Introduction
Postpartum haemorrhage (PPH) is the leading cause of maternal mortality
and severe morbidity worldwide.1 In addition,
increasing incidences of PPH have been reported in developed
countries.2-4 It is widely recognised that earlier
awareness of exacerbation of vital signs using the shock index (SI),
proper initial treatment, earlier transfer to tertiary hospitals, and
good intra- and inter-hospital relationships can improve maternal
clinical outcomes.5-13 Surprisingly, 95% of maternal
deaths due to PPH had some chance of preventability, and 70% of deaths
had a good-to-strong chance of preventability.14Although simulation-based training does not supplant on-the-job
training, it is believed to play an important role for maternal outcome
improvement. Thus, clinical guidelines and standardised protocols are
recommended to prevent adverse outcomes.15 Although
several studies reported that teamwork and communication improved
clinical outcomes for PPH, there is not enough evidence that these
programmes equally improve maternal outcomes.15-18 To
assess the effectiveness of simulation-based training, the Kirkpatrick
model is useful (level 1: reaction, level 2: learning, level 3:
behaviour, and level 4: results).19 Previous reports
revealed the effectiveness of level 3, but there is still a lack of
compelling evidence about the effectiveness of level
4.8,13,17
In Japan, the frequency of maternal deaths due to PPH reduced from 29%
in 2010 to 7% in 2017.20 They concluded that
simulation-based training: the Japan Maternal Emergency Life-saving
Course (J-MELS) contributed to reduced maternal
deaths.20 In Japan, 46% of deliveries occur in
private clinics that are operated by one or two
obstetricians.21 Once PPH occurs, the women are
transferred to tertiary hospitals. Half of the reported maternal deaths
are women who delivered in private clinics and were transferred to
tertiary hospitals because of maternal crises. Thus, team bundles in
intra- and inter-hospitals are important to avoid preventable deaths.
Since 2017, the Kagoshima Association of Obstetricians and
Gynaecologists has recommended that obstetrical providers complete the
J-MELS programme and enabled clinicians to use the same standardised
protocol. This movement was broadcasted by instructors in Kagoshima City
Hospital and Kagoshima University Hospital. We expected this initiative
would lead to earlier awareness of maternal crises and an earlier
decision regarding maternal transfer, subsequently leading to improved
maternal outcomes. To assess the efficacy, this study aimed to evaluate
providers’ behaviours and the maternal outcomes for patients who were
transferred to the Kagoshima City Hospital and Kagoshima University
Hospital with PPH before and after providers attended the J-MELS.