Competence and Skills Training

Introduction and Historical Context

Improving maternal and perinatal care, and reducing preventable intrapartum harm in particular, are global priorities. Improved training for intrapartum care is at least part of the solution, but this must be both effective and sustainable.

As early as 1760, a French midwife, Madame du Coudray, recognized that training deficiencies for rebreak: accou cheurs could directly cause harm and furthermore, that training on an ‘obstetric machine’ (mannequin) could reduce preventable harm.

Over 250 years after Madame du Coudray was commissioned to start a national training programme across France, at first glance we appear to have made little progress; a systematic review of obstetric emergencies training published in 2003 concluded that few methods of obstetric skills training had been evaluated, and there was minimal evidence of their effectiveness.

However, since 2003, a nascent evidence base for intrapartum skills training has emerged, and in this chapter we present a review of the current evidence for effective intrapartum skills training to improve care and outcomes, as well as provide some guidance for how training can be sustainably organized and delivered.

Preventable Harm

Women, their families and their insurers have all identified safety in labour as a priority. However, in 2008, the UK-based Kings Fund report Safe Births: Everybody’s Business observed that while the overwhelming majority of births in England are safe, some births are less safe than they could and should be. This observation accurately summarizes the last century of obstetric care in the UK.

In 1917, the UK Medical Research Committee reported that ‘52% of infant deaths were avoidable’ and in 1924 the author of a national UK Maternal Mortality Report described maternal deaths as a ‘burden of avoidable suffering’.

Although perinatal outcomes have improved over the last century, the proportion of ‘avoidable suffering’ has remained depressingly static since these early reports: >50% of intrapartum stillbirths were deemed avoidable with better care in the 4th Confidential Enquiry into Stillbirths and Deaths in Infancy report, published in 1997, and the most recent Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK Perinatal Mortality Surveillance report, published in 2018, for stillbirths and neonatal deaths in 2016, identified improvements in care that may have made a difference to the outcome were present in 60–80% of perinatal deaths at term.

The investigation of the root cause of these maternal and perinatal deaths reveals a consistent and repeated set of themes related to substandard care, including failure to recognize problems; failure to seek senior input ; poor or nonexistent team working ; and the requirement to improve skills, such as communication, with emphasis on teams and not individuals.

Improving maternal and perinatal care is also a global priority; the World Health Organization (WHO) has estimated that 1500 women die every day from preventable complications of pregnancy and childbirth. Worldwide, there are approximately four million neonatal deaths each year, with a similar number of stillbirths, and these have become the focus for two of the Millennium Development Goals.

Finally, this preventable harm is extraordinarily expensive. Substandard care and its sequelae cost the NHS £3.1 billion in the decade 2000−2010, individual, family and societal costs notwithstanding, and this figure is very likely to rise further.

Skills Training

Effective multiprofessional training appears to be one of the most promising strategies to improve perinatal outcomes across the world, localized for best fit, with a parallel evaluation of outcomes to ensure benefit.

Training has been recommended almost annually since the 1990s; as early as 1996, the 5th Confidential Enquiry into Stillbirths and Deaths in Infancy recommended a ‘high level of awareness and training for all birth attendants’. Annual ‘Skill Drills’ have been recommended by both the Royal College of Midwives (RCM) and RCOG, as well as national bodies on both sides of the Atlantic; the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in the USA, and the maternity Clinical Negligence Scheme for Trusts (CNST), whose risk management standards have mandated training in the UK since 2000. Training should address teamwork, situational awareness and human factors to improve quality of care. Annual training appears to be appropriate because skills and knowledge are retained for 12 months following training. However, in many healthcare organizations there are frequent rotations of staff that may require an increased frequency of training.

Training is not magic, nor is it automatically effective; therefore, we must ensure that training improves outcomes. There are now numerous studies evaluating the effectiveness of skills training for obstetric emergencies, with increasing evidence that practical training is associated with improvements in clinical outcomes. However, not all training is equal and there are a number of studies where training either did not improve clinical outcome or was associated with an increase in perinatal morbidity. Only when training has been demonstrated to be effective should it be widely implemented, but it can then also be included in national guidance.

Good intrapartum care demands sensitivity, clinical skill and acumen from a multiprofessional team working together in an efficient and effective manner. Therefore high-quality training should be holistic and address all these elements. This requires a broad range of training techniques and tools. The Kings Fund recognized that ‘maternity units could easily provide their own simulation-based training … Any such training should include clinical skills, communication, team working, and awareness of roles within the team’.

We will review the evidence for skills training, particularly focusing on the key elements that are required for successful training, as well as providing some practical recommendations to implement skills training into practice.

Key Elements for Skills Training

In order to improve skills training, it is vital that some key elements are considered. Training should not be an ad hoc endeavour but must be considered, planned and organized in order for it to be effective, enjoyable and sustainable.