Volume 93, Issue 5 p. 517-520
Short Research Report
Free Access

Comparing hands-on and video training for postpartum hemorrhage management

Cecilia Nilsson

Corresponding Author

Cecilia Nilsson

Surgical Department, Nordsjællands Hospital, Hillerød, Denmark


Cecilia Nilsson, Nordsjællands Hospital, Surgical department, Dyrehavevej 29, 3400 Hillerød, Denmark. E-mail: [email protected]

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Bjarke Lund Sørensen

Bjarke Lund Sørensen

Obstetrics and Gynecology Department, Roskilde Hospital and University of Copenhagen, Roskilde, Denmark

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Jette Led Sørensen

Jette Led Sørensen

Juliane Marie Center for Children, Women and Reproduction, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark

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First published: 05 March 2014
Citations: 26
The authors have stated explicitly that there is no conflict of interest. The authors alone are responsible for the content and writing of the paper.


The objective was to compare two teaching methods for postpartum hemorrhage management: interactive hands-on training and non-interactive video training. In a controlled intervention study at a secondary health care center in Kenya, the two training methods, based on the Advanced Life Support in Obstetrics curriculum, were evaluated utilizing structured observation of a standardized scenario before and after training. Both intervention groups significantly increased in performance scores after receiving hands-on training: 40% (95% CI 29.5–47.0) and video training: 34.5% (95% CI 25.0–42.0); likewise, pass rates improved significantly. No significant differences in performance score or pass rates were found between the two methods. The findings indicate that postpartum hemorrhage management training by mobile media might be just as effective as conventional hands-on training and a feasible way to overcome the outreach gap in sub-Saharan Africa's rural areas, where peripheral health facilities are generally difficult to reach with conventional training programs.


  • ALSO®
  • Advanced Life Support in Obstetrics
  • EmOC
  • emergency obstetric care
  • mHealth
  • mobile technology
  • PPH
  • postpartum hemorrhage
  • Introduction

    Postpartum hemorrhage (PPH) is one of the most common obstetric complications in the developing world and its management is one of the key components in emergency obstetric care (EmOC) 1. Recently it has become increasingly clear that the quality of EmOC within health facilities in sub-Saharan Africa is extensively deficient and needs to be improved to ensure safe deliveries 2, 3. One of the most widespread EmOC courses globally is Advanced Life Support in Obstetrics (ALSO®), which more than 150 000 health providers worldwide have attended 4. A prospective study conducted in a low-resource environment in Tanzania showed that the two-day ALSO® course significantly reduced the incidence of PPH by almost 50% 5. However, quality assurance of EmOC in sub-Saharan Africa is challenged by an outreach gap as most health facility deliveries and obstetric emergencies take place peripherally and are difficult to reach with conventional training programs. Due to the increase in internet access and the growing availability and use of mobile phones and smartphones in Africa, the promotion of health services via mobile phones or other mobile technology (mHealth) has been suggested as a mean to bridge the outreach gap 6. However, the effectiveness of mHealth for EmOC training programs compared with conventional EmOC training programs such as hands-on training remains to be assessed. The objective of this study was to compare interactive hands-on training with non-interactive video training for management of PPH.

    Material and methods

    A controlled intervention study was performed, with two groups receiving either interactive hands-on training or a non-interactive video training in prevention and management of PPH. The participants were assessed by structured observation in a standardized test-scenario before and after the intervention (Figure 1). All senior nursing students, in total 35, were asked to participate in the study and 27 agreed to participate. They were informed about the objectives and assured confidentiality and anonymity. All participants had undergone theoretical and practical training in gynecology and obstetrics, including EmOC, as a part of their curriculum. Their age varied between 22 and 36 years and included both males (n = 6) and females (n = 21). The 27 participants were divided into two intervention groups; the hands-on group included 15, although two did not complete the post-test and were ultimately excluded from the analysis, leaving a total of 13 participants. The video group included 12 participants. Assignment to the intervention groups was done by the headmaster of the school and based exclusively on the students' evening- and night shifts at the hospital. The headmaster had no information on which type of training the two groups received and had no conflict of interest in the intervention.

    Details are in the caption following the image
    Overview of the training sequence.

    Prior to effectuation of the study, teaching material based exclusively on the ALSO® curriculum was developed by the authors. The material includes: one PowerPoint presentation with pre-recorded vocal instructions and one training video (Video S1) demonstrating the role-play for prevention and management of PPH. The interactive hands-on training lasted 90 min, consisting of a 30-min PowerPoint lecture on prevention and management of PPH followed by a 60-min workshop consisting of a hands-on role-play scenario with a teamwork approach. The non-interactive video training lasted 35 min. The teaching materials included a 12-min PowerPoint presentation with pre-recorded vocal instructions and an 11-min video (Video S1), demonstrating prevention and management of PPH. These non-interactive teaching materials corresponded directly to what was taught in the hands-on training. As an instructor was not present, the participants were unable to ask questions. The participants were evaluated utilizing structured observation and numeric scoring of a standardized scenario before and after training.

    For both intervention groups the scores were compared before and after the training using the Hodges–Lehman test for non-parametric dependent samples, and median differences calculated with p-Values calculated using Wilcoxon test. The differences in pre- and post-test scores for each participant were calculated and were compared between the two training groups using the Mann–Whitney U-test for non-parametric, independent samples. To pass the ALSO® examination, 70% of the maximum obtainable points are required. The number of passed or failed participants was compared before and after training in both groups by Fisher's exact two-tailed analysis. The number of students that had failed before and subsequently passed after the training was compared between the two groups with the same analysis. Furthermore, for each of the specific parameters in the scoring form, the improvement after training was compared by Fisher's exact two-tailed analysis. The statistical software program used was SPSS 20 (IBM Corp., Armonk, NY, USA).


    The performance scores of both intervention groups increased significantly after they receiving training. The non-interactive training video group had a median increase of 35% (95% CI 25.0–42.0). The hands-on group had a median increase of 40% (95% CI 29.5–47.0). There were no significant differences in either pre-training test scores (p = 0.852) or post-training test scores (p = 0.367) between the intervention groups. In both intervention groups, the number of participants who passed the test significantly improved after the training (Table 1). In the hands-on group (= 13) none passed before training, whereas nine passed after training (< 0.001). In the non-interactive training video group (= 12), one passed before training, whereas 10 passed after training (< 0.001). Specific parameters included in the scoring sheet significantly improved for both intervention groups after training: bimanual compression (< 0.001), misoprostol administration (< 0.001), and inserting two large-bore IV cannulas (< 0.05) (Table 1).

    Table 1. Numbers of participants passing and or failing the test and skills that improved after the training
    Hands-on training = 13 Video training = 12
    Pre-test Post-test p-Value Pre-test Post-test p- value
    Passed test 0 9 0.001 1 10 0.001
    Failed test 13 4 11 2
    Realize urgency, General resuscitative measures 9 13 0.096 10 12 0.478
    Insert 2 large-bore IV cannula 7 13 0.015 4 10 0.036
    Draw/send bloods 6 12 0.030 4 9 0.099
    Initiate 2 L of crystalloid 10 11 0.500 10 11 1.0

    If no response?

    Give blood; Type specific/O-neg.

    4 3 1.000 4 5 1.0
    Uterine massage 12 12 1.000 12 12 1.0
    Indwelling catheter 2 6 0.202 7 11 0.725
    Bimanual compression 0 13 0.001 0 9 0.001
    Describe the causes of PPH 13 12 1.0 12 12 1.0
    Oxytocin infusion 13 13 1.0 11 12 1.0
    Misoprostol PR 0 12 0.001 0 10 0.001

    If situation remains unstable;

    Early transfer to theater

    5 10 0.111 1 7 0.027
    • PPH, postpartum hemorrhage; PR, per rectum.


    Video has the potential to reach out to most rural areas in Africa where the challenge of high maternal mortality and quality assurance of EmOC is the greatest 7. According to the present study, a non-interactive training video may be just as effective as interactive hands-on training in management of PPH. Both training methods tested showed significant improvement between the pre- and post-test scores, but no significant differences were demonstrated between the two methods.

    Due to the expanding internet and mobile phone penetration in Africa, it is easier to access and spread information and education. Attention and enthusiasm around mHealth has accelerated over the last year and it is among a fast-growing field of interventions. However, research and evidence on the effectiveness of mHealth are scarce, and evaluation of efficacy and cost-effectiveness of mHealth is needed to ensure that time and money are not wasted on ineffective programs 8-10.

    The limitations of the study can be categorized into four elements: sample size, randomization, assessment instrument and procedure of testing. First, the small sample size increases the risk of type two errors. Secondly, the randomization should optimally have been done under blinded conditions but due to scheduled shifts at the hospitals this was not possible. Thirdly, the assessment instrument used has not been validated. Fourthly, for the procedure of testing, the same scenario was used both pre- and post intervention, which can result in test-enhanced learning. Furthermore, Cecilia Nilsson did all the assessments, resulting in risk of bias due to a non-blinded rater. There was also a risk of contamination of data in-between the groups, as it was not possible to strictly separate the participants while they waited to be tested.

    The effectiveness of mHealth in medical education is mainly shown in studies including e-learning, but also m-learning. mHealth is suggested to improve medical education, being a cost-effective supplement to lecture-based learning, and allowing the learner to tailor their own learning objectives and give control over content, pace of learning, time and media 11, 12. The present study suggests that a training video could be used for educational purposes in a low-resource setting and enhanced education and knowledge in the prevention and management of PPH. The prevalent use of mobile phones suggests that a training video could be adapted as an application to provide a more convenient educational tool. PPH management training by mobile media may be as effective as conventional hands-on training and a feasible way to overcome the outreach gap in sub-Saharan Africa's rural areas, where peripheral health facilities are generally difficult to reach with conventional teaching methods.


    No special funding.