Practice Makes Perfect and Saves Lives: The Case for Obstetric Emergency Drills

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By: Katie Millar, Senior Project Manager, Women and Health Initiative, Harvard T.H. Chan School of Public Health

Drills diagramThis post is the second of four, which discuss three interventions that worked synergistically to strengthen a health system and improve obstetric emergency management in Addis Ababa, Ethiopia.

Luckily, devastating obstetric emergencies are rare. But due to their rarity, pregnant women are at risk of not receiving the care they need when they face life-threatening complications if clinicians don’t have a way to maintain knowledge and skills in managing obstetric emergencies. Stepping outside of the classroom, obstetric emergency drills—a simulation of managing a woman with the most common obstetric emergencies—allows both midwives and physicians to gain and maintain knowledge, build skills, develop teamwork and improve communication to safely manage these complications.

An obstetric emergency drill is similar to other emergency drills, such as fire drills and allows providers to practice applying their skills and knowledge in the same setting, as they would manage a real emergency – in this case, their own facility.

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Mother and newborn in the postpartum unit at St. Paul’s Hospital (Photo: Katie Millar/MHTF)

The Maternal Health Task Force partnered with the Institute for Clinical Effectiveness and Health Policy (IECS), an Argentinean organization, to carry out obstetric emergency drills training for midwives and physicians for facilities in the St. Paul’s Hospital Referral Network, in Addis Ababa, Ethiopia. Training a few clinicians from each facility strengthened the entire network, since clinicians return to their respective health centers and train other providers, strengthening each facility’s capacity to manage postpartum hemorrhage (PPH) and eclampsia, the two most common obstetric complications.

But acting out drills is only one part of the learning process. The drills are actually made up of three parts. First, participants in the drills training have a classroom review of the steps of managing PPH and eclampsia prior to the simulation. Second, participants are organized into teams, each assuming a specific role, and perform the emergency drills, which are recorded. Third, the recordings are reviewed by the trainer with the drill team in order to celebrate strengthens and identify, discuss and correct weaknesses in the management of the obstetric emergency. The review of the video and the debriefing afterwards are key to solidifying the skills and knowledge gained during the simulation.

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Mekiya Abdela, midwife at Addis Ketima Health Center. (Photo: Katie Millar/MHTF)

When providers in Addis Ababa first heard about drills, they weren’t sure they would be useful, but perceptions quickly changed. “Before the drill we thought, ‘Emergency care? We know how to provide it because we learned it in the college.  So, what is the useful thing in the drill?’  But after a drill, after practice, we found drills to be most useful. Even after the project stops, we will continue doing drills,” said Mekiya Abdela, a midwife at Addis Ketima Health Center.

Others thought that the drills just sounded like a drama or play to act out, not something that would build skills.  “Initially it sounds somehow strange, because there is an actress, so it looks fictitious or something. May be difficult to apply in our setting, I thought.  But subsequently it was easy to practice after the training and I think it brought up many positive changes in our practice,” said Biruck Gashawbeza, a 3rd year obstetrics and gynecology resident at St. Paul’s Hospital.

Drills change clinicians’ practice

Despite initial doubts of the effectiveness of the drills, participants reported an increase in teamwork, communication, confidence and skills in managing obstetric emergencies.

The drills built teamwork not only within facilities, but between facilities. Clinicians from throughout the referral network worked together for the first time during the drills training, which strengthened relationships between these providers, leading to better inter-facility communication.

Kedir Adem, a midwife from Selam Health Center, said, “We manage obstetric emergencies by teamwork and develop a sense of ‘we can accomplish anything,’ as long as we work together as a team. It is very important to develop a team spirit among the providers.”

Dr. Delayehu Bekele, shows a delivery room at St. Paul's Hospital Ethiopia labor and delivery maternal health addis ababa
Dr. Delayehu Bekele, shows a delivery room at St. Paul’s Hospital (Photo: Katie Millar/MHTF)

When clinicians finished the training, they implemented drills in their own facilities, building teamwork and communication between clinicians who work together every day. According to Delayehu Bekele, then Chair of Obstetrics & Gynecology at St. Paul’s Hospital Millennium Medical College, before the drills training, communication was very hierarchical at St. Paul’s Hospital, with no two-way communication: physicians would give midwives and other staff commands without follow-up and without teamwork. But drills changed that.

“[When] we started the drills, we noticed there were some communication gaps which used to exist… So we do the drills because it’s desirable to fix those kinds of communication gaps, especially between providers and the patient,” said Bekele.

Increased communication with patients also improved respectful maternity care. Clinicians learned how to “communicate, help each other, call [colleagues] by name, even call patients by name and explain to the patient the type of disease she has,” said Adem.

Gaps in workflow during obstetric emergencies were identified and corrected. With the first drills, providers wasted time gathering supplies. The drills helped people to know where all the equipment was and how to use it to respond more quickly. It also helped them to reorganize emergency supplies and make sure they were easily accessible in each room.

Clinical skills in managing PPH and eclampsia were strengthened. “There [was] no emergency readiness available in delivery room before beginning the drills [exercise]. And after we started the drill, our provider[s] [were] capable of managing emergency cases of eclampsia and PPH and they also make emergency readiness available in the delivery room,” said Adem.

ethiopia Biruck Gashawbeza maternal health obstetric emergency drills
Biruck Gashawbeza, a 3rd year obstetrics and gynecology resident at St. Paul’s Hospital (Photo: Katie Millar/MHTF)

Gashawbeza reflected on a patient with PPH that he successfully managed after participating in the drills. “This was a severe case of PPH. She had lost a lot of blood …. So, I thought, that’s going to be very difficult. But the [supply] pack has helped us. The drill also alerted us and let us know what to do with that patient with PPH.”

The debriefing sessions were particularly useful in evaluating and strengthening skills. During the session, mistakes were reviewed and participants watched the video recording of their performance. Adem said that most participants did not accept their mistakes until they were able to review the video, making it a key aspect of learning


Implementing drills came with challenges. Due to a high rate of staff turnover, clinicians who attended the initial course spend their time training and re-training staff from their own health center, leaving them without time to reach out to other health centers as they had planned to do.

Other challenges to continuing the drills include lack of an “owner” of the program to monitor progress, lack of transport and time and difficulty in finding skilled actresses who understand what it’s like to have an obstetric emergency.

What now?

Now that the project has finished, participants are committed to continuing drills in their facilities. “Everybody is convinced that this is important,” said Bekele.

Gashawbeza finds the drills so helpful, that he plans to expand the scope of the drills: “We are trying to expand it for other obstetric emergencies like shoulder dystocia, and even failed intubations. But now we just test on eclampsia and PPH. These are common killers in our center, so it’s a good start.”

The drills have had such a great impact on the St. Paul’s network, that other networks within Addis Ababa have obtained the necessary material to implement drills in their own facility.