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Anaesthesia2023,78,1354–1364 doi:10.1111/anae.16091
OriginalArticle
EvaluationofpracticechangefollowingSAFEobstetric
coursesinTanzania:aprospectivecohortstudy
M.Lilaonitkul, 1 A.Zacharia, T.J.Law, N.Yusuf, P.Saria andJ.Moore 5 6
1AssistantClinicalProfessor,3AssistantProfessor,DepartmentofAnesthesiaandPeri-operativeCare,Universityof
CaliforniaSanFrancisco,CA,USA
2AnaesthesiologistandClinicalLecturer,MbeyaZonalReferralHospital,UniversityofDaresSalaam,MbeyaCollegeof
HealthandAlliedSciences,DaresSalaam,Tanzania
4Anaesthesiologist,DepartmentofAnaesthesia,TangaRegionalReferralHospital,Tanzania
5Anaesthesiologist,DepartmentofAnesthesia,CCBRTHospital,DaresSalaam,Tanzania
6Consultant,DepartmentofAnaesthesia,NHSGrampian,Aberdeen,UK
Summary
Anaesthesia has been shown to contribute disproportionately to maternal mortality in low-resource settings.
This figure exceeds 500 per 100,000 live births in Tanzania, where anaesthesia is mainly provided by non-
physician anaesthetists, many of whom are working as independent practitioners in rural areas without any
support or opportunity for continuous medical education. The three-day Safer Anaesthesia from Education
(SAFE) course was developed to address this gap by providing in-service training in obstetric anaesthesia to
improve patient safety. Two obstetric SAFE courses with refresher training were delivered to 75 non-physician
anaesthetists in the Mbeya region of Tanzania between August 2019 and July 2020. To evaluate translation of
knowledge into practice, we conducted direct observation of the SAFE obstetric participants at their workplace
in five facilities using a binary checklist of expected behaviours, to assess the peri-operative management of
patients undergoing caesarean deliveries. The observations were conducted over a 2-week period at pre,
immediately post, 6-month and 12-month post-SAFE obstetric training. A total of 320 cases completed by 35
participants were observed. Significant improvements in behaviours, sustained at 12 months after training
included: pre-operative assessment of patients (32% (pre-training) to 88% (12 months after training),
p < 0.001); checking for functioning suction (73% to 85%, p = 0.003); using aseptic spinal technique (67% to
100%, p < 0.001); timely administration of prophylactic antibiotics (66% to 95%, p < 0.001); and checking
spinal block adequacy (32% to 71%, p < 0.001). Our study has demonstrated positive sustained changes in the
clinical practice amongst non-physician anaesthetists as a result of SAFE obstetric training. The findings can be
usedtoguidedevelopmentofachecklistspecificforanaesthesiaforcaesareansectiontoimprovethequalityof
careforpatientsinlow-resourcesettings.
.................................................................................................................................................................
Correspondenceto:M.Lilaonitkul
Email:maytinee.lilaointkul@ucsf.edu
Accepted:16June2023
Keywords: CME;in-servicetraining;knowledgetranslation;LMIC;obstetricanaesthesia;SAFE
ThisarticleisaccompaniedbyaneditorialbyA.M.Crawford,Anaesthesia2023;78:1323–1326.
Presented at the virtual World Congress of Anaesthesiologists, September 2021 and the American Society of Anesthesiologists
AnnualMeeting,NewOrleans,LA,USA,October2022.
Twitter:@Jo_N_Moore
1354 ©2023TheAuthors.AnaesthesiapublishedbyJohnWiley&SonsLtdonbehalfofAssociationofAnaesthetists.
ThisisanopenaccessarticleunderthetermsoftheCreativeCommonsAttribution-NonCommercialLicense,whichpermitsuse,
distributionandreproductioninanymedium,providedtheoriginalworkisproperlycitedandisnotusedforcommercialpurposes. 3
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sustainability of these changes in five regional referral d
Introduction o
hospitalsintheSouthernHighlandszoneofTanzania. m
Many women worldwide die during childbirth because they p
/
do not have access to safe anaesthetic care. A recent study s
c
has shown that women undergoing caesarean delivery in Methods t
n
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sub-SaharanAfricaare50timesmorelikelytodiethanthose The study was approved by Mbeya Medical Research and a
t
in high-income countries [1]. The deficiency in the number Ethics Committee and the institutional review boards of the t
s
of anaesthesia providers and inadequate training pose University of Aberdeen and University of California, San u
l
major barriers to safe obstetric anaesthetic care in these Francisco. As this research represents an international a
n
o
settings[2,3]. partnership,thereflexivitystatementregardingthisworkcan i
e
In Tanzania, maternal mortality is high, exceeding 500 befoundinonlineSupportingInformationAppendixS1. r
y
per 100,000 live births [4]. Anaesthesia is extremely under- The SAFE-OB course participants came from facilities w
y
resourced, with only 50 physician anaesthesia providers, throughout the Southern Highlands zone, from which five o
m
o
140 nurse anaesthetists and 40 other cadre providers, for a facilities were selected as observation sites. Facility 1
1
population of almost 54 million [5]. This makes the non- selection considerations included ensuring geographic 1
n
physician anaesthesia providers the backbone of the variation within the region, sufficient volume of caesarean e
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country’s workforce. The training pathways for the non- sections (>15 per week), referral level facilities and not an 9
b
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physician anaesthesia providers are not standardised with urban teaching hospital. The five facilities were Mbeya s
W
high variability in duration and clinical exposure, reflecting Zonal, Mbeya Regional, Iringa Regional, Njombe Regional e
O
the trendinthe region[6, 7].Inmanyrural areasofTanzania, and Sumbawanga Regional Referral Hospitals. Participants l
e
the training could comprise a learn-on-the-job model or a wereeligibleiftheywereanaestheticprovidersatoneofthe i
a
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one-year certification programme, often without any prior included hospitals. Written consent was obtained from n
1
qualification requirement. Furthermore, once the provider participants by research assistants after written and verbal 0
2
becomes an independent practitioner, access to continuing information regarding the study was provided. No patient 2
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medical education opportunities is almost non-existent. identifiable data was recorded and consent from patients e
h
T
This may partly explain why anaesthesia has been shown to wasdeemedunnecessarybytheinstitutionalreviewboards. r
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contribute disproportionately to maternal mortality in low- The World Federation of Societies of Anaesthesiologists n
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and middle-income countries (LMIC), with the risk (WFSA) Anaesthesia Facility Assessment Toolwas utilised to n
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increasing by almost two-fold when anaesthesia is conduct facility level assessments before commencement n
h
p
administeredbyanon-physicianprovider[8]. of the first (pre-SAFE-OB) observation period, to establish /
n
The SAFE (Safer Anaesthesia from Education) Obstetric whether there were significant differences in resource n
b
Anaesthesia (SAFE-OB) course is a three-day refresher availability that might impact on the behaviour of r
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course that was developed to fill this gap in training and anaesthesia providers [17]. The observation checklist was e
c
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provide continuing medical education to in-service developed based on SAFE course content, established best e
m
anaesthesia providers in resource-constrained settings [9]. practice guidelines for caesarean section anaesthetic care a
d
The value of short courses such as SAFE-OB and the and previous studies looking at self-reported behavioural o
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sustainability of its impact in these settings have been change [15, 18, 19]. The checklist included observations o
)
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scrutinised [10]. Previous studies of SAFE courses have and documentation of: patient pre-operative assessment; W
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demonstrated retention of skills and knowledge and, pre-operative preparation; team communication; conduct O
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through qualitative methods, have reported change in of spinal anaesthesia; behaviours specific to anaesthesia e
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practice and impact at a system level [11–15]. However, no management of pregnant patients and caesarean delivery; a
y
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study to date has performed Kirkpatrick Level-3 evaluations and occurrence of adverse events and their management. l
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to assess the degree to which SAFE course participants Observable behaviours were included from the time of pre- f
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apply what they have learnt to their daily job [16]. To operative assessment through to the patient reaching their O
A
ultimately improve the quality of obstetric anaesthesia care immediate postoperative destination (online Supporting i
e
a
and patient safety, translation of knowledge into practice is Information Appendix S2). Five study observers were either g
v
thefirststepthatneedstotakeplace. physician anaesthetists or registrars with training and n
d
Using a pre-/post-interventional study design, we clinical experience in anaesthesia for caesarean section. y
h
aimed to identify the main behavioural changes following None of the observers worked at the facilities included in a
l
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SAFE-OB participation and to evaluate the degree and this study. A detailed observation instruction manual was e
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distributed to observers, and a training session provided based on exposure to SAFE-OB to increase the sample of d
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where observers and a co-investigator observed a cases. Results were reviewed visually and in tabular form to h
p
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caesarean section, compared checklist scoring and identify candidate behaviours that were most likely to show s
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discussed discrepanciesof anyelements.This was repeated a difference. Chi-squared tests were used to identify i
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in five cases over a two-day period until observers were differencesinpre-SAFE-OBandimmediatelypost-SAFE-OB a
e
found toscore elementssimilarly. Developedin2011 bythe values for candidate behaviours, with Fisher’s exact test h
i
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WFSA and the Association of Anaesthetists, the SAFE-OB used where appropriate. Behaviours with statistically u
i
course is a three-day course for anaesthesia providers significant differences were selected for regression. A t
n
focused on the fundamentals of obstetric anaesthesia. To mixed effects logistic regression was used to examine the o
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date, 6435 providers have been trained on 216 SAFE-OB change in behaviour frequency at the different observation i
a
courses in 47 countries (WFSA, personal communication). phases, controlling for participant and hospital. Analysis .
i
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Non-physician anaesthesia providers in the Southern revealed that the sample was indeed too small to measure o
d
Highlands zone of Tanzania were invited to attend one of the magnitude of behavioural change with meaningful i
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two SAFE-OB courses followed by a 1.5-day refresher precision; the odds ratios are nonetheless reported here as 1
1
course at three months. The refresher course included skills a measure of directional change across phases, rather than n
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practice and focused discussions on change management magnitude.AnalyseswereperformedinStata15(StataCorp 1
y
andovercomingbarrierstochangeandwasofferedatthree LP,College Station, TX, USA)and Python 3.9.12 with Pandas e
,
locations in geographical proximity to participants’ place of library1.5.2[22]. W
y
work. O
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Data collection occurred between September 2019 Results b
r
and September 2020. Once attendance at the course was Thematernal mortality ratioof the facilities ranged from248 o
[
confirmed and the sites selected, pre-intervention to 502 per 100,000 patients and the neonatal mortality rate /
7
observations were taken. Study observers visited each ranged from 22 to 84 per 1000 live births. These were 0
]
comparable with reported national rates of a maternal S
hospital for a two-week data collection period during all e
e
phases of the study. The study observer would wait for mortality ratio of 524 (World Bank data 2018) and neonatal e
m
caesarean sections and proceed with the checklist of mortality rate of 21 (World Bank data 2017). In the year the a
d
observations. Observations were conducted 24 h per day study commenced, these facilities reported a mean (SD) of o
i
and repeated immediately after completion of SAFE-OB 4170 (1642) births. The caesarean section rate across all o
s
t
(generally within 2 weeks of the course) and at 6 and facilities was 46% (9598/20,850 deliveries) with 74–97% of :
o
12 months. these conducted under spinal anaesthesia. Each study site i
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Observations began when participants interacted with had between one and five functioning operating theatres. a
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the patient. A printed observation package was used to Facilities were similar in terms of infrastructure (e.g. i
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record participant actions in real time. Study data were availability of water, electricity, oxygen and blood, and /
m
collected and managed using REDCap electronic data information management) and equipment and medication -
d
capture tools hosted at the University of California, San (except for propofol and some alternative uterotonics c
d
Francisco [20, 21]. Study observers were instructed not to and vasopressors; see online Supporting Information i
s
o
intervene unless they deemed their assistance was required Appendix S3). Only one facility had physician anaesthetic W
l
to provide lifesaving care to the patient or neonate. These providers, who were excluded from the study due to y
n
occurrences were noted separately and excluded from the involvement as study co-ordinators. No site had either e
L
mainanalysis. physician or non-physician anaesthetists in training. Before a
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A typical approach to sample size calculation is to the study, the World Health Organisation (WHO) Surgical r
u
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include an estimate of possible effect size. Given the wide Safety Checklist was used ``rarely´´ at two facilities, and f
e
variety of behaviours observed, and that an in-situ study of ``sometimes´´, ``often´´ and ``always´´ in each of the remaining O
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operating theatre behavioural change had not occurred, an threefacilities. t
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a priori estimate of effect size was not possible. Therefore, A total of 320 cases completed by 35 participants were a
e
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for this initial study, we aimed to observe as many cases as observed by five study observers. The distribution of the r
d
possible. Descriptive statistics were calculated for all number of anaesthetics per participant, per phase and at y
h
variables. To evaluate the effect of SAFE-OB over each referral regional hospital can be found in online a
l
time, comparisons were made between pre- and post- Supporting Information Appendix S4. Nurse anaesthetists a
e
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intervention behaviour frequency. Cases were pooled performed 89% (n = 284) of cases and 71% (n = 227) were a
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Table 1 Characteristicsofcasesobservedperphaseofstudy.Valuesarenumber(proportion). r
m
Immediately 6-months 12-months t
:
Pre-SAFE-OB post-SAFE-OB post-SAFE-OB post-SAFE-OB All s
n = 100 n = 89 n = 89 n = 43 n = 320 o
t
n
Hospital a
a
IringaRegional 16(16%) 7(8%) 9(10%) 6(14%) 38(12%) h
i
MbeyaRegional 30(30%) 20(22%) 10(11%) 10(23%) 70(22%) s
u
NjombeRegional 4(4%) 11(12%) 10(11%) 8(19%) 33(10%) c
i
s
SumbawangaRegional 18(18%) 12(13%) 1(1%) 3(6%) 34(10%) n
n
MbeyaZonal 32(32%) 39(44%) 59(66%) 16(37%) 146(46%) b
r
Cadre w
e
Assistantnurseanaesthetist 15(15%) 14(16%) 1(1%) 0 30(9%) c
m
Nurseanaesthetist 84(84%) 75(84%) 82(93%) 43(100%) 284(89%) o
1
Other(specify) 0 0 5(6%) 0 5(2%) 1
1
n
Caseurgency e
6
Elective 25(25%) 28(31%) 23(26%) 16(37%) 92(28%) 1
y
Emergency 73(74%) 61(69%) 66(74%) 27(63%) 227(71%) T
,
Indication W
y
Breechpresentation 0 4(4%) 3(3%) 5(11%) 12(3%) O
n
Eclampsia 0 1(1%) 0 0 1(0%) L
b
y
Fetaldistress 11(11%) 5(5%) 21(23%) 8(18%) 45(14%) o
1
Multiplepregnancy 1(1%) 5(5%) 4(4%) 0 10(3%) 0
2
Obstructedlabour 22(22%) 16(17%) 13(14%) 6(13%) 57(17%) 2
.
Other 16(16%) 16(17%) 14(15%) 5(11%) 51(15%) e
h
Placentalabruption 1(1%) 0 0 0 1(0%) T
m
s
Severepre-eclampsia 0 4(4%) 1(1%) 0 5(1%) d
C
Previousscars 51(51%) 46(51%) 47(52%) 23(53%) 167(52%) d
o
s
t
s
o
emergency/urgent, withthe most common indication being from 68% to 86% (p = 0.006) immediately post-SAFE-OB i
l
a labouring patient in the presence of a previous uterine and continued to increase. The other elements of the WHO a
.
scar (52%, n = 167) (Table 1). Patient ASA physical status checklist all significantly increased from baseline when i
y
was not recorded in 62% (n = 199) of the cases. With compared with immediately post-SAFE-OB (sign-in 12% to m
t
regards to the types of providers in the operating theatre, 52% (p < 0.001), time-out 12% to 51% (p < 0.001) and sign- m
a
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the anaesthesia provider was present 100% of the time; out 3% to 20% (p < 0.001)) and remained above baseline o
i
interns 69–76%, medical officers (non-speciality trained) values through the remaining phases (Tables 2 and 3, o
)
29–65%; obstetric residents 13–31%; obstetric consultants Fig. 1). In both unadjusted and adjusted analyses, these n
i
11–17%; midwives 92–97%; nurses 90–97%; and scrub trends remained significant through all phases (Table 3). y
O
nurses 74–80% of the time during the caesarean sections. Five of eight main categories of pre-operative preparation n
L
Eightcaseswereexcludedwheretheobserverintervenedin behaviours significantly improved from baseline when r
y
case management (pre-SAFE-OB n = 3, post-SAFE-OB compared with immediately post-SAFE-OB (Fig. 1, Table 2). o
u
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n = 3, 6-months post-SAFE-OB n = 2). These included two These included: pre-operative assessment of patients; f
s
cases of high spinal; a failed intubation; an obstetric checking for functioning anaesthetic machine; functioning O
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haemorrhage; a case of severe refractory hypotension; one suction; airway equipment; and neonatal resuscitation t
e
case at the request of the anaesthesia provider; and two equipment. The former two behaviours were sustained a
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cases where the observer had to intervene in neonatal through all phases in unadjusted analysis, while pre- v
n
resuscitationandthuswasunabletocontinueobservations. operative anaesthesia assessment and checking for d
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Informed consent was obtained > 90% of the time in all functioning suction were sustained through all phases in e
p
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observation phases. Communication about the surgical adjusted analyses (Table 3). Five of the 13 behaviours in this b
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indication between the surgeon and anaesthetist increased section improved significantly from baseline to immediately e
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Table 2 Clinicalbehavioursandadverseeventsobservedduringcaesareandeliveries.Valuesarenumber(proportion). f
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Immediately 6-months 12-months h
s
Pre-SAFE-OB post-SAFE-OB post-SAFE- post-SAFE-OB All a
n = 100 n = 89 OBn = 89 n = 43 n = 320 x 2 o
a
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CommunicationandWHOchecklist a
e
Consent 93(93%) 89(100%) 89(100%) 43(100%) 314(98%) 0.03 h
s
Indication 68(68%) 75(86%) 88(99%) 43(100%) 274(86%) 0.006 -
b
Sign-in 12(12%) 46(52%) 51(57%) 28(65%) 137(43%) <0.001 a
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Time-out 12(12%) 45(51%) 47(53%) 19(44%) 123(38%) <0.001 .
l
Sign-out 3(3%) 18(20%) 26(30%) 13(30%) 60(19%) <0.001 l
r
Pre-operativepreparation y
l
Pre-operativeanaestheticassessment 32(32%) 45(51%) 61(69%) 38(88%) 176(55%) 0.01 .
m
ChecksrecentHblevel 42(42%) 35(40%) 37(44%) 31(74%) 145(46%) 0.67 d
1
1
Anaestheticmachinechecked 44(44%) 55(62%) 79(91%) 40(93%) 218(68%) 0.014 1
n
ChecksavailabilityofGAdrugs 64(64%) 57(64%) 72(81%) 43(100%) 236(74%) 0.995 e
6
Airwayequipmentchecked 86(86%) 88(99%) 81(91%) 40(93%) 295(92%) 0.001 1
y
Suctionpresentandworking 73(73%) 82(92%) 80(90%) 37(86%) 272(85%) <0.001 e
,
Vasopressorpresent 100(100%) 89(100%) 85(96%) 43(100%) 317(99%) - i
y
Confirmsneonatalequipmentavailable 92(92%) 88(99%) 88(99%) 42(100%) 310(97%) 0.037 n
e
Obtainsi.v.access 99(100%) 88(100%) 89(100%) 42(100%) 318(100%) - i
a
Attachesrunningfluids 99(100%) 87(100%) 89(100%) 41(100%) 316(100%) - o
[
Spinalmanagement /
/
Wearshat 95(100%) 84(100%) 87(98%) 41(100%) 307(99%) - 2
.
Wearsmask 95(100%) 84(100%) 86(97%) 40(98%) 305(99%) - e
h
Wearssterilegloves 95(100%) 84(100%) 89(100%) 41(100%) 309(100%) - T
m
Usescleaningsolution 92(98%) 83(100%) 89(100%) 41(100%) 305(99%) 0.499 s
d
Maintainssterilefield 63(67%) 73(87%) 84(94%) 41(100%) 261(85%) 0.002 o
i
o
Appliestiltorwedgeafterspinal 41(43%) 57(69%) 76(86%) 33(80%) 207(67%) <0.001 (
p
Monitorsvitalsignsafterspinal 93(98%) 84(100%) 89(100%) 40(98%) 306(99%) 0.499 /
n
Measuresblockheight 30(32%) 55(65%) 63(71%) 29(71%) 177(57%) <0.001 e
b
Administersvasopressorwhen 43(49%) 37(67%) 27(71%) 14(70%) 121(60%) 0.037 y
appropriate w
y
Administers/confirmsi.v.antibiotics 63(66%) 74(88%) 81(93%) 38(95%) 256(84%) <0.001 o
t
Administersoxytocin 93(98%) 84(100%) 89(100%) 39(95%) 305(99%) 0.499 m
a
d
Oxytocinadministeredatthecorrecttime 51(54%) 48(58%) 52(60%) 26(63%) 177(58%) 0.632 o
i
Remainspresentinthetheatre 74(80%) 66(80%) 66(76%) 36(90%) 242(80%) 0.88 n
)
Adverseevents W
l
Failedspinal(inadequateblock) 19(19%) 9(10%) 2(2%) 2(5%) 32(10%) 0.086 y
n
Lossofconsciousness 1(1%) 1(1%) 0 0 2(1%) 1.0 e
i
Prolongedhypoxia 5(5%) 1(1%) 0 0 6(2%) 0.216 a
f
Persistenthypotension 52(52%) 44(49%) 24(27%) 16(37%) 136(42%) 0.725 r
e
Majorhaemorrhage 2(2%) 0 0 0 2(1%) 0.499 o
s
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WHO,WorldHealthOrganization;GA,generalanaesthesia;i.v.,intravenous. A
t
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a
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post-SAFE-OB. These included: maintenance of sterile field to 69%, p < 0.001); and administration of vasopressor to v
n
while administering spinal (67% to 87%, p = 0.002); treat spinal hypotension (49% to 67%, p = 0.037) (Fig. 1). b
t
administration of antibiotics within 1 h of incision (66% to This was largely true across all phases in adjusted and e
p
88%, p < 0.001); measurement of height of spinal blockade unadjusted analyses, with the notable exception that a
e
(32% to 65%, p < 0.001); application of left lateral tilt (43% appropriate vasopressor administration was not consistent r
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Table 3 Oddsratioofbehaviouralchangeatimmediately,6-monthsand12-monthspost-trainingcomparedwithpre-SAFE-OB d
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observations. m
p
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Immediately 6-months 12-months s
post-SAFE-OB post-SAFE-OB post-SAFE-OB c
i
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OR(95%CI) pvalue OR(95%CI) pvalue OR(95%CI) pvalue n
e
Unadjustedanalysis e
s
CommunicationandWHOchecklist p
b
a
Consent 1.0 - 1.0 - 1.0 - o
o
Indication 2.76(1.31–5.81) 0.008 38.82(5.16–291.89) <0.001 1.0 - i
l
Sign-in 7.84(3.77–16.32) <0.001 9.84(4.72–20.53) <0.001 13.69(5.73–32.68) <0.001 r
y
Time-out 7.5(3.61–15.6) <0.001 8.41(4.03–17.52) <0.001 5.81(2.48–13.61) <0.001 i
y
Sign-out 8.2(2.33–28.9) 0.001 13.56(3.94–46.71) <0.001 14.01(3.74–52.47) <0.001 o
d
Pre-operativepreparation /
.
Pre-operative 2.17(1.2–3.92) 0.01 4.63(2.51–8.55) <0.001 16.15(5.81–44.91) <0.001 1
a
anaesthetic a
1
assessment 9
b
Anaesthetic machine 2.06(1.15–3.68) 0.015 12.57(5.49–28.75) <0.001 16.97(4.92–58.52) <0.001 T
checked t
W
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Airwayequipment 14.33(1.84–111.33) 0.011 1.65(0.66–4.14) 0.287 2.17(0.59–7.98) 0.243 O
checked i
e
Suction present and 4.33(1.78–10.54) 0.001 3.29(1.45–7.45) 0.004 2.28(0.87–6.01) 0.095 b
r
working o
1
Confirmsneonatal 7.65(0.94–62.44) 0.057 7.65(0.94–62.44) 0.057 1.0 - /
/
equipmentavailable 2
.
Spinalvariables e
h
Maintainssterilefield 3.27(1.52–7.02) 0.002 8.27(3.04–22.46) <0.001 1.0 - T
m
Applies tilt or wedge 2.89(1.56–5.35) <0.001 8.34(4.01–17.34) <0.001 5.43(2.27–13.0) <0.001 s
d
afterspinal o
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Measuresblock 4.11(2.2–7.67) <0.001 5.25(2.8–9.85) <0.001 5.24(2.35–11.65) <0.001 o
s
height t
:
Administers 2.1(1.04–4.25) 0.038 2.51(1.11–5.69) 0.027 2.39(0.84–6.79) 0.103 o
vasopressorwhen n
i
appropriate a
w
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Sign-in 15.79(4.53–55.08) <0.001 11.8(3.16–43.99) <0.001 55.1(12.54–242.08) <0.001 l
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Time-out 13.38(3.81–46.92) <0.001 6.78(1.77–25.93) 0.005 25.17(5.69–111.33) <0.001 i
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anaesthetic A
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Anaesthetic machine 1.87(0.81–4.32) 0.144 26.99(6.5–112.01) <0.001 202.61(23.38–1755.89) <0.001 e
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Airway equipment 14.35(1.83–112.65) 0.011 1.58(0.58–4.27) 0.37 2.01(0.53–7.61) 0.305 y
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Immediately 6-months 12-months p
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OR(95%CI) pvalue OR(95%CI) pvalue OR(95%CI) pvalue o
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Suction present and 9.94(2.87–34.41) <0.001 8.06(2.49–26.05) <0.001 7.92(2.03–31.0) 0.003 s
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working s
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afterspinal c
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Measuresblock 8.52(3.31–21.91) <0.001 10.79(4.17–27.97) <0.001 14.78(4.57–47.77) <0.001 o
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height 1
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Administers 2.49(0.95–6.49) 0.062 3.14(1.01–9.78) 0.049 6.16(1.37–27.76) 0.018 n
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vasopressorwhen 6
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5
throughout (Tables 2 and 3). Persistent hypotension, defined knowledge,thisisthefirststudytoevaluateLevel3bydirect 7
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as systolic blood pressure < 80 mmHg or > 20% below observationofbehavioursandtodemonstratetranslationof S
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baseline for > 10 min, occurred in 42% of all the cases knowledge into the workplace in low-resource settings e
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baseline to 10% immediately post-SAFE-OB, 4% at 6 months method of evaluating training programmes. In 2015, the i
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and 5% at 12 months. However, this was not statistically original model was revised to emphasise the importance of t
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significant which may bedue tothe low sample size (Table 2). the relationship of training on participants’ work [23]. The n
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Intravenous ketamine supplementation was used in 78% of four levels outlined in the model are: reaction; learning; i
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all failed spinal cases while the remaining 22% were behaviour; and results. Results evaluation focuses on .
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convertedtogeneralanaesthesia.Highproportions(84–99%) evaluating outcomes, which in the context of the SAFE-OB .
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of patients were recovered in the corridor of the operating course, relates to improved safety of anaesthesia, reduction m
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theatre complex and 52–85% of postoperative patients were in critical incidents and ultimately, maternal mortality. In our d
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unattendedinallthephasesofstudy. study, > 70% of cases were emergency and 52% of these i
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were a labouring patient with a previous uterine scar. This )
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The three-day SAFE-OB course has been shown to lead to resource settings compared with higher income countries, i
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improved, and retained, skills and knowledge, as well as where many of these cases would have been scheduled as b
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reportedpracticechangesandimpactatasystemlevel.This electivecases.Theoperatingtheatreteamcompositionmay f
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study performed a Kirkpatrick Level 3 evaluation, utilising also be unique to this setting, predominantly comprising e
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direct observations in the workplace to assess the degree to junior obstetric staff, medical officers, non-physician u
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which SAFE-OB participants apply what they have learnt to anaesthetists and nurses. All these factors can have a r
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their practice. Through observations of a cohort of non- potential impact on patient care and outcome, making s
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physician anaesthesia providers practising in Tanzania, we resultsevaluationhighlycomplexandchallenging. o
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report sustained improvements across all three observed Our results highlight the changes in clinical behaviours e
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domains of clinical practice during anaesthesia for that are aligned with evidence-based medicine and best t
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caesarean section: communication; pre-operative practice guidelines in obstetric anaesthesia. Our study c
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preparation; and intra-operative management. To our participants showed improvement in administration of C
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prophylactic antibiotics and maintaining a sterile technique incidents which occurred, their infrequent occurrence, r
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during spinal procedure, both of which have been limited observation period and the need for the observer to t
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recommended by the WHO and shown to reduce serious intervene and assist, made their numbers too small to a
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infectious complications [24, 25]. There was also analyse. This is also the case for obstetric general a
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improvement in measurement of spinal block height pre- anaesthesia, with most of these cases managed with f
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incision,whichlikelycontributedtoareductionintherateof ketamine and an unsecured airway. The possibility of t
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immediately post-SAFE-OB to 2–4% at 6 and 12 months observed, for example the Hawthorne effect, may have t
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[26, 27] and increased utilisation of vasopressor to prevent contributed. Whilst efforts were made to utilise observers o
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spinal hypotension, which is in keeping with best-practice from external facilities who were not known to the i
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guidelines [28]. We observed an increase in the uptake of participants, their presence may have led to altered actions. .
l
.
the WHO Surgical Safety Checklist, a tool which has been The impact on patient outcome was not evaluated. As m
d
shown to reduce postoperative complications by up to 25% discussed earlier, this is difficult as morbidity and mortality /
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andmortalityaftersurgeryby0.5–5%[29,30]. solelyattributed toanaesthesia israre andisoften impacted 1
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Studies have shown that low-dose, high-frequency bymultiplefactors. a
1
models for in-service training can lead to improved process Through direct observation of clinical behaviours, 9
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of care, health outcomes and cost-effectiveness in low- our study has built on previous findings and highlighted T
s
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resource settings [31–33]. We incorporated a 1.5-day the value of short courses such as SAFE-OB for in- e
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follow-up refresher component which was conducted near service practitioners in low-resource settings. Whilst it is l
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participants’ workplaces, to focus on skill practice and recognised that the expansion of the anaesthesia i
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discussions on change management and overcoming workforce in LMICs is a necessity, this needs to be done y
n
barriers to change. The incorporation of this component in conjunction with quality training of both pre- and in- 5
7
mayhaveimpactedonsustainedbehaviourchange. service providers in order to decrease maternal 0
4
S
As well as behaviours that did change, it is important to mortality. Our findings also suggest future potential e
e
consider those which did not, so we can identify gaps in initiatives including development of an educational e
m
training or barriers to practice change. Despite notable or behavioural checklist specific for anaesthesia for a
d
improvements in use of the WHO Surgical Safety Checklist, caesarean section and improvement in postoperative n
i
overall use remained low. This is not unexpected care in low-resource settings. n
(
as successful implementation requires multidisciplinary p
/
n
operating theatre team training and a longitudinal effort Acknowledgements n
b
to overcome local contextual barriers [34, 35]. Despite The study was funded by the Laerdal Foundation. ML and r
w
improved administration of vasopressors to treat AZ are joint first authors. We would like to thank the World e
c
hypotension, the rate of persistent hypotension remained Federation of Societies of Anaesthesiologists and the m
e
high throughout all phases of the study. This may be related Association of Anaesthetists, UK for operational and s
n
to limited resources (e.g. availability of additional administrative support. We would also like to express our -
n
t
vasopressors) or may relate to lack of learners’ deepest gratitude to the faculty and research assistants: B. n
o
understanding of its implication. Our study also shows Asnake, A. Chamwanzi, A. Cheng, T. Kasole, K. Khalid, L. W
l
severe deficiency in the infrastructure, personnel and Frostan Komba, C. L. S. Kwan, A. F. Lwiza, P. Massawe, B. y
n
monitoring equipment for post-anaesthesia care at all study McKenna, S. S. Mohamed, C. Msadabwe, P. Murambi, A. n
L
sites, reflecting a neglected area within the healthcare Musgrave, M. C. Mutagwaba, G. Mwakisambwe, A. S. a
y
system in these settings. Postoperative death is now being Ndebeya, S. G. Ndezi, H. Phiri, P. Ponsian, R. Samwel, E. r
u
s
recognised as a leading cause of death globally, with half Shang’a and R. Swai. This paper is dedicated to the memory f
e
occurring in LMICs, highlighting the need for urgent of our dear friend and colleague, Soloman Gerald Ndezi O
a
initiativestoaddressthisproblem[36,37]. (1984–2022), who was a dedicated teacher and i
e
Due to a relatively small sample size, the width of the compassionatedoctor.Nocompetinginterestsdeclared. r
g
confidence intervals makes it difficult to interpret the e
n
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37. ThePostoperativeShortCourseContentStudy group.Priorities AppendixS1.Structuredreflexivitystatement. d
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forcontentforashort-course onpostoperative care relevant for m
AppendixS2.Structuredobservationchecklist. t
low- and middle-income countries: an e-Delphi process with s
Appendix S3. Facility assessments of infrastructure, a
trainingfacilitators.Anaesthesia2022;77:570–9. s
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equipmentandanaestheticdrugsofthefivestudysites. i
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SupportingInformation AppendixS4.Numberofcaesareansectionsobserved f
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Additional supporting information may be found online via per participant, per phase of study at each referral regional e
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