Obstetric Anaesthesia Course with Train the Trainers Cotonou, Benin 14 th 17 th February 2017

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1 Obstetric Anaesthesia Course with Train the Trainers Cotonou, Benin 14 th 17 th February 2017 Report for the Association of Anaesthetists of Great Britain & Ireland Written by

2 P a g e 2 Table of Contents Executive Summary...3 Acknowledgements...4 Background...5 Course Venue...6 The February 2017 SAFE Obstetrics Course...7 Monitoring, Evaluation and Results...8 Participants Feedback...9 Post Intervention Activity...11 Summary...11 Appendices Faculty List...12 Course Photographs...13

3 P a g e 3 Executive Summary The SAFE (Safer Anaesthesia From Education) Obstetric Anaesthesia Course has been delivered in many countries worldwide. The curriculum was developed by Dr Kate Grady for the Association of Anaesthetists of Great Britain and Ireland (AAGBI), aimed primarily at anaesthetic officers, to provide training in obstetric anaesthesia and emergencies. This was the second time that SAFE Obs had been delivered in Benin during this Mercy Ships field service. The course was conducted in French, using local and international interpreters. We used the same format that worked well on the previous course in Benin. The course director was Dr Emma Halliwell. The lead contacts in Benin were Professor Martin Chobli and Professor Eugene Zoumenou. The faculty comprised of four consultant anaesthetists, two anaesthetic registrars and one Congolese anaesthetist. Five local interpreters provided excellent assistance throughout, however the two fluent French-speaking faculty taught without translation. Delegates were invited from hospitals in and around Cotonou. Attendees on the course were predominantly from the capital, but some had travelled from further afield, with one candidate travelling from Niger. A total of 25 Anaesthetic Officers and Physicians attended. There was no drop off throughout the course with each delegate completing all 3 days. Before the course started, we ran a Train the Trainers course with 7 local anaesthetic practitioners who had been invited from the previous SAFE Obs course in Benin. Each Beninese practitioner was then assigned a mentor who they followed and taught alongside throughout the remainder of the SAFE Obs course. The Safe Obs course itself was then taught over the remaining three days- using the exact same programme that had worked well previously. Evaluation of the SAFE course was conducted through the standard use of candidate pre and post-course written knowledge (MCQs) and skills tests. We saw a significant increase in results; the MCQ increased from average 68.7% pre-course, to 80.2% on the final day of the course (p<0.001). The skills tests showed a 34% increase in score.

4 P a g e 4 Acknowledgements Our sincere thanks go to Mercy Ships, without whom, the course could not have run. Recruitment of delegates, logistics and organisation were handled by medical capacity building project managers Krissy Close and Abby Watrous. Many thanks to the Association of Anaesthetists of Great Britain and Ireland (AAGBI) for their support and financial contribution to the cost of our flights. The faculty and interpreters worked extremely hard over the week and functioned very well as a team. Particular thanks go to the Beninese anaesthetists who attended the Train the Trainers course. They were extremely enthusiastic throughout and showed great willingness to continue the course once the Mercy Ships leaves Benin. Finally, our grateful thanks to the delegates for their attendance and enthusiasm.

5 P a g e 5 Background Benin is a West African country on the Gulf of Guinea that sits between Togo and Nigeria. The total population is just over 10 million. The Maternal Mortality Ratio (MMR) in Benin is 350 per 100,000 births. National statistics from show that 85.8% of pregnant women attended at least one antenatal visit and 60.5% of women receive the four prenatal visits recommended by WHO. A skilled health professional is present at 84.1% of births, although this figure varies by household wealth, falling to 51.6% for the poorest 20% of the population. The caesarean section rate is reported as 3.6%, however, we were informed that the rate is considerably higher (approximately 40%) at Hopital da le Mere et L enfant la Lagune (HOMEL), the tertiary maternity hospital in Cotonou. In 2009, the government implemented a scheme to provide free Caesarean section at several hospitals including HOMEL as part of its policy to reduce maternal mortality. This is not the case for hospital based normal deliveries, and the doctors we spoke to suggested that since the inception of the scheme they have noticed an increase in the number of families requesting CS. There are 35 members of the Benin Society of Physician Anaesthetists, of which 22 are currently working in the country. There are currently 34 Physician Anaesthetists completing a four year training course, 8 of whom are in their final year of study. Of these, one student is from Benin, the others are international students. The vast majority of anaesthetics performed in the country are done by the approximately 250 Anaesthetic Officers. Unfortunately, funding for the anaesthetic officer training school was suspended 3 years ago but there are plans being developed to start a new 2- year MSc anaesthetic conversion course for trained nurses.

6 P a g e 6 The Venue The course took place in the Novotel Cotonou Orisha Hotel. The hotel provided a great environment for both the lectures and the small group break-out sessions, with a large room for lectures, and a smaller room nearby to aid with running the smaller break-out sessions. Lunch and Coffee was also provided by the hotel, and was of a very high standard. 1 The Novotel Hotel 4 Lunch 3 Coffee Break 2 The Lecture Room

7 P a g e 7 The February 2017 SAFE Obstetrics Course The SAFE Obstetrics course was run over four days. A Train The Trainers course was held on the first of the four days. There were seven candidates on this course and these delegates then helped the visiting faculty to teach on the main course itself. Each Beninese practitioner was assigned a mentor who they followed throughout the remainder of the SAFE Obs course. Each workshop was delivered four separate times. The local Beninese instructor would have the opportunity to observe the visiting faculty and then eventually take over teaching duties once they felt comfortable. There were twenty-five candidates on course with 100% attendance throughout. The course followed the same format as previous SAFE courses, with a mixture of lectures, skills sessions, group discussions and scenarios. 12 Feb 13 Feb 14 Feb 15 Feb 16 Feb 17/18 Feb Flights to Train the Safe course Safe course Cotonou trainers Day 1 Day 2 Meet Translators/ Course preparation Safe Course Day 3/ Return flights

8 P a g e 8 Monitoring, Evaluation and Results Evaluation of the SAFE course was conducted through the standard use of candidate pre and post-course written knowledge (MCQs) and skills tests. The Pre and Post course written exam comprises of 50 Multiple Choice Questions on areas of obstetric anaesthesia including management of emergency cases, conduct of anaesthesia and processes such as use of the WHO checklist. We saw a significant increase in results from average 68.7% pre-course, to 80.2% on the final day of the course (p<0.001). In addition to the written exam, participants of the course were asked to complete one skill station; Rapid Sequence Intubation (RSI), Maternal CPR, Neonatal Resuscitation or Management of an Eclamptic Seizure. They were marked using the standard OSCE style proforma out of 10, and were tested with the same skill both at the beginning of the course, and on the final afternoon of the course. In all the skill stations we saw a marked increase in performance (please see table for more detailed results). It was notable that before the course, the participants scored well in pure anaesthetic stations compared to more specialised obstetric topics (e.g pre course average for an RSI was 8 compared to Neonatal Resuscitation of 3.7 or Management of Eclampsia was 4.6). Neonatal Resuscitation Management of a Fit 3.7 Pre-Course Average 4.6 Pre-Course Average 8.5 Post-Course Average 8.5 Post-Course Average 48% Increase in Skills 39% Increase in Skills RSI Maternal CPR 8 Pre-Course Average 6.4 Pre-Course Average 9.6 Post-Course Average 9.2 Post-Course Average 16% Increase in Skills 28% Increase in Skills Overall 34% Increase in Skills

9 P a g e 9 Participants Feedback Evaluation of the provision and the running of the course were also assessed by individual feedback from the participants. Below is a summary of directly translated comments: Responses from students: (Average 1-10 response) Do you like the Program? 9.96 Was the program helpful? 9.83 How has confidence in the skills increased? 9.83 Do you think the program will allow you to improve practices at work? 9.79 Will you share this information with others/colleagues/students? 9.79 Important skills learned during training: The management of patient by the ABCD system. Good resuscitation of the new born. The management of obstetric emergencies Correct management of obstetric emergencies. Treatment of pre-eclampsia and eclampsia. Improvement of skills in haemorrhage management Collaboration with all the team in the surgical block Management of eclampsia crisis The resuscitation of newborn Management of haemorrhage emergency The usefulness of the call for help The management of mother's resuscitation Assessment of the patient by ABCDE method What changes do you expect to make to your practice areas as a result of the training you received? Strengthening teamwork Ability to deal with neonatal resuscitation Working under the ABCDE Approaches How to take care of the pregnant woman Patient management by: Call for help, Agreement between colleagues in the system, ABCDE system Rapid sequence in general anaesthesia The organization of debriefing after each critical situation Stopping the inappropriate aspiration of the newborn Build a box for management of eclampsia

10 P a g e 10 Having a difficult intubation kit The first action that consist of oxygenating all new born in resuscitation. Stabilize blood pressure before anaesthesia and less filling. Multidisciplinary management of cardiomyopathy. Train the midwives on the practical resuscitation of the newborn. Ventilate the new born as soon as possible instead of sucking. Put into practice The ABCD approach for the management of the patient. Use of magnesium sulphate. Water restriction in the case of pre-eclampsia or eclampsia. Facing patients, always use the checklist. Always use the checklist of surgical safety. Always use oxygen in case of distress. I will follow the checklist. I will put into practice the skills received during the training for a better management of the patient. What problems would you encounter in making these changes? The non-accession of all colleagues The lack of equipment Stock-outs of equipment Lack of motivation The reluctance of the administration office to acquire certain products Lack of help from the administration and non-availability of equipment Lack of collaboration The reluctance of surgeons to the checklist The non availability of material. The lack of qualified staff. The most important obstacle is the non availability of adequate equipments for a better management. Other comments: Thanks and happy return! We love the various trainers The training has been good. Infinite thanks to all the trainers. You are excellent!

11 P a g e 11 Post-Intervention Activity All candidates received a certificate for completion of the course, and a copy of the learning material on a USB stick for further reference. They were also provided with a logbook, to be used for ongoing evaluation and self-reflection of practice. In addition, those who attended the Train the Trainers Course, were provided with the course manuals giving details on how to organise their own courses in the future, and the medical information and scenarios used for teaching. Mercy Ships plan to contact students 3 months after the course to assess whether they have managed to implement the teaching, and assess ongoing challenges. In addition, multiple other training programmes are running in parallel including SAFE Paediatrics and training on the WHO checklist. This is the last Safe Obs course Mercy Ships plan to facilitate in this current field service in Benin. Summary The SAFE Obs course aims to equip anaesthetic providers with increased skills and knowledge to manage obstetric emergencies and provide safe anaesthetic care in resource poor countries. The course has been run successfully in Benin for the second time during the field service of Mercy Ships. There was a demonstration of increase in knowledge and skill level from assessment made on the course, and positive feedback from the candidates. Seven of the strongest candidates from the previous SAFE Obs course also attended the Train the Trainers Course, and took part in teaching the course alongside the visiting faculty. They are enthusiastic to continue using these teaching skills in their place of work.

12 P a g e 12 SAFE Obstetrics Faculty Dr Emma Halliwell Dr James Eldridge Dr Gill Van Hasselt Dr Albert Urwyler Dr Doriane Makambila Dr Nikki Cox Dr Scott McNeill Course Director Consultant Anaesthetist, Salisbury Consultant Anaesthetist, Portsmouth Consultant Anaesthetist, Poole Consultant Anaesthetist, Basel Consultant Anaesthetist Pointe Noire, Congo-Brazzaville Specialist Trainee Anaesthetics, Wessex Deanery Specialist Trainee Anaesthetics South East Scotland Deanery TOT Participants teaching on SAFE Obstetrics Marcos OSSENI Serge MEWANOU Ambroise GUEGNI Florentine AGBANDI Salifou MAMA Fidegnon AKPOVI Roger HOUNDESSIME Translators Segla SOHOUNOU Adonis LOGBO Parsifal LOGBO Zouliha SALAMI Ganiou ADJADE

13 P a g e 13 Train the Trainers Course 14 th February 2017 SAFE Obstetric Course 15 th -17 th February 2017

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