Introduction
Despite an impressive worldwide drop in maternal mortality since 2000, every day approximately 810 women still die from preventable complications related to pregnancy and childbirth [1]. Roughly two-thirds of these deaths occur in sub-Saharan Africa [1]. The major complications responsible for these deaths are severe bleeding, infections, and high blood pressure during pregnancy, complications from delivery, and unsafe abortion [1]. Most of these complications are preventable or treatable, as the healthcare solutions to prevent or manage these situations are well known [1]. Factors that prevent women from receiving and seeking care for these situations are poverty, distance to health facilities, lack of knowledge, cultural beliefs and practices, but also inadequate healthcare services [2]. Barriers in these services include poor management of emergency obstetric care provision, delayed referral practices, and limited coordination among staff [1, 2]. Simulation-based emergency obstetric training can be a valuable tool to enhance the performance of obstetric care teams.
The observation made by Black et al. in 2003 revealed a gap in the availability and evaluation of training programs in acute obstetric emergencies in both high-income countries and low- and middle income countries [3]. Since this observation, the number of obstetric simulation peer-reviewed reports has increased exponentially with merging evidence that simulation-based emergency obstetric training can improve healthcare provider knowledge and skills, clinical practice, and health outcomes [3, 4, 5, 6, 7, 8, 9, 10]. However, these results were not consistent across all training programs. The prioritization of scaling up effective training packages was recommended with further evaluation research beyond the outcome-based Kirkpatrick levels to delve deeper into the mechanisms that drive or hinder the achievement of training outcomes [4, 11].
Kirkpatrick’s theoretical model is a frequently used framework for evaluating the effectiveness of a training program [12]. This model contains four levels [12]. The first two levels assess trainees’ experience and learning in an educational setting, while level three and four shift to the effects on actual health workers’ behaviour and patient outcomes. The effectiveness of simulation-based training depends, among other things, on the instructional design of the training program. The instructional design is generally referred as the ‘set of prescriptions for teaching methods to improve the quality of instruction with a goal of optimizing learning outcomes’ [13]. The evidence from systematic reviews identified essential instructional design features for simulation-based medical education [14, 15]. Evaluation of these features provides a deeper understanding of the strengths and weaknesses of training courses.
This review gives an overview of studies about emergency obstetric, postgraduate, simulation-based training in sub-Saharan and Central Africa, and provides insight into the attention given to the instructional design of training programs. The rationale for focusing on sub-Saharan and Central Africa was due to the persisting high maternal and neonatal mortality rates from preventable causes related to pregnancy and childbirth. Moreover, worldwide variations in ethnic and geographical perspectives, as well as local clinical settings, impact learning approaches and outcomes in educational settings [16].
Materials and Methods
Search strategy
We searched Medline, Embase and Cochrane Library from inception to May 2021. Keywords used for the search included combinations of ‘Obstetrics’ AND ‘Simulation training’ AND ‘Sub-Saharan and Central Africa’ (see Appendix 1 for the complete search strategy).
Eligibility criteria
We selected all peer-reviewed articles on simulation-based training evaluation in obstetric emergencies including technical skills, non-technical skills or both, provided for obstetric qualified healthcare providers in sub-Saharan and Central Africa. We excluded editorials, opinions, conference abstract, study protocols, reviews, non-English publications, and articles describing courses for unqualified obstetric healthcare workers, including birth attendants without formal training.
Simulation training was defined as ‘an artificial representation of a real world process to achieve educational goals through experiential learning and is characterised by the use of simulation tools that serve as an alternative for real patients’ [17]. Additionally, articles were included when simulation-based training was applied as major component of obstetric quality improvement activities related directly to the direct causes of maternal and neonatal deaths. Obstetric emergencies were defined as complications that arise during pregnancy and childbirth that can threaten the well-being of mother and/or child [18]. Studies on obstetric training without simulation, and simulation-based training in medical fields other than obstetrics were excluded.
Study selection
Two authors (AT and RM) independently reviewed all titles and abstracts. Based on title and abstract, full text articles were assessed for eligibility. Any disagreements were resolved by a third author (BH or AF).
Data extraction and analysis
Data extraction was done independently by four authors (AT, RM, PT, NW). Any disagreements were resolved by discussion between the authors or, if required, by consultation of another author (BH). The characteristics of the included studies were extracted into a predesigned summary table and the strength of the evidence was appraised using the Oxford Centre for Evidence-Based Medicine (OCEBM, 2011) levels of evidence [19]. Outcome measures according to the four levels of Kirkpatrick’s model were summarized. To assess the instructional design of the training programs, each article was subjected to evaluation using the ID-SIM (Instructional Design of a Simulation Improved by Monitoring) questionnaire. The ID-SIM questionnaire is an evidence-based assessment tool comprising of 42 items. This tool serves a dual purpose, assisting both in the development and evaluation of a simulation-based team training [20]. The items represent ten instructional design features described by Issenberg et al. and McGaghie et al. Per instructional design features, the number of items ranges from two to six [14, 15]. Examples of these instructional design features include feedback, repetitive practice, and ranging difficulty level. Rather than adopting the rating system validated within the ID-SIM questionnaire, we opted to quantify the addressed items from the questionnaire for each article. This decision was driven by the wide variation in the descriptions of instructional design items across the reviewed studies, which made a qualitative content-based evaluation impossible.
Results
Search results
Details of the study selection process are depicted in Figure 1. From the identified 1206 unique records, 127 articles were selected according to the selection criteria after reading title and abstract. After examination of the 127 full articles, 80 articles were excluded. Among these, 43 articles were excluded as they did not report on simulation-based training in obstetric emergencies within the specified regions of sub-Saharan and Central Africa. Additionally, 36 articles were excluded due to their format, including abstracts, posters, letters to the editor, study protocols or reviews. Furthermore, one article was excluded for being non-English. Hence, a total of 47 peer-reviewed studies were included in this review.
Enlarge this image.Figure 1 Study flow diagram to map the number of articles identified, included and excluded.
Study characteristics
Table 1 provides a detailed description of the study characteristics of the 47 included studies. The studies span a diverse array of study designs including eighteen pre-post studies [21, 22, 31, 32, 33, 34, 35, 36, 37, 38, 23, 24, 25, 26, 27, 28, 29, 30], seven cluster-randomized controlled trials [39, 40, 41, 42, 43, 44, 45], five descriptive studies [46, 47, 48, 49, 50], two quasi-experimental studies [51, 52], and one observational study [53]. Ten studies included both descriptive and pre-post data [54, 55, 56, 57, 58, 59, 60, 61, 62, 63], and two studies included both descriptive and observational data [64, 65]. In addition, two studies were cost analysis studies [66, 67]. Five out of seven cluster-randomized controlled trials were published since 2018 [42, 43, 44, 45, 68].
[Table Omitted: See PDF]
Thirteen of the 47 included articles were related to the Helping Babies Breath program [22, 25, 72, 73, 74, 27, 42, 49, 51, 65, 69, 70, 71], and eight to the Helping Mothers Survive: Bleeding After Birth program [34, 42, 43, 49, 75, 76, 77, 78]. Over the years, the insights gained from evaluations of these training programs have led to the modification and refinement of instructional design features. The addition of refresher courses to the original course program, leading to a change in the instructional design feature of repetitive practice, is an example of this. Additionally, simulation-based training programs were increasingly accompanied by other quality improvement collaboratives such as maternal death reviews, supportive supervision visits, mobile mentoring (by phone or SMS), or peer-assistant learning [26, 39, 52, 66, 79, 40, 41, 42, 43, 45, 47, 49, 51]. Most studies were conducted in Tanzania [22, 28, 71, 74, 75, 78, 80, 30, 34, 51, 63, 64, 65, 69, 70], Ghana [27, 33, 41, 47, 54, 60, 80, 81], Kenya [45, 58, 63, 72, 73, 80], Uganda [42, 43, 45, 49, 57, 61], and Malawi [36, 63, 64, 80]. The range of involved hospitals spans the whole spectrum from rural health clinics to tertiary teaching hospitals.
Study population and duration
Participants of the training programs included providers from all healthcare levels in paediatrics, obstetrics, anaesthetics, and ambulance drivers. In six studies training was set up uniprofessional [25, 27, 35, 41, 54, 61] and in 37 studies interprofessional [31, 32, 45, 47, 48, 49, 51, 52, 55, 56, 58, 60, 33, 62, 63, 64, 65, 70, 71, 72, 73, 74, 75, 34, 77, 78, 81, 82, 83, 84, 85, 36, 37, 38, 40, 43, 44]. Twenty-seven studies concentrated on technical skills [21, 22, 48, 51, 52, 54, 56, 62, 64, 65, 69, 71, 25, 72, 73, 74, 78, 84, 85, 86, 27, 32, 34, 37, 38, 42, 43], one study on non-technical skills [35], and nineteen on both technical and non-technical skills [30, 33, 63, 68, 79, 80, 81, 82, 83, 87, 88, 36, 45, 47, 49, 55, 58, 60, 61]. The total duration of the training exhibited a notable variability, spanning from a half day to a 18-day training. The diversity in training duration was complemented by a broad spectrum of repetitive training schedules, encompassing intervals ranging from annual repetitions to weekly sessions over the span of a year. The duration of the repetition training also varied between three minutes up to a half day of training. As the years have progressed, an increasing inclusion of repetitive training schedules has been observed.
Outcome measures on Kirkpatrick’s four levels
Table 1 gives an overview of all evaluated levels of Kirkpatrick’s model. Eighteen studies described results on Kirkpatrick level 1 [36, 44, 61, 62, 63, 64, 65, 75, 83, 84, 47, 48, 49, 54, 55, 56, 58, 60]. All studies showed positive reactions, and challenges and recommendations were faced in twelve studies (Table 2). These challenges include frequent staff rotation, work schedules that prevented trainees from attending training, and low financial incentives [48, 49, 65, 79]. The recommendation to extend training duration and adding refresher training sessions was made in nine articles [48, 50, 55, 57, 58, 60, 61, 63, 65].
[Table Omitted: See PDF]
Twenty-nine studies documented results at Kirkpatrick level 2 [25, 27, 51, 52, 54, 55, 56, 58, 60, 61, 62, 63, 32, 64, 65, 70, 72, 80, 83, 84, 85, 86, 34, 35, 38, 41, 42, 43, 44]. Eighteen of these studies showed improvements in participant’s knowledge levels, as evidenced by a an increase from pre-training to post-training assessments [32, 34, 62, 63, 64, 72, 77, 80, 84, 85, 38, 41, 43, 44, 55, 58, 60, 61]. Moreover, fifteen studies reported on positive advancements in participants’skills [25, 32, 63, 72, 77, 80, 89, 34, 35, 41, 43, 44, 54, 55, 57]. Sustained improvements in knowledge and/or skills over a period of 3 to 12 months post-training were mentioned in eight studies [25, 34, 41, 42, 44, 52, 56, 58]. A decrease in knowledge and/or skills over time was showed in six studies [27, 51, 65, 72, 77, 84]. Several independent predictors of training results on Kirkpatrick level 2 were revealed, such as trainees profession, experience in obstetrics, gender, and previous training sessions (Table 2).
Twelve studies investigated the effectiveness of training at Kirkpatrick level 3 [22, 29, 70, 90, 30, 36, 42, 43, 49, 54, 55, 58]. Seven studies described improvements of skills on the job [22, 30, 36, 42, 55, 71, 78], and two studies reported on organizational changes in workplace [55, 58]. One study reported no transfer of skills into clinical practice [70].
Twenty-two studies evaluated outcome measures at Kirkpatrick level 4 [22, 27, 43, 45, 52, 54, 69, 71, 73, 74, 78, 81, 30, 82, 91, 32, 33, 36, 37, 40, 41, 42], with eight studies describing improvements of neonatal or perinatal morbidity or mortality [22, 27, 41, 42, 45, 69, 71, 73]. One of these studies showed that initial improvements declined over time [73]. Additionally, eight studies revealed results of improvements on maternal outcomes, mostly related to postpartum haemorrhage and maternal mortality [30, 36, 37, 40, 42, 43, 78, 82]. Another study highlighted an increase in respectful maternity care [33]. Furthermore, two studies mentioned an improvement in signal functions (the major interventions for averting maternal and neonatal mortalities) [32, 55], and three studies provided cost-estimations for training rollout [52, 74, 81].
Thirteen studies reported on results not only at Kirkpatrick level 4, but also at level 2 and/or 3, hence reporting on the translation of acquired skills and knowledge into on-the-job behaviours and patient outcomes [22, 27, 55, 71, 78, 30, 32, 36, 41, 42, 43, 52, 54]. Two of the included studies provided data for all four levels of Kirkpatrick’s training evaluation model [54, 55].
Instructional design features
Analysing the reported items of the 42-item ID-SIM questionnaire across the included articles, a range emerges, spanning from 6 to 28 described items per article (14.3–66.7 percent) (Table 1). Ten articles described less than 10 items [22, 32, 41, 43, 45, 48, 55, 65, 70, 80], 34 articles mentioned between 10 and 20 items [25, 27, 42, 47, 49, 52, 54, 56, 58, 60, 61, 62, 30, 63, 64, 69, 71, 72, 73, 74, 75, 78, 81, 33, 82, 84, 85, 86, 34, 35, 36, 37, 38, 40], and only three article stated more than 20 items [51, 79, 83]. The items related to the instructional design features ‘learning strategies’ and ‘defined outcomes’ emerged as the most frequently described items across the articles (Appendix 2). The items about ‘difficulty range’ and ‘individualized learning’ were rarely mentioned.
Discussion
Main findings
This review gives an overview of 47 studies on emergency obstetric, postgraduate, simulation-based training in sub-Saharan and Central Africa, and examines the applied instructional design features of training programs. Results comprise rising evidence that training can have a positive impact across all four levels of Kirkpatrick’s training evaluation model. However, results were not consistent across all studies and the effects vary over time. To understand why some simulation-based training programs were more effective than others, we incorporated a quality assessment of the instructional design within the evaluated training programs. However, the heterogeneous nature of descriptions for instructional design items introduced a significant challenge to achieve an objective scoring. In fact, the number of described instructional design items varied between 14.3 and 66.7 percent, with only three out of 47 articles describing more than 20 out of 42 items.
In general, the results of this review on Kirkpatrick’s levels of training evaluation correspond with the findings of other reviews that evaluate emergency obstetric simulation-based training including other geographical regions than sub-Saharan and Central Africa. One literature review about emergency obstetric and neonatal care training in high-income and low- and middle-income countries focused on Kirkpatrick levels 3 and 4, and reported mostly positive changes in behaviour, the process, and patient outcomes [92]. A subsequent review about the effectiveness of training in emergency obstetric care in high-income and low- and middle-income countries noted improvements in healthcare providers knowledge, skills, clinical practice, and neonatal outcomes [93]. However, the strength of evidence for a reduction in stillbirths, maternal morbidity, and maternal mortality was less strong [93]. Another review by Brogaard et al. about obstetric emergency team training in high-resource settings suggests a positive effect on some neonatal outcomes, but also stated conflicting results on neonatal and maternal outcomes [94]. Finally, Fransen et al. assessed the effects of simulation-based obstetric team training in high-income and low- and middle-income countries, and included only randomised controlled trials in their review [8]. Results of eight included studies showed that training, compared with no training, may help to improve team performance of obstetric teams, and that it might contribute to improvement of specific maternal and perinatal outcomes [8]. Both Brogaard et al. and Fransen et al. highlighted the need to undertake future high-quality studies, including comparisons between training courses with a different instructional design, to identify the optimal methodology for effective team training [8, 94].
The majority of included studies in this review reported positive results when evaluating their training program on patient outcomes. This effect may be partly due to the higher incidence of adverse maternal and perinatal outcome in sub-Saharan and Central Africa, allowing for an easier detection of a change. The high prevalence of positive training results could also potentially be influenced by publication bias favouring positive outcomes. The observed lower emphasis on the instructional design of training programs in sub-Saharan and Central Africa can be attributed to a combination of factors such as unfamiliarity of instructional design items, and resource limitations prevalent in these regions, including inadequate staffing and constrained budgets. The staff may prioritize clinical work and providing training, instead of evaluating and improving training programs.
An aspect to bear in mind is the original intention of the ID-SIM questionnaire, which was designed to assess instructional design features within the context of simulation-based team training. However, the scope of this review encompassed training programs that targeted uniprofessional training as well. Some of the instructional design items may be less relevant for uniprofessional training programs, what may have resulted in bias in the number of described items. An additional layer of complexity arises from the practice observed in some articles, wherein reference is made to prior publications that delve into the same training program. As we based the scoring on the information provided in the current article only, this may have led to underreported items. Combing the results of the articles on the same training programs (Helping Babies Breath project (23–32), Helping Mothers Survive: Bleeding After Birth program (33–36), QUARITE study (37,38)) did not give an objective result, because evaluation of these training programs resulted in modification of instructional design features over the years. Hence, the evaluation of the instructional design of training programs with a single name, may still differ per location and moment.
Strengths and limitations
The strength of this review is that we did not solely overview studies on emergency obstetric, postgraduate, simulation-based training in sub-Saharan and Central Africa, but also examined the applied instructional design of training programs. Two authors independently assessed all published studies and selected the studies for inclusion in order to minimize bias. Four authors performed the data extraction, data synthesis, and quality of evidence assessment. Any disagreements were resolved by discussion between the authors or, if required, by consultation of another author. Analyses was performed with a narrative syntheses, rather than meta-analyses, as studies were heterogenous with regard to design, training program, and measures of effectiveness. Most included studies in this review used pre-post study designs. While these designs offer valuable insights into training impact, they also introduce potential bias arising from concurrent events or changes that might have occurred during the training evaluation periods. An essential aspect to bear in mind is the challenge posed by the heterogeneous descriptions of instructional design items across the reviewed studies. As a consequence, it was impossible to explore a potential correlation between ID-SIM scores and the effectiveness of training programs.
Implications for practice
The rationale for focusing on sub-Saharan and Central Africa was due to the persisting high number of deaths due to complications related to pregnancy and childbirth [1]. Challenges in these areas comprise the wide variation in local settings including under-resourced health services, inadequate medical staff, and regular rotation of medical staff. Under these circumstances, perhaps with the most need for training, appropriate knowledge of simulation-based training in obstetrics will be useful to develop and evaluate sustainable, clinically effective training programs [95]. This review showed that additional evidence is available that emergency obstetric simulation-based training can have a positive impact in sub-Saharan and Central Africa, but also that future high-quality studies are necessary to identify the optimal methodology for most effective training. Over the years, simulation-based training programs were increasingly accompanied by other quality improvement collaboratives such as maternal death reviews and supportive supervision visits. In the context of sub-Saharan and Central Africa, the choice to opt for on-site training over off-site venues may create the opportunity to reach more staff members by avoiding the logistical challenges of going to a simulation center. Another advantage of on-site training is that it generates more suggestions for organizational changes compared to off-site simulation training [96]. Another implication for practice is to include non-technical skills during emergency obstetric simulation-based training in sub-Saharan and Central Africa. While most studies in this review mainly focused on technical skills, training of non-technical skills became more frequently part of training programs. Development of non-technical skills such as situational awareness, decision-making, communication, teamwork, and leadership may be even more important while managing emergency obstetric and neonatal conditions in the complex healthcare landscape of sub-Saharan and Central Africa.
Recommendations for future research
To attain a comprehensive understanding of the mechanisms that determines why certain training programs are more effective in improving maternal and neonatal healthcare outcomes than other, the imperative lies in conducting robust, well-designed studies including detailed descriptions of instructional design features of the evaluated training programs. Most included studies in this review were pre-post design studies. Nevertheless, the design of the studies became stronger over the years through including control groups and setting up randomized controlled trials.
Conclusion
This review provides an overview of 47 articles about emergency obstetric, postgraduate, simulation-based training in sub-Saharan and Central Africa. Results of these studies comprise rising evidence that training can have a positive impact across all four levels of Kirkpatrick’s training evaluation model. However, results were not consistent across all studies, and the effects vary over time. To understand why some simulation-based training programs were more effective than others, we incorporated a quality assessment of the instructional design within the evaluated training programs. However, instructional design items were heterogeneously applied and described, what made objective scoring and comparing of the items impossible. A detailed description of the instructional design features of a training program will contribute to a deeper understanding of the underlying mechanisms that determine why certain training programs are more effective in improving maternal and neonatal healthcare outcomes than others.
Additional File
The additional file for this article can be found as follows:
Appendices
Appendix 1 and 2. DOI: https://doi.org/10.5334/aogh.3891.s1
Acknowledgements
We thank Eugenie Delvaux for the search.
Funding Information
This study is not funded by any organization. All researchers are independent from any funder.
Competing Interests
The authors have no competing interests to declare.
Author Contribution
All authors had access to the data and a role in writing the manuscript.
1. World Health Organization. Maternal mortality. https://www.who.int/gho/maternal_health/mortality/maternal_mortality_text/en/ Accessed December 2022.
2. Geleto A, Chojenta C, Musa A, Loxton D. Barriers to access and utilization of emergency obstetric care at health facilities in sub-Saharan Africa-a systematic review protocol. Syst Rev. 2018; 7(1). DOI: https://doi.org/10.1186/s13643-018-0720-y
3. Black RS, Brocklehurst P. A systematic review of training in acute obstetric emergencies. BJOG An Int J Obstet Gynaecol. 2003; 110(9): 837–841. DOI: https://doi.org/10.1111/j.1471-0528.2003.02488.x
4. Bergh A-M, Baloyi S, Pattinson RC. What is the impact of multi-professional emergency obstetric and neonatal care training? Best Pract Res Clin Obstet Gynaecol. 2015; 29(8): 1028–1043. DOI: https://doi.org/10.1016/j.bpobgyn.2015.03.017
5. Ameh CA, Mdegela M, White S, Van Den Broek N. The effectiveness of training in emergency obstetric care: A systematic literature review. Health Policy Plan. 2019; 34(4): 257–270. DOI: https://doi.org/10.1093/heapol/czz028
6. Merien AER, van de Ven J, Mol BW, Houterman S, Oei SG. Multidisciplinary team training in a simulation setting for acute obstetric emergencies: A systematic review. Obstet Gynecol. 2010; 115(5): 1021–1031. DOI: https://doi.org/10.1097/AOG.0b013e3181d9f4cd
7. Van Lonkhuijzen L. A systematic review of the effectiveness of training in emergency obstetric care in low-resource environments: Authors reply. BJOG An Int J Obstet Gynaecol. 2010; 117(12): 1562–1563. DOI: https://doi.org/10.1111/j.1471-0528.2010.02678.x
8. Fransen AF, van de Ven J, Banga FR, Mol BWJ, Oei SG. Multi-professional simulation-based team training in obstetric emergencies for improving patient outcomes and trainees’ performance. Cochrane Database Syst Rev. 2020; 2020(12). DOI: https://doi.org/10.1002/14651858.CD011545.pub2
9. Opiyo N, English M. In-service training for health professionals to improve care of the seriously ill newborn or child in low and middle-income countries (Review). Cochrane database Syst Rev. 2010; 4: CD007071. DOI: https://doi.org/10.1002/14651858.CD007071.pub2
10. Crofts JF, Winter C, Sowter MC. Practical simulation training for maternity care-where we are and where next. BJOG An Int J Obstet Gynaecol. 2011; 118(SUPPL. 3): 11–16. DOI: https://doi.org/10.1111/j.1471-0528.2011.03175.x
11. Parker K, Burrows G, Nash H, Rosenblum ND. Going beyond Kirkpatrick in evaluating a clinician scientist program: It’s not “if It Works” but “how It Works.” Acad Med. 2011; 86(11): 1389–1396. DOI: https://doi.org/10.1097/ACM.0b013e31823053f3
12. Kirkpatrick DL, Kirkpatrick JD. Evaluating Training Programs: The Four Levels. Berrett-Koehlar; 1994.
13. Fraser KL, Ayres P, Sweller J. Cognitive load theory for the design of medical simulations. Simul Heal. 2015; 10(5): 295–307. DOI: https://doi.org/10.1097/SIH.0000000000000097
14. McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research: 2003–2009. Med Educ. 2010; 44(1): 50–63. DOI: https://doi.org/10.1111/j.1365-2923.2009.03547.x
15. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Med Teach. 2005; 27(1): 10–28. DOI: https://doi.org/10.1080/01421590500046924
16. Kelly AM, Balakrishnan A, Naren K. Cultural considerations in simulation-based education. Asia Pacific Sch. 2018; 3(3): 1–4. DOI: https://doi.org/10.29060/TAPS.2018-3-3/GP1070
17. Rall M, Dieckmann P. Simulation and patient safety: The use of simulation to enhance patient safety on a systems level. Curr Anaesth Crit Care. 2005; 16: 273–18. DOI: https://doi.org/10.1016/j.cacc.2005.11.007
18. Maine D, Bailey P, Lobis S, Fortney J. Monitoring emergency obstetric care: a handbook. World Heal Organ. Published online 2009: 1–152. DOI: https://doi.org/10.3109/01443611003791730
19. Oxford Centre for Evidence Based Medicine. Oxford Centre for Evidence-based Medicine—Levels of Evidence (March 2009). Published 2011. https://www.cebm.ox.ac.uk/resources/levels-of-evidence/oxford-centre-for-evidence-based-medicine-levels-of-evidence-march-2009 Assessed Nov 2021.
20. van der Hout-van der Jagt MB, Gardner R, van Runnard Heimel PJ, et al. Assessment tool for the instructional design of simulation-based team training courses: The ID-SIM. BMJ Simul Technol Enhanc Learn. 2017; 4(2): 59–64. DOI: https://doi.org/10.1136/bmjstel-2016-000192
21. Ersdal HL, Vossius C, Bayo E, et al. A one-day “Helping Babies Breathe” course improves simulated performance but not clinical management of neonates. Resuscitation. 2013; 84(10): 1422–1427. DOI: https://doi.org/10.1016/j.resuscitation.2013.04.005
22. Msemo G, Massawe A, Mmbando D, et al. Newborn mortality and fresh stillbirth rates in Tanzania after helping babies breathe training. Pediatrics. 2013; 131: e353–60. DOI: https://doi.org/10.1542/peds.2012-1795
23. Mduma E, Ersdal H, Svensen E, Kidanto H, Auestad B, Perlman J. Frequent brief on-site simulation training and reduction in 24-h neonatal mortality-An educational intervention study. Resuscitation. 2015; 93: 1–7. DOI: https://doi.org/10.1016/j.resuscitation.2015.04.019
24. Bang A, Patel A, Bellad R, et al. Helping Babies Breathe (HBB) training: What happens to knowledge and skills over time? BMC Pregnancy Childbirth. 2016; 16(1). DOI: https://doi.org/10.1186/s12884-016-1141-3
25. Arabi AME, Ibrahim SA, Ahmed SE, et al. Skills retention in sudanese village midwives 1 year following Helping Babies Breathe training. Arch Dis Child. 2016; 101(5): 439–442. DOI: https://doi.org/10.1136/archdischild-2015-309190
26. Rule ARL, Maina E, Cheruiyot D, Mueri P, Simmons JM, KamathRayne BD. Using quality improvement to decrease birth asphyxia rates after “Helping Babies Breathe” training in Kenya. Acta Paediatr Int J Paediatr. 2017; 106(10): 1666–1673. DOI: https://doi.org/10.1111/apa.13940
27. Eblovi D, Kelly P, Afua G, Agyapong S, Dante S, Pellerite M. Retention and use of newborn resuscitation skills following a series of helping babies breathe trainings for midwives in rural Ghana. Glob Health Action. 2017; 10(1): 1387985. DOI: https://doi.org/10.1080/16549716.2017.1387985
28. Nelissen E, Ersdal H, Mduma E, Evjen-Olsen B, Broerse J, van Roosmalen J, Stekelenburg J. Helping mothers survive bleeding after birth: Retention of knowledge, skills, and confidence nine months after obstetric simulation-based training. BMC Pregnancy Childbirth. 2015; 15(1). DOI: https://doi.org/10.1186/s12884-015-0612-2
29. Nelissen E, Ersdal H, Mduma E, et al. Clinical performance and patient outcome after simulation-based training in prevention and management of postpartum haemorrhage: An educational intervention study in a low-resource setting. BMC Pregnancy Childbirth. Sep 11; 17(1): 301. DOI: https://doi.org/10.1186/s12884-017-1481-7
30. Sorensen BL, Rasch V, Massawe S, Nyakina J, Elsass P, Nielsen BB. Advanced life support in obstetrics (ALSO) and post-partum hemorrhage: A prospective intervention study in Tanzania. Acta Obstet Gynecol Scand. 2011; 90(6): 609–614. DOI: https://doi.org/10.1111/j.1600-0412.2011.01115.x
31. Ameh CA, Kerr R, Madaj B, et al. Knowledge and skills of healthcare providers in sub-Saharan Africa and Asia before and after competency-based training in emergency obstetric and early newborn care. PLoS One. 2016; 11(12): e0167270. DOI: https://doi.org/10.1371/journal.pone.0167270
32. Pattinson RC, Bergh AM, Makin J, et al. Obstetrics knowledge and skills training as a catalyst for change. South African Med J. 2018; 108(9): 748–755. DOI: https://doi.org/10.7196/SAMJ.2018.v108i9.13073
33. Afulani PA, Aborigo RA, Walker D, Moyer CA, Cohen S, Williams J. Can an integrated obstetric emergency simulation training improve respectful maternity care? Results from a pilot study in Ghana. Birth. 2019; 46(3): 523–532. DOI: https://doi.org/10.1111/birt.12418
34. Al-Beity FA, Pembe AB, Marrone G, Baker U, Hanson C. Predictors of change of health workers’ knowledge and skills after the Helping Mothers Survive Bleeding after Birth (HMS BAB) in-facility training in Tanzania. PLoS One. 2020; 15(5): 1–16. DOI: https://doi.org/10.1371/journal.pone.0232983
35. Cavicchiolo ME, Cavallin F, Staffler A, et al. Decision making and situational awareness in neonatal resuscitation in low resource settings. Resuscitation. 2019; 134(August 2018): 41–48. DOI: https://doi.org/10.1016/j.resuscitation.2018.10.034
36. Chang OH, Levy B, Lytle H, et al. Implementation of the alliance for innovation on maternal health program to reduce maternal mortality in Malawi. Obstet Gynecol. 2019; 133(3): 507–514. DOI: https://doi.org/10.1097/AOG.0000000000003108
37. Pattinson RC, Bergh AM, Ameh C, et al. Reducing maternal deaths by skills-and-drills training in managing obstetric emergencies: A before-and-after observational study. South African Med J. 2019; 109(4): 241–245. DOI: https://doi.org/10.7196/SAMJ.2019.v109i4.13578
38. Rosenberg A, Williams K, Nyinawankusi JD, et al. Prehospital emergency obstetric and neonatal care train-the-trainers program in Rwanda. Int J Gynecol Obstet. 2021; 153(3): 503–507. DOI: https://doi.org/10.1002/ijgo.13491
39. Dumont A, Fournier P, Abrahamowicz M, Traore M, Haddad S, Fraser WD. Quality of care, risk management, and technology in obstetrics to reduce hospital-based maternal mortality in Senegal and Mali (QUARITE): A cluster-randomised trial. Lancet (London, England). 2013; 382(9887): 146–157. DOI: https://doi.org/10.1016/S0140-6736(13)60593-0
40. Zongo A, Dumont A, Fournier P, Traore M, Kouanda S, Sondo B. Effect of maternal death reviews and training on maternal mortality among cesarean delivery: Post-hoc analysis of a cluster-randomized controlled trial. Eur J Obstet Gynecol Reprod Biol. 2015; 185: 174–180. DOI: https://doi.org/10.1016/j.ejogrb.2014.12.023
41. Gomez PP, Nelson AR, Asiedu A, et al. Accelerating newborn survival in Ghana through a low-dose, high-frequency health worker training approach: A cluster randomized trial. BMC Pregnancy Childbirth. 2018 Mar 22; 18(1): 72. DOI: https://doi.org/10.1186/s12884-018-1705-5
42. Lynn Evans C, Bazant E, Atukunda I, et al. Peer-assisted learning after onsite, low-dose, high-frequency training and practice on simulators to prevent and treat postpartum hemorrhage and neonatal asphyxia: A pragmatic trial in 12 districts in Uganda. PLoS One. 2018; 13(12): 1–17. DOI: https://doi.org/10.1371/journal.pone.0207909
43. Hanson C, Atuhairwe S, Lucy Atim J, Marrone G, Morris JL, Kaharuza F. Effects of the Helping Mothers Survive Bleeding after Birth training on near miss morbidity and mortality in Uganda: A cluster-randomized trial. Int J Gynecol Obstet. 2021; 152(3): 386–394. DOI: https://doi.org/10.1002/ijgo.13395
44. Ugwa E, Otolorin E, Kabue M, et al. Simulation-based low-dose, high-frequency plus mobile mentoring versus traditional group-based training approaches on day of birth care among maternal and newborn healthcare providers in Ebonyi and Kogi States, Nigeria; a randomized controlled trial. BMC Health Serv Res. 2018; 18(1): 2. DOI: https://doi.org/10.1186/s12913-018-3405-2
45. Walker D, Otieno P, Butrick E, et al. Effect of a quality improvement package for intrapartum and immediate newborn care on fresh stillbirth and neonatal mortality among preterm and low-birthweight babies in Kenya and Uganda: A cluster-randomised facility-based trial. Lancet Glob Heal. 2020; 8(8): e1061–e1070. DOI: https://doi.org/10.1016/S2214-109X(20)30232-1
46. Reynolds A, Zaky A, MoreiraBarros J, Bernardes J. Building a maternal and newborn care training programme for health-care professionals in Guinea-Bissau. Acta Med Port. 2017; 30(10): 734–741. DOI: https://doi.org/10.20344/amp.8453
47. Asiedu A, Nelson AR, Gomez PP, Tappis H, Effah F, Allen C. “It builds your confidence… you’ve done well”: Healthcare workers’ experiences of participating in a low-dose, high-frequency training to improve newborn survival on the day of birth in Ghana. Gates Open Res. 2019; 3: 1–15. DOI: https://doi.org/10.12688/gatesopenres.12998.1
48. Tuyisenge G, Hategeka C, Luginaah I, Babenko-Mould Y, Cechetto D, Rulisa S. Continuing professional development in maternal health care: Barriers to applying new knowledge and skills in the hospitals of Rwanda. Matern Child Health J. 2018; 22(8): 1200–1207. DOI: https://doi.org/10.1007/s10995-018-2505-2
49. Williams E, Bazant ES, Holcombe S, et al. “Practice so that the skill does not disappear”: Mixed methods evaluation of simulator-based learning for midwives in Uganda. Hum Resour Health. 2019; 17(1): 1–11. DOI: https://doi.org/10.1186/s12960-019-0350-z
50. Egenberg S, Karlsen B, Massay D, Kimaro H, Bru LE. “No patient should die of PPH just for the lack of training!” Experiences from multi-professional simulation training on postpartum hemorrhage in northern Tanzania: A qualitative study. BMC Med Educ. 2017; 17(1): 5. DOI: https://doi.org/10.1186/s12909-017-0957-5
51. Drake M, Bishanga DR, Temu A, et al. Structured on-the-job training to improve retention of newborn resuscitation skills: A national cohort Helping Babies Breathe study in Tanzania. BMC Pediatr. 2019; 19(1): 1–8. DOI: https://doi.org/10.1186/s12887-019-1419-5
52. Yigzaw M, Tebekaw Y, Kim YM, Kols A, Ayalew F, Eyassu G. Comparing the effectiveness of a blended learning approach with a conventional learning approach for basic emergency obstetric and newborn care training in Ethiopia. Midwifery. 2019; 78: 42–49. DOI: https://doi.org/10.1016/j.midw.2019.07.014
53. Mduma ER, Ersdal H, Kvaloy JT, et al. Using statistical process control methods to trace small changes in perinatal mortality after a training program in a low-resource setting. Int J Qual Heal care J Int Soc Qual Heal Care. 2018; 30(4): 271–275. DOI: https://doi.org/10.1093/intqhc/mzy003
54. Andreatta P, Gans-Larty F, Debpuur D, Ofosu A, Perosky J. Evaluation of simulation-based training on the ability of birth attendants to correctly perform bimanual compression as obstetric first aid. Int J Nurs Stud. 2011; 48(10): 1275–1280. DOI: https://doi.org/10.1016/j.ijnurstu.2011.03.001
55. Ameh C, Adegoke A, Hofman J, Ismail FM, Ahmed FM, van den Broek N. The impact of emergency obstetric care training in Somaliland, Somalia. Int J Gynaecol Obstet. 2012; 117(3): 283–287. DOI: https://doi.org/10.1016/j.ijgo.2012.01.015
56. Mirkuzie AH, Sisay MM, Bedane MM. Standard basic emergency obstetric and neonatal care training in Addis Ababa: Trainees reaction and knowledge acquisition. BMC Med Educ. 2014; 14: 201. DOI: https://doi.org/10.1186/1472-6920-14-201
57. Mildenberger C, Ellis C, Lee K. Neonatal resuscitation training for midwives in Uganda: Strengthening skill and knowledge retention. Midwifery. 2017; 50: 36–41. DOI: https://doi.org/10.1016/j.midw.2017.03.017
58. Dettinger JC, Kamau S, Calkins K, et al. Measuring movement towards improved emergency obstetric care in rural Kenya with implementation of the PRONTO simulation and team training program. Matern Child Nutr. 2018; 14 Suppl 1:10.1111/mcn.12465. DOI: https://doi.org/10.1111/mcn.12465
59. Umar LW, Ahmad HR, Isah A, et al. Evaluation of the cognitive effect of newborn resuscitation training on health-care workers in selected states in Northern Nigeria. Ann Afr Med. 2018; 17(1): 33–39. DOI: https://doi.org/10.4103/aam.aam_47_17
60. Afulani PA, Dyer J, Calkins K, Aborigo RA, Mcnally B, Cohen SR. Provider knowledge and perceptions following an integrated simulation training on emergency obstetric and neonatal care and respectful maternity care: A mixed-methods study in Ghana. Midwifery. 2020; 85: 102667. DOI: https://doi.org/10.1016/j.midw.2020.102667
61. van Tetering AAC, Martine Segers MH, Ntuyo P, et al. Evaluating the instructional design and effect on knowledge, teamwork, and skills of technology-enhanced simulation-based training in obstetrics in Uganda: Stepped-wedge cluster randomized trial. JMIR Med Educ. 2021; 7(1). DOI: https://doi.org/10.2196/17277
62. Zanardo V, Simbi A, Micaglio M, Cavallin F, Tshilolo L, Trevisanuto D. Laryngeal Mask Airway for neonatal resuscitation in a developing country: Evaluation of an educational intervention. Neonatal LMA: An educational intervention in DRC. BMC Health Serv Res. 2010; 10: 254. DOI: https://doi.org/10.1186/1472-6963-10-254
63. Grady K, Ameh C, Adegoke A, et al. Improving essential obstetric and newborn care in resource-poor countries. J Obstet Gynaecol. 2011; 31(1): 18–23. DOI: https://doi.org/10.3109/01443615.2010.533218
64. Evans CL, Johnson P, Bazant E, Bhatnagar N, Zgambo J, Khamis AR. Competency-based training Helping Mothers Survive: Bleeding after Birth for providers from central and remote facilities in three countries. Int J Gynecol Obstet. 2014; 126: 286–290. DOI: https://doi.org/10.1016/j.ijgo.2014.02.021
65. Arlington L, Kairuki AK, Isangula KG, et al. Implementation of “Helping Babies Breathe”: A 3-year experience in Tanzania. Pediatrics. 2017; 139(5): e20162132. DOI: https://doi.org/10.1542/peds.2016-2132
66. Willcox M, Harrison H, Asiedu A, Nelson A, Gomez P, LeFevre A. Incremental cost and cost-effectiveness of low-dose, high-frequency training in basic emergency obstetric and newborn care as compared to status quo: Part of a cluster-randomized training intervention evaluation in Ghana. Global Health. 2017; 13(1): x. DOI: https://doi.org/10.1186/s12992-017-0313-x
67. Chaudhury S, Arlington L, Brenan S, et al. Cost analysis of large-scale implementation of the “Helping Babies Breathe” newborn resuscitation-training program in Tanzania. BMC Health Serv Res. 2016; 16(1): 681. DOI: https://doi.org/10.1186/s12913-016-1924-2
68. Gomez PP, Nelson AR, Asiedu A, et al. Accelerating newborn survival in Ghana through a low-dose, high-frequency health worker training approach: A cluster randomized trial. BMC Pregnancy Childbirth. 2018; 18(1): 5. DOI: https://doi.org/10.1186/s12884-018-1705-5
69. Mduma ER, Ersdal H, Kvaloy JT, et al. Using statistical process control methods to trace small changes in perinatal mortality after a training program in a low-resource setting. J Int Soc Qual Heal Care. 2018; 30(4): 271–275. DOI: https://doi.org/10.1093/intqhc/mzy003
70. Ersdal HL, Vossius C, Bayo E, et al. A one-day “Helping Babies Breathe” course improves simulated performance but not clinical management of neonates. Resuscitation. 2013; 84(10): 1422–1427. DOI: https://doi.org/10.1016/j.resuscitation.2013.04.005
71. Mduma E, Ersdal H, Svensen E, Kidanto H, Auestad B, Perlman J. Frequent brief on-site simulation training and reduction in 24-h neonatal mortality-An educational intervention study. Resuscitation. 2015; 93: 1–7. DOI: https://doi.org/10.1016/j.resuscitation.2015.04.019
72. Bang A, Patel A, Bellad R, et al. Helping Babies Breathe (HBB) training: What happens to knowledge and skills over time? BMC Pregnancy Childbirth. 2016 Nov 22; 16(1): 364. DOI: https://doi.org/10.1186/s12884-016-1141-3
73. Rule ARL, Maina E, Cheruiyot D, Mueri P, Simmons JM, Kamath-Rayne BD. Using quality improvement to decrease birth asphyxia rates after “Helping Babies Breathe” training in Kenya. Acta Paediatr. 2017; 106(10): 1666–1673. DOI: https://doi.org/10.1111/apa.13940
74. Chaudhury S, Arlington L, Brenan S, et al. Cost analysis of large-scale implementation of the “Helping Babies Breathe” newborn resuscitation-training program in Tanzania. BMC Health Serv Res. 2016; 16(1): 2. DOI: https://doi.org/10.1186/s12913-016-1924-2
75. Egenberg S, Karlsen B, Massay D, Kimaro H, Bru LE. “No patient should die of PPH just for the lack of training!” Experiences from multi-professional simulation training on postpartum hemorrhage in northern Tanzania: A qualitative study. BMC Med Educ. 2017; 17(1): 119. DOI: https://doi.org/10.1186/s12909-017-0957-5
76. Evans CL, Johnson P, Bazant E, Bhatnagar N, Zgambo J, Khamis AR. Competency-based training Helping Mothers Survive: Bleeding after Birth for providers from central and remote facilities in three countries. Int J Gynecol Obstet. 2014; 126(3): 286–290. DOI: https://doi.org/10.1016/j.ijgo.2014.02.021
77. Nelissen E, Ersdal H, Mduma E, et al. Helping Mothers Survive Bleeding After Birth: retention of knowledge, skills, and confidence nine months after obstetric simulation-based training. BMC Pregnancy Childbirth. 2015; 15: 2. DOI: https://doi.org/10.1186/s12884-015-0612-2
78. Nelissen E, Ersdal H, Mduma E, et al. Clinical performance and patient outcome after simulation-based training in prevention and management of postpartum haemorrhage: An educational intervention study in a low-resource setting. BMC Pregnancy Childbirth. 2017; 17(1): 7. DOI: https://doi.org/10.1186/s12884-017-1481-7
79. Ugwa E, Kabue M, Otolorin E, et al. Simulation-based low-dose, high-frequency plus mobile mentoring versus traditional group-based trainings among health workers on day of birth care in Nigeria; A cluster randomized controlled trial. BMC Health Serv Res. 2020; 20(1): 1–14. DOI: https://doi.org/10.1186/s12913-020-05450-9
80. Ameh CA, Kerr R, Madaj B, et al. Knowledge and skills of healthcare providers in sub-Saharan Africa and Asia before and after competency-based training in emergency obstetric and early Newborn Care. PLoS One. 2016 Dec 22; 11(12): e0167270. DOI: https://doi.org/10.1371/journal.pone.0167270
81. Willcox M, Harrison H, Asiedu A, Nelson A, Gomez P, LeFevre A. Incremental cost and cost-effectiveness of low-dose, high-frequency training in basic emergency obstetric and newborn care as compared to status quo: Part of a cluster-randomized training intervention evaluation in Ghana. Global Health. 2017; 13(1): 88. DOI: https://doi.org/10.1186/s12992-017-0313-x
82. Dumont A, Fournier P, Abrahamowicz M, Traor M, Haddad S, Fraser WD. Quality of care, risk management, and technology in obstetrics to reduce hospital-based maternal mortality in Senegal and Mali (QUARITE): A cluster-randomised trial. Lancet. 2013; 382(9887): 146–157. DOI: https://doi.org/10.1016/S0140-6736(13)60593-0
83. Reynolds A, Zaky A, Moreira-Barros J, Bernardes J. Building a maternal and newborn care training programme for health-care professionals in Guinea-Bissau. Acta Med Port. 2017; 30(10): 734–741. DOI: https://doi.org/10.20344/amp.8453
84. Mildenberger C, Ellis C, Lee K. Neonatal resuscitation training for midwives in Uganda: Strengthening skill and knowledge retention. Midwifery. 2017; 50: 36–41. DOI: https://doi.org/10.1016/j.midw.2017.03.017
85. Umar LW, Ahmad HR, Isah A, et al. Evaluation of the cognitive effect of newborn resuscitation training on health-care workers in selected states in Northern Nigeria. Ann Afr Med. 2018; 17(1): 33–39. DOI: https://doi.org/10.4103/aam.aam_47_17
86. Nelissen E, Ersdal H, Mduma E, et al. Helping Mothers Survive Bleeding After Birth: Retention of knowledge, skills, and confidence nine months after obstetric simulation-based training. BMC Pregnancy Childbirth. 2015; 15(1): 1–7. DOI: https://doi.org/10.1186/s12884-015-0612-2
87. Egenberg S, Masenga G, Bru LE, et al. Impact of multi-professional, scenario-based training on postpartum hemorrhage in Tanzania: A quasi-experimental, pre- vs. post-intervention study. BMC Pregnancy Childbirth. 2017; 17(1). DOI: https://doi.org/10.1186/s12884-017-1478-2
88. Zongo A, Dumont A, Fournier P, Traore M, Kouanda S, Sondo B. Effect of maternal death reviews and training on maternal mortality among cesarean delivery: Post-hoc analysis of a cluster-randomized controlled trial. Eur J Obstet Gynecol Reprod Biol. 2015; 185(2015): 174–180. DOI: https://doi.org/10.1016/j.ejogrb.2014.12.023
89. Ersdal HL, Vossius C, Bayo E, et al. A one-day “Helping Babies Breathe” course improves simulated performance but not clinical management of neonates. Resuscitation. 2013; 84: 1422–1427. DOI: https://doi.org/10.1016/j.resuscitation.2013.04.005
90. Mduma E, Ersdal H, Svensen E, Kidanto H, Auestad B, Perlman J. Frequent brief on-site simulation training and reduction in 24-h neonatal mortality-An educational intervention study. Resuscitation. 2015; 93(2015): 1–7. DOI: https://doi.org/10.1016/j.resuscitation.2015.04.019
91. Ameh C, Adegoke A, Hofman J, Ismail FM, Ahmed FM, Van Den Broek N. The impact of emergency obstetric care training in Somaliland, Somalia. Int J Gynecol Obstet. 2012; 117(3): 283–287. DOI: https://doi.org/10.1016/j.ijgo.2012.01.015
92. Bergh AM, Baloyi S, Pattinson RC. What is the impact of multi-professional emergency obstetric and neonatal care training? Best Pract Res Clin Obstet Gynaecol. 2015; 29(8): 1028–1043. DOI: https://doi.org/10.1016/j.bpobgyn.2015.03.017
93. Ameh CA, Msuya S, Van Den Broek N. Impact of emergency obstetric care training of skilled birth attendants in Kenya. Int J Gynecol Obstet 20th FIGO World Congr Gynecol Obstet Italy Conference Publ. 2012 Jun; 117(3): 283–287. DOI: https://doi.org/10.1016/S0020-7292(12)60479-2
94. Brogaard L, Glerup Lauridsen K, Løfgren B, et al. The effects of obstetric emergency team training on patient outcome: A systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2022; 101(1): 25–36. DOI: https://doi.org/10.1111/j.1471-0528.2011.03175.x
95. Crofts JF, Winter C, Sowter MC. Practical simulation training for maternity care--where we are and where next. BJOG. 2011; 118(Suppl): 11–16. DOI: https://doi.org/10.1111/j.1471-0528.2011.03175.x
96. Sørensen JL, van der Vleuten C, Rosthøj S, et al. Simulation-based multiprofessional obstetric anaesthesia training conducted in situ versus off-site leads to similar individual and team outcomes: A randomised educational trial. BMJ Open. 2015; 5(10): no pagination. DOI: https://doi.org/10.1136/bmjopen-2015-008344
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