Comparing Low-Fidelity and High-Fidelity Simulation to Standard Training in Obstetric Emergencies: A Systematic Review

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Data may be preliminary. 11 August 2025 V1 Latest version Share on Comparing Low-Fidelity and High-Fidelity Simulation to Standard Training in Obstetric Emergencies: A Systematic Review Authors : Safi Ullah Khan 0009-0007-0025-1749 [email protected] , Deepa Lachhman Das , Kinza Tanveer , Amna Kashif , Faiqa Hassan 0009-0004-5912-2966 , and Alina Batool 0009-0009-7179-3662 Authors Info & Affiliations https://doi.org/10.22541/au.175491763.34365560/v1 308 views 173 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background: Simulation-based training is increasingly used to enhance clinical competence in obstetric emergencies, yet evidence comparing high- and low-fidelity simulation against standard training remains fragmented. Objectives: To systematically evaluate the effectiveness of high-fidelity and low-fidelity simulation-based training compared with standard non-simulation training in improving knowledge, clinical skills, confidence, teamwork and communication among healthcare professionals managing obstetric emergencies. Search strategy: A comprehensive search of PubMed, Cochrane CENTRAL, Embase and Scopus was conducted from inception to 30 May 2025. Reference lists of relevant studies were also screened. Selection criteria: Randomised controlled trials (RCTs) or quasi-RCTs comparing high- or low-fidelity simulation with standard training for obstetric emergencies were eligible. Studies had to report at least one quantitative outcome related to knowledge, skills, confidence, teamwork, communication or patient outcomes. Data collection and analysis: Two reviewers independently screened, extracted data and assessed risk of bias using the Cochrane RoB 2.0 tool. Due to substantial heterogeneity in study design, populations and outcomes, results were narratively synthesised. Main results: Sixteen RCTs including 1,453 participants met the inclusion criteria. Eleven studies evaluated high-fidelity simulation; five examined low-fidelity simulation. Most studies demonstrated significant improvements in knowledge acquisition, clinical skills, confidence and teamwork compared to standard training. High-fidelity simulation was generally associated with greater improvements than low-fidelity approaches. Risk of bias was predominantly low, with some concerns for selective reporting. Conclusions: Simulation-based training, particularly high-fidelity modalities, appears to enhance learning and performance in obstetric emergencies compared with standard training. Further research should address long-term retention, patient-centred outcomes and cost-effectiveness. Full Title: Comparing Low-Fidelity and High-Fidelity Simulation to Standard Training in Obstetric Emergencies: A Systematic Review Running Title: Simulation Fidelity in Obstetric Emergencies Authors: Safi Ullah Khan 1 , Deepa Lachhman Das 2 , Kinza Tanveer 3 , Amna Kashif 4 , Faiqa Hassan 4 , Alina Batool 5 Affiliations: 1 Bahria University Medical College, Karachi, Pakistan 2 Indus Medical College, TMK, Pakistan 3 Karachi Metropolitan University, Karachi, Pakistan 4 Jinnah Sindh Medical University, Karachi, Pakistan 5 Khyber Girls Medical College, Peshawar, Pakistan Corresponding Author: Safi Ullah Khan Bahria University Medical College, Karachi, Pakistan +923226906520 Email: [email protected] ORCID IDs: Safi Ullah Khan: 0009-0007-0025-1749 Deepa Lachhman Das: 0009-0001-5087-5273 Kinza Tanveer: 0009-0003-9176-1605 Amna Kashif: 0009-0001-6799-4965 Faiqa Hassan: 0009-0004-5912-2966 Alina Batool: 0009-0009-7179-3662 Word Count: 3950 PROSPERO Registration: CRD420251069240 Funding: This research did not receive any external funding. Background: Simulation-based training is increasingly used to enhance clinical competence in obstetric emergencies, yet evidence comparing high- and low-fidelity simulation against standard training remains fragmented. Objectives: To systematically evaluate the effectiveness of high-fidelity and low-fidelity simulation-based training compared with standard non-simulation training in improving knowledge, clinical skills, confidence, teamwork and communication among healthcare professionals managing obstetric emergencies. Search strategy: A comprehensive search of PubMed, Cochrane CENTRAL, Embase and Scopus was conducted from inception to 30 May 2025. Reference lists of relevant studies were also screened. Selection criteria: Randomised controlled trials (RCTs) or quasi-RCTs comparing high- or low-fidelity simulation with standard training for obstetric emergencies were eligible. Studies had to report at least one quantitative outcome related to knowledge, skills, confidence, teamwork, communication or patient outcomes. Data collection and analysis: Two reviewers independently screened, extracted data and assessed risk of bias using the Cochrane RoB 2.0 tool. Due to substantial heterogeneity in study design, populations and outcomes, results were narratively synthesised. Main results: Sixteen RCTs including 1,453 participants met the inclusion criteria. Eleven studies evaluated high-fidelity simulation; five examined low-fidelity simulation. Most studies demonstrated significant improvements in knowledge acquisition, clinical skills, confidence and teamwork compared to standard training. High-fidelity simulation was generally associated with greater improvements than low-fidelity approaches. Risk of bias was predominantly low, with some concerns for selective reporting. Conclusions: Simulation-based training, particularly high-fidelity modalities, appears to enhance learning and performance in obstetric emergencies compared with standard training. Further research should address long-term retention, patient-centred outcomes and cost-effectiveness. Funding: No external funding was received for this project. Keywords: Obstetric Emergencies, Low Fidelity Simulation, High Fidelity Simulation, Systematic Review INTRODUCTION: The simulation-based training enhances the learning experiences and clinical competency of healthcare professionals by mimicking clinical scenarios. These practices increase patients’ safety and provide a broad area to improve skills and confidence to make decisions in managing variable clinical scenarios [1]. One of the fields that require simulation training to improve practicing skills is obstetrician, which aims towards the health of mothers and children and reduces anxiety among clinicians in high-stakes clinical environments [2]. Simulation in nursing is categorized into 3 levels based on fidelity, low-fidelity, moderate fidelity and high fidelity. These categories are differentiated based on resemblance to real life. Low-fidelity uses non-computer manikins, moderate-fidelity uses standardized patients and high-fidelity uses computerized manikins showing real-life findings like breathing sounds, heartbeats, etc. [3]. While multiple RCTs address the comparison of either high-fidelity or low fidelity with standard simulator or non-simulator based training, the data has not been systemically reviewed. This systemic review will provide clarity to the fragmented data by evaluating all possible outcomes. Early clinical trials have demonstrated outcomes like mortality and morbidity by comparing simulation-based training and non-simulation-based or traditional training [4]. However, existing literature has not sufficiently evaluated how the fidelity of simulation, low versus high, impacts learning outcomes when compared with traditional or standard non-simulation-based training . Further, more trials are limited either by field of study or by emphasizing different outcomes [5,6]. Therefore, a systemic review is needed to address these gaps and identify the areas required for further investigations. This review synthesizes evidence comparing low- and high-fidelity simulation to standard training in obstetric emergencies. Precisely, it will examine quantitative measures including knowledge acquisition, clinical skill performance, confidence/self-efficacy, teamwork, communication skills, and patient-related outcomes (e.g., Apgar scores, time to intervention) [7]. By evaluating RCTs, this review seeks to provide a comprehensive and up-to-date overview of these clinical trials. METHODS: This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines [8]. The protocol was prospectively registered with PROSPERO (CRD420251069240) to ensure transparency [9]. We included RCTs and quasi-RCTs comparing either high- or low-fidelity simulation-based training with standard non-simulation training for the management of obstetric emergencies. Eligible participants were healthcare professionals or trainees involved in obstetric care, including obstetricians, midwives, nurses or medical students. Studies were required to report at least one quantitative outcome related to knowledge acquisition, clinical skills, confidence, teamwork, communication skills or patient-related outcomes. We excluded purely qualitative studies, studies without a control group, and non-primary sources such as reviews, editorials, or conference abstracts. A comprehensive literature search was conducted across PubMed, Cochrane CENTRAL, Embase, and Scopus from inception to 30 May 2025, with no language or date restrictions. We also manually screened the reference lists of included studies and relevant reviews to identify additional eligible trials. The search strategy combined MeSH and free-text terms including ”obstetric emergencies,” ”simulation training,” ”standard training,” and variations of ”randomised controlled trials,” using Boolean operators to maximise retrieval. The full PubMed search strategy is provided in Appendix S1, with similar adaptations applied to the other databases. Two reviewers independently screened all titles, abstracts, and full-text articles to assess eligibility, resolving any discrepancies through discussion or consultation with a third reviewer when necessary. Data extraction was carried out independently by two reviewers using a standardised form, capturing study characteristics, participant demographics, intervention and comparator details, simulation fidelity, outcome measures and results. The risk of bias for each study was assessed using the Cochrane Risk of Bias 2.0 tool [10]. Given the substantial clinical and methodological heterogeneity among included studies, particularly regarding participant populations, simulation modalities, and outcome measures, a quantitative meta-analysis was not feasible. Therefore, we conducted a narrative synthesis and described results qualitatively within predefined domains, including subgroup comparisons of high- and low-fidelity simulation against standard training. Certainty of evidence was not formally assessed, however, risk of bias, consistency and study limitations were considered in the interpretation of findings. As this review was based solely on published data, no ethical approval was required. No patients or members of the public were involved in the design, conduct, or reporting of this review. RESULTS: Study selection A total of 80 records were identified across databases and other sources. Following removal of duplicates and screening, 16 RCTs were included in the final review. The study selection process is summarised in the PRISMA flow diagram (Figure 1). Study characteristics The included studies comprised 1,453 participants across diverse obstetric settings. Key study characteristics, including design, sample size, simulation modality and risk of bias, are presented in Table S1 in supplementary files. Risk of bias assessment Ten included studies demonstrated low risk of bias, two with some concerns and two with high risk. A summary of the risk of bias assessment for each included study is shown in Figure 2. Outcomes Table 1 summarises the effects of high- and low-fidelity simulation on key outcomes compared to standard training. The effects of simulation training on key domains: knowledge acquisition, clinical skill performance, confidence, teamwork, and patient-centered outcomes are summarised below. Knowledge acquisition Knowledge acquisition outcomes were evaluated in ten studies involving 506 participants. Seven studies compared high-fidelity simulation with standard training, and three studies compared low-fidelity simulation with standard training. High-fidelity simulation: Bruno et al. (2015) used seven multiple-choice questions to assess knowledge acquisition among obstetrics residents at baseline, three months, and six months post-training. The simulation-based group showed improved knowledge after training, although some decline was observed at three and six months. Daniels et al. (2010) also evaluated knowledge acquisition of nurses and obstetric residents using a 20-item multiple-choice questionnaire based on ACOG and expert guidelines. Post-training scores improved but the change was not statistically significant at baseline or post-training. Birch et al. (2007) used pre-training, immediate post-training, and three-month post-training evaluations to assess junior and senior medical and midwifery staff. All groups showed improvement, but the simulation-based teaching (SBT) group was the only one to maintain higher scores at three months compared to lecture-only or lecture-plus-simulation groups. Mangla et al. (2024) found that medical students’ scores on eclampsia management rose significantly from 6.13 ± 1.39 to 9.17 ± 1.34 (p < 0.0001) in the simulation group, compared to an increase from 6.05 ± 1.54 to 7.37 ± 1.70 (p = 0.005) in the conventional group. Cikwanine et al. (2025) assessed healthcare providers using a multiple-choice test based on the JHPIEGO Helping Mothers Survive module. Scores improved immediately after training and at three and six months, but declined over time, with the theory-only group falling near baseline at six months. Holmstrom et al. (2011) measured retention using oral and written exams after a four-week clerkship; the simulation group scored significantly higher than the lecture-only group on both the oral (p = 0.004) and written exams (p = 0.009). Tetering et al. (2021) reported that scores improved from 63.4% before training to 78.9% after training (p < 0.001). Low-fidelity simulation: Magee et al. (2013) used written and oral exams six months post-intervention. Family medicine residents in the simulation group scored higher than the lecture group for postpartum haemorrhage, but no significant difference was found for preeclampsia/eclampsia. Coelho et al. (2024) assessed nurses with a 15-item pre- and post-test. The simulation group showed a 67.8% improvement in correct responses compared to 57.4% in the control group (p < 0.001). Kato et al. (2017) used a 25-item multiple-choice test one month after training; the simulation group showed significantly greater improvement compared to controls (p < 0.001). Overall, studies consistently favoured simulation-based training over standard training for knowledge acquisition. Clinical skill performance Clinical skill performance was assessed in nine studies involving 1,043 participants. Eight studies compared high-fidelity simulation with standard training; two studies evaluated low-fidelity simulation. High-fidelity simulation: Bruno et al. (2015) used a newborn mannequin to grade 21 tasks related to ventilation and resuscitation. At three months, the simulation group outperformed the lecture group (p < 0.001) but not at six months (p = 0.11). Daniels et al. (2010) evaluated skill performance through video-recorded drills on shoulder dystocia and eclampsia management, with teams assessed by blinded reviewers. The simulation group performed significantly better: shoulder dystocia (11.75 vs 6.88, p = 0.002) and eclampsia (13.25 vs 11.38, p = 0.032). Fisher et al. (2010) used similar methods and found significantly higher scores for maternal and eclampsia management (p < 0.05), though differences in fetal and magnesium toxicity scores were not significant. Birch et al. (2007) found that the SBT group showed constant improvement in managing postpartum haemorrhage, outperforming the lecture-only group. Wang et al. (2024) used the Checklist for Performance of Simulated Forceps-Assisted Vaginal Delivery and found immediate post-training scores significantly higher (p < 0.001), though differences faded after one year (p = 0.59). OSCEs used by Cikwanine et al. (2025) showed significant skill improvement (p < 0.05) with better retention at six months. Fritz et al. (2017) observed healthcare providers during 641 births; simulation-based training led to significant improvements in evidence-based practices such as AMTSL (p = 0.044), delayed cord clamping (p = 0.004), and skin-to-skin contact (p = 0.067), while reducing non-evidence-based practices. Low-fidelity simulation: Kato et al. (2017) used a PPH scenario performance test and found the simulation group scored significantly higher (p < 0.001). Erkek et al. (2021) evaluated midwifery students performing episiotomy repair and found significant improvements in technique scores (p < 0.05). Overall, clinical skill performance improved more consistently with simulation training than standard methods. Confidence and self-efficacy Confidence and self-efficacy outcomes were evaluated in six studies involving 394 participants. Five studies compared high-fidelity simulation with standard training while one study assessed low-fidelity simulation. High-fidelity simulation: Bruno et al. (2015) used a five-point Likert scale and found that simulation group confidence increased significantly and remained above baseline at three and six months. Birch et al. (2007) reported improved confidence through semi-structured interviews one year after training. Wang et al. (2024) found no significant difference in operational confidence (p > 0.05) despite improved skills. Cikwanine et al. (2025) used a four-item self-confidence scale for PPH management and teamwork, showing significant improvements (p < 0.05) maintained at three and six months. Holmstrom et al. (2011) found significantly higher self-reported confidence in performing vaginal deliveries (p < 0.01) post-training, though differences diminished over time. Low-fidelity simulation: Yi Chan et al. (2025) used the Self-Efficacy of Teamwork Competencies Scale and found significant improvements in teamwork self-efficacy (p = 0.044). Teamwork and communication skills Teamwork and communication skills were evaluated in four studies involving 233 participants. Three studies compared high-fidelity simulation with standard training; one study assessed low-fidelity simulation. High-fidelity simulation: Karkowsky et al. (2016) evaluated communication through self-assessment, faculty observation, and standardised patient feedback. The verbal subscore showed significant improvement in the simulation-debrief group (p = 0.001), but no significant differences were found in faculty or SP evaluations. For the non-verbal subscore, faculty evaluations favoured the simulation group (p = 0.05). Birch et al. (2007) found sustained improvements in communication skills in the SBT group one year post-training. Tetering et al. (2021) found no significant difference in teamwork scores using the Clinical Teamwork Scale (CTS) (p = 0.78). Low-fidelity simulation: Yi Chan et al. (2025) used the CTS to assess performance. Significant differences were found in scenario performance (p = 0.021), communication (p = 0.036), situational awareness (p = 0.028), and role responsibility (p = 0.029). No significant differences were observed for patient friendliness or decision-making. DISCUSSION: This systematic review synthesised 16 RCTs comparing high- and low-fidelity simulation with standard training in obstetric emergencies. As shown in Table 1, both simulation modalities enhanced learning outcomes, with high-fidelity simulation demonstrating greater impact on both technical and non-technical skills. These findings support the growing body of evidence that simulation-based training improves clinical preparedness. High-fidelity methods appear especially beneficial for complex competencies such as team communication and situational awareness. Main Findings This systematic review synthesised evidence from 16 RCTs comparing high- and low-fidelity simulation-based training with standard training in obstetric emergencies. As summarised in Table 1, both simulation modalities improved learning outcomes, with high-fidelity simulation demonstrating greater impact across technical and non-technical domains. Low-fidelity models also showed benefits, particularly in foundational skills, and may be more feasible in low-resource settings. Knowledge Acquisition High-fidelity simulation generally improved knowledge scores, with most studies reporting short-term gains and some demonstrating sustained improvements over several months. Notably, studies involving obstetric residents and students showed significant post-training increases in knowledge related to emergency protocols and management. Low-fidelity simulation also led to improvements in knowledge acquisition, particularly in managing postpartum haemorrhage. However, effects were more variable, and some studies reported limited gains in complex clinical topics such as preeclampsia. Clinical Skill Performance Simulation consistently enhanced clinical skill performance. High-fidelity simulation was particularly effective in improving procedural accuracy and response time in obstetric scenarios, including shoulder dystocia, neonatal resuscitation, and eclampsia management. Some studies reported short-term retention, while others demonstrated performance decline over time. Low-fidelity simulation improved basic procedural skills in tasks such as postpartum haemorrhage control and episiotomy repair. While improvements were evident, they were generally smaller in magnitude, and few studies assessed long-term retention. Confidence and Self-Efficacy High-fidelity simulation enhanced learners’ confidence and perceived self-efficacy in managing obstetric emergencies. Several studies showed improvements that persisted at three to six months post-training, although some decline over time was observed. Low-fidelity simulation showed modest benefits in confidence building, particularly for teamwork and communication. However, fewer studies assessed this outcome, and effects on technical confidence were less consistent. Teamwork and Communication Skills High-fidelity simulation contributed to improved teamwork and communication, particularly in multidisciplinary teams. Studies highlighted gains in verbal and non-verbal communication, role clarity, and team coordination, although outcomes varied by measurement method and simulation design. Low-fidelity simulation also showed positive effects on teamwork and scenario performance in at least one study. Improvements were noted in situational awareness and communication, although data on long-term effects were lacking. Patient-Centered Outcomes Few studies evaluated direct patient outcomes. One high-fidelity simulation study reported improvements in evidence-based practices during childbirth, including delayed cord clamping and skin-to-skin contact. None of the low-fidelity studies directly assessed patient-centred outcomes. The impact of simulation fidelity on maternal and neonatal outcomes remains underexplored and warrants further investigation. Strengths and Limitations This review synthesises evidence from RCTs conducted across diverse regions, participant groups, and simulation modalities, enhancing the generalisability of findings. The inclusion of recent trials up to 2025 strengthens the currency and clinical relevance of the results. By evaluating both high- and low-fidelity simulation across multiple learning domains, this review provides a comprehensive overview of current educational strategies in obstetric emergencies. However, significant heterogeneity in simulation design, training duration, and outcome measures limited the feasibility of meta-analysis. Several studies used non-validated, self-reported measures for outcomes such as confidence and teamwork, increasing the risk of measurement bias. Moreover, most outcomes were assessed immediately post-training, with limited data on long-term retention or direct patient-centred effects. Interpretation and Implications Our findings are consistent with previous evidence, including the meta-analysis by Tarrahi et al. [3] and the Cochrane review by Fransen et al. [5], both of which support simulation as a valuable tool in obstetric education despite noted heterogeneity. This review adds to the evidence base by incorporating newer studies and presenting outcomes by domain, offering practical insights for curriculum planners. Future research should focus on consistent outcome measures, objective assessments, and long-term follow-up, including patient-centred metrics such as maternal morbidity, neonatal outcomes, and timeliness of interventions. CONCLUSION: This systematic review demonstrates that both high-fidelity and low-fidelity simulation-based training enhance knowledge, clinical skills, confidence, and teamwork in obstetric emergencies when compared with standard non-simulation training. High-fidelity simulation is more effective for advanced skills, while low-fidelity models offer value in low-resource contexts. Training programmes should integrate both modalities with repeated exposure to maximise impact. Future large-scale trials should assess long-term retention, patient-centred outcomes, and cost-effectiveness to strengthen evidence for policy and curriculum development. DECLARATIONS: Author contributions Safi Ullah Khan and Deepa Lachhman Das conceptualised and finalised the review topic. Deepa Lachhman Das conducted the literature search. Alina Batool and Amna Kashif performed the initial screening of titles and abstracts. Full-text screening and data extraction were undertaken by Deepa Lachhman Das and Faiqa Hassan, with any conflicts resolved by Safi Ullah Khan. Risk of bias assessment was carried out by Amna Kashif, and statistical analysis was performed by Kinza Tanveer. For manuscript preparation, the Introduction was drafted by Deepa Lachhman Das, the Methods by Safi Ullah Khan, the Results by Kinza Tanveer, and the Discussion by Alina Batool and Amna Kashif. The Conclusion was jointly written by Safi Ullah Khan and Kinza Tanveer. Safi Ullah Khan undertook the final editing and formatting of the manuscript. All authors reviewed and approved the final version. Funding statement No external funding was received for this work. Acknowledgements An AI language model (ChatGPT, OpenAI) was used to assist with language editing and improving manuscript readability and structure. All content was reviewed and verified by the authors for accuracy. Conflict of interest The authors declare no conflicts of interest relevant to this work. REFERENCES: 1. Elendu C, Amaechi DC, Okatta AU, Amaechi EC, Elendu TC, Ezeh CP, Elendu ID. The impact of simulation-based training in medical education: a review. Medicine (Baltimore) 2024;103(27):e38813. doi:10.1097/MD.0000000000038813 2. Massoth C, Röder H, Ohlenburg H, Hessler M, Zarbock A, Pöpping DM, et al. High-fidelity is not superior to low-fidelity simulation but leads to overconfidence in medical students. BMC Med Educ 2019;19:29. doi:10.1186/s12909-019-1464-7 3. 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Low‑cost, high‑yield: simulation of obstetric emergencies for family medicine training. Teach Learn Med. 2013;25(3):207‑10. doi:10.1080/10401334.2013.797353. 23. Coelho TS, Fonseca LMM, Cardoso MVLML, Aquino PS, da Costa CC, Maciel NS, Damasceno AKC. Clinical simulation for nurses’ knowledge on postpartum hemorrhage: a randomized clinical trial. Rev Bras Enferm. 2025 Mar 14;78(Suppl 1):e20240214. doi:10.1590/0034-7167-2024-0214. 24. Kato C, Suzuki Y, Kimura M, Yamamoto M, Yoshizawa Y. Simulation training program for midwives to manage postpartum hemorrhage. Nurse Educ Today. 2017 May;50:83–88. doi:10.1016/j.nedt.2016.12.010. 25.Yılar Erkek Z, Öztürk Altınayak S. The effect of simulation teaching technique on the improvement of episiotomy performance skills and state anxiety of midwifery students in Turkey: RCT. Clin Simul Nurs. 2021;54:62–9. doi:10.1016/j.ecns.2021.01.014. 26. Chan MY, Ma STJ, Auyeung E . Effectiveness of crew resource management based simulation training (CRM-ST) program in improving midwifery students’ performance in the management of primary postpartum hemorrhage: A randomized controlled trial. Clin Simul Nurs. 2025;99:101677. doi:10.1016/j.ecns.2024.101677. Table 1. Summary of Outcomes by Simulation Type Compared to Standard Training Knowledge Acquisition 10 High-Fidelity Improved knowledge scores in most studies Some decline at 3–6 months Bruno et al., Birch et al., Mangla et al. Knowledge Acquisition 3 Low-Fidelity Improved scores, though smaller effect sizes Mixed Coelho et al., Kato et al. Clinical Skills 8 High-Fidelity Improved procedural performance Fades in some (e.g., 1 year follow-up) Daniels et al., Cikwanine et al. Clinical Skills 2 Low-Fidelity Improved basic technical skills Not assessed or short-term only Erkek et al., Kato et al. Confidence/Self-Efficacy 5 High-Fidelity Increased confidence/self-efficacy post-training Often reduced over time Bruno et al., Holmstrom et al. Confidence/Self-Efficacy 1 Low-Fidelity Improved teamwork-related self-efficacy Not assessed Yi Chan et al. Teamwork/Communication 3 High-Fidelity Enhanced team coordination and role clarity Sustained in some Karkowsky et al., Birch et al. Teamwork/Communication 1 Low-Fidelity Improved communication and scenario awareness Not assessed Yi Chan et al. Patient-Centered Outcomes 1 High-Fidelity Improved clinical practice behaviors Not directly measured Fritz et al. Figure Legends Figure 1. PRISMA 2020 flow diagram of study selection process. Figure 2. Summary of risk of bias assessment for included studies. Information & Authors Information Version history V1 Version 1 11 August 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords general obstetrics obstetric haemorrhage Authors Affiliations Safi Ullah Khan 0009-0007-0025-1749 [email protected] Bahria University Medical and Dental College View all articles by this author Deepa Lachhman Das Indus Medical College View all articles by this author Kinza Tanveer Karachi Medical and Dental College View all articles by this author Amna Kashif Jinnah Sindh Medical University View all articles by this author Faiqa Hassan 0009-0004-5912-2966 Jinnah Sindh Medical University View all articles by this author Alina Batool 0009-0009-7179-3662 Khyber Girls Medical College View all articles by this author Metrics & Citations Metrics Article Usage 308 views 173 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Safi Ullah Khan, Deepa Lachhman Das, Kinza Tanveer, et al. Comparing Low-Fidelity and High-Fidelity Simulation to Standard Training in Obstetric Emergencies: A Systematic Review. Authorea . 11 August 2025. 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