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.