe (HBB) and Helping Mothers Survive Bleeding after Birth (HMS BAB) training and the use of SBBC clinical tools ( 25 – 27 ). Four pre-written scenarios were provided, two HBB newborn resuscitation scenarios and two HMS BAB scenarios. In addition, scenarios addressing active management of third stage of labour, eclampsia and antepartum haemorrhage were designed during the study period. Continuous quality improvement and the Circle of Learning The local facility champions facilitated continuous QI loops utilising simulation-based training following strategies illustrated in the Circle of Learning model (Fig. 2) ( 28 ). The circle of learning strategies aim to “bridge cognitive and skill-based learning with real-life clinical experience” ( 23 ). The model leans towards theories related to experiential learning, competency- based education and training efficiency ( 29 , 30 ). Kolb is about experiential learning, and his circle is also appropriate to explain what we do in simulations (experience – reflection). Competency-based education is a movement away from exams (knowledge tests) – trainees are able to do things (master) – a combination of knowledge, skills and attitude. QI areas were identified through weekly review of the SBBC facilities’ own clinical data. A list of 52 quality indicators were provided every week and discussed in facility champion or national facilitator led debriefing sessions using a deliberate practice approach ( 31 ). Through these discussions, clinical gaps were identified and categorized into sections: knowledge, individual skills, or team skills. Appropriate training interventions were planned, executed, and translated into clinical care. SBBC innovative tools SBBC introduced several innovative tools designed to improve quality of care and to support the training interventions. The innovations were co-created by clinicians in Tanzania, researchers and engineers from Norway, and produced by Laerdal Global Health, Stavanger, Norway. Clinical tools: Moyo is a fetal heart rate monitor designed for intermittent or continuous monitoring. Moyo aims to detect fetal distress, to support timely decision-making, and reduce midwives’ workload ( 32 – 34 ). NeoBeat is a newborn heart rate monitor designed to detect heart rate, guiding resuscitation attempts, and to support timely decision-making ( 35 ). The Upright bag is a vertical bag-mask newborn ventilation device designed to improve mask seal and ventilation quality ( 36 ). Training tools: The NeoNatalie Live simulator is a newborn resuscitation simulator that provides feedback on the quality of ventilation, airway management, and time to first ventilation. The simulator records and uploads all training activities to a database ( 18 ). MamaNatalie is a wearable simulator designed to practice the third stage of labour and complications like retained placenta and PPH ( 21 ). Both simulators were used for individual skill-training and team simulations. No clinical tools were introduced for the maternal population, only the novel training component and the data-driven QI. Sustainability and scalability A close collaboration with local, regional, and national health authorities was established before the start of the program. The SBBC tools were distributed to all included facilities, and all training content aligned with national obstetric and newborn care guidelines. Each SBBC facility established a dedicated ”training corner” in the labour ward. A mentorship program, aiming to develop and support the national facilitators continuously, were established. The facility champions and the maternity ward staff at the facilities received supervision visits from the national facilitators every third month where they received mentoring on clinical topics, clinical data, training, simulation, and the facilitator role. Data collection and management This study utilises observational data from March 01, 2021 through December 31, 2023, from the 30 SBBC sites. The overall data collection and management is described in the SBBC study protocol and the primary paper ( 22 , 23 ). Every healthcare facility had two data collectors collecting routine provider registered clinical data on daily basis by using a case report file installed on mobile phones or tablets. Pre-implementation data collection started March 1st, 2021 at all sites. Start of SBBC implementation in the different regions is indicated in Table 1. The facility champions documented training activities in a facility-based training database on a regular basis. These data provided information about the simulation sessions. The database also documented how simulation training activities and continuous QI processes were implemented in the SBBC facilities. Statistical analysis Numerical data were presented as numbers, means with standard deviations and medians, categorical data as numbers and proportions. The main analysis objective was to study the association between the number of trainings one month and maternal deaths the following month. A Poisson regression mixed model approach was used to analyse this relationship over time, taking into account dependency within regions and facilities. A logarithm transformation of the number of trainings was used for appropriate model fit. Furthermore, an ordinary Poisson regression model with period ( 1 , 2 and 3 ) as categorical predictor variable was used to model the change in total number of trainings in the three periods following introduction of SimBegin® level 1, 2 and 3, respectively. SPSS version 29.0.1.0 (171) and R version 4.3.3 were used for statistical analysis. A p-value ≤ 0.05 was considered significant. Results Following the initial SimBegin® training of the 15 national facilitators and facility champions, 464 HCWs participated in frequent and regular simulation sessions, referred to as recurrent participants. The simulation sessions described included all sessions regardless of medical topic. A total of 281 165 parturient women were enrolled in the study, 63 868 in baseline and 217 297 after start SBBC. The total number of maternal deaths was 291, i.e., 152 (240/100 000 births) in baseline and 139 (60/100 000 births) after start SBBC. Table 2 describes the incidence of maternal deaths at a regional level. Training frequencies After the start of SBBC implementation, 1220 simulation sessions featuring 6160 recurrent participants were documented (Table 1). A median of 186 (quartiles 102, 287) recurrent participants attended the simulation sessions per facility throughout the implementation period. The simulation sessions had an overall average attendance of 5 participants per session. A total of 591/1286 (46%) of all the simulation sessions had a HMS topic, focusing on management of PPH (n=283), antepartum bleeding (n=3), active management of third stage of labour (n=252), or eclampsia (n=53). In total, 3293/6231 (53%) recurrent participants attended the HMS simulation sessions. This translates to an average attendance of 7 HMS related sessions per healthcare worker during the implementation period. The overall frequency of simulation sessions increased significantly after implementation of the different levels of SimBegin®, i.e., an average of 1.9, 9.8 , and 56 trainings/month (P<0.001) were documented after introduction of Level 1, 2 and 3, respectively (Fig 3). On average 2 (SD 3) simulation sessions and 8 (SD 15) participants were documented per facility per month. However, with large differences between the facilities, illustrated by a median of 0 (quartiles 0,2) simulation sessions per month. Time from the initial SBBC training (start of implementation) in the regions to uptake of regular training within the facilities varied. Manyara, Geita, Shinyanga and Mwanza started simulation trainings immediately after SBBC implementation, while Tabora started simulation trainings in January 2022, 5 months post-implementation (Table 1). In Manyara, Geita, Shinyanga, and Mwanza there seem to be an increase in training frequency following the mentoring visits. In Tabora, an increase can be seen after five mentoring visits. Shinyanga had the highest average of (n=56) monthly recurrent participants and simulation sessions (n=13) (Table 1). Association between training frequency and maternal deaths Figures 4 and 5 shows the associations between the frequency of simulation sessions (Fig 4) and the number of recurrent participants (Fig 5) and maternal deaths the following month. For every one unit increase in the number of training sessions on log scale, the risk of maternal death next month decreased by 23% (risk ratio exp(-0.257)=0.77; P=0.0018). For every one unit increase in the number of recurrent participants on log scale, the risk of maternal death next month decreased by 16% (risk ratio exp(-0.16978)=0.84; P=0.0006). Discussion In this study, we document significant associations between the frequency of simulation sessions, the number of recurring participants and reduction in maternal deaths the following month. An overall reduction of 75% in maternal deaths from baseline to after implementation of SBBC has been reported ( 23 ), and we report a large increase in the number of simulation sessions over the same period. The training activities following the introduction of this program, was the only intervention targeting the maternal population, and we document a 23% and 16% reduced risk of maternal deaths the following month if the number of simulation sessions and recurrent participants, respectively, are increased with one unit on a logarithmic scale. An increase of one unit on log scale would correspond to for instance increasing from 1 to 3 trainings or from 4 to 11 trainings or going from 10 to 27 participants or from 20 to 54 participants. Frequency of simulation sessions This study documents a large number of simulation sessions following the introduction of the SimBegin® program. To the best of our knowledge, no other comparable program has previously reported – such numbers of simulation trainings over time in a low resource context. Despite a high burden of work for each of the 464 healthcare workers working in the 30 SBBC facilities at any time, the simulation sessions involved 6231 recurring participants over the 24–32 months of SBBC implementation. This is particularly interesting, given the very low provider-patient ratio typical for these contexts. There are some variations in the uptake and implementation of simulation training across the regions and between the facilities, but a previous SBBC study did not document any association between a high burden of work and simulation training frequencies in the various SBBC sites ( 37 ). We designed the SimBegin® facilitator training program based on existing evidence and previous practices. However, we did not have any experience in implementing simulation training in resource challenged contexts where few healthcare workers had no prior exposure to simulation or reflection-based debriefings. Our previous experiences from facilitator courses and faculty development programs, indicated that a common stand-alone train-the-facilitator training would not be sufficient to start simulation trainings. Therefore, an implementation strategy was designed for the purpose, and Fig. 3 demonstrates how the number of simulation sessions increased after conducting SimBegin® Level 2 and Level 3 trainings of selected facilitators. By this, we demonstrate the time, efforts, and follow up required to establish a system supporting frequent simulation training. The 15 national facilitators had stakeholder’s support from the Tanzanian ministry of health, professional bodies, regional and local healthcare authorities as well as local institutional support. They received mentoring and more advanced training (including advanced debriefing techniques, human factors/cognitive skills and social skills, and scenario-design) from simulation experts over time. As a result, their competency and confidence likely improved and benefitted the entire training cascade, leading to more frequent simulation training ( 23 , 24 ). We observed a decrease in frequency of simulation sessions towards the end of the study period, and this is a concern that requires follow up. The SBBC program is currently scaled up to 150 facilities, including a continuation of the initial 30 sites, allowing for further monitoring and evaluation over time. If the goal is to use simulation methodology appropriately and to improve quality of care, a current recommendation is to train those who are involved in facilitating simulation activities ( 17 ). The 2023 Association for Simulated Practice in Healthcare (ASPIH) standard states that facilitators should receive facilitator training, learning how to establishing psychological safety and conduct debriefing ( 38 ). Due to limited resources, we were not able to formally train all the local facility champions as Level 1 facilitators through the SimBegin® program. However, the national facilitators reported that the champions seemed to have learned by participating in simulation sessions conducted by the national facilitators during mentoring visits. This learning methodology is well known and described by Bandura ( 39 ). We believe that the limited number of pre-written scenarios available in the facilities (only four in the initial phase) in combination with the easy-to-follow SimBegin® debriefing framework (named CORE) and printed cue-cards used as cognitive aids, made it easier for the champions to learn how to run simulation sessions and structured reflection driven debriefings. Since this learning process did not follow a specific structure or schedule, it might have contributed to what seems to be a slow uptake following the introduction of different Levels of SimBegin®, as indicated in Fig. 3 and Table 1. Despite the high number of simulation sessions reported in this study, we still think that there are unreleased potential and that the number of sessions could increase. Previous research from high resource contexts have found weekly simulation training to be feasible, and to improve patient outcomes ( 40 , 41 ). We believe that this frequency may be possible also in a low resource context. As indicated in Table 1, we were able to reach an average of 2 (SD 3) team-simulations and 8 (SD 15) participants per month across the 30 SBBC sites. We believe that a formal facilitator training will improve competence and confidence of the facilitators and that again will foster motivation to conduct more simulation sessions. Future studies are needed to investigate these associations. The association between frequency of simulation sessions and reduced maternal mortality This is the first study to our knowledge demonstrating an association between frequency of simulation sessions, number of recurring participants, and reduction in maternal mortality rates. The more simulation sessions conducted at the SBBC sites, the fewer mothers died the following month. The steep initial reduction in maternal deaths shows that the impact per added simulation session or participant is highest when the numbers of sessions or participants are low. We believe several factors enforced the impact of the simulation sessions. The systematic weekly review of own data with the healthcare workers might have contributed to ownership to performance gaps revealed during these discussions, thus motivating training aiming to close these gaps. In addition to medical topics, the simulation sessions focused on team skills. All pre-written scenarios provided in the SBBC project had one team skill focused learning objective in addition to medical objectives. A series of studies from Brogaard and colleagues on obstetric emergencies found significant association between clinical teams’ team (non-technical) skills and team performance regardless of type of incident ( 42 – 45 ). By strengthening the team (non-technical) skills of the clinical team, the clinical performance is also improved regardless of the nature of the medical emergency. Systematic QI efforts and the utilisation of the Circle of Learning as a QI tool The SBBC training components and the systematic QI efforts were the only interventions in the SBBC bundle addressing maternal emergencies. The Circle of Learning was introduced as a translational tool, used to identify and categorise clinical gaps through a deliberate practice approach, and to use suitable training methods when designing training to close the gaps ( 46 ). The results indicate that the systematic efforts led to increased quality of care and improved patient outcomes ( 23 ). Another SBBC study reported that frequent simulation trainings empowered midwives ( 47 ). Through increased knowledge, skills and confidence, the midwifes were enabled to treat life threatening conditions like PPH without having to wait for a physician to do the life-saving interventions like removal of a retained placenta. The training also triggered a cultural shift from a “blame and shame” into a more learning culture. The healthcare workers reported increased psychological safety ( 47 ). A significant improvement in documentation of various patient indicators and outcomes was also found post SBBC implementation (Table 2 ) ( 48 ). A newly published Cocrane review on implementation models to prevent, detect and treat PPH, could not document any strategies leading to improved maternal outcomes ( 49 ). We believe the SBBC implementation model differs from the included studies in several ways, i.e., 1) proper training of facilitators through the SimBegin program, 2) leading to frequent simulation trainings followed by reflective debriefs, 3) with systematic data-driven QI efforts using the Circle of Learning approach led by the local staff, 4) with regular support and mentorship visits, and finally 5) close collaboration with national health authorities. Strengths and limitations The large patient population, inclusion of different levels of health facilities (Health centres, district and regional hospitals), a study period of 2–2,5 years, and high number of team-simulation sessions strengthen the findings in this study. The project had decision-makers endorsement from the Ministry of Health, local project lead, local follow up and mentoring. This facilitated a good overview and control of potential confounding non SBBC interventions or trainings in the healthcare facilities during the data collection period. No such confounders were identified or reported. Limitations of this study: The manual documentation in logbooks added extra burden of work to the facility champions after conducting the simulation sessions, and we believe this might have led to missing documentation of trainings. We did not have a system to identify the individual simulation attendants, and we could not identify how many trainings each of the 464 healthcare workers attended as recurrent participants. Conclusion This study indicates that the introduction of the SimBegin® program and the implementation strategy led to frequent and regular simulation sessions in the 30 SBBC facilities. A higher frequency of simulation trainings and number of recurrent participants were associated with reduced maternal deaths the following month. Further research is needed to investigate how the potential training capacity can be utilised more efficiently and how documentation of the training activities might improve. Abbreviations SBBC Safer Births Bundle of Care CQI continuous quality improvement WHO World Health Organization QI Quality improvement PPH postpartum haemorrhage TAMA Tanzanian Midwifery Association (nevnt en gang, må vi ha med forkortelse?) PAT Pediatric Associations of Tanzania (nevnt en gang, må vi ha med forkortelse?) AGOTA Association of Obstetricians and Gynaecology (nevnt en gang, må vi ha med forkortelse?) HBB Helping Babies Breathe HMS BAB Helping Mothers Survive Bleeding after Birth ASPIH The Association for Simulated Practice in Healthcare Declarations Acknowledgements We would like to acknowledge the national trainers and the healthcare workers involved in the work on ground in the 30 healthcare facilities. We would also like to thank Haydom Lutheran Hospital for all the organizing and warm hospitality for all SBBC staff and researchers during training sessions and meetings. Data availability The data that support the findings of this study are available from Haydom Lutheran Hospital, Research Department but restriction apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of Haydom Lutheran Hospital, Research Department Funding The main SBBC project was funded by The World Bank Global Financing Facility for Women, Children and Adolescents (Grant number TZA/PCA202066/HPD2020107). The funder had no role in the design or conduct of this study. KT and FSK hold an unconditional PhD grant from the Laerdal Foundation (Grant number 2022-0100). Author information Contributions Study conception, design and plan by KT, HE, BK and DØ. Acquisition and quality approval of data by KT, RM, FSK. Analysis and interpretation of data by JTK, KT, HE, BK, RM, DØ. KT drafted the manuscript, and all authors contributed in revisions and approval of the final manuscript as submitted. Corresponding author Kjetil Torgeirsen - [email protected] Ethics declarations The study was approved by ethical committees in Tanzania (Ref. NIMR/HQ/R.8a/ Vol.IX/3458) and Norway (Ref. REK West. 229725), and by COSTECH (CST00000555-2024-2024-00892). Consent for publication Not applicable Competing interests The authors declare no competing interest References World Health Organization. WHO Guidelines Approved by the Guidelines Review Committee. Geneva: World Health Organization, Licence: CC BY-NC-SA 3.0 IGO 2023. Maternal mortality: WHO; 2023. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality . Assessed 27 June 2025. World Health Organization. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF. 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Born not breathing: a randomised trial comparing two self-inflating bag-masks during newborn resuscitation in Tanzania. Resuscitation. 2017;116:66–72. Kamala BA, Moshiro R, Kalabamu FS, Kjetil T, Guga G, Githiri B, et al. Practice, Experiences, and Facilitators of Simulation-Based Training During One Year of Implementation in 30 Hospitals in Tanzania. SAGE Open Nursing. 2025;11:23779608241309447. Diaz-Navarro C, Laws-Chapman C, Moneypenny M, Purva M. The ASPiH Standards-2023: guiding simulation-based practice in health and care. Int J Healthc Simul. 2024:1–12. Bandura A, Walters RH. Social learning theory: Prentice-hall Englewood Cliffs, NJ; 1977. Ajmi SC, Advani R, Fjetland L, Kurz KD, Lindner T, Qvindesland SA, et al. Reducing door-to-needle times in stroke thrombolysis to 13 min through protocol revision and simulation training: a quality improvement project in a Norwegian stroke centre. BMJ quality & safety. 2019;28(11):939–48. Theilen U, Fraser L, Jones P, Leonard P, Simpson D. Regular in-situ simulation training of paediatric Medical Emergency Team leads to sustained improvements in hospital response to deteriorating patients, improved outcomes in intensive care and financial savings. Resuscitation. 2017;115:61–7. Brogaard L, Hvidman L, Esberg G, Finer N, Hjorth-Hansen KR, Manser T, et al. Teamwork and adherence to guideline on newborn resuscitation—video review of neonatal interdisciplinary teams. Frontiers in Pediatrics. 2022;10:828297. Brogaard L, Rosvig L, Hjorth-Hansen KR, Hvidman L, Hinshaw K, Kierkegaard O, et al. Team performance during vacuum-assisted vaginal delivery: Video review of obstetric multidisciplinary teams. Frontiers in Medicine.11:1330457. Brogaard L, Kierkegaard O, Hvidman L, Jensen K, Musaeus P, Uldbjerg N, et al. The importance of non-technical performance for teams managing postpartum haemorrhage: video review of 99 obstetric teams. BJOG: An International Journal of Obstetrics & Gynaecology. 2019;126(8):1015–23. Hjorth-Hansen KR, Rosvig L, Hvidman L, Kierkegaard O, Uldbjerg N, Manser T, et al. Video analysis of real‐life shoulder dystocia to assess technical and non‐technical performance. Acta Obstetricia et Gynecologica Scandinavica. 2024. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic medicine. 2004;79(10):S70-S81. Mdoe P, Mduma E, Rivenes Lafontan S, Ersdal H, Massay C, Daudi V, et al., editors. Healthcare Workers’ Perceptions on the “SaferBirths Bundle of Care”: A Qualitative Study. Healthcare; 2023: MDPI. Kamala BA, Ersdal H, Moshiro R, Mduma E, Baker U, Guga G, et al., editors. Improvements in Obstetric and Newborn Health Information Documentation following the Implementation of the Safer Births Bundle of Care at 30 Facilities in Tanzania. Healthcare; 2024: MDPI. Semrau K, Litman E, Molina RL, Marx Delaney M, Choi L, Robertson L, et al. Implementation strategies for WHO guidelines to prevent, detect, and treat postpartum hemorrhage. Cochrane Database of Systematic Reviews. 2025(2, 2025). Tables Table 1 is available in the Supplementary Files section. Table 2 . Study periods, included women, and maternal deaths by region Region Time period Included women Missing outcome data Maternal deaths Maternal survival Manyara Baseline 01.03.21 06.06.21 3928 438 (11,2) 6 (0,15) 3484 (88.7) Implementation 07.06.21 31.12.23 36449 114 (0,31) 12 (0,03) 36323 (99.65) Tabora Baseline 01.03.21 15.08.21 6497 56 (0,86) 9 (0.14) 6432 (99) Implementation 16.08.21 31.12.23 42190 265 (0.63) 54 (0.13) 41871 (99.24) Geita Baseline 01.03.21 14.11.21 17869 60 (0.34) 28 (0.56) 17781 (99.51) Implementation 15.11.21 31.12.23 63137 35 (0.06) 27 (0.04) 63075 (99.90) Shinyanga Baseline 01.03.21 30.01.22 15360 998 (6.5) 43 (0.28) 14319 (93.22) Implementation 01.02.22 31.12.23 34875 60 80.17) 22 (0.06) 34793 (99.76) Mwanza Baseline 01.03.21 06.02.23 20126 101 8 (0.50) 66 (0.33) 19959 (99.17) Implementation 07.02.23 31.12.23 40646 142 (0.35) 24 (0.06) 40480 (99.59) All regions Baseline 01.03.21 06.02.22 63868 1653 (2.6) 152 (0.24) 62063 (97.17) Implementation 07.06.21 31.12.23 217297 616 (0.28) 139 (0.06) 216542 (99.65) Total 01.03.21 31.12.23 281165 2269 (0.81) 291 (0.10) 278605 (99.09) Study periods for each region, number of included women in baseline and implementation, number of women with missing outcome information, and maternal deaths during baseline and after start implementation. Cases are showed as numbers (percentages). Additional Declarations No competing interests reported. Supplementary Files Table1HCWtrainedandnumberofteamsimulationsessionsregionallevel.docx Cite Share Download PDF Status: Published Journal Publication published 14 Nov, 2025 Read the published version in Advances in Simulation → Version 1 posted Editorial decision: Revision requested 04 Sep, 2025 Reviews received at journal 03 Sep, 2025 Reviewers agreed at journal 03 Sep, 2025 Reviews received at journal 15 Jul, 2025 Reviewers agreed at journal 15 Jul, 2025 Reviewers agreed at journal 14 Jul, 2025 Reviewers invited by journal 08 Jul, 2025 Editor assigned by journal 27 Jun, 2025 Submission checks completed at journal 27 Jun, 2025 First submitted to journal 27 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6990205","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":482467312,"identity":"e9fa465d-8d22-420d-ac0a-9d0aa71966ff","order_by":0,"name":"Kjetil Torgeirsen","email":"data:image/png;base64,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","orcid":"","institution":"SAFER simulation center","correspondingAuthor":true,"prefix":"","firstName":"Kjetil","middleName":"","lastName":"Torgeirsen","suffix":""},{"id":482467313,"identity":"c3f22ea5-a704-42ab-93e1-01a455e3599c","order_by":1,"name":"Benjamin Kamala","email":"","orcid":"","institution":"Haydom Lutheran Hospital","correspondingAuthor":false,"prefix":"","firstName":"Benjamin","middleName":"","lastName":"Kamala","suffix":""},{"id":482467314,"identity":"d01bc0e7-060a-4eba-b5d1-b60574d27869","order_by":2,"name":"Estomih Mduma","email":"","orcid":"","institution":"Haydom Lutheran Hospital","correspondingAuthor":false,"prefix":"","firstName":"Estomih","middleName":"","lastName":"Mduma","suffix":""},{"id":482467315,"identity":"9516dd64-63e8-42ff-8ec7-a5454e37acdf","order_by":3,"name":"Florence Salvatory Kalabamu","email":"","orcid":"","institution":"Muhimbili University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Florence","middleName":"Salvatory","lastName":"Kalabamu","suffix":""},{"id":482467316,"identity":"0ebea5ee-98e7-4db0-bb2e-86ab5a33fd0e","order_by":4,"name":"Robert Moshiro","email":"","orcid":"","institution":"Muhimbili University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"Moshiro","suffix":""},{"id":482467317,"identity":"550f2e4c-139e-4285-8edf-6e31c60e1197","order_by":5,"name":"Doris Østergaard","email":"","orcid":"","institution":"University of Copenhagen","correspondingAuthor":false,"prefix":"","firstName":"Doris","middleName":"","lastName":"Østergaard","suffix":""},{"id":482467318,"identity":"bff99cc2-585c-45f1-86fa-4d8f6c4e8a04","order_by":6,"name":"Jan Terje Kvaløy","email":"","orcid":"","institution":"Stavanger University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jan","middleName":"Terje","lastName":"Kvaløy","suffix":""},{"id":482467319,"identity":"3ae06f66-8a74-4688-b2d9-083aabf61d2c","order_by":7,"name":"Hege Langli Ersdal","email":"","orcid":"","institution":"University of Stavanger","correspondingAuthor":false,"prefix":"","firstName":"Hege","middleName":"Langli","lastName":"Ersdal","suffix":""}],"badges":[],"createdAt":"2025-06-27 09:38:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6990205/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6990205/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s41077-025-00387-7","type":"published","date":"2025-11-14T15:58:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":86659289,"identity":"03b37b1d-a2dc-44f5-92b2-008d58343b84","added_by":"auto","created_at":"2025-07-14 10:30:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":38888,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTraining intervention timeline\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverview of the implementation of the SBBC training components intervention for national facilitators and local facility champions.\u003c/p\u003e\n\u003cp\u003eThe initial training consisted of a 12-day training program conducted at Haydom Lutheran Hospital in February 2021. The national facilitators were trained to a level of master trainers of the SBBC tools, the HBB, and the HMS BAB programs. Team simulation training was introduced through the SimBegin® Level 1 training program by simulation experts from SAFER simulation center. The simulation sessions used the following framework: brief, scenario and a structured reflection-based debrief.\u003c/p\u003e\n\u003cp\u003eIn November 2021, the national facilitators completed SimBegin® Level 2 training, enabling them to mentor facility champions responsible for frequent onsite team-simulation sessions at the 30 SBBC facilities.\u003c/p\u003e\n\u003cp\u003eIn March 2022, eight of the national facilitators were selected and trained to a faculty/educator level, i.e., SimBegin® Level 3, competent to train new facilitators in Level 1 simulation methodology.\u003c/p\u003e\n\u003cp\u003eBetween May 2021 and January 2022, 90 selected facility champions (two-three from each facility) were trained by the national facilitators for six days at Haydom Lutheran Hospital. During these days, the facility champions underwent HBB and HMS BAB training, including theory and skill-training, and the use of the innovative SBBC clinical tools. They also got an introduction to simulation training.\u003c/p\u003e","description":"","filename":"Figure1Traininginterventiontimeline.png","url":"https://assets-eu.researchsquare.com/files/rs-6990205/v1/6fb2125a82c4d204a26fb01c.png"},{"id":86657300,"identity":"a6978abc-be37-4f02-99e2-3eaead92607e","added_by":"auto","created_at":"2025-07-14 10:22:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":45772,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe Circle of Learning\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe SimBegin program equips facilitators and mentors with tools to categorize clinical gaps and to plan training using the Circle of Learning. This framework focuses on five key areas:\u003c/p\u003e\n\u003cp\u003e1)\u003cstrong\u003eHealthcare quality improvement\u003c/strong\u003e, where SimBegin participants learn to identify gaps using clinical performance indicators.\u003c/p\u003e\n\u003cp\u003e2) \u003cstrong\u003eKnowledge acquisition\u003c/strong\u003e, ensuring healthcare workers have the necessary knowledge for clinical problem-solving 3) S\u003cstrong\u003ekills proficiency \u003c/strong\u003eensuring healthcare workers master necessary skills to handle medical challenges presented in the simulation scenario. SimBegin mentors are trained to use Peyton’s method for design of effective skill-training.\u003c/p\u003e\n\u003cp\u003e4) \u003cstrong\u003eSimulation in teams\u003c/strong\u003e, where healthcare workers can care for simulated patients in collaboration with others in a simulated relevant environment where they need to practice their knowledge and clinical skills.\u003c/p\u003e\n\u003cp\u003e5) \u003cstrong\u003eClinical care\u003c/strong\u003e. Team simulations foster non-technical skills and are believed to be a driver for transformation of training learning outcomes into \u003cstrong\u003eclinical care\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eBy teaching SimBegin participants how to plan and run a pre-written scenario, do reflective debriefing, mentoring, and facilitator training SimBegin helps improve clinical performance, ensuring healthcare teams are better prepared to address medical challenges.\u003c/p\u003e","description":"","filename":"Figure2CoL.png","url":"https://assets-eu.researchsquare.com/files/rs-6990205/v1/24fa45fa91627cd8caa8a53c.png"},{"id":86659291,"identity":"a93be446-1b51-48f1-beae-e5937be9aaea","added_by":"auto","created_at":"2025-07-14 10:30:56","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":57823,"visible":true,"origin":"","legend":"\u003cp\u003eIntroduction of the different SimBegin leves and number of team-simulation sessions in all regions.\u003c/p\u003e\n\u003cp\u003eAt the start of SBBC implementation in March 2021, all the 15 selected facilitators were trained in SimBegin Level 1 (green stippled line). SimBegin Level 2 training was provided to all the 15 facilitators in November 2021 (red stippled line), and in March 2022, 8/15 facilitators were trained in Level 3 (blue stippled line). Every dot represents the overall number of in-situ team simulation training sessions for consecutive months.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-6990205/v1/0820625792fa85d4c382f99f.png"},{"id":86659290,"identity":"0468e6fb-e830-493c-b462-75cdc6b41104","added_by":"auto","created_at":"2025-07-14 10:30:56","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":49566,"visible":true,"origin":"","legend":"\u003cp\u003eAssociation between maternal deaths and by region number of facilitator-led team-simulations.\u003c/p\u003e\n\u003cp\u003ePresents the number of all team-simulation sessions (both newborn resuscitation and maternal emergencies) by region versus maternal deaths the following month.\u003c/p\u003e\n\u003cp\u003eThe solid grey line illustrates the estimated logarithmic association between the number of training sessions per region per month and expected maternal deaths the following month, with pointwise 95% confidence intervals added as dashed lines. There are 6 facilities in each region, thus avalue of 30 trainings on the x-axis translates to an average of 5 trainings per facility per month. A value of 6 on the x-axis translates to an average of 1 training per facility per month.\u003c/p\u003e","description":"","filename":"Figure4Maternaldeathsvsnumberofteamsimulationsessions1.png","url":"https://assets-eu.researchsquare.com/files/rs-6990205/v1/fd34dc9945f138ed325bf8ea.png"},{"id":86657306,"identity":"04eb0074-76fb-41f9-ad92-ff2fbef06f6c","added_by":"auto","created_at":"2025-07-14 10:22:56","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":52273,"visible":true,"origin":"","legend":"\u003cp\u003eAssociation between maternal deaths and by region number of recurrent participants in these sessions.\u003c/p\u003e\n\u003cp\u003ePresents the number of recurrent participants in the team-simulation sessions (both newborn resuscitation and maternal emergencies) by region versus maternal deaths the following month.\u003c/p\u003e\n\u003cp\u003eThe solid grey line illustrates the estimated logarithmic association between the number of recurrent participants per region per month and expected maternal deaths the following month, with pointwise 95% confidence intervals added as dashed lines. There are 6 facilities in each region, thus a value of 30 healthcare workers on the x-axis translates to an average of 5 recurrent participants per facility per month.\u003c/p\u003e","description":"","filename":"Figure4Maternaldeathsvsnumberofteamsimulationsessions2.png","url":"https://assets-eu.researchsquare.com/files/rs-6990205/v1/e8a88851b600882f1a7b7c78.png"},{"id":96105076,"identity":"7e3626b8-b39a-4b93-acea-81ea21bbb13c","added_by":"auto","created_at":"2025-11-17 16:08:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1104680,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6990205/v1/d8fc8b6e-1d97-4bac-aca6-c65cd47c667b.pdf"},{"id":86657299,"identity":"a3fcbb19-a07d-41e2-9aa8-3703fbf44799","added_by":"auto","created_at":"2025-07-14 10:22:56","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":26101,"visible":true,"origin":"","legend":"","description":"","filename":"Table1HCWtrainedandnumberofteamsimulationsessionsregionallevel.docx","url":"https://assets-eu.researchsquare.com/files/rs-6990205/v1/7e2b4e61cf1266db22519f92.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Frequency of team-simulation and reduction in maternal deaths following Safer Births Bundle of Care implementation – a prospective observational study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn 2020, an estimated 287 000 women died due to pregnancy and childbirth (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The burden of maternal deaths is high in Sub-Saharan African countries, where 70% of maternal deaths occur (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). For Tanzania, the reported numbers of maternal deaths were 104 per 100,000 live births in 2022 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) .\u003c/p\u003e\u003cp\u003eBleeding after birth is the leading cause of maternal deaths\u003c/p\u003e\u003cp\u003e. Globally, about 14\u0026nbsp;million women suffer from postpartum haemorrhage (PPH) each year, primarily caused by uterine atony (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The majority of PPH related deaths are preventable by timely and appropriate management following the WHO recommendations (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWHO has described poor quality healthcare as a global concern. Several human factors contribute to reduced patient safety, like communication breakdown, ineffective teamwork, and cognitive bias (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Simulation is recognized as an efficient training method to improve patient safety and as a component of continuous quality improvement (QI), targeting individual medical expertise skills -individual skills as well as social (communication, collaboration and leadership) and cognitive (situation awareness and decision making) -team skills (\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In this study, the term simulation is used to describe facilitator led, in-situ team simulation training.\u003c/p\u003e\u003cp\u003eCommon barriers for implementation of simulation-based training in healthcare are financial constraints, high burden of work, lack of simulation resources, and a need of more patient outcome oriented evidence supporting simulation training (\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePrevious Safer Births studies in Tanzania have indicated that frequent individual and team-simulation training are feasible in a low resource context and can impact clinical behaviour and patient outcomes (\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Nelissen et al found a 38% reduction of PPH and improved clinical outcomes after a half-day obstetric simulation training (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Another study found a limited clinical impact of low dose high frequency newborn resuscitation skill-training and demonstrated the need for frequent simulation sessions to improve outcomes (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn 2021, the SBBC program was introduced in five resource challenged regions in Tanzania, including 30 healthcare facilities. The bundle is a result of over a decade of multidisciplinary collaboration between institutions inside and outside Tanzania and consists of several components: Clinical innovations and a strategy for sustainable and scalable team-simulations and data-driven QI, aiming to improve quality of care around birth and reduce perinatal and maternal mortality (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSBBC included almost 300,000 births over a three-year period, and the recently published report documents a 75% reduction in maternal death within seven days postpartum (from 240/100,000 to 60/100,000 births) after full implementation of the program (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThe aim of this study was to describe the frequency of team-simulations and number of recurrent participants in the 30 facilities during SBBC implementation and investigate association to maternal death.\u003c/p\u003e\n\u003cp\u003eStudy design and participants\u003c/p\u003e\n\u003cp\u003eThis study is part of the SBBC stepped-wedge cluster randomised controlled implementation trial, which ran from March 1, 2021, to December 31, 2023 (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe study population included all healthcare workers and parturient women in the 30 healthcare facilities in five regions of Tanzania with a high burden of newborn and maternal deaths (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe training component of the SBBC program aims to strengthen competencies in day-of-birth emergency care through frequent individual skill-training and in-situ facilitator led team-simulation training sessions.\u003c/p\u003e\n\u003cp\u003eStudy interventions\u003c/p\u003e\n\u003cp\u003eThe SBBC program encompasses four main components: simulation training interventions, continuous QI efforts, innovative clinical tools, and systems for sustainability and scalability.\u003c/p\u003e\n\u003cp\u003eTraining of facilitators and healthcare workers\u003c/p\u003e\n\u003cp\u003eThrough the SimBegin\u0026reg; program, facilitators were trained to conduct simulation sessions for the team with reflection-based and structured debriefings, to identify learning needs and plan proper training interventions, and to train new facilitators. The SimBegin\u0026reg; program is designed to be highly scalable to increase accessibility and efficiency of simulation training. The goal is to establish a sustainable system for simulation training by training selected individuals to a level where they can train new facilitators. The SimBegin\u0026reg; program has a three steps design: Level 1 (becoming a facilitator), Level 2 (becoming a mentor) and Level 3 (becoming SimBegin\u0026reg; course faculty) training, with practicing of facilitator skills between each level (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e). The implementation of SimBegin\u0026reg; in SBBC followed an implementation strategy and a training cascade model, aiming to stimulate frequent interprofessional simulation sessions at the facilities.\u003c/p\u003e\n\u003cp\u003eThe flexibility of the SimBegin\u0026reg; program enabled us to conduct the initial training of the national facilitators online. Travelling restrictions due to the ongoing COVID 19 pandemic, prohibited simulation experts from Norway to travel abroad.\u003c/p\u003e\n\u003cp\u003eInitially, 15 members from the Tanzanian Midwifery Association (TAMA), Pediatric Associations of Tanzania (PAT), and Association of Obstetricians and Gynaecology (AGOTA) were selected to become national facilitators (completed SimBegin\u0026reg; Level 2 and 3), responsible for cascading the SBBC trainings and to mentor local facility champions at the SBBC facilities (Fig.\u0026nbsp;1). The training of national facilitators and facility champions also included Helping Babies Breathe (HBB) and Helping Mothers Survive Bleeding after Birth (HMS BAB) training and the use of SBBC clinical tools (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e). Four pre-written scenarios were provided, two HBB newborn resuscitation scenarios and two HMS BAB scenarios. In addition, scenarios addressing active management of third stage of labour, eclampsia and antepartum haemorrhage were designed during the study period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContinuous quality improvement and the Circle of Learning\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe local facility champions facilitated continuous QI loops utilising simulation-based training following strategies illustrated in the Circle of Learning model (Fig.\u0026nbsp;2) (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e). The circle of learning strategies aim to \u0026ldquo;bridge cognitive and skill-based learning with real-life clinical experience\u0026rdquo; (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e). The model leans towards theories related to experiential learning, competency- based education and training efficiency (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e). Kolb is about experiential learning, and his circle is also appropriate to explain what we do in simulations (experience \u0026ndash; reflection). Competency-based education is a movement away from exams (knowledge tests) \u0026ndash; trainees are able to do things (master) \u0026ndash; a combination of knowledge, skills and attitude.\u003c/p\u003e\n\u003cp\u003eQI areas were identified through weekly review of the SBBC facilities\u0026rsquo; own clinical data. A list of 52 quality indicators were provided every week and discussed in facility champion or national facilitator led debriefing sessions using a deliberate practice approach (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e). Through these discussions, clinical gaps were identified and categorized into sections: knowledge, individual skills, or team skills. Appropriate training interventions were planned, executed, and translated into clinical care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSBBC innovative tools\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSBBC introduced several innovative tools designed to improve quality of care and to support the training interventions. The innovations were co-created by clinicians in Tanzania, researchers and engineers from Norway, and produced by Laerdal Global Health, Stavanger, Norway.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eClinical tools:\u003c/h2\u003e\n \u003cp\u003eMoyo is a fetal heart rate monitor designed for intermittent or continuous monitoring. Moyo aims to detect fetal distress, to support timely decision-making, and reduce midwives\u0026rsquo; workload (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e). NeoBeat is a newborn heart rate monitor designed to detect heart rate, guiding resuscitation attempts, and to support timely decision-making (\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e). The Upright bag is a vertical bag-mask newborn ventilation device designed to improve mask seal and ventilation quality (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eTraining tools:\u003c/h3\u003e\n\u003cp\u003eThe NeoNatalie Live simulator is a newborn resuscitation simulator that provides feedback on the quality of ventilation, airway management, and time to first ventilation. The simulator records and uploads all training activities to a database (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e). MamaNatalie is a wearable simulator designed to practice the third stage of labour and complications like retained placenta and PPH (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e). Both simulators were used for individual skill-training and team simulations. No clinical tools were introduced for the maternal population, only the novel training component and the data-driven QI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSustainability and scalability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA close collaboration with local, regional, and national health authorities was established before the start of the program. The SBBC tools were distributed to all included facilities, and all training content aligned with national obstetric and newborn care guidelines. Each SBBC facility established a dedicated \u0026rdquo;training corner\u0026rdquo; in the labour ward. A mentorship program, aiming to develop and support the national facilitators continuously, were established. The facility champions and the maternity ward staff at the facilities received supervision visits from the national facilitators every third month where they received mentoring on clinical topics, clinical data, training, simulation, and the facilitator role.\u003c/p\u003e\n\u003cp\u003eData collection and management\u003c/p\u003e\n\u003cp\u003eThis study utilises observational data from March 01, 2021 through December 31, 2023, from the 30 SBBC sites. The overall data collection and management is described in the SBBC study protocol and the primary paper (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e). Every healthcare facility had two data collectors collecting routine provider registered clinical data on daily basis by using a case report file installed on mobile phones or tablets. Pre-implementation data collection started March 1st, 2021 at all sites. Start of SBBC implementation in the different regions is indicated in Table\u0026nbsp;1.\u003c/p\u003e\n\u003cp\u003eThe facility champions documented training activities in a facility-based training database on a regular basis. These data provided information about the simulation sessions. The database also documented how simulation training activities and continuous QI processes were implemented in the SBBC facilities.\u003c/p\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical analysis\u003c/h2\u003e\n \u003cp\u003eNumerical data were presented as numbers, means with standard deviations and medians, categorical data as numbers and proportions. The main analysis objective was to study the association between the number of trainings one month and maternal deaths the following month. A Poisson regression mixed model approach was used to analyse this relationship over time, taking into account dependency within regions and facilities. A logarithm transformation of the number of trainings was used for appropriate model fit. Furthermore, an ordinary Poisson regression model with period (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e and \u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) as categorical predictor variable was used to model the change in total number of trainings in the three periods following introduction of SimBegin\u0026reg; level 1, 2 and 3, respectively. SPSS version 29.0.1.0 (171) and R version 4.3.3 were used for statistical analysis. A p-value\u0026thinsp;\u0026le;\u0026thinsp;0.05 was considered significant.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFollowing the initial SimBegin\u0026reg; training of the 15 national facilitators and facility champions, 464 HCWs participated in frequent and regular simulation sessions, referred to as recurrent participants. The simulation sessions described included all sessions regardless of medical topic. A total of 281 165 parturient women were enrolled in the study, 63 868 in baseline and 217 297 after start SBBC. The total number of maternal deaths was 291, i.e., 152 (240/100 000 births) in baseline and 139 (60/100 000 births) after start SBBC. Table 2 describes the incidence of maternal deaths at a regional level.\u003c/p\u003e\n\u003ch2\u003eTraining frequencies\u003c/h2\u003e\n\u003cp\u003eAfter the start of SBBC implementation, 1220 simulation sessions featuring 6160 recurrent participants were documented (Table 1). A median of 186 (quartiles 102, 287) recurrent participants attended the simulation sessions per facility throughout the implementation period. The simulation sessions had an overall average attendance of 5 participants per session. A total of 591/1286 (46%) of all the simulation sessions had a HMS topic, focusing on management of PPH (n=283), antepartum bleeding (n=3), active management of third stage of labour (n=252), or eclampsia (n=53). In total, 3293/6231 (53%) recurrent participants attended the HMS simulation sessions. This translates to an average attendance of 7 HMS related sessions per healthcare worker during the implementation \u0026nbsp;period.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe overall frequency of simulation sessions increased significantly after implementation of the different levels of SimBegin\u0026reg;, i.e., an average of 1.9, \u0026nbsp;9.8 , and 56 trainings/month (P\u0026lt;0.001) were documented after introduction of Level 1, 2 and 3, respectively (Fig 3). On average 2 (SD 3) simulation sessions and 8 (SD 15) participants were documented per facility per month. However, with large differences between the facilities, illustrated by a median of 0 (quartiles 0,2) \u0026nbsp;simulation sessions per month.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTime from the initial SBBC training (start of implementation) in the regions to uptake of regular training within the facilities varied. Manyara, Geita, Shinyanga and Mwanza started simulation trainings immediately after SBBC implementation, while Tabora started simulation trainings in January 2022, 5 months post-implementation (Table 1). In Manyara, Geita, Shinyanga, and Mwanza there seem to be an increase in training frequency following the mentoring visits. In Tabora, an increase can be seen after five mentoring visits. Shinyanga had the highest average of (n=56) monthly recurrent participants and simulation sessions (n=13) (Table 1). \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAssociation between training frequency and maternal deaths\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eFigures 4 and 5 shows the associations between the frequency of simulation sessions (Fig 4) \u0026nbsp;and the number of recurrent participants (Fig 5) and maternal deaths the following month. For every one unit increase in the number of training sessions on log scale, the risk of maternal death next month decreased by 23% (risk ratio exp(-0.257)=0.77; P=0.0018). For every one unit increase in the number of recurrent participants on log scale, the risk of maternal death next month decreased by 16% (risk ratio exp(-0.16978)=0.84; P=0.0006).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we document significant associations between the frequency of simulation sessions, the number of recurring participants and reduction in maternal deaths the following month. An overall reduction of 75% in maternal deaths from baseline to after implementation of SBBC has been reported (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), and we report a large increase in the number of simulation sessions over the same period. The training activities following the introduction of this program, was the only intervention targeting the maternal population, and we document a 23% and 16% reduced risk of maternal deaths the following month if the number of simulation sessions and recurrent participants, respectively, are increased with one unit on a logarithmic scale. An increase of one unit on log scale would correspond to for instance increasing from 1 to 3 trainings or from 4 to 11 trainings or going from 10 to 27 participants or from 20 to 54 participants.\u003c/p\u003e\u003cp\u003eFrequency of simulation sessions\u003c/p\u003e\u003cp\u003eThis study documents a large number of simulation sessions following the introduction of the SimBegin\u0026reg; program. To the best of our knowledge, no other comparable program has previously reported \u0026ndash; such numbers of simulation trainings over time in a low resource context. Despite a high burden of work for each of the 464 healthcare workers working in the 30 SBBC facilities at any time, the simulation sessions involved 6231 recurring participants over the 24\u0026ndash;32 months of SBBC implementation. This is particularly interesting, given the very low provider-patient ratio typical for these contexts. There are some variations in the uptake and implementation of simulation training across the regions and between the facilities, but a previous SBBC study did not document any association between a high burden of work and simulation training frequencies in the various SBBC sites (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWe designed the SimBegin\u0026reg; facilitator training program based on existing evidence and previous practices. However, we did not have any experience in implementing simulation training in resource challenged contexts where few healthcare workers had no prior exposure to simulation or reflection-based debriefings. Our previous experiences from facilitator courses and faculty development programs, indicated that a common stand-alone train-the-facilitator training would not be sufficient to start simulation trainings. Therefore, an implementation strategy was designed for the purpose, and Fig.\u0026nbsp;3 demonstrates how the number of simulation sessions increased after conducting SimBegin\u0026reg; Level 2 and Level 3 trainings of selected facilitators. By this, we demonstrate the time, efforts, and follow up required to establish a system supporting frequent simulation training. The 15 national facilitators had stakeholder\u0026rsquo;s support from the Tanzanian ministry of health, professional bodies, regional and local healthcare authorities as well as local institutional support. They received mentoring and more advanced training (including advanced debriefing techniques, human factors/cognitive skills and social skills, and scenario-design) from simulation experts over time. As a result, their competency and confidence likely improved and benefitted the entire training cascade, leading to more frequent simulation training (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). We observed a decrease in frequency of simulation sessions towards the end of the study period, and this is a concern that requires follow up. The SBBC program is currently scaled up to 150 facilities, including a continuation of the initial 30 sites, allowing for further monitoring and evaluation over time.\u003c/p\u003e\u003cp\u003eIf the goal is to use simulation methodology appropriately and to improve quality of care, a current recommendation is to train those who are involved in facilitating simulation activities (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The 2023 Association for Simulated Practice in Healthcare (ASPIH) standard states that facilitators should receive facilitator training, learning how to establishing psychological safety and conduct debriefing (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Due to limited resources, we were not able to formally train all the local facility champions as Level 1 facilitators through the SimBegin\u0026reg; program. However, the national facilitators reported that the champions seemed to have learned by participating in simulation sessions conducted by the national facilitators during mentoring visits. This learning methodology is well known and described by Bandura (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). We believe that the limited number of pre-written scenarios available in the facilities (only four in the initial phase) in combination with the easy-to-follow SimBegin\u0026reg; debriefing framework (named CORE) and printed cue-cards used as cognitive aids, made it easier for the champions to learn how to run simulation sessions and structured reflection driven debriefings. Since this learning process did not follow a specific structure or schedule, it might have contributed to what seems to be a slow uptake following the introduction of different Levels of SimBegin\u0026reg;, as indicated in Fig.\u0026nbsp;3 and Table\u0026nbsp;1.\u003c/p\u003e\u003cp\u003eDespite the high number of simulation sessions reported in this study, we still think that there are unreleased potential and that the number of sessions could increase. Previous research from high resource contexts have found weekly simulation training to be feasible, and to improve patient outcomes (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). We believe that this frequency may be possible also in a low resource context. As indicated in Table\u0026nbsp;1, we were able to reach an average of 2 (SD 3) team-simulations and 8 (SD 15) participants per month across the 30 SBBC sites. We believe that a formal facilitator training will improve competence and confidence of the facilitators and that again will foster motivation to conduct more simulation sessions. Future studies are needed to investigate these associations.\u003c/p\u003e\u003cp\u003eThe association between frequency of simulation sessions and reduced maternal mortality\u003c/p\u003e\u003cp\u003eThis is the first study to our knowledge demonstrating an association between frequency of simulation sessions, number of recurring participants, and reduction in maternal mortality rates. The more simulation sessions conducted at the SBBC sites, the fewer mothers died the following month. The steep initial reduction in maternal deaths shows that the impact per added simulation session or participant is highest when the numbers of sessions or participants are low.\u003c/p\u003e\u003cp\u003eWe believe several factors enforced the impact of the simulation sessions. The systematic weekly review of own data with the healthcare workers might have contributed to ownership to performance gaps revealed during these discussions, thus motivating training aiming to close these gaps.\u003c/p\u003e\u003cp\u003eIn addition to medical topics, the simulation sessions focused on team skills. All pre-written scenarios provided in the SBBC project had one team skill focused learning objective in addition to medical objectives. A series of studies from Brogaard and colleagues on obstetric emergencies found significant association between clinical teams\u0026rsquo; team (non-technical) skills and team performance regardless of type of incident (\u003cspan additionalcitationids=\"CR43 CR44\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). By strengthening the team (non-technical) skills of the clinical team, the clinical performance is also improved regardless of the nature of the medical emergency.\u003c/p\u003e\u003cp\u003eSystematic QI efforts and the utilisation of the Circle of Learning as a QI tool\u003c/p\u003e\u003cp\u003eThe SBBC training components and the systematic QI efforts were the only interventions in the SBBC bundle addressing maternal emergencies. The Circle of Learning was introduced as a translational tool, used to identify and categorise clinical gaps through a deliberate practice approach, and to use suitable training methods when designing training to close the gaps (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). The results indicate that the systematic efforts led to increased quality of care and improved patient outcomes (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Another SBBC study reported that frequent simulation trainings empowered midwives (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Through increased knowledge, skills and confidence, the midwifes were enabled to treat life threatening conditions like PPH without having to wait for a physician to do the life-saving interventions like removal of a retained placenta. The training also triggered a cultural shift from a \u0026ldquo;blame and shame\u0026rdquo; into a more learning culture. The healthcare workers reported increased psychological safety (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). A significant improvement in documentation of various patient indicators and outcomes was also found post SBBC implementation (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e) (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA newly published Cocrane review on implementation models to prevent, detect and treat PPH, could not document any strategies leading to improved maternal outcomes (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). We believe the SBBC implementation model differs from the included studies in several ways, i.e., 1) proper training of facilitators through the SimBegin program, 2) leading to frequent simulation trainings followed by reflective debriefs, 3) with systematic data-driven QI efforts using the Circle of Learning approach led by the local staff, 4) with regular support and mentorship visits, and finally 5) close collaboration with national health authorities.\u003c/p\u003e\u003cp\u003eStrengths and limitations\u003c/p\u003e\u003cp\u003eThe large patient population, inclusion of different levels of health facilities (Health centres, district and regional hospitals), a study period of 2\u0026ndash;2,5 years, and high number of team-simulation sessions strengthen the findings in this study. The project had decision-makers endorsement from the Ministry of Health, local project lead, local follow up and mentoring. This facilitated a good overview and control of potential confounding non SBBC interventions or trainings in the healthcare facilities during the data collection period. No such confounders were identified or reported.\u003c/p\u003e\u003cp\u003eLimitations of this study: The manual documentation in logbooks added extra burden of work to the facility champions after conducting the simulation sessions, and we believe this might have led to missing documentation of trainings. We did not have a system to identify the individual simulation attendants, and we could not identify how many trainings each of the 464 healthcare workers attended as recurrent participants.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study indicates that the introduction of the SimBegin\u0026reg; program and the implementation strategy led to frequent and regular simulation sessions in the 30 SBBC facilities. A higher frequency of simulation trainings and number of recurrent participants were associated with reduced maternal deaths the following month. Further research is needed to investigate how the potential training capacity can be utilised more efficiently and how documentation of the training activities might improve.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSBBC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSafer Births Bundle of Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCQI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003econtinuous quality improvement\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eQI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eQuality improvement\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePPH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003epostpartum haemorrhage\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTAMA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTanzanian Midwifery Association (nevnt en gang, m\u0026aring; vi ha med forkortelse?)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePAT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePediatric Associations of Tanzania (nevnt en gang, m\u0026aring; vi ha med forkortelse?)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAGOTA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAssociation of Obstetricians and Gynaecology (nevnt en gang, m\u0026aring; vi ha med forkortelse?)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHBB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHelping Babies Breathe\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHMS BAB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHelping Mothers Survive Bleeding after Birth\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eASPIH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eThe Association for Simulated Practice in Healthcare\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe would like to acknowledge the national trainers and the healthcare workers involved in the work on ground in the 30 healthcare facilities. We would also like to thank Haydom Lutheran Hospital for all the organizing and warm hospitality for all SBBC staff and researchers during training sessions and meetings.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData availability\u003c/h2\u003e\n\u003cp\u003eThe data that support the findings of this study are available from Haydom Lutheran Hospital, Research Department but restriction apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of Haydom Lutheran Hospital, Research Department\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe main SBBC project was funded by The World Bank Global Financing Facility for Women, Children and Adolescents (Grant number TZA/PCA202066/HPD2020107). The funder had no role in the design or conduct of this study. KT and FSK hold an unconditional PhD grant from the Laerdal Foundation (Grant number 2022-0100).\u003c/p\u003e\n\u003ch2\u003eAuthor information\u003c/h2\u003e\n\u003ch2\u003eContributions\u003c/h2\u003e\n\u003cp\u003eStudy conception, design and plan by KT, HE, BK and D\u0026Oslash;. Acquisition and quality approval of data by KT, RM, FSK. Analysis and interpretation of data by JTK, KT, HE, BK, RM, D\u0026Oslash;. KT drafted the manuscript, and all authors contributed in revisions and approval of \u0026nbsp;the final manuscript as submitted.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eCorresponding author\u003c/h2\u003e\n\u003cp\u003eKjetil Torgeirsen - [email protected]\u003c/p\u003e\n\u003ch2\u003eEthics declarations\u003c/h2\u003e\n\u003cp\u003eThe study \u0026nbsp;was approved by ethical committees in Tanzania (Ref. NIMR/HQ/R.8a/ Vol.IX/3458) and Norway (Ref. REK West. 229725), and by COSTECH (CST00000555-2024-2024-00892).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare no competing interest\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. WHO Guidelines Approved by the Guidelines Review Committee. Geneva: World Health Organization, Licence: CC BY-NC-SA 3.0 IGO 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMaternal mortality: WHO; 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/maternal-mortality\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/maternal-mortality\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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Acta Obstetricia et Gynecologica Scandinavica. 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEricsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic medicine. 2004;79(10):S70-S81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMdoe P, Mduma E, Rivenes Lafontan S, Ersdal H, Massay C, Daudi V, et al., editors. Healthcare Workers\u0026rsquo; Perceptions on the \u0026ldquo;SaferBirths Bundle of Care\u0026rdquo;: A Qualitative Study. Healthcare; 2023: MDPI.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKamala BA, Ersdal H, Moshiro R, Mduma E, Baker U, Guga G, et al., editors. Improvements in Obstetric and Newborn Health Information Documentation following the Implementation of the Safer Births Bundle of Care at 30 Facilities in Tanzania. Healthcare; 2024: MDPI.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSemrau K, Litman E, Molina RL, Marx Delaney M, Choi L, Robertson L, et al. Implementation strategies for WHO guidelines to prevent, detect, and treat postpartum hemorrhage. Cochrane Database of Systematic Reviews. 2025(2, 2025).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. Study periods, included women, and maternal deaths by region\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"696\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRegion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime period\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIncluded women\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMissing outcome data\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal deaths\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal survival\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eManyara\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e01.03.21\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e06.06.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003e3928\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e438 (11,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e6 (0,15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e3484 (88.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e07.06.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e31.12.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003e36449\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e114 (0,31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e12 (0,03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e36323 (99.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTabora\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e01.03.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e15.08.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003e6497\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e56 (0,86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e9 (0.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e6432 (99)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e16.08.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e31.12.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003e42190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e265 (0.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e54 (0.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e41871 (99.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeita\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e01.03.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e14.11.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003e17869\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e60 (0.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e28 (0.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e17781 (99.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e15.11.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e31.12.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003e63137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e35 (0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e27 (0.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e63075 (99.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eShinyanga\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e01.03.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e30.01.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003e15360\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e998 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e43 (0.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e14319 (93.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e01.02.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e31.12.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003e34875\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e60 80.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e22 (0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e34793 (99.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMwanza\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e01.03.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e06.02.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003e20126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e101 8 (0.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e66 (0.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e19959 (99.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e07.02.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e31.12.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003e40646\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e142 (0.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e24 (0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e40480 (99.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll regions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e01.03.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e06.02.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003e63868\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1653 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e152 (0.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e62063 (97.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e07.06.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e31.12.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003e217297\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e616 (0.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e139 (0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e216542 (99.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e01.03.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e31.12.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003e281165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e2269 (0.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003e291 (0.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003e278605 (99.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cp\u003eStudy periods for each region, number of included women in baseline and implementation, number of women with missing outcome information, and maternal deaths during baseline and after start implementation. Cases are showed as numbers (percentages).\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"advances-in-simulation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"asim","sideBox":"Learn more about [Advances in Simulation](http://advancesinsimulation.biomedcentral.com/)","snPcode":"41077","submissionUrl":"https://submission.springernature.com/new-submission/41077/3","title":"Advances in Simulation","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6990205/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6990205/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eSafer 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e 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.\u003c/p\u003e\n\u003cp\u003eClinical 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutput measures\u003c/strong\u003e were the frequency of simulation sessions, the number of recurring participants, and maternal death within 7 days postpartum the following month.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOverall, 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).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: 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.\u003c/p\u003e\n\u003cp\u003eSBBC main protocol ISRCTN Registry: ISRCTN30541755. 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